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Participation in traditional center-based cardiac rehabilitation exercise programs (exCR) is limited by accessibility barriers. Mobile health (mHealth) technologies can overcome these barriers while preserving critical attributes of center-based exCR monitoring and coaching, but these opportunities have not yet been capitalized on.
We aimed to design and develop an evidence- and theory-based mHealth platform for remote delivery of exCR to any geographical location.
An iterative process was used to design and develop an evidence- and theory-based mHealth platform (REMOTE-CR) that provides real-time remote exercise monitoring and coaching, behavior change education, and social support.
The REMOTE-CR platform comprises a commercially available smartphone and wearable sensor, custom smartphone and Web-based applications (apps), and a custom middleware. The platform allows exCR specialists to monitor patients’ exercise and provide individualized coaching in real-time, from almost any location, and provide behavior change education and social support. Intervention content incorporates Social Cognitive Theory, Self-determination Theory, and a taxonomy of behavior change techniques. Exercise components are based on guidelines for clinical exercise prescription.
The REMOTE-CR platform extends the capabilities of previous telehealth exCR platforms and narrows the gap between existing center- and home-based exCR services. REMOTE-CR can complement center-based exCR by providing an alternative option for patients whose needs are not being met. Remotely monitored exCR may be more cost-effective than establishing additional center-based programs. The effectiveness and acceptability of REMOTE-CR are now being evaluated in a noninferiority randomized controlled trial.
Coronary heart disease (CHD) is a leading cause of mortality and morbidity worldwide. CHD accounts for 1 in 7 deaths in the United States, approximately 1 in 20 adults have diagnosed CHD, and its prevalence is expected to increase ≈18% by 2030 [
Cardiac rehabilitation (CR) is an essential component of contemporary cardiac care, and exercise training is consistently identified as a central element in international guidelines [
Home-based exCR programs enhance accessibility [
Information and communication technologies offer opportunities to augment home-based exCR by connecting exCR specialists with patients outside the clinical environment. Telehealth-assisted programs have commonly used fixed-line telephones, email, and mobile phone short message service (SMS) to deliver motivational support, behavioral change counseling, and feedback about goal achievement or exercise adherence [
Telehealth exCR has, to date, been unable to provide exercise monitoring, feedback, coaching, and individualized exercise prescription in a manner consistent with best practice international CR guidelines; however, rapid advances in mobile sensor and communication technologies can help bridge this gap. Increasingly powerful smartphones, rapid mobile broadband connection speeds, and interoperable wearable sensors mean the technological capability for real-time remote exercise monitoring and coaching is now readily available. Smartphones are appealing for health intervention delivery as they enable individualized and timely provision of intervention content [
The feasibility of more advanced mobile health (mHealth) exCR platforms comprising wearable sensors, smartphones and real-time remote data transmission has been demonstrated [
Real-time remotely monitored exercise improves submaximal aerobic exercise capacity and health-related quality of life (HRQoL) for patients undergoing percutaneous coronary intervention; [
Embracing advances in wearable sensor and mobile communication technologies can enable mHealth exCR to combine the universal accessibility of home-based exCR with the clinical expertise, supervision, and coaching that has traditionally been limited to center-based exCR. These opportunities have yet to be capitalized on and addressing them could substantially increase the reach of exCR by providing more flexible, responsive, and interactive alternatives to existing center- and home-based programs. This article describes the development of an mHealth exCR platform designed to address these limitations. The paper first defines the main platform design objectives and then describes how components of an mHealth CR development framework were integrated into the design process. Subsequent sections outline the platform design, including the technology components and intervention content development.
The primary purpose of the mHealth exCR platform was to overcome accessibility barriers that limit center-based exCR participation while retaining the clinical expertise provided by exCR specialists during center-based programs. The major platform design objectives were to provide universal access to real-time exercise monitoring, coaching, and feedback and theory-based behavior change strategies. To achieve these objectives, we aimed to develop an alternative for the large number of CHD patients whose needs are not currently being fulfilled by center-based exCR programs.
