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Health care in a technological world

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Health care in a technological world
Danny Meetoo, Rebecca Rylance, Hanan Abdulrahman Abuhaimid
ABSTRACT
Ongoing innovation in the field of mobile health (mHealth) has the potential
to change the landscape of healthcare practice both inside and outside
formal clinical settings. mHealth could enhance patient education, prevent
disease, improve diagnosis and research-based treatment, reduce healthcare
costs and enable patients to manage long-term conditions. In addition,
unimpeded by geographical distance, smartphone-linked wearable sensors,
built around real-time connectivity, will improve communication between
health professionals and improve the understanding of physiological
N
variability, thereby improving clinical decisions and quality of care. However,
despite the potential of mHealth, there are still significant information
gaps regarding its long-term effects, acceptability, costs and risks. There is
therefore a significant need for continued research to evaluate the functions
and appropriateness of these medical devices that are slowly entering the
healthcare arena, while not neglecting the rights of the individual.
Key words: eHealth  ■ mHealth  ■ Medical devices  ■ Smartphone ■ Apps
■ Sensor  ■ Remote care  ■ Ethics
H
ealth care in the 21st century is witnessing
remarkable technological developments,
BJ
including powerful, portable computing devices.
Alongside these innovations, global connection
methods are being made, including broadband
and satellite technologies, resulting in an ever-increasing number
of ‘connected users’ that can share information.Within the care
industry, the emergence of mobile healthcare (mHealth) is the
consequence of the intersection of concurrent issues such as:
■ An urgent need to address the rising tide of chronic
conditions
■ Moore’s law, which proposes that the exponential increase
in computing power results in the development of smaller
and cheaper mobile electronics (Moore, 1985)
■ Healthcare models shifting to increasingly patient-centric
designs (Topol, 2010).
The development of progressively miniaturised and
increasingly powerful mobile computing capabilities has enabled
individuals to become more able to monitor, track and transmit
Danny Meetoo, Programme Leader, MSc Diabetes Care,
University of Salford, D.Meetoo@salford.ac.uk
Rebecca Rylance, Assistant Director, Health Directorate, School
of Health and Society, University of Salford
Hanan Abdulrahman Abuhaimid, Head of Nursing Education and
Training Department, Nursing Administration, Riyadh Health Affairs
Accepted for publication: October 2018
1172
health metrics continuously and in real time. This has the
potential to redefine acute disease diagnosis and to move the
management of long-term condition away from the GP surgery
or hospital into the home.
Defining mHealth
Nurses have opportunities to empower patients to manage their
care proactively by increasing awareness and use of mHealth
technologies in preventive care. In teaching these skills to patients
to help them manage a healthy lifestyle it is important that nurses
understand both the potential and the limitations of mHealth
technologies as well as the ethical principles. It is against this
backdrop that this article aims to define and review mHealth
along with other technological advances in health care.
A universally accepted definition of mHealth has yet to be
established. For the purpose of this article, the World Health
Organization (WHO) definition has been adopted, which has
defined it as:
‘…the medical and public health practice
supported by mobile devices, such as mobile
phones, patient monitoring devices, personal
digital assistants (PDAs), and other
wireless devices’.
(WHO Global Observatory for eHealth 2011: 6)
In addition to the mobile devices mentioned in this definition,
smartphones, portable media players and tablet computers can
be used in mHealth (Free et al, 2013). The functions of these
devices as used in health care include but are not limited to
text messaging (short message services/SMS), paging, automated
sensing, mobile applications (apps), video conferencing and
media capabilities such as seeking information online and being
able to play podcasts/videos (Klasnja and Pratt, 2012; Free et
al, 2013).
The use of these devices at the point of care (Meetoo and
Wong, 2015) is changing how healthcare is delivered from one
that is generated by health systems to one that is remote and
generated by patients (Kumar et al, 2013; Topol et al, 2015).
These factors culminate to offer unparalleled opportunities
to increase patient engagement, reduce healthcare costs and
improve outcomes (Silva et al, 2015).
As technologies are developed, how data are transferred
needs consideration, especially around how information derived
from mHealth devices is integrated into clinical workflows.
© 2018 MA Healthcare Ltd
A closed data loop is usually necessary. This involves a cycle
initiated by the patient or provider, followed by internet/cloud-
based data transfer, interpretation of these findings or automated
algorithms, and the data being returned to the patient and
provider for clinical decisions (Figure 1).
British Journal of Nursing, 2018, Vol 27, No 20
 TECHNOLOGY

