Patients perspectives on integrating eHealth in regular care pathways for atrial fibrillation: evaluating photoplethysmography for remote self-assessment

Abstract

Aims

Smartphone applications for heart rate and rhythm assessment are increasingly used for the management of atrial fibrillation (AF). Although the use of a photoplethysmography (PPG)-based smartphone application with subsequent (tele)consultations for AF management has been proven feasible in the TeleCheck-AF project, specific needs, and expectations of patients with AF are unclear. The aim of this study is to evaluate patients’ perspectives on the use of remote PPG-based electronical health (eHealth) integrated in regular care pathways for AF.

Methods and results

A qualitative study was conducted among patients with known AF, who have used a PPG-based smartphone application around scheduled (tele)consultations. Semi-structured interviews were audio-recorded and transcribed verbatim. Data were analysed according to conventional content analysis.

In total, 14 patients were interviewed. Five main themes were defined after analysis, i.e. smartphone application usability, requirements for eHealth implementation, remote self-assessment, patient engagement, and blended care (i.e. combining digital and face-to-face care). Overall, the participants were positive about the use of the PPG-based smartphone application and subsequent (tele)consultation. Using this application made the participants feel involved and led to active participation. In addition, the healthcare provider-patient relationship appeared an important aspect for adequate implementation. Particularly, timely consultation was found important, to discuss the results with their healthcare provider.

Conclusion

The results of this study emphasize the importance of blended care for the implementation of remote PPG-based eHealth in AF management. The use of a PPG-based smartphone application in regular care can support patient engagement and subsequently the process of shared decision making.

Graphical abstract

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Introduction

Atrial fibrillation (AF) is the most common arrhythmia and has a significant impact on health and healthcare by increasing cardiovascular morbidity and mortality.¹ Patients are faced with an increased burden affecting their daily life.² The diversity in clinical presentation requires comprehensive but patient-tailored management involving several healthcare professionals, and this calls for well-organized integrated care.

Electronic health (eHealth) is an important tool to support integrated care and has the potential to increase patient engagement.^3,4 The combination of digital interventions with traditional face-to-face interactions is referred to as blended care.⁵ Photoplethysmography (PPG)^6,7 is available in smartphone applications and the European Heart Rhythm Association (EHRA) proposed several strategies on how to integrate digital devices in existing care pathways for patients with AF to allow remote on-demand rate and rhythm assessment.⁸ One example is the TeleCheck-AF approach, which has previously implemented a PPG-based smartphone application with subsequent (tele)consultations in dedicated AF outpatient clinics.⁹ This has been shown feasible on international level¹⁰ and is currently emerging in daily clinical practice. However, co-design is crucial in the development and implementation of eHealth and accompanied healthcare pathways.^11,12 To expand this approach and improve sustainability, needs and expectations of patients with AF should be systematically assessed and considered.

The aim of this study is to conduct a qualitative assessment to evaluate patients’ perspectives on remote PPG-based eHealth in AF management, by examining (1) the patients’ views about the current content and user-friendliness of the provided PPG-application; (2) the experienced added value of PPG-based smartphone applications and subsequent (tele)consultations in regular care pathways for AF; (3) essential features to be incorporated for implementation of PPG-based eHealth in daily clinical practice.

Methods

Study design

This is a qualitative study using semi-structured interviews to evaluate patients’ perspectives on remote PPG-based eHealth within regular care pathways for AF. The research conformed to the principles outlined in the Declaration of Helsinki and to local ethical regulations (METC 2021-2997). Written informed consent was obtained from all patients.

Participants

Patients were recruited at the dedicated outpatient AF-Clinic of the Maastricht University Medical Centre+ (MUMC+) between April and September 2022. Adult patients (>18 years) with known AF were enrolled based on criterion and convenience sampling.¹³ All patients with ECG-diagnosed AF were eligible, regardless of initiated medical treatment or time since diagnosis. The inclusion criterion for this study was the use of a PPG-based smartphone application for remote rhythm registration prior to a scheduled (tele)consultation at the outpatient AF-Clinic of the MUMC+. A smartphone was required for application usage. Previous use of (an earlier version of) the PPG-based smartphone application was no exclusion criterion. A good command of the Dutch language was mandatory to ensure sufficient interview quality. Enrolment of participants was stopped after data saturation was reached.¹⁴

PPG-based smartphone application

All patients used a Conformité Européenne (CE)-marked smartphone application (i.e. FibriCheck) based on PPG^6,7 within regular care. This PPG-based smartphone application can assess heart rate and heart rhythm using the smartphone’s camera.¹⁵ A recording of 60 s (Figure 1) is made by positioning a fingertip in front of the camera and the flashlight. The application provides the main results (i.e. heart rate and rhythm) of the registration directly (Figure 1). Additionally, the application provides educational information about AF, its complications and treatment. A comprehensive report with more detailed information is available and can be downloaded if preferred. This smartphone application was provided to the patients (reimbursed by the health-insurance) as part of a scheduled outpatient (tele)consultation at the AF-Clinic of the MUMC+.