We developed an mHealth exCR platform, named REMOTE-CR, that integrates smartphones, wearable sensors, and custom smartphone and Web-based apps to provide real-time remote exercise monitoring, evidence-based exercise prescription and coaching, theory-based behavior change education, and social support to CHD outpatients in almost any location. REMOTE-CR was designed to optimize ease of use and allow rapid scalability while adhering to evidence-based guidelines, as these characteristics will likely facilitate transition into practice [
A recently proposed mHealth CR development and evaluation framework suggests CR interventions should address the core components of CR, apply behavior change theory, enable individual tailoring of features, demonstrate high usability, and be evaluated in a randomized controlled trial that assesses patient-centered outcomes [
The core components of CR include patient evaluation, medical and lifestyle risk factor management, cardioprotective therapies, psychosocial management, exercise training, and health behavior change education [
Theory-based interventions are considered more effective than those without theoretical underpinning, and integrating principles from behavior change theories into mHealth intervention design may significantly increase the likelihood of success [
Self-efficacy refers to individuals’ perceptions that they can control their health behaviors [
Self-determination Theory proposes motivational orientation lies on a continuum anchored by intrinsic and extrinsic motivation, where an individual’s orientation is determined by effects of environmental and individual factors on the satisfaction of three basic psychological needs: autonomy, competence, and relatedness [
While Social Cognitive Theory and Self-determination Theory serve as the theoretical constructs underlying design and development of REMOTE-CR, they do not provide tangible or identifiable intervention components, per se. A taxonomy of behavior change techniques has been developed to identify, define, and categorize active intervention components that are designed to alter processes underlying behavior regulation [
REMOTE-CR behavior change techniquesa.
Category | Behavior change technique | |||||
1 | Goals and planning | |||||
1.1b,c | Goal setting (behavior) | |||||
1.2d | Problem solving | |||||
1.3a | Goal setting (outcome) | |||||
1.4b,d | Action planning | |||||
1.5b,c,d | Review behavior goal(s) | |||||
1.6b,c | Discrepancy between current behavior and goal | |||||
2 | Feedback and monitoring | |||||
2.1b,c | Monitoring of behavior by others without feedback | |||||
2.2b,c | Feedback on behavior | |||||
2.3b | Self-monitoring of behavior | |||||
2.4b,d | Self-monitoring of outcome(s) of behavior | |||||
2.6b | Biofeedback | |||||
3 | Social support | |||||
3.1b,c,d | Social support (unspecified) | |||||
3.3b,c,d | Social support (emotional) | |||||
4 | Shaping knowledge | |||||
4.1c,d | Instruction on a behavioral act | |||||
5 | Natural consequences | |||||
5.1c,d | Information about health consequences | |||||
8 | Repetition and substitution | |||||
8.1b | Behavioral practice/rehearsal | |||||
8.6d | Generalization of a target behavior | |||||
8.7c | Graded tasks | |||||
9 | Comparison of outcomes | |||||
9.1c,d | Credible source | |||||
10 | Reward and threat | |||||
10.4c | Social reward | |||||
10.9d | Self-reward | |||||
13 | Identity | |||||
13.2d | Framing/reframing | |||||
15 | Self-belief | |||||
15.1c | Verbal persuasion about capability | |||||
15.3d | Focus on past success |
aBehavior change techniques defined by Michie et al [
bPatient-facing mobile phone app.
cexCR specialist-facing Web-based app.
dBehavior change education content.
A review of mHealth behavior change suggests individualized interventions are more effective at changing behavior, although few interventions have implemented tailored components [
CHD patients are mostly of older age; therefore, use of smartphones and wearable sensors presents substantial usability challenges that may affect adoption and adherence. Factors that facilitate mHealth exCR usability are not well defined [
As REMOTE-CR has been designed to provide an alternative to existing center-based exCR it will be necessary to determine how the program compares with traditional programs before it can be recommended to patients. Therefore, a noninferiority randomized controlled trial comparing mHealth and center-based exCR was planned. This intended evaluation informed aspects of platform and intervention content design, such as exercise prescription, monitoring and coaching, intervention content, and intervention duration. The planned evaluation is in progress, and in-line with the adopted mHealth development framework [
Previous mHealth exCR platforms have provided limited exercise monitoring, feedback, and coaching capabilities, and this may limit intervention effectiveness in terms of exercise-induced risk factor modification [
The REMOTE-CR platform comprises a commercially available Android-based smartphone mobile phone and wearable sensor, custom smartphone and Web-based apps, and a custom middleware platform (
Smartphones were considered to be the optimal communication platform as near ubiquitous mobile broadband availability in many developed countries allows mHealth exCR to be delivered to patients in almost any location. The Android smartphone operating system (Google Inc., USA) was selected as the basis for the REMOTE-CR smartphone app as it has a majority share of the smartphone operating system market [
The BioHarness 3 wearable sensor (Zephyr Technology, USA) was selected because its multisensor array is well suited for monitoring exercise among CHD patients, inbuilt Bluetooth connectivity enables integration with almost all current smartphones and commercial availability will assist accessibility and translation into practice. The BioHarness sensor array quantifies electrocardiogram (ECG, including waveform data), heart rate, heart rate variability, respiratory rate, torso posture, and triaxial acceleration. The capability to monitor heart rhythm in addition to the more ubiquitous heart rate, and respiratory rate were considered advantageous for monitoring cardiovascular workload during exercise among CHD patients. While previous versions of the BioHarness have been validated [
The custom software components of the REMOTE-CR platform include a middleware named Odin, a patient-facing Android smartphone app, and a clinical exCR specialist-facing Web-based app. All software components were designed and built by the research team. The Odin middleware links smartphone and server-side software to manage communication and logistic functions including data security, network connectivity, and device resource usage [
The REMOTE-CR smartphone app [
REMOTE-CR platform schematic.
