key: cord-0314221-8fj1l2w0 authors: Finucane, A.; O'Donnell, H.; Lugton, J.; Swenson, C.; Pagliari, C. title: Digital Health Interventions in Palliative Care: A Systematic Meta-Review and Evidence Synthesis date: 2020-09-18 journal: nan DOI: 10.1101/2020.09.16.20195834 sha: b7b5373d748d74a26f1d13c892adb6cbba919576 doc_id: 314221 cord_uid: 8fj1l2w0 Digital health interventions (DHIs) have the potential to improve the accessibility and effectiveness of palliative care but heterogeneity amongst existing systematic reviews presents a challenge for evidence synthesis. This rigorous meta-review applied a structured search of 10 databases from 2006 to 2020, revealing 21 relevant systematic reviews, encompassing 332 unique publications. Most reviews were moderate quality. Interventions delivered via videoconferencing (17%), electronic healthcare records (16%) and phone (13%) were most frequently described. DHIs were typically used in palliative care for education (20%), symptom management (15%), decision-making support (13%), information provision or management (13%), and communication (9%). Positive impacts were reported on education, decision-making, information-sharing, communication, and costs. Impacts on symptom management were either positive or showed no harmful effects. However often DHIs were described but not evaluated. Responsive pragmatic research designs are now needed to guide further evaluation, implementation and to inform future service innovation. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09. 16.20195834 doi: medRxiv preprint Characteristics of the 21 included reviews are shown in Table 1 (See Appendix). Most included a range of study populations -patients, family members, caregivers, and health professionals. Three reviews focused on cancer, 21-23 others did not limit their inclusion criteria a specific disease. The reviews were carried out by research teams based in the following countries: USA (9), 17,24-31 UK (6) , 16 ,23,32-35 Australia (2), 14, 36 Canada (1) 22 Chile (1), 15 Denmark (1) 37 and Brazil (1) 38 . The number of studies related to DHIs and palliative care in each review ranged from 5 33 to 39 37 Taken together the reviews summarised evidence from 332 unique publications, including four systematic reviews. The 21 reviews were published between 2007 and 2019 and included a total of 41 RCTs. None of the reviews pooled data to perform meta-analyses due to the heterogeneity of included studies. Ten systematic reviews covered broad areas such as telehealth, 14, 16, 24, 30, 31, 34 telehospice, 17 We classified the types of DHIs described in 328 publications included in the 21 reviews ( Table 2) . The most featured DHIs involved videoconferencing or videophone (n = 56, 17%), EHRs (n = 51, 16%) and telephone or mobile phone (n = 41, 13%). Online interventions, including educational websites and online courses, were described in 31 publications (9%). Only six publications were . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09. 16.20195834 doi: medRxiv preprint focused on social media (2%), e.g. interactive online blogs. We found a relatively large proportion of studies describing mixed or unspecified DHIs (n = 50, 15%). Mixed DHIs were delivered using a choice of DHIs, or using a DHI with multiple components (e.g. telephone call with follow-up video-consultation). Unspecified studies included general surveys or qualitative studies examining the use of DHIs in general. Studies describing and evaluating EHRs increased over the review period, with more publications on EHRs compared with any other DHI each year since 2016. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09. 16.20195834 doi: medRxiv preprint Main purpose of DHIs described in palliative care reviews DHIs were used for a range of purposes in palliative care (Table 3) . A fifth of publications described DHIs for educational purposes (n=64) most frequently involving online learning, simulators and videoconferencing. Symptom management was the main aim of DHIs outlined in 15% of publications, and all types of DHI were used for this purpose. Decision-making support for patients and professionals was the main purpose of DHIs described in 13% of publications -video aids and EHRs were often used for this purpose. Information provision or management, often using EHRs, was the main aim of DHIs in 13% of publications. Communication was the main aim of DHIs in 9% of publications, with videoconferencing most often used. Overall, 15% of publications described DHIs for mixed or unspecified purposes. Mixed purposes could include information support and decision-making; or communication and information-sharing. Unspecified purposes had no specific focus. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint The quality of the 21 included reviews varied, with AMSTAR scores ranging from 3 to 10, out of a possible total score of 11 (Supplementary material 1). Most reviews (n=11) were of moderate quality (AMSTAR score between 5 and 8). The median rating of reviews published between 2007 and 2017 was 4, compared to a median rating of 8 for reviews published in 2018 and 2019. All reviews described the characteristics of included studies; most described a comprehensive search strategy (17 of 21) and used independent data extractors (15 of 21). Just over half assessed the quality of evidence and used this information to contextualise the results (11 of 21). Approximately half referred to a protocol or a-priori research objectives (11 of 21). Less than half specified the methods used to combine the results of studies (9 of 21). Only a third of reviews (7 of 21) searched grey or unpublished literature. None of the reviews considered publication bias, and only one included a list of excluded studies. Eleven reviews assessed the quality of evidence. 