@article {1293, title = {Designing mHealth for maternity services in primary health facilities in a low-income setting - lessons from a partially successful implementation.}, journal = {BMC Med Inform Decis Mak}, volume = {18}, year = {2018}, month = {2018 11 12}, pages = {96}, abstract = {

BACKGROUND: Increasing mobile phone ownership, functionality and access to mobile-broad band internet services has triggered growing interest to harness the potential of mobile phone technology to improve health services in low-income settings. The present project aimed at designing an mHealth system that assists midlevel health workers to provide better maternal health care services by automating the data collection and decision-making process. This paper describes the development process and technical aspects of the system considered critical for possible replication. It also highlights key lessons learned and challenges during implementation.

METHODS: The mHealth system had front-end and back-end components. The front-end component was implemented as a mobile based application while the back-end component was implemented as a web-based application that ran on a central server for data aggregation and report generation. The current mHealth system had four applications; namely, data collection/reporting, electronic health records, decision support, and provider education along the continuum of care including antenatal, delivery and postnatal care. The system was pilot-tested and deployed in selected health centers of North Shewa Zone, Amhara region, Ethiopia.

RESULTS: The system was used in 5 health centers since Jan 2014 and later expanded to additional 10 health centers in June 2016 with a total of 5927 electronic forms submitted to the back-end system. The submissions through the mHealth system were slightly lower compared to the actual number of clients who visited those facilities as verified by record reviews. Regarding timeliness, only 11\% of the electronic forms were submitted on the day of the client visit, while an additional 17\% of the forms were submitted within 10~days of clients{\textquoteright} visit. On average forms were submitted 39~days after the day of clients visit with a range of 0 to 150~days.

CONCLUSIONS: In conclusion, the study illustrated that an effective mHealth intervention can be developed using an open source platform and local resources. The system impacted key health outcomes and contributed to timely and complete data submission. Lessons learned through the process including success factors and challenges are discussed.

}, keywords = {Cell Phone, Delivery of Health Care, electronic health records, Ethiopia, Female, Health Facilities, Humans, Maternal Health Services, Mobile Applications, Poverty, Pregnancy, Telemedicine}, issn = {1472-6947}, doi = {10.1186/s12911-018-0704-9}, author = {Shiferaw, Solomon and Workneh, Andualem and Yirgu, Robel and Dinant, Geert-Jan and Spigt, Mark} } @article {1204, title = {The mobile sleep lab app: {An} open-source framework for mobile sleep assessment based on consumer-grade wearable devices}, journal = {Computers in Biology and Medicine}, volume = {103}, year = {2018}, pages = {8{\textendash}16}, abstract = {BACKGROUND: Sleep disorders have a prevalence of up to 50\% and are commonly diagnosed using polysomnography. However, polysomnography requires trained staff and specific equipment in a laboratory setting, which are expensive and limited resources are available. Mobile and wearable devices such as fitness wristbands can perform limited sleep monitoring but are not evaluated well. Here, the development and evaluation of a mobile application to record and synchronize data from consumer-grade sensors suitable for sleep monitoring is presented and evaluated for data collection capability in a clinical trial. METHODS: Wearable and ambient consumer-grade sensors were selected to mimic the functionalities of clinical sleep laboratories. Then, a modular application was developed for recording, processing and visualizing the sensor data. A validation was performed in three phases: (1) sensor functionalities were evaluated, (2) self-experiments were performed in full-night experiments, and (3) the application was tested for usability in a clinical trial on primary snoring. RESULTS: The evaluation of the sensors indicated their suitability for assessing basic sleep characteristics. Additionally, the application successfully recorded full-night sleep. The collected data was of sufficient quality to detect and measure body movements, cardiac activity, snoring and brightness. The ongoing clinical trial phase showed the successful deployment of the application by medical professionals. CONCLUSION: The proposed software demonstrated a strong potential for medical usage. With low costs, it can be proposed for screening, long-term monitoring or in resource-austere environments. However, further validations are needed, in particular the comparison to a clinical sleep laboratory.}, keywords = {Mobile sleep laboratory, Sleep screening, Smartphone, Telemedicine, Wearable technology}, issn = {1879-0534}, doi = {10.1016/j.compbiomed.2018.09.025}, author = {Burgdorf, Andreas and G{\"u}the, Inga and Jovanovi{\'c}, Marko and Kutafina, Ekaterina and Kohlschein, Christian and Bitsch, J{\'o} {\'A}gila and Jonas, Stephan M.} } @article {1236, title = {Development and Deployment of the OpenMRS-Ebola Electronic Health Record System for an Ebola Treatment Center in Sierra Leone.}, journal = {J Med Internet Res}, volume = {19}, year = {2017}, month = {2017 08 21}, pages = {e294}, abstract = {

