We investigate the ethical and privacy implications of voice-first ambient interfaces (VFAIs) for aging in place through an in-depth engagement with five older adults. Our participants were in the process of becoming experienced VFAI users, and had used a VFAI-based design probe for health data reporting. We create and iteratively refine an interview protocol using Privacy Cards. We customize Privacy Cards by drawing on participants' previous interviews and device usage logs. Using Privacy Cards, we conduct interviews to surface their mental models, and explore their privacy concerns. We find insufficient mental models for proper consent. For example, participants did not know who could access their data, and experienced difficulty distinguishing built-in functionality from third-party apps. Participants initially expressed little worry about VFAI-related ethical concerns, but interviews with Privacy Cards revealed nuanced issues, resulting in various implications for future research and design.

Background: The development of clinical tools to combat extreme heat events (EHEs) is urgently needed. However, the collection, linkage, and application of data and technology required to address the health consequences of EHEs—through individualized decision-making, population-focused interventions, and health system planning—remain in its infancy despite the wealth of data infrastructure in health care systems. Methods: In this paper, we describe a use case for data-intensive system architecture that can enable best practices for addressing EHE-related health risks in older adults with cardiovascular disease (CVD), a population uniquely vulnerable to EHEs. Results: Descriptions of various data sources integrated into a modular approach are discussed that allows multilevel (ie, individual-level, population-level) evaluation of EHE-related risk. Individual data streams include batched data from personal digital health devices such as wearables, indoor temperature sensors, and electronic medical record data linked through unique identifiers. Data collection, processing, and analysis as well as related challenges (eg, data quality, processing requirements, and health care system attribution) are also discussed. How this data architecture can then address important preclinical, clinical, and related questions are then described, including: (1) which physiological signals (including cardiovascular and sleep measures) may best anticipate EHE-related health care utilization in older adults with CVD; (2) how do heat thresholds that increase EHE-related health care utilization differ by medication use and type, and comorbidities; and (3) how does indoor versus outdoor temperature measures influence these associations—all understudied aspects of EHE risk in older adults. Conclusions: With considered effort and expertise, a modular data architecture that allows the combination of different elements will enable the development of clinical tools to address EHE-related health risk among older adults with CVD at multilevel scales.

Disease progression models are widely used to inform the diagnosis and treatment of many progressive diseases. However, a significant limitation of existing models is that they do not account for health disparities that can bias the observed data. To address this, we develop an interpretable Bayesian disease progression model that captures three key health disparities: certain patient populations may (1) start receiving care only when their disease is more severe, (2) experience faster disease progression even while receiving care, or (3) receive follow-up care less frequently conditional on disease severity. We show theoretically and empirically that failing to account for any of these disparities can result in biased estimates of severity (e.g., underestimating severity for disadvantaged groups). On a dataset of heart failure patients, we show that our model can identify groups that face each type of health disparity, and that accounting for these disparities while inferring disease severity meaningfully shifts which patients are considered high-risk.

From ELIZA to Alexa, Conversational Agents (CAs) have been deliberately designed to elicit or project empathy. Although empathy can help technology better serve human needs, it can also be deceptive and potentially exploitative. In this work, we characterize empathy in interactions with CAs, highlighting the importance of distinguishing evocations of empathy between two humans from ones between a human and a CA. To this end, we systematically prompt CAs backed by large language models (LLMs) to display empathy while conversing with, or about, 65 distinct human identities, and also compare how different LLMs display or model empathy. We find that CAs make value judgments about certain identities, and can be encouraging of identities related to harmful ideologies (e.g., Nazism and xenophobia). Moreover, a computational approach to understanding empathy reveals that despite their ability to display empathy, CAs do poorly when interpreting and exploring a user’s experience, contrasting with their human counterparts.