14, 17, 24, 25, [29] [30] [31] [34] [35] [36] [37] Four used the Cochrane risk of bias tool. 25,30,31,36 One used the Critical Appraisal Skills (CASP) programme tool. 14 Five reviews used different tools previously described in the literature 24,29,34,35,37 while one review developed a quality appraisal framework specifically for their review. 17 Only three reviews described evidence as moderate to high quality. 14, 17, 24 Eight reviews reported evidence of low to moderate quality. 25,29-31,34-37 This was due to small sample size, insufficient detail on study design, unclear or high risk of bias, non-blinding of participants and outcomes, and poorly defined comparison groups. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint Findings from each review are described in Table 4 (See Appendix) in relation to seven thematic areas: education symptom management, information sharing, decision-making, communication, quality of life and cost-effectiveness. Eight reviews identified DHIs for education, of which most focused on describing interventions rather than evaluating their outcomes. 15, 16, 24, 25, 29, 33, 34, 38 Educational interventions were delivered via online learning for professionals, 15, 25, 30, 38 videoconferencing for professionals, 16, 34, 40 videos for professionals, 19 ,25,28 online symptom reporting for caregivers, 24 simulation based learning experiences (SBLEs) for professionals; 29 and mobile phones/text messaging for education and training of providers and patients. 33 Two reviews reported that online learning was a feasible alternative to in-person training, though quality of evidence was not assessed. 16, 38 In a review of distance learning for healthcare professionals, Taroca et al. suggested that online case consultations involving active participation of students facilitated knowledge retention. 38 They also noted the prevalence of mixed educational initiatives (i.e. distance learning and classroom based), with 64% of studies involving mixed approaches, suggesting a need for classroom activity to consolidate knowledge acquired at a distance. There was no consensus about the most effective learning methods, and most virtual learning environments used a variety of multimedia to support communication and feedback mechanisms. Kidd et al. 16 suggested that online learning and remote access to guidelines supports dissemination of good practice but also reported that face-to-face teaching methods are preferred when discussing emotional or psychological issues. 16 Ostherr et . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint Thirteen reviews referenced the role of DHIs in monitoring, assessing, and managing physical and psychological symptoms. [14] [15] [16] [17] [22] [23] [24] [25] 27, 30, 31, 34, 37 EHRs were used to record symptoms 27,34 while telephone and videoconferencing were frequently used to monitor, assess and treat symptoms. 15 Oliver et al. 17 identified studies examining the effect of DHIs on anxiety, though studies were not large enough to detect significant differences in outcomes. Jess et al. 37 found mostly positive impacts of video-conferencing on patient and caregiver anxiety, with the exception of one RCT which found negative impacts. 41 This RCT compared weekly video-consultations by a palliative care specialist with treatment as usual in home-dwelling patients with advanced cancer. The authors concluded that higher distress in the video-consultation arm may have been due to excess focus on symptoms and suffering, and the provision of pre-scheduled support over 3 months as opposed to when it was actually needed. 41 Ngwenya et al. 39 focusing on online blogging, reported that patients experienced a sense of emotional support, social connections and empowerment through writing online blogs. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint Nine reviews considered the information-sharing value of DHIs, with most describing the value of the information rather than evaluating specific outcomes. 15, 16, 23, [26] [27] [28] 35, 36 In an early low quality review of internet use, Willis et al. described the positive impacts of the internet as an additional source of information for patients, families and clinicians. 26 They found that patients and carers used online support groups and chatrooms to exchange information and support about an illness and alternative treatments. Patients and carers developed a connection with others online and appreciated the anonymity associated with online support. Capurro et al. 15 reported that DHIs were used by clinicians, patients and carers to meet informational needs regarding pain and symptom management and medication use; although the quality of evidence was not assessed. Kidd et al. highlighted the importance of telephone helplines for general practitioners (GPs), nurses, and caregivers for gathering information about managing symptoms and medical equipment. 16 These telehealth interventions improved the reliability and accuracy of information exchanged. 16 Allsop et al. 23 noted that many systems designed to capture information from a patient for use by a healthcare professional, involved relaying symptoms without engaging in active forms of communication. Four reviews highlighted the information-sharing function of EHRs in palliative care. 27,28,35,36 All were moderate quality. These reviews concluded that EHRs available across settings and platforms allow patient preferences regarding advance care planning (ACP) to be shared; improving continuity of care and ensuring that patients are treated in line with their wishes. Bush et al. 27 reported that in low resource settings, the implementation of a standalone EHR system capturing patient demographics and palliative care treatment information was found to significantly improve . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint clinical workflow. Leniz et al. 35 found that those with an EHR shared across settings were more likely to die in their preferred place compared with those who did not have an EHR. However, EHRs were limited in their capacity to capture important qualitative information such as information on anxiety or family distress. 27 Furthermore, finding the location of relevant ACP information within the EHR was often challenging; 36 though could be improved by ensuring all ACP information is documented in a specific area. 27 Documentation templates, order sets and prompts, may also improve the quality and incidence of ACP within EHRs. 28 Having an EHR improves documentation of advance care plans and communication of care planning information; 27,28,36 but this can come at the cost of increased workload, 35 challenges identifying which patients should have a shared EHR, 36 and concerns regarding data-sharing, security and consent. 35 Huber et al. 28 suggest that further research focused on developing a consensus definition for ACP documentation and related quality elements in EHRs is needed. Four reviews considered the role of DHIs in decision-making by patients 25 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint felt overwhelmed by the involvement of too many participants. Smith et al. 29 found that simulation based-based learning was frequently used to teach nursing students communication skills in palliative care settings, but due to the lack of standardization and poor evaluation, it was difficult to identify best practices. Seven reviews considered the effects of DHIs on quality of life (QoL). 14 with patients with advanced cancer reduced the patient burden by eliminating the need to come into hospital, facilitating a better QoL, though quality of evidence was not assessed and insufficient data on included studies was provided. 22 In a review of telehealth and hospice care, Oliver et al. 17 reported that studies examining QoL were too small to identify clinically significant differences. In their review of videoconferencing, Jess et al. identified several studies incorporating a QoL measure in their design, but QoL outcomes were not described in their key findings. 37 In a review of weblogs in palliative care, Ngwenya and Mills 39 concluded that weblogs improve patient and QoL by empowering patients and giving them a sense of active participation in their treatment, but this was a small scale study with no quality assessment of included studies. In reviews of EHRs, outcomes relating to QoL were rarely assessed. 34,35 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint Five reviews considered the financial implications of DHIs, with most reporting positive impacts of DHIs on costs. 14-17,37 Jess et al. described cost savings associated with video-consultation in palliative care for clinicians, service providers, patients, and caregivers. 37 In two studies included in their review, video consultations between healthcare professionals and patients resulted in costsavings for the hospital, compared to in-person consultations, and in clinician travel expenses for home visits. Travel cost savings were also noted for patients and carers in rural settings. 37 In a review of DHIs in hospices, Oliver et al. 17 identified one telehospice cost analysis study; this study reported reduced costs for telehospice visits versus traditional hospice homecare. Bradford et al. 14 described cost efficiencies when video-visits were used in place of home visits; and when videoconferencing was used to educate patients about self-care; but cautioned that the costeffectiveness will depend on whether DHIs are used in parallel with, or as a replacement for, traditional approaches. Kidd et al. described DHIs as an efficient alternative for patients and clinicians when time and distance is limiting. 16 Capurro et al. described cost efficiencies related to reduced hospital visits, but this was based on only one study in their review. 15 Overall, evidence on cost effectiveness was positive, though interventions and outcomes assessed were heterogeneous, findings were based on a small number of studies, evidence quality was not always assessed and robust economic evaluation not undertaken. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. To date this is the most comprehensive meta-review focused on DHIs in palliative care. Compared to a previous meta-review which encompassed six reviews, 20 it examined a wider range of databases and identified 21 systematic reviews for critical appraisal and synthesis. This meta-review shows that DHIs are more prevalent in palliative care than previously described; are used for a broader range of purposes, that impacts are generally positive, and overall quality of research evidence is improving. Limitations of this study: The heterogeneity of reviews aims, methods, and presentation of results created challenges for evidence synthesis. In many reviews DHIs were described but outcomes . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint were not described or evaluated in any detail. Although the searches were completed in January 2020, the dates of the primary studies ranged from 1997 to 2018, reflecting the time lag in academic publishing. None of the eligible systematic reviews focused on smartphone applications for palliative care, despite their growing use in this context. 