The use of a PPG-based smartphone application with subsequent (tele)consultation was part of the regular care pathway for AF. The initial infrastructure is described in the TeleCheck-AF approach⁹ and incorporates three important components: (i) a structured teleconsultation (‘Tele’), (ii) a CE-marked app-based on-demand heart rate and rhythm monitoring infrastructure (‘Check’), and (iii) comprehensive AF management (‘AF’). Patients with a clinical indication for heart rhythm registration received digital instructions on installation and handling of the application at least one week before scheduled (tele)consultation. Patients received an individual (QR-)code for credential and downloaded the application on their own smartphone. In case of questions, a specialized nurse from the AF-Clinic was available by phone or email during office hours. Patients were asked to perform PPG-recordings preferably three times daily and when experiencing symptoms. Duration of monitoring varied between one week and several months dependent on medical indication. PPG-registrations were stored in a digital cloud and are accessible for the healthcare providers of the specialized AF-team. Results of the remote rhythm monitoring were discussed with the patients during the (tele)consultation. The scheduled consultation could either be face-to-face or digital. Within regular care, a face-to-face consultation was always combined with a 12-lead ECG, which was not the case in remote teleconsultation.

Interviews

Semi-structured interviews consisting of mainly open-ended questions were performed on an individual level. The partners of the patients were allowed to participate in the interview based on patient preference. An independent researcher (M.M.) co-ordinated and performed the interviews face-to-face. She is a female medical doctor working as a clinical investigator, and trained in conducting interviews. Based on expert opinion, a topic list (see Supplementary material  S1) focused on the research questions was compiled and an interview guide (see Supplementary material  S2) was formulated to guide the semi-structured interviews. The topic list and interview guide were discussed by the team members and approved by all researchers. During the course of this study, minor adjustments were made to the content of the interview guide, as part of an iterative process.

Data analysis

All interviews were audio-recorded, and were transcribed verbatim by the researchers. The quotes were translated from Dutch to English by one researcher (M.M.). To maintain the authenticity of the quotes, both original and translated quotes were reviewed by all authors. Data were analysed according to the conventional content analysis^16,17 using ATLAS.ti Version 23.0.1 (ATLAS.ti Scientific Software Development GmbH). Transcripts were analysed by two independent reviewers (M.M. and L.K.). Both reviewers read the first five transcripts, and an inductive coding scheme was developed in consensus. The remainder of the transcripts were read, analysed, and coded by the first researcher (M.M.). New codes in the remainder of the transcripts were discussed by both researchers and added to the schedule by consensus. The codes were structured into categories and sub-categories. Thereafter, all (sub)categories were assessed separately by both researchers and findings and quotes (Q) were reported after consensus (Table 1).

Results

After analysis of 14 semi-structured interviews, five main themes were defined in consensus, i.e. smartphone application usability, requirements for eHealth implementation, remote self-assessment, patient engagement and active participation, and blended care. The findings within these themes are discussed successively.

Patient characteristics

In total, 14 patients were interviewed. Two patients preferred to involve their partner in the interview. Duration of the interviews varied between 40 and 94 min. Patients were aged between 60 and 81 years, and 7 patients were female. All patients were known with paroxysmal or persistent AF. Nine patients previously underwent a catheter AF ablation. Three participants were already familiar with this smartphone application and had used (an earlier version of) this smartphone application prior to this study as part of routine care. Before the interview, all patients recently had a face-to-face or telephone consultation with their physician for routine follow-up, and they used the PPG-based smartphone application for at least 1 week before their scheduled (tele)consultation.

