Community Research and Development Information Service - CORDIS

H2020

PATHway Report Summary

Project ID: 643491
Funded under: H2020-EU.3.1.

Periodic Reporting for period 1 - PATHway (PATHway: Technology enabled behavioural change as a pathway towards better self-management of CVD)

Reporting period: 2015-02-01 to 2016-01-31

Summary of the context and overall objectives of the project

Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe (WHO [1], 2013). While community-based phase 3 [2] cardiac rehabilitation (CR) has been shown to be very effective, they are healthcare profession driven and uptake is extremely low [3] (Nicholos [4] et al., 2012).
PATHway proposes a radically novel approach to CR that will ensure a paradigm shift towards empowering patients to more effectively self-manage their CVD, set within a collaborative care context with health professionals. A central tenet will be the use of behavioral change theory to drive PATHway design, as well as optimize communication, interaction and behavioural change intervention strategies. PATHway has the potential to deliver significant cost savings to the healthcare system, and direct more appropriate utilization of healthcare resources. This will be achieved via a patient-centric holistic approach that specifically addresses community-based rehabilitation uptake/adherence [severe lack of programmes, travel time, scheduling issues, lack of peer mentoring, and low self-efficacy associated with poor exercise technique and perceived poor ‘body image’ (not wanting to exercise with large groups of ‘strangers’)].
PATHway will provide individualized rehabilitation programs that use regular, socially inclusive exercise sessions as the basis upon which to provide a personalized comprehensive lifestyle intervention program (exercise/physical activity (PA), smoking, diet, stress management, alcohol use, medication compliance) to enable patients to both better understand and deal with their own condition and to lead a healthier lifestyle in general. This will be made possible by the provision of an internet enabled sensor-based home exercise platform that allows remote participation in CR exercise programs at any time, by a small group of patients from the comfort of their own living room.
PATHway will develop an end-to-end modular technology platform that will allow CVD patients to better self-manage their illness through a supportive, holistic, home-based cardiac rehabilitation (CR) programme, which has increased uptake and long-term adherence to exercise as its core aim. An ‘exercise module’ will deliver an appropriate, patient determined exercise programme (both an exercise class [ExerClass] and an exercise game [ExerGame]) and monitor in real-time the patient’s actions and physiological response in order to provide personalised feedback via a virtual ‘Avatar’ coach. A ‘social connectivity module’ will enable small groups of remote participants to exercise together in a virtual space providing patients with health affecting social interaction, peer support and peer mentoring. The extent to which the patient socially interacts and enjoys the exercise programme (‘affective response module’) will be monitored. An ‘all-day assessment module’ will monitor participants’ physiological responses, sitting behaviour and physical activity levels during and after exercise, and aggregate and abstract this data over time to provide pertinent feedback to the health professionals (‘health service data management module’). All collected patient data will be structured to seamlessly and securely link with their medical records, where permission is granted. The delivery of timely and relevant information to the patient will be driven by best practice in behavioural change [5,6]. Behavioural change will not only focus on the increasing exercise adherence, but will take a holistic approach to improving a healthy lifestyle, by additionally targeting improved dietary habits, smoking cessation, and alcohol moderation. Similarly, PATHway social interaction and peer support will be utilised to improve these healthy lifestyle components.
PATHway incorporates a number of sensors: Microsoft Kinect to capture motion & social interaction, a cardio-physiology monitor sensor, PA/heart rate sensors and a blood pressure monitor sensor. PATHway will automatically collect substantial quantitative data via these sensors. It will also collect data on which behavioural change information the patient accesses and engages with on the PATHway portal, along with information input by the patient as requested by the (exercise coach) avatar; entered either by gesture recognition or keyboard. All of this information will be mined, analysed, modeled and turned into knowledge to: (i) adaptively modify the exercise programme, social interaction and the behavioural change interventions, (ii) motivate and empower patients to better understand and self-manage their own health, (iii) provide information to help healthcare professionals make better patient care decisions in partnership with the patient, (iv) improve understanding of the behavioural change process, and (v) accurately determine the health outcomes.
In summary, PATHway constitutes a home-based (and out-door) lifestyle behavioural change program that will adapt to a patient’s progress through the CR program as well as providing feedback on this progress to both the patient and the clinician. Realising the PATHway vision offers a unique opportunity to put in place a novel approach to CR that has the potential to address key limitations associated with the currently unsustainable provision of healthcare for CVD. Furthermore, the overall concept and system is easily transferrable to address other diseases/conditions including diabetes, osteoporosis, breast/colon cancers, and obesity providing market opportunities for the commercialization of PATHway beyond CVD.

