care informatics and technologies project knowledge gaps ... · semwal m, whiting p, bajpai r,...

Care Informatics and Technologies project

Knowledge gaps in Digital Health

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Demonstrating value must be a precursor of the use of any technologies that claim to

improve clinical treatment or population health. The safety, acceptability and usability

by different stakeholders, as well as efficacy, effectiveness, cost-effectiveness and real-

world performance of technologies are critical issues for adoption of technologies..

Research plays a key role in help bridging this gap in order to an evidence-based use of

technology that leads to meaningful outcomes to individuals and communities. Thus,

knowledge on research methods on how to plan, develop, evaluate and deploy technologies is

fundamental to developing this area.

We searched for statements suggestive of knowledge gap due to low evidence level or

paucity of data in reviews on any aspect of technology use in any health context

published in Pubmed/Medline in Digital Health from September, 2018 to September,

2019.

We then classified these gaps in 15 different knowledge gaps.

1.Does technology improve access to reliable/quality data? ..................................................... 2

2.Do technologies enable health professionals’ development? ................................................. 3

3. Do technologies help disease prevention/manage of health conditions? .............................. 6

4. Do technologies improve patients’ outcomes? ...................................................................... 9

5. Do technologies help to improve adherence to treatments? .............................................. 12

6. Can technology support care? ............................................................................................. 14

7. Do technologies support health system improvement? ...................................................... 16

8. What are effective strategies to implement digital health in practice?................................ 20

9. How technologies should be developed and deployed to engage users? ............................. 21

10. How do users interact with technologies in health care settings? ...................................... 22

11. Are technologies able to maintain the privacy of health interactions? .............................. 23

12. What is the impact of technologies on equity in health?.................................................... 24

13. Do technologies contribute to health literacy? ................................................................. 24

14. Does technology impact on patient safety? ....................................................................... 25

15. How do technologies affect communication in health? ..................................................... 27



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Please note that each of this knowledge gaps can be divided into several others if a

specific technology, health context or population group is applied. For example, for the

knowledge gap ‘Does technology support care’, other questions can arise, such as

‘Does telehealth support care for adolescents surviving cancer treatment?’.

Find bellow, for each of the knowledge gaps, the reviews that were identified and the

authors’ statements highlighting the need for future research in particular contexts.

1.Does technology improve access to reliable/quality data?

Reference Authors´statement suggestive of knowledge gap

JMIR Mhealth Uhealth. 2018 Dec 14;6(12):e10026. doi: 10.2196/10026. Use of Mobile Devices to Help Cancer Patients Meet Their Information Needs in Non-Inpatient Settings: Systematic Review. Richards R, Kinnersley P, Brain K, McCutchan G, Staffurth J, Wood F.

There were no interventions designed to meet patients' full range of cancer-related information needs, from information on psychological support to how to manage finances during cancer, and the long-term effects of treatment. More comprehensive interventions are required for patients to meet their information needs when managing their condition in non-inpatient settings. Controlled evaluations are needed to further determine the effectiveness of these types of intervention.

Diagnosis (Berl). 2018 Sep 25;5:95-105. doi: 10.1515/dx-2018-0009. Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. Millenson ML, Baldwin JL, Zipperer L, Singh H.

Overall, the current evidence base on DTC, interactive diagnostic apps is sparse in scope, uneven in the information provided and inconclusive with respect to safety and effectiveness, with no studies of clinical risks and benefits involving real-world consumer use.

JMIR Med Inform. 2019 Mar 20;7:e11496. doi: 10.2196/11496. Telemonitoring to Manage Chronic Obstructive Pulmonary Disease: Systematic Literature Review. Kruse C, Pesek B(#), Anderson M(#), Brennan K(#), Comfort H(#).

Future research should emphasize standardization of telemonitoring services and predictability of exacerbations.



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JMIR Ment Health. 2019 Feb 20;6:e9819. doi: 10.2196/mental.9819. Mobile Phone and Wearable Sensor-Based mHealth Approaches for Psychiatric Disorders and Symptoms: Systematic Review. Seppälä J(#), De Vita I(#), Jämsä T, Miettunen J, Isohanni M, Rubinstein K, Feldman Y, Grasa E(10), Corripio , Berdun J, D'Amico E; M-RESIST Group, Bulgheroni M.

Although the data from sensors demonstrated an association with the symptoms of schizophrenia, bipolar disorders, and depression, their usability in clinical settings to support therapeutic intervention is not yet fully assessed and needs to be scrutinized more thoroughly.

Br J Ophthalmol. 2019 Feb;103:167-175. doi: 10.1136/bjophthalmol-2018-313173. Epub 2018 Oct 25. Artificial intelligence and deep learning in ophthalmology. Ting DSW, Pasquale LR, Peng L, Campbell JP, Lee AY, Raman R, Tan GSW, Schmetterer L, Keane PA, Wong TY.

DL could potentially revolutionise how ophthalmology is practised in the future.

2.Do technologies enable health professionals’ development?


J Med Internet Res. 2019 May 23;21:e13868. doi: 10.2196/13868. Digital Education of Health Professionals on the Management of Domestic Violence: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Divakar U, Nazeha N, Posadzki P, Jarbrink K, Bajpai R, Ho AHY, Campbell J, Feder G, Car J.

Evidence of the effectiveness of digital education on health professionals' understanding of domestic violence is promising. However, the certainty of the evidence is predominantly low and merits further research.



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J Med Internet Res. 2019 Apr 24;21:e12968. doi: 10.2196/12968. Offline Digital Education for Postregistration Health Professions: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Posadzki P, Bala MM, Kyaw BM, Semwal M, Divakar U, Koperny M, Sliwka A, Car J.

Future high-quality studies are needed to increase generalizability and inform use of this modality of education.