Usability of PPG-based smartphone application

Patients were overall very positive about the user-friendliness of the PPG-based smartphone application within regular care. Patients found the application easy to use. The provided instructions were clear and accessible. A minority of the patients asked family or close friends for help with the initial installation. The recording of heart rhythm registration was self-evident (Q1), and patients adapted their body posture or the position of their finger intuitively when they received an error notification. The reliability and safety of the application were not considered as an issue. Confidence in the application was often linked to the fact that it was personally recommended by the healthcare provider. As a remark, some patients noticed some unknown terms (Q2), and suggested to provide a link to additional explanation. All participants were willing to use the PPG-based smartphone application again in the future and would recommend the use of this application to other patients. Some participants already actively proposed this application to friends, family, or for example even their general practitioner.

Requirements for eHealth implementation

First, user-friendliness of the application is an important feature for implementation in regular care. Some patients (n = 2) received error messages during a previous monitoring period in one of the first versions of the application, and this diminished their motivation. None of the participants encountered errors with the recent usage. Furthermore, for adequate utilisation of the application, the connection with the healthcare provider is an important feature. Patients are less prone to use the application without linkage to their healthcare provider. Particularly, participants found it important that the self-assessment was followed by a timely consultation, to discuss the results and possible consequences for therapy (Q3, Q4). Additionally, adequate instructions are important for implementation, and it was suggested to provide contact details for required assistance. Finally, reimbursement by the health insurance was found mandatory for use within clinical care. In addition to clinical usage, a paid version of this application is available to everyone. Several patients indicated that they would use the application more often if the additional use were reimbursed.

Incremental value of remote self-assessment

Patients rated the remote self-assessment as a reliable method. Several benefits were mentioned, such as the availability of multiple recordings and the possibility to make a recording at any moment and during symptoms, instead of one examination during a fixed appointment (Q5). Patients were asked to make a recording three times a day for at least one week, and they found it easy to incorporate into their daily routine (Q6). Participants cited time-savings and cost-effectiveness as key benefits of using this remote application.

Patients found it favourable that they were able to perform self-monitoring and that they were provided with direct results. Patients were able to interpret the results of this self-assessment (Q7). Additionally, it is possible to open a comprehensive report with supplementary information and graphs of the measurement. Although some patients were interested to gain more information and explored this report, the greater part of the participants had no intention to opening it. When the report was opened nevertheless, not all content was understood (Q8). Therefore, it was suggested to provide an additional manual within the application or for example online to guide the interested user through this extensive report.

Patient engagement and active participation

Information provision was found an important advantage of self-assessment. The recording enabled the patients to correlate the presence or absence of (physical) complaints to their heart rhythm and patients felt more connected to their own body (Q9). Moreover, all patients mentioned ‘reassurance’ and ‘confirmation’ (Q10) as main advantages of this remote self-assessment method. Reassurance was attributed to negative test results (i.e. sinus rhythm) (Q11). In addition, the feeling of being connected to the healthcare providers was also seen as comforting. On the other hand, positive test results (i.e. AF) were accounted as affirmative, but none of the patients experienced (increase of) anxiety with a positive test result (Q12). The confirmation of AF when experiencing complaints resulted in an increased sense of being taken seriously (Q13).

Using this PPG-based smartphone application, the participants felt involved in several different ways. First, the patients are actively participating by performing the recordings themselves (Q14). Furthermore, the patients received information more often by the direct results provided (Q15). Together, these aspects lead to more engagement. The level of engagement varies between the individual patients and depends on their needs. Indirectly, the self-assessment and provided information seem to influence the behaviour of the patients. The participants discuss several examples of how they interpret and act on the provided results. These examples describe the recognition of the physical complaints (Q9, Q16), the direct effect on patients’ health behaviour (Q17), the consideration of medical therapy (Q18), and the influence on approaching healthcare providers (Q19). At last, some participants mentioned that this self-assessment enables them to take more control in their own health management (Q20), and this stimulates the process of shared decision making (Q21, Q22).

Blended care

When evaluating the PPG-application and implementation in regular care, the healthcare provider-patient relationship appeared an important and recurring theme. Especially, communication and information provision are valuable aspects for patients (Q22). Specific important features mentioned within the healthcare provider-patient communication, are time and sincere attention for the person behind the patient (Q23). Together, this leads to experiencing trust and reassurance by the patients, and this makes them feel involved in their healthcare process (Q24).

In general, the participants are positive about the implementation of this application and subsequent (tele)consultations and have several ideas about expansion of this or other applications for various cardiac and non-cardiac diseases. The patients found it favourable that eHealth creates an opportunity for remote teleconsultations, which can be time-saving and limits travelling. Furthermore, patient did not think that the usage of this application is limited to specialized care. They argued that this or a similar application could also be beneficial in primary care on condition that the general practitioner has adequate knowledge of the application.