Transfer of health information

between patient and practitioners

Patient Patient Cloud-based Healthcare Practitioner

interpretation self-measurement data transfer practitioner interpretation

Automated diagnostic
algorithms

N Source: Bhavnani (2016)

Figure 1. Closed loop data flow for clinical care

Overview of apps
Apps have become commonplace over the past 5 years, fuelled
by the widespread availability of tablets and smartphones.Tens
of thousands of health, wellness and medical apps are available
for download to devices from online stores (Aitken, Gauntlett,
2013). Harnessing the power of apps for health care has become
a focal point of innovation, particularly those that can be used
by patients or other consumers as part of their wellness,
prevention or treatment strategies.
BJ
A mobile application (or mobile app) is a software application
that runs on smartphones, tablets and other mobile devices.
They are available through application distribution platforms,
which are typically operated by the owner of the mobile
operating system, such as the Apple App Store, Google Play
(Android), Windows Phone Store and BlackBerry AppWorld.
At present, it is estimated that the majority of smartphone users
around the world have more than 20 apps on their device but
this is closer to 30 in many cases; gaming apps and social media
apps such as Facebook command the most of users’ time (Aitken
and Gauntlett, 2013).
Digital devices
While there is a great deal of interest in apps and enthusiasm
for their use, they have not yet become part of mainstream
healthcare provision. Nurses should therefore embrace the
contribution that digital devices can make to improving care
in a timely, cost-effective manner.
Research and development continue to produce miniaturised
and powerful digital devices designed to solve clinical problems.
In the context of this article, five mHealth technologies will
be briefly described:
© 2018 MA Healthcare Ltd
Smartphone-connected rhythm
monitoring devices
One example of smartphone-connected rhythm monitoring
devices approved for use in the US and the European Union
is the iECG, a smartphone case that incorporates electrodes for
wireless cardiac telemetry monitoring.This creates a real-time
display of the cardiac rhythm by converting an electrical signal
into ultrasound, which is then captured by the smartphone’s
microphone; this provides practitioners with an immediate
rhythm analysis of atrial fibrillation. The iECG is particularly
useful for patients at high risk of developing an arrhythmia, as
it captures subclinical atrial arrhythmia in real time for prompt
clinical decisions in the prevention of cryptogenic stroke (Kamel,
2014).
Although the iECG is not designed to be a continuous
rhythm monitor, its relatively low cost (£70–90 or US$70–90)
and the high proportion of patients who own smartphones
make it a potentially practical alternative for monitoring
individuals at high risk over the long term (Saxon et al, 2012).
Plans for its development include extending the single-lead
monitor to multiple iECG leads for remote monitoring of
acute coronary syndrome (Muhlestein et al, 2015).
Wearable sensors
Engineers have designed and developed a wide variety of
wearable biometric sensors, such as bracelets, watches, skin
patches, headbands, earphones and clothing. Although these
sensors take many forms and have numerous functions, their
unifying aim is to enable individuals to undertake unobtrusive,
passive and, when appropriate, continuous monitoring.
A key feature of these devices is their ability to seamlessly

■■ Smartphone-connected devices track and transfer all biometric data into an informative,
■■ Wearable sensors actionable user interface that can be shared with healthcare
■■ Lab-on-a-chip providers, researchers, family members or social networks.
■■ Implantable and ingestible sensors The potential capabilities of wrist-worn sensors alone are
■■ Electronic health records (EHRs) (Walsh et al, 2014). illustrated by developers reporting that they could be used to

