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Telemedicine and Mobile Health Technology in the Diagnosis, Monitoring and Treatment of Respiratory Allergies
C H A P T E R
18 Telemedicine and Mobile Health Technology in the Diagnosis, Monitoring and Treatment of Respiratory Allergies Stephanie Hofmaier1, Xinyuan Huang2 and Paolo Maria Matricardi1 1
Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charite´ Medical University, Berlin, Germany 2Department of Pediatric, Shengzhou People’s Hospital, Zhejiang, China
Allergic rhinitis and asthma are very common diseases, estimated to affect over 300 million individuals around the globe. Often under-diagnosed and under-treated, they create a substantial burden to individuals and families, while restricting a patient’s activities possibly for his or her lifetime [1]. Most asthmatics suffer also from allergic rhinitis (AR) [2], a common chronic disease with an often significant negative impact on the quality of life (QOL). The level of AR control remains inadequate for many patients [3]. Patients with asthma and/or AR can take systemic drugs and/or inhaled corticosteroids (ICS) to reduce inflammation, as well as beta-2 agonists or antihistamines to alleviate their symptoms. Still, they suffer from the disease recurrently when not taking their medication. Many patients need ICS for a long time, but they often forget to take them until their symptoms urge them to do so. Poor adherence to medication leads to worse treatment outcomes, higher hospitalization rates, and increased health care costs [4]. Therefore, patients with asthma and/or AR need education programs to achieve adequate adherence to medication [5]. To control asthma and AR, patients should also monitor their symptoms, avoid triggers, and follow their treatment plan [6]. Successful asthma treatment can be largely attributed to education, not only to medication. The education of patients and health professionals on the proper use of inhalers is one of the mainstays for the treatment of asthma, especially in the pediatric population [7]. The traditional education method is face to face between patient and general practitioner, nurse or medical professional. Although every patient should be directly seen by a doctor, some patients with minor disorders try self-medication, without consideration of it being adequate or not. On the other hand, many patients with chronic diseases who do see a doctor, have a poor adherence to the prescribed medicine after their visits [8 10]. Strategies to improve the patient’s adherence to prescription are therefore essential in the management of chronic disease and asthma.
THE EVOLUTION OF MOBILE TECHNOLOGY IN HEALTHCARE Since the 1980s, mobile technology has allowed not only real-time bilateral voice communication, but also realtime bilateral transmission of written messages. In recent years, smartphones have incorporated also media players, a camera with flash (flashlight), video cameras, GPS navigation/geolocalisation, NFC (Near Field Communication), gravity sensor level meter, and other technologies, making them feature-rich devices. Today, high-resolution touch screens and web browsers can display also standard web pages and mobile-optimized content. Through Wi-Fi and mobile broadband, smartphones can achieve high-speed data throughput and allow
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cloud computing as a standard. While email has become common on mobile devices, stable connections among various phones or with other electronic devices via Bluetooth, Wi-Fi or mobile internet also make data transfer an easy task. Mobile applications (“apps”) employ increasingly intelligent functions and are used in many areas of life. Accordingly, the mobile app market underwent a rapid development in the areas of mobile commerce, game industry, and social real-time communication networks. In parallel, the worldwide smartphone sales volume is enormous (over 1,200 million units in 2014) [11]. Mobile phone has become an important device in day-today life, allowing a continuous and real-time transfer of data independently from the user’s location [12]. This world of mobile technology is rapidly expanding and it is changing many aspects of our daily life. The dramatic increase in the ownership of cellphones and smartphones has resulted in a plethora of mobile health (mHealth) applications, which are becoming increasingly popular among physicians, patients and the general public. mHealth utilizes mobile devices to carry out the task of viewing electronic medical records, reserving appointments with a patient’s medical provider and electronically refilling prescriptions. The term is most commonly used in reference to using mobile communication devices, such as mobile phones, tablet computers and PDAs, for health services and information [13]. Already in 2012, estimations predicted the mobile phone with health applications to become the most popular health service device in the world [14]. Many apps for allergists aim at forecasting symptoms and allergen exposure in addition to providing expert systems, remote monitoring, allergy management, patient or doctor education, and guideline implementation. This new world is particularly attractive for younger patients and younger doctors.