Although most patients did not experience remote teleconsultation to be inferior to face-to-face consultation, they preferred a combination of both throughout the medical follow-up. The utilisation of a remote teleconsultation has to be tailored to the moment and purpose of the appointment (Q25). The patient’s view is also argued to be taken into account, as some patients can have a strong preference for a face-to-face consultation. Regardless of individual preferences, the participants all agreed that the application cannot replace the healthcare provider (Q26). However, using eHealth in addition to the existing healthcare structure can yield various benefits.

Discussion

In this qualitative study, where patients’ perspectives on integrated PPG-based eHealth in regular care pathways for AF were evaluated, participants were positive about the use of the PPG-based smartphone application and subsequent (tele)consultation. The results underlined the interplay between the PPG-based smartphone application, the healthcare provider and the patient for adequate implementation of eHealth in regular care. User-friendliness of the application and support by the healthcare provider are the main requirements for integration of the PPG-based smartphone application. Remote self-assessment using a PPG-application can improve information provision and active participation. Consequently, when remote PPG-based eHealth is adequately integrated and combined with face-to-face interaction in blended care, it is able to support patient engagement and the process of shared decision making in the management of AF.

The results of this study provide insight in the essential elements and (potential) pitfalls for successful integration of remote PPG-based eHealth from the patients’ perspective. These requirements and pitfalls were modelled into an interplay of the smartphone application, the healthcare provider and the individual patient (Figure 2). This conforms to the three principles previously proposed for successful integration of eHealth into existing healthcare structure, i.e. attuned technology, alignment of human resources, and patient engagement.¹⁸

Requirements of PPG-based eHealth

There are numerous digital devices available for the management of AF.⁸ Although this study focuses on healthcare provider-initiated PPG-based smartphone application use, some aspects can be discussed and translated to a broader level of digital devices. In this study, a number of basic fundamental requirements for eHealth implementation emerged, i.e. user-friendliness of the application and adequate instructions. In this context, the patient’s digital health literacy is also an important aspect to be aware of as a healthcare provider.^19,20 Furthermore, participants indicated that reimbursement is crucial for clinical use. Healthcare providers agree that reimbursement should be applied for clinical use of digital devices, although unfortunately there is a lack in several countries.²¹

Safety and reliability are primary requirements for implementation of smartphone applications and digital devices to guarantee good care. Recent research showed the lack of self-management applications of sufficient standard.¹² Explaining eHealth is essential for correct usage. This demands good coordination between the eHealth application and the healthcare provider and should entail explanation about the utility and limitations of the digital application, but also its role within the healthcare structure. In this study, the positive attitude of the healthcare provider enhanced the participants’ trust in the PPG-application, but false security should be avoided. Several participants within this study used the application actively to evaluate their symptoms through self-assessment. Subsequently, in absence of a positive test result they attributed their complaints to other irrelevant causes. On one hand, this indicates several potential positive effects, such as reduced demand for consultation, more awareness of physical sensations in the context of AF and ultimately self-management. On the other hand, the potential pitfall of (inadequate) self-management and false security should be acknowledged. Here it is important to distinguish between physician-initiated and self-initiated eHealth use, as this determines who is responsible for the potential risks. Under all circumstances, the patients should be aware of alarm signals and when to contact their healthcare provider actively. In the current pathway, the remote self-assessment is always followed by a timely (tele)consultation to discuss the patient’s condition and the results, and this limits potential harm. Therefore, adequate implementation of eHealth is not possible without clear communication and understanding of its usage and purpose.

Self-assessment improves patient engagement

Within this study, we evaluated the implementation of a PPG-based application that enables remote self-assessment. Participants were positive about their experiences with this application and would like to use the remote self-assessment again in the future. This is also reflected by a recent patient survey, in which 826 participants agreed that this application was easy to use and gave a safe feeling,¹⁰ which was associated with an overall good patient adherence within the TeleCheck-AF project.²² Previous research has shown positive acceptability for comparable eHealth applications within AF management.^23–25 The self-assessment provides patients with direct results on their heart rhythm and heart rate, and gives them more insight in their disease process. By using this application, the participants felt reassured, safe and taken seriously. This could possibly have a positive effect on the symptom experience and improve wellbeing. Previous research demonstrated that direct feedback on heart rate and rhythm decreased the level of anxiety and depression, an improved symptom severity and improved quality of life.²⁶

