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This chapter describes the growing influence of point-of-care diagnostics (POCD) on the daily lives of citizens, their immediate families, and healthcare providers. With a view to the future, the most important contemporary developments in this field are discussed, such as noninvasive sensor technology in the diagnostic process, practical examples of point-of-care diagnostics (POCD), including the quantify-self movement and infrared technology. Cost-effectiveness, adoption of POCD, and the contribution of POCD innovations to self-management and health literacy are also discussed. Developments in which deep learning and artificial intelligence are used to make the diagnostic results more reliable are also conferred, such as the development of point-of-care Internet diagnostics. The discussion of professional advice dilemma’s in POCD, the patient’s appreciation of POCD, and ethical and philosophical considerations conclude this chapter.
Hanze University of Applied Sciences, Groningen, The Netherlands
Department of Critical Care, University Medical Centre Groningen, Groningen, The Netherlands
*Address all correspondence to: w.paans@pl.hanze.nl
1. Introduction
The gradually more aging population, as well as the demand for self-management, calls for new and creative possibilities to better monitor health processes in a preventive way and to better monitor recovery processes after a period of illness. Technology-driven diagnostics are becoming increasingly important through making informed decisions regarding the treatment of patients [1, 2]. This chapter describes the development of technological diagnostic support in general and examines more precisely its significance for the patient, his immediate family, and the healthcare professional.
Much of the technological support for diagnostics can be summarized under “point-of-care diagnostics” (POCD) [3, 4]. This is, therefore, the focus of this chapter.
In this chapter, the concept of “POCD” is interpreted broadly. This concerns developments in which technology is used for rapid, noninvasive diagnostics where the result is immediately available for the patient and his immediate family and/or the healthcare professional. When a central laboratory analyzes a test, there is generally a lead time between administering the test and receiving the test results at the end user of the test (i.e. a healthcare professional or patient). In the case of POCD, the end user receives the test results immediately, without significant delay.
The use of POCD can increasingly be seen as an important part of regular diagnostics, although it is not yet widely implemented in education curricula or in the (nursing) care process. This chapter can be regarded as an introduction to a modern view of POCD.
In the literature, a difference is noted between point-of-care testing (POCT) and point-of-care diagnostics (POCD). At POCT, the focus is on the measurement and the (use of the) measuring instrument and received data. In addition, it is often related to the replacement of laboratory test testing to bedside testing. “POCD” is a broader concept. It is about the entire diagnostic process in which technology at hand has a supporting role. You could say that “point-of-care diagnostics” is the entire (academic) field of knowledge that focuses on technological support where directly aggregated diagnostic results are delivered in a way that is directly and relatively easy to interpret in the context of the subject. This field of knowledge also includes the way in which such diagnostic test results can be used to achieve self-management, self-reliance, a better physical and mental condition, and more resilience or less vulnerability. It can also contribute to a higher level of health literacy and better family support.
So, point-of-care testing (POCT) is the test-related technology used in POCD (POCT, also “rapid bedside testing” or “rapid test”). The actions are performed outside specific test centers by, for example, nurses and regularly not by laboratory personnel.
Today, POCT is no longer just about tests based on, for example, a venipuncture, finger prick, or urine sample. It can also involve diagnostic tests that are performed on the basis of biosensors, thermal measurements, and Internet-related information exchange. Still, the most well-known “rapid bedside tests” are measuring body temperature, blood pressure, and blood gas saturation and measuring glucose in blood and urine [1, 2, 3, 4].
3. Essence of technology in the diagnostic process
The ability to accurately determine the nature (cause and consequence) of a health problem in order to plan, implement, and evaluate appropriate treatment and care provision has been regarded as one of the most essential basic professional competences in the field of health professionals in the medical, paramedical, allied healthcare, and nursing domains.
However, recent research has shown that diagnostic skills and applications can regularly be improved in practice, which means that optimally appropriate care is not always available. Preconditions for appropriate care are, in particular, diagnostic (reasoning) skills based on declarative, procedural, and metacognitive knowledge that is made operational and is visibly expressed in a care process.
The application of technology within the diagnostic process is steadily increasing. However, this development is still often viewed separately from the empirical, symptomatic diagnostics, such as abductive diagnostics, in which a diagnosis is made mainly on the basis of intuitive, inductive, deductive, and cognitive methods.