Exercise monitoring and coaching capabilities have been modeled on center-based exCR, where exCR specialists provide patients with face-to-face supervision, individualized coaching, behavior change education, and social support. Real-time remote exercise monitoring and coaching allows more responsive and individualized management of patients’ exercise training in comparison to previous telehealth exCR platforms, which commonly enable only periodic interaction between specialists and patients, based on asynchronous measurement of physical activity level or exercise adherence. Responsive supervision and coaching will help maximize the benefits of exercise with gradual and appropriate progression of exercise prescription parameters, and teach patients how to manage their exercise within suitable ranges of duration and intensity level [
A dedicated exercise monitoring component of the patient-facing smartphone app receives wearable sensor data via Bluetooth. Sensor data are displayed continuously alongside geolocation data (provided by the smartphone) and an aggregate measure of training load (ie, exercise dose) [
Real-time interaction allows responsive modification of exercise behavior and provision of individualized competence information that supports exercise-related confidence (ie, self-efficacy, perceived competence). Immersive real-time social support is expected to enhance perceptions of relatedness. Remotely monitored exCR inherently supports perceived autonomy in a way that face-to-face supervision may not, as patients will develop exercise behaviors in real-world environments that remain accessible beyond the program duration. This may streamline the transition to independent exercise, and promote long-term exercise adherence.
Patients can report cardiovascular symptoms including angina, dyspnea, and light headedness during exercise, using an accepted clinical symptom rating scale that has been adapted for use on smartphones [
The exercise monitoring component of the specialist-facing Web-based app continuously retrieves patients’ exercise data from a secure Web server and visualizes them for real-time review. ExCR specialists view patient data within individual monitoring panes that display instantaneous data for all exercise variables and a configurable time-series graph to enable trend analysis. Simultaneous monitoring of multiple patients is supported. Exercise intensity level is displayed as a percentage of heart rate reserve (%HRR, the proportional difference between rest and maximal exercise heart rates) [
The Web-based app enables exCR specialists to provide patients with real-time individualized coaching, feedback, social support, and instructions related to cardiovascular symptoms via a text-to-audio messaging system. Written messages are processed by a text-to-audio converter before being presented to patients in real time, typically via earphones. Audio messages will enhance patients’ perceptions of relatedness as they can closely approximate interaction provided during center-based exCR. Audio messages help preserve the real-time context of the message content, and enhance usability by eliminating the need for patients to manually check message content via the smartphone. Patients can manually replay audio messages and review message text during exercise, if required.
Real-time exercise monitoring and coaching features integrate behavior change techniques [
Exercise intervention content is informed by evidence-based guidelines for prescribing exercise to cardiac patients [
REMOTE-CR mobile phone app screenshots.
REMOTE-CR web-based app screenshots.