BACKGROUND:Although family caregivers play a critical role in care delivery, research has shown that they face significant physical, emotional, and informational challenges. One promising avenue to address some of caregivers' unmet needs is via the design of digital technologies that support caregivers' complex portfolio of responsibilities. Augmented reality (AR) applications, specifically, offer new affordances to aid caregivers as they perform care tasks in the home. OBJECTIVE:This study explored how AR might assist family caregivers with the delivery of home-based cancer care. The specific objectives were to shed light on challenges caregivers face where AR might help, investigate opportunities for AR to support caregivers, and understand the risks of AR exacerbating caregiver burdens. METHODS:We conducted a qualitative video elicitation study with clinicians and caregivers. We created 3 video elicitations that offer ways in which AR might support caregivers as they perform often high-stakes, unfamiliar, and anxiety-inducing tasks in postsurgical cancer care: wound care, drain care, and rehabilitative exercise. The elicitations show functional AR applications built using Unity Technologies software and Microsoft Hololens2. Using elicitations enabled us to avoid rediscovering known usability issues with current AR technologies, allowing us to focus on high-level, substantive feedback on potential future roles for AR in caregiving. Moreover, it enabled nonintrusive exploration of the inherently sensitive in-home cancer care context. RESULTS:We recruited 22 participants for our study: 15 clinicians (eg, oncologists and nurses) and 7 family caregivers. Our findings shed light on clinicians' and caregivers' perceptions of current information and communication challenges caregivers face as they perform important physical care tasks as part of cancer treatment plans. Most significant was the need to provide better and ongoing support for execution of caregiving tasks in situ, when and where the tasks need to be performed. Such support needs to be tailored to the specific needs of the patient, to the stress-impaired capacities of the caregiver, and to the time-constrained communication availability of clinicians. We uncover opportunities for AR technologies to potentially increase caregiver confidence and reduce anxiety by supporting the capture and review of images and videos and by improving communication with clinicians. However, our findings also suggest ways in which, if not deployed carefully, AR technologies might exacerbate caregivers' already significant burdens. CONCLUSIONS:These findings can inform both the design of future AR devices, software, and applications and the design of caregiver support interventions based on already available technology and processes. Our study suggests that AR technologies and the affordances they provide (eg, tailored support, enhanced monitoring and task accuracy, and improved communications) should be considered as a part of an integrated care journey involving multiple stakeholders, changing information needs, and different communication channels that blend in-person and internet-based synchronous and asynchronous care, illness, and recovery.

Researchers in ubiquitous computing have long promised that passive sensing will revolutionize mental health measurement by detecting individuals in a population experiencing a mental health disorder or specific symptoms. Recent work suggests that detection tools do not generalize well when trained and tested in more heterogeneous samples. In this work, we contribute a narrative review and findings from two studies with 41 mental health clinicians to understand these generalization challenges. Our findings motivate research on actionable sensing, as an alternative to detection research, studying how passive sensing can augment traditional mental health measures to support actions in clinical care. Specifically, we identify how passive sensing can support clinical actions by revealing patients' presenting problems for treatment and identifying targets for behavior change and symptom reduction, but passive data requires additional contextual information to be appropriately interpreted and used in care. We conclude by suggesting research at the intersection of actionable sensing and mental healthcare, to align technical research in ubiquitous computing with clinical actions and needs.