British Journal of Nursing, 2018, Vol 27, No 201173

 measure more than a dozen biometric parameters continuously.
Many commercially available devices allow individuals to
determine their cardiac rhythm via a single-lead electrocardiogram
(ECG) by using their smartphone for rhythm capture or by
wearing a patch for prolonged continuous rhythm tracking
(Barrett et al, 2014).
The approach to monitoring blood pressure will likely be
changed by technology, with photoplethysmography replacint
the inflatable cuff. Devices using this technique, which will be
invaluable in intensive care units, will be able to detect blood
volume changes in tissue microvasculature and pulse transition
time and permit more frequent or even continuous blood
pressure tracking (Henry et al, 2011). Of interest is the family
of sensors that have been developed around abilities to monitor
autonomic nervous system function, electrodermal metrics or
galvanic skin response and/or heart rate variability, with the
goal of providing objective data of individual daily variations
in levels of emotional stress and anxiety (Poh et al, 2010).
N Other notable examples of sensor technologies under
development will allow a more personalised understanding of
people’s daily response to the environment. These include
technologies that track sleep stages and disruptions (Verbraecken,
2013), monitor respiratory diseases (McLean et al, 2012) and
continuously track blood glucose concentrations (Hu et al, 2013).
Lab-on-a-chip
Beyond sensor capabilities, the processing power and connectivity
offered by smartphones allow a range of medical testing to be
taken out of the specialised core laboratory and brought directly
to the individual. A combination of microfluidics and
BJ
microelectronics allows for the ‘digitisation’ of sweat, blood,
saliva, urine, tears and breath (Sackmann et al, 2014). These
offer entirely new diagnostic capabilities that would be accessible
virtually anywhere at any time, especially in low-resource sectors
of low-income countries (Chin et al, 2011).
Furthermore, smartphone-linked genetic diagnostics are
being designed to enable rapid, accurate point-of-care
identification of a wide range of pathogens. Future applications
include clinical measurements and fields of study, such as
pharmacogenomics, where rapid genetic diagnosis would be
beneficial (Stedtfeld et al, 2012).
Ingestible and implantable sensors
Unlike the modern, technologically loaded motor vehicle that
is equipped with sensors that inform the driver about matters
out of view, the human body does not have similar alert
mechanisms to monitor internal physiological functions. However,
some implantable biosensors are available that behave as a ‘fuel
gauge’ by transmitting internal measurements of physiological
function (Chen et al, 2014; Gurun et al, 2014), such as those
used in patients with heart failure (Abraham et al, 2011).
Ingestible sensors
Ingestible sensing capsules are fast emerging as a critical
technology that has the ability to greatly affect health, nutrition
and clinical areas (Kalantar-Zadeh et al, 2017).
The passage of ingestible sensors through the gut lumen
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gives them access to each organ of the gastrointestinal tract.
With widespread access to smartphones connected to the
internet, the data produced by this technology can be readily
seen and reviewed online, and accessed by both patients and
physicians.The outputs provide invaluable information to reveal
the state of gut health and disorders as well as the impact of
food, food supplements, medication and environmental changes
on the gastrointestinal tract.
Ingestible sensors offer the ability to gather images and
monitor luminal fluid and the contents of each gut segment
including electrolytes, enzymes, metabolites, hormones and
microbial communities. As such, an incredible wealth of
knowledge regarding the functionality and state of health of
individuals through key gut biomarkers can be obtained.
Implantable sensors
Implantable sensors (IS) act as a ‘fuel gauge’ by transmitting
internal measurements of physiological function in a step
towards digitising the human body (Chen et al, 2014; Gurun
et al, 2014).
These can be used, for example, in monitoring adherence
to prescribed therapy. Evidence suggests that 60% of patients
with cardiovascular diseases are non-adherent to medications,
which contributes to symptom recurrence and adverse outcomes
(Baroletti and Dell’Orfano, 2010). A novel ingestible wireless
sensor (Proteus Digital) has therefore been developed (Kalantar-
Zadeh et al, 2017) to monitor medication adherence (DiCarlo
et al, 2012). This device has two major components: an edible
integrated circuit sensor; and a wearable receiver patch.
Activation by gastric fluids generates a voltage between two
electrodes, which is transmitted to an overlying abdominal
patch the size of a sticking plaster.The digital data is transferred
to a smartphone application and a cloud-based platform for
review by patients and practitioners.The safety and performance
of this networked sensor system has been evaluated in patients
with hypertension and heart failure and has demonstrated a
positive detection accuracy of 97%, with false signals observed
in 2% of ingestions (Au-Yeung et al, 2011).
These sensors may be most effective where there is the
greatest need to monitor adherence, and among patients where
non-adherence risks adverse outcomes. Examples include:
patients who have heart failure and are at high risk of readmission,
who are taking diuretics or beta-blockers; patients with atrial
fibrillation who are at increased risk of bleeding or
thromboembolic complications and are taking anticoagulation
therapy; and among those receiving dual antiplatelet therapy,
to reduce the risk of stent thrombosis (Bhavnani et al, 2016).
Electronic health records (EHRs)
Healthcare practice is gradually moving from a predominantly
paper-based environment to one that is mainly electronic or
paper light. To support this, a variety of computer and
© 2018 MA Healthcare Ltd
information technologies are being adopted and implemented
by and for providers, administrators and consumers in the
healthcare industry. Electronic health records (EHRs) are a key
part of this (Adler-Milstein et al, 2015). Although an
internationally accepted definition is lacking, an EHR is
British Journal of Nursing, 2018, Vol 27, No 20

