The Quadruple Aim, improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care, as well as improving the work life of healthcare providers, is used as a framework to describe informatics applications to support rural and remote health. Applications that improve the patient experience of care include remote monitoring, personal alarms, mobile apps, and telehealth. Applications that improve the health of populations include geographical information systems and the electronic health record (EHR). Applications that improve the work life of healthcare providers include e-consults, peer learning networks, and access to online resources. Finally, while a variety of technologies may reduce per capita healthcare costs, definitive data are not yet available. The Quadruple Aim is an extension of the Triple Aim, originally envisioned by the Institute for Healthcare Improvement when Don Berwick served as CEO. Goals of the Triple Aim are improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of healthcare. When Berwick moved to lead the Centers for Medicare and Medicaid services (CMS) under the Obama administration, that agency similarly adopted the goals of better care for individuals, better health for populations, and lower cost, in the transition toward value based healthcare programs. Citing the decrease in patient satisfaction and health outcomes associated with provider burnout, Bodenheimer and Sinsky (2014) added a fourth aim, improving the work life of healthcare providers. The Quadruple Aim framework will be used to organize this chapter in describing informatics applications to support rural and remote health. Individuals, families, and communities in rural and remote areas tend to encounter disparities when compared with counterparts in urban settings. These include “geographical isolation, socioeconomic disadvantage, shortages of healthcare providers, decreased ability to access e-health services, a greater exposure to risks of injury, and stoicism in the face of adversity” (Banbury, Roots, & Nancarrow, 2014, p. 211). Thus, maximizing use of informatics to enhance healthcare quality in remote and rural regions is important. The rudimentary roots of telemedicine extend back to ancient times where simple forms of distance communication, such as the use of light reflections and smoke signals, were used to relay messages about external threats, famines, and disease. Long-distance communication evolved from these modest beginnings to systems such as the telegraph, radio, and onward to advanced digital communication and communication systems (Bashshur & Shannon, 2009). Telehealth applications have evolved from simple communications to sophisticated, pervasive, and widespread systems in the home that make use of wireless, wearable, robotic, and multisensorial technologies. In the past, trends in telehealth applications were grouped according to the various media: voice, data, and video. But with the convergence of these technologies, newer technologies merge across these media. Despite these newer technologies, voice applications remain a mainstay of telehealth applications. The tools of telemedicine offer effective and efficient solutions for remote monitoring of the chronically ill, as well as an avenue to allow for diagnosis and treatment of individuals who have no access to healthcare because of geographic limitations (Bashshur & Shannon, 2009). The informatics applications that improve the patient experience are categorized broadly as e-health initiatives. E-health is an emerging field of medical informatics, referring to the organization and delivery of health services and information using the Web and related technologies. In a broader sense, the term characterizes not only technical development, but also a new way of working, an attitude, and a commitment for networked, global thinking to improve healthcare locally, regionally, and worldwide by using information and communication technology. E-health represents optimism, allowing patients and professionals to do what was previously impossible (Pagliari et al., 2005). E-health technologies provide opportunities for customized and meaningful communication, enabling patients to receive individually tailored information that can be viewed and responded to at their convenience. Patients can also post their comments and advice to virtual communities (Kreps & Neuhauser, 2010). The World Health Organization (2012) identified that “technological advances, economic investment, and social and cultural changes are also contributing to the realization that the health sector must now integrate technology into its way of doing business” (p. 1). E-health can empower consumers and patients, and it opens doors for new types of relationships, such as shared decision-making between a patient and his or her healthcare provider. Telehealth can be considered another component of the e-health concept, with the difference being around the delivery mechanisms, which can include live video conferencing; store-and-forward systems, such as those used to store digital images; telephone conferencing; and remote patient monitoring and e-visits via a secure Web portal. Teleconferencing and digital networking systems are now merging, giving rise to “group consultation” opportunities (Waegemann, 2010). While variations in the definitions of telemedicine and telehealth exist, there is an agreement on the broad conception of this field as “the delivery of personal and nonpersonal health services and of consumer and provider education as well as a means for safeguarding the living environment via information and communication technology” (p. 601) (Bashshur & Shannon, 2009). Another component of e-health is mobile-health (m-health), which can be considered a delivery mechanism for e-health. M-health typically refers to the use of a wireless communication device that supports public health and clinical practices (Eytan, 2010). M-Health is seen as a valuable tool as the digitization of health and