A living lab approach to define patients needs and expectations for eHealth-based cardiac rehabilitation in Germany and Spain: the TIMELY study
Authors: Schmitz B , Wirtz S , Sestayo-Fernandez M , Schaefer H , Douma E R , Alonso M , Gonzalez-Salvado V , Habibovic M , Kop W J , Pena-Gil C , Mooren F C 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020.

Background
eHealth solutions may be used for personalized care and to provide assistance for disease control to CAD patients over the compendium of the disease. TIMELY is the first artificial intelligence-driven eHealth approach based on cardiac rehabilitation (CR) components connected with internet of things devices. For usability and acceptance of the TIMELY eHealth solution, patients are actively involved in development through a Living Lab approach.

Purpose
To define patients’ needs for an eHealth-based self-care support CR maintenance program.

Methods
The Living Lab used a guided survey among CAD patients at CR centers in Germany and Spain during inpatient or outpatient CR, respectively. Questions referred to use of technology and patients’ opinion on usefulness of suggested eHealth features. Importance/usefulness was rated on a 5-point Likert scale (median score).

Results
79 CAD patients (20% female) participated (Spain, n=30; Germany, n=49). Patients’ mean age was 57 years (range 37–79), educational level was 87% ≤high school. All patients owned a smartphone also used for information (76%) and documentation (43%). Patients rated the importance of CR components (diet, stress management, regular exercise, risk factor reduction, smoking cessation) along the continuum of care as "very high" (5/5), with no difference between the two centers. Individual support for regular exercise after structured CR was rated "high" (4/5). Renewal of recommended training intensity (heart rate), evaluation of training progress, and suggestions on activities were rated "useful" (4/5) to "very useful" (5/5). The importance of support for stress management, risk factor management, diet, and medication adherence was rated 3/5. Usefulness of an education platform was rated 4/5, motivational messages scored 3/5. Individual feedback by a person was rated over feedback by a virtual agent (4/5 vs. 3/5). The availability of electronic health records was evaluated as "very useful" (5/5) remote blood pressure management and ECG monitoring were rated as "useful" (4/5). All items ranged between 1-5, indicating large interindividual differences. No differences between nationalities were detected for exercise-/medical-related features. For other CR features, overall progression documentation was significantly rated as more useful by German patients compared to Spanish patients (5/5 vs. 4/5, p&lt;0.001) and German patients rated individual feedback of a real person higher than Spanish patients (5/5 vs. 4/5, p=0.005). No differences existed between women and men.

Conclusions
Patients expressed a strong need for individual support of physical exercise and updated training recommendations during CR maintenance. The observed inter-individual differences regarding usefulness and acceptance indicate the need for an adaptive system to reduce barriers for eHealth access. Patients from Germany and Spain showed equally high acceptance of eHealth components for the management of CAD.