The wish is to continue the abovementioned critical reasoning but, if possible, to expand it synergistically in the areas of knowledge as follows:
The use of POCD to better involve patients as well as family members in the diagnosis. So, more Social Diagnostics with the aim of providing appropriate care for vulnerable recipients and their relatives, addressing the values and wishes of the patient’s as well as the relatives. Involving family members in all kinds of conditional measurements of the patient concerned, for instance, can have a stimulating and motivating effect on undertaking (revalidation) activities. The use of an additional genogram application (smartphone app) providing information about the family structure, and who might be able to support the patient during revalidation activities, can provide insight in the care needed in this regard for everyone involved, professionals as well as family members. Further on, to involve patients more specifically in the possibility of performing self-measurements, by giving them specific explanations and advice regarding the positive consequences of achieved results, so that better understanding can be developed in (preventive) health behavior.
The use of POCD to support professional diagnostics to be accurately and timely informed about the patient’s health status. This can be of great importance in various sectors. Think of the simple blood glucose and saturation checks that ambulance personnel perform, for the remote monitoring of chronically ill single patients by nurse specialists and general practitioners (GPs). Health professionals can use the principles of POCD to tailor the care planning more related to the personal health context of patients and their relatives.
The use of POCD as a part of diagnostic technology where, for example, tiny robots can have an additional detecting function. For example, in a hemiplegic patient, the awareness that the bladder is almost full can be announced in a friendly, personal spoken way. Then, a self-catheterization can be considered at the right time (not too early or too late or too often) before going shopping. So, the aim is to use diagnostic technology in the (health)care and treatment plan appropriately, whereby the technological application is not an end in itself, but where goals are formulated that are holistic in nature, patient-oriented, and that demonstrably support patient empowerment, self-management, improved health literacy throughout the entire healthcare chain, and further life cycle.
There are many possibilities in the field of POCD. Very well-known are of course the virus testers, the pregnancy tests, and the aforementioned blood glucose tests. However, there are interpretations of how POCD could also be understood that are related to existing adjacent knowledge areas such as the “quantify-self movement.”
4.1 Quantify-self movement
In addition, the “quantify-self movement” can be mentioned; the use of the so-called activity trackers (ATs). Activity trackers (ATs) can play an essential role in supporting patients in self-management. ATs can, for instance, contribute in dealing with the nursing diagnosis of “sedentary lifestyle” in patients with heart failure or diabetes.
ATs are small, noninvasive devices that are mostly worn on the wrist. The number of steps users take along with other health measures is registered as a variable related to physical activity. Mostly in combination with an associated mobile application, this gives the person in question insight into their own health behavior.
ATs may be a promising addition to the care process enhancing the physical activity patterns of patients. Using ATs, nurses can use a tool to deliver tailored treatment to patients enhancing their capacity for self-management [5].
4.2 How to implement point-of-care diagnostics: A quantify-self (QS) example
There are various frames of reference on the basis of which the relationship can be established between the use of POCD and its individual application in the care plan. In the following overview (see Table 1), which is an extraction from a table previously published in the International Journal of Nursing and Health Care Research (vol. 5, p. 1312), a classification system for nurses has been used as reference. This concerns the following nursing classification: NANDA-I for diagnoses; Nursing Intervention Classification (NIC) for interventions; and Nursing Outcome classification (NOC) for nursing outcomes.
Assessment Physical Activity (PA)
Insufficient interest in PA.
Insufficient knowledge of benefits of PA.
Insufficient motivation.
Insufficient resources for PA.
Insufficient training for PA.
Functions of Activity Trackers (AT) related to Assessment
Objective registration of PA (steps/day), heart frequency, sedentary time, active time.
Awareness in PA and active/sedentary time for the client and health professional.
Diagnosis PA Physical activity level is lower than recommended: Sedentary lifestyle at less than 300 steps/day.
Physical deconditioning.
Preference for activity in low level.
Functions of AT related to Diagnosis
Can be used to assess a sedentary lifestyle based on steps/day and sedentary time.
Identify client groups at risk.
Begin preventive actions to enhance awareness and level of PA.
