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Mobile Health Monitoring for Chronic Hypertension
 

Summary
 

This case report focuses on chronic hypertension in Saudi Arabia and the role of ‘mHealth’ in chronic hypertension management. In addition to mHealth, the report presents one example of current wireless mobile technology in a blood pressure device, used to capture and transmit blood pressure readings. It then explores current Ministry of Health (MOH) mobile applications, making recommendations for the implementation of mHealth in the current infrastructure, aligned with the MOH transformation programme to support its Saudi Hypertension Management Society (SHMS).
 

Introduction
 

Cardiovascular diseases (CVDs) are recorded as the commonest cause of death in the world, responsible for 30% of all mortality. In 2000, 26% of the world’s adult population (972 million individuals) were diagnosed with hypertension, which is considered as a key risk factor for CVD . This figure is expected to reach 29% (1.56 billion) by 2025. Therefore, CVDs place a heavy load on society and economic activity (Lee and Cooper 2009). Therefore, hypertension is an important public health issue, with more research and standardisation required to be able to identify and maximise existing opportunities to reduce the global burden of CVDs.
 

Hypertension affects more than 20% of the adult Saudi population and this is expected to increase. Despite evidence to show that lowering blood pressure reduces morbidity and mortality (Dahlöf et al., 2003), it is not adequately controlled at present, due to poor patient compliance and the indifference of healthcare providers. Therefore, the Saudi Hypertension Management Society (SHMS) was established in 2001 to develop Clinical Practice Guidelines for the management of hypertension in Saudi Arabia.
 

Mobile Technology
 

Mobile access is possible almost everywhere in developed countries and the adoption of smartphones is rapidly increasing with the sale of cell phones. Coupled with this is the increased availability of 3G and 4G networks, which enable video-calling and high-speed data transfer. The rapid production of mobile healthcare devices and software has greatly expanded the potential for self-care across all healthcare activities. In fact, today’s smartphones allow patients and their families to access various materials for health education and services from anywhere and at any time. Many self-help wellness and fitness programmes are also available for those who are interested in improving their health or engaging in some kind of fitness regime.
 

Nowadays, mobile services and solutions provide a wide range of disease prevention, diagnosis and treatment measures. However, the greatest strength of mobile health (mHealth) solutions for patients could be specified as disease monitoring. This is because smartphones or other portable devices enable the remote monitoring of vital parameters so that health problems can be diagnosed, responses to the treatment of chronic illnesses can be tracked, drifts from control detected, and early warning signals provided wherever there are potentially dangerous changes in the health status of patients.
 

Mobile Health (mHealth) in Hypertension Management
 

Mobile health (mHealth) can significantly improve the management of chronic disease, in addition to enabling the transmission of blood pressure data to health medical records (Hamine, 2015). Secure communication channels via the Web represent real-time data flow, giving the physicians and pharmacists responsible a means of optimising patient care and improving blood pressure control for those with hypertension (Green, Cook and Ralston et al., 2008).
According to Gee (2015), adherence to chronic disease management approaches is critical for achieving improved health outcomes, enhanced quality of life and cost-effective healthcare. However, there is no evidence that mHealth has any impact on cost-effectiveness (Whittaker, 2012). Furthermore, no reduction in secondary care use is claimed in association with tele-health (Steventon, 2016). On the other hand, according to Brath (2013), adherence management based on mHealth is feasible and well-accepted by patients. In addition, health applications are appropriate for interventions that depend on patients’ adherence to monitoring schedules and prescribed treatments (Logan, 2013 ).
 

Mobile Usage in the Kingdom of Saudi Arabia (KSA)
 

Mobile usage is growing all over the world each year. The Figure from Statista presented below shows the number of smartphone users in Saudi Arabia from 2014 to 2019. This number is estimated to reach 15.9 million this year, 2016(Statista, 2016).
 