BACKGROUND: Stringent infection control requirements at Ebola treatment centers (ETCs), which are specialized facilities for isolating and treating Ebola patients, create substantial challenges for recording and reviewing patient information. During the 2014-2016 West African Ebola epidemic, paper-based data collection systems at ETCs compromised the quality, quantity, and confidentiality of patient data. Electronic health record (EHR) systems have the potential to address such problems, with benefits for patient care, surveillance, and research. However, no suitable software was available for deployment when large-scale ETCs opened as the epidemic escalated in 2014.

OBJECTIVE: We present our work on rapidly developing and deploying OpenMRS-Ebola, an EHR system for the Kerry Town ETC in Sierra Leone. We describe our experience, lessons learned, and recommendations for future health emergencies.

METHODS: We used the OpenMRS platform and Agile software development approaches to build OpenMRS-Ebola. Key features of our work included daily communications between the development team and ground-based operations team, iterative processes, and phased development and implementation. We made design decisions based on the restrictions of the ETC environment and regular user feedback. To evaluate the system, we conducted predeployment user questionnaires and compared the EHR records with duplicate paper records.

RESULTS: We successfully built OpenMRS-Ebola, a modular stand-alone EHR system with a tablet-based application for infectious patient wards and a desktop-based application for noninfectious areas. OpenMRS-Ebola supports patient tracking (registration, bed allocation, and discharge); recording of vital signs and symptoms; medication and intravenous fluid ordering and monitoring; laboratory results; clinician notes; and data export. It displays relevant patient information to clinicians in infectious and noninfectious zones. We implemented phase 1 (patient tracking; drug ordering and monitoring) after 2.5 months of full-time development. OpenMRS-Ebola was used for 112 patient registrations, 569 prescription orders, and 971 medication administration recordings. We were unable to fully implement phases 2 and 3 as the ETC closed because of a decrease in new Ebola cases. The phase 1 evaluation suggested that OpenMRS-Ebola worked well in the context of the rollout, and the user feedback was positive.

CONCLUSIONS: To our knowledge, OpenMRS-Ebola is the most comprehensive adaptable clinical EHR built for a low-resource setting health emergency. It is designed to address the main challenges of data collection in highly infectious environments that require robust infection prevention and control measures and it is interoperable with other electronic health systems. Although we built and deployed OpenMRS-Ebola more rapidly than typical software, our work highlights the challenges of having to develop an appropriate system during an emergency rather than being able to rapidly adapt an existing one. Lessons learned from this and previous emergencies should be used to ensure that a set of well-designed, easy-to-use, pretested health software is ready for quick deployment in future.

}, keywords = {electronic health records, Epidemics, Hemorrhagic Fever, Ebola, Humans, Infection Control, Sierra Leone, Telemedicine}, issn = {1438-8871}, doi = {10.2196/jmir.7881}, author = {Oza, Shefali and Jazayeri, Darius and Teich, Jonathan M and Ball, Ellen and Nankubuge, Patricia Alexandra and Rwebembera, Job and Wing, Kevin and Sesay, Alieu Amara and Kanter, Andrew S and Ramos, Glauber D and Walton, David and Cummings, Rachael and Checchi, Francesco and Fraser, Hamish S} } @article {1033, title = {Making cytological diagnoses on digital images using the iPath network.}, journal = {Acta Cytol}, volume = {58}, year = {2014}, month = {2014}, pages = {453-60}, abstract = {

BACKGROUND: The iPath telemedicine platform Basel is mainly used for histological and cytological consultations, but also serves as a valuable learning tool.

AIM: To study the level of accuracy in making diagnoses based on still images achieved by experienced cytopathologists, to identify limiting factors, and to provide a cytological image series as a learning set.

