JMIR HUMAN FACTORS Liu et al

Original Paper

Remote Monitoring Systems for Chronic Patients on Home

Hemodialysis: Field Test of a Copresence-Enhanced Design

Na Liu1; Jinman Kim2,3, PhD; Younhyun Jung2,4, PhD; Adani Arisy2; Mary Ann Nicdao4; Mary Mikaheal4; Tanya
Baldacchino3; Mohamed Khadra2,3; Kamal Sud4,5,6
1
School of Information Technologies, Sydney, Australia
2
Biomedical and Multimedia Information Technology (BMIT) Group, School of Information Technologies, Sydney, Australia
3
Nepean Telehealth Technology Centre, Nepean Hospital, Kingswood, Sydney, Australia
4
Home Haemodialysis Unit, Regional Dialysis Centre, Blacktown Hospital, Sydney, Australia
5
Department of Renal Medicine, Nepean Hospital, Kingswood, Sydney, Australia
6
Sydney Medical School (Nepean Clinical School), The University of Sydney, Sydney, Australia

Corresponding Author:
Jinman Kim, PhD
Biomedical and Multimedia Information Technology (BMIT) Group
School of Information Technologies
J12, School of IT
Sydney,
Australia
Phone: 61 2 9036 9804
Email: [email protected]

Abstract
Background: Patients undertaking long-term and chronic home hemodialysis (HHD) are subject to feelings of isolation and
anxiety due to the absence of physical contact with their health care professionals and lack of feedback in regards to their dialysis
treatments. Therefore, it is important for these patients to feel the “presence” of the health care professionals remotely while on
hemodialysis at home for better compliance with the dialysis regime and to feel connected with health care professionals.
Objective: This study presents an HHD system design for hemodialysis patients with features to enhance patient’s perceived
“copresence” with their health care professionals. Various mechanisms to enhance this perception were designed and implemented,
including digital logbooks, emotion sharing, and feedback tools. The mechanism in our HHD system aims to address the limitations
associated with existing self-monitoring tools for HHD patients.
Methods: A field trial involving 3 nurses and 74 patients was conducted to test the pilot implementation of the copresence
design in our HHD system. Mixed method research was conducted to evaluate the system, including surveys, interviews, and
analysis of system data.
Results: Patients created 2757 entries of dialysis cases during the period of study. Altogether there were 492 entries submitted
with “Very Happy” as the emotional status, 2167 entries with a “Happy” status, 56 entries with a “Neutral” status, 18 entries with
an “Unhappy” status, and 24 entries with a “Very unhappy” status. Patients felt assured to share their emotions with health care
professionals. Health care professionals were able to prioritize the review of the entries based on the emotional status and also
felt assured to see patients’ change in mood. There were 989 entries sent with short notes. Entries with negative emotions had a
higher percentage of supplementary notes entered compared to the entries with positive and neutral emotions. The qualitative
data further showed that the HHD system was able to improve patients’ feelings of being connected with their health care
professionals and thus enhance their self-care on HHD. The health care professionals felt better assured with patients’ status with
the use of the system and reported improved productivity and satisfaction with the copresence enhancement mechanism. The
survey on the system usability indicated a high level of satisfaction among patients and nurses.
Conclusions: The copresence enhancement design complements the conventional use of a digitized HHD logbook and will
further benefit the design of future telehealth systems.

