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UNSTRUCTURED International deployment of remote monitoring and virtual care (RMVC) technologies would efficiently harness their positive impact on outcomes. Since Canada and the UK have similar populations, healthcare systems, and digital health landscapes, transferring digital health innovations between them should be relatively straightforward. Yet, examples of successful attempts are scarce. In a workshop, we identified six differences that may complicate RMVC transfer between Canada and the UK, and provide recommendations for addressing. These key differences include: 1) minority groups, (2) physical geography, (3) clinical pathways, (4) value propositions, (5) governmental priorities and support for digital innovation, (6) regulatory pathways. We detail four broad recommendations to plan for sustainability including: the need to formally consider how highlighted country-specific recommendations may impact RMVC and contingency planning to overcome challenges; the need to map which pathways are available as an innovator to support cross-country transfer; the need to report on and apply learnings from regulatory barriers and facilitators so that everyone may benefit; and explore existing guidance to successfully transfer digital health solutions while developing further guidance (e.g., extending the NASSS framework for cross-country transfer). Finally, we present an ecosystem readiness checklist. Considering these recommendations will contribute to successful international deployment and increased positive impact of RMVC technologies.

BACKGROUND The Covid-19 pandemic forced the spread of digital health to address limited clinical resources for managing chronic health conditions. At the same time, it illuminated the population of older patients who could not access this care without an informal caregiver (IC) due to accessibility, technological literacy, or English proficiency concerns. For patients with heart failure, this rapid transition to digital health further exacerbated the demand on ICs and pushed Canadians towards a dyadic care model in the management of chronic diseases, where patients and ICs work to manage care together. Our previous work identified an opportunity to improve this dyadic HF experience through a shared model of dyadic digital health. We call this alternative model of care “Caretown,” which empowers ICs to concurrently expand the patient’s ability for self-care while acknowledging IC needs to facilitate a greater level of support. OBJECTIVE The aim of this viewpoint paper is to present the systematic design and development of the Caretown dyadic management module.While heart failure is the outlined use-case, we report on disease agnostic features. METHODS To build the Caretown model, we 1) leveraged the Knowledge to Action (KTA) framework for its ability to translate knowledge into action, and 2) borrowed the Google Sprint from industry titans to quickly “solve big problems and test new ideas” which has been effective in the medical and digital health space. Specifically, we blended these two concepts into a new framework called the “KTA Sprint”. RESULTS Six core disease-agnostic features were identified to support ICs in care dyads to provide more effective care and to capitalize on the synergistic benefits of dyadic care. These six features were designed to be customizable to suit the patient’s condition, were informed by stakeholder and task analysis, corroborated with literature, and vetted through user needs assessment interviews. These features include (1) Live Reports to enhance data sharing and facilitate appropriate IC support; (2) Care Cards to enhance guidance on the caregiving role; (3) Direct Messaging to dissolve the disconnect across the circle of care; (4) Medication Wallet to improve guidance on managing complex medication regimens; (5) Medical Events Timeline to improve and consolidate management and organization; and (6) Caregiver Resources to provide disease-specific education and support their self-care. CONCLUSIONS These disease-agnostic features were designed to address informal caregiver needs in supporting their care partner. We anticipate the implementation of these features will empower a shared model of care for chronic disease management through digital health, and will improve outcomes for care dyads.