BACKGROUND:Over the last decade, augmented reality (AR) has emerged in health care as a tool for visualizing data and enhancing simulation learning. AR, which has largely been explored for communication and collaboration in nonhealth contexts, could play a role in shaping future remote medical services and training. This review summarized existing studies implementing AR in real-time telemedicine and telementoring to create a foundation for health care providers and technology developers to understand future opportunities in remote care and education. OBJECTIVE:This review described devices and platforms that use AR for real-time telemedicine and telementoring, the tasks for which AR was implemented, and the ways in which these implementations were evaluated to identify gaps in research that provide opportunities for further study. METHODS:We searched PubMed, Scopus, Embase, and MEDLINE to identify English-language studies published between January 1, 2012, and October 18, 2022, implementing AR technology in a real-time interaction related to telemedicine or telementoring. The search terms were "augmented reality" OR "AR" AND "remote" OR "telemedicine" OR "telehealth" OR "telementoring." Systematic reviews, meta-analyses, and discussion-based articles were excluded from analysis. RESULTS:A total of 39 articles met the inclusion criteria and were categorized into themes of patient evaluation, medical intervention, and education. In total, 20 devices and platforms using AR were identified, with common features being the ability for remote users to annotate, display graphics, and display their hands or tools in the local user's view. Common themes across the studies included consultation and procedural education, with surgery, emergency, and hospital medicine being the most represented specialties. Outcomes were most often measured using feedback surveys and interviews. The most common objective measures were time to task completion and performance. Long-term outcome and resource cost measurements were rare. Across the studies, user feedback was consistently positive for perceived efficacy, feasibility, and acceptability. Comparative trials demonstrated that AR-assisted conditions had noninferior reliability and performance and did not consistently extend procedure times compared with in-person controls. CONCLUSIONS:Studies implementing AR in telemedicine and telementoring demonstrated the technology's ability to enhance access to information and facilitate guidance in multiple health care settings. However, AR's role as an alternative to current telecommunication platforms or even in-person interactions remains to be validated, with many disciplines and provider-to-nonprovider uses still lacking robust investigation. Additional studies comparing existing methods may offer more insight into this intersection, but the early stage of technical development and the lack of standardized tools and adoption have hindered the conduct of larger longitudinal and randomized controlled trials. Overall, AR has the potential to complement and advance the capabilities of remote medical care and learning, creating unique opportunities for innovator, provider, and patient involvement.

BACKGROUND:Augmented reality (AR) and virtual reality (VR) have increasingly appeared in the medical literature in the past decade, with AR recently being studied for its potential role in remote health care delivery and communication. Recent literature describes AR's implementation in real-time telemedicine contexts across multiple specialties and settings, with remote emergency services in particular using AR to enhance disaster support and simulation education. Despite the introduction of AR in the medical literature and its potential to shape the future of remote medical services, studies have yet to investigate the perspectives of telemedicine providers regarding this novel technology. OBJECTIVE:This study aimed to understand the applications and challenges of AR in telemedicine anticipated by emergency medicine providers with a range of experiences in using telemedicine and AR or VR technology. METHODS:Across 10 academic medical institutions, 21 emergency medicine providers with variable exposures to telemedicine and AR or VR technology were recruited for semistructured interviews via snowball sampling. The interview questions focused on various potential uses of AR, anticipated obstacles that prevent its implementation in the telemedicine area, and how providers and patients might respond to its introduction. We included video demonstrations of a prototype using AR during the interviews to elicit more informed and complete insights regarding AR's potential in remote health care. Interviews were transcribed and analyzed via thematic coding. RESULTS:Our study identified 2 major areas of use for AR in telemedicine. First, AR is perceived to facilitate information gathering by enhancing observational tasks such as visual examination and granting simultaneous access to data and remote experts. Second, AR is anticipated to supplement distance learning of both minor and major procedures and nonprocedural skills such as cue recognition and empathy for patients and trainees. AR may also supplement long-distance education programs and thereby support less specialized medical facilities. However, the addition of AR may exacerbate the preexisting financial, structural, and literacy barriers to telemedicine. Providers seek value demonstrated by extensive research on the clinical outcome, satisfaction, and financial benefits of AR. They also seek institutional support and early training before adopting novel tools such as AR. Although an overall mixed reception is anticipated, consumer adoption and awareness are key components in AR's adoption. CONCLUSIONS:AR has the potential to enhance the ability to gather observational and medical information, which would serve a diverse set of applications in remote health care delivery and education. However, AR faces obstacles similar to those faced by the current telemedicine technology, such as lack of access, infrastructure, and familiarity. This paper discusses the potential areas of investigation that would inform future studies and approaches to implementing AR in telemedicine.

