What is e-Health?

 The process of transformation of healthcare to be more digital has been accelerated by the current Covid-19 health emergency, which has necessitated much less face-to-face contact and more remote working. A recent review by Eric Topol on preparing the workforce for a digital future outlines the ways technology will change how we provide healthcare: the three key areas identified were telemedicine, smartphone Applications  and sensors and wearables Indeed, the smartphone is now a portable  personal computer and communications device, with nearly 80% of adults in high-income countries regularly using it to access the internet. The smartphone is arguably the key tool which facilitates m-Health.

This brief review will explore how the digital landscape of e-Health is changing the practice of cardiology and transforming the treatment and prevention of cardiovascular disease in general.

Electronic health records.

EHRs are a fundamental component of e-Health. Different EHRs offer varying levels of functionality, from basic documentation to real-time display of clinical signs and observations, often linked to communication with other healthcare professionals and electronic prescribing. EHRs have so far had a mixed reception from clinicians: a survey of US primary care physicians reported that although 63% believed EHRs have generally led to improved care, 74% reported that using an EHR increased their workload, and 68% stated that EHRs took valuable time away from patient care. A time and motion study from the USA showed that 49% of clinician time was spent on EHRs and administration.

There is no unified EHR across Europe: even within a single country, individual healthcare organisations typically procure their own software and can be at varying levels of digital maturity. Interestingly, primary care tends to have a more unified approach to EHRs than hospital-based systems. Interoperability is consequently a key challenge: data cannot easily be transferred from one system to another, the coding used may differ, and much of the information may not be easily searchable. Across Europe there is also the issue of language differences.

For clinicians to be able to make the best use of data from m-Health approaches (including Apps and wearables), the data have to be easily viewed, imported into the EHR, and shared with other relevant healthcare professionals. A clear “audit” trail is required to show on what basis decisions were made.

M-Health:

m-Health is the use of mobile wireless technologies for health. This often, but not always, involves the use of a smartphone. A simple use of m-Health is remote access to healthcare information and services. Estonia’s “e-Health record” is an example of a nationwide system whereby patients and emergency services are able to access summary health data remotely via an “e-Patient portal”. The National Health Service in the UK has recently launched the NHS App which allows patients to access their summary medical record.and book appointments, with further functionality being added rapidly. The European Society of Cardiology produces Apps for healthcare professionals, such as clinical guideline Apps, but also Apps for patients. The “My AF” App allows patients to record symptoms and quality-of-life data, which can be shared with healthcare professionals to add further value to interactions with clinicians.

Patient education is a key factor in improving health outcomes, particularly in cardiovascular disease, with improvements in diet, exercise, smoking cessation and medication compliance helping to optimise the outcome of care and lifestyle choices. Health literacy in Europe is poor: in a study across eight European countries, 47% of participants had low or inadequate health literacy, rising to 61% for those with more than one long-term illness  The NHS recently partnered with Amazon to allow people to access health advice via its voice assistant Alexa, and there is a proliferation of educational Apps aimed at presenting information in a more visual, easy-to-understand manner. Others allow symptom tracking and/or are even able to perform basic triage and provide health advice.

 Sensors

Sensors are integral to m-Health. A sensor measures a signal and collects data which can be transmitted or recorded for further analysis. This may be as simple as a Bluetooth-enabled scale to measure weight, or as complex as a multiparameter monitoring device. Broadly, sensors can be divided into invasive or non-invasive, the latter including both wearable and non-wearable technologies.

Non-invasive sensors

Bluetooth-enabled “smart” devices allow sensors to connect to smartphones or computers to track data and provide trends. Self-blood pressure monitoring, when combined with antihypertensive medication titration in response to readings, successfully reduces systolic blood pressure compared with usual care Patient-activated lead-I ECG recorders such as the KardiaMobileTM device have transformed the diagnosis of atrial fibrillation  and paroxysmal arrhythmia. Whilst previously diagnosis was usually made using Holter monitors, which are often limited by availability, technician analysis time and how long they can be worn, personal lead-I ECG monitors are being increasingly used. The Kardia device has been reported to have a 98.5% sensitivity and 91.4% sensitivity  in the community diagnosis of AF

Wearables

Wearable devices  are increasingly popular consumer products. The most common features of wearable devices are activity monitoring and heart rate monitoring and, whilst these are usually used to track fitness, step counters can be useful adjuncts in cardiac rehabilitation  and may provide data for prognostication of heart failure  Wearable, continuous ECG recording can also be done via patches or vests  which are more comfortable, less cumbersome and can monitor for longer than standard Holter monitors. Some “smart” watches, such as the Watch also have irregular pulse detection algorithms, and lead-I ECG recording capabilities. The Heart Study demonstrated that its irregular pulse algorithm had potential for community screening of AF. Over 400,000 patients were recruited, 0.5% had an irregular pulse notification and, of those who had an irregular pulse notification and sent back a 7-day ECG patch recorder, 34% had AF diagnosed by ECG. The study particularly highlights how digital technology has transformed research: there were no study centres and recruitment of a large number of study participants was done rapidly and at relatively low cost.

Invasive sensors

Cardiac implantable electronic devices such as pacemakers and implantable loop recorders are invasive sensors; a computer-based algorithm, rather than a physician, analyses the data in real time. More sophisticated implantable devices can monitor not just cardiac electrograms, but several other physiological variables such as intrathoracic impedance, respiratory rate and sleep apnoea. Proprietary algorithms using such data show promise in identifying patients at short-term risk of HF decompensation and can send an alert to the clinician . A significant increase in pulmonary artery pressure usually precedes HF decompensation and so implantable pulmonary artery pressure monitors can be used to titrate HF therapies and significantly reduce repeat hospitalisation in HF patients with recent hospitalisation.

Telehealth, self-care and personalised care

Telehealth is not yet widely used in cardiology but the growing pressures on outpatient departments will likely accelerate its deployment. The number of outpatient appointments is rising steadily: in the UK, for example, outpatient appointments have nearly doubled in the past 10 years, with cardiology clinic appointments accounting for more than 3% of all NHS outpatient attendances Alternatives to face-to-face consultations are therefore required, not only to address limited capacity, but also for patient convenience. Video consultations have so far been well received by patients because of reduced waiting times and travel cost , but there are few data on outcomes for specialist appointments for long-term health conditions. Telehealth also has the potential to connect clinicians from different specialties or between primary and secondary care, creating a “virtual Heart Team” and potentially saving unnecessary appointments and supporting more holistic care.