BACKGROUND Comprehensive models of survivorship care are necessary to improve access and coordination of care and to address the complexity of physical and psychosocial problems and long-term health needs experienced by patients following cancer treatment. Our group is building a nurse-led virtual clinic to support men living with prostate cancer (PCa) in the post-treatment follow-up phase of their survivorship journey. OBJECTIVE This paper presents our expert-informed, rules-based, survivorship algorithm to build a nurse-led model of survivorship care for prostate cancer survivors with “no evidence of disease” (Ned) to support more timely decision-making, enhanced safety and continuity of care. METHODS An initial rule-set was developed via a literature review and working groups with clinical experts across Canada (e.g., nurse experts, physician experts, scientists) (n=20), and patient partners (n=3). Algorithm priorities were defined through a multidisciplinary consensus meeting with clinical nurse specialists, nurse scientists, nurse practitioners, urologic oncologists, urologists, and radiation oncologists (n=17). The system was refined and validated using nominal group technique. RESULTS Four levels of alert classification were established, initiated by responses on the EPIC-CP survey, and mediated by changes in minimal clinically important different alert thresholds, alert history, clinical urgency with patient autonomy influencing clinical acuity. Patient autonomy was supported through tailored education as a first line of response, and alert escalation depending on a patient-initiated request for a nurse consultation. CONCLUSIONS The Ned algorithm is positioned to facilitate PCa nurse-led care models with a high nurse to patient ratio. This novel expert-informed PCa survivorship care algorithm contains a defined escalation pathway for clinically urgent symptoms while honoring patient preference. Though further validation is required through a pragmatic trial, we anticipate the Ned algorithm will support more timely decision-making, enhance continuity of care through automation of more frequent automated check points, while empowering patients to self-manage their symptoms more effectively than standard care. INTERNATIONAL REGISTERED REPORT RR2-10.1136/bmjopen-2020-045806

Background: A total of 45% of older adults living in long-term care (LTC) have some form of malnutrition. Several methods of tracking food and fluid intake exist, but they are limited in terms of their accuracy and ease of application. An easy-to-use, objective, accurate, and comprehensive food intake system designed with LTC in mind may provide additional insights regarding nutritional support systems and nutritional interventions. Objective: The aim of this study was to conduct a multistage participatory iterative design sprint of a Goldilocks quality horizontal prototype for the Automated Food Imaging and Nutrient Intake Tracking (AFINI-T) system. Specific design objectives included the following: (1) identify practice-relevant problems and solutions through user-centered participatory design, (2) mitigate feasibility-related barriers to uptake, and (3) employ user-centered technology development. Methods: A 6-stage iterative participatory design sprint was developed and executed. A total of 38 participants and advisors representing 15 distinct roles (eg, personal support worker, nurse, and dietitian) were engaged in the design sprint. Subjective workload (Raw Task Load Index), subjective usability scales, and a modified Ravden checklist were used to assess project advisors’ perceptions of the AFINI-T system prototype compared with the current method of food and fluid intake charting. Results: The top priorities for this system were identified as the following: ease of use, high accuracy, system reliability, ease of maintenance, and requirement of integrating with the current PointClickCare system. Data from project advisors informed design decisions leading to a Goldilocks quality horizontal prototype of the AFINI-T system. Compared with the current food and fluid intake charting system, AFINI-T was perceived to have the following: less time demands (t10.8=4.89; P

With one in four individuals afflicted with malnutrition, computer vision may provide a way of introducing a new level of automation in the nutrition field to reliably monitor food and nutrient intake. In this study, we present a novel approach to modeling the link between color and vitamin A content using transmittance imaging of a pureed foods dilution series in a computer vision powered nutrient sensing system via a fine-tuned deep autoencoder network, which in this case was trained to predict the relative concentration of sweet potato purees. Experimental results show the deep autoencoder network can achieve an accuracy of 80% across beginner (6 month) and intermediate (8 month) commercially prepared pureed sweet potato samples. Prediction errors may be explained by fundamental differences in optical properties which are further discussed., 3 pages