We focus on the stories of five older adults who became voice assistant users through our study, and with whom we speculated about future interfaces through two design probes, one for health data reporting and one for positive reminiscing. We delivered a voice-first ambient interface (VFAI) to each participant, and closely observed participants' journeys through periodic themed interviews (16 hours, 21 minutes of transcribed recordings), usage log reviews (4,657 entries), and phone and text support. Participants' lived experiences impacted their perceptions and interactions with their VFAI, fueling rich insights about how to design for diverse needs. For example, while one participant saw increased potential in the VFAI after interacting with the design probe for health data reporting, another was skeptical of using it to communicate with her doctor. We contribute an in-depth exploration of VFAIs to support aging in place, implications for design, and areas for future work for tailoring VFAIs towards enabling continuity of care in people's homes.

BACKGROUND:Digital health-tracking tools are changing mental health care by giving patients the ability to collect passively measured patient-generated health data (PGHD; ie, data collected from connected devices with little to no patient effort). Although there are existing clinical guidelines for how mental health clinicians should use more traditional, active forms of PGHD for clinical decision-making, there is less clarity on how passive PGHD can be used. OBJECTIVE:We conducted a qualitative study to understand mental health clinicians' perceptions and concerns regarding the use of technology-enabled, passively collected PGHD for clinical decision-making. Our interviews sought to understand participants' current experiences with and visions for using passive PGHD. METHODS:Mental health clinicians providing outpatient services were recruited to participate in semistructured interviews. Interview recordings were deidentified, transcribed, and qualitatively coded to identify overarching themes. RESULTS:Overall, 12 mental health clinicians (n=11, 92% psychiatrists and n=1, 8% clinical psychologist) were interviewed. We identified 4 overarching themes. First, passive PGHD are patient driven-we found that current passive PGHD use was patient driven, not clinician driven; participating clinicians only considered passive PGHD for clinical decision-making when patients brought passive data to clinical encounters. The second theme was active versus passive data as subjective versus objective data-participants viewed the contrast between active and passive PGHD as a contrast between interpretive data on patients' mental health and objective information on behavior. Participants believed that prioritizing passive over self-reported, active PGHD would reduce opportunities for patients to reflect upon their mental health, reducing treatment engagement and raising questions about how passive data can best complement active data for clinical decision-making. Third, passive PGHD must be delivered at appropriate times for action-participants were concerned with the real-time nature of passive PGHD; they believed that it would be infeasible to use passive PGHD for real-time patient monitoring outside clinical encounters and more feasible to use passive PGHD during clinical encounters when clinicians can make treatment decisions. The fourth theme was protecting patient privacy-participating clinicians wanted to protect patient privacy within passive PGHD-sharing programs and discussed opportunities to refine data sharing consent to improve transparency surrounding passive PGHD collection and use. CONCLUSIONS:Although passive PGHD has the potential to enable more contextualized measurement, this study highlights the need for building and disseminating an evidence base describing how and when passive measures should be used for clinical decision-making. This evidence base should clarify how to use passive data alongside more traditional forms of active PGHD, when clinicians should view passive PGHD to make treatment decisions, and how to protect patient privacy within passive data-sharing programs. Clear evidence would more effectively support the uptake and effective use of these novel tools for both patients and their clinicians.

Background Participation in ambulatory cardiac rehabilitation remains low, especially among older adults. Although mobile health cardiac rehabilitation (mHealth-CR) provides a novel opportunity to deliver care, age-specific impairments may limit older adults’ uptake, and efficacy data are currently lacking. Objective This study aims to describe the design of the rehabilitation using mobile health for older adults with ischemic heart disease in the home setting (RESILIENT) trial. Methods RESILIENT is a multicenter randomized clinical trial that is enrolling patients aged ≥65 years with ischemic heart disease in a 3:1 ratio to either an intervention (mHealth-CR) or control (usual care) arm, with a target sample size of 400 participants. mHealth-CR consists of a commercially available mobile health software platform coupled with weekly exercise therapist sessions to review progress and set new activity goals. The primary outcome is a change in functional mobility (6-minute walk distance), which is measured at baseline and 3 months. Secondary outcomes are health status, goal attainment, hospital readmission, and mortality. Among intervention participants, engagement with the mHealth-CR platform will be analyzed to understand the characteristics that determine different patterns of use (eg, persistent high engagement and declining engagement). Results As of December 2021, the RESILIENT trial had enrolled 116 participants. Enrollment is projected to continue until October 2023. The trial results are expected to be reported in 2024. Conclusions The RESILIENT trial will generate important evidence about the efficacy of mHealth-CR among older adults in multiple domains and characteristics that determine the sustained use of mHealth-CR. These findings will help design future precision medicine approaches to mobile health implementation in older adults. This knowledge is especially important in light of the COVID-19 pandemic that has shifted much of health care to a remote, internet-based setting. Trial Registration ClinicalTrials.gov NCT03978130; https://clinicaltrials.gov/ct2/show/NCT03978130 International Registered Report Identifier (IRRID) DERR1-10.2196/32163