(JMIR Hum Factors 2017;4(3):e21) doi: 10.2196/humanfactors.7078

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 1

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

KEYWORDS
remote-monitoring; home hemodialysis; co-presence enhancement; design

self-monitoring or logging apps. Medical professionals are also

Introduction devoting efforts to building customized computer-based
End stage renal disease (ESRD) is the most severe form of self-monitoring systems [10,11], with features such as
chronic kidney disease (CKD), and patients suffering from this summative information of health signs, and electronic reminders
condition have poor life expectancy if left untreated. Patients sent at a predefined frequency. Some of those apps are similar
who are not suitable for a transplant have to remain on dialysis to paper-based logs, while others may have additional functions
for the rest of their lives, making dialysis an essential to remind patients to report their vital signs in a timely manner.
life-prolonging treatment modality for patients with ESRD [1]. Although with the setting of reminders, noncompliance might
Dialysis replaces kidney function through the removal of be improved. However, the lack of presence of health care
accumulated metabolic waste products, by a process of diffusion, professionals onsite (ie, at home for patients on HHD) may still
as well as removal of excess fluids from the body, by a process make patients feel isolated and anxious about whether their
of ultrafiltration [2]. Dialysis can essentially be performed by dialysis-related parameters are stable and within expected range
two modalities: peritoneal dialysis, which uses the patients’ and anxious about whether treatments are being monitored by
own peritoneal membrane, and hemodialysis, which uses a trained health professionals. Prior study has pointed out that
synthetic membrane for diffusion and ultrafiltration to occur. addressing social isolation and emotional needs of users is a
While chronic peritoneal dialysis is usually performed by major challenge to the emerging telemonitoring and smart care
patients at home, hemodialysis is typically conducted for 4-5 technologies [12].
hours 3 times a week in a hospital setting (in-center In this study, we propose an exemplar design for an HHD system
hemodialysis) or in a community setting (satellite hemodialysis). optimized for HHD patients with novel mechanisms to enhance
In addition, patients (or their families) can also be trained to patient’s perceived “copresence” with their health care
conduct hemodialysis treatments at home (home hemodialysis). professionals. Our design addresses the social and emotional
Home hemodialysis (HHD) has a number of advantages over needs of the patients. The pilot deployment of the HHD system
other forms of dialyses as it leads to better patient survival, employs multimethod data collection including system entries,
better quality of life, greater independence and opportunity for survey questionnaire, and interview. The study aims to reveal
rehabilitation [3], and is more cost effective [4]. However, HHD how patients perceive and utilize the functions related to emotion
is not without its drawbacks. Although patients and their families sharing and copresence enhancement. The results will
are trained to deliver these seemingly complex treatments at demonstrate how the feelings of being connected with their
home, patients on HHD often feel abandoned by the health health care professional can be improved to enhance patients’
system because of a constant lack of real-time oversight by experience on HHD. This study presents the system design and
trained health professionals, which may increase patients’ the analysis of the impact of the copresence enhancement
anxiety [5]. This lack of oversight may also promote mechanism. The clinical improvements from the pilot, such as
noncompliance, such as violating dietary and fluid intake change in dialysis prescription, patient and staff time-saving
restrictions [6,7], noncompliance to medications [6], and associated with consultation and travel times, and user
skipping or shortening dialysis sessions [8]. Moreover, the satisfaction, were presented as a separate study [13]. The rest
feelings of isolation and difficulty in accessing assistance may of the paper is organized as follows: related work on information
also lead to lack of confidence and poor decisions, including technology (IT) enabled self-monitoring is reviewed, followed
abandoning this otherwise very useful and effective dialysis by a discussion of theoretical foundation informing the design.
modality [9] and increasing the risk of complications [6]. The System development will then be discussed, followed by system
common practice to address some of the limitations associated usability evaluation.
with HHD is to make frequent phone calls or home visits and Background
use paper-based logbooks to record a number of dialysis-related
IT-enabled patient monitoring systems play an important role
parameters of hemodialysis treatments conducted at home.
in well-being and chronic illness management. They are
However, these paper-based logs can be reviewed only when a
changing the way health services, patient data, and medical
patient sees their health care professional face-to-face. The
interferences interact and are able to reduce the number of
problem with this approach is that it could take a long time until
hospitalized patients, minimize the load on clinical staff, and
the patient sees their health care professionals, rendering it
lower the total caring costs for governments. In general,
impossible for them to take early corrective actions for any
IT-enabled patient monitoring systems would benefit both
worrisome deviations in these parameters. Additionally, patients
patients and medical professionals by providing digitization of
may forget to bring their logbooks at the time of consultations
and rapid access to health information. They have been used to
or logs could be lost or unintentionally erased before their health
monitor various types of illness, including cardiac and heart
care professionals have a chance to review them.
illness [14-16], diabetes [14,17,18], mental illness [19,20],
Although there is no system specifically designed for HHD, asthma [21], obesity [22], and other types of illness.
there are multiple attempts at addressing the identified
Prior studies on patient monitoring systems usually consist of
limitations above for other health conditions. There are a number
three main components: (1) tracking physiological parameters,
of mobile phone apps developed to be used as simple
http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 2
(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