Purpose This paper presents the first standardized physical environmental assessment tool titled Dining Environment Audit Protocol (DEAP) specifically designed for dining spaces in care homes and reports the results of its psychometric properties. Items rated include: adequacy of lighting, glare, personal control, clutter, staff supervision support, restraint use, and seating arrangement option for social interaction. Two scales summarize the prior items and rate the overall homelikeness and functionality of the space. Methods Ten dining rooms in three long-term care homes were selected for assessment. Data were collected over 11 days across 5 weeks. Two trained assessors completed DEAP independently on the same day. Interrater-reliability was completed for lighting, glare, space, homelike aspects, seating arrangements and the two summary scales, homelikeness and functionality of the space. For categorical measures, measure responses were dichotomized at logical points and Cohen's Kappa and concordance on ratings were determined. Results The two overall rating scales on homelikeness and functionality of space were found to be reliable intraclass correlation coefficient (ICC) (~0.7). The mean rating for homelikeness for Assessor 1 was 3.5 (SD 1.35) and for functionality of the room was 5.3. (SD 0.82; median 5.5). Implications The findings indicate that the tool's interrater-reliability scores are promising. The high concordance on the overall scores for homelikeness and functionality is indicative of the strength of the individual items in generating a reliable global assessment score on these two important aspects of the dining space.

Purpose Malnutrition is common in residential care environments, primarily due to poor intake. Micronutrient deficiency, although poorly investigated to date, is also reported to be high. Improving the nutrient density of consumed foods is a potential mechanism to promote increased nutrient intake. A scoping review was conducted to: (1) explore the evidence on micronutrient food fortification strategies, (2) identify candidate nutrients and food vehicles for successful food fortification, and (3) identify gaps for future research. Methods The scoping review framework of Arksey and O'Malley was used. A comprehensive search strategy of 4 electronic databases (MEDLINE, EMBASE, CINAHL, and Web of Science) was completed. Two reviewers were involved in screening and data extraction for all selected articles. Results A total of 4394 relevant articles were identified for screening, and application of inclusion/exclusion criteria resulted in 6 food fortification studies (8 citations; 1 study had 3 citations). Overall, vitamin D (n = 5 studies) and calcium (n = 4 studies) were the most common micronutrients fortified; milk products, margarine, bread, and pureed foods were fortification vehicles. Most studies fortified below the RDA recommendation and did not include clinical outcomes. Samples were small and intervention periods were short (3–6 months). Conclusions Fortification is a viable strategy for improving the nutrient density of foods consumed in residential care. Although disparate, this literature suggests the potential for further undertaking of fortification to prevent micronutrient deficiencies among residents and future research should consider multinutrient preparations and clinical outcomes.

BACKGROUND A total of 45% of older adults living in long-term care (LTC) have some form of malnutrition. Several methods of tracking food and fluid intake exist, but they are limited in terms of their accuracy and ease of application. An easy-to-use, objective, accurate, and comprehensive food intake system designed with LTC in mind may provide additional insights regarding nutritional support systems and nutritional interventions. OBJECTIVE The aim of this study was to conduct a multistage participatory iterative design sprint of a Goldilocks quality horizontal prototype for the Automated Food Imaging and Nutrient Intake Tracking (AFINI-T) system. Specific design objectives included the following: (1) identify practice-relevant problems and solutions through user-centered participatory design, (2) mitigate feasibility-related barriers to uptake, and (3) employ user-centered technology development. METHODS A 6-stage iterative participatory design sprint was developed and executed. A total of 38 participants and advisors representing 15 distinct roles (eg, personal support worker, nurse, and dietitian) were engaged in the design sprint. Subjective workload (Raw Task Load Index), subjective usability scales, and a modified Ravden checklist were used to assess project advisors’ perceptions of the AFINI-T system prototype compared with the current method of food and fluid intake charting. RESULTS The top priorities for this system were identified as the following: ease of use, high accuracy, system reliability, ease of maintenance, and requirement of integrating with the current PointClickCare system. Data from project advisors informed design decisions leading to a Goldilocks quality horizontal prototype of the AFINI-T system. Compared with the current food and fluid intake charting system, AFINI-T was perceived to have the following: less time demands (t10.8=4.89; P CONCLUSIONS The AFINI-T concept system appears to have good practice relevance as a tool for an intelligent food and fluid intake tracking system in LTC. The AFINI-T concept system may provide improvement over the current system, and advisors are keen to try the AFINI-T system. This research gives tangible examples of how the sprint method can be adapted and applied to the development of novel needs-based application-driven technology.