Cardiovascular disease (CVD) is the leading cause of premature death (30% of all deaths) and disability in Europe and worldwide (WHO [7], 2013), costing the EU economy almost EUR 196 billion a year. With changing demographics and deteriorating lifestyle this situation will worsen considerably [8], which is neither economically or socially sustainable. While effective Cardiac Rehabilitation (CR) can significantly improve mortality and morbidity rates, it is generally healthcare-profession driven (limiting patient empowerment and self-management) with a low uptake across member states [9] (approx. 11%). This uptake is further diminished by low subsequent adherence rates. Key reasons for this include: severe lack of programmes, travel time, scheduling issues, lack of peer mentoring, and low self-efficacy associated with poor exercise technique and perceived poor ‘body image’ (not wanting to exercise with large groups of ‘strangers’). The concept behind PATHway is to address these barriers to undertaking community based CR, by providing a home-based internet-enabled alternative, which focuses on empowering patients to more effectively self-manage their CVD, through implementation of behavioral change strategies.
The main objectives are:
1. Develop PATHway to empower ordinary people to become ‘expert patients’, their own primary caregiver, with the know-how to self-manage their CVD. PATHway, using modules on self- management education will augment traditional patient education by providing remote, direct monitoring, training and feedback to patients, enabling them to gain an understanding of their own health and its challenges; helping them to identify ambiguity to their behavioural change and to develop confidence and action plans to accomplish new behaviours.
2. Design PATHway to specifically optimize patients’ fitness (peak oxygen uptake) and reduce patients’ CVD risk SCORE [10] (Systematic COronary Risk Evaluation) through: (1) enhancing their participation in moderate to vigorous aerobic-based exercise or daily physical activity; (2) monitoring and reducing their time spent sitting; (3) improved patient adherence to standard CV prevention and treatment guidelines, including their medication regimen, their dietary behaviour and maintaining an optimum weight; stopping smoking (if a smoker) and moderating their alcohol intake.
3. Develop gender and age specific CVD exercise programs (an ‘Exerclass’ and ‘Exergame’) and an autonomous agent, manifested as a virtual coach, to deliver the exercise programmes and associated behavioural change methodologies. This is in line with standard CVD rehabilitation, where exercise will be the central focus. Integrated technology modules will be developed to: (a) monitor patient actions during exercising, (b) provide remote, direct feedback on patient physiological responses during exercise and activities of daily living, (c) allow up to 4 patients to exercise together though remotely, and (d) monitor and encourage patient social interaction and directly provide peer mentoring through PATHway ambassadors.
4. Develop a ‘co-production of health’ business model from a multi- stakeholder eco-system (patient, healthcare professionals, public healthcare regulators, health data managers, insurers and assurers, and commercial entities) that will maximise the likelihood of integrating PATHway into healthcare systems across Europe.
5. Develop a sophisticated, European and internationally compliant, data management system, capable of processing and handling the large amounts of monitored exercise, movement, physiological response, social interaction, lifestyle and behavioural change data (from Objective 2); and capable of linking seamlessly with patient data records in compliance with data protection and security requirements.
6. Create an information-driven PATHway platform, where data is transformed to knowledge that can be used to develop a collaborative patient-professional partnership, a co-production of health, with the aim of optimising the patient’s quality of life. The professional who is an expert in CVD and the patient who is an expert in their own lives will collaborate through PATHway, to solve problems in order to reach agreed health outcomes.
7. Build the PATHway platform with an open, service-oriented architecture, utilizing open source software and developer APIs, to facilitate new business models and commercial opportunities in integrating new sensors, producing new applications, selling new games for rehabilitation and exercise promotion, and delivering new services. This will allow future applications the capacity for simple conversion of PATHway to other diseases and conditions related to physical inactivity and detrimental lifestyle choices.
8. Provide, from the human intervention study, a framework to objectively model the complex relationship between patients’ adherence to exercise and lifestyle behaviour change programs; their underlying determining factors (e.g. exercise programme design, level of PA, physiological adaptations to exercise, amount of social interaction, attitude and practices towards disease management); and resultant change in health (e.g. CVD SCORE). This model will be used to identify individualised predictive models for more optimised intervention strategies.
9. Determine if gender, age and socio-economic background influence the relationships identified in Objective 8.

References:
[1] World Health Organisation, CVD Factsheet, March 2013
[2] Phase 1 CR is the period of hospitalisation following an acute cardiac event and consists of early mobilisation and education, phase 2 is the outpatient cardiac rehabilitation program consisting of supervised exercise training in combination with lifestyle interventions, phase 3 is the long-term maintenance phase where the patient is encouraged to stay active and healthy and where community-based cardiac rehabilitation is offered.
[3] Bjarnasson-Wehrens B et al. Cardiac Rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey. Eur J Cardiovasc Prev Rehabil 2010; 17: 410-418
[4] Nichols M, Townsend N, Luengo-Fernandez R, Leal J, Gray A, Scarborough P, Rayner M (2012). European Cardiovascular Disease Statistics 2012. European Heart Network, Brussels, European Society of Cardiology, Sophia Antipolis

[5] Bandura A. Human agency in social cognitive theory. American Psychologist 1989; 44:1175-84.

[6] A. R. Hughes, N. Mutrie, and P. D. MacIntyre, Effect of an exercise consultation on maintenance of physical activity after completion of phase III exercise-based cardiac rehabilitation, European Journal of Cardiovascular Prevention & Rehabilitation, vol. 14, no. 1, pp. 114–121. 2007
[7] World Health Organisation, CVD Factsheet, March 2013

[8] Nichols M, Townsend N, Luengo-Fernandez R, Leal J, Gray A, Scarborough P, Rayner M (2012). European Cardiovascular Disease Statistics 2012. European Heart Network, Brussels, European Society of Cardiology, Sophia Antipolis

[9] Bjarnasson-Wehrens B et al. Cardiac Rehabilitation in Europe: results from the European Cardiac Rehabilitation Inventory Survey. Eur J Cardiovasc Prev Rehabil 2010; 17: 410-418
[10] European Guidelines on CVD Prevention in Clinical Practice (2012). Systematic Coronary Risk Evaluation (SCORE). European Heart Journal, 33, 1635-1701 – doi: 10.1093/eurheartj/ehs092

Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far

"Work package 1. Project Management and Coordination (M1-44)
Tasks 1.1, 1.2, 1.3 and 1.4 (M1-44)
The overall aims of this work package are to ensure that the following are implemented: T1.1 effective financial, stakeholder and contractual management processes, T1.2 appropriate data management systems and structures, T1.3 oversight for the monitoring and control of technical progress, and T1.4 effective financial management and reporting systems.

To date we have specifically:
T1.1 provided mechanisms for pre-financing transfer and completing the first transfer; supported partners in the submission of financial reports; coordinated the writing of the Consortium Agreement, implemented the Project Management System (D1.1 submitted on time), and coordinated regular meetings.
T1.2 Provided all necessary oversight of responsibilities for data protection, preservation and sharing within a legal and ethical framework as required in the data management plan (D1.3 submitted on time). We also defined project procedures to ensure compliance with the deployment architecture. In addition, the technical and standard requirements for adhering to H2020 goals of open data access were provided.
T1.3 Initiated a system for on-going project management: a monthly Consortium-wide conference calls; regular task/deliverable conference calls (e.g bi-weekly calls between technical partners); consortium wide meetings (three to date: March in Dublin, June in Leuven, November in Belfast; Technical partners meeting planned for February in Amsterdam); produced of a Project Handbook (operating, risk, quality assurance and management procedures - D1.2 submitted on time); a web-based project management system was put in place (BaseCamp); an ‘issues’ tracking tool was established by CERTH/ITI on the Redmine platform to provide quality control support related to the implementation methods of PATHway.
T1.4 Templates and tools have been put in place for official reporting, along with appropriate internal processes and quality rules. Financial mechanisms include: handling of items that are centrally managed (e.g. equipment); analysis of financial data on a six-monthly basis; addressing budgetary modifications [including applications to the Commission for the – (a) re-instatement of the Mater Hospital, Ireland, as a full partner; (b) spending of equipment budget in year 2/3 to map to the time-line of the human/clinical trials with negative effect of depreciation].

Work package 2. Requirements, user needs analysis and exercise programme design: M1-44; Tasks 2.1 (M1-8), 2.2 (M1-22), 2.3 (M9-22)
The overall aims of this work package are to ensure that the following are implemented:
T2.1 Gather the clinical, regulatory, technical and functional requirements of the PATHway system involving all identified stakeholders. T2.2 Provide the required use-case and functional and technical specifications to WP4 to guide integration. T2.3 To co-design the PATHway content in collaboration with patients, exercise specialists clinicians and other key-stakeholders.

To date we specifically:
T2.1 Completed a comprehensive needs identification and analysis of patients (end-users) and stakeholders (health workforce). Ethical approval was obtained from DCU [DCUREC/2015/067] and KUL [clinical trial center reference S57837 and Belgian registry reference B322201524694]. Two analyses were undertaken with patients. The first was a The Technology Usage questionnaire (TUQ) (N=310) to examine their technology competencies, needs and wants. These results were then drafted into a manuscript entitled ""Cardiac patients show high interest in technology enabled cardiovascular rehabilitation"" to the European Journal of Preventive Cardiology for peer review and publication. The second analyses examined key personal, social and physical factors that inhibit or promote their capacity to self-regulate their exercise, physical activity (PA) and sedentary behaviour (SB). This invoved 33 indepth one-to-one interviews. (D2.2 submitted on time).
T2.2 We focused on the elicitation of the use-centric requirements (functional and not functional), which represented the main input to properly proceed with the definition of the PATHway architecture (run by T4.1). This result was achieved by collecting contributions from patient/stakeholders (by means of interviews run in T2.1) to technical partners (in order to receive an immediate technical check). Requirements were then properly analyzed and formalized by means of UML use cases (D2.3 submitted on time).
T2.3 Focus groups will be completed as part of this task, but the ethical approval has been received in both sites (DCU [REC/2015/216] and KUL [clinical trial center reference S57837 and Belgian registry reference B322201524694]. An initial suite of exercises and health behaviour change content has been developed.

Work package 3. Patient and home exercise monitoring and interaction components: M3-26; Tasks 3.1, 3.2, 3.3, 3.4, 3.5, 3.6 (M3-26)
The overall aims of this work package are to ensure that the following are implemented:
T3.1 Development of an accurate and user-friendly motion capturing platform for exercise rehabilitation in the home, which will allow a comparison to the targeted/ideal movement form of the virtual exercise coach. T3.2 Development of a body-worn system (e.g. ECG, heart rate) for patient monitoring during exercise and ambulatory tasks; including both hardware and associated management software. T3.3 Development of an emotion analysis system, to detect and recognize the enjoyment level of the patient during exercising.
T3.4 Development of a decision support system (DSS) to allow adaptation and personalization of the CVD patient cardiac rehabilitation programme in PATHway, based on his/her vital measurements and exercising performance. T3.5 Development of game-based, user friendly interfaces.

To date we specifically:
T3.1 Currently, a motion capturing component has been developed, using the skeleton tracking data given from the Microsoft Kinect SDK filtered with Kalman filter, in order to provide the human motion information in real-time, while it offers the RGB and the depth (RGB-D) streams as well for further usage of the other components. Further, the development of an exercise evaluation component has been realized, whose input is the motion data captured from the motion capturing component and the pre-recorded motion data of an exercise (used as reference). Its output is the exercise repetition detection/identification and evaluation (i.e. accuracy) in comparison with the reference exercise, per repetition as well as overall.
T3.2 Research on improved algorithms for enhanced recording of vital signs signals has been done, a real-time heart-rate measurement system that uses a wrist-sensor has been developed (the communication is achieved via Bluetooth), while an investigation has been carried out to identify the device that will meet the PATHway indoor and outdoor requirements.
T3.3 Research on the enjoyment level recognition has been done based on the raw data given from the Kinect sensor (RGB-D) and motion data from the motion capturing component. Unobtrusive questionnaires have been implemented to gather life-style and holistic data where possible on sleep, diet, smoking, alcohol, stress, social relationships and medication adherence.
T3.4 A decision support system has been developed to analyse the information given from the questionnaires as well as the combination of the exercise evaluation component outcome and the heart rate measurements, in order to allow for personalization and adjust the exercise program to better fit the patient’s behavioural status.
T3.5 Currently, ExerClass interface has been implemented with user-friendly scenes and graphics to strengthen the CVD patient’s motivation and their adherence to their rehabilitation program. The developments of WP3 have been showcased with the Lisbon demo, during ICT15 in October 2015

Work package 4. PATHway platform specification, implementation and validation: M4-36; Tasks 4.1 (M4-16), 4.2 (M6-27), 4.3 (M6-27), 4.4 (M12-36)
The overall aims of this work package are to ensure that the following are implemented: T4.1 Design of the PATHway’s platform architecture with appropriate identification of each component role and communication protocols (interfaces) between them, finalized to a smooth integration, T4.2 offering of an EHR compatible patients’ data management solutions, ensuring secure and ethical usage, T4.3 provisioning of end user interfaces to both patients and clinicians and, T4.4 a solution assessment through validation tests based on use cases and scenarios, identified during the requirements gathering process.

To date we have specifically:
T4.1 provided a detailed description of the PATHway’s Platform with emphasis on the definition of the logical and deployment architecture finalized to clearly identify the expected components (to develop in WP3), their relationships and where they reside. Special attention was dedicated as well in identifying the unified data model for all the information generated and processed within the PATHway system, which serve as the basis for realizing the requirements and goals for the rest of the architecture and design of the various components (D4.1 submitted on time).
T4.2 A first approximation of the Health Data Management System (HDMS) was delivered, including an updated user interface, as a translation of input from WP2. Dedicated visits to Leuven and Dublin were made to discuss the data needs of the clinical partners in PATHway related to HDMS and to present the PATHway project to IT responsible executives at KUL, Mater and Beaumont Hospital in Dublin which DCU collaborates with. Programmer interfaces and documentation according to the specification designed in conjunction with T4.1 (e.g., RESTful interfaces) were provided to relevant technical project partners (Annex 2 of D4.1 submitted on time).
A discussion has started with current patient health information owners (healthcare professionals and hospitals) on the physical deployment architectures (location of HDMS) for the HDMS.
T4.3 provided initial implementation of the main final user interfaces as expected by the specified architecture (see T4.1). Such interfaces are focused at the date (i) in providing summary information to the healthcare professionals (ii) in offering, to the patient, an environment dedicated to the Exerclass execution and (iii) in supporting the patient to access his\her exercising progress information following different modalities. (No official deliverable. Results captured by the Prototype presented at ICT event in Lisbon ).
T4.4 Although this task is officially not yet started, an activity was already triggered and performed aimed at specifying a Validation Test Plan definition with related accepted & usability tests and integration tests.

Work package 5. Evaluation of PATHway: M12-44; Tasks 5.1 (M12-14), 5.2 (M27-44), 5.3 (M21-44), 5.4 (M36-44)
The overall aims of this work package are to ensure that the following actions have been taken: T5.1 Human intervention study design and ethical analysis; T5.2 implementation of the human intervention study along with the subsequent evaluation of the PATHway system.
T5.3 Modelling of the economic, health and social impact of PATHway; and T5.4 post intervention debrief of patients and key stakeholders.

To date we have specifically:
T5.1 While this task is not due to start until month 12, the study protocol has been discussed with all partners and it is now being finalized, aiming at submitting to the ethical committees of the participating hospitals and universities at the end of M12.

Work package 6. Dissemination, exploitation and commercialisation: M1-44;
Tasks 6.1, 6.2, 6.3, 6.4 (M1-44),
The overall aims of this work package are to ensure that the following actions have been taken:
T6.1 Perform a continuous market watch on the technological trends, available solutions and products, their market positioning to further perform an appropriate competitive analysis to feed the exploitation activities. T6.2 Ensure an appropriate exploitation of PATHway results during and after the project runtime. Various potential business models and commercialization routes supposed to be identified and analyzed, and the value proposition developed to ensure the application of the most suitable strategy of engaging with stakeholders and therefore successful exploitation of the project. Such analysis will be mapped in two versions of Exploitation plan (D6.5 and D6.7) and a final exploitation report (D6.11). T6.3 ensure that the appropriate actions are performed for the public outreach and visibility of the project. This will be addressed (but not limited to) through online presence, dissemination and marketing collateral, scientific publication, engagement with external stakeholders, presence at relevant conferences, workshops, etc. T6.4 communication with external stakeholders and healthcare related communities as well as the analysis of European health care developments have to be performed to set a business plan considering EU regulations, IP handling and serves as an integral part of the exploitation plan