Older adults around the world lack access to a wide range of potentially life-changing digital applications, services, and information that could be provided by voice assistants (such as Amazon’s Alexa, Google’s Assistant, or Apple’s Siri). However, older adults’ needs are underrepresented in the design of voice assistants. Because of this, we are missing opportunities for digital inclusion, and increasing risks of excluding older adults as these devices permeate public settings. In this work, we video record older adults (n=26) interacting with a multi-modal voice assistants while waiting in line at food pantries, and use Interaction Analysis to draw insights from these recordings. We find that by being agnostic to body language, audio-prosodic features, and other contextual factors, voice assistants fail to capture and react to some important aspects of interactions. We discuss design (e.g, interpreting users’ posture as a cue to wake the device when they are leaning towards the device) and research (e.g., surveillance trade-offs) implications, and argue for the use of multi-modal inputs with attention to privacy. Designing and training voice assistants to take in and appropriately respond to non-verbal cues may increase their inclusivity, helping them fulfill important needs of our aging population.

Digital health advances have transformed many clinical areas including psychiatric and cardiovascular care. However, digital health innovation is relatively nascent in cancer care, which represents the fastest growing area of health-care spending. Opportunities for digital health innovation in oncology include patient-facing technologies that improve patient experience, safety, and patient-clinician interactions; clinician-facing technologies that improve their ability to diagnose pathology and predict adverse events; and quality of care and research infrastructure to improve clinical workflows, documentation, decision support, and clinical trial monitoring. The COVID-19 pandemic and associated shifts of care to the home and community dramatically accelerated the integration of digital health technologies into virtually every aspect of oncology care. However, the pandemic has also exposed potential flaws in the digital health ecosystem, namely in clinical integration strategies; data access, quality, and security; and regulatory oversight and reimbursement for digital health technologies. Stemming from the proceedings of a 2020 workshop convened by the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine, this article summarizes the current state of digital health technologies in medical practice and strategies to improve clinical utility and integration. These recommendations, with calls to action for clinicians, health systems, technology innovators, and policy makers, will facilitate efficient yet safe integration of digital health technologies into cancer care.

In this short paper we explore the opportunities and challenges of designing XR technologies to support the collaborative work between family caregivers and clinicians as they attend to the physical care needs of patients in the home setting.

Digital biomarkers of mental health, created using data extracted from everyday technologies including smartphones, wearable devices, social media and computer interactions, have the opportunity to revolutionise mental health diagnosis and treatment by providing near-continuous unobtrusive and remote measures of behaviours associated with mental health symptoms. Machine learning models process data traces from these technologies to identify digital biomarkers. In this editorial, we caution clinicians against using digital biomarkers in practice until models are assessed for equitable predictions (‘model equity’) across demographically diverse patients at scale, behaviours over time, and data types extracted from different devices and platforms. We posit that it will be difficult for any individual clinic or large-scale study to assess and ensure model equity and alternatively call for the creation of a repository of open de-identified data for digital biomarker development.

A well-established tool for assessing fitness in older adults with cancer is geriatric assessment (GA) [1]. We developed a web-based electronic Rapid Fitness Assessment (eRFA) [1,2] to assess preoperative fitness. While 90% of our patients expressed a strong preference for completing the eRFA instead of the paper-based GA, approximately 50% of them used some degree of assistance to complete the eRFA. Not surprisingly, our preliminary data shows that frailer patients used more assistance. This finding is important as non-completion of GA tools such as the eRFA may result in undiagnosed or undertreated frailty, which would have a negative impact on outcomes.