Interventions PA Explain the effect of PA on body functioning and well-being to the client.
Determine the possible barriers to being physically active.
Begin an activity with a warm up and end with a cool down.
Check vital signs such as heart rate before starting exercise.
Assist the client from the beginning to the last part of the exercise.
Recommend keeping a record of activity.
Suggest that the client have an exercise Buddy.
Encourage involvement in active forms of social activities.
Functions of AT related to Interventions
Feedback function to client.
Continue monitoring of goals.
Enhances self-management and self-esteem.
Possible positive effect on behavior change.
Sharing data with health professional and other AT users to support.
Outcomes PA
Increase awareness or knowledge on
importance and benefits of PA.
Identify self-monitoring techniques.
Engagement in planned exercise programs.
Increase gradually in PA.
Improve PA, mental, social, and emotional
functioning of the body.
Functions of AT related to Outcomes
Define SMART outcomes based on the
individual client, their needs using the AT.
AT stimulates the client to meet their goal, and enhances motivation.
AT provides reminders to meet the individual goals.
Table 1.
Activity trackers as part of POCD in the personal care plan [5].
In the context of this chapter, the use of ATs can be seen as part of POCD; the point here is not only to look at the (benefits of the) measurement itself, but also to ensure careful implementation in the personal care plan. It is just an example; in many technological diagnostic applications, it can be related in such a way to a knowledge framework and a process-based use.
This approach could potentially catalyze the adoption and implementation of healthcare technology support in general. The propensity to use a technological tool is greater if a direct relationship with the benefits for the end users can be established (Figure 1).
Figure 1.
A quote from an AT user.
4.3 Infrared
There are also POCD developments in the field of infrared measurements. The forehead thermometer is an example of this, although some questions can still be asked about the specificity of the measurements [6].
Superficial inflammation can now also be detected with infrared applications. This is being developed, for example, for the better detection of wound healing in burn patients. In this regard, nurses have recently been able to use the so-called hyperspectral imaging (HSI) cameras. Recordings from such a camera, which was developed by NASA, can provide insight into where wound exudate accumulates. The blood flow and oxygen supply in and around the wound area can also be provided relatively easily, without being burdensome for the patient [7].
The blood circulation measurement in the foot in diabetic patients is also an example of POCD. It was already known in the first century BC that local temperature increase is a symptom that can indicate a (starting) inflammation/infection. Celsus, a Roman, already described “dolor, calor, tumor, and rubor” as inflammatory symptoms. And to date, not much has been added to that as “loss of function” as a symptom. Many nurses will be aware that these phenomena can occur when the deeper tissues in the foot are affected, in conjunction with nervous system abnormalities, neuropathies, and/or abnormalities of the blood vessels in the legs, and related angiopathies.
Diagnosis to prevent diabetic foot neuropathy (DFN) seems simple for professionals and relies on these historical principles. But it might become even easier for the patient using POCD: ask the person to use a measuring device (i.e., TempStat™) daily at home, more or less as if he were using a bathroom scale, but in this case, local heat is measured in the toes and sole of the foot. If a location the size of a pinhead with an elevated temperature is present, a message can be sent with a mobile phone to the general practitioner or nurse specialist, so that immediate action can be taken [8, 9, 10].
The thermal detection of phlebitis by using infrared techniques is an example of an innovation, currently in the experimental phase.
It is well known to clinical nurses that phlebitis is a common, painful complication of peripheral catheter infusion, occurring around the infusion needle insertion opening. Not only is it painful, but it can also lead to a longer hospital stay and even, rarely, death. The severity of phlebitis is currently scored using the “visual infusion phlebitis scale,” the so-called (VIP) score, ranging from 0 (no phlebitis) to 5 (thrombophlebitis). In many cases, the scoring takes place when the damage has already been done and there is already an onset or already advanced thrombophlebitis at the time of the first measurement. Based on an experimental pilot study with expensive thermal cameras, which in principle were not developed for medical applications, thermal measurements were performed in adult I.C. patients (see Figure 2). A first pilot trial with relatively cheap smartphone applications shows that a very affordable and practical early thermal detection of ignition sources also seems possible. Further developments and trials will be needed before it will be possible to use the aforementioned camera’s and measurement methods in practice [11].