42, 43 Two reviews emerged after our searches had been completed, including a rapid review on video-consultations in palliative care in context of COVID-19, 44 and a scoping review of patient experiences of telehealth for palliative care at home. 45 Neither would have been eligible, as they were not systematic reviews, however we suggest that future meta-reviews include all review types. Methodological gaps: The meta-review findings echo the wider literature on digital health 46 and palliative care, 47 which point to the need for more rigorous evaluations, cost-effectiveness analyses, implementation studies and patient centred research. The lack of rigorous cost-effectiveness studies seen in the literature on DHI in palliative care, reflects findings from previous metareviews 48, 49 and systematic reviews [50] [51] [52] in digital health. There is a need for greater clarity on what is being compared in cost-effectiveness studies, and whether the DHI is offered in addition to, or as a replacement to the standard approach. 14,25,37 Undertaking large, well-powered RCTs on DHIs is challenging, partly because technological developments may outpace the timescale for conventional clinical trials; 53 and also because, in practice, DHIs are implemented in complex systems as opposed to controlled settings. 54 More rapid research paradigms, 53 using responsive pragmatic designs that take account of the context and setting in which the DHI is being evaluated and pay greater attention to the factors that facilitate or hinder adoption, may be more realistic and fruitful in future evaluations of DHIs for palliative care. Interdisciplinary evaluation, combining economic, social and clinical research, is needed to better understand the role of different settings, healthcare . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint needs and patient preferences for ensuring the appropriate, safe, acceptable and sustainable use of DHIs in palliative care. Early user involvement (patients, caregivers and staff) will also be key in the design, evaluation and implementation of DHIs in this setting. 55 Technology evidence gaps: Personal health monitoring devices, such as wrist-worn activity trackers and smartwatches are now widely used and have been evaluated in other digital health contexts. 56 The absence of evidence about the use of these may reflect the fact that most studies of trackers are taking place in the context of chronic disease management. Nevertheless, it suggests a need for further research in palliative care, particularly for patients managing at home, for whom wearables and ambient computing (e.g. smart homes) are likely to be increasingly useful. The included systematic reviews did not include studies on the use of smartphone apps. Descriptive reviews on the potential that such apps may have in palliative care are emerging and further research is warranted. 42, 43 Studies using machine learning and artificial intelligence for risk detection and prediction, or for delivering personalised support based on data from individual patients, were also not represented amongst the included reviews, despite progress in AI-enabled healthcare delivery. 57 Research exploring the use of machine learning using EHRs to predict mortality, and identify patients who would benefit from palliative care shows promise; future reviews need to consider this emerging evidence. 58 Studies involving robots or chatbots were not identified despite their potential application in palliative care. 59 Evidence on these types of DHIs in palliative care is needed, to understand their benefits and risks. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint Stakeholder evidence gaps: The WHO has developed a classification framework for DHIs which provides a shared vocabulary for all stakeholders, including researchers, when evaluating effectiveness and identifying gaps in the implementation of DHIs across healthcare settings. 60 The WHO organizes DHIs into overarching categories by user group: clients (e.g. patients or carers), healthcare providers, health system or resource managers and data services. Most of the research evidence on DHIs in palliative care identified in this metareview was focused on DHIs for healthcare providers (e.g. healthcare provider decision support, remote consultations; healthcare provider communication and training) and to a lesser extent for clients/ patients (e.g. client-to-client communication via online peer group support). No research on interventions for health system managers or administrators in palliative care was found. Using the WHO framework to situate research on DHIs in palliative care and identify gaps facilitates engagement with the wider health and social care sector and highlights the type of DHIs that may need to be prioritised for development and evaluation. Telemedicine and related evidence gaps: Most of the evidence identified in this meta-review focused on telemedicine, specifically remote consultations via phone and video. This evidence is timely as the Covid-19 pandemic has pivoted attention towards these approaches. 61 This metareview found that remote consultations are feasible in palliative care and generally acceptable to patients 14,16,22,37 and caregivers. 30,37 Remote consultations are perceived as particularly helpful when increasing access to care for families who are otherwise isolated by geography or housebound, 14 reflecting the context for many patients and families due to social distancing requirements during the COVID pandemic. This should help reassure healthcare professionals that patients and caregivers often welcome these approaches, especially when face-to-face options are limited. While guidance regarding undertaking a remote consultation in palliative care is emerging, 62 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint evidence gaps remain. There is a need for research to determine when a face-to-face consultation is essential for terminally ill patients and when remote consultation is sufficient or preferred. Research is needed to understand contextual factors influencing the acceptability or effectiveness of remote consultations in palliative care 49 and to shed light on inconsistent findings around symptom management. 