wellness data increases. It is postulated that many tools will be required, as no single tool will serve all needs for all people. As a result, there is a need to stop focusing on the technological components separately and work toward aggregating these communication technologies in an integrated system. Once this is accomplished, an ecosystem for integrated broad-scale deployment of e-health tools can be achieved (Eytan, 2010). M-Health is the new generation of telemedicine that is laying the foundation for a new generation of healthcare (Waegemann, 2010). E-health has a focus on using electronic medical records and other technologies, while m-Health focuses on behavioral and structural changes. The current idea that telemedicine requires dedicated connections does not fit the new worldview of m-Health. The m-Health revolution is introducing patient-centered, communication-based care in a system that includes wellness and healthcare providers. The healthcare model itself is moving from a provider-driven to a largely participatory model including all stakeholders such as long-term caregivers, dentists, insurance companies, hospitals, public health officials, primary care providers, consumers, and health systems involved in wellness. It is crucial to note that these changes will be global in distribution. M-Health is going to allow basic care to be provided that might not otherwise be available in regions of Africa, Asia, and South America. In developing countries, mobile phones far outnumber personal computers, and they offer support services on both health and technology fronts. The power of these technologies to improve health and the human condition cannot be underestimated. For most of the world this will be the only computer they will own; it is on the Web and they can carry it everywhere. The impact on healthcare could be great. As m-Health continues to progress, nursing care will need to evolve. Traditionally, nurses have been hands-on caregivers; now, nurses are challenged with developing new models for nursing care that address “care at a distance” using innovations such as mobile phones and text messaging. Communication is at the core of nursing care, and the methods of communication are rapidly changing and growing. Nurses will be able to utilize text messaging over a secure network to send automated appointment reminders, health tips, and messages about available resources in the area. Nurses will need to consider their standards of care and the impact these new modalities will have on care delivery. The rapid and pervasive worldwide adoption of mobile cell phones is going to drive tremendous growth in handheld healthcare over the next decade. Wireless communication technologies are forcing a transformation in how and where healthcare is delivered. The abilities to collaborate, share high-resolution images, and even have live broadcasting of surgeries are all enabled by new technologies. Application areas for m-Health include consumer education, emergency response systems, professional and patient communications (e.g., text messaging, e-mail, social networking), health promotion and community mobilization, and public and population health (Waegemann, 2010). M-health growth has been around the world with significant demand from “bottom-of-the-pyramid” consumers located in rural areas. Pilot projects are ongoing in countries such as Indonesia, Brazil, Sudan, and Uganda. In Africa, health personnel use mobile phones to provide emergency medical care; their phones use solar charges. A toll-free mobile service is being launched in remote areas of Tanzania, Kenya, and Uganda. In developing economies, m-Health will be a major part of e-health. M-health will need to be integrated into the training of healthcare workers, so professionals have the knowledge and skills required to use the technology safely and effectively. A qualitative study of m-Health in rural areas revealed themes suggesting the value of applications as well as some barriers. Participants found m-Health apps useful for medication and disease information, dietary information, and quicker communication. Some of the barriers noted were the complexity of apps, privacy, limited communication, and cost (Serafica et al., 2019). One specific e-health approach to enhancing patient experience is the use of remote monitoring. Wearable health monitoring systems are designed to use noninvasive sensors that record and or transmit respiratory rate, heart rate, blood pressure, body temperature, and other physiological measures like an electrocardiogram, blood glucose monitoring, pulse oximetry, or motion detection. The sensors can be imbedded into a lightweight vest for an individual to wear unobtrusively without impeding movement. Wireless technology is used to convey the measures to a healthcare provider at a distance. Remote patient monitoring, considered experimental a few years ago, is now maturing, with a number of applications available. The VitalJacket is one example that utilizes microelectronics in a wearable T-shirt that continuously monitors electrocardiogram waves and heart rate. The shirt can be used for patients or for healthy subjects involved in fitness activities or sports (The Future of Things, 2019). There are a number of wearable monitoring systems that focus on weight loss, health, and fitness. These come in the form of watches, phones, and armbands. When paired with a mobile app, they allow for tracking of activity via an accelerometer as well as heart rate and blood pressure. In addition, many apps to accompany them allow for personalization of a fitness regime to meet the user’s goals—strength, endurance, or flexibility (Nichols, 2017).
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Informatics Applications to Support Rural and Remote Health
ABSTRACT
INTRODUCTION
APPLICATIONS TO IMPROVE THE PATIENT EXPERIENCE
Historical Context of E-Health
Telehealth
M-Health
Remote Monitoring
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