Figure 2.
Infrared image of a patient with a VIP 1 score. The maximum temperature at the insertion site (left circle) is 36.4°C and that of the proximal reference point (right circle) is 34.4°C. ΔT in this case is 2.0°C [11].
4.4 Further developments related to POCD
What are the developments now and in the future in technological diagnostics? Out of many, the following are prominent promising examples:
Hyperautomation technology deals with the application of artificial intelligence (AI) and machine learning (ML) to increasingly (digitally) automate human processes. It concerns an intelligent form of robotization, in which self-learning computers (i.e., “avatars”) continuously try to improve the results of their own actions. “Babylon Health” is a well-known British company that mainly focuses on this [12].
Multiexperience technology abandons the traditional idea of a computer that has only a single point of interaction (i.e., a display). But it is based on multisensory and “multitouchpoint interfaces.” This means that multiple interacting biosensors are linked to devices with which the results are presented attractively, such as wearables and the representation of (audible, tactile, and visible) results on trackers, watches, spectacle frames, and tablets. There are already many relatively simple applications on the Internet for this [13].
Democratization technology aims to make it easier for more and more people to become digitally skilled, and make the applications more “clunky,” more intuitive, and more attractive for a wide audience, without the need for tedious, extensive explanation or training [14].
Human augmentation, in this context, is the use of technology to improve someone’s cognitive and physical experiences, which can, for example, be used to increase the quality of the diagnostic process (i.e., to find an underlying reason for being inactive), with the aim to improve lifestyle more tailored (i.e., virtual 3D techniques) [15].
Transparency and traceability technology responds to the increasing responsibility, liability, and complexity in the safe, transparently ordered, usable, and findable storage of the ever-increasing amount of data of citizens (i.e., “e-patient movement”) [16, 17].
Haptic Tech, or “kinesthetic communication,” is the technology that allows the patient to relive the sense of touch through forces, vibrations, or movements in, for example, rehabilitation medicine [18].
Fem Tech (Female technology) is technology specifically aimed at women, such as fertility diagnostics, menstrual cycle tracking apps, and pregnancy monitoring [19].
Swallowable Tech: Sensors, such as “Smart-Pills,” are oral capsules designed to collect data in the digestive tract for (additional) diagnostics such as local temperature and acid measurements. There are also capsule-shaped pills (partly in an experimental stage) that photograph and film the journey through the body [20, 21].
4.5 POCD and cost-effectiveness
Questions about cost-effectiveness (in the long run) when implementing POCD are not easy to answer scientifically. Because what is “quality of care” in relation to “efficiency in care provision”? What exactly do you measure that against? What is an acceptable gold standard? And in what (technological, professional) context is that valid?
The literature does talk about the way in which efficiency can be achieved by means of POCD; waiting times and lead time can be saved, as well as on transfers, reports, and other logistics processes: POCD could be more efficient.
It is hardly possible to find the scientific generalizability of a verifiable, workable, efficiency approach, on the basis of which demonstrable time and (financial) resources can be saved and where the quality of care is guaranteed. POCD could also be seen as a task burden. POCT can be added to the daily work practice of, for example, nurses, tests that were previously performed in the laboratory. It seems important in this context to look closely at adoption processes that can play a role in POCD [21, 22, 23].
4.6 Adoption of POCD
Implementing diagnostic technology does not happen by itself. Whether these will actually be used depends on several factors. The nature of the technological innovation, personal factors, team composition, and the degree of urgency that management attributes seem to play a role. The awareness that diagnostic technology has specific advantages for the patient, but could also lead to a reduction in the task—workload—of nurses, can be a positive influencing factor. This means that some diagnostic tests can offer a solution, not only to be able to diagnose quickly and efficiently so that you can act as a professional nurse, but also to be able to act appropriately on the basis of these quick and accurate results for use to immediate plan (preventive) actions to be carried out by the patient himself [22, 23].