Remote self-assessment by the application engages patients and their caregivers in care delivery, including involvement in decision-making and undertaking self-management activities to support the treatment through a simple task that can be easily integrated into their daily activities. The combination of enhanced information provision and active participation stimulated the patient involvement and patient engagement. The quotes of this study showed personal examples of increased disease awareness, improved correlation of physical symptoms, and more reflection on the medical therapy. This suggests that patients could be more connected to their physical well-being, illness, and medical therapy by encouraging patient engagement. These aspects may improve the role of the patient as conversational partner and their autonomy in the disease management. This supports the view that successfully integrated eHealth can support patient-centred care and the process of shared decision making.^27,28

Blended care

Blended care is defined as the combination of digital and regular care.⁵ Previous research has shown that telemedicine is an appropriate tool for follow-up care in patients with cardiovascular disease.²⁹ Increasing use of eHealth devices affects the role of the healthcare provider, but does not diminish its importance. Participants in the current study unanimously agreed that eHealth could not replace the healthcare provider, but can be supportive. The healthcare provider-patient relationship was an important and recurring theme. When experienced positive, it has great potential to support implementation of eHealth, corresponding with previous research.^25,30

Although the healthcare provider remains indispensable, eHealth has great potential to support the traditional healthcare structure and can have incremental value on different levels. In this study, well-attuned interaction between the healthcare provider and the smartphone application resulted in positive participants’ experiences. This is an example of healthcare provider-initiated eHealth use, which by definition suggests collaboration between the healthcare provider and the application. The integration of the PPG-based smartphone application in regular care empowered the patients through active participation, enhanced information provision, and self-management. The participants felt engaged and part of the team. Implementation of eHealth offers new opportunities, and the healthcare provider can provide the right framework. Patient-initiated or self-initiated use of eHealth is also increasingly common in healthcare settings today, but it involves a different interaction between the healthcare provider, eHealth and the patient, and faces different issues and challenges. Blended care allows to adjust the use of eHealth and also the level of active participation to the patient’s preference, as some patients prefer more guidance or more independence. Together, implementation of eHealth in regular care pathways, as supposed by the EHRA practical guide⁸ can support personalized care.

Strengths, limitations, and clinical practice

Currently, the PPG-based smartphone application and subsequent (tele)consultation is part of regular care pathway for AF management at MUMC+, the Netherlands. The implementation of this application in the outpatient clinic of the Cardiology department has been well accepted on an international level.¹⁰ This qualitative study with in-depth interviews allowed to gain more detailed insight in the underlying attitudes of the patients, and the findings create awareness of both the requirements and the pitfalls of remote PPG-based eHealth. Co-design should be the standard in the development of eHealth and accompanied healthcare structures.^11,12 The insights of this study may therefore provide guidance for future implementation of (comparable) PPG-based smartphone applications in daily clinical practice. This can support expansion of PPG-applications within specialized centres, but also more widespread expansion to primary care should be considered. Moreover, the findings of this study can also serve as a foundation for the implementation of a wider range of (cardiac) eHealth solutions.

When interpreting the results, also potential limitations need to be addressed. All participants were recruited at a specialized AF-Clinic, which reduced diversity. An important number of the participants, but not all, underwent ablation, but there was a diversity of age and gender among the participants. Nevertheless, symptom burden could potentially influence motivation for self-monitoring and use of the PPG-device. Although the experiences of the participants could be centre-related, the used method of in-depth interviewing is focused on unravelling the underlying argumentation instead of a trivial exploration and sufficient time was taken to evaluate this properly. In addition, all participants had used the PPG-application. Patients who had previously decided not to use the application were not included in the study. However, the number of non-users in the outpatient clinic was limited and the use of this application is accepted by the majority of the population. Therefore, the findings are assumed to be representative of a majority of AF patients.

Conclusions

The results of this study highlight the importance of the inextricable interplay between remote PPG-based eHealth, the healthcare provider and the patient for adequate implementation in daily clinical practice in AF management. Consequently, blended care can support patient engagement and subsequently the process of shared decision making.

Supplementary material

Supplementary material is available at European Journal of Cardiovascular Nursing online.

Acknowledgements

Our thanks go to N.A.H.A. Pluymaekers and J.M. Hendriks for all their work in the initiation and successful implementation of the TeleCheck-AF study, as this was the fundament and enabled us to conduct the current research. We thank Stijn Evens and Anaïs Joubard for providing us with examples of the smartphone application (i.e. FibriCheck) as used in the illustration.

Funding

Not applicable.

Data availability

Data are available on request.

References

Author notes