such as respiration rate, heart rate [23], blood pressure, and were able to perceive their interaction with a partner and that
blood glucose level [24], some of which are able to be captured their interaction partner actively perceived them [28].
by wearable sensors [25] while others rely on patients’ self-input
Copresence was widely studied in the field of human-computer
[26]; (2) a dashboard for clinicians to view data through a Web
interactions, and its application has been used in the context of
interface or mobile interface enables authorized personnel to
virtual team collaboration [31] and online shopping experiences
monitor the patients’ condition and facilitate remote diagnosis;
[32]. Higher perceived copresence directly influences the
and (3) a messaging function to provide reminders or alerts to
satisfaction of the communication medium [28]. However,
both patients and physicians. These systems are continuously
existing studies of remote patient monitoring have not yet
being enhanced, but challenges remain to improve their clinical
capitalized on the importance and capabilities of copresence.
impact. Data security and privacy are believed to be major
threats to IT-enabled patient monitoring systems, especially in
terms of patient identification and confidentiality of medical
Methods
information [27]. Another concern is the battery life or energy A field trial involving 3 nurses and 74 participants was
consumption of the design, as continuous data collection and conducted to evaluate the copresence-enhanced HHD system,
processing can impose on a phone’s battery runtime [27]. over a 6-month period.
Prior research suggests that addressing social isolation and The Home Hemodialysis System Architecture
emotional needs of users is a challenge to the emerging
telemonitoring and smart care technologies [12]. The feeling The home-monitoring system consisted of three main
of isolation is also a serious problem in patients on HHD [5] as components. The first component is the HHD app installed in
there is a lack of face-to-face communications between patients the patient’s mobile device. The second component is the cloud
and health care professionals. As the HHD procedures require server built on Windows Azure services with SQL storage as
patients to perform the complex dialysis treatments the database. The third component is the Web app also hosted
autonomously, the feeling of isolation from health care on the Azure server. Azure provides industry-leading protection
professionals may cause anxiety and lower their mood and and privacy of the data. Patients use their own mobile device
self-confidence. When patients feel disconnected from their to record their hemodialysis-related data. These data are sent
health care professionals, their compliance to medical advice immediately whenever the mobile device has an Internet
drops and their confidence of self-care also comes down [5]. connection. After the Azure cloud service retrieves the data, it
Thus, in this study we have paid attention to the social nature is stored in its database. Patients’ health care professionals
of using technology and introduce the concept of copresence. (including their HHD nurses and renal specialists) can choose
We discuss how we designed a remote-monitoring system for to access the website at any time. The website provides the
patients on HHD to reduce patients’ feelings of isolation. patient’s up-to-date status with regards to their HHD treatment
parameters, along with trends in these parameters over time,
Copresence, referring to the sense of connection with another enabling the clinical team to make appropriate decisions on a
interactant [28], exists when people feel that they are actively patient’s dialysis prescription, blood pressure, and body weight
perceiving others and feel that others are also actively perceiving that are a surrogate of their body fluid status. Reports along
them [29]. Specifically, copresence refers to the perception by with trends in various parameters over time can be generated
a communicator that another person in a mediated or online and saved as printable documents. Figure 1 illustrates the
environment is real, immediate, or present [30]. Thus, described functionality, users, and the exchange of information
copresence is a reflection of psychological connection to and and emotion between the patients and the health care
with another person. It is required that interactants feel they professionals. The detailed functions of the HHD system and
the copresence enhancement features will be described below.

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 3

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

Figure 1. Design of the copresence-enhanced home hemodialysis system.

perspectives, including a participant’s perception of their

The Basic Functions partner’s involvement in the interaction (perceived others’
The basic functions of the self-monitoring system allow patients copresence) and a participant’s own involvement in the
to record their hemodialysis session data (eg, pre- and interaction (self-reported copresence) [33]. The realization of
postdialysis body weights, blood pressures, ultra-filtration copresence requires mutual synchronization attention and
volumes, blood flow rates, venous and arterial pressures, session emotion in a computer-mediated environment [34]. Our system
times) to the system and get alerts on abnormal parameters or enables patients to rate their emotions at the end of the dialysis
if they did not perform dialysis within a certain amount of time. session as part of the self-health reporting exercise, so that health
At the end of each dialysis session, patients report their status care professionals can have a general understanding of patients’
on how they are feeling on a 5-point sliding scale, to flag if feelings at the end of their dialysis sessions. The emotions are
future dialysis sessions may need to be modified. Patient are reported on a 5-point scale, with 1=Very Happy, 2=Happy,
also able to enter shorts notes in the textbox of the app for each 3=Neutral, 4=Unhappy, and 5=Very Unhappy. Figure 2 shows
entry submission. Health care professionals can review patient the interface in the app that allows patients to share their
data, either in real time or at intervals based on patients’ clinical emotions. Patients are also allowed to include text as additional
needs, thereby allowing monitoring of patients’ parameters as comments to each submission (Figure 2). Figure 3 provides an
well as noncompliance to dialysis regimens, skipping dialysis interface of the dashboard on how the emotions are reviewed
sessions, or shortened dialysis sessions. They can also get a list from the health care professionals’ side. Dialysis data of patients
of patients who have an abnormal status at the end of expressing a low mood are reviewed as a priority.
hemodialysis sessions, prompting remote analysis of their
dialysis data to take remedial actions for their subsequent Health care professionals can also send feedback (with or
hemodialysis treatments. without comments) by simply clicking the confirmed function
in the system, to let patients know their dialysis data have been
The Copresence Enhancement Mechanisms reviewed (Figures 4 and 5).
Besides the basic functions that provide the digital data log and The features of sharing emotions and one-click feedback
enable remote monitoring of patients, copresence enhancement functions were designed to collectively enhance the mutual
mechanisms are related to the feeling of connection between attention and emotion between patients and health care
two people. Given its dual nature, this usually consists of two professionals, while not increasing staff workload significantly.

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 4

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

Figure 2. Patients’ interface to input their emotions.

Figure 3. Dashboard view of patients’ emotions.