63 Critically, research on equitable access to palliative care delivered using DHIs is urgently needed to ensure that all those who need palliative care can benefit from it. Palliative care research participation: Research involving people who are terminally ill is difficult due to the perceived vulnerability of the population and professional caution. 40 Professional gatekeeping is a challenge, 64 and biased samples consisting of patients who are mostly well or particularly motivated is often problematic. However there is ample evidence that many terminally ill patients are interested in taking part in research and may benefit from doing so. 65, 66 As patients and caregivers grow accustomed to receiving care remotely, there will be more opportunities to engage patients and their families in research remotely, reducing burden and travel costs. Providing a variety of ways in which patient and caregiver data can be collected, including online interviews and focus groups, maximises research participation, and is recommended. DHIs are increasingly being implemented in the context of palliative care and the Covid-19 crisis has given this further impetus, particularly for clinical and supportive interventions at a distance. This meta-review has synthesised the corpus of research evidence represented by existing systematic reviews in this area. Overall, this indicates that DHIs are can be useful, safe, and . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09. 16.20195834 doi: medRxiv preprint acceptable to many terminally ill patients, their caregivers and staff involved in their care. DHIs are frequently used for education, symptom management, information sharing, decision-making and communication to improve quality of life without increasing costs. The evidence, though weak to moderate in quality, describes mostly positive impacts or no adverse effects. A greater emphasis on patient and caregiver outcomes is needed; and rapid research paradigms, evaluation and implementation studies now need to be prioritised. Future meta-reviews would benefit from looser inclusion criteria to capture other types of reviews containing evidence on emerging innovations such as wearables, smartphone apps, robotics and artificial intelligence. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The search strategy targeted systematic reviews explicitly focused on DHIs in palliative care. Systematic reviews of broader healthcare areas which included and separately reported or synthesized studies of DHIs in palliative care were also eligible for inclusion. Using the PICO process, 67 we defined our target population (P) as children and adults who would benefit from palliative care, caregivers (informal and formal), and healthcare professionals delivering palliative care via DHIs or using DHIs to support palliative care decision-making. For the purposes of this review DHIs (I), were defined as approaches in which digital Information and Communication Technologies (ICT) are used to deliver, facilitate or augment palliative care services, including . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint psychological therapies, social support interventions, education, information, anticipatory care planning, remote care support, self-medication/management support, clinical decision support etc. Examples of relevant ICT include telephone, smartphone apps, mobile phones/SMS, videoconferencing, voice over IP (VoIP), instant messaging, email, internet resources, tablets, wearables, electronic patient records. Both synchronous (e.g. videoconferencing) and asynchronous (e.g. email) approaches were included. Our comparator of interest (C) was no DHIs or usual care. No limitations were placed on outcomes (O), as we were interested in identifying the broad range of outcomes potentially influenced by palliative care DHIs. The first and second authors (AF and HO) undertook the database searches and initial screening of titles and abstracts. Where uncertainty existed in relation to potential eligibility, titles and abstracts were independently screened by a third author and ambiguities or disagreements resolved through discussion with the wider team. HO and AF independently assessed papers identified for full-text review, with CP arbitrating where it was unclear whether a review paper should be included. Disagreements and uncertainties were resolved during full team discussions and the authors came to a 100% agreement. Three co-authors extracted the following information from each of the included systematic reviews: authors, date of publication, country, review aims, search strategy, number of studies included, total number of participants, definition of palliative care, details of participants, functions and medium of DHIs included, reported outcomes, quality assessment methods and conclusions. Three co-authors team then extracted the types of digital health technologies and the intended purposes of the technologies from the individual studies from the included reviews and sought advice from to a fourth co-author in cases of uncertainty. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint All reviews were imported into NVivo. Findings from each review were thematically analysed. These themes were then used to structure the results. The Assessment of Multiple Systematic Reviews (AMSTAR) checklist was used to critically appraise and score included reviews. 