J Med Internet Res. 2019 Mar 1;21:e12998. doi: 10.2196/12998. Medical Doctors' Offline Computer-Assisted Digital Education: Systematic Review by the Digital Health Education Collaboration. Wahabi HA, Esmaeil SA, Bahkali KH, Titi MA, Amer YS, Fayed AA, Jamal A, Zakaria N, Siddiqui AR, Semwal M, Car LT, Posadzki P, Car J.

The effect of OCDE compared with other methods of education on medical doctors' knowledge and cognitive skill gain is uncertain.

J Med Internet Res. 2019 Mar 4;21:e13000. doi: 10.2196/13000. Digital Education for Health Professions on Smoking Cessation Management: Systematic Review by the Digital Health Education Collaboration. Semwal M, Whiting P, Bajpai R, Bajpai S, Kyaw BM, Tudor Car L.

limitations in the evidence base mean that these conclusions should be interpreted with some caution.

J Med Internet Res. 2019 Feb 28;21:e12945. doi: 10.2196/12945. Digital Problem-Based Learning in Health Professions: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Tudor Car L, Kyaw BM, Dunleavy G, Smart NA, Semwal M, Rotgans JI, Low-Beer N, Campbell J.

Further studies should evaluate the use of digital technology for the delivery ofother problem-based learning (PBL) components as well as PBL overall.

J Med Internet Res. 2019 Jul 2;21:e14676. doi: 10.2196/14676.Virtual Patient

Further research should explore the utility of different design variants of virtual patients.



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Simulations in Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Kononowicz AA, Woodham LA, Edelbring S, Stathakarou N, Davies D, Saxena N, Tudor Car L, Carlstedt-Duke J, Car J, Zary N

Acta Paediatr. 2019 May;108:814-822. doi: 10.1111/apa.14686. Epub 2019 Jan 15. Digital stethoscopes in paediatric medicine. Ramanathan A, Zhou L, Marzbanrad F, Roseby R, Tan K, Kevat A, Malhotra A.

Further validation and testing of available DS devices is required.

J Med Internet Res. 2019 Jan 22;21:e12959. doi: 10.2196/12959. Virtual Reality for Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Kyaw BM, Saxena N, Posadzki P, Vseteckova J, Nikolaou CK, George PP, Divakar U, Masiello I, Kononowicz AA, Zary N, Tudor Car L.

Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction,cost-effectiveness, and clinical practice or behavior change.

J Med Internet Res. 2019 Feb 25;21:e13269. doi: 10.2196/13269. Online Digital Education for Postregistration Training of Medical Doctors: Systematic Review by the Digital Health Education Collaboration. George PP, Zhabenko O, Kyaw BM, Antoniou P, Posadzki P, Saxena N, Semwal M, Tudor Car L, Zary N(10), Lockwood C, Car J.

The quality of the evidence in these studies was found to be very low for knowledge. Further high-quality randomized controlled trials are required to confirm these findings.

Med Internet Res. 2019 Feb 21;21:e12997. doi: 10.2196/12997.

The paucity and low quality of the available evidence call for urgent and well-designed studies focusing on important outcomes



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Digital Health Professions Education on Diabetes Management: Systematic Review by the Digital Health Education Collaboration. Huang Z, Semwal M, Lee SY, Tee M, Ong W, Tan WS, Bajpai R, Tudor Car L.

such as health care professionals' behavior, patient outcomes, and cost-effectiveness as well as its impact in diverse settings, including developing countries.

BMC Health Serv Res. 2019 Feb 19;19:128. doi: 10.1186/s12913-019-3906-7. Using information and communication technologies to involve patients and the public in health education in rural and remote areas: a scoping review. Dogba MJ, Dossa AR, Breton E, Gandonou-Migan R.

No study measured the impact of ICT for PPI in health education in rural areas. Due to this, measuring the impact of ICT in rural and remote areas as a means for PPI in health education of medical students, health professionals and patients requires further study.

Glob Health Sci Pract. 2018 Oct 10;6(Suppl 1):S41-S48. doi:10.9745/GHSP-D-18-00167. Print 2018 Oct 10. Digital Technologies for Health Workforce Development in Low- and Middle-Income Countries: A Scoping Review. Long LA, Pariyo G, Kallander K.

There is, however, agrowing urgency in global health to move beyond small-scale demonstration projects and to define the capital and recurring costs of implementation and scale up of digital health interventions, including the return on investment.

J Med Internet Res. 2019 Aug 27;21:e12967. doi: 10.2196/12967. Effectiveness of Digital Education on Communication Skills Among Medical Students: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Kyaw BM, Posadzki P, Paddock S, Car J, Campbell J, Tudor Car L.

There is a need for further research to evaluate the effectiveness of other forms of digital education such as virtual reality, serious gaming, and mobile learning on medical students' attitude, satisfaction, and patient-related outcomes as well as the adverse effects and cost-effectiveness of digital education.

3. Do technologies help disease prevention/manage of health conditions?



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Digit Health. 2019 Mar 27;5:2055207619839883. doi: 10.1177/2055207619839883. eCollection 2019 Jan-Dec. Mobile health interventions to promote physical activity and reduce sedentary behaviour in the workplace: A systematic review. Buckingham SA, Williams AJ, Morrissey K, Price L, Harrison J.

The impact in the longer term and on SB is less clear. Higher quality, mixed methods studies are needed to explore the reasons for decline in engagement with time and the longer-term potential of mHealth in workplace interventions.

JMIR Mhealth Uhealth. 2019 Apr 17;7:e13250. doi: 10.2196/13250. Application of Mobile Health Technologies Aimed at Salt Reduction: Systematic Review. Ali SH(#), Luo R(#), Li Y, Liu X, Tang C, Zhang P.

Salt reduction in mHealth initiatives remains relatively unexplored

JMIR Mhealth Uhealth. 2019 Mar 19;7:e10855. doi: 10.2196/10855. Training Cognitive Functions Using Mobile Apps in Breast Cancer Patients: Systematic Review. Vergani L(#), Marton G(#), Pizzoli SFM, Monzani D, Mazzocco K, Pravettoni G.