RECOGNITION OF EHEALTH INNOVATIONS BY MEDICAL ASSOCIATIONS The World Health Organization (WHO) is continuously following and reporting globally on new developments of mobile technology in the healthcare sector (Fig. 18.1) [15]. In addition, a toolkit for the development of National eHealth Roadmaps has been created in order to support the member states in developing their own eHealth strategies. As the evaluation of existing eHealth programs is also fundamental, the Global Observatory for eHealth (GOe) and partner institutions are aiming to build up an evaluation framework, providing concrete measurable indicators. A global database with concise information on research findings in the digital health sector will be built, including a particular focus on developing countries’ initiatives. This pool of knowledge will be
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FIGURE 18.1 Percentage of countries with each mHealth program type by established, pilot or informal phase. Reprinted with permission from World Health Organisation (2016) Global diffusion of eHealth: Making universal health coverage achievable. Report of the third global survey on eHealth. http://www.who.int/goe/publications/global_diffusion/en/ (Last accessed on: 19 February, 2018).
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accessible to all member states of the WHO to facilitate project planning, as well as the preparation of new proposals. Also at a national level, the importance of eHealth is well known. Recently, the American College of Allergy, Asthma and Immunology (ACAAI) published a position paper on the use of telemedicine for allergists. [16] In this document, the ACAAI underlines the importance of investigations in the relatively new area of telemedicine and depicts the advantages and limitations of a new approach to allergy care. The authors foresee an increase in the demand of mHealth services and stress the need of well-designed tools to improve the quality of patient care. The acquisition of an accurate and complete clinical history, as well as an improved patient-doctor interaction and the resulting enhanced continuity of care represent valuable advantages at a sustainable cost [16].
DIGITAL HEALTH IN CLINICAL DECISION-MAKING A seminal study published in 2004 suggested that the collection of asthma diary data through a mobile phone and the use of Short Message Service (SMS) as an alert system is a feasible way to support the self-management of asthma in motivated and self-efficacious patients. In 2015, a worldwide consortium, led by Jean Bousquet, proposed an integrated plan for the use of the mobile health technology in the management of allergic rhinitis (MASK, MACVIA-ARIA Sentinel Network for allergic rhinitis) [17]. Other groups have demonstrated that many disease management problems can be solved by using electronic clinical diaries (e-Diary) at no to low costs [18,19]. A software system may even develop automatically clinical scores, which then graphically match a patient’s symptom-medication-score trajectories with those of the local pollen counts [20]. In addition to symptom recording, many medical disciplines take advantage of mHealth technology as part of a Clinical Decision Support System (CDSS), created to assist clinicians as point-of-care technology [21,22]. Similarly, allergists may find advantages in various CDSS using symptom monitoring to facilitate the diagnosis of respiratory allergies [20,23].
POINTS OF CONTACT FOR A BETTER PATIENT MANAGEMENT Different mHealth features have been successfully used to improve patient management, including SMS, apps, telephone and cloud-computing systems. The simplest and by far most diffused tool is the SMS. Randomized controlled studies have proven that SMS alerts are not only well accepted by patients, but also improve adherence to medication and the objectively recorded asthma control test score (ACT). These studies suggested that an SMS service might be more effective than conventional telephone-call management [24]. It may also improve the perceived control of asthma and quality of life [25], as well as adherence to treatment [26]. Our group demonstrated a higher adherence to ICS (mometasone) treatment among 30 German children with seasonal allergic rhinitis, compared to 31 controls receiving usual care, as they could record their symptoms and medication on a eHealth platform (electronic diary) and received SMS alerts (Fig. 18.2) [27]. Similarly, a Swedish study has shown that the nasal, eye and lower airway symptoms of patients with allergic rhinitis and asthma were lower in the group using SMS reminders and e-diaries, when compared to controls following usual care [28]. Additionally, email or SMS and social media websites have been shown to be very useful tools to facilitate communication between medical staff and asthma patients [29]. SMS can provide useful personalized feedback on medication adherence and may be used to adapt a possible intervention to each patient’s specific need, personal barriers to medication adherence and patterns of medication use [30]. Similarly, teen-agers with asthma had better disease self-management when supported by an SMS alert system [31].
PATIENT-DOCTOR-COMMUNICATION: TELEMEDICINE FACILITATES INTERVENTIONS Telephone consultations and automatic voice recognition as well as response systems facilitate coaching interventions that may improve asthma control and disease-related quality of life while at the same time reducing urgent care events in asthma care [32]. As an intervention, phone consultations were feasible and showed indicators of effectiveness, suggesting the design was well suited for a robust study to evaluate its impact in
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FIGURE 18.2 Estimated frequency (normal approximation) of daily consumption of mometasone in 63 children with hay fever, by allocation to the eHealth platform AllergyMonitor or to usual care. Reprinted with permission from Pizzulli A, Perna S, Florack J et al. (2014) The impact of telemonitoring on adherence to nasal corticosteroid treatment in children with seasonal allergic rhinoconjunctivitis. Clin Exp Allergy 44:1246-1254.