Vitamin B12 (B12) deficiency, although treatable, impacts up to 43% of community-living older adults; long-term care (LTC) residents may be at greater risk. Recommendations for screening require further evidence on prevalence and incidence in LTC. Small, ungeneralizable samples provide a limited perspective on these issues. The purposes of this study were to report prevalence of B12 deficiency at admission to LTC, incidence 1 year post-admission, and identify subgroups with differential risk. This multi-site (8), retrospective prevalence study used random proportionate sampling of resident charts (n = 412). Data at admission extracted included demographics, B12 status, B12 supplementation, medications, diagnoses, functional independence, cognitive performance, and nutrition. Prevalence at admission of B12 deficiency (300 pmol/L). One year post-admission incidence was 4%. Better B12 status was significantly associated with supplementation use prior to LTC admission. Other characteristics were not associated with status. This work provides a better estimate of B12 deficiency prevalence than previously available for LTC, upon which to base protocols and policy. Prospective studies are needed to establish treatment efficacy and effect on health related outcomes.

Dysphagia (swallowing difficulty) increases risk for malnutrition and affects at least 15p of American older adults, and 590 million people worldwide. Malnutrition is associated with increased mortality, increased morbidity, decreased quality of life, and accounts for over d15 billion (USD) health-care related costs each year. While modified texture diets (e.g., pureed food) reduce the risk of choking, quality assurance is necessary for monitoring nutrient density to ensure food meets nutritional requirements. However, current methods are subjective and time consuming. The purpose of this study was to investigate the feasibility of optical techniques for an objective assessment of food nutrient density in pureed samples. Motivated by a theoretical optical dilution model, broadband spectral images of commercially prepared puree samples were acquired. Specifically, 13 flavors at five dilutions relative to initial concentration, each with six replicates, were acquired for a total of 390 samples. Puree samples were prepared and loaded onto a white reflectance back plane to maximize photon traversal path length through the puree. The sample was illuminated with a tungsten-halogen illumination source fitted with a front glass fabric diffuser for spatially homogeneous illumination. This broadband illuminant was chosen to observe as many food-light spectral absorbance interactions as possible. Flavor-stratified correlation analysis was performed on this food image dataset to investigate the relationship between nutritional information and color space transformations. A special case of blueberry is presented as the effect of anthocyanins was quantitatively observed through normalized spectral trends in response to pH perturbations across dilutions.

Obstructive sleep apnea (OSA) affects 20p of the adult population, and is associated with cardiovascular and cognitive morbidities. However, it is estimated that up to 80p of treatable OSA cases remain undiagnosed. Cur- rent methods for diagnosing OSA are expensive, labor-intensive, and involve uncomfortable wearable sensors. This study explored the feasibility of non-contact biophotonic assessment of OSA cardiovascular biomarkers via photoplethysmography imaging (PPGI). In particular, PPGI was used to monitor the hemodynamic response to obstructive respiratory events. Sleep apnea onset was simulated using Muller's maneuver in which breathing was obstructed by a respiratory clamp. A custom PPGI system, coded hemodynamic imaging (CHI), was positioned 1 m above the bed and illuminated the participant's head with 850 nm light, providing non-intrusive illumination for night-time monitoring. A video was recorded before, during and following an apnea event at 60 fps, yielding 17 ms temporal resolution. Per-pixel absorbance signals were extracted using a Beer-Lambert derived light transport model, and subsequently denoised. The extracted hemodynamic signal exhibited dynamic temporal modulation during and following the apnea event. In particular, the pulse wave amplitude (PWA) decreased during obstructed breathing, indicating vasoconstriction. Upon successful inhalation, the PWA gradually increased toward homeostasis following a temporal phase delay. This temporal vascular tone modulation provides insight into autonomic and vascular response, and may be used to assess sleep apnea using non-contact biophotonic imaging.