METHOD: Images from 167 consecutive cytological specimens of different origin were uploaded on the iPath platform and evaluated by four cytopathologists. Only wet-fixed and well-stained specimens were used. The consultants made specific diagnoses and categorized each as benign, suspicious or malignant.

RESULTS: For all consultants, specificity and sensitivity regarding categorized diagnoses were 83-92 and 85-93\%, respectively; the overall accuracy was 88-90\%. The interobserver agreement was substantial (κ = 0.791). The lowest rate of concordance was achieved in urine and bladder washings and in the identification of benign lesions.

CONCLUSION: Using a digital image set for diagnostic purposes implies that even under optimal conditions the accuracy rate will not exceed to 80-90\%, mainly because of lacking supportive immunocytochemical or molecular tests. This limitation does not disqualify digital images for teleconsulting or as a learning aid. The series of images used for the study are open to the public at http://pathorama.wordpress.com/extragenital-cytology-2013/.

}, keywords = {Adolescent, Adult, Aged, Aged, 80 and over, Child, Child, Preschool, Computers, Handheld, Cytodiagnosis, Diagnosis, Differential, Female, Humans, Hyperplasia, Infant, Male, Metaplasia, Middle Aged, Neoplasms, Observer Variation, Reproducibility of Results, Sensitivity and Specificity, Telemedicine}, issn = {0001-5547}, doi = {10.1159/000369241}, author = {Dalquen, Peter and Savic Prince, Spasenija and Spieler, Peter and Kunze, Dietmar and Neumann, Heinrich and Eppenberger-Castori, Serenella and Adams, Heiner and Glatz, Katharina and Bubendorf, Lukas} } @article {1034, title = {Telecytological diagnosis of space-occupying lesions of the liver.}, journal = {Acta Cytol}, volume = {58}, year = {2014}, month = {2014}, pages = {174-81}, abstract = {

OBJECTIVE: In this study, the efficiency of telemedical consulting with regard to fine needle aspirates from space-occupying lesions (SOLs) of the liver is investigated for the first time.

STUDY DESIGN: The study includes fine needle aspirations from 62 patients, 33 with hepatocellular carcinoma (HCC) and 29 with non-hepatic tumors. Using the Internet-based iPath system, the initial pathologist submitted 1-8 images from smears and cell block sections. One consultant assessed the cytological and another one the histological images. Both made their diagnoses independent of each other. A final diagnosis was made by immunochemistry of cell block sections. The cytological images were analyzed retrospectively for the occurrence of the most typical HCC indicators. The number of these indicators was related to the initial diagnoses of the three pathologists, and possible reasons for diagnostic errors were analyzed based on this analysis.

RESULTS: The accuracy of the preliminary telemedical diagnoses regarding HCC was 82.0\% for the cytological images and 87.7\% for the histological images. Most of the false diagnoses occurred in tumors with unusual cytological and histological patterns.

CONCLUSIONS: Telemedical consulting is a valuable tool to obtain a second opinion. However, for improvement of the diagnosis of HCC, supplementary immunochemical tests are necessary.

}, keywords = {Adult, Aged, Aged, 80 and over, Carcinoma, Hepatocellular, Female, Humans, Image-Guided Biopsy, Liver, Liver Neoplasms, Male, Middle Aged, Retrospective Studies, Telemedicine}, issn = {0001-5547}, doi = {10.1159/000357195}, author = {Mostafa, Mohammad Golam and Dalquen, Peter and Kunze, Dietmar and Terracciano, Luigi} } @article {863, title = {DICOM RIS/PACS Telemedicine Network Implementation using Free Open Source Software}, journal = {Latin America Transactions, IEEE (Revista IEEE America Latina)}, volume = {11}, year = {2013}, pages = {168-171}, abstract = {The increasing incorporation of modern medical imaging equipment requires the operation of systems that store, transmit and display images, PACS (Picture Archiving and Communication System) via digital networks to provide health services with higher quality. These revolutionized radiology systems based on digital techniques, communications, visualization and information technologies. One of the major problems that arise in institutions working with Imaging Diagnosis (Dx) in the interconnection network or equipment, are the "bottlenecks" caused by the high flow of network data. This flux is given by the transfer of images in DICOM (Digital Imaging and Communications in Medicine) to the various devices that make up a DICOM network, called Service Class Users (SCU) and Service Class Providers (SCP). This paper describes the development and implementation of a network of medical images using free software and its compatibility with its own data network of a RIS (Radiology Information System). Describes techniques used for the interconnection of local nodes on a LAN (Local Area Network) remote WAN Wide Area Network) via Internet and WLAN (Wireless Area Network.}, keywords = {DICOM, Free Software, Medical Imaging, Telemedicine}, issn = {1548-0992}, doi = {10.1109/TLA.2013.6502797}, author = {Alvarez, Luis R. and Vargas Solis, Roberto} } @article {1280, title = {What do electronic health record vendors reveal about their products: an analysis of vendor websites.}, journal = {J Med Internet Res}, volume = {15}, year = {2013}, month = {2013 Feb 19}, pages = {e36}, abstract = {

