mHealth in the

COVID-19 era and beyond

Traditional Care Disruption
Areas of Care Disruption

Limited
staff
Patients
quarantined

Pre and
postsurgical In-patient visits
care affected cancelled

Screenings Surgeries
cancelled cancelled
Mobile Health as a Solution

Chronic Disease
Management

Overcoming
Care
Disruptions

Remote
Patient Telemedicine
Monitoring
1. Chronic Disease
Management Chronic diseases Management: An integrated care
approach to managing illness.

mHealth applications in Chronic Disease

Management
- Screening and survey
- Patient education
- Remote consultation
- Medication adherence support
- Medical social networks for peer-support
The Chronic Care Model. Developed by the
MacColl Institute, ©ACPJSIM Journals and Books
1.2 Case Study: Impact of COVID on Cancer Management

WHO model of “continuum of care” in association with palliative cancer care:

Curative Care:
surgery,
radiotherapy,
systemic therapy,...

Palliative Care:
suppressing the
cancer to a
subclinical state to
ensure good
quality of life.

Blum, T., & Schönfeld, N.

(2015). The lung cancer
patient, the pneumologist
and palliative care: a
developing alliance.
European Respiratory
Journal, 45(1), 211226.
1.2 Case Study: Impact of COVID on Cancer Management
Cancino, Ramon S., et al. "The Impact of COVID19 on Cancer Screening: Challenges and Opportunities." JMIR cancer 6.2
(2020).

Estimated impact of COVID on Cancer Care Outcomes:

- Screenings for cancers of the breast, colon, and cervix have dropped by 94%, 86%, and 94%
between January 20, 2020, and April 21, 2020, respectively.

- Possible increase of later-stage cancer diagnosis in patients. Early data from the United Kingdom
predicts a substantial increase in the number of avoidable cancer-related deaths in England [70].

- COVID19 will result in 10,000 excess deaths from breast and colorectal cancer.
1.2 Case Study: Impact of COVID on Cancer Management
Cancino, Ramon S., et al. "The Impact of COVID19 on Cancer Screening: Challenges and Opportunities." JMIR cancer 6.2
(2020).

Cancer screening plays a critical role in early cancer detection.

mHealth applications
Patient-centered : can serve the needs of
different stakeholders…
- Proactive outreach to
patients due for screening
using mobile screening tools
- Social media communication
to patients about risks of
cancer and screening Healthcare Practitioners:
procedures
- mHealth literacy
Health systems: and readiness
education
- Initial assessment and results
follow-up via tele consultation
1.2 Case Study: Impact of COVID on Cancer Management
Tashkandi, E. et al.(2020). V2: web-based questionnaire study. Journal of medical Internet research, 22(6), e19691.

Study setup: 222 responses from validated oncologists from 10 countries.

Key findings:

Oncologists have a high level of awareness of

virtual management: 82% aware of virtual clinics
and 59% reported being personally involved during
COVID.

46% oncologists responded that they would

“definitely” prefer to manage patients with cancer
virtually.

Although their survey responses indicated they

second and third line palliative treatments should
be interrupted, they stated that adjuvant,
Figure to the left: Respondents’ reported challenges
perioperative,
regarding and firstline palliative treatments
virtual management.
should continue.
1.3 Case Study: Mobile Cardiology in COVID

Patients PreCOVID Care Option COVID Care Option

Patients with Face-to-face ● Scheduled

cardiovascular conditions consultations in a practice outpatient
are considered vulnerable or outpatient clinic. consultation
and their management cancelled to keep
requires a comprehensive vulnerable patients
assessment of vital signs out of the hospital
and regular adaptation of ● Face-to-face
medication. appointments were
converted into
teleconsultations.
1.3 Case Study: Mobile Cardiology during COVID
Linz, D., Pluymaekers, N. A., & Hendriks, J. M. (2020). TeleCheckAF for COVID19: A European mHealth project to facilitate
atrial fibrillation management through teleconsultation during COVID19.

TeleCheckAF: A European mHealth project to facilitate Atrial Fibrillation (AF) management through
teleconsultation during COVID19.
1.3 Case Study: Mobile Cardiology during COVID
Linz, D., Pluymaekers, N. A., & Hendriks, J. M. (2020). TeleCheckAF for COVID19: A European mHealth project to facilitate
atrial fibrillation management through teleconsultation during COVID19.

Key findings:

- 49% of patients would continue using remote care in addition to traditional ones in the future.
- 38% of teleconsultations was scheduled to evaluate arrhythmias

Possible mHealth Improvements:

- Coordination of care is critical to effective mHealth-based management in the COVID era.

- Care coordinators those who would initiate contact with the patient, provide education and
instruction, and offer additional technical helps are integral to the successful implementation of
complex care management intervention.
- Remote patients education is essential.
 1.4 Case Study: Diabetes Management
Existing mHealth framework/tools for diabetes
management:
1.4 Case Study: Diabetes Management
Gamble, A., Pham, Q., Goyal, S., & Cafazzo, J. A. (2020). The
challenges of COVID19 for people living with diabetes:
considerations for digital health. JMIR diabetes, 5(2), e19581.

Certain demographic groups within the diabetic

community are at higher risks…

Older adults
- higher risk of COVID19 exposure,
complications, and death
Multiple Comorbidities
- Obesity, emphysema, hypertension,and heart
failure, etc.
- Greater risk of viral infection
Low SES Status
- For people who are insulin dependent, the risk
of an insulin shortage or delayed delivery is
Figure. Challenges of COVID19 for people living with diabetes
deadly. and the opportunities of diabetes digital health.
Case Study 3: Remote Monitoring of Home Dialysis
Problem
In-person dialysis services cancelled due to risk
of exposure to COVID-19

Solution
Remote monitoring and telemedicine support
of patients to receive dialysis at home.