Background Intervertebral disc pathology is the most common identifiable cause of chronic lower back pain (CLBP). There are limited conservative alternatives to treat discogenic axial CLBP. Back Rx is a mobile application (app) developed to treat patients with this condition, following the Back Rx exercise program, assisted by a virtual coach. Methods Patients 18 to 65 years of age, with axial CLBP (more than 3 months), and evidence of lumbar disc pathology by magnetic resonance imaging (MRI) were enrolled to the study. Patients’ symptomatology was prospectively evaluated at baseline and after 3 months of using the Back Rx app. The main outcome of the study was back pain evaluated using the visual analog scale (VAS) for pain. Secondary outcomes were the patient's functionality, the weekly pain medication intake, the patients’ adherence to the app, and the patients´ satisfaction rate. Results Seventy-five patients with CLBP were enrolled in the study. All patients had a statistically significant improvement from baseline to final follow-up in the average VAS scores, and the functionality evaluations. Average VAS scores decreased from 5.17 ± 2.1 at baseline to 3.8 ± 2.6 at final follow-up ( P = 0.016). Patients showed a significant decrease in the number of pain medications taken during a week ( P = 0.001). Overall compliance with the app was 52%, and 65% of the patients rated the overall experience as good or excellent. Conclusion The Back Rx app decreased pain and increased function in patients with discogenic axial CLBP compared to their baseline status. Further measures are needed to increase patients' compliance with the app and the Back Rx program. Trial registration Retrospectively registered in 2/2/2017 NCT03040310 (ClinicalTrials.gov).

Broadcasting plays an important role in the communication protocol design and it acts as a fundamental operation in wireless sensor network (WSN). This paper investigates the Minimum Latency Broadcast Scheduling in Duty Cycled (MLBSDC) problem in WSN. The MLBSDC problem aims to find a broadcast scheduling that minimizes the time in which the last node receives the broadcast message with minimum collision. The focus is mainly on providing minimum collision and finding the lower bound of broadcast latency. In this paper, a novel algorithm Collision Optimized Broadcast Scheduling (COBS) is proposed which is a refinement of Effective Broadcast Scheduling with Optimized Latency (EBSOL) [9] algorithm. COBS allow nodes in different layers of the broadcast tree to transmit the message simultaneously. In EBSOL, the latency is efficiently reduced by layer by layer approach and the broadcast tree is constructed. It is proved that COBS produces a latency of at most 12 |T|, where T denotes the number of time slots in a scheduling period. To prevent collision, each node maintains an effective routing table and only one parent node transmits the message to the child node. The results from extensive simulation show that COBS has a better performance than the existing One To All Broadcast (OTAB) algorithm in terms of reduction in latency, number of transmission and collision.

There is now a significant and growing functional gap between the public Internet, whose basic architecture has remained unchanged for several decades, and a new generation of more sophisticated private networks. To address this increasing divergence of functionality and overcome the Internet's architectural stagnation, we argue for the creation of an Extensible Internet (EI) that supports in-network services that go beyond best-effort packet delivery. To gain experience with this approach, we hope to soon deploy both an experimental version (for researchers) and a prototype version (for early adopters) of EI. In the longer term, making the Internet extensible will require a community to initiate and oversee the effort; this paper is the first step in creating such a community.

Digital medical records have enabled us to employ clinical data in many new and innovative ways. However, these advances have brought with them a complex set of demands for healthcare institutions regarding data sharing with topics such as data ownership, the loss of privacy, and the protection of the intellectual property. The lack of clear guidance from government entities often creates conflicting messages about data policy, leaving institutions to develop guidelines themselves. Through discussions with multiple stakeholders at various institutions, we have generated a set of guidelines with 10 key principles to guide the responsible and appropriate use and sharing of clinical data for the purposes of care and discovery. Industry, universities, and healthcare institutions can build upon these guidelines toward creating a responsible, ethical, and practical response to data sharing.