BACKGROUND: Purchasing electronic health records (EHRs) typically follows a process in which potential adopters actively seek information, compare alternatives, and form attitudes towards the product. A potential source of information on EHRs that can be used in the process is vendor websites. It is unclear how much product information is presented on EHR vendor websites or the extent of its value during EHR purchasing decisions.

OBJECTIVE: To explore what features of EHR systems are presented by vendors in Ontario, Canada, on their websites, and the persuasive means they use to market such systems; to compare the online information available about primary care EHR systems with that about hospital EHR systems, and with data compiled by OntarioMD, a regional certifying agency.

METHODS: A list of EHR systems available in Ontario was created. The contents of vendor websites were analyzed. A template for data collection and organization was developed and used to collect and organize information on the vendor, website content, and EHR features. First, we mapped information on system features to categories based on a framework from the Institute of Medicine (IOM). Second, we used a grounded theory-like approach to explore information for building consumer confidence in the vendor and product, and the various persuasive strategies employed on vendor websites. All data were first coded by one researcher. A peer reviewer independently analyzed a randomly chosen subset of the websites (10 of 21; 48\%) and provided feedback towards a unified coding scheme. All data were then re-coded and categorized into themes. Finally, we compared information from vendor websites and data gathered by OntarioMD.

RESULTS: Vendors provided little specific product information on their websites. Only two of five acute care EHR websites (40\%) and nine of 16 websites for primary care systems (56\%) featured seven or all eight of the IOM components. Several vendor websites included system interface demonstrations: screenshots (six websites), public videos or slideshows (four websites), or for registered viewers only (three websites). Persuasive means used by vendors included testimonials on 14/21 (67\%) websites, and directional language. Except for one free system, trial EHR versions were not available. OntarioMD provided more comprehensive information about primary care systems than the vendors{\textquoteright} websites. Of 14 points of comparison, only the inclusion of templates and bilingual interfaces were fully represented in both data sources. For all other categories, the vendor websites were less complete than the OntarioMD site.

CONCLUSIONS: EHR vendor websites employ various persuasive means, but lack product-specific information and do not provide options for trying systems on a limited basis. This may impede the ability of potential adopters to form perceptions and compare various offerings. Both vendors and clients could benefit from greater transparency and more specific product information on the Web.

TRIAL REGISTRATION: N/A.

}, keywords = {Commerce, electronic health records, Humans, Internet, Marketing of Health Services, Ontario, Telemedicine}, issn = {1438-8871}, doi = {10.2196/jmir.2312}, author = {Yeung, Natalie K and Jadad, Alejandro R and Shachak, Aviv} } @article {1049, title = {Designing and Implementing an Innovative SMS-based alert system (RapidSMS-MCH) to monitor pregnancy and reduce maternal and child deaths in Rwanda.}, journal = {Pan Afr Med J}, volume = {13}, year = {2012}, month = {2012}, pages = {31}, abstract = {

INTRODUCTION: With the continuous growth of mobile network coverage and unprecedented penetration of mobile devices in the developing world, several mHealth initiatives are being implemented in developing countries. This paper aims to describe requirements for designing and implementing a mobile phone-based communication system aiming at monitoring pregnancy and reducing bottlenecks in communication associated with maternal and newborn deaths; and document challenges and lessons learned.