uncontrolled asthma patients. Pharmacists helping patients to manage asthma through telecommunication systems, may resolve access barriers and improve care [33]. The Asthma Control Score (ACS) and the Asthma Action Plan (AAP) actively administered during telephone calls with an operator, were a feasible and accepted strategy for the patients to improve their asthma control without the need for an office visit [34]. A voice response system (Telesage) gave a quantitative and qualitative assessment of asthma symptoms as well as adherence with daily calls to the patient’s mobile phone for one month. These systems were used clinically for problem solving or as feedback to adolescents in a mobile or web-based support system [35]. Speech recognition systems, i.e. automatically tailored calls thanks to the information obtained from the e-record and parents’ answers, can improve adherence to inhaled corticosteroid [36].
MOBILE HEALTH APPS Mobile apps are the third and the most interesting and rapidly expanding technology, which has been recently used and investigated in patients with asthma and allergies. Studies focused on self-management of asthma [6,37 39] as well as doctor- or nurse-driven management of asthma and/or allergic rhinitis [40 42]. Many apps provide tools for daily self-monitoring of symptoms and consequent adjustment of therapy for a better asthma control. Such an app proved also useful in facilitating the implementation of GINA guidelines in the routine management of asthma, producing a better quality of life, less asthma exacerbations and unscheduled visits in patients using it, than in the control group. Hence, mobile telephone based interactive self-care systems may provide convenient and practical tools for self-monitoring and self-management in order to improve asthma control [37]. Asthmatic patients who registered their symptoms and peak flow data daily and automatically received control assessment, advice about treatment and environmental alerts (e.g. air quality), reported that the app was easy to use and asked to continue using it also after the study. Mobile health technology could therefore integrate the asthma action plan and support knowledge at both patient and provider levels [39]. On the contrary, a large randomized, controlled trial, in adolescent and adult British patients with poorly controlled asthma showed no difference in asthma control or self-efficacy among patients using or not using mHealth support [38]. In this trial, however, the “control” patients were using a traditional diary (on paper) and monitoring system, which is extremely time consuming and rarely used in the routine clinical practice. The study demonstrated that “the
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FIGURE 18.3 Trajectories of symptom severity vs pollen counts in two patients with allergic rhinitis living in Ascoli Piceno (Italy). Data on severity of symptoms collected with a SmartPhone app have been reported as Rhinoconjunctivitis Total Symptom Score (RTSS) (Upper graphs: patient 1; Lower graphs: patient 2). Pollen counts (grains/m3) were obtained from the pollen station of Ascoli Piceno. Reprinted with permission from Bianchi A, Tsilochristou O, Gabrielli F et al. (2016) The smartphone: a novel diagnostic tool in pollen allergy? J Investig Allergol Clin Immunol 26:204-207.
diary” itself, and not the way it is realized (on paper or electronic, traditional or innovative), is essential for a treatment success. Another study, allowed patients to answer a questionnaire on asthma to record daily symptoms and medication, to record an attack and the respective trigger, to receive alerts about medication and monitor drug intake and addressed improvement in the management of the asthmatic patients [6]. Interestingly, some apps have recently been specifically designed to facilitate communication between the doctor (or the nurse) and the patient with asthma [41] while others are useful in improving adherence to sublingual immunotherapy
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(SLIT) [40] and predicting symptoms exacerbations in poly-sensitized patients with pollen allergy [42]. Apps specifically dedicated to the management of pollen allergic patients have been proven to be useful in the etiological diagnosis of the pollen responsible for the seasonal symptoms. The diagnosis is based on the comparison of Rhinoconjuctivitis Total Symptom Score (RTSS) with the trajectories of the pollen counts recorded by the local aerobiological service. Such a comparison can guide the physician in the choice of the correct composition of pollen-specific immunotherapy. This approach is particularly important in southern European countries, where poly-sensitized patients react to pollen with overlapping seasonality (Fig. 18.3) [43].