Figure 4. Sending feedback to patients.

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 5

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

Figure 5. Patients’ view of health professional’s feedback.

explain whether they felt better connected with the health care
Timeline of the Study and Data Collection professionals and whether they were more confident in doing
In order to evaluate the effectiveness of the system in general their dialysis at home. Content analysis techniques were used
and the copresence enhancement mechanisms, a field trail was for analyzing the qualitative data obtained. Content analysis is
conducted with users at the Home Hemodialysis Unit at the a research tool used to determine the presence of certain words
Regional Dialysis Unit, Blacktown Hospital in Sydney. The or phrases within texts, and from these, infer the meanings that
Home Hemodialysis Unit is part of the Western Renal Service underlie these passages of text [35]. Researchers use these
in Western Sydney that has a philosophy of promoting home techniques to make inferences about the messages within the
dialysis and is one of the largest home dialysis services in texts by analyzing the presence, meanings, and relationships of
Australia. certain words and concepts [35]. The purpose is to reveal the
A 2-week trial to test the app’s functionality on an Android insights related to the system usage rather than establishing
platform commenced initially with 10 patients and 2 health care casual relationships.
professionals (nurses). Improvements were made based on the Basic quality assurance surveys were also conducted with the
feedback received, and an iOS version was launched along with patients, where patients were required to answer a few questions
updated Android version. Patient recruitment was scaled up to in a 5-point Likert form to evaluate the systems along three
74 patients and also to 3 nurses. The timeline of the study is dimensions: ease of use, reliability and performance, and
summarized in Figure 6. usefulness. The questions were adopted from prior validated
Once the HHD system was implemented within the Unit, an instruments with minor modification to the context of dialysis
audit was conducted wherein qualitative data were collected patients. Sample survey questions and interview protocols are
through semistructured interviews to understand the efficacy included in Multimedia Appendix 1. The interview data were
of the copresence enhancement mechanism with nurses and analyzed together with basic quality assurance survey to look
patients. The interview was structured based on the system at patients’ and nurses’ feedback on general system usage,
evaluation: ease of use, reliability and performance, and copresence enhancement mechanisms, and effectiveness of the
usefulness. The patients were allowed to give general comments system. System data including the frequency of self-reporting
along these three dimensions. They were further probed to and the time being acknowledged are also analyzed.

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 6

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

Figure 6. Timeline of the study.

of the system. The results were further analyzed by patients and

Results staff.
General Information Analysis of Patients
Among the 74 participants of the study, there were 25 female Frequency and duration of using the app was dependant on the
and 49 male patients. The age distribution is shown in Figure date the patient was enrolled in the trial. The total number of
7 with more than half of the patients over 50 years old. The entries reported with a different emotional status is summarized
oldest patient was 78 years old and the youngest 21 years old. in Table 1. Altogether there were 492 entries submitted by
There were altogether 2757 entries created by the patients during indicating “Very Happy” as the emotional status, 2167 entries
the trial period (Table 1). The average duration for the patients with a “Happy” status, 56 entries with a “Neutral” status, 18
participating in the study was 128 days, with a standard entries with an “Unhappy” status, and 24 entries with a “Very
deviation of 46.5 days. The minimum duration of participation unhappy” status. On average, each patient had 37 entries for
is 9 days while the maximum is 180 days. Based on the results hemodialysis cases during the period of pilot study, with a
of the quality assurance survey and semistructured interview, standard deviation of 27.8. The maximum number of entries
both patients and nurses reported high ease of use and usefulness created by patients is 91, and the patient duration of participation
is 180 days.
Figure 7. Participants' age distribution.

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 7

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

Table 1. The number of entries patients made during the evaluation period.
Entries Very happy Happy Neutral Unhappy Very unhappy
Entries, total N 2757 492 2167 56 18 24
Percentage of different emotional status, % 100 17.8 78.6 2.03 0.65 0.87
Average entries per patient, n 37 6.6 29.3 0.76 0.24 0.32