METHODS: An SMS-based system was developed to improve maternal and child health (MCH) using RapidSMS({\textregistered}), a free and open-sourced software development framework. To achieve the expected results, the RapidSMS-MCH system was customized to allow interactive communication between a community health worker (CHW)following mother-infant pairs in their community, a national centralized database, the health facility and in case of an emergency alert, the ambulance driver. The RapidSMS-MCH system was piloted in Musanze district, Nothern province of Rwanda over a 12-month period.

RESULTS: A total of 432 CHW were trained and equipped with mobile phones. A total of 35,734 SMS were sent by 432 CHW from May 2010 to April 2011. A total of 11,502 pregnancies were monitored. A total of 362 SMS alerts for urgent and life threatening events were registered. We registered a 27\% increase in facility based delivery from 72\% twelve months before to 92\% at the end of the twelve months pilot phase. Major challenges were telephone maintenance and replacement. Disctrict heath team capacity to manage and supervise the system was strengthened by the end of pilot phase. Highly committed CHWs and effective coordination by the District health team were critical enablers.

CONCLUSION: We successully designed and implemented a mobile phone SMS-based system to track pregnancy and maternal and child outcomes in limited resources setting. Implementation of mobile-phone systems at community level could contribute to improving emergency obstetric and neonatal care, yet it requires a well-organized community health structure in limited resource settings.

}, keywords = {Cell Phones, Child Mortality, Child, Preschool, Emergency Medical Services, Female, Fetal Death, Health Plan Implementation, Humans, Infant, Newborn, Maternal Death, Maternal Health Services, Maternal-Child Health Centers, Monitoring, Physiologic, Pregnancy, Prenatal Care, Program Development, Rwanda, Telemedicine}, issn = {1937-8688}, author = {Ngabo, Fidele and Nguimfack, Judith and Nwaigwe, Friday and Mugeni, Catherine and Muhoza, Denis and Wilson, David R and Kalach, John and Gakuba, Richard and Karema, Corrine and Binagwaho, Agnes} } @inbook {1080, title = {Development of an mHealth Open Source Platform for Diabetic Foot Ulcers Tele-consultations}, booktitle = {Wireless Mobile Communication and Healthcare}, series = {Lecture Notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering}, volume = {83}, year = {2012}, pages = {158-164}, publisher = {Springer Berlin Heidelberg}, organization = {Springer Berlin Heidelberg}, keywords = {diabetic foot ulcers, m-health, Telemedicine}, isbn = {978-3-642-29733-5}, doi = {10.1007/978-3-642-29734-2_22}, url = {http://dx.doi.org/10.1007/978-3-642-29734-2_22}, author = {Dafoulas, GeorgeE. and Koutsias, Stylianos and Behar, Joachim and Osorio, Juan and Malley, Brian and Gruentzig, Alexander and Celi, LeoAnthony and Angelidis, Pantelis and Theodorou, Kyriaki and Giannoukas, Athanasios}, editor = {Nikita, KonstantinaS. and Lin, JamesC. and Fotiadis, DimitriosI. and Arredondo Waldmeyer, Maria-Teresa} } @inbook {851, title = {Development of an mHealth Open Source Platform for Diabetic Foot Ulcers Tele-consultations}, booktitle = {Wireless Mobile Communication and Healthcare}, series = {Lecture Notes of the Institute for Computer Sciences, Social Informatics and Telecommunications Engineering}, volume = {83}, year = {2012}, pages = {158-164}, publisher = {Springer Berlin Heidelberg}, organization = {Springer Berlin Heidelberg}, abstract = {Diabetes is one of the foremost causes of death in many countries and a leading cause of blindness, renal failure, and non-traumatic amputation. Therefore, diabetic foot ulceration and amputation cause extensive burden on individuals and health care systems in developed and developing countries. Due to the multi-disciplinary requirements for the treatment of diabetic foot ulceration, telemedicine has been introduced to facilitate the access of the patients to specialized health professionals. In this paper the development of an open source mobile health platform is presented, able to support diagnostic algorithms, with the use of a smartphone.}, keywords = {diabetic foot ulcers, m-health, Telemedicine}, isbn = {978-3-642-29733-5}, doi = {10.1007/978-3-642-29734-2_22}, url = {http://dx.doi.org/10.1007/978-3-642-29734-2_22}, author = {Dafoulas, GeorgeE. and Koutsias, Stylianos and Behar, Joachim and Osorio, Juan and Malley, Brian and Gruentzig, Alexander and Celi, LeoAnthony and Angelidis, Pantelis and Theodorou, Kyriaki and Giannoukas, Athanasios}, editor = {Nikita, KonstantinaS. and Lin, JamesC. and Fotiadis, DimitriosI. and Arredondo Waldmeyer, Maria-Teresa} } @article {1037, title = {A telemedicine network to support paediatric care in small hospitals in rural Tanzania.}, journal = {J Telemed Telecare}, volume = {18}, year = {2012}, month = {2012 Jan}, pages = {59-62}, abstract = {