MOH eHealth and Mobile Applications
 

The Ministry of Health (MOH) strives to provide distinct health services to citizens and residents. It has a wide network of hospitals and other health amenities throughout the Kingdom of Saudi Arabia (KSA). The MOH wants citizens and residents to take full advantage of these facilities and so it provides multiple online platforms to help users. The MOH App is used for this purpose; allowing users to view their medical details, such as height, weight and blood group, as well as availing themselves of different services via a mobile device.
Mobile applications establish the development of new systems , providing patients with MOH services, such as information on the nearest medical centres, facilities for booking appointments and a means of requesting or receiving medical notificationswhile in transit or going about daily activities. Mobile applications are built on two different platforms, iPhone operating systems (IOS) and Android. Both applications use the same set of Web services, ensuring a seamless experience for end-users between mobile devices and portals. These applications can be used by the patients themselves or for their dependents.

 

Figure 2. Seha-Tech (MOH) mobile application: mHealth and Blood Pressure Monitoring
 

mHealthsystems now offer a wider range of new services, driven by the development of biomedical sensors and the availability of highmobile bandwidth. This development has rendered the idea of health monitoring from within the home more practical and provides opportunities for assessment in ‘real-world’ environments, producing more ecologically valid data.Today, due to high performance hardware and the practical features of smart mobile devices, such devices are being more commonly used. It is therefore considered that these devices could be successfully used in biomedical applications. According to one eMarketer global report , there were 1.76 billion smartphone users in 2014 (excluding users of tablets), but it is predicted that this number will rise by 15.9% to 2.04 billion worldwide in 2015.
 

Studies have been carried out on the measurement of blood pressure using smart mobile devices and Bluetooth to transmit data from a blood pressure cuff to a mobile device. This newly developed blood pressure measuring device was tested on 18 patients and 20 healthy individuals of different ages, under a physician’s supervision. When the test results were compared with measurements taken using a sphygmomanometer, it was shown that an average accuracy of 93.52% for unhealthy individuals and 94.53% accuracy for healthy individuals could be achieved with the new device (İlhana, İbrahim and Kayrakb, 2016).
 
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Infrastructural Framework and Standards
 
Saudi Arabia has recently announced a strategic national transformation plan to accelerate economic growth through diversification, thus offsetting the impact of falling oil prices. The MOH has therefore launched an eHealth transformation, which aims to expand health services across the Kingdomby implementing electronic health records (EHR) and data exchange through system interoperability. The illustration below shows the suggested third party mobile application (mHealth for blood pressure monitoring) in its position among the national platforms, which are governed by the MOH.
 

Figure 3. Mobile application infrastructure (Figure created by the present author)
 

Discussion of Wireless Blood Pressure Technology
 

The Figure presented below shows how the MOH can capture blood pressure readings for patients with chronic hypertension and monitorpatientsusing an alarm signal to the Saudi Hypertension Management Society.
 

Figure 4. Structure of smartphone blood pressure tele-monitoring system (Logan, 2013 )
The wireless blood pressure cuff picks up and transmits blood pressure readings via Bluetooth to a smartphone. Mobile blood pressure applications then receive these blood pressure readings from the wireless cuff and record them in a data server, using a wireless or 4G communication channel. In addition, communication channels connect smartphone applications to the Internet and carry data via a cellular network or wireless to a host server.
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Application Server and Chronic Hypertension Disease Database
 

All blood pressure readings shall be saved on the chronic diseases databaseand processed, with triggers being set in accordance with the chronic hypertension medical team. Moreover, alerts and notifications shall be sent to patients as well as the chronic hypertension medical team. The patients will receive notifications of high readings and measurement frequency on their smart devices. On the other hand, the hypertension medical team will monitor blood pressure readings from the dashboard and will be notified of abnormal readings according to their setup. In addition, patients will be followed up, with referrals to a clinic if required.
 

Interoperability
 

The mobile application must support standards of interoperability (DICOM, HL7 and FHIR) that enable data integration into the chronic disease management platform and patients’ unified electronic health records via the IHE (Integrating the Health Enterprise) layer.
 