68 For the purpose of this meta-review the following thresholds were used: low (0-4), moderate (5) (6) (7) (8) , and high (9-11). 69, 70 Quality appraisal was conducted by four co-authors, with two co-authors independently rating each review. Where disagreements or uncertainties appeared, these were resolved through discussion with the wider team. We expected substantial heterogeneity amongst systematic reviews as well as amongst the studies included within the reviews. Consequently, we planned to undertake a narrative synthesis. Interpretation was facilitated by discussion amongst the team. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. The author(s) disclosed that no financial support was provided for the research, authorship, and/or publication of this article. The posts of AMF and CS were funded by Marie Curie: https://www.mariecurie.org.uk/ . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . https://doi.org/10.1101/2020.09.16.20195834 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 18, 2020. 2 None Not assessed * majority of studies were nonspecified non-randomised * no consistent measurement tools used across studies. * ICT helps with gathering clinical information before consultation * provides flexibility of symptom reporting * 2 types of communication identified: patient to health professional with no feedback and patient to health professional with feedback after health professional reviews information. * communication: systems for facilitating communication did not increase communication between patient and health professionals ICT systems for symptom reporting are emerging in the palliative care context. Most are at an early stage of development. There is a need to increase the quality and scale of development work and explore how to effectively use system feedback with patients. As quality assessment was not undertaken, the strength of evidence reported is not known. 3 Oxford Centre for Evidencebased Medicine framework Medium to high quality * improved communication * improved satisfaction levels * improved anxiety levels and QOL * improved problem-solving abilities * 1 study showed no differences in parental QOL between control group and telehealth group Telehealth provides positive effects for caregivers of people with chronic diseases who are receiving palliative care, including improved satisfaction, quality of life and psychological wellbeing. Findings are based on a sub-sample of studies reported in the full paper. Overall evidence was assessed as medium to high quality. Studies were judged to be at medium to high risk of bias, mainly due to non blinding of participants and outcomes, and small sample sizes. * ICTs were most commonly used to provide information or education, serve as decision aids, promote advance care planning (ACP), and relieve physical symptom distress *Over half of all included studies used video, and the evidence base for the use of video in EOL communication was judged as strong. *Video was an effective decision support tool for ACP. *Video were useful for education and communication purposes. The evidence base for the use of video in end-of-life care communication was judged as strong, though overall evidence was judged to be at medium to high risk of bias. Several studies demonstrated the efficacy of video as a decision support tool in ACP. Few studies involving mobile and connected platforms. The value of video in helping patients clarify their treatment preferences should motivate more providers to experiment with this medium using mobile devices. Further research based on mobile technologies is needed. 3 Of the nine studies, the majority (77.8%) were judged as moderate quality. Only two of the nine studies reported a randomized process of participant recruitment and allocation, and none reported using a process for blinding participants. * 5 studies on QOL did not show any significant differences between the intervention and control groups * 4 studies reported telehealth interventions are feasible * 5 studies found caregivers' to be satisfied with the telehealth intervention * Decreased physical QOL in one study * 2 studies show significant decrease in anxiety levels after the intervention, but 1 showed no significant improvement * 1 study reported reduced burden on caregivers * 1 study did not show any significant differences on burden levels * 1 study found improved family functioning * 1 study found online symptom reporting reduced negative mood * 1 study found decreased depression and perceived stress over time There is evidence of overall satisfaction in caregivers who use a telehealth intervention, but outcomes reported were often not substantial. Overall study quality was judged moderate, but methodological flaws and small sample sizes negatively affected study quality. More rigorous research to test and evaluate such palliative interventions is needed. Definition of Palliative Care Palliative care from diagnosis to death Comprehensive and Integrated Palliative Care for People With Advanced Chronic Conditions: An Update From Several European Initiatives and Recommendations for Policy Putting palliative care on the global health agenda What Is eHealth (4): A Scoping Exercise to Map the Field Food and Drug Administration (US). Digital Health Digitisation and the patient-professional relationship in palliative care What does 'palliative care' mean? Diverse definitions from cancer care providers Using videoconferencing in palliative care Electronic palliative care coordination systems (EPaCCS): a systematic review Mobile health for cancer in low to middle income countries: priorities for research and development The social dynamics of lung cancer talk on Twitter, Facebook and Macmillan.org.uk. npj Digital Medