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Obesity is increasing in the pediatric population and it represents an important risk factor for the life-long development of several diseases. The aim of this work is to reduce children obesity through an educational program delivered through a mobile application. Novelties of our approach are the involvement of the families in the program and a design inspired to psychological/behavioral change theories, with the aim of maximizing the chance of patients' compliance to the program. A pilot usability and acceptability study has been performed on ten children aged 6-12 years using a questionnaire to evaluate eight system features on a Likert scale from 1 to 5. Encouraging results were obtained: mean scores were all above 3.

Obstructive sleep apnea (OSA) is a common sleep disorder and polysomnography (PSG) is the gold standard for its diagnosis and treatment monitoring. There are nowadays several activity trackers measuring sleep quality through the detection of sleep stages. To allow an easier monitoring of the treatment efficacy at home, this work explores the possibility of using one of those commercial smart-bands. To this aim, we studied the signals provided by PSG and a Fitbit smart-band on 26 consecutive patients, admitted to the hospital after the diagnosis of OSA, and submitted to ventilation or positional treatment. They underwent monitoring for three nights (basal, titration, and control). We developed both a visualization software allowing doctors to visually compare the two hypnograms, and a set of statistics for assessing the concordance of the two methods. Results indicate that Fitbit can detect normal sleep patterns, while it is less able to detect the abnormal ones.

Patient reported outcomes have been shown to be predictive of cancer patients' prognosis, and their monitoring through electronic applications have been shown to positively impact survival. On the other hand, patient apps in general show a number of criticalities that often lead patients to abandon their use. One of them is usability. A scarce attention to usability during app development leads to unsatisfactory user experience. In this work, we present an algorithm to facilitate patient symptoms reporting, by personalising the list of symptoms according to their probability of occurrence in the specific patient. This avoids searching long lists of items, thus decreasing the patients' burden in symptom reporting.

The CAPABLE project has been funded by the EU Horizon 2020 Programme over the years 2020-24 to support home care. A system is being designed and implemented supporting remote monitoring and virtual coaching for cancer patients. The system is based on a distributed modular architecture involving many components encapsulating various knowledge. The Case Manager has been designed as a separate component with the aim of coordinating the problem solving strategies. A first version of the Case Manager has been released and used by the components in a prototypical scenario shown at the first project review.

CoRe is a system for cognitive rehabilitation that has been successfully used for several years in hospital settings. Leveraging on the positive survey results from the potential final users (patients and their home caregivers), we developed HomeCoRe. This new version of the system will allow discharged patients to continue the rehabilitation treatment at home.

In this work we exploited an algorithm, already present in the literature, and based on the notion of signal permutation entropy, to analyze a very long time series of sleep data from a single subject. The aim of the work is to explore methods for personalizing alerts related to sleep anomalies, and recommendations for improving sleep quality. As a matter of fact, sleep duration and sleep quality may differently affect daily performance of different people, as well as daily activities may differently affect sleeping during the night. Data have been collected from a Fitbit Alta HR activity tracker worn by the subject for about three years. Results show that personalized inferences may be very different from the generic (population-based) ones, and that correlations found may suggest subject-specific life-style modifications useful to improve sleep quality.

Background: There is no successful pharmacological treatment for cognitive impairment in Parkinson's Disease, therefore treatments capable of slowing down the progression of cognitive dysfunction are needed., Objective: To evaluate the effectiveness of a cognitive training, supported by the CoRe computerized tool, in patients with Parkinson's Disease Mild Cognitive Impairment., Methods: This is a prospective, open-unblinded, randomized, controlled study. After baseline cognitive assessment (T0), enrolled patients were randomized to receive motor rehabilitation plus cognitive intervention (G1) or motor rehabilitation only (G2). Follow-up assessments were scheduled 4 weeks (T1) and 6 months after (T2). Global cognitive functioning scores (MOCA and MMSE) were considered as primary outcome. Outcome measures at T0, T1 and T2 were compared within- and between-groups. A percentage change score between T0 and next assessments was calculated to identify patients who improved, remain stable or worsened., Results: Differently from G2, G1 showed a medium/large effect size improvement in primary (MoCA) and secondary outcome, both between T0 and T1 and T0 and T2. Moreover, within G1, most patients improved their cognitive state compared to the baseline., Conclusions: Patients trained with CoRe showed a better evolution of cognitive decline, while untreated patients tended to get worse over time.

Ketogenic Diet (KD) is a high-fat diet used to treat refractory epilepsy in patients, also including children. Because of the inherent differences with a balanced diet, patients starting KD face an abrupt switch of dietary habits. Moreover, KD is associated with several side effects that should be closely monitored. In this paper, we propose an mHealth application for training and empowering patients in managing KD. The application also acts as a bridge connecting patients with the health care staff for coaching and monitoring purposes.

In this work we describe an experiment involving aphasic patients, where the same speech rehabilitation exercise was administered in three different modalities, two of which are computer-based. In particular, one modality exploits the "Makey Makey", an electronic board which allows interacting with the computer using physical objects.

Studies describing Computer-Interpretable Clinical Guidelines (CIG) with temporal constrains (TC) generally have not addressed issues related to their integration into Electronic Health Record (EHR) systems. This study aimed to represent TCs contained in clinical guidelines by applying archetypes and Guideline Definition Language (GDL) to incorporate decision support into EHRs. An example of each TC class in the clinical guideline for management of Atrial Fibrillation was represented using archetypes and GDL.

The paper illustrates a pilot study involving nurses and paramedic staff to evaluate a mobile platform for rendering and distributing emergengy care protocols. Its specific features were developed to simplify the consultation and reduce the factors that negatively affect the adherence to standards. The study was planned to last one month and two questionnaires are administered to the participants: one at the starting phase, pre-intervention, and one at the end, post-intervention. Here we report the results and considerations coming from the first administration.

Leveraging the experience of the European project MobiGuide, this paper elaborates on the nurses' role in developing, delivering and evaluating e-health based services. We focus on the home monitoring of atrial fibrillation. Patients enrolled in our study are provided with a smartphone and an ECG sensor, and receive recommendations, reminders and alerts concerning medications and measurements that they should perform through a mobile decision support system that is constantly updated by a backend system. Patients' data are sent to health care personnel that may visualize them, and act accordingly. Nurses play a central role in such setting. After being involved in the design of the caregiver interface, they are responsible for the patients' enrollment phase (which includes patients' training), for the daily checking of incoming data, for the triage of patients' complaints, and for the final phase of the study where patients are interviewed about their experience with the system.

An increasing prevalence of chronic diseases is observed, among which cancer is now included because of its survival rates. That trend requires new ways of supporting outpatients and improving their compliance to treatments. This paper introduces HeNeA, a mobile application designed to support patients affected by Head and Neck cancer during their treatments. The application leverages on the mHealth features described in the literature and has been reviewed by a small set of patients during its development. Further evaluation is expected to occur when it will be offered to every eligible patient discharged from the Head and Neck division of a major Italian cancer centre.

Spinal cord injury (SCI) is a damage to the spinal cord resulting in a change, either temporary or permanent, in motor, sensory, or autonomic functions. Patients with SCI usually have permanent and often devastating neurologic deficits and disability. Trunk motor control is crucial for postural stability and propulsion after low thoracic SCI and several rehabilitative strategies are aimed at trunk stability and control. Tablet technology and gaming systems are novel and potentially useful strategies that apply relevant concepts in rehabilitation for these patients. In this study we combined the traditional training of trunk control with exercises administered through two iPad games apps, 2 or 3 times a week. All the participant patients showed increasing game scores during the treatment, as well as increasing Trunk Recovery Scale scores, showing a significant improvement in trunk control. Also the personal judgment of the patients, collected through evaluation questionnaires, was very positive.

We recently developed UceWeb, an application for direct elicitation of utility coefficients (UCs), i.e. a measure of health states quality perceived by patients. UceWeb was used to interview a sample of patients affected by spinal cord injury (SCI). A standard questionnaire for measuring quality of life (QoL) and another one for the system evaluation were also administered to the same patients. The aims of this work are to (i) evaluate UceWeb usability; (ii) investigate relationships among QoL values elicited with different methods, (iii) create a reference set of UCs for the health states experienced by SCI patients. We show preliminary results obtained with the first 20 patients. Despite great variability found among QoL values elicited with the different methods, interesting correlations with patients' condition and profile have been found.

The paper describes the adaptation of a mobile platform initially developed for designing and administering questionnaires to a new context supporting checklists in emergency care. We took part in the checklists formalization process together with the domain experts and recognized that some tasks would highly benefit from the inherent features offered by the mobile technology. Thus we exploited the robustness of the model already designed for navigating among questionnaires and implemented additional functionalities that improved the usability of the mobile application, making it suitable for the paramedic staff and the volunteers that manage emergency cases.

Quality of life is a complex concept, entailing the person's physical health and level of independence, as well as psychological well-being, social participation and the relationship with specific and relevant aspects of the environment. The World Health Organization encourages the integration of a comprehensive definition of health when examining patient-related outcomes after injury or disease. This study aims at evaluating the quality of life of 130 Italian patients with spinal cord injury, focusing on the associations among functional status and health dimensions elicited by SF-36 questionnaire. The subscale scores that revealed a stronger impact of the lesion were those related to the physical domains, especially for the physical functioning and physical role functioning. Physical functioning scores were significantly different in the acute phase with respect to chronic phase, in inpatients with respect to outpatients and in patients with lower functional impairment versus patients with higher functional impairment. Moreover, the functional impairment influenced significantly physical role, bodily pain and vitality scales. Disease phases also showed significantly different scores for general health. No differences were highlighted between tetraplegic and paraplegic patients.

We illustrate G-quest, a platform originally meant to deliver questionnaires on mobile devices that supports the accomplishment of studies involving outpatients. However the constructs made available by the platform proved to be useful also for distributing learning material and checklists, after a paradigm shift in their application was adopted. Thus, in addition to questionnaires, we designed a guide for educating patients affected by a rare disease and conducted a small survey to assess this new application context. Presently we are exploiting G-quest for the provision of medical checklists in critical care.

MobiGuide is a project devoted to the development of a patient-centric decision support system based on computerized clinical guidelines for chronic illnesses including Atrial Fibrillation (AF). In this paper we describe the process of (1) identifying guideline recommendations that will require patients to take actions (e.g., take measurement, take drug), thus impacting patients' daily-life behavior, (2) eliciting from the medical experts the corresponding set of personalized operationalized advices that are not explicitly written in the guideline (patient-tailored workflow patterns) and (3) delivering this advice to patients. The analysis of the AF guideline has resulted in four types of patient-tailored workflow patterns: therapy-related advisors, measurements advisors, suggestions for dealing with interventions that may require modulating patient therapy, and personalized packages for close monitoring of patients. We will show how these patterns can be generated using information stored in a patient health record that embeds clinical data and data about the patient's personal context and preferences.

This work evaluates the users' satisfaction with an SMS-based reminder system that is being used since about six years by an Italian healthcare organization. The system was implemented for reducing dropouts. This goal has been achieved, as dropout decreased from 8% to 4%. During these years, a number of reminded citizens, even not required, sent an SMS message back, with comments about the service, further requirements, etc. We collected some thousands of them. Their analysis may represent a useful feedback to the healthcare organization. We used conditional random fields as the information extraction method for classifying messages into appreciation, critique, inappropriateness, etc. The classification system achieved a very good overall performance (F1-measure of 94%), thus it can be used from here on to monitor the users' satisfaction in time.

The blood transfusion is a complex activity subject to a high risk of eventually fatal errors. The development and application of computer-based systems could help reducing the error rate, playing a fundamental role in the improvement of the quality of care. This poster presents an under development eLearning tool formalizing the guidelines of the transfusion process. This system, implemented in YAWL (Yet Another Workflow Language), will be used to train the personnel in order to improve the efficiency of care and to reduce errors.

Computer-based approaches can add great value to the traditional paper-based approaches for cognitive rehabilitation. The management of a big amount of stimuli and the use of multimedia features permits to improve the patient's involvement and to reuse and recombine them to create new exercises, whose difficulty level should be adapted to the patient's performance. This work proposes an ontological organization of the stimuli, to support the automatic generation of new exercises, tailored on the patient's preferences and skills, and its integration into a commercial cognitive rehabilitation tool. The possibilities offered by this approach are presented with the help of real examples.

The system described in this paper is aimed at improving the clinical workflow of post-stroke patients under oral anticoagulant therapy (OAT). The system helps both physicians and patients during the periodic control visits necessary to assess the anticoagulation status and the next therapeutic plan. Controls represent a burden for both patients, which after blood drawing must wait for the result, and for physicians, that, after assessing the therapy plan, must communicate it to patients, face-to-face or by telephone. A system is proposed, which embeds an algorithm for the patient-tailored calculation of the drug dosage and scheduling, and an automatic telephone dialogue for the communication of the therapy plan, once it has been validated or adjusted by the physician.

In a competitive health-care market, hospitals have to focus on ways to streamline their processes in order to deliver high quality care while at the same time reducing costs. To accomplish this goal, hospital managers need a thorough understanding of the actual processes. Diffusion of Information and Communication Technology tools within hospitals, such as electronic clinical charts, computerized guidelines and, more generally, decision support systems, make huge collections of data available, not only for data analysis, but also for process analysis. Process mining can be used to extract process related information (e.g., process models) from data, i.e., process mining describes a family of a-posteriori analysis techniques exploiting the information recorded in the event logs. This process information can be used to understand and redesign processes to become efficient high quality processes. In this paper, we apply process mining on two datasets for stroke patients and present the most interesting results. Above all, the paper demonstrates the applicability of process mining in the health-care domain.

Stroke is a serious neurological accident which accounts for a wide fraction of the healthcare costs in industrialized societies. Recovery from stroke and other neurological accidents usually include motor rehabilitation, maintained for several months, and logopedic training for the recovery of cognitive and speech abilities. The MyHeart consortium is addressing several aspects of cardiovascular diseases' management by combining clothes with embedded biomedical sensors and information technologies. One of the application areas is especially devoted to supporting Neurological Rehabilitation (NR). This article describes how MyHeart's Concept NR is structured and how technologies are leveraged to support both motor rehabilitation and speech/cognitive training. Information technology and garment-embedded sensors, combined, permit assisted training both at the clinic and at home, after discharge from the intensive care unit.

This work describes the results of the implementation of a workflow management system integrated into the electronic clinical chart of a Stroke Unit. The workflow logic is based on the rules provided by the SPREAD guidelines for stroke management. In this way, the already existing clinical chart has been transformed into an evidence-based, real-time decision support system, meanwhile maintaining the same look the users were familiar with. Since the final aim of the work was to improve evidence-based behavior and detect possible organizational bottlenecks, non-compliance to the clinical practice guidelines, before and after the system introduction, have been analyzed, as well as the accuracy of the clinical chart compilation, some care process variables, and system usability. Results show that the system enhances the clinical practice without boring users. Moreover, non-compliance analysis gives rise to ideas for further improvement.

The objective of this work is to reduce the number of outpatients dropouts, i.e. appointments that, unexpectedly, are not attended by the scheduled patients, thus causing disturbances to the regular ambulatory workflow, waste of resources, and, eventually, longer waiting lists for ambulatory care. A collateral, but not less important result is the improvement of the relationship between citizens and the public Hospital Company. The method proposed consists in sending short instant messages to remind the appointment. After the promising estimates obtained by a preliminary cost-benefit analysis, a commercial product was purchased for the communication infrastructure, while a software module has been developed for interacting with the legacy system, in order to retrieve the information necessary to compose the text of every sms and send it to the citizen. The system has been implemented since seven months, and its benefits have been measured. Dropouts trend, stable at 7-8% during last years, is clearly decreasing, while the number of citizens providing their mobile number to the healthcare booking facilities is constantly increasing. Our conclusion is that the cost of the system will be amortised in a very short time, leading to a significant cost saving and, hopefully, to shorter waiting lists.

This paper describes the architecture of NewGuide, a guide-line management system for handling the whole life cycle of a computerized clinical practice guideline. NewGuide components are organized in a distributed architecture: an editor to formalize guidelines, a repository to store them, an inference engine to implement guidelines instances in a multi-user environment, and a reporting system storing the guidelines logs in order to be able to completely trace any individual physician guideline-based decision process. There is a system "central level" that maintains official versions of the guidelines, and local Healthcare Organizations may download and implement them according to their needs. The architecture has been implemented using the Java 2 Enterprise Edition (J2EE) platform. Simple Object Access Protocol (SOAP) and a set of con-tracts are the key factors for the integration of NewGuide with healthcare legacy systems. They allow maintaining unchanged legacy user interfaces and connecting the system with what-ever electronic patient record. The system functionality will be illustrated in three different contexts: homecare-based pressure ulcer prevention, acute ischemic stroke treatment and heart failure management by general practitioners.

Guidelines are often based on a mixture of evidence-based and consensus-based recommendations. It is not straightforward that providing a series of "good" recommendations result in a guideline that is easily applicable, and it is not straightforward that acting according to such recommendations leads to an effective and efficient clinical practice. In this paper we summarize our experience in evaluating both the usability and the impact of a guideline for the acute/subacute stroke management. A computerised version of the guideline has been implemented and linked to the electronic patient record. We collected data on 386 patients. Our analysis highlighted a number of non-compliances. Some of them can be easily justified, while others depend only on physician resistance to behavioural changes and on cultural biases. From our results, health outcomes and costs are related to guideline compliance: a unit increase in the number of non-compliance results in a 7% increase of mortality at six months. Patients treated according to guidelines showed a 13% increase in treatment effectiveness at discharge, and an average cost of 2929 Euros vs 3694 Euros for the others.

In recent years, the concept of "global cardiovascular risk assessment" has grown in interest for its role in primary prevention of cerebro-cardiovascular diseases. Interventions for reducing the risk of relapse for persons with past history of these diseases are well agreed-on. On the contrary, the risk status of persons without such a history varies greatly, and this variability implies a range in the intensity of interventions. In several countries, guidelines for general practitioners have been diffused about pharmaceutical prescriptions in presence of various risk degrees. In particular, in Italy, a governmental drug management commission has established that statins, the most used cholesterol lowering medicines, can be refunded by the National Healthcare System only if prescribed to hyper-cholesterol patients with a global risk greater than 20%. The question is: how to calculate the risk? We performed a review of both the web and the literature and we found a lot of different "risk calculators". By means of a simulation study, we showed that these tools, when applied to the same person, may lead to very different results. We estimated the economic impact of using one or another calculator.

Recent advances in automatic speech recognition and related technologies allow computers to carry on conversations by telephone. We developed an intelligent dialog system that interacts with hypertensive patients to collect data about their health status. Patients thus avoid the inconvenience of going for frequent visits that monitor some clinical variables they can easily measure at home; the physician is facilitated in acquiring and reviewing patient information and related risk indicators, which are evaluated from the data according to noted guidelines. The system described here is a prototype of future configurable and component-based dialog systems, which may allow a new modality for users and physicians to access electronic health records.

Medical knowledge in clinical practice guideline (GL) texts is the source of task-based computer-interpretable clinical guideline models (CIGMs). We have used Unified Medical Language System (UMLS) semantic types (STs) to understand the percentage of GL text which belongs to a particular ST. We also use UMLS semantic network together with the CIGM-specific ontology to derive a semantic meaning behind the GL text. In order to achieve this objective, we took nine GL texts from the National Guideline Clearinghouse (NGC) and marked up the text dealing with a particular ST. The STs we took into consideration were restricted taking into account the requirements of a task-based CIGM. We used DARPA Agent Markup Language and Ontology Inference Layer (DAML + OIL) to create the UMLS and CIGM specific semantic network. For the latter, as a bench test, we used the 1999 WHO-International Society of Hypertension Guidelines for the Management of Hypertension. We took into consideration the UMLS STs closest to the clinical tasks. The percentage of the GL text dealing with the ST "Health Care Activity" and subtypes "Laboratory Procedure", "Diagnostic Procedure" and "Therapeutic or Preventive Procedure" were measured. The parts of text belonging to other STs or comments were separated. A mapping of terms belonging to other STs was done to the STs under "HCA" for representation in DAML + OIL. As a result, we found that the three STs under "HCA" were the predominant STs present in the GL text. In cases where the terms of related STs existed, they were mapped into one of the three STs. The DAML + OIL representation was able to describe the hierarchy in task-based CIGMs. To conclude, we understood that the three STs could be used to represent the semantic network of the task-bases CIGMs. We identified some mapping operators which could be used for the mapping of other STs into these.

The aim of this work is to promote the use of standard terminology for nursing documentation and for nurse protocols' description. We implemented an ICNP browser and we integrated it into two different systems: the nursing electronic patient record and the nursing protocols editor. The former allows nurses to choose ICNP terms for filling the clinical chart, while the latter allows computerising protocols using ICNP terms for the actions specification. Since, in a nursing information system, it should be worth to integrate protocols with the electronic patient record, sharing the same terminology is a crucial issue. We also show how we tailored the information system to the different wards. For each ward, we devised the most frequent patient needs and nursing actions. These lists are used to customise the different interfaces. Finally, by testing the prototype using real-world documents (clinical charts and protocols), we carried out an evaluation of the terminology itself, about its completeness and usability.

This paper describes the development and use of a simulation model representing part of the medical practice within a Stroke Unit. In particular, we modelled the medical activities as described in a guideline for the ischemic stroke treatment, adopted by the Stroke Unit of our hospital. The Petri net formalism has been chosen for the model representation. The numerical parameters have been estimated both using a database of about 100 patients collected during the last two years, and eliciting knowledge from the neurologists. A commercial tool was used for performing simulations, while ad-hoc routines were written for tailoring the result presentation to the specific context. We consider simulation a very useful preliminary step for the subsequent implementation of a patient workflow (careflow) management system. In fact, simulation is based on the process model (the clinical practice guideline) and on the organisation model (human and technological resources), so allowing to detect bottlenecks in the care delivery organisation and to find the optimal resource allocation. For example, we show that simulation has been able to find some of the causes of the delay in the patients treatment, and accordingly, to suggest changes in the organisation.

This work illustrates the implementation of a computerised guideline for the pressure ulcers prevention. In particular, we describe the site-specification of a guideline delivered by the Agency for Health Care Policy Research, its integration with the electronic patient record, and its introduction within the clinical routine. The system facilitates trained nurses in the patient management by producing daily workplans, and novice nurses by running as an educational tool.

Patient management is a distributed activity involving general practitioners, clinicians, analysts, nurses, etc. Thus an integrated Patient Workflow Management System (WfMS), based on a detailed model of both the organizational and medical knowledge, could heavily improve Health Care System's performance in terms of collaborative work and resource utilization. A set of tools was developed to improve 1) acquisition of medical knowledge represented through clinical practice Guideline, and 2) acquisition of organizational knowledge describing the work process.

This paper describes a general framework for clinical practice guidelines development, dissemination and use. We propose an ontological description of the medical knowledge and of the organizational context, in order to produce clinical guidelines which, on one hand, can be widely shared between different institutions and, on the other, can be efficiently tailored to consider the peculiarities of each clinical context.