These results highlight the lack of empirical evidence on the efficacy of currently available apps to train cognitive function.

J Med Internet Res. 2019 Jun 17;21:e10896. doi: 10.2196/10896. Context-Aware Systems for Chronic Disease Patients: Scoping Review. Yin K(#), Laranjo L(#), Tong HL, Lau AY, Kocaballi AB, Martin P, Vagholkar S, Coiera E.

RCTs are needed to evaluate the effectiveness of context-aware systems in improving patient work, self-management practices, and health outcomes in chronic disease patients.

JMIR Mhealth Uhealth. 2019 Feb 12;7:e13080. doi: 10.2196/13080. Evaluation of Self-Management Support Functions in Apps for People With

Although 2 apps (Headspace and SuperBetter) were validated to show improved health outcomes, none were tested in people with persistent pain.



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Persistent Pain: Systematic Review. Devan H(#), Farmery D, Peebles L, Grainger R. JMIR Mhealth Uhealth. 2018 Oct 22;6(10):e11231. doi: 10.2196/11231. Benefits of Mobile Apps in Pain Management: Systematic Review. Thurnheer SE, Gravestock I, Pichierri G, Steurer J, Burgstaller JM.

Medicine could profit from this development as indicated by our results, but there is a need for more scientific inputs.

JMIR Mhealth Uhealth. 2019 Jan 16;7:e11098. doi: 10.2196/11098. User Models for Personalized Physical Activity Interventions: Scoping Review. Ghanvatkar S, Kankanhalli A, Rajan V.

Finally, the long-term effects of such interventions as well as the technology medium used for the interventions need to be evaluated rigorously.

JMIR Mhealth Uhealth. 2019 Jan 15;7:e12297. doi: 10.2196/12297. The Efficacy of Mobile Phone Apps for Lifestyle Modification in Diabetes: Systematic Review and Meta-Analysis. Wu X, Guo X, Zhang Z.

The evidence is inconclusive for the other diabetes subtypes.

Curr Diab Rep. 2018 Oct 18;18(12):130. doi: 10.1007/s11892-018-1105-2. Effect of Health Information Technologies on Glycemic Control Among Patients with Type 2 Diabetes. Yoshida Y, Boren SA, Soares J, Popescu M, Nielson SD, Simoes EJ.

Future studies should examine long-term effects of HITs and explore factors that influence their effectiveness.



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4. Do technologies improve patients’ outcomes?


Heart Fail Rev. 2019 May 24. doi: 10.1007/s10741-019-09801-5. [Epub ahead of print] Effectiveness of telemedicine systems for adults with heart failure: a meta-analysis of randomized controlled trials. Zhu Y, Gu X, Xu C.

Further research is required to confirm these observational findings and identify optimal telemedicine strategies and the duration of follow-up for which it confers benefits.

Curr HIV/AIDS Rep. 2019 Feb;16:113-119. doi: 10.1007/s11904-019-00430-z. A Review of Telehealth Innovations for HIV Pre-Exposure Prophylaxis (PrEP). Touger R, Wood BR.

Future research should assess and compare outcomes, scalability, cost-effectiveness, and sustainability.

J Am Geriatr Soc. 2019 Aug;67:1737-1749. doi: 10.1111/jgs.15959. Epub 2019 May 8. Effectiveness of Ambulatory Telemedicine Care in Older Adults: A Systematic Review. Batsis JA, DiMilia PR, Seo LM, Fortuna KL, Kennedy MA, Blunt HB, Bagley PJ, Brooks J, Brooks E, Kim SY, Masutani RK, Bruce ML, Bartels SJ.

Research should focus on well-designed randomized trials to overcome the high degree of bias observed in our synthesis.

Expert Rev Cardiovasc Ther. 2019 Mar;17:185-192. doi: 10.1080/14779072.2019.1580570. Epub 2019 Feb 19. eHealth to improve patient outcome in rehabilitating myocardial infarction patients. Verburg A, Selder JL, Schalij MJ, Schuuring MJ, Treskes RW.

eHealth might be clinically beneficial in post-MI patients, particularly for risk estimation. Moreover, eHealth as a tool for remote coaching on activity is a good addition to traditional cardiac rehabilitation programs.Further research needs to corroborate these findings.

J Med Internet Res. 2019 Jun 17;21:e10896. doi: 10.2196/10896. Context-Aware Systems for Chronic Disease Patients: Scoping Review. Yin K(#), Laranjo L(#), Tong HL, Lau AY, Kocaballi AB, Martin P, Vagholkar S, Coiera E.

RCTs are needed to evaluate the effectiveness of context-aware systems in improving patient work, self-management practices, and health outcomes in chronic disease patients.



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Int J Nurs Stud. 2019 Apr;92:1-15. doi: 10.1016/j.ijnurstu.2018.12.006. Epub 2019 Jan 2. Effectiveness of tele-monitoring by patient severity and intervention type in chronic obstructive pulmonary disease patients: A systematic review and meta-analysis. Hong Y, Lee SH.

Further studies such as large size randomized controlled trials with sub-group by patient severity and intervention type is needed to confirm these finding.

JMIR Mhealth Uhealth. 2019 Apr 26;7:e10967. doi: 10.2196/10967. Augmented Reality in Medicine: Systematic and Bibliographic Review. Eckert M(#), Volmerg JS(#), Friedrich CM.

Clinical studies proving the effectiveness of applied AR technologies are still lacking.

CJEM. 2018 Nov;20:920-928. doi: 10.1017/cem.2017.382. Epub 2017 Aug 22. Real-time video telemedicine applications in the emergency department: a scoping review of literature. Kelton DK, Szulewski A, Howes D.

Telemedicine support for emergency department physicians is an application with significant potential but is still lacking evidence supporting improved patient outcomes.