considered to mean a digital, longitudinal record of a patient’s
health and health care that can be shared by healthcare providers
(Black et al, 2011). This technology is widely viewed as being
central to modernising organisations and delivering sustainable,
high-quality health care. There is no doubt that healthcare
providers of the future will be required to use EHRs.
Approaches to the deployment of EHRs vary from home-
grown systems in single organisations that have the technical
and managerial capacity to the adoption of interoperable
standards for linking multiple IT systems.
Despite the widespread dissemination of this technology, the
integration of EHRs into healthcare systems remains a global
challenge (Luchenski et al, 2013).The uptake of EHRs in hospitals
has tended to be slow (Jha et al, 2009; Luchenski et al, 2013).
A number of issues pose a challenge to EHRs, from technical
issues such as access speeds and content lag to the inevitable
interruptions caused by technological malfunction.To this end,
while it would be reasonable to suggest that EHRs are a means
N to strengthen communication between healthcare providers
(Krist, 2015; O’Malley et al, 2015), more work is necessary to
improve how well they function.
Until EHRs become commonly used, nurses should be
equipped to advocate for improvement in:
‘…areas of integrated practice registries, care
management software integration, whole-person
oriented care plans, and longitudinal tracking of
individual patients.’
O’Malley et al, 2015: 433
BJ
Challenges
The examples given above indicate the great potential that
mHealth technologies have to re-engineer almost every facet
of health care and, in the process, markedly improve the
understanding of human physiology in health and disease.
With regard to growth, financial analysts estimate that the
market for mHealth technology will grow at an annual rate of
nearly 55%, from $1.5 billion globally in 2012 to $21.5 billion
by 2018 (BCC Research, 2014). However, growth in evidence
to drive transformational changes in healthcare has not been
keeping up with the increase in financial support.
Although the number of mHealth-related publications is
rising gradually, the majority of the published evidence in
support of clinical use is limited to underpowered pilot data.
For example, a recent study of mobile-enabled cardiac
rehabilitation received a great deal of coverage in both the lay
and medical press after it reported a 40% reduction in hospital
readmissions (Free et al, 2013; Comstock, 2014). However,
although the findings were positive, this study was limited by
its small sample. There continues to be a general agreement
that high-quality evidence is lacking for the use of mHealth
to effect behavioural changes or to manage long-term conditions
© 2018 MA Healthcare Ltd
(Prgomet et al, 2009; Free et al, 2013).
mHealth, ethics and nursing
The nature of clinical practice and the demands of the nurse–
patient relationship mean that a significant moral component
British Journal of Nursing, 2018, Vol 27, No 201175
TECHNOLOGY
is inevitably involved. Nurses encounter a range of complex
situations that require the skills of clinical reasoning and decision-
making. Many of these decisions will have an ethical component.
The advent of mobile devices means that nurses of the 21st
century will encounter increasingly complex ethical problems
when dealing with people using technology.
Perfect solutions to ethical questions and dilemmas cannot
be achieved and should not be sought (Meetoo, 2009). However,
there is an expectation that, when exercising professional
judgment, the practitioner has an obligation to do what is right.
This is equally important in the context of device use where
many issues need to be considered before technology is
implemented to improve people’s health.
However, views that new ethical guidelines should be
developed because publications on this topic area are scarce
(Thompson, 2007) have been contested (Mnyusiwalla et al,
2003). Given the unknown future design of devices, Ebbesen
et al (2006) are confident that the open-ended nature of
Beauchamp and Childress’ (2001) principles-based model
underpinning autonomy, beneficence, non-maleficence and
justice is sufficiently sensitive to address emerging ethical issues
within this domain.
Education
The integration of technology in health care does not require
a transformation of nursing education and competencies since
the importance of technology-based practice has long been
embedded in curricula (van Houwelingen et al, 2016).
However, the pace of technological advancement means
that the next generation of practitioners, as well as those already
in practice, must be supported to deal with existing challenges
and those to come.This would require educators to anticipate
how nursing will evolve beyond current practice paradigms.
Curricular revision is often complex and time consuming, and
there will be inherent challenges in keeping up with technology
trends. Standalone health informatics courses may allow for
more flexibility and responsive ongoing revision in
nursing programmes.
Ethics
The possibility of creating thinking machines raises a host of
ethical issues.These questions relate both to ensuring that such
machines do not cause harm, and to the moral status of the
machines themselves.
This raises many ethical issues for health professionals,
society and politicians, as well as regulators. If machines are
used in staff recruitment and performance assessment, how
would we know that their decisions are fair, reasonable and
free from bias? If decisions are wrong, who will be held legally
accountable in instances of medical negligence and errors?
(Meetoo and Rylance, 2018). How will choices relating to the
patient journey and the experience of living with a condition—
such as likes, dislikes, accepting or refusing treatment, death
and dying­—be made? While there are no issues around
accountability with regard to sensor and automated diagnoses,
this could arise where there is a collaboration between humans
and machines.