We reviewed our experience with the Tanzanian Telemedicine Network in supporting paediatric care at 40 small, rural hospitals in the country. The network began operating in 2008. Store and forward telemedicine was provided via the open source software iPath. The 33 volunteer consultants were based in several countries, although most of them had practical experience in Tanzania. During the first three years of network operation there were 533 referrals. There were 159 paediatric cases (median age five years). Three paediatric specialists provided most consultations (64\%), but other specialists provided recommendations when required. The response time was usually less than two days (median 6 h; inter-quartile range 2-24 h). A precise recommendation was not always provided, but since all consultants had an intimate knowledge of the state of health services in Tanzania, their advice was usually well adapted to the local circumstances of the hospitals. Referral to a higher level of care was recommended in 26 cases (16\%). A simple web-based telemedicine system combined with email alerts is feasible in remote locations in Tanzania, even where fast Internet connections are not available.

}, keywords = {Child, Child, Preschool, Electronic Mail, Female, Hospitals, Rural, Humans, Internet, Male, Pediatrics, Physician{\textquoteright}s Practice Patterns, Referral and Consultation, Retrospective Studies, Rural Health Services, Tanzania, Telemedicine}, issn = {1758-1109}, doi = {10.1258/jtt.2011.110312}, author = {Kr{\"u}ger, Carsten and Niemi, Mauri} } @article {1038, title = {An online method for diagnosis of difficult TB cases for developing countries.}, journal = {Stud Health Technol Inform}, volume = {164}, year = {2011}, month = {2011}, pages = {168-73}, abstract = {

Optimal use of limited human, technical and financial resources is a major concern for tuberculosis (TB) control in developing nations. Further impediments include a lack of trained physicians, and logistical difficulties in arranging face-to-face (f-2-f) TB Diagnostic Committee (TBDC) consultations. Use of e-Health for virtual TBDCs (Internet and "iPath"), to address such issues is being studied in the Philippines and Pakistan. In Pakistan, radiological diagnosis of 88 sputum smear negative but suspected TB patients has been compared with the {\textquoteright}gold standards{\textquoteright} (TB culture, and 2-month clinical follow up). Of 88 diagnostic decisions made by primary physicians at the spoke site and electronic TBDC (e-TBDC) at hub site, there was agreement in 71 cases and disagreement on 17 cases. The turn-around time (TAT; patient registration at spoke site for f-2-f diagnosis to receiving the electronic diagnosis), averaged 34.6 hours; ranging 9 minutes to 289.2 hours. Average TAT at the rural site (59.15 hours) was more than the urban site (15.9 hours). Comparison of e-TBDC and f-2-f diagnosis with the gold standards showed only slight differences. Using culture as the gold standard, e-TBDC decisions showed greater accuracy (sensitivity - 32.4\%) as compared to f-2-f (27.6\%); using 2-month clinical follow-up as the gold standard, f-2-f diagnosis showed slightly better improvement in patient symptoms and weight as compared to e-TBDC. In Philippines "iPath" was trialed and demonstrated that e-TBDCs have potential. Such groups could review cases, diagnose, and write comments remotely, reducing the diagnosis and treatment delay compared to usual care.

}, keywords = {Adult, Developing Countries, Diagnostic Techniques and Procedures, Female, Humans, Internet, Male, Middle Aged, Mycobacterium Infections, Nontuberculous, Pakistan, Philippines, Telemedicine, Tuberculosis, Pulmonary}, issn = {0926-9630}, author = {Marcelo, Alvin and Fatmi, Zafar and Firaza, Paul Nimrod and Shaikh, Shiraz and Dandan, Alvin Joseph and Irfan, Muhammad and Bari, Vaqar and Scott, Richard E} }