JMIR Mhealth Uhealth. 2019 Oct 7;7(10):e14877. doi: 10.2196/14877. Mobile Health for First Nations Populations: Systematic Review. Hobson GR, Caffery LJ, Neuhaus M, Langbecker DH.

Evidence of efficacy is limited.

JMIR Mhealth Uhealth. 2019 Jan 29;7:e10899. doi: 10.2196/10899. Mobile Health Interventions for Self-Control of Unhealthy Alcohol Use: Systematic Review. Song T, Qian S, Yu P.

Further studies are needed to gather sound evidence about the effects of mHealth interventions on improving physiological and cognitive outcomes as well as the optimal design of these interventions, their implementation, and effects in supporting self-control of UAU.

J Med Internet Res. 2019 Aug 19;21:e14630. doi: 10.2196/14630. Digital Health Apps in the Clinical Care of Inflammatory Bowel Disease: Scoping Review.

While studies have shown that digital health can fit into, complement, and improve the standard clinical care of patients with IBD, there is



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Yin AL, Hachuel D, Pollak JP, Scherl EJ, Estrin D.

a need for further validation and improvement, from both a clinical and patient perspective.

Dunn P, Hazzard E. Technology approaches to digital health literacy. Int J Cardiol. 2019 Oct 15;293:294-296.

Health technology represents enormous promise in the building of digital health literacy skills and improved health outcomes in patients with cardiovascular and other chronic conditions. This is a promise, however, that is yet to be fulfilled.

Patel ML, Wakayama LN, Bass MB, Breland JY.Motivational interviewing in eHealth and telehealth interventions for weight loss: A systematic review. Prev Med. 2019 Sep;126:105738.

There is a dearth of evidence to support the use of motivational interviewing via eHealth, signaling a needed research area.

JCO Clin Cancer Inform. 2018 Dec;2:1-15. doi: 10.1200/CCI.17.00138. Digital Health Interventions for Adolescent and Young Adult Cancer Survivors. Devine KA, Viola AS, Coups EJ, Wu YP.

Researchers should use rigorous development and evaluation methods to demonstrate the efficacy of these approaches to improve health outcomes for AYA survivors.

Digit Health. 2019 Apr 23;5:2055207619845831. doi: 10.1177/2055207619845831. eCollection 2019 Jan-Dec. Internet videoconferencing for patient-clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations. Ignatowicz A, Atherton H, Bernstein CJ, Bryce C, Court R, Sturt J, Griffiths F.

While the current evidence base for internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published.



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Wang Z, Zhu Y, Cui L, Qu B. Electronic Health Interventions to Improve Adherence to Antiretroviral Therapy in People Living With HIV: Systematic Review and Meta-Analysis. JMIR Mhealth Uhealth. 2019 Oct 16;7(10):e14404.

Future studies need to determine the features of eHealth interventions to better improve ART adherence along with long-term effectiveness of interventions, effectiveness of real-time adherence monitoring, enhancement of study design, and influences on biochemical outcomes.

Redfern J. Can Older Adults Benefit from Smart Devices, Wearables, and Other. Digital Health Options to Enhance Cardiac Rehabilitation? Clin Geriatr Med. 2019 Nov;35:489-497.

ther areas of research investigating the use of wearable devices are still emerging but lack robust data.

Glob Health Sci Pract. 2018 Oct 10;6(Suppl 1):S61-S71. doi:10.9745/GHSP-D-18-00229. Print 2018 Oct 10. Strengthening Delivery of Health Services Using Digital Devices. Orton M, Agarwal S, Muhoza P, Vasudevan L, Vu A.

Despite encouraging advances in the evidence base on digital strategies for health service delivery, the current body of evidence is still quite limited in 3 main areas: the effectiveness of interventions on health outcomes, improvement in health system efficiencies for service delivery, and the human capacity required to implement and support digital health strategies at scale.

J Voice. 2019 Jan 14. pii: S0892-1997(18)30259-5. doi: 10.1016/j.jvoice.2018.12.018. [Epub ahead of print] The Current State and Future Possibilities of Mobile Phone "Voice Analyser" Applications, in Relation to Otorhinolaryngology. Munnings AJ.

The benefits of mobile technology in this field, particularly in voice rehabilitation, warrant further research into its widespread implementation.

5. Do technologies help to improve adherence to treatments?



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Abd- Alrazaq AA, Alajlani M, Alalwan AA, Bewick BM, Gardner P,Househ M.An overview of the features of chatbots in mental health: A scoping review. Int J Med Inform. 2019 Sep 25;132:103978.

More reviews are needed to summarise the evidence regarding the effectiveness and acceptability of chatbots in mental health.

J Telemed Telecare. 2019 May;25:249-260. doi: 10.1177/1357633X18755883. Epub 2018 Feb 13. Telepractice delivery of family-centred early intervention for children who are deaf or hard of hearing: A scoping review. McCarthy M, Leigh G, Arthur-Kelly M.

more research is needed to substantiate the use of telepractice as a viable alternative to traditional in-person services, rather than being seen as supplemental to such services.

Gaffney H, Mansell W, Tai S. Conversational Agents in the Treatment of Mental Health Problems: Mixed-Method Systematic Review. JMIR Ment Health. 2019 Oct 18;6(10):e14166.

The efficacy and acceptability of conversational agent interventions for mental health problems are promising. However, a more robust experimental design is required to demonstrate efficacy and efficiency.

Digit Health. 2019 Apr 12;5:2055207619842986. doi: 10.1177/2055207619842986. eCollection 2019 Jan-Dec. Efficacy of mobile application interventions for the treatment of post-traumatic stress disorder: A systematic review. Wickersham A, Petrides PM, Williamson V, Leightley D.

Evidence for the efficacy of mobile interventions for treating PTSD was inconclusive

Hobson GR, Caffery LJ, Neuhaus M, Langbecker DH. Mobile Health for First Nations Populations: Systematic Review.JMIR Mhealth Uhealth. 2019 Oct 7;7(10):e14877.