Patients reported an average of 4.2 on ease of use of the system were submitted with short notes. We compared the notes entered
(SD 0.77). Patients also reported an average of 4.1 for reliability against the emotion status submitted (see Table 2). Among 492
and performance of the system (SD 0.87). The average perceived entries with the “Very Happy” status, 256 entries were
usefulness of the system was 4.1 (SD 1.4). They also gave supplemented with patients’ short notes. For the “Happy” status,
positive feedback regarding the usage of the system during their 30.69% (665/2167) of entries had additional notes. For “Neutral”
interviews. status, 59% (33/56) had text notes in the entries. For the
“Unhappy” status, all 18 entries consisted of notes input from
The patients also showed greater awareness of copresence
the patients. For the “Very unhappy” status, 71% (17/24) of
enhancement design mechanisms that we associate with the
entries had notes input. The result shows that when patients are
interview responses such as “not feeling alone,” “knowing I am
in negative mood, they would like to express themselves with
monitored,” and other similar phrases. They reported that they
the support of text messages and to improve nurses’
felt relaxed to know that their dialysis parameters and treatments
understanding on their status. The patients also expressed that:
were being monitored, especially when they received
“When I am not feeling well, I want to get the nurses’ immediate
acknowledgements from the nurses after submitting their
attention” and “I am glad that they are paying attentions to our
dialysis-related data. When asked about the functions of entering
problems and emotions.”
notes and emotions into the system, one of the patients
mentioned, “It is comforting to know that my results are being We also coded the notes entered by the patients into the system,
monitored and you are not alone.” As the negative modes (Very which fell into three categories: (1) describing health status,
unhappy and Unhappy) usually get the fastest response from such as “a bit dizzy in the last hour,” “notice my BP increasing,”
the health care professionals, the patients who expressed “my bleeding didn’t stop quickly it took almost 2 hrs,” “all
negative emotions also expressed that they felt “care and good,” (2) greeting to health care professionals, such as “thanks,
responsiveness from the health care professionals all the time.” Maryann,” “have a nice day,” “A big smile”; this type of
The copresence enhancement design of the system was shown message is very common for the entries “Very happy” and
to improve the mutual attention and mutual emotion for “Happy” emotions, and (3) expressing technical difficulty, such
patient-nurse communication. The patients mentioned being as “Power failure after 30 mins.” The patients mentioned that
“motivated to keep dialysis schedule” by the features in the app. that by entering notes to the system, their queries can be quickly
In addition, the patients mentioned that they may append some attended by the health care professionals and they do not need
notes to some submitted entries as they know “the nurse will to wait till next consultation. They also mention it is an effective
get the message.” way to communicate with staff and feel they are “virtually
connected” with the staff all the time.
We further analyzed the entries with notes appended. Out of
the 2757 entries created during the study period, 989 entries

Table 2. The number of entries submitted with text notes.

Notes Entries with Entries with Entries with Entries with notes Entries with notes
notes for notes for notes for for “Unhappy” for “Very Unhappy”
“Very Hap- “Happy” “Neutral”
py”
Total N 989 256 665 33 18 17
Percentage by type of emotions, % 100 25.9 67.2 3.3 1.8 1.7
Average per patient, n 13 3.5 9.0 0.45 0.24 0.23
Note average per emotion entry, % 52 31 59 100 71

nurses reported satisfaction with the system features during the

Analysis of Clinical Staff interview, especially by mentioning it is a “time saving tool.”
With the implemented system, there were on average 12 patients
remotely reviewed per week. It resulted in savings of 7 hours The nurses mentioned that getting a glimpse of patients’
in nursing and patient times each, from reduced home and/or emotional status with a simplified rating was reassuring. They
unit visits, equating to a total saving of 11 hours of travel time reported a positive feeling of being able to “reach out” to more
and 544 kilometres of travel distance. This paper focuses on patients. The notes entered by the patients also provide a better
the copresence mechanism; additional details about the understanding of whether the problem was technical or
operational benefits can be found in another paper [13]. The illness-related. When seeing some greeting messages, the nurse