The patient-facing smartphone app and specialist-facing Web-based app both include dedicated components for retrospectively reviewing exercise performance data. Both components synchronize with a secure Web server; data presentation varies to suit differing needs of patients and exCR specialists. The patient-facing smartphone app summarizes exercise duration, distance, speed, heart rate reserve, training load, received messages, reported symptoms, and location for each training session. Information is also aggregated over calendar months (
The specialist-facing Web app allows exCR specialists to view full resolution data for each training session, including cardiovascular symptoms and ECG, and summarizes patients’ compliance with individualized exercise prescription parameters (
Patient- and specialist-facing exercise performance review features provide information that will inform patients’ perceptions of self-efficacy and competence, and integrate behavior change techniques [
Goal setting components are included in both the patient-facing smartphone app and the specialist-facing Web-based app. Patients are able to set individualized weekly goals related to exercise parameters such as duration, frequency, distance, level of intensity, and training load (
ExCR specialists can set goals in conjunction with individualized exercise prescription and/or physical activity recommendations. Visual feedback is presented for short- and long-term goal achievement in order to facilitate monitoring of patients’ adherence to prescribed exercise volumes and recommended physical activity levels.
Patient- and specialist-facing goal setting features are discrete; that is, specialists do not see patients’ goals and vice versa. This allows patients to take ownership of goal setting, and individualization will help ensure goals enhance motivation. Similarly, exCR specialists can monitor patients’ performance against evidence-based exercise prescription parameters and physical activity guidelines. This helps exCR specialists to optimize exercise prescription, coaching, and behavior change content for individual patients. Patient and specialist goals can be reset or modified as required to align with progress throughout the program and maintain an optimal motivational effect.
Goal setting features support patients’ perceptions of autonomy, competence, and self-efficacy, and integrate behavior change techniques such as goal setting (behaviour, outcomes of behaviours), reviewing behavior goals, and reviewing discrepancies between current and goal behaviors.
A suite of behavior change messages are delivered to patients as audio messages throughout the exercise program. Messages are received during exercise, and can be reviewed at any time as part of the exercise performance review features described above. Message content was adapted from previous mHealth CR interventions designed for delivery via SMS [
In the current REMOTE-CR implementation, social support is provided via real-time exercise coaching and behavior change messages, as described above. A dedicated social support component was also designed, but has not yet been implemented. Social support, from other cardiac patients in particular, is a highly valued aspect of CR [
Social support features were designed to support patients’ perceptions of self-efficacy and relatedness, and integrate behavior change techniques [
To ensure privacy, the REMOTE-CR platform requires user accounts to be registered into a database on a secure Web server; access to the database is limited to the study team. The patient-facing smartphone app is publicly available via the Google Play Store [
This article outlines the development of an evidence- and theory-based mHealth exCR platform that provides real-time remote exercise monitoring and coaching, social support, and behavior change education. Rather than redesigning the fundamental exCR process, REMOTE-CR aimed to close the current gap between center- and home-based exCR programs by mobilizing the expertize of exCR specialists. Advanced wearable sensor and smartphone technologies overcome common accessibility barriers that limit center-based exCR participation, while preserving clinical oversight that is commonly recommended in exCR guidelines [
REMOTE-CR builds on previous telehealth exCR platforms that have commonly relied on periodic telephone, email, or SMS interaction between patients, and exCR specialists and/or clinicians [
While real-time exercise monitoring and coaching was the primary design focus, the REMOTE-CR platform also includes a strong theoretical foundation. Many elements of the platform design and intervention content are grounded in behavior change theories that aim to enhance patients’ self-efficacy, competence, autonomy, and relatedness. This empowering approach is expected to build confidence and resilience [
The REMOTE-CR platform was designed to enable rapid and cost-effective scalability. Rural and remote populations have reduced access to specialist services [
While the theory- and evidence-based REMOTE-CR platform provides exciting opportunities to improve the provision and uptake of exCR services, it is not free from limitations. The REMOTE-CR platform achieved the primary objective to provide comprehensive exercise training and behavior change features, but does not currently include all core CR components recommended by international guidelines [
The development framework adopted for this work recommends mHealth platforms should be rigorously evaluated in studies that use randomized controlled trial design and include patient-centered outcomes to evaluate physical, mental, and social health outcomes [
coronary heart disease
cardiac rehabilitation
electrocardiogram
exercise-based cardiac rehabilitation
heart rate reserve (difference between resting and maximal heart rates)
health-related quality of life
mobile health
remote exCR platform
short message service
maximal aerobic exercise capacity
JR was primarily responsible for designing the mHealth platform. AM was primarily responsible for technical development. RM, IW, and NG assisted with design and technical development. All authors contributed to the preparation and final approval of the manuscript. We (authors) accept accountability for all aspects of the work.
None declared.