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Assoc. Prof Nico Bruining ,
Editor-in-Chief, European Heart Journal – Digital Health
e-Health has become an integrated part of clinical practice. The current pandemic has underlined how valuable e-Health applications are both for caregivers and for patients as well. Over the past weeks the e-Journal of Cardiology Practice has presented an interesting series of papers describing several of the very beneficial e-Health applications related to cardiology care and what it takes to implement them with respect to privacy and security. This editorial gives you a short overview of these papers and, in addition, presents you with some more information about the digital health (DH) strategies of the European Society of Cardiology (ESC) for the near future.
As mentioned above, the e-Journal of Cardiology Practice recently presented an interesting and educational series of papers starting with a description of the fundamentals of e-Health, followed by a paper describing portable ECG recorders and e-Health applications for heart failure (HF) patients. The series was concluded by a paper touching on the important topics of privacy, cybersecurity and ethics.
Although cardiology was an early adopter of computer technology to assist in daily clinical practice, it is only more recently that it has received mainstream attention. Until the current pandemic of COVID-19, the increased interest was mainly driven by innovations using artificial intelligence (AI), machine learning (ML), big data, etc. The European Society of Cardiology (ESC) brought e-Health, often also referred to as digital health (DH), into the spotlight by inviting Prof. Eric Topol to open the annual ESC congress in 2017. Prof. Topol is a pioneer in this field and has published several books about how DH is going to disrupt medicine. That inaugural lecture is available online at https://bit.ly/2OtXEJe. If you scroll through the video to the time of 22:10 minutes, Prof. Jeroen Bax, the ESC president in 2017, introduces Prof. Topol.
Another initiative of the ESC was the creation of the Digital Health Committee (DHC) which organised the past two annual ESC congresses’ well visited dedicated DH symposia. In addition, last year the ESC organised a DH summit in Tallinn, Estonia, where hundreds of engaged scientists, cardiologists and healthcare professionals gathered to exchange and discuss the latest information on DH developments within cardiology. Later this year this will be followed up by an online digital health week.
Finally, at the time of the virtual annual ESC congress at the end of August, a dedicated DH journal is being launched entitled European Heart Journal – Digital Health (EHJ DH).
We are all used to computer technology playing a major role in our daily lives. However, the current terminology of e-Health, Digital Health, and m-Health can be confusing. The paper by Arvind Singhal and the chair of the ESC DHC Prof. Martin Cowie  describes in detail what e-Health encompasses and touches on the topics which are expected to be beneficial such as telemedicine, smartphone Apps and wearable sensors. Indeed, the current pandemic has shown how valuable applications within these areas can be. Patients could not go, or did not want to visit the caregivers, whether they were their general practitioners or hospitals. That caused a major change in many hospitals where teleconsultations were rapidly introduced. It also tackled the problem under discussion for many years, namely reimbursement of teleconsultations. In many countries, health insurance covers these costs now, seeing the need and the advantages.
The use of Apps on smartphones has exploded over the past few years. The smartphone has become the personal computer which >80% of the population in developed countries carry with them constantly. Major companies such as Apple and Google have dedicated health divisions working on health and lifestyle Apps. Many applications can be found in the App stores; however, care must be taken as to whether the quality of these Apps meet the required quality standards which we need to be able to use them clinically. The paper by Paglialonga et al describes potential pitfalls .
Apps on the smartphone can be enhanced when connected to additional sensors. Smartwatches and other lifestyle products such as Fitbits, etc., are very popular. The sensors to which they can connect are rapidly becoming more “medical grade”. Applications such as ECG measurements, until now used mostly to detect arrhythmias such as atrial fibrillation (AF), are under investigation and some studies can be found in the highest ranking journals [3-5]. Other developments, which are highly anticipated, are sleep trackers and the possibility to continuously monitor SpO2. This could be extremely interesting for early detection of and/or to follow up COVID-19 patients. Some hospitals are already providing discharged COVID-19 patients with an SpO2 device to monitor possible deterioration.
Where the above-mentioned paper provides in-depth information about the concept of e-Health, the paper by Mario Bocchiardo and Riccardo Asteggiano zooms in on the use of portable ECG devices . They present an extensive overview of these devices and their particular pros and cons. Indeed, many of these devices do have the possibility to transmit their recordings to the caregivers by the Global System for Mobile Communications (GSM) or via the internet, for example using external or implantable loop recorders. In addition, other device specifications, and importantly whether they have received FDA clearance, are also provided.