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 8

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

also said that these patients were also treating them as friends, suggest that social and emotional needs of users are overlooked
so the system still maintains a certain level of connection in current solutions [12]. Patients expressed that better
between patients and them. The digital log kept a history of connections were built with staff through submitting emotional
patients’ dialysis-related data and allowed nurses to track feedback for the dialysis session. The design of one-click
changes in the patient’s dialysis parameters over time. The feedback function is also highly regarded by the nurses.
system also enabled nurses to change dialysis prescriptions and
patients’ dry weights in a timely manner, prompting patients to
Limitations and Future Work
know that they were continuously monitored by nurses. This study has a few limitations, but it opens up exciting avenues
for future research. First, there is no comparison group in the
Discussion study, since the aim was not to establish causal relationship,
but rather to reveal in-depth insights based on a combination
Principal Considerations of subjective and objective data. Future study can plan for a
This study is one of the first studies on copresence in remote randomized controlled trial and draw causal relationships
monitoring in health care settings. Despite many efforts devoted between system usage and clinical benefits. In the future, we
to building and understanding the effectiveness of plan to conduct a prospective study to measure the long-term
computer-based self-monitoring systems [10,11], few studies benefits to patients and on the efficacy and productivity of health
have looked at the importance of enhancing the social emotional care professional’s care delivery with the use of our copresence
needs of patients. Our study indicates that equipped with the enhancement mechanisms. Second, feelings such as isolation
copresence enhancement mechanisms, the HHD system received were not directly measured using questionnaires. The current
positive feedback from both patients and nurses. The field trial study only interpreted such meanings based on the qualitative
implies that HHD might reduce patients’ feeling of isolation data collected through interview. Future studies should include
and anxiety caused by independently conducting hemodialysis quantitative measurements of feelings and emotions. Third,
treatments at home. there might be other possible features that can be implemented
to enhance copresence. For example, studies have found that
Although the system usage was voluntary for the patients and using an avatar can enhance perceived copresence in the context
they could still enter their HHD-related data into the of teleconferencing and virtual learning [36]. As this study was
conventional exercise books without using the app, this mixed to test the idea of copresence enhancement mechanisms while
method study revealed that the app usage has achieved its not overloading patients with too many functions, these features
effectiveness as designed. With the feeling of being monitored were not implemented in the HHD system. Future study can
and connected to their nurses at all times, patients’ motivations definitely implement and test the effectiveness of different
to adherence was increased. The system empowered patients to copresence enhancement features. Additionally, we plan to
better understand and take care of their health care and therefore further complement our copresence mechanism by incorporating
suggests that the system has the potential to improve patient a video conferencing tool to improve communication between
uptake and retention on HHD programs and improve patients and health care professionals and to ensure the safety
relationships with their nursing staff. The nurses also felt assured of patients doing dialysis at home, as videoconferencing can
to have a simplified view of patients’ emotions and dialysis enable assessment of patients’ fluid status, visual inspection of
parameters. vascular access integrity, dialysis machine malfunctions, and
Our study has demonstrated the effectiveness of copresence alarms.
enhancement mechanism in the context of remote monitoring Conclusion
of dialysis parameters in patients on HHD. IT-enabled patient
In this paper, we propose an exemplary design of an HHD
monitoring is a trend and the benefits have been demonstrated
system by incorporating copresence enhancement mechanisms.
including reducing nurse-patient ratio, reducing operational
The design was able to address the challenges of monitoring
cost, and improving data accuracy. There are also issues and
patients’ dialysis-related parameters while they are on HHD
challenges with the use of technology, and a significant one is
and their feeling of isolation when conducting these treatments.
that patients are not able to have face-to-face communication
Our user-centered HHD system was designed to enhance
with health care professionals and may feel isolated and lose
nurse-patient mutual attention and emotion without overloading
compliance and confidence through the self-disease management
them with complicated functions. The proposed mechanisms
process. While current ways to reduce patient isolation require
were shown to improve the feeling of connectedness with
additional investment of physicians’ and nurses’ time, such as
clinicians for the patients, improve adherence to their dialysis
increasing standby hours or having a video conferencing call,
treatments and schedules, and also enhance emotional well-being
our study proposes a concise design by introducing functions
of patients. It is one of the first studies to address social concerns
like sharing emotions using emojis, sending quick notes, sending
and emotional feelings for patients on home dialysis. Our results
acknowledgment, and having a prioritized response to patients’
from patients and the health care team have been positive and
records. The features provide health care professionals a
affirm that the proposed copresence-enhanced mechanisms have
preliminary filtering of patients’ situations and provide patients
many benefits to HHD. We suggest that our copresence
the feeling that they are cared for and monitored constantly.
enhancement mechanisms are relevant to other remote chronic
Our study also highlighted the importance of communicating disease management systems.
emotions with health care professionals. Prior studies on telecare

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 9

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

Conflicts of Interest
None declared.

Multimedia Appendix 1
Survey and interview instruments.
[PDF File (Adobe PDF File), 26KB-Multimedia Appendix 1]