LIMITATIONS FOR THE USE OF EHEALTH DEVICES While the euphoria about new technology is often big, especially among users, the enormous advantages of new technologies should always be matched against their potential or real disadvantages and limitations. A telephone will never substitute the power of a direct human contact between patient and medical worker [40]. While it is clear to doctors that a face-to-face visit is indispensable for the diagnostic decision-making, treatment prescription and outcome evaluation, many patients prefer to seek dubious advice in online communities. It must remain clear that this cannot replace a thorough clinical examination including inspection, palpation, percussion, auscultation, and comprehensive analysis before diagnosis. As this cannot be done entirely remotely, it represents a limiting factor of telemedicine. Also the monitoring and interventional abilities of digital health devices may be limited, as it has been shown during a short-term study analyzing the remote support via SMS. This tool was not able to reduce the number of visits to the emergency department or hospital admissions [24]. A potential reason for this outcome was the fact that especially older patients were not sufficiently familiar with the use of a mobile phone or did not speak English. A study with similar results among pediatric patients assumed that the SMS procedure may have been too complicated and time-consuming for children and their parents [28]. Among a study population of urban African-American emerging adults, some patients reported confusion with event-based SMS [30]. Chinese academics found no significant differences in the changes of FEV1% and sputum eosinophil as well as neutrophil counts after using SMS technology in asthma patients [25]. As mentioned before, Ryan et al. could also not confirm any advantage in terms of clinical support or cost effectiveness when comparing digital to paper diaries [38]. But also the availability of digital services may represent a limiting factor. For example, many students may not able to use their mobile phone at school [35] or medical staff may not have enough time to accept calls or reply using SMS [41]. Another crucial limitation is frequent difficulties in terms of compatibility between mobile technologies and the informatics system run by a hospital or private practice. If this compatibility is not achieved, it may increase significantly the workload of medical workers instead of simplifying patient management [41].
CONCLUSIONS Studies on the impact of eHealth in asthma and allergies are still few. Mobile health technology has an enormous potential and may be in the future a feasible, cost-effective and useful tool not only for allergic diseases, but also for many other medical disciplines. Still, many technical issues such as compatibility and legal aspects concerning data security remain to be studied and hopefully solved along with this rapid technological evolution. It is also fundamental to involve public health departments to provide all relevant information for patients suffering from allergies and asthma in a regularly and dynamically (ideally real-time) updated manner. Governmental funding, adequate coordination and clinical studies are required to identify the best and most sustainable use of mobile phone technologies for all patients.
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[15] World Health Organisation (2016) Global diffusion of eHealth: Making universal health coverage achievable. Report of the third global survey on eHealth. http://www.who.int/goe/publications/global_diffusion/en/ (Last accessed on: 19 February, 2018). [16] Elliott T, Shih J, Dinakar C, et al. American college of allergy, asthma & immunology position paper on the use of telemedicine for allergists. Ann Allergy Asthma Immunol 2017;119:512 17. [17] Bousquet J, Schunemann HJ, Fonseca J, et al. MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation. Allergy 2015;70:1372 92. [18] Florack J, Brighetti MA, Perna S, et al. Comparison of six disease severity scores for allergic rhinitis against pollen counts a prospective analysis at population and individual level. Pediatr Allergy Immunol 2016;27:382 90. [19] Perry TT, Marshall A, Berlinski A, Rettiganti M, Brown RH, Randle SM, et al. Smartphone-based vs paper-based asthma action plans for adolescents. Ann Allergy Asthma Immunol. 2017;118:298 303. [20] Bastl K, Kmenta M, Pessi AM, Prank M, Saarto A, Sofiev M, et al. First comparison of symptom data with allergen content (Bet v 1 and Phl p 5 measurements) and pollen data from four European regions during 2009-2011. Sci Total Environ 2016,1;548-549:229 35. [21] Guo Y, Chen Y, Lane DA, et al. Mobile health technology for atrial fibrillation management integrating decision support, education, and patient involvement: mAF App trial. Am J Med 2017;130:1388 96. [22] Kharbanda AB, Madhok M, Krause E, Vazquez-Benitez G, Kharbanda EO, Mize W, et al. Implementation of electronic clinical decision support for pediatric appendicitis. Pediatrics 2016;137:5. [23] Bousquet J, Schu¨nemann HJ, Hellings PW, et al. MACVIA clinical decision algorithm in adolescents and adults with allergic rhinitis. J Allergy Clin Immunol 2016;138:367 74. [24] Prabhakaran L, Chee WY, Chua KC, et al. The use of text messaging to improve asthma control: a pilot study using the mobile phone short messaging service (SMS). J Telemed Telecare 2010;16:286 90. [25] Lv Y, Zhao H, Liang Z, et al. A mobile phone short message service improves perceived control of asthma: a randomized controlled trial. Telemed J E Health 2012;18:420 6. [26] De Vera MA, Sadatsafavi M, Tsao NW, et al. Empowering pharmacists in asthma management through interactive SMS (EmPhAsIS): study protocol for a randomized controlled trial. Trials 2014;15:488. [27] Pizzulli A, Perna S, Florack J, et al. The impact of telemonitoring on adherence to nasal corticosteroid treatment in children with seasonal allergic rhinoconjunctivitis. Clin Exp Allergy 2014;44:1246 54. [28] Aberg N, Dahl A, Benson M. A nasally applied cellulose powder in seasonal allergic rhinitis (SAR) in children and adolescents; reduction of symptoms and relation to pollen load. Pediatr Allergy Immunol 2011;22:594 9. [29] Baptist AP, Thompson M, Grossman KS, et al. Social media, text messaging, and email-preferences of asthma patients between 12 and 40 years old. J Asthma 2011;48:824 30. [30] MacDonell K, Gibson-Scipio W, Lam P, et al. Text messaging to measure asthma medication use and symptoms in urban African American emerging adults: a feasibility study. J Asthma 2012;49:1092 6. [31] Britto MT, Munafo JK, Schoettker PJ, et al. Pilot and feasibility test of adolescent-controlled text messaging reminders. Clin Pediatr (Phila) 2012;51:114 21. [32] Garbutt JM, Highstein G, Yan Y, et al. Partner randomized controlled trial: study protocol and coaching intervention. BMC Pediatr 2012;12:42. [33] Young HN, Havican SN, Griesbach S, et al. Patient and phaRmacist telephonic encounters (PARTE) in an underserved rural patient population with asthma: results of a pilot study. Telemed J E Health 2012;18:427 33. [34] Raju JD, Soni A, Aziz N, et al. A patient-centered telephone intervention using the asthma action plan. Fam Med 2012;44:348 50. [35] Mulvaney SA, Ho YX, Cala CM, et al. Assessing adolescent asthma symptoms and adherence using mobile phones. J Med Internet Res 2013;15:e141. [36] Bender BG, Cvietusa PJ, Goodrich GK, et al. Pragmatic trial of health care technologies to improve adherence to pediatric asthma treatment: a randomized clinical trial. JAMA Pediatr 2015;169:317 23. [37] Liu WT, Huang CD, Wang CH, et al. A mobile telephone-based interactive self-care system improves asthma control. Eur Respir J 2011;37:310 17.
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[38] Ryan D, Price D, Musgrave SD, et al. Clinical and cost effectiveness of mobile phone supported self monitoring of asthma: multicentre randomised controlled trial. BMJ 2012;344:e1756. [39] Licskai C, Sands TW, Ferrone M. Development and pilot testing of a mobile health solution for asthma self-management: asthma action plan smartphone application pilot study. Can Respir J 2013;20:301 6. [40] Tripodi S, Comberiati P, Di Rienzo Businco A. A web-based tool for improving adherence to sublingual immunotherapy. Pediatr Allergy Immunol 2014;25:611 12. [41] Haze KA, Lynaugh J. Building patient relationships: a smartphone application supporting communication between teenagers with asthma and the RN care coordinator. Comput Inform Nurs 2013;31:266 71 quiz 272-263. [42] Costa C, Menesatti P, Brighetti MA, et al. Pilot study on the short-term prediction of symptoms in children with hay fever monitored with e-Health technology. Eur Ann Allergy Clin Immunol 2014;46:216 25. [43] Bianchi A, Tsilochristou O, Gabrielli F, et al. The smartphone: a novel diagnostic tool in pollen allergy? J Investig Allergol Clin Immunol 2016;26:204 7.
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18 Telemedicine and Mobile Health Technology in the Diagnosis, Monitoring and Treatment of Respiratory Allergies Stephanie Hofmaier1, Xinyuan Huang2 and Paolo Maria Matricardi1 1
Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charite´ Medical University, Berlin, Germany 2Department of Pediatric, Shengzhou People’s Hospital, Zhejiang, China
Allergic rhinitis and asthma are very common diseases, estimated to affect over 300 million individuals around the globe. Often under-diagnosed and under-treated, they create a substantial burden to individuals and families, while restricting a patient’s activities possibly for his or her lifetime [1]. Most asthmatics suffer also from allergic rhinitis (AR) [2], a common chronic disease with an often significant negative impact on the quality of life (QOL). The level of AR control remains inadequate for many patients [3]. Patients with asthma and/or AR can take systemic drugs and/or inhaled corticosteroids (ICS) to reduce inflammation, as well as beta-2 agonists or antihistamines to alleviate their symptoms. Still, they suffer from the disease recurrently when not taking their medication. Many patients need ICS for a long time, but they often forget to take them until their symptoms urge them to do so. Poor adherence to medication leads to worse treatment outcomes, higher hospitalization rates, and increased health care costs [4]. Therefore, patients with asthma and/or AR need education programs to achieve adequate adherence to medication [5]. To control asthma and AR, patients should also monitor their symptoms, avoid triggers, and follow their treatment plan [6]. Successful asthma treatment can be largely attributed to education, not only to medication. The education of patients and health professionals on the proper use of inhalers is one of the mainstays for the treatment of asthma, especially in the pediatric population [7]. The traditional education method is face to face between patient and general practitioner, nurse or medical professional. Although every patient should be directly seen by a doctor, some patients with minor disorders try self-medication, without consideration of it being adequate or not. On the other hand, many patients with chronic diseases who do see a doctor, have a poor adherence to the prescribed medicine after their visits [8 10]. Strategies to improve the patient’s adherence to prescription are therefore essential in the management of chronic disease and asthma.
THE EVOLUTION OF MOBILE TECHNOLOGY IN HEALTHCARE Since the 1980s, mobile technology has allowed not only real-time bilateral voice communication, but also realtime bilateral transmission of written messages. In recent years, smartphones have incorporated also media players, a camera with flash (flashlight), video cameras, GPS navigation/geolocalisation, NFC (Near Field Communication), gravity sensor level meter, and other technologies, making them feature-rich devices. Today, high-resolution touch screens and web browsers can display also standard web pages and mobile-optimized content. Through Wi-Fi and mobile broadband, smartphones can achieve high-speed data throughput and allow
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cloud computing as a standard. While email has become common on mobile devices, stable connections among various phones or with other electronic devices via Bluetooth, Wi-Fi or mobile internet also make data transfer an easy task. Mobile applications (“apps”) employ increasingly intelligent functions and are used in many areas of life. Accordingly, the mobile app market underwent a rapid development in the areas of mobile commerce, game industry, and social real-time communication networks. In parallel, the worldwide smartphone sales volume is enormous (over 1,200 million units in 2014) [11]. Mobile phone has become an important device in day-today life, allowing a continuous and real-time transfer of data independently from the user’s location [12]. This world of mobile technology is rapidly expanding and it is changing many aspects of our daily life. The dramatic increase in the ownership of cellphones and smartphones has resulted in a plethora of mobile health (mHealth) applications, which are becoming increasingly popular among physicians, patients and the general public. mHealth utilizes mobile devices to carry out the task of viewing electronic medical records, reserving appointments with a patient’s medical provider and electronically refilling prescriptions. The term is most commonly used in reference to using mobile communication devices, such as mobile phones, tablet computers and PDAs, for health services and information [13]. Already in 2012, estimations predicted the mobile phone with health applications to become the most popular health service device in the world [14]. Many apps for allergists aim at forecasting symptoms and allergen exposure in addition to providing expert systems, remote monitoring, allergy management, patient or doctor education, and guideline implementation. This new world is particularly attractive for younger patients and younger doctors.
RECOGNITION OF EHEALTH INNOVATIONS BY MEDICAL ASSOCIATIONS The World Health Organization (WHO) is continuously following and reporting globally on new developments of mobile technology in the healthcare sector (Fig. 18.1) [15]. In addition, a toolkit for the development of National eHealth Roadmaps has been created in order to support the member states in developing their own eHealth strategies. As the evaluation of existing eHealth programs is also fundamental, the Global Observatory for eHealth (GOe) and partner institutions are aiming to build up an evaluation framework, providing concrete measurable indicators. A global database with concise information on research findings in the digital health sector will be built, including a particular focus on developing countries’ initiatives. This pool of knowledge will be
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FIGURE 18.1 Percentage of countries with each mHealth program type by established, pilot or informal phase. Reprinted with permission from World Health Organisation (2016) Global diffusion of eHealth: Making universal health coverage achievable. Report of the third global survey on eHealth. http://www.who.int/goe/publications/global_diffusion/en/ (Last accessed on: 19 February, 2018).
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accessible to all member states of the WHO to facilitate project planning, as well as the preparation of new proposals. Also at a national level, the importance of eHealth is well known. Recently, the American College of Allergy, Asthma and Immunology (ACAAI) published a position paper on the use of telemedicine for allergists. [16] In this document, the ACAAI underlines the importance of investigations in the relatively new area of telemedicine and depicts the advantages and limitations of a new approach to allergy care. The authors foresee an increase in the demand of mHealth services and stress the need of well-designed tools to improve the quality of patient care. The acquisition of an accurate and complete clinical history, as well as an improved patient-doctor interaction and the resulting enhanced continuity of care represent valuable advantages at a sustainable cost [16].
DIGITAL HEALTH IN CLINICAL DECISION-MAKING A seminal study published in 2004 suggested that the collection of asthma diary data through a mobile phone and the use of Short Message Service (SMS) as an alert system is a feasible way to support the self-management of asthma in motivated and self-efficacious patients. In 2015, a worldwide consortium, led by Jean Bousquet, proposed an integrated plan for the use of the mobile health technology in the management of allergic rhinitis (MASK, MACVIA-ARIA Sentinel Network for allergic rhinitis) [17]. Other groups have demonstrated that many disease management problems can be solved by using electronic clinical diaries (e-Diary) at no to low costs [18,19]. A software system may even develop automatically clinical scores, which then graphically match a patient’s symptom-medication-score trajectories with those of the local pollen counts [20]. In addition to symptom recording, many medical disciplines take advantage of mHealth technology as part of a Clinical Decision Support System (CDSS), created to assist clinicians as point-of-care technology [21,22]. Similarly, allergists may find advantages in various CDSS using symptom monitoring to facilitate the diagnosis of respiratory allergies [20,23].
POINTS OF CONTACT FOR A BETTER PATIENT MANAGEMENT Different mHealth features have been successfully used to improve patient management, including SMS, apps, telephone and cloud-computing systems. The simplest and by far most diffused tool is the SMS. Randomized controlled studies have proven that SMS alerts are not only well accepted by patients, but also improve adherence to medication and the objectively recorded asthma control test score (ACT). These studies suggested that an SMS service might be more effective than conventional telephone-call management [24]. It may also improve the perceived control of asthma and quality of life [25], as well as adherence to treatment [26]. Our group demonstrated a higher adherence to ICS (mometasone) treatment among 30 German children with seasonal allergic rhinitis, compared to 31 controls receiving usual care, as they could record their symptoms and medication on a eHealth platform (electronic diary) and received SMS alerts (Fig. 18.2) [27]. Similarly, a Swedish study has shown that the nasal, eye and lower airway symptoms of patients with allergic rhinitis and asthma were lower in the group using SMS reminders and e-diaries, when compared to controls following usual care [28]. Additionally, email or SMS and social media websites have been shown to be very useful tools to facilitate communication between medical staff and asthma patients [29]. SMS can provide useful personalized feedback on medication adherence and may be used to adapt a possible intervention to each patient’s specific need, personal barriers to medication adherence and patterns of medication use [30]. Similarly, teen-agers with asthma had better disease self-management when supported by an SMS alert system [31].
PATIENT-DOCTOR-COMMUNICATION: TELEMEDICINE FACILITATES INTERVENTIONS Telephone consultations and automatic voice recognition as well as response systems facilitate coaching interventions that may improve asthma control and disease-related quality of life while at the same time reducing urgent care events in asthma care [32]. As an intervention, phone consultations were feasible and showed indicators of effectiveness, suggesting the design was well suited for a robust study to evaluate its impact in
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FIGURE 18.2 Estimated frequency (normal approximation) of daily consumption of mometasone in 63 children with hay fever, by allocation to the eHealth platform AllergyMonitor or to usual care. Reprinted with permission from Pizzulli A, Perna S, Florack J et al. (2014) The impact of telemonitoring on adherence to nasal corticosteroid treatment in children with seasonal allergic rhinoconjunctivitis. Clin Exp Allergy 44:1246-1254.
uncontrolled asthma patients. Pharmacists helping patients to manage asthma through telecommunication systems, may resolve access barriers and improve care [33]. The Asthma Control Score (ACS) and the Asthma Action Plan (AAP) actively administered during telephone calls with an operator, were a feasible and accepted strategy for the patients to improve their asthma control without the need for an office visit [34]. A voice response system (Telesage) gave a quantitative and qualitative assessment of asthma symptoms as well as adherence with daily calls to the patient’s mobile phone for one month. These systems were used clinically for problem solving or as feedback to adolescents in a mobile or web-based support system [35]. Speech recognition systems, i.e. automatically tailored calls thanks to the information obtained from the e-record and parents’ answers, can improve adherence to inhaled corticosteroid [36].
MOBILE HEALTH APPS Mobile apps are the third and the most interesting and rapidly expanding technology, which has been recently used and investigated in patients with asthma and allergies. Studies focused on self-management of asthma [6,37 39] as well as doctor- or nurse-driven management of asthma and/or allergic rhinitis [40 42]. Many apps provide tools for daily self-monitoring of symptoms and consequent adjustment of therapy for a better asthma control. Such an app proved also useful in facilitating the implementation of GINA guidelines in the routine management of asthma, producing a better quality of life, less asthma exacerbations and unscheduled visits in patients using it, than in the control group. Hence, mobile telephone based interactive self-care systems may provide convenient and practical tools for self-monitoring and self-management in order to improve asthma control [37]. Asthmatic patients who registered their symptoms and peak flow data daily and automatically received control assessment, advice about treatment and environmental alerts (e.g. air quality), reported that the app was easy to use and asked to continue using it also after the study. Mobile health technology could therefore integrate the asthma action plan and support knowledge at both patient and provider levels [39]. On the contrary, a large randomized, controlled trial, in adolescent and adult British patients with poorly controlled asthma showed no difference in asthma control or self-efficacy among patients using or not using mHealth support [38]. In this trial, however, the “control” patients were using a traditional diary (on paper) and monitoring system, which is extremely time consuming and rarely used in the routine clinical practice. The study demonstrated that “the
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FIGURE 18.3 Trajectories of symptom severity vs pollen counts in two patients with allergic rhinitis living in Ascoli Piceno (Italy). Data on severity of symptoms collected with a SmartPhone app have been reported as Rhinoconjunctivitis Total Symptom Score (RTSS) (Upper graphs: patient 1; Lower graphs: patient 2). Pollen counts (grains/m3) were obtained from the pollen station of Ascoli Piceno. Reprinted with permission from Bianchi A, Tsilochristou O, Gabrielli F et al. (2016) The smartphone: a novel diagnostic tool in pollen allergy? J Investig Allergol Clin Immunol 26:204-207.
diary” itself, and not the way it is realized (on paper or electronic, traditional or innovative), is essential for a treatment success. Another study, allowed patients to answer a questionnaire on asthma to record daily symptoms and medication, to record an attack and the respective trigger, to receive alerts about medication and monitor drug intake and addressed improvement in the management of the asthmatic patients [6]. Interestingly, some apps have recently been specifically designed to facilitate communication between the doctor (or the nurse) and the patient with asthma [41] while others are useful in improving adherence to sublingual immunotherapy
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(SLIT) [40] and predicting symptoms exacerbations in poly-sensitized patients with pollen allergy [42]. Apps specifically dedicated to the management of pollen allergic patients have been proven to be useful in the etiological diagnosis of the pollen responsible for the seasonal symptoms. The diagnosis is based on the comparison of Rhinoconjuctivitis Total Symptom Score (RTSS) with the trajectories of the pollen counts recorded by the local aerobiological service. Such a comparison can guide the physician in the choice of the correct composition of pollen-specific immunotherapy. This approach is particularly important in southern European countries, where poly-sensitized patients react to pollen with overlapping seasonality (Fig. 18.3) [43].
LIMITATIONS FOR THE USE OF EHEALTH DEVICES While the euphoria about new technology is often big, especially among users, the enormous advantages of new technologies should always be matched against their potential or real disadvantages and limitations. A telephone will never substitute the power of a direct human contact between patient and medical worker [40]. While it is clear to doctors that a face-to-face visit is indispensable for the diagnostic decision-making, treatment prescription and outcome evaluation, many patients prefer to seek dubious advice in online communities. It must remain clear that this cannot replace a thorough clinical examination including inspection, palpation, percussion, auscultation, and comprehensive analysis before diagnosis. As this cannot be done entirely remotely, it represents a limiting factor of telemedicine. Also the monitoring and interventional abilities of digital health devices may be limited, as it has been shown during a short-term study analyzing the remote support via SMS. This tool was not able to reduce the number of visits to the emergency department or hospital admissions [24]. A potential reason for this outcome was the fact that especially older patients were not sufficiently familiar with the use of a mobile phone or did not speak English. A study with similar results among pediatric patients assumed that the SMS procedure may have been too complicated and time-consuming for children and their parents [28]. Among a study population of urban African-American emerging adults, some patients reported confusion with event-based SMS [30]. Chinese academics found no significant differences in the changes of FEV1% and sputum eosinophil as well as neutrophil counts after using SMS technology in asthma patients [25]. As mentioned before, Ryan et al. could also not confirm any advantage in terms of clinical support or cost effectiveness when comparing digital to paper diaries [38]. But also the availability of digital services may represent a limiting factor. For example, many students may not able to use their mobile phone at school [35] or medical staff may not have enough time to accept calls or reply using SMS [41]. Another crucial limitation is frequent difficulties in terms of compatibility between mobile technologies and the informatics system run by a hospital or private practice. If this compatibility is not achieved, it may increase significantly the workload of medical workers instead of simplifying patient management [41].
CONCLUSIONS Studies on the impact of eHealth in asthma and allergies are still few. Mobile health technology has an enormous potential and may be in the future a feasible, cost-effective and useful tool not only for allergic diseases, but also for many other medical disciplines. Still, many technical issues such as compatibility and legal aspects concerning data security remain to be studied and hopefully solved along with this rapid technological evolution. It is also fundamental to involve public health departments to provide all relevant information for patients suffering from allergies and asthma in a regularly and dynamically (ideally real-time) updated manner. Governmental funding, adequate coordination and clinical studies are required to identify the best and most sustainable use of mobile phone technologies for all patients.
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