Principles of Health Informatics: Social networks, telehealth, and mobile health. Last delivered in 2023. All educational material listed or linked to on these pages in relation to King's College London may be provided for reference only, and therefore does not necessarily reflect the current course content.

1. Lecture 14: Social networks, telehealth, and
mobile health
Dr. Martin Chapman
Principles of Health Informatics (7MPE1000). https://martinchapman.co.uk/teaching

2. Recall: Communication services
In Lecture 13 we looked at communication systems, a key component
of which is communication services. We looked at the general
operation of these services.
In this lecture, we will consider the application of each service to
healthcare, and to the delivery of interventions.

3. Lecture structure
1. Social media (networks)
2. Video services
3. Email and text messages
4. Voice services
5. Mobile applications
Telehealth and
mobile health

4. Learning outcomes
1. To understand the concept of social networks, and how to
measure their various properties.
2. To understand the concept of a network intervention, and how it
can be used (within social networks) to affect change.
3. To understand how the remaining communication services can,
under the banner of mobile and telehealth, support different
interventions.

5. Social media

6. Background: Social networks
Social networks quantify the relationships and interactions between
groups of people.
They can, once again, be represented as a graph with nodes
indicating people and edges indicating connections. This is
sometimes known as a sociogram.
We’ve already seen similar structures used for search spaces (Lecture
3) and for organising a terminology (Lecture 11), but each have a
specific purpose.
Social networks are distinct
from social media, which we will
look at shortly.

7. Social networks
By representing a social network in this way, we can determine
various properties of the individuals in the network.
These include degree centrality, betweenness centrality (including
shortest paths) and communities.
Node
(person)
Edge (social connection)
Note that these network are not
hierarchical (e.g. don’t have a
root node), unlike what we’ve
seen previously.
Edges can be directional
(but we will abstract away
from this for simplicity)
These properties
will be useful later.

8. 1. Degree centrality
When we calculate centrality we are effectively working out those
individuals who are most influential in a network.
We can do this using a number of different (sub-)methods, with the
most straightforward being to count the connections each node has,
or each node’s degree.
2
3 2

9. 2. Communities
The notion of node degree gives rise to the concept of communities,
or sections of our graph that are closely connected.
In the above, we can broadly see the emergence of a health
informatics community and an informatics community.
Highly connected set of nodes
forming a community

10. 2. Betweeness centrality
With the notion of a community in mind, we can now consider the
related idea of betweenness centrality.
At a high level, individuals with a high betweenness centrality are
those that span multiple communities, otherwise known as boundary
spanners. We can quantify betweenness centrality but first…

11. Aside: Shortest path
A key notion related to betweenness centrality is that of the shortest
path between two nodes.
As the name suggests, the shortest path is the least number of hops
it takes to get from one node to another. There can be multiple
shortest paths.
A
B
C D
E
If we label our nodes, the
shortest path from A to E is
shown.
A longer path would go via B.

12. 2. Betweeness Centrality
We can calculate betweenness centrality for a given node by
considering the number of shortest paths that node appears on. In
other words, an individual that is often involved in communications.
Node pair Number of
shortest paths
Shortest paths that
pass through C
Shortest paths that pass through C
Number of shortest paths
A - B 1 0 0
A - D 1 1 1
A - E 1 1 1
B – D 1 1 1
B – E 1 1 1
D – E 1 0 0
Adding these
together we get
a betweenness
centrality of 4
for C.
We
don’t
need
to
repeat
in
reverse
order
(e.g.
B
–
A)

13. Other social network measures
There are a number of other ways to measure the properties of a
social network:
- Closeness centrality – similar to betweenness centrality; measures
the length of the shortest path(s) from one node to others.
- Network size – a simple measure of the number of individuals in a
network.
- Tie strength – adding a weight to the edges between individuals.
We will look at the impact of social network measures shortly, but
for now let’s consider our first communication service.

