This thesis investigates methods for remote collaboration and communication within a Mixed Reality (MR) rehabilitation environment. Based on the research on remote communication methods and an interview with an occupational therapist with previous experience in MR rehabilitation, a video and audio stream communication method was chosen to be implemented. The implementation consists of two applications, one patient application developed for HoloLens 2 and one therapist application for Android devices. The latter was tested on professional occupational therapists to investigate the feasibility of the method.  The result of the test indicated that the general attitude toward remote rehabilitation was positive. However, the chosen method did not allow the therapist to see the patient's face and surroundings which was a problem for a majority of the test participants. The cognitive workload for the therapist when communicating with the patient was in magnitude to similar tasks and the application was relatively easy to navigate.

<p>This thesis reports on the development of a Two Way Interactive Video eConsult System (TWIVES), a telemedicine application for the continuity of care in rural communities, remote areas, and in developing countries. In developed countries like Canada, there has been much development of complex telemedicine solutions that may not be suitable for rural communities in developing countries. TWIVES can be a useful alternative when mobility is limited, the patient is disabled, or commuting is not an option for the patient. This system is both easy and inexpensive to use, and operates well in the low bandwidth Internet connections available in these areas.</p> <p>TWIVES aims to facilitate an environment where users can securely request medical consultations from healthcare providers at distant locations, thereby saving time, money, and providing patients access to medical expertise that would otherwise not be available. TWIVES also introduces the concept of web-based submission of requests, replacing the existing traditional method of telephoning to arrange personal face-to-face appointments.</p> <p>TWIVES is a proof of concept (POC) designed and built with the Drupal framework, with particular attention paid to access control and user management, content management, custom search, private messaging and file sharing, request management, and real time video consultation. This thesis explain the purpose and features of TWIVES, its interfaces, what it can do, the constraints under which it must operate, and how it will react to external stimuli.</p> / Master of Science (MSc)

<p> Telemedicine traffic transmission over wireless cellular networks has gained in importance during the last few years. Most of the current research in the field has focused on software and hardware implementations for telemedicine transmission, without discussing the case of simultaneous transmission of both urgent telemedicine traffic and regular multimedia traffic over the network.</p> <p> Due to the fact that telemedicine traffic carries critical information regarding the patients' condition, it is vitally important that this traffic has highest transmission priority in comparison to all other types of traffic in the cellular network. However, the need for expedited and correct transmission of telemedicine traffic calls for a guaranteed bandwidth to telemedicine users. This creates a tradeoff between the satisfaction of the very strict Quality of Service (QoS) requirements of telemedicine traffic and the loss of the guaranteed bandwidth in the numerous cases when it is left unused, due to the infrequent nature of telemedicine traffic. This waste of the bandwidth may lead to a lack of sufficient bandwidth for regular traffic, hence degrading its QoS.</p> <p> To resolve this complex problem, in this thesis, we propose a) an adaptive bandwidth reservation scheme based on road map information and on users' mobility, and b) a fair scheduling scheme for video traffic transmission over wireless cellular networks. The proposed combination of the two schemes, which is evaluated over a hexagonal cellular structure, is shown to achieve high channel bandwidth utilization while offering full priority to telemedicine traffic.</p> / Thesis / Master of Applied Science (MASc)

The term telemedicine is broadly defined as the use of information and communication technology to deliver health care at a distance. However, the concept of ‘telemedicine’ still lacks consensus both in the literature and in practice. Generation of telemedicine knowledge and evidence for clinical practice is still controversial within the telemedicine scholarship and among decision-makers as telemedicine objectives remain ill-defined and outcomes vary in time. In Ontario, despite the fast pace of information and communication technology change and the increased interest in its health applications, telemedicine is not a mainstream model of care delivery within the medical system. This study empirically investigates the social construction of telemedicine technologies to understand how telemedicine expectations shaped telemedicine in Ontario (Canada) from 1993 to 2017. Drawing from the Social Construction of Technologies framework (SCOT) and historical narrative analytical techniques, it identifies the shared understandings of what telemedicine is (and is not) and what role telemedicine plays in the health care system. I used grounded theory methodology to develop a narrative theory of how the future of telemedicine in Ontario has been constructed over the last 24 years from national newspaper articles, stakeholder documents, service provider websites, and semi-structured interviews with relevant telemedicine stakeholders. Findings show that the development of telemedicine narratives in Ontario is a multi-storied process of conflicting and overlapping visions and expectations among stakeholders and interests. Telemedicine expectations focus mostly on the process of innovation, the provideroriented approach to telemedicine, and the advantages and risks of adopting consumercontrolled telemedicine in a publicly insured health care system. The telemedicine visions result fragmented among different stakeholders and practices, overall inhibiting telemedicine’s future agenda. These findings intend to help researchers, policy makers, private vendors, and health care providers to create a vision of telemedicine that accommodates competing expectations among the clinical, technical, political, and commercial worlds. / Thesis / Doctor of Science (PhD) / Telemedicine delivers health care at a distance by letting doctors talk to patients or other doctors via video, email, or text messages. However, as simple as this idea is, researchers, physicians, policy-makers, and entrepreneurs have speculative, overlapping, and conflicting views about what it should be. These differing views create ambiguity and often confuse the aims of health policy decision-makers and end-users limiting telemedicine’s development. I intend to clarify telemedicine’s shared and diverging understandings of what telemedicine should be by analyzing how stakeholders in Ontario have told and tell stories about telemedicine’s future over the last three decades. I view stories of the technology’s future as persuasive policy arguments that stakeholders adopt to shape and use telemedicine according to their visions and goals. These findings will help researchers, policy-makers, doctors, and businesspeople understand what telemedicine is (and is not) to help them define policies and guidelines for its adoption and implementation.

Since the 1800's, technological advances have extended the foundation on which telemedicine could build. With its evolution, telemedicine has proven to be a means of offering effective health care interventions, from a multitude of disciplines. Teledermatology, a specialty application of telemedicine, offers great potential in improving the standard of dermatologic care by bridging the gap between the expert opinion of dermatologists and those without access to basic dermatologic care, particularly in developing nations, where skin disease continues to be a major public health problem. In Honduras, the setting for this study, and other developing nations, technology to support telemedicine is available. Dermatologic disease is among the most common disease presentations in the developing world, which left untreated due to a lack of access to adequate medical care, can progress causing increased morbidity or even death. A potential but untested solution is teledermatology. Teledermatology offers great potential in improving the standard of dermatologic care by bridging the gap between the expert opinion of dermatologists and those without access to basic dermatologic care. The purpose of this study was to evaluate the prevalence and types of dermatologic conditions and the feasibility of a store-and-forward teledermatology system in an underserved area of Honduras, so as to potentially provide more timely diagnosis and treatment, implementation of preventative measures, and offer long term solutions.so as The justification and significance of this study was the potential of store-and-forward teledermatology to improve the standard of dermatologic care by improving access of populations in underserved areas to dermatology specialists through affordable technology. The methodology of this study was primarily case study descriptive. This study was conducted at a public primary care clinic (JMA Clinic) and satellite sites in underserved areas of Francisco Morazán, Honduras. During a four week period in Spring 2011, patients with dermatologic conditions were examined and photos taken of condition. The patient information was sent to 3 U.S. board certified dermatologists, who provided diagnosis and treatment within 24 hours, which allowed the clinic physician sufficient time to review recommendations before patient follow-up. Patients would receive follow-up within 48 hours of initial visit. Diagnostic agreement, image quality, and user satisfaction were evaluated. IRB forms were submitted and clearance given. The data was analyzed with SPSS using descriptive statistics. The primary findings were the types of dermatologic conditions, interobserver agreement, image quality, and patient and physician satisfaction. The findings of this study substantiate the need for dermatologic care, as approximately 1 out of every 5 patients of the JMA Clinic presented with a dermatologic condition. The majority of these patients were children or women in their late 20s and early 30s; many of whom had their condition for more than a year and most had not received prior therapy. The types of dermatologic conditions observed were typical of that seen at a dermatology clinic in the U.S., yet inclusive of tropical and regional differences. Dermatitis, infectious and pigmentary conditions were the most common presentations. The interobserver diagnostic agreement achieved was 78%, and improved when considering differential diagnoses. Image quality received high ratings. Patients and physicians recorded a high level of overall satisfaction. Physicians indicated improved knowledge of teledermatology. Because of the unique environment and circumstances, the results are limited to the setting in which the study occurs. This project was a pilot study limited to 4 weeks of data collection and will be limited in significance by its duration and small sample size with respect to the conclusions that can be drawn about the prevalence and types of dermatologic conditions. This study illustrates that teledermatology is a viable means of providing dermatologic care to those in an underserved area of Honduras, where a lack of or limited access to general healthcare or specialty dermatologic care exists. The data offers insights to draw conclusions and recommendations on the potential for similar models to be implemented in underserved areas throughout Honduras and other similar regions. / Ph. D.

Teleradiology has far-reaching implications for the health of remote and underserved populations. With coordination of radiographic evaluation and diagnosis from a distance, teleradiology has the potential to raise the standard of patient care throughout the world. Perhaps the safest and most cost-effective mode of teleradiology today is telesonography. The current research determined that telesonography improves the standard of care at a rural, government-run primary clinic within the Dominican Republic. The work reported herein is intended to compare the use of telesonography to the current standard of sonographic examination which is referral to government hospital 60km from the clinic. the following research questions were addressed: When compared to the standard of care, (1) To what extent does the use of asynchronous telesonography increase the percentage of received sonographic reports based on the total number of ultrasound referrals (sonographic reports / total number of referrals)? (2) To what extent does the use of asynchronous telesonography increase the rate of successful follow-up visits based on the total number of ultrasound referrals? (3) To what extent does the elapsed time between ultrasound referral and sonographic report delivery decrease with the use of asynchronous telesonography? (4) To what extent does the elapsed time between ultrasound referral and patient follow-up decrease with the use of asynchronous telesonography? Research methodology included randomly assigning 100 patients with clinical indications for sonographic examination into experimental and control groups during a 9-week implementation period. Findings from this study indicate that the implemented telesonography system, along with patient awareness of such a system, while not having an appreciable effect on the time to patient follow-up, provided a 4-fold increase in the proportion of patient follow-ups and a 6-fold increase in the proportion of returned radiological reports, and delivered those reports to the referring physician 6-times faster than in the control group. This study demonstrates the feasibility of utilizing a store-and forward telesonography system within this setting. Additional research focusing on the impact of telesonography on patient outcomes within this setting is recommended. / Ph. D.

Adults aged 65 years and above have grown substantially over with past decade. However, the chance of developing multiple comorbidities only increases with age. Because elderly residents of rural Appalachia often encounter barriers to healthcare, rural nurses, providers, and policy makers must overcome physical and structural barriers, but also gain a more in-depth understanding of the personal and cultural attitudes impacting the use of new and innovative forms of healthcare delivery. With a slow and variable uptake of telehealth adoption in rural Appalachia, and in the presence of well-documented medical mistrust, this study was designed to better understand the degree of medical mistrust existing in the elderly of rural Appalachia and to assess if medical mistrust may be inhibiting efforts related to telehealth acceptance. A correlational design was utilized administering the Medical Mistrust Index (MMI) and Technology Acceptance Model (TAM) questionnaire via electronic survey to those age 65 years and above living in rural Appalachia. Deemed well-established and validated, the MMI measures medical mistrust from a broader perspective, while TAM assesses telehealth acceptance in terms of perceived usefulness, perceived ease of use, and overall attitude towards telehealth as a technology. Demographics of gender, income, education, and previous telehealth experience were compared to MMI and TAM scores. The study revealed a moderate level of medical mistrust and telehealth acceptance among the elderly of rural Appalachia. A statistically significant negative relationship was found between MMI and TAM for those reporting previous telehealth experience, and among all demographics, with the strongest correlations found among females and participants of lower education. Elderly rural Appalachians have a rich social and cultural history, but past experiences and long-held beliefs have resulted in medical mistrust and slow telehealth uptake. Stakeholders have a responsibility to meet individuals where they are understanding that elderly residents of rural Appalachia may not be ready or fully prepared to incorporate telehealth into their management of care. However, quality rural nursing practice and continued research has the ability to evolve to meet the needs that exist among those of advancing age with limited healthcare resources such as those found in rural Appalachia.

Yes / Background: Online communities hold great potential as interventions for health, particularly for the management of chronic illness. The social support that online communities can provide has been associated with positive treatment outcomes, including medication adherence. There are few studies that have attempted to assess whether membership of an online community improves health outcomes using rigorous designs. Objective: Our objective was to conduct a rigorous proof-of-concept randomized controlled trial of an online community intervention for improving adherence to asthma medicine. Methods: This 9-week intervention included a sample of asthmatic adults from the United Kingdom who were prescribed an inhaled corticosteroid preventer. Participants were recruited via email and randomized to either an “online community” or “no online community” (diary) condition. After each instance of preventer use, participants (N=216) were required to report the number of doses of medication taken in a short post. Those randomized to the online community condition (n=99) could read the posts of other community members, reply, and create their own posts. Participants randomized to the no online community condition (n=117) also posted their medication use, but could not read others’ posts. The main outcome measures were self-reported medication adherence at baseline and follow-up (9 weeks postbaseline) and an objective measure of adherence to the intervention (visits to site). Results: In all, 103 participants completed the study (intervention: 37.8%, 39/99; control: 62.2%, 64/117). MANCOVA of self-reported adherence to asthma preventer medicine at follow-up was not significantly different between conditions in either intention-to-treat (P=.92) or per-protocol (P=.68) analysis. Site use was generally higher in the control compared to intervention conditions. Conclusions: Joining an online community did not improve adherence to preventer medication for asthma patients. Without the encouragement of greater community support or more components / Funded by a pilot grant from the University of Leeds School of Psychology. A Fulbright Scholarship from the US-UK Fulbright Commission supported the first author

Yes / Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke. Methods: A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up. Results: Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log. Conclusions: Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings. / The SCRIPT (Supervised Care & Rehabilitation Involving Personal Telerobotics) project was partly funded by the European Commission Seventh Framework Program under grant agreement no. FP7-ICT-288698.

Yes / The increasing prevalence and associated cost of treating chronic obstructive pulmonary disease (COPD) is unsustainable. Health care organizations are focusing on ways to support self-management and prevent hospital admissions, including telehealth-monitoring services capturing physiological and health status data. This paper reports on data captured during a pilot randomized controlled trial of telehealth-supported care within a community-based service for patients discharged from hospital following an exacerbation of their COPD. The aim was to undertake the first analysis of system data to determine whether telehealth monitoring can identify an exacerbation of COPD, providing clinicians with an opportunity to intervene with timely treatment and prevent hospital readmission. Methods: A total of 23 participants received a telehealth-supported intervention. This paper reports on the analysis of data from a telehealth monitoring system that captured data from two sources: (1) data uploaded both manually and using Bluetooth peripheral devices by the 23 participants and (2) clinical records entered as nursing notes by the clinicians. Rules embedded in the telehealth monitoring system triggered system alerts to be reviewed by remote clinicians who determined whether clinical intervention was required. We also analyzed data on the frequency and length (bed days) of hospital admissions, frequency of hospital Accident and Emergency visits that did not lead to hospital admission, and frequency and type of community health care service contacts—other than the COPD discharge service—for all participants for the duration of the intervention and 6 months postintervention. Results: Patients generated 512 alerts, 451 of which occurred during the first 42 days that all participants used the equipment. Patients generated fewer alerts over time with typically seven alerts per day within the first 10 days and four alerts per day thereafter. They also had three times more days without alerts than with alerts. Alerts were most commonly triggered by reports of being more tired, having difficulty with self-care, and blood pressure being out of range. During the 8-week intervention, and for 6-month follow-up, eight of the 23 patients were hospitalized. Hospital readmission rates (2/23, 9%) in the first 28 days of service were lower than the 20% UK norm. Conclusions: It seems that the clinical team can identify exacerbations based on both an increase in alerts and the types of system-generated alerts as evidenced by their efforts to provided treatment interventions. There was some indication that telehealth monitoring potentially delayed hospitalizations until after patients had been discharged from the service. We suggest that telehealth-supported care can fulfill an important role in enabling patients with COPD to better manage their condition and remain out of hospital, but adequate resourcing and timely response to alerts is a critical factor in supporting patients to remain at home. / This project was funded by the National Institute for Health Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber (CLAHRC YH).