To date we specifically:
T6.1 An analysis of the existing solutions on the market, or those in the development to identify potential possibilities of PATHway exploitation was completed. Further, technological trends were identified and evaluated. A comparative advantage and disadvantage of PATHway solution to other competitors has been incorporated in the D6.3 (pending for submission). This task mapped the first input for future value chain analysis under T6.2
T6.2 First steps towards the exploitation of PATHway have been done. First of all, partners presented the project in the number of conferences and trade fairs, where first communication with stakeholders took place. Under this task, the consortium proceeded with the development of the exploitation plan with initial SWOT and PESTL analysis. An investigation on potential commercialization routes started with stakeholder analysis. Apart from identifying primary stakeholders while attending events targeted towards exploitation and dissemination of the PATHway project, the consortium proceeded with snowball sampling methodology for stakeholder identification. Primary stakeholders have been grouped and classified for future stakeholder mapping and the engagement plan creation.
T6.3 We ensured the online presence of the project through a web page (http://www.pathway2health.eu/) and social networks (Facebook, Twitter, YouTube), reported in D6.1, as well as a creation of a number of disseminating materials. For this purpose a Pathway Brochure and Pull-Up banner as well as a dedicated newsletter were created. High visibility was ensured through a number scientific publications and presences at industrial exhibition events (ConhIT, ICT event in Lisbon) .
T6.4 Until now, this task took an unofficial route as long as key stakeholders, key projects for liaison activities have yet to be identified, and a complete financial calculation of business cases have to be addressed after market analysis, possible business model- and stakeholder- analysis running under T6.1 and T6.2. Although first unofficial contacts and liaison activities have been done by consortium partners."

Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)

WP1: Progress beyond state of the art to date
None. This work package solely relates to ‘Project Management and Coordination’.

WP1: Expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)
Not applicable

WP2: Progress beyond state of the art to date
WP2 Through its objectives to gather clinical, regulatory, technical and functional requirements we have provided an incremental advance in terms of knowledge regarding technology solutions for physical activity uptake and monitoring and their use within Cardiac rehabilitation (CR). Previously, it has been unclear what the current technology usage is of CVD patients, and their needs and interests for technology enabled CR. Through the development of the Technology Usage Questionnaire (submitted to the Journal of Cardioplumonary Rehabilitation and Prevention), this research has demonstrated the interest for technology enabled home-based CR, which is integral in guiding the design of a technology-based, virtual CR intervention.

WP2: Expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)
The results will be used to optimise the design of PATHway and increase adherence rates of CVD patients to exercise focused cardiac rehabilitation, which are currently very low (11-25%) in community-based programmes. Increased participation will have societal implications through better patient self-management of CVD and increased health.

WP3: Progress beyond state of the art to date
T3.1 CERTH-ITI is leading one of the main PATHway features, a human motion analysis system that allows the extraction of the patient exercising analytics. The key functionality is the ability to capture the patient exercising programme and evaluate it in comparison with exercises that have been prescribed in order to return feedback to the patient and to the health care professionals. In particular, to the best of our knowledge, low cost human motion capturing systems in combination with action recognition and exercise evaluation algorithms have been used for first time in a CVD tele-rehabilitation platform that brings together CVD patients, researchers and health professionals. In particular, MS Kinect sensor has been used for the motion capturing component while real-time action recognition has been implemented to identify an action and detect its time interval. The motion data segment of this time interval is evaluated in comparison with a pre-recorded exercise (stored motion data).
T3.2 The development of the vital signs recording device by UU has been undertaken with several positive outputs that advance the current state of the art in ECG monitoring and diagnostics.
In the first article [Finlay et al., 2015 ] we have published results that show how ECG electrode placement can impact upon particular types of computerized diagnostic algorithms. These algorithms are widely used in the majority of ECG recording devices particularly in those that record 12-lead ECGs. In light of this we are currently investigating modified electrode locations for use in the PATHway system. In the second article [Guldenring et al., 2015 ] we have investigated a novel technique that allows for the estimation of unmeasured diagnostic parameters from an exercise compatible ECG recording format, which uses a reduced number of recording sites. Both of the previous articles have been presented at and published in the proceedings (IEEE publisher) of the 42nd Annual Conference of Computing in Cardiology. This is an important forum for all work relating to the development of new algorithms and devices for use in clinical cardiology. Thirdly an abstract has been submitted for consideration at the 41st Annual Conference of the International Society for Computerised Electrocardiology. This article describes work that has been undertaken to improve the diagnostic accuracy of devices designed to detect atrial fibrillation from the ECG. This is a very prevalent condition however current algorithms suffer from a high rate of false positives. Our work has developed an algorithm that combines the outputs from several current approaches to form an ensemble classifier that has been shown to yield better performance.
T3.4 This task aims to design, develop, and evaluate the DSS of PATHway, based on which patient safety is ensured, the exercise programme is optimized according to patient characteristics and needs, and goals and strategies for health behavior change are recommended. During the first year of the project, a prototype DSS was designed, developed and integrated successfully within the PATHway system focusing on adapting the exercise programme according to patient’s status and performance. To our knowledge, this is the first time where a sensor-enhanced tele-rehabilitation programme for CVD patients is enriched with a multifaceted decision support, combining exercise accuracy and intensity with behavioral and physiological factors.