14. Recall: Social media
As we’ve seen social media is a communication service with a diverse
set of components (e.g. channels and media).
It is primarily designed to support
group interaction, and thus maps to
the social networks we have seen.
Indeed, social media allows real
world social networks to be emulated
in a digital space.
Facebook graph

15. General social media health applications
These large digital networks offer a number of facilities, with two
significant ones being (ethical) access to large amounts of
crowdsourced data and access to a large network for communication.
Both of these things can be leveraged in the health domain, and we
might view their use as a form of high-level intervention.
In the next few slides we will explore some of these practices.

16. General social media health applications: Data
The large amount of data generated by users on social media can be
harnessed in a number of different ways in a health context:
- Quality measures. Reviews on things such
as the quality and safety of health services
can be useful in evaluating them (being
aware of noise!)

17. General social media health applications: Data
The large amount of data generated by users on social media can be
harnessed in a number of different ways in a health context:
- Infectious disease surveillance: crowdsourcing patient data with
the purpose of identifying outbreaks and tracking their
development.
As an indirect form of social
media KCL’s ZOE app is/was
used to track the prevalence of
COVID, including key
symptoms.

18. General social media health applications: Data
The large amount of data generated by users on social media can be
harnessed in a number of different ways in a health context:
- Disease management: Create spaces where patients can interact
(with clinicians), share experiences and receive support.
Work at KCL looked at
identifying users with depression
on Twitter by analysing their
Tweets.
Social media can exist as a
part of larger Personally
Controlled Health
Management Systems
(PCHMSs), along with
EHRs and booking
services.

19. General social media health applications:
Communication
The reach that social media provides can also be useful in a health
context:
- Emergency services – Using social
media as an emergency broadcast
channel, using it to locate people,
or as a place to share plans around
disaster mitigation.
- Public health messaging and
promotion – Using social media to
share positive health messages.
More money saved on
energy = more money
to heat home = better
health outcomes

20. Network interventions
A more formal way to approach interventions via social media is to
explicitly leverage the social network properties we’ve seen in order to
enact change into the network.
These network interventions are mostly based on the concept of
social contagion, or the idea that people will change their (health)
behaviours to match those of their peers.
Network interventions include: individuals, groups, induction and
alteration.

21. 1. Network interventions - Individuals
If I wanted to affect change via a social network, I could identify
those individuals with a high degree or betweenness centrality and try
and change their behaviours, so that the behaviours of others change
too.

22. 2. Network interventions - Groups
However, some behaviours are so embedded in entire communities
(also known as norms), that we have no choice but to target the
entire group if we want to affect change.

23. 3. Network interventions - Induction
Rather than focusing on individuals, we can, instead, focus on the
links between individuals, specifically the utilisation of these links. If
we try and increase peer-to-peer communication we are thus
manipulating our network via induction.

24. 4. Network interventions - Alteration
We might decide that we cannot affect change in a network given
its current structure. In this case, we can look to change that
structure, specifically by manipulating the communities in which
individuals exist.

25. Considerations around the use of social media in
healthcare
Accessing social media can have some negative impacts on health,
which include amplifying public displays of negative health
behaviours, exposure to harmful health marketing material and
controversial views tainting public health messages.
There are also certain prerequisites for social networks (and media)
to be used to support interventions. These are fairly logical, such as
the fact that there must be evidence of the spread of a disease (such
as obesity) via social links in order for interventions to be successful.

26. Telehealth and mobile health

27. Telehealth and mobile health
For the remainder of this lecture, we will consider the remaining
communication services, and the interventions they might support.
The use of our remaining services – video, email and text messages,
voice and mobile applications – in healthcare is often referred to as
telemedicine or, for mobile devices specifically, mobile health (often
seen as an evolution of the former).
Formally, telemedicine and mobile health is technology-mediated
communication that facilitates healthcare.

28. Video services
Note: the products and services
shown are just examples, and
not any particular kind of
endorsement.

29. Video services
Although telemedicine is broader, video services, specifically video
consultations, are often (erroneously) considered to be the same as
telemedicine.
Video services succeed in facilitating
intervention delivery perhaps more so than
other services as one can more closely
emulate an in-person interaction, with
visual cues and gestures.

30. Video services – Patient-to-clinician interactions
We typically consider the use of video services
to support intervention delivery directly (i.e.
supporting remote patient-to-clinician
interactions), but they can also support
clinician-to-clinician interactions, and thus
interventions indirectly.