Furthermore, the broad adoption of the aforementioned technology in regular general practice depends on many aspects. Other frequently mentioned influencing factors in the literature are:
degree of familiarity (unknown makes unloved);
costs (i.e., lack of clarity as to what reimbursement options are available with insurers);
usability and user-friendliness (the essential success and failure factors);
reliability (often only tested on the basis of “healthy standards”);
validity (once on the market, after the experimental phase, often made reasonably clear);
safety (sometimes unclear to patients in specific situations. “Can this be done with my pacemaker?”).
compatibility (intelligently linked technological applications offer a broader diagnostic power compared to the (abovementioned) applications separately. This technology can, therefore, be used more cost-effectively) [20].
Various recent government, industry, vision, and association reports state that technological innovations in general practice should contribute to two core values: “quality of life” and “affordability of care.” This can, therefore, be seen as a qualitative and financial specification of the overarching objective: “accommodating the growing and changing demand for care.” But, today, it does not stop there. Here is a “Top Ten” of frequently mentioned “innovation requirements” found in the various relevant reports.
5.1 A POCD innovation in general practice must
be effective (in terms of patient outcomes);
be efficient and sustainable (cost-effective and efficient);
not only serve the patient, but also “support the citizen in their social network”;
allow the citizen (or the patient) and his/her immediate relatives to retain control (stimulation of self-management and joint management);
be wish-driven and demand-driven;
provide the citizen (or the patient) with information and knowledge in order to be able to use care in an appropriate and desired manner, and only if this is really necessary;
not only be used to diagnose diseases, but also for prevention and to improve lifestyle;
contribute to making the healthcare chain more transparent and accessible;
be safe (user safe and respect the legal frameworks regarding privacy);
be user-friendly for a (very) broad group of users [1, 2, 3, 4, 21, 23].
The advent of technological diagnostics is no longer just a matter that concerns the healthcare professional. The patient or his immediate loved one will search for themselves if they cannot find a suitable answer to their question in regular care.
They find their way on digital patient forums, fellow sufferer forums, and the countless websites that present themselves as particularly reliable in diagnosing health problems. In any case, this development affects the practice of general practitioners. But the patient also comes to the specialist more often with Internet prior knowledge.
6.1 What is the quality of Internet diagnostics?
Few representative scientific results are known about medical diagnostic Internet services and what, for example, health effects, risks, and patient satisfaction are. According to these companies, which claim to be based on “years of best-practice experiences” and “scientifically substantiated action,” on average at least equivalent to a visit to a general practitioner, and sometimes even more reliable compared to the diagnoses and the advice obtained during a visit to the GP practice.
With techniques from artificial intelligence, the facial expression of the patient is also mapped and interpreted (is the conversation partner tense? Is there perhaps a question of pain?), whereby the self-learning ability of the systems used continues to reduce the margins of error. An app for transdermal blood analyzes is currently being worked on, and uploading the spectrum of a urine sample at home will also be an option. It is easy to guess what else the quantum computer can offer in the future [24, 25, 26].
6.2 A self-learning avatar
Is it not mostly advanced computer programs with extensive databases and search engines that do the work? Probably, at least to an increasing extent. Complaints that are relatively easy to understand are diagnosed by a friendly avatar in an unmistakable human guise; you can choose one that suits your preference: do you want to start a conversation with a man, a woman, an oriental, or a western appearance? The choice is yours. Photos of your skin, eyes, mucous membranes, etc. can provide additional diagnostic resources and can be uploaded immediately for review [24, 25, 27].
6.3 Commercial services in the diagnostic technology market
At the moment, (commercial) diagnostic service providers are appearing on the market who are happy to take work off the hands of the general practitioner and the nurse specialist. They even try to tempt the patient not to go to a general practice.
Advertisements in the form of YouTube films with street interviews in which citizens express their dissatisfaction with the travel time, poor accessibility, parking problems, waiting in the waiting room, the inconveniences they experience in the transfer of care, the problems in obtaining (repeat) prescriptions, the alleged dangers of contamination, going to the pharmacy with again long waiting times, etc. According to these stakeholders, it appears that a substantial part of the patients is ashamed of their own body and that they sometimes find it difficult to talk about personal problems in the consultation room, as a result of which they inadvertently create a barrier for themselves. These Internet services have the ultimate solution they proclaim themselves [24, 25, 26].
6.4 Diagnostic decision support systems
Whoever or whatever carries out the diagnostics, both the patient and the healthcare professional have an interest in the unambiguity and completeness of the diagnostic information and that it is only accessible in a legitimate form to those who, in good faith, want to know in an efficient manner taking this information.