References
1. de Fijter JW. Kidney allocation: where utility and fairness meet. Nephrol Dial Transplant 2010 Jun;25(6):1746-1749. [doi:
10.1093/ndt/gfq164] [Medline: 20360015]
2. Daugirdas J, Ing TS, Blake P. Physiological principles and urea kinetic modelling. In: Handbook of Dialysis. Philadelphia,
PA: Lippincot Williams & Wilkins; 2001.
3. Tong A, Palmer S, Manns B, Craig JC, Ruospo M, Gargano I, et al. Clinician beliefs and attitudes about home haemodialysis:
a multinational interview study. BMJ Open 2012;2(6) [FREE Full text] [doi: 10.1136/bmjopen-2012-002146] [Medline:
23242245]
4. McClure DN. Home haemodialysis in Australia - is the wheel turning full circle? Med J Aust 2010 Nov 01;193(9):559.
[Medline: 21034399]
5. Richmond JM, Lindsay RM, Burton HJ, Conley J, Wai L. Psychological and physiological factors predicting the outcome
on home hemodialysis. Clin Nephrol 1982 Mar;17(3):109-113. [Medline: 7067172]
6. Bame SI, Petersen N, Wray NP. Variation in hemodialysis patient compliance according to demographic characteristics.
Soc Sci Med 1993 Oct;37(8):1035-1043. [Medline: 8235736]
7. Kugler C, Vlaminck H, Haverich A, Maes B. Nonadherence with diet and fluid restrictions among adults having hemodialysis.
J Nurs Scholarsh 2005;37(1):25-29. [Medline: 15813583]
8. Leggat J, Orzol SM, Hulbert-Shearon TE, Golper TA, Jones CA, Held PJ, et al. Noncompliance in hemodialysis: predictors
and survival analysis. Am J Kidney Dis 1998 Jul;32(1):139-145. [Medline: 9669435]
9. Peters A. Safety issues in home dialysis. Nephrol Nurs J 2014;41(1):89-92. [Medline: 24689271]
10. Faurholt-Jepsen M, Munkholm K, Frost M, Bardram JE, Kessing LV. Electronic self-monitoring of mood using IT platforms
in adult patients with bipolar disorder: A systematic review of the validity and evidence. BMC Psychiatry 2016 Jan 15;16:7
[FREE Full text] [doi: 10.1186/s12888-016-0713-0] [Medline: 26769120]
11. Or C, Tao DA. A 3-Month Randomized Controlled Pilot Trial of a Patient-Centered, Computer-Based Self-Monitoring
System for the Care of Type 2 Diabetes Mellitus and Hypertension. J Med Syst 2016 Apr;40(4):81. [doi:
10.1007/s10916-016-0437-1] [Medline: 26802011]
12. Milligan C, Roberts C, Mort M. Telecare and older people: who cares where? Soc Sci Med 2011 Feb;72(3):347-354. [doi:
10.1016/j.socscimed.2010.08.014] [Medline: 20880624]
13. Nicdao M, Kim JM, Baldacchino T, Jung Y, Mikaheal M, Patekar A, et al. 'My Home Hemo' app - a new telehealth tool
for remote monitoring of patients on home haemodialysis. Renal Society of Australasia Journal 2016;12(2):41-47.
14. Karhula T, Vuorinen AL, Rääpysjärvi K, Pakanen M, Itkonen P, Tepponen M, et al. Telemonitoring and Mobile Phone-Based
Health Coaching Among Finnish Diabetic and Heart Disease Patients: Randomized Controlled Trial. J Med Internet Res
2015 Jun 17;17(6):e153 [FREE Full text] [doi: 10.2196/jmir.4059] [Medline: 26084979]
15. Nägele H, Lipoldová J, Oswald H, Klein G, Elvan A, Vester E, et al. Home monitoring of implantable
cardioverter-defibrillators: interpretation reliability of the second-generation “IEGM Online” system. Europace 2015
Apr;17(4):584-590 [FREE Full text] [doi: 10.1093/europace/euu349] [Medline: 25567067]
16. Olmos C, Franco E, Suárez-Barrientos A, Fortuny E, Martín-García A, Viliani D, et al. Wearable wireless remote monitoring
system: an alternative for prolonged electrocardiographic monitoring. Int J Cardiol 2014 Mar 01;172(1):e43-e44. [doi:
10.1016/j.ijcard.2013.12.068] [Medline: 24412464]
17. Katalenich B, Shi L, Liu S, Shao H, McDuffie R, Carpio G, et al. Evaluation of a Remote Monitoring System for Diabetes
Control. Clin Ther 2015 Jun 01;37(6):1216-1225 [FREE Full text] [doi: 10.1016/j.clinthera.2015.03.022] [Medline:
25869625]
18. Tang T, Digby EM, Wright AM, Chan JHM, Mazanderani AB, Ross SA, et al. Real-time continuous glucose monitoring
versus internet-based blood glucose monitoring in adults with type 2 diabetes: a study of treatment satisfaction. Diabetes
Res Clin Pract 2014 Dec;106(3):481-486. [doi: 10.1016/j.diabres.2014.09.050] [Medline: 25458333]
19. Lanata A, Valenza G, Nardelli M, Gentili C, Scilingo EP. Complexity index from a personalized wearable monitoring
system for assessing remission in mental health. IEEE J Biomed Health Inform 2015 Jan;19(1):132-139. [doi:
10.1109/JBHI.2014.2360711] [Medline: 25291802]
20. Naslund J, Marsch LA, McHugo GJ, Bartels SJ. Emerging mHealth and eHealth interventions for serious mental illness:
a review of the literature. J Ment Health 2015;24(5):321-332 [FREE Full text] [doi: 10.3109/09638237.2015.1019054]
[Medline: 26017625]