Results
Patients were reassured with providing
themselves home dialysis; Only 1 adverse
episodes out of 300.
1.5 Patients' Perspective: Intentions and Barriers to Use

CamachoRivera, M., Islam, J. Y., Rivera, A., & Vidot, D. C. (2020). Attitudes Toward Using COVID19 mHealth Tools Among Adults
With Chronic Health Conditions: Secondary Data Analysis of the COVID19 Impact Survey. JMIR mHealth and uHealth, 8(12), e24693.

Camacho Rivera et.al analyzed differences in attitudes toward the use of COVID19 mHealth tools
emerged across various chronic health conditions.

- Of the 10,760 respondents, 21.8% of respondents were extremely/very likely to use a mobile
phone app or a website to track their COVID19 symptoms and receive recommendations.
- 24.1% of respondents were extremely/very likely to use a mobile phone app to track their location
and receive push notifications about whether they have been exposed to COVID19.

Disparities in attitudes toward COVID19 mHealth tools across age, sex, race/ethnicity, education, and
region.
1.5 Patients' Perspective: Intentions and Barriers to Use

CamachoRivera, M., Islam, J. Y., Rivera, A., & Vidot, D. C. (2020). Attitudes Toward Using COVID19 mHealth Tools Among Adults
With Chronic Health Conditions: Secondary Data Analysis of the COVID19 Impact Survey. JMIR mHealth and uHealth, 8(12), e24693.

Main Findings:

1. Respondents aged 18-29 years reported being less likely to use apps for tracking COVID19
symptoms and exposure compared to participants aged ≥60 years.
2. Respondents with lower levels of education were less likely to use an app for tracking COVID19
symptoms or exposure compared to respondents with a college degree or higher.
3. Respondents with a racial/ethnic minority background had a greater likelihood of using COVID19
mHealth tools than nonHispanic White respondents in our entire sample.
4. Adults with mental health conditions were the most likely to report being extremely/very or
moderately likely to use each mHealth intervention compared to those without such conditions.
5. Women were more likely to report positive attitudes toward using an app or website to track
potential COVID19 exposures or symptoms compared to men.
2. Remote Patient Monitoring
Case Study 1: Monitoring Diabetic Patients in Hospitals
Problem
Glucose is traditionally measured via finger
pricking. Due to COVID-19, patients are
quarantined to prevent COVID-19 transmission
Solution
Consumer Continuous Glucose Monitor (CGM)
is used instead and results sent wirelessly to
single data platform (tablet, phone, etc.)
Results
Less interactions and COVID-19 infections;
Glucose levels improved (less incidents for
hypoglycemia) for patients receiving continuous
insulin infusion.

Shehav-Zaltzman, Gilat et al. “Remote Glucose Monitoring of Hospitalized, Quarantined Patients With Diabetes and COVID-19.” Diabetes care 43.7 (2020): e75–e76. Web.
Case Study 2: Monitoring Advanced Heart Failure Patients
Problem
Due to COVID-19, in-patient checkups are
cancelled for advanced heart failure (HF)
patients

Solution
Cardiac Implantable Electronic Devices (CIEDs)
are used to monitor patient conditions at home
Results
Medication optimization and detect potential
escalation in disease severity or other cardiac
conditions such as atrial fibrillation

Egolum, Ugochukwu O et al. “Applications of the Multisensor HeartLogic Heart Failure

Monitoring Algorithm During the COVID-19 Global Pandemic.” JACC. Case reports
vol. 2,14 (2020): 2265-2269.
Drawbacks and Challenges of Remote Patient Monitoring
1. Access issues (cost, devices, internet
connections) for patients
2. Additional infrastructure needed for
providers, healthcare organizations
8 years later...
3. Training for both users and clinicians
4. Data analysis and potential overload

5. Data privacy
6. Ease of use
AHA Guideline on RPM for HF patients (2019)
7. Reliability and accuracy
Future Improvements
Ease of Use Accuracy and reliability

AliveCor CardiaMobile 6L Eko Stethoscope

ECG
Telemedicine

Modalities:

● Synchronous
● Asynchronous
● Remote patient monitoring
Benefits

● Monitoring clinical signs of chronic conditions

● Access for people in rural areas
● Easy follow up visits
Benefits: Time to get care

Telemedicine visit: 15 minutes on average (American Well)

In-person visit: 121 minutes on average (Harvard Medical School):

● 37 minutes travel time

● 64 minutes waiting and paperwork
● Only 20 minutes face-to-face with doctor

Average wait time for a new patient appointment is 24 days (Merritt Hawkins),
compared to 20 minutes for a telemedicine appointment (eVisit)
Benefits: COVID-19

● Reduce staff exposure to illnesses

● Reduce compromised patients' exposure to illnesses
● Reduce COVID transmission in general
● Preserve PPE
● Minimize impact of patient surges
Challenges: Fraud
Challenges: Data Security
● Single health record worth $250-$1,000
● Hospitals opening up to cyberattacks?
1. Key takeaways:
1. Underserved populations, such as low income or ethnic minorities, were disproportionately affected
by COVID.
2. mHealth could either mitigate or reinforce health disparity issues, depending on how applications
were designed and implemented.
3. The chronically ill population express generally positive attitudes toward mHealth interventions and
will likely to use remote care after COVID.
4. New areas of interest emerge during COVID, include ineffective cancer screening, insulin shortage,
managing comorbidities, caring for high risk populations.