Clinicoecon Outcomes Res. 2019 May 6;11:325-333. doi: 10.2147/CEOR.S195597. eCollection 2019. Electronic referral systems in health care: a scoping review.

The evidence base on the effectiveness of eReferral systems to improve communication between primary care and specialists and to decrease wait times is positive but limited. Economic evaluations are



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Azamar-Alonso A, Costa AP, Huebner LA, Tarride JE.

needed to examine the clinical and economic value of eReferral systems in health care.

Wang Z, Zhu Y, Cui L, Qu B. Electronic Health Interventions to Improve Adherence to Antiretroviral Therapy in People Living With HIV: Systematic Review and Meta-Analysis. JMIR Mhealth Uhealth. 2019 Oct 16;7(10):e14404.

Future studies need to determine the features of eHealth interventions to better improve ART adherence along with long-term effectiveness of interventions, effectiveness of real-time adherence monitoring, enhancement of study design, and influences on biochemical outcomes

Santo K, Redfern J. The Potential of mHealth Applications in Improving Resistant Hypertension Self-Assessment, Treatment and Control. Curr Hypertens Rep. 2019 Oct 9;21(10):81.

Future research, including large-scale randomised clinical trials with user-centred design, is crucial to further evaluate the potential scalability and effectiveness of such mHealth apps in the resistant hypertension context.

Psychiatr Q. 2018 Dec;89:779-794. doi: 10.1007/s11126-018-9576-5. Are Digitally Delivered Psychological Interventions for Depression the Way Forward? A Review. Stefanopoulou E, Lewis D, Taylor M, Broscombe J, Ahmad J, Larkin J.

Future research is pertinent to investigate further the influence of therapist input, the reasons for dropout, how to improve users' experience and therapeutic engagement and maintain improvements at post-treatment.

6. Can technology support care?


Dementia (London). 2019 Feb;18:725-741. doi: 10.1177/1471301217691617. Epub 2017 Feb 8. Technology-based tools and services for people with dementia and carers: Mapping technology onto the dementia care pathway.

While the review found a range of technologies available for people with dementia and carers there is very little evidence of widespread practical application.



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Lorenz K, Freddolino PP, Comas-Herrera A, Knapp M, Damant J. JMIR Mhealth Uhealth. 2019 Jan 29;7:e10899. doi: 10.2196/10899. Mobile Health Interventions for Self-Control of Unhealthy Alcohol Use: Systematic Review. Song T, Qian S, Yu P.

Further studies are needed to gather sound evidence about the effects of mHealth interventions on improving physiological and cognitive outcomes as well as the optimal design of these interventions, their implementation, and effects in supporting self-control of UAU.

Matern Child Nutr. 2019 Apr;15:e12777. doi: 10.1111/mcn.12777. Epub 2019 Feb 6. mHealth interventions targeting pregnancy intakes in low and lower-middle income countries: Systematic review. Saronga NJ, Burrows T, Collins CE, Ashman AM, Rollo ME.

Further studies are needed to address the limited evidence base related to mHealth nutrition interventions targeting dietary intakes of pregnant women in LLMIC.

Int Psychogeriatr. 2018 Dec;30(12):1783-1795. doi: 10.1017/S1041610218000340. Epub 2018 May 11. Remote delivery of psychological interventions for Parkinson's disease. Swalwell C, Pachana NA, Dissanayaka NN.

Further research should be conducted evaluating telehealth VC modalities for delivery of psychotherapy including CBT, as well as mindfulness-based therapy and acceptance and commitment therapy for remote treatment of depression and anxiety in PD.

JCO Clin Cancer Inform. 2018 Dec;2:1-15. doi: 10.1200/CCI.17.00138. Digital Health Interventions for Adolescent and Young Adult Cancer Survivors. Devine KA, Viola AS, Coups EJ, Wu YP.

Researchers should use rigorous development and evaluation methods to demonstrate the efficacy of these approaches to improve health outcomes for AYA survivors.

Rheumatol Int. 2018 Nov;38(11):1949-1957. doi: 10.1007/s00296-018-4037-x. Epub 2018 Apr 30. Digital health: a new dimension in rheumatology patient care. Kataria S, Ravindran V.

However, more data, efficacy and objective results are needed which would be fulfilled by ongoing observational studies, clinical trials, systematic review and meta-analysis to further establish the role of digital health in the realms of patient care.



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Patel ML, Wakayama LN, Bass MB, Breland JY.Motivational interviewing in eHealth and telehealth interventions for weight loss: A systematic review. Prev Med. 2019 Sep;126:105738.

There is a dearth of evidence to support the use of motivational interviewing via eHealth, signaling a needed research area.

J Cancer Surviv. 2019 Feb;13:97-107. doi: 10.1007/s11764-018-0730-8. Epub 2019 Jan 11. The effectiveness of mHealth for self-management in improving pain, psychological distress, fatigue, and sleep in cancer survivors: a systematic review. Hernandez Silva E, Lawler S, Langbecker D.

Further development and investigation of mHealth is needed, incorporating targeted, evidence-based models of care into app design.

Schizophr Bull. 2019 Feb 1;45(45 Suppl 1):S32-S42. doi: 10.1093/schbul/sby103. Potential Applications of Digital Technology in Assessment, Treatment, and Self-help for Hallucinations. Thomas N, Bless JJ, Alderson-Day B, Bell IH, Cella M, Craig T, Delespaul P, Hugdahl K, Laloyaux J, Larøi F, Lincoln TM, Schlier B, Urwyler P, van den Berg D, Jardri R

Although there is a well-established Internet-based peer support network, digital resources for hallucinations have yet to be implemented in routine practice.

JMIR Mhealth Uhealth. 2019 Jan 30;7:e11836. doi: 10.2196/11836. Effects of Social Media and Mobile Health Apps on Pregnancy Care: Meta-Analysis. Chan KL, Chen M.