31. Video services – Clinician-to-clinician interactions
Clinician-to-clinician interactions using video services can take many
forms:
- Rich discussions on interventions can
take place between specialists and non-
specialists in an area (e.g. a GP to a
dermatologist), often involving shared
objects like images. This can also be
used to increase wider skill levels.
A ‘teledermatology’ session.

32. Video services – Clinician-to-clinician interactions
Clinician-to-clinician interactions using video services can take many
forms:
- Video services can also have a significant
application in inter-hospital communication,
where specialist services – particularly those
present in larger national hospitals ones – can
be shared.

33. Video services – Clinician-to-clinician interactions
Clinician-to-clinician interactions using video services can take many
forms:
- This includes, in particular, (1) emergency care
services, where the synchronous element of
video services is essential, (2) intensive care
services where, again, the ability to look at
shared objects in real-time (such as a shared
EHR) is important and (3) support for chronic
conditions.

34. Email and text messages

35. Email and text messages
Although we’ve just seen how important the rich,
synchronous communication provided by video
services can be in intervention delivery, there is also
a place for simpler, asynchronous communication
too, such as emails and text messages, in
healthcare.

36. Email – Primary care
One particular area in which email specifically is beneficial is primary
care, where it can (also) be used to support patient-to-clinician
interactions.
- This mechanism of communication
tends to result in high levels of
patient satisfaction, potentially
because the offline, synchronous
nature is actually appealing – patients
feel more able to discuss sensitive
topics, for example.
Emails may be sent directly, or
facilitated by something like an
online form.

37. Email – Primary care
One particular area in which email specifically is beneficial is primary
care, where it can (also) be used to support patient-to-clinician
interactions.
- It can also be a more efficient way to
conduct administrative tasks, like
accessing health record data or
rearranging appointments.

38. Text messages – Behaviour change
There can, of course, also be clinician-to-patient interactions
facilitated by (typically) asynchronous communication, such as
emails responding to queries or (automated) emails containing
reminders about appointments.
A more specific intervention-driven
example of clinician-to-patient
interactions is the use of automated text
messages in an attempt to change
behaviour, such as sending regular,
motivating messages to those who wish
to stop smoking. This could be the first step in a network
intervention, which we looked at previously.

39. Voice services

40. Voice services
Although voice services are, in effect, a
component of video services (which we’ve
already looked at) – and in many cases they
can be used interchangeably to support care –
they do have a role to play in healthcare and
interventions as a standalone service.

41. Voice services – Triage
Situations in which standalone voice may be preferable to video are
those where time and reach are a factor, because the use of video
services may be more time-consuming, and not everyone may readily
have access to video services.
As such, a key application area is (primary care) triage, where one
wants to quickly interact with as large a number of patients seeking
medical assistance as soon as possible.
Through voice services, assistance can be provided with appointment
making, patients can be directed to secondary services if they require
more urgent care, or they can be informed that no visit is required.

42. Voice services – Triage
In the UK, a key example of this is the ‘111’ telephone service.

43. Voice services – Medication reminders
We should also remember that voice services can be one-way and
asynchronous.
Therefore, voice services have a role to play in interventions that
target things like poor medication adherence.
For example, automated calls can be made to patients, or voicemails
can be left for them, reminding them to take a certain medication.

44. Mobile applications

45. Mobile applications
As technology progresses, of course
things like medication reminders are
less likely to come via a voice service
and more likely to come through
something like a mobile application.
Medication reminders like this are part
of wider remote patient monitoring and
intervention initiatives.

46. Mobile applications – Remote patient monitoring
The management of chronic
conditions is a significant challenge
for health services around the world.
Conditions include things like
diabetes, cardiovascular diseases
(CVD) and stroke.
One of the main challenges is cost,
both financially and in terms of
time.

47. Mobile applications – Remote patient monitoring
One possible solution is to allow chronically ill patients to remain
at home (rather than keeping them in direct care), and to both
monitor and intervene as necessary remotely (telemonitoring), thus
addressing both these challenges.
Although lots of the services we’ve looked at contribute to
telemonitoring (voice, video, etc.), the use of app-based services is
becoming more common.