The authors describe the clinical indications of when to use these portable devices, what the possible pitfalls in the interpretation of the recorded ECG signals are and the legal considerations to be taken into account. The final part of this paper touches on the use of smartphones and smartwatches and provides an overview of the latest studies using these devices in the literature. The authors indicate that the new ECG monitoring devices are changing clinical practice and that needs adaptation requiring new legal and scientific rules, which in turn requires more study.
HF patients potentially represent the fastest growing patient population within cardiology. This chronic condition needs close attention/monitoring to prevent further patient deterioration, which could ultimately result in hospital admission(s). As most patients, although limited by their cardiac function, are still as far as possible participating in society, there is a large demand for remote-patient management (RPM). In addition, this pathology also often requires peer contacts, e.g., doctor to doctor. The paper by Sandra Prescher, Johanna Koehler and Prof. Friedrich Koehler presents an overview of how HF patients can be remotely monitored and managed, including an overview of the most important trials in the literature .
As the authors describe, there is a large variety of available devices to monitor HF patients invasively or non-invasively. The integration of the data these devices acquire can be a challenge in clinical practice. Seamless integration into the electronic medical record systems is in many cases not yet available. Despite this, remote monitoring of HF patients is the most investigated telecardiology application. More than a decade ago early developments were already described, showing the great potential of telemonitoring for HF patients [8,9]. The more recent literature is presented and discussed by the authors.
As the authors state, the clinical benefits of RPM are still a topic for further research. Positive effects are being found in patient cohorts up to one year after treatment. However, whether these will be sustained over longer time periods is not yet known, requiring more study. Additional developments to monitor HF patients, such as the previously mentioned smartwatches and the application of AI-driven developments including voice analysis devices, are also described by the authors.
The last paper in this e-Health series written by Prof. Enrico Caiani touches on the topic of ethics and digital tools , an important and complex topic. Digitisation has brought us many conveniences in our everyday daily lives. For example, look at how we handle our financial business, have access to science, news and information, communicate with each other and remotely monitor our smart homes. However, we also face the downside(s) of digital comfort such as cybercrime, including unauthorised access to the most valued information about ourselves including our finances and medical data. Many medical institutions are working hard to avoid these threats, also taking into account European privacy law(s) such as the General Data Protection Regulation (GDPR) .
Besides these privacy concerns as to who has access to, and how our medical data are protected, there are also concerns about new computer-based technologies such as AI. AI algorithms can be self-learning and change their behaviour (set of rules) over time and in contrast computer codes developed by humans, AI algorithms could become a sort of black box where no-one can explain exactly how it works and thus how it came to a certain “result”. Prof. Caiani carefully explains the many different ethical aspects that need to be addressed so that we can move forward, further investigating the possible advantages that these new advanced computer technologies can bring to daily clinical practice safe in the knowledge that they provide accurate outcomes and keep our most valued data secure.
Our world has changed since COVID-19. The worldwide lockdowns have prohibited us from travelling and so we are unable to participate physically in congresses where the latest in cardiology science is shared. However, it is also here that computer technology can be of great help, enabling the organisation of virtual symposia and congresses. Although not the same experience, since we will miss the personal contact with our colleagues and friends, they allow us to exchange study results and new insights and experience in clinical practice which can further optimise patient care. Virtual congresses also permit a much larger participation since there is no need to travel. Travel can be a limiting factor as it can be time-consuming and costly. I am looking forward to the evaluation of how we all experienced the virtual dissemination of science.
e-Health brings many advantages in clinical practice for healthcare professionals and patients. A couple of important e-Health applications have been described in this series of papers. The current pandemic has shown us how fragile our health is with the dangers out there. Luckily, the further digitisation of healthcare systems can help us to overcome the limitations brought upon us as caregivers as well as for our patients. Therefore, this series describing several different e-Health applications is of great value.
As clinicians, scientists, healthcare professionals and industry, we are presently limited in terms of being able to meet each other physically to exchange the latest results of cardiovascular research and care. However, here too digitisation provides a method to overcome this problem by giving us the opportunity to meet online.
Nico Bruining1,2, PhD, FESC
Address for correspondence:
Associate Professor Nico Bruining, Erasmus MC, Room Na-312, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
The author has no conflicts of interest to declare.
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