More large-scale clinical trials focusing on different health outcomes are suggested for future studies.

7. Do technologies support health system improvement?

Reference Authors´statement indicating knowledge gap

Expert Rev Med Devices. 2019 Aug;16:653-661. doi: 10.1080/17434440.2019.1640116. Epub 2019 Jul 18. Telemonitoring for

hypertensive disease in

Core topics for ongoing and future research are discussed, with special emphasis on feasibility and validation of technologies, methodological standardization, patient safety,



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pregnancy. Khalil A(1)(2), Perry H(1)(2),

Lanssens D(3), Gyselaers W(4)

privacy and acceptability, and health economics and governance.

Trends Cardiovasc Med. 2019 Feb;29:109-117. doi: 10.1016/j.tcm.2018.07.002. Epub 2018 Jul 12. Telepharmacy for the management of cardiovascular patients in the community. Omboni S, Tenti M.

the clinical efficacy of telepharmacy, and its cost effectiveness, are far from being fully proved,

Curr HIV/AIDS Rep. 2019 Feb;16:113-119. doi: 10.1007/s11904-019-00430-z. A Review of Telehealth Innovations for HIV Pre-Exposure Prophylaxis (PrEP). Touger R, Wood BR.

Future research should assess and compare outcomes, scalability, cost-effectiveness, and sustainability.

Expert Rev Cardiovasc Ther. 2019 Mar;17:185-192. doi: 10.1080/14779072.2019.1580570. Epub 2019 Feb 19. eHealth to improve patient outcome in rehabilitating myocardial infarction patients. Verburg A, Selder JL, Schalij MJ, Schuuring MJ, Treskes RW.

eHealth might be clinically beneficial in post-MI patients, particularly for risk estimation. Moreover, eHealth as a tool for remote coaching on activity is a good addition to traditional cardiac rehabilitation programs.Further research needs to corroborate these findings.

Neuroeng Rehabil. 2019 Jan 31;16:20. doi: 10.1186/s12984-019-0481-4. Tele-monitored tDCS rehabilitation: feasibility, challenges and future perspectives in Parkinson's disease. Cucca A, Sharma K, Agarwal S, Feigin AS, Biagioni MC.

The use of telemedicine combined with transcranial direct current stimulation (tDCS) protocols is increasing, although the safety of this approach in different clinical settings awaits further assessment.

Neth Heart J. 2019 Jan;27:5-15. doi: 10.1007/s12471-018-1202-5. Telemedicine in heart failure-more than nice to have? Eurlings CGMJ, Boyne JJ, de Boer RA, Brunner-La Rocca HP.

In the future perspective, telemedicine should be better standardised and evolve to be more than an addition to standard care to improve care and reduce costs.

Curr HIV/AIDS Rep. 2018 Dec;15:414-422. doi: 10.1007/s11904-018-0416-x. A Missing Link: HIV-/AIDS-Related mHealth Interventions for Health Workers in Low- and Middle-Income Countries.

Although a growing number of HIV mHealth tools have been developed to support health workers, few of these tools



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Gimbel S, Kawakyu N, Dau H, Unger JA. have been rigorously evaluated and even fewer have been brought to scale.

Health Aff (Millwood). 2018 Dec;37(12):1975-1982. doi: 10.1377/hlthaff.2018.05132. The Current State Of Telehealth Evidence: A Rapid Review. Shigekawa E, Fix M, Corbett G, Roby DH, Coffman J.

telehealth's impact on the use of other services is unclear

Int Rev Psychiatry. 2018 Dec;30:292-309. doi: 10.1080/09540261.2019.1571483. Epub 2019 Mar 1. Telepsychiatry and other technologies for integrated care: evidence base, best practice models and competencies. Hilty DM, Sunderji N, Suo S, Chan S, McCarron RM.

Research is needed upon all technology models related to IC for adult and paediatric primary care populations.

JMIR Ment Health. 2018 Nov 21;5:e62. doi: 10.2196/mental.8816. Application and Effectiveness of Telehealth to Support Severe Mental Illness Management: Systematic Review. Lawes-Wickwar S, McBain H, Mulligan K.

Further research is warranted to establish the full potential benefits of telehealth for improving the quality of life in people with SMI, acceptability from the service user perspective, and cost-effectiveness.

PLoS One. 2018 Nov 15;13(11):e0207332. doi: 10.1371/journal.pone.0207332. eCollection 2018. How does it work? Factors involved in telemedicine home-interventions effectiveness: A review of reviews. Bertoncello C, Colucci M, Baldovin T, Buja A, Baldo V.

Factors that may be involved in ICT-based interventions, affecting their effectiveness or cost-effectiveness, are not enough studied in the literature.

JMIR Mhealth Uhealth. 2018 Oct 26;6(10):e11440. doi: 10.2196/11440. Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review. Bassi A, John O, Praveen D, Maulik PK, Panda R, Jha V.

Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening



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Glob Health Sci Pract. 2018 Oct 10;6(Suppl 1):S61-S71. doi: 10.9745/GHSP-D-18-00229. Print 2018 Oct 10. Strengthening Delivery of Health Services Using Digital Devices. Orton M, Agarwal S, Muhoza P, Vasudevan L, Vu A.

Despite encouraging advances in the evidence base on digital strategies for health service delivery, the current body of evidence is still quite limited in 3 main areas: the effectiveness of interventions on health outcomes,improvement in health system efficiencies for service delivery, and the human capacity required to implement and support digital health strategies at scale.

Glob Health Sci Pract. 2018 Oct 10;6(Suppl 1):S49-S60. doi: 10.9745/GHSP-D-18-00165. Print 2018 Oct 10. The State of Digital Interventions for Demand Generation in Low- and Middle-Income Countries: Considerations, Emerging Approaches, and Research Gaps. Gibson DG, Tamrat T, Mehl G.