Measuring nutritional intake is a tool that is critical to themonitoring of health, both as an individual or of a group. It isespecially important in the monitoring of those at risk formalnutrition, an issue which costs billions of dollars globally, andcurrent methods used in practice are manual, time-consuming,and have inherent biases and inaccuracies. This study proposes anovel imaging system with a superpixel-based segmentationalgorithm as part of an automated nutritional intake system. Thestudy also examines three important parameters of the algorithmand their ideal values; region size and spatial regularization forsuperpixel segmentation, as well as spatial weighting inclustering. The experimental results demonstrate that theproposed system is effective in segmenting an image of a plate intoits constituent foods.

Dysphagia affects 590 million people worldwide and increases risk for malnutrition. Pureed food may reduce choking, however preparation differences impact nutrient density making quality assurance necessary. This paper is the first study to investigate the feasibility of computational pureed food nutritional density analysis using an imaging system. Motivated by a theoretical optical dilution model, a novel deep neural network (DNN) was evaluated using 390 samples from thirteen types of commercially prepared purees at five dilutions. The DNN predicted relative concentration of the puree sample (20%, 40%, 60%, 80%, 100% initial concentration). Data were captured using same-side reflectance of multispectral imaging data at different polarizations at three exposures. Experimental results yielded an average top-1 prediction accuracy of 92.2% ± 0.41% with sensitivity and specificity of 83.0% ± 15.0% and 95.0% ± 4.8%, respectively. This DNN imaging system for nutrient density analysis of pureed food shows promise as a novel tool for nutrient quality assurance.

BACKGROUND AND OBJECTIVES: Poor food intake is common in long-term care (LTC). The mealtime experience has been identified as influential, yet, research has been limited by lack of quality, standardized measures. The purpose of this study was to develop and test for inter-rater reliability the Mealtime Scan (MTS), an observational measure. RESEARCH DESIGN AND METHODS: MTS was derived from the literature on ambiance, mealtime experience, social interactions at mealtimes, and social models of care. Three scales on person-centered care and physical and social environments are used to summarize key aspects observed with MTS. Two raters assessed MTS for reliability at 30 different meals conducted in 10 dining rooms, within three LTC residences. Intraclass correlation coefficient (ICC) was used to assess reliability. RESULTS: MTS demonstrated good to excellent reliability on the three summative scales (physical ICC = 0.73, social ICC = 0.81, person-centered care ICC = 0.83) and other scalable items had good to excellent reliability (e.g., background noise ICC = 0.65, Mealtime Relational Care checklist: negative interactions ICC = 0.85). DISCUSSION AND IMPLICATIONS: MTS is reliable and face valid for assessing mealtime experience. Future work will explore construct validity of this measure. MTS can be used to support improving the mealtime experience for residents living in LTC.

Objectives: Reminiscence is a popular intervention for seniors, but, with mixed evidence supporting its efficacy, questions have been raised about the mechanisms underlying improvement. The present paper addresses this question by investigating the degree to which health effects depend on the development of a shared sense of group identification. This is examined in the context of traditional story-based reminiscence as well as novel forms of song-based reminiscence.Method: As the focus of a manualized intervention, 40 participants were randomly assigned to secular song (n = 13), religious song (n = 13), or standard story reminiscence (n = 14) groups. These were run over six weeks with cognitive performance, anxiety, and life satisfaction measured before and after the intervention. Measures of group fit were included to examine whether social identification contributed to outcomes.Results: No evidence of change emerged over time as a function of intervention form alone, but analysis of identification data revealed significant interactions with the type of reminiscence group. Specifically, initial fit with the story reminiscence group was associated with enhanced cognitive outcomes and greater life satisfaction, while fit with the religious song reminiscence group was associated with greater life satisfaction and less anxiety.Conclusion: These findings show that group identification is a key moderator through which reminiscence promotes health outcomes. Implications for theory and practice highlight an inherent limitation in randomized controlled trials insofar as they may compromise participants group identification.