48. Mobile applications – CONSULT
We can look at one example of a remote patient monitoring
system – initially designed for stroke patients – which illustrates
the general components of such as system.
This system was developed at King’s and is called CONSULT.
CONSULT is, more
broadly, a (clinical)
decision support
system, which
illustrates the
connection between
these two concepts.

49. Mobile applications – CONSULT
Sensors (wearables) help to
monitor a patient’s state remotely. We store our data
centrally using a
standard, and
communicate in the
same standard.
We have a reasoning
engine, providing the
DSS component.
Patients (and clinicians) can view
the data collected by the system,
and the recommendations
(interventions) suggested.
The EHR can also
be referenced to
contextualise
sensor readings
and interventions
A real focus on taking
telemonitoring to the next
level in terms of
promoting self-
management.
Martin Chapman, Abigail G-Medhin, et al. Using microservices to design patient-facing
research software. In Proceedings of the IEEE 18th International Conference
on e-Science (e-Science), 2022.

50. Summary (It all comes back to interventions…)
Different communication services can support different areas of
healthcare and, more importantly, different interventions.
In other words, there are certain services that best support certain
interventions.
Social media can support behavioural change interventions, by
providing a means to establish and represent social connections,
which can in turn be leveraged.

51. Summary (It all comes back to interventions…)
Synchronous video services can help ensure that the remote delivery
of interventions feels more like a face-to-face interaction, and is thus
just as effective.
Asynchronous services like email and text messages also have a role
to play in interventions like behaviour change.
Voice services come into play when scale is a factor, and voice triage
helps to ensure that the right interventions get to the right people.
Mobile applications perhaps represent the future of remote
interventions, given their potential to reduce burdens on the health
system.

52. Epilogue: Is telehealth and mobile health
working?

53. Epilogue: Is telehealth and mobile health working?
Despite the promise of tele and mobile health, there are actually
mixed reports as to its impact:
- Lots of studies that appear to show good results actually have
flaws (e.g. low patient sample sizes).
- Despite aiming to save costs, the introduction of technology can
simply add different costs (e.g. the equipment itself, training and
maintenance costs).

54. Epilogue: Is telehealth and mobile health working?
In perhaps the most important area, health outcomes, there is also
uncertainty:
- Where positive results have been noted, there tends to be a focus
on the technology itself, rather than conducting proper trials.
- Similarly, where good outcomes do exist, these are mostly
reserved for certain areas (like psychiatry where verbal interaction,
facilitated by communication services, is key).
- Fortunately there are objectively good outcomes in the
management of chronic conditions using telemedicine.
Hopefully, in time, we will see more objective and rigorous examples
of telemedicine’s success.

55. References and Images
Enrico Coiera. Guide to Health Informatics (3rd ed.). CRC Press, 2015.
https://www.gov.uk/government/news/small-changes-mean-energy-advice-campaign-adds-up-to-big-savings
https://www.nhs.uk/nhs-services/gps/using-an-online-form-to-contact-your-gp-surgery
https://111.nhs.uk/
https://carecalls.co.uk/
https://www.safeandsoundhealth.co.uk/
https://www.ncoa.org/article/the-top-10-most-common-chronic-conditions-in-older-adults
https://mathematica.stackexchange.com/questions/11673/how-to-play-with-facebook-data-inside-mathematica
https://www.boredpanda.com/funny-suspiciously-specific-amazon-reviews
https://health-study.joinzoe.com/

56. References and Images
https://www.lifewire.com/mark-yourself-safe-on-facebook-5070481
https://www.access-board.gov/files/presentations/USAB_2021-01-13_Accessible_Virtual_Meetings.pdf
https://partners.pushdoctor.co.uk/
https://www.babylonhealth.com/en-gb
https://www.skincarenetwork.co.uk/dermatology/teledermatology/
https://www.superoffice.com/blog/follow-up-email/
https://www.softwareadvice.com/resources/patient-centered-technology-modern-medical-practice/
https://www.theguardian.com/healthcare-network/2011/jun/30/motivational-text-messages-help-smokers-quit
https://simpsons.fandom.com/wiki/AT-5000_Auto-dialer