We propose a research agenda to help guide the field of digital demand generation studies and programs within a broader health systems strengthening agenda, including establishing and documenting the influence of intervention characteristics within different populations and health domains and examining the long-term effects and cost-effectiveness of digital demand generation interventions, as well as equity in access to such interventions.

Glob Health Sci Pract. 2018 Oct 10;6(Suppl 1):S18-S28. doi: 10.9745/GHSP-D-18-00270. Print 2018 Oct 10. What Does It Take to Be an Effective National Steward of Digital Health Integration for Health Systems Strengthening in Low- and Middle-Income Countries?

Available evidence for the remaining themes was sparse, drawing attention to key areas for future work.



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Frost MJ, Tran JB, Khatun F, Friberg IK, Rodríguez DC. this situation should challenge us

to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Varsi C, Solberg Nes L, Kristjansdottir OB, Kelders SM,Stenberg U, Zangi HA, Børøsund E, Weiss KE, Stubhaug A, Asbjørnsen RA, Westeng M, Ødegaard M, Eide H. Implementation Strategies to Enhance the Implementation of eHealth Programs for Patients With Chronic Illnesses: Realist Systematic Review.J Med Internet Res. 2019 Sep 27;21:e14255.

The review also points to the lack of eHealth studies that report implementation strategies in a comprehensive way and highlights the need to design robust studies focusing on implementation strategies in the future.

Eden R, Burton-Jones A, Scott I, Staib A, Sullivan C. Effects of eHealth on hospital practice: synthesis of the current literature. Aust Health Rev. 2018 Sep;42:568-578.

Limited evidence of effectiveness exists for computerised provider order entry and ePrescribing.

8. What are effective strategies to implement digital health in practice?


JMIR Cancer. 2019 Jul 31;5:e12071. doi: 10.2196/12071. Digital Interventions to Support Adolescents and Young Adults With Cancer:Systematic Review. McCann L, McMillan KA(#), Pugh G(#).

Many of these interventions have yet to be deployed, implemented, and evaluated at scale.

Stud Health Technol Inform. 2019;257:140-145. Use of Agile Project Methodology in Health Care IT

The authors identify there is a strong need for research to look into project management methodologies and identify areas in the project



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Implementations: A Scoping Review. Goodison R, Borycki EM, Kushniruk AW.

lifecycle, where change is needed to increase clinical systems adoption.

Curr HIV/AIDS Rep. 2018 Dec;15:403-413. doi: 10.1007/s11904-018-0415-y. Implementation of eHealth Interventions Across the HIV Care Cascade: a Review of Recent Research. Kemp CG, Velloza J.

No studies explored sustainability and few used theoretical frameworks for implementation research or validated measures of implementation outcomes.

Int J Health Plann Manage. 2019 Apr;34:e1016-e1025. doi: 10.1002/hpm.2754. Epub 2019 Feb 14. Research evidence on strategies enabling integration of electronic health records in the health care systems of low- and middle-income countries: A literature review. Kumar M, Mostafa J.

The findings describe the narrow focus of electronic health record implementation

9. How technologies should be developed and deployed to engage users?


Diabetologia. 2019 Jun;62:877-887. doi: 10.1007/s00125-019-4864-7. Epub 2019 Apr 8. Digital health technology and mobile devices for the management of diabetes mellitus: state of the art. Shan R, Sarkar S, Martin SS.

More work is needed to investigate how individual demographic, socioeconomic, behavioural and clinical characteristics contribute to patient engagement and the efficacy of mHealth tools for diabetes.

Int J Med Inform. 2019 Jun;126:95-104. doi: 10.1016/j.ijmedinf.2019.03.018. Epub 2019 Mar 31.

Further research is needed into which methods are best suited for the different types of eHealth applications, according to their target



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Methods of usability testing in the development of eHealth applications: A scoping review. Maramba I, Chatterjee A, Newman C.

users and the health conditions being addressed.

Diabetologia. 2019 Jun;62:877-887. doi: 10.1007/s00125-019-4864-7. Epub 2019 Apr 8. Digital health technology and mobile devices for the management of diabetes mellitus: state of the art. Shan R, Sarkar S, Martin SS.

More work is needed to investigate how individual demographic, socioeconomic, behavioural and clinical characteristics contribute to patient engagement and the efficacy of mHealth tools for diabetes.

Healthc Inform Res. 2019 Apr;25:61-72. doi: 10.4258/hir.2019.25.2.61. Epub 2019 Apr 30. Analyzing and Visualizing Knowledge Structures of Health Informatics from 1974 to 2018: A Bibliometric and Social Network Analysis. Saheb T, Saheb M.

This study found that the future strands of research may be patient-generated health data, deep learning algorithms, quantified self and self-tracking tools, and Internet of Things based decision support systems.

Ames HM, Glenton C, Lewin S, Tamrat T, Akama E, Leon N. Clients' perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2019 Oct 14;10:CD013447.

Future trial authors also need to actively address these factors and to report their efforts in their trial publications.

10. How do users interact with technologies in health care settings?


J Med Internet Res. 2019 Sep 25;21:e13940. doi: 10.2196/13940.

Potential future research topics are the influences on the chain of online interaction, specifications and principles of privacy design within online health care



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The Antecedents and Consequences of Health Care Professional-Patient Online Interactions: Systematic Review. Shang L, Zuo M, Ma D, Yu Q.

settings, and roles that sociodemographic and psychological characteristics play.

11. Are technologies able to maintain the privacy of health interactions?


J Med Internet Res. 2019 Sep 25;21:e13940. doi: 10.2196/13940. The Antecedents and Consequences of Health Care Professional-Patient Online Interactions: Systematic Review. Shang L, Zuo M, Ma D, Yu Q.

Potential future research topics are the influences on the chain of online interaction, specifications and principles of privacy design within online health care settings, and roles that sociodemographic and psychological characteristics play.