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 10

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

21. Finkelstein J, Cabrera MR, Hripcsak G. Internet-based home asthma telemonitoring: can patients handle the technology?
Chest 2000 Jan;117(1):148-155. [Medline: 10631213]
22. Luley C, Blaik A, Reschke K, Klose S, Westphal S. Weight loss in obese patients with type 2 diabetes: effects of
telemonitoring plus a diet combination - the Active Body Control (ABC) Program. Diabetes Res Clin Pract 2011
Mar;91(3):286-292. [doi: 10.1016/j.diabres.2010.11.020] [Medline: 21168231]
23. Louis A, Turner T, Gretton M, Baksh A, Cleland JGF. A systematic review of telemonitoring for the management of heart
failure. Eur J Heart Fail 2003 Oct;5(5):583-590 [FREE Full text] [Medline: 14607195]
24. Paré G, Moqadem K, Pineau G, St-Hilaire C. Clinical effects of home telemonitoring in the context of diabetes, asthma,
heart failure and hypertension: a systematic review. J Med Internet Res 2010 Jun 16;12(2):e21 [FREE Full text] [doi:
10.2196/jmir.1357] [Medline: 20554500]
25. Corchado JM, Bajo J, Tapia DI, Abraham A. Using heterogeneous wireless sensor networks in a telemonitoring system for
healthcare. IEEE Trans Inf Technol Biomed 2010 Mar;14(2):234-240. [doi: 10.1109/TITB.2009.2034369] [Medline:
19858034]
26. Maric B, Kaan A, Ignaszewski A, Lear SA. A systematic review of telemonitoring technologies in heart failure. Eur J Heart
Fail 2009 May;11(5):506-517 [FREE Full text] [doi: 10.1093/eurjhf/hfp036] [Medline: 19332417]
27. Baig M, Gholamhosseini H. Smart health monitoring systems: an overview of design and modeling. J Med Syst 2013
Apr;37(2):9898. [doi: 10.1007/s10916-012-9898-z] [Medline: 23321968]
28. Nowak K. Defining and differentiating copresence, social presence and presence as transportation. In: Presence 2001. 2001
Presented at: 4th Annual International Workshop on Presence; May 21-23, 2001; Philadelphia, PA p. 1-23.
29. Goffman E. Behavior in public places: Notes on the social organization of gatherings. In: Behavior in Public Places. New
York: Free Press; 1963.
30. Callaway Russo T. Operationalizing mediated presence: Initial steps toward a measure of the construct. In: Presence 2001.
2001 Presented at: 4th Annual International Workshop on Presence; May 21-23, 2001; Philadelphia, PA.
31. Kahai S, Carroll E, Jestice R. Team collaboration in virtual worlds. SIGMIS Database 2007 Oct 28;38(4):61. [doi:
10.1145/1314234.1314246]
32. Kim H, Suh K, Lee U. Effects of collaborative online shopping on shopping experience through social and relational
perspectives. Information & Management 2013 Jun;50(4):169-180. [doi: 10.1016/j.im.2013.02.003]
33. Nowak K, Biocca F. The Effect of the Agency and Anthropomorphism on Users' Sense of Telepresence, Copresence, and
Social Presence in Virtual Environments. Presence: Teleoperators and Virtual Environments 2003 Oct;12(5):481-494. [doi:
10.1162/105474603322761289]
34. Campos-Castillo C, Hitlin S. Copresence. Sociological Theory 2013 Jul 19;31(2):168-192. [doi: 10.1177/0735275113489811]
35. Krippendorff K. Content Analysis: An Introduction to Its Methodology. Thousand Oaks, CA: Sage Publications; 2013.
36. Jo D, Kim KH, Kim GJ. Effects of avatar and background representation forms to co-presence in mixed reality (MR)
tele-conference systems. In: Virtual Reality Meets Physical Reality: Modelling and Simulating Virtual Humans and
Environments. 2016 Presented at: SIGGRAPH ASIA; Dec 5-8, 2016; Macao p. 12.

Abbreviations
CKD: chronic kidney disease
ESRD: end stage renal disease
HHD: home hemodialysis

Edited by G Eysenbach; submitted 29.11.16; peer-reviewed by N Goonawardene, X Wang, T Cui, CF Chung; comments to author
08.02.17; revised version received 13.05.17; accepted 27.07.17; published 29.08.17
Please cite as:
Liu N, Kim J, Jung Y, Arisy A, Nicdao MA, Mikaheal M, Baldacchino T, Khadra M, Sud K
Remote Monitoring Systems for Chronic Patients on Home Hemodialysis: Field Test of a Copresence-Enhanced Design
JMIR Hum Factors 2017;4(3):e21
URL: http://humanfactors.jmir.org/2017/3/e21/
doi: 10.2196/humanfactors.7078
PMID: 28851680

©Na Liu, Jinman Kim, Younhyun Jung, Adani Arisy, Mary Ann Nicdao, Mary Mikaheal, Tanya Baldacchino, Mohamed Khadra,
Kamal Sud. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 29.08.2017. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 11

(page number not for citation purposes)
XSL• FO
RenderX
 JMIR HUMAN FACTORS Liu et al

Human Factors, is properly cited. The complete bibliographic information, a link to the original publication on
http://humanfactors.jmir.org, as well as this copyright and license information must be included.

http://humanfactors.jmir.org/2017/3/e21/ JMIR Hum Factors 2017 | vol. 4 | iss. 3 | e21 | p. 12

(page number not for citation purposes)
XSL• FO
RenderX