Cardiovascular monitoring is important to prevent diseases from progressing. The jugular venous pulse (JVP) waveform offers important clinical information about cardiac health, but is not routinely examined due to its invasive catheterisation procedure. Here, we demonstrate for the first time that the JVP can be consistently observed in a non-contact manner using a novel light-based photoplethysmographic imaging system, coded hemodynamic imaging (CHI). While traditional monitoring methods measure the JVP at a single location, CHI's wide-field imaging capabilities were able to observe the jugular venous pulse's spatial flow profile for the first time. The important inflection points in the JVP were observed, meaning that cardiac abnormalities can be assessed through JVP distortions. CHI provides a new way to assess cardiac health through non-contact light-based JVP monitoring, and can be used in non-surgical environments for cardiac assessment., Comment: 10 pages, 8 figures

Impact trauma may cause a hematoma, which is the leakage of venous blood into surrounding tissues. Large hematomas can be dangerous as they may inhibit local blood ow. Hematomas are often diagnosed visually, which may be problematic if the hematoma leaks deeper than the visible penetration depth. Furthermore, vascular wound healing is often monitored at home without the aid of a clinician. We therefore investigated the use of near infrared (NIR) re ectance photoplethysmographic imaging (PPGI) to assess vascular damage resulting from a hematoma, and monitor the healing process. In this case study, the participant experienced internal vascular damage in the form of a hematoma. Using a PPGI system with dual-mode temporally coded illumination for ambient-agnostic data acquisition and mounted optical elements, the tissue was illuminated with a spatially uniform irradiance pattern of 850 nm wavelength light for increased tissue penetration and high oxy-to-deoxyhemoglobin absorption ratio. Initial and follow-up PPGI data collection was performed to assess vascular damage and healing. The tissue PPGI sequences were spectrally analyzed, producing spectral maps of the tissue area. Experimental results show that spatial differences in spectral information can be observed around the damaged area. In particular, the damaged site exhibited lower pulsatility than the surrounding healthy tissue. This pulsatility was largely restored in the follow-up data, suggesting that the tissue had undergone vascular healing. These results indicate that hematomas can be assessed and monitored in a non-contact visual manner, and suggests that PPGI can be used for tissue health assessment, with potential extensions to peripheral vascular disease.

Photoplethysmography (PPG) devices are widely used for monitoring cardiovascular function. However, these devices require skin contact, which restricts their use to at-rest short-term monitoring. Photoplethysmographic imaging (PPGI) has been recently proposed as a non-contact monitoring alternative by measuring blood pulse signals across a spatial region of interest. Existing systems operate in reflectance mode, many of which are limited to short-distance monitoring and are prone to temporal changes in ambient illumination. This paper is the first study to investigate the feasibility of long-distance non-contact cardiovascular monitoring at the supermeter level using transmittance PPGI. For this purpose, a novel PPGI system was designed at the hardware and software level. Temporally coded illumination (TCI) is proposed for ambient correction and a signal processing pipeline is proposed for PPGI signal extraction. Experimental results show that the processing steps yielded a substantially more pulsatile PPGI signal than the raw acquired signal, resulting in statistically significant increases in correlation to ground-truth PPG in both short- "Equation missing" and long-distance "Equation missing" monitoring. The results support the hypothesis that long-distance heart rate monitoring is feasible using transmittance PPGI, allowing for new possibilities of monitoring cardiovascular function in a non-contact manner.

Mealtime satisfaction is an important component of quality of life (QOL) in residential care, yet there currently is no self-administered tool described in the literature. The purpose of this study is to investigate internal and test–retest reliability, and construct validity of a mealtime satisfaction questionnaire (MSQ) designed for residential care, more specifically retirement homes. A 15-item MSQ was developed and eligible participants from four retirement homes (n = 749) were invited to participate. The participation rate was 24% and the median age was 88 years for respondents. The internal consistency of the MSQ was high (Cronbach Alpha = 0.83) and the test–retest reliability was also high (Intraclass coefficient = 0.91, P