Data Security and Users’ Permission
 

The MOH must host the application on its mobile platform, in order to be able to ensure national security and privacy, thus authenticating the users via a national information centre and applying a level of permission to access its data.
 

Risk and Issues
The image below describes the stakeholders’ roles in the maturity of mHealth (IMS Institute, 2015 ).

Figure 5. Stakeholders’ roles in the maturity of mHealth (IMS Institute, 2015)
 

Patients’ Technology Acceptance
 

Technology plays a major role, since there has been long-term engagement in the monitoring of hypertension. This can be achieved by patient education in chronic disease departments, with the pursuit of interests in mHealth technology and the adoption of an active role in healthcare management. Dialogue needs to be maintained with healthcare providers and as part of social interaction.
 
Communication and Connection
 

The above image illustrates 3G and 4G Internet coverage across KSA, including all providers. However, there are some areas where there is no coverage, due to interruptions in hypertension tele-monitoring. In order to mitigate this risk, hypertension readings should be temporarily captured in anmHealth application, until the device is connected and patient records can be updated .
 
Data Security and Integration
 
In order to secure patient data, third party mHealth applications must be brought under the umbrella of the MOH, so that national governance on data exchange and security can be implemented.

 

Clinical and Patient Benefits
 
Quicker Actions and Response
 
The interventions implemented by both physicians and patients will be processed live and with less delay, since the data on the blood pressure readings will be captured and stored synchronously (Hjelm,2005).
 
Reducing the Number of Patient Visits to Clinics
mHealth technology enables physicians and patients to monitor hypertension data and receive alerts for abnormal readings or reminders on medication adherence. Visits will therefore be limited to those who cannot maintain control over their blood pressure.
 
Access at any Time
 
The physician’s dashboard will improve care management and permit secure monitoring, reminders and referral of patients to clinics (Dobkin, Dorsch, 2011).
 
The Organisational, Clinical and Financial Implications
 

The management of mHealth requires valid supporting information, medical expertise amongst healthcare practitioners and a context of medical procedures (Papadopoulos, 2006). However, there are implications, such as patient privacy, the absence of health policy and procedures, a lack of mHealth medical resources, the cost of mHealth wireless blood pressure devices and the sustainability of anmHealth project. One randomised controlled trial was carried out on 110 diabetic patients with uncontrolled hypertension. These subjects were randomly assigned to two different groups: one mHealth-monitored group and one monitored for blood pressure at home, without mHealth support. One year later, the mean daytime blood pressure had dropped significantly in the mHealth group, with no change being observed in the home-monitored group without mHealth support.
 

The mean difference between the above groups was 7.1 mm Hg. Moreover, 51% of the patients in the mHealth group met the recommended guidelines of <130/80 mm Hg, compared with the 31% recorded for the home-monitored group (Logan, 2012). In contrast to previous tele-monitoring studies (Omboni, 2013), significant improvement was achieved without prescribing further anti-hypertensive medication. In addition, there were no extra visits to physicians in the mHealthgroup .   Recommendation to Reduce mHealthCosts and Increase Efficiency
 
mHealth Business Model
 
The MOH recommends a different approach to the big data and business model covering mHealth project implementation and sustainability (Teece, 2010), in the form of revenue shared with a third party (Chesbrough, 2010).
 
eHealth Investment
 
The MOH should take into consideration the fact that eHealth may not decrease overall costs. However, overall costs may rise as usage increases, even if unit costs decline. The unit cost for specific services can be decreased and the benefits increased, such as improved patient access to quality healthcare.
In Table (1), Schweitzer (2012) summarises the potential of eHealth investment to reduce costs and increase efficiency. Moreover, it is demonstrated that an evaluation of the benefits of eHealth programmes can be of support in determining the cost-effectiveness of eHealth investments. According to Dávalos et al. (2009), analysis should focus on clinical and social outcomes using reliable conversion factors. These outcomes focus on benefits to the patient and the provider alike. Table (2) (Schweitzer, 2012) demonstrates benchmarks for the evaluation of clinical and social outcomes.
 
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