It is very likely and hoped that the development of the current, rather limited functionality of the electronic file will be further developed into the so-called diagnostic decision support systems, which are supportive to both laymen and professionals. This development will continue for the time being on the basis of existing techniques (e.g., speech recognition, camera recognition, and artificial intelligence) and new (biometric) sensor applications. In the near future, patients will increasingly demand their data to search electronic systems and electronic forums around the world in order to obtain the very best solution for their health problems. Now you might be still—rightly—skeptical: “So you are worried because you found something on the Internet that resembles what you might have?“But perhaps the patient of the future will increasingly have an opinion that is similar to the conclusion you as a professional also draw. Certainly, if your own system will soon contain rich, reliable, logically ordered information and explanations, in that case, you may even want to stimulate your patient’s digital search [15, 16, 28, 29].
A dilemma can arise if the introduction of a diagnostic application takes place via the patient. Increasingly, technology is presented to the physician by the patient or his close relative: “Doctor, I found this device on the Internet, is something like this suitable for me? “Diagnostic applications generally do not require a prescription and are widely available over the counter.
A nurse specialist who is well aware of recent technological diagnostic developments may be able to offer appropriate advice. But, unfortunately, there is no such thing as a repertory for the use of diagnostic technology, and a search for information will have to take place before really good advice can be given. [The database IEEE (ieee.org) does offer possibilities for quickly finding knowledge about diagnostic eHealth applications.]
7.1 Counseling dilemma
There could be a dilemma in providing information without the intervention of a healthcare professional, such as a physician or nurse specialist, if the diagnosis reveals a life-threatening, serious condition, for example. The traditional conversation, in which guidance with emotional information that has a major impact on life is central, may disappear in case of unguided, digital information gathering. Attention must be paid to this ethical dilemma. Being able to set up personal information filters could be a solution here. This does not alter the fact that professional, humane, compassionate guidance must always be available in case it is desired. The risk of POCD interfering with timely professional counseling and guidance should be avoided at all costs. In-depth qualitative and quantitative research to look specifically at these ethical aspects and to develop targeted interventions for this is, therefore, desirable. POCD should certainly also be followed from a philosophical point of view in this context.
7.2 The patient’s appreciation of POCD
A lot will change in the service provision within healthcare in the coming years. A complete takeover by the healthcare avatar is not yet on the agenda, but it seems inevitable that it will acquire a place.
There are still some questions, concerns, and problems about “machine automated diagnostics” at the moment, such as legal issues, privacy issues, and ethical considerations (Is the provision of care still sufficiently “human,” “patient-oriented,” and “oriented to the entire social system”?)
The value that patients themselves attach to diagnostic possibilities (including Internet services) will determine its success. Insurers will be happy to join in on this.
Whether, for example, the nurse specialist and the general practitioner will eventually survive the technological revolution will depend, among other things, on whether they are also prepared to adopt POCD, QS techniques, and advanced Internet services, as digital services in many ways are expected to become an increasingly important part of healthcare procurement.
The promises are great. Before long, we will have arrived at automatic self-regulation, in which technical systems monitor, diagnose, and treat (semi) autonomously via noninvasive applications that are simply worn on the ankle.
Research, in that future juncture, will have to show whether it has ultimately contributed to the quality of life of many and aspects of healthy aging in general.
Point-of-care diagnostics will in all probability take off in a big way over the next 20–50 years. This will give many citizens the opportunity to monitor their own health accurately. In addition, it will increasingly provide automated information that helps prevent health risks. Increasing the compatibility of POCD applications with well-designed digital information systems over the chain of care, whereby the ease of use will be further amplified, shall be a necessary simultaneous development.
The further development of POCD will offer many possibilities for gathering knowledge by using new quantitative and qualitative research designs. Research, both on a phenomenological basis and on positivistic rounds in large samples, will support further professional development as well as enable citizens to make their own, well-informed choices. However, all these developments should never stand in the way of interpersonal, humane, and compassionate face-to-face care when it is really needed.
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Written By
Wolter Paans
Submitted: 06 October 2022Reviewed: 23 December 2022Published: 28 January 2023
Open access peer-reviewed chapter