Expert Rev Med Devices. 2019 Aug;16:653-661. doi:10.1080/17434440.2019.1640116. Epub 2019 Jul 18. Telemonitoring for hypertensive disease in pregnancy. Khalil A, Perry H, Lanssens D, Gyselaers W.

Core topics for ongoing and future research are discussed, with special emphasis on feasibility and validation of technologies, methodological standardization, patient safety, privacy and acceptability, and health economics and governance.

J Med Internet Res. 2019 Sep 25;21:e13940. doi: 10.2196/13940. The Antecedents and Consequences of Health Care Professional-Patient Online Interactions: Systematic Review. Shang L, Zuo M, Ma D, Yu Q.

Potential future research topics are the influences on the chain of online interaction, specifications and principles of privacy design within online health care settings, and roles that sociodemographic and psychological characteristics play.

Healthcare (Basel). 2019 Apr 4;7. pii: E56. doi: 10.3390/healthcare7020056.

there is still the need for more research to better understand,



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Blockchain Technology in Healthcare: A Systematic Review. Agbo CC, Mahmoud QH, Eklund JM.

characterize and evaluate the utility of blockchain in healthcare.

12. What is the impact of technologies on equity in health?


Glob Health Sci Pract. 2018 Oct 10;6(Suppl 1):S49-S60. doi: 10.9745/GHSP-D-18-00165. Print 2018 Oct 10. The State of Digital Interventions for Demand Generation in Low- and Middle-Income Countries: Considerations, Emerging Approaches, and Research Gaps. Gibson DG, Tamrat T, Mehl G.

We propose a research agenda to help guide the field of digital demand generation studies and programs within a broader health systems strengthening agenda, including establishing and documenting the influence of intervention characteristics within different populations and health domains and examining the long-term effects and cost-effectiveness of digital demand generation interventions, as well as equity in access to such interventions.

13. Do technologies contribute to health literacy?




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Dunn P, Hazzard E. Technology approaches to digital health literacy. Int J Cardiol. 2019 Oct 15;293:294-296.

Health technology represents enormous promise in the building of digital health literacy skills and improved health outcomes in patients with cardiovascular and other chronic conditions. This is a promise, however, that is yet to be fulfilled.

14. Does technology impact on patient safety?

Reference Authors´ statement suggestive of knowledge gap

J Med Internet Res. 2019 Mar 1;21:e10736. doi: 10.2196/10736. eHealth Apps Replacing or Complementing Health Care Contacts: Scoping Review on Adverse Effects. Stevens WJM, van der Sande R, Beijer LJ, Gerritsen MG, Assendelft WJ.

There is a lack of high-quality empirical research on adverse effects of eHealth apps that replace or complement face-to-face care.

Diagnosis (Berl). 2018 Sep 25;5:95-105. doi: 10.1515/dx-2018-0009. Beyond Dr. Google: the evidence on consumer-facing digital tools for diagnosis. Millenson ML, Baldwin JL, Zipperer L, Singh H.

Overall, the current evidence base on DTC, interactive diagnostic apps is sparse in scope, uneven in the information provided and inconclusive with respect to safety and effectiveness, with no studies of clinical risks and benefits involving real-world consumer use.

Expert Rev Med Devices. 2019 Aug;16:653-661. doi:10.1080/17434440.2019.1640116. Epub 2019 Jul 18. Telemonitoring for hypertensive disease in pregnancy. Khalil A, Perry H, Lanssens D, Gyselaers W.

Core topics for ongoing and future research are discussed, with special emphasis on feasibility and validation of technologies, methodological standardization, patient safety,



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privacy and acceptability, and health economics and governance.

Healthcare (Basel). 2019 Apr 4;7. pii: E56. doi: 10.3390/healthcare7020056. Blockchain Technology in Healthcare: A Systematic Review. Agbo CC, Mahmoud QH, Eklund JM.

there is still the need for more research to better understand, characterize and evaluate the utility of blockchain in healthcare.

Neuroeng Rehabil. 2019 Jan 31;16:20. doi: 10.1186/s12984-019-0481-4. Tele-monitored tDCS rehabilitation: feasibility, challenges and future perspectives in Parkinson's disease. Cucca A, Sharma K, Agarwal S, Feigin AS, Biagioni MC.

The use of telemedicine combined with transcranial direct current stimulation (tDCS) protocols is increasing, although the safety of this approach in different clinical settings awaits further assessment.

Stud Health Technol Inform. 2019 Jul 4;262:340-343. doi: 10.3233/SHTI190088. Improving Patient Safety by Reducing Falls in Hospitals Among the Elderly: A Review of Successful Strategies. Khalifa M.

The utilization of innovative approaches of big data mining to explore reasons, circumstances of falls, and ways of reducing them are recommended through further research.



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15. How do technologies affect communication in health?

Reference Authors´ statement suggestive of knowledge fap

Clinicoecon Outcomes Res. 2019 May 6;11:325-333. doi: 10.2147/CEOR.S195597. eCollection 2019. Electronic referral systems in health care: a scoping review. Azamar-Alonso A, Costa AP, Huebner LA, Tarride JE.

The evidence base on the effectiveness of eReferral systems to improve communication between primary care and specialists and to decrease wait times is positive but limited. Economic evaluations are needed to examine the clinical and economic value of eReferral systems in health care.

Digit Health. 2019 Apr23;5:2055207619845831. doi: 10.1177/2055207619845831. eCollection 2019 Jan-Dec. Internet videoconferencing for patient-clinician consultations in long-term conditions: A review of reviews and applications in line with guidelines and recommendations. Ignatowicz A, Atherton H, Bernstein CJ, Bryce C, Court R, Sturt J, Griffiths F.

While the current evidence base for internet videoconferencing is equivocal, it is likely to change as more research is undertaken and evidence published.

care informatics and technologies project knowledge gaps ... · semwal m, whiting p, bajpai r,...

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