WP3: Expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)
T3.1 An initial step was made in order to successfully access patient’s clinical status during the execution of the exercises as well as to modify the exercise plan according to patient needs. Furthermore, exercise prescription, in a session-to-session basis, was also considered through the personalization of the exercise programme, in order to maximize the beneficial effects of the Cardiac rehabilitation program for PATHway users.
T3.2. This work will potentially improve the capacity to accurately analyse longitudinally peoples’ response to exercise in a home and outdoor environment paving the way to better targeted exercise programming.
T3.4 The successful integration of our DSS within the PATHway system, as achieved during the first year, is the first step toward providing useful adaptations and recommendations for the patient’s exercise programme. This is very likely to lead to better compliance to CVD rehabilitation and self-management of the patient condition with patient safety elements, bringing subsequent improved health outcomes and reduction in resources and cost required for the management of CVD patients.

WP4: Progress beyond state of the art to date
T4.1 The specification of the PATHway architecture involved the adoption of a well-defined (and quality proven) approach (i.e. ISO RM-ODP standard) and specification language (UML). It proceeded strongly driven by the gathered requirements/UCs (see D2.3) drafting the sequence diagrams associated to them for the identification and specification of the expected PATHway software modules (at logical and deployment level). Such process happened not at the end of the requirements gathering step (T2.2) but in parallel to it allowing a better tuning of the design activity. Even if in the context of a framework of consolidated techniques and approach, at the best of our knowledge it is not so common (i) the implementation of such a process (and related standard) in a so formal way (ii) the execution of the design steps in parallel to the requirements gathering advances (iii) the continuous sharing\exchange, among the different heterogeneous development teams, of formal UML based design artifacts.
T4.2 The PATHway HDMS is an Electronic Health Record (EHR) with functionality to include patients into Clinical Studies with integrated Clinical Research Forms to collect research data taking into account patient privacy and including patient consent.

WP4: Expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)
T4.1 The expected natural impact is represented by the specification of design documents able to translate at the best the PATHway expected requirements by implicating a risk reduction about the requirements coverage.
T4.2 Easy and cost effective re-use of clinical data for clinical/population research. Supporting Open Data.

WP5: Progress beyond state of the art to date
None. This WP does not begin until month 12

WP5: Expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)
Not applicable

WP6: Progress beyond state of the art to date
To better address the progress beyond the state of the art, a continuous watch on the current market developments has been performed. Consortium proceeded with the identification of competitors and their profiles to better address the progress beyond the state of the art within PATHway solution.
First steps towards the stakeholder analysis and engagement with them have been made mapping the future exploitation of PATHway solution. Initial publications have begun to publicise our research to date beyond state of the art (section 1.6.1)

WP6: Expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)
During public outreach activities (publications section 1.6.1; dissemination and communication activities section 1.6.2) we have begun to highlight the potential of PATHway to improve the health of participants recovering from CVD. While reaching the targeting stakeholders, the consortium focuses on wider adaption of the PATHway solution into healthcare services. Identifying and reaching out to the crucial stakeholders on different levels (local, national, international) can create a socio-economic impact, by triggering behavioral change on the individual/community level and provoking changes to policy implications on the governmental level.

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