KEY POINTS
■■ Mobile health (mHealth)—medical and public health practice supported
by mobile devices such as smartphones and tablets—is transforming
healthcare practice
■■ Health professionals are likely to encounter ethical dilemmas around using
mHealth, which need to be resolved
■■ mHealth can be used to stream real-time data, supported by automated
clinical decision-making, to improve the understanding of physiological
variability and enable care
■■ Research should continually evaluate the functions and appropriateness
of mobile devices
■■ The potential of mHealth can be realised only if patients, healthcare
providers and healthcare systems can trust the reliability, privacy and
security of their data, as well as the devices that collect and share
this information
N Given the unknown future design of devices, should society,
as Ebbesen et al (2006) suggest, continue to place faith in the
open-ended nature of Beauchamp and Childress’ (2001)
principles-based model or will it be necessary to introduce a
new set of ethical principle for digital technology?
In the future, concerns could arise around privacy and
confidentiality if devices are programmed to disclose certain
types of information without the knowledge of the patient.
Conclusion
Today, our world is entering a period of truly transformative
BJ
change where many people are surprised by the scale and pace
of developments that they simply had not anticipated. Innovations
in mHealth technology, for example, truly offer the potential
to promote healthcare management and health behaviour
change outside formal clinical settings. Health professionals,
particularly nurses, can move mHealth into mainstream health
care by understanding its potential to change the landscape of
health intervention delivery.
Tremendous potential lies in technological advances, yet with
these opportunities come tremendous responsibilities.An avalanche
of technological advances will undoubtedly reshape the very
essence of humanity and touch every aspect of life on the planet.
Although digital mobile traffic is predicted to rise 10-fold
from the current exabyte (one quintillion bytes or a billion
gigabytes) between 2016 and 2018 (Peckham, 2016), mHealth
is still in its early, formative stages, in terms of both technology
development and incorporation in care systems. However, in
line with Moore’s law, with circuits becoming smaller and
cheaper, mHealth devices have the potential to decrease the
cost of both clinical research and health care (Skinner, 2013).
While mHealth has considerable promise, without rigorous
testing in clinical trials, it runs the risk of following the same
path as the use of robotics in surgery, where therapeutic
interventions are undertaken without any supporting evidence
(Steinhubl et al, 2015). BJN
Declaration of interest: none
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BJ
■■ How do you feel about the medical technology that will potentially change the landscape of heathcare practice?
■■ What should be done to prepare practitioners to deal with this transformation?
■■ What do you think are the advantages and drawbacks of introducing medical technology in care delivery?
■■ How does medical technology empower healthcare consumers?
■■ What ethical issues, if any, should be considered when implementing medical technology?

Autism and Asperger’s Conditions About this book

Autism and
Asperger’s Conditions
Autism and Asperger’s Conditions

Autism and Asperger’s Conditions covers

a wide range of issues relating to the
care and support of those with autism
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interventions, the history of autism,
and understanding of what these
possible causes, diagnostic issues, nursing
and issues that affect children, adolescents
A practical guide for nurses
Autism and Asperger’s Conditions covers a wide range of issues relating to the care and support of those
adults with these conditions and their and
families. A highly practical and accessible
autism spectrum conditions are covered text,
from a variety of perspectives, both
and outside of a learning disability setting. within
Christopher Barber
with autism and Asperger’s syndrome. This book aims to improve nurses’ professional interactions withAbout the author

those with autism spectrum disorders through improved awareness, knowledge and understanding of whatChristopher Barber is an agency registered
nurse who has worked in a variety of
A practical guide for nurses

clinical settings including learning disability,

autism, mental health and forensic/
secure units. He is currently serving on
editorial boards for the British Journal

these conditions are and what they are not, possible causes, diagnostic issues, nursing interventions, the
Nursing, British Journal of Health Care of
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Assistants and the Journal of Psychiatric

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was himself recently diagnosed with and
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perspectives, both within and outside of a learning disability setting.

ISBN: 978-1-85642-411-0; 234x156mm; 200 pages; publication date: 2011; £22.50

© 2018 MA Healthcare Ltd

Christopher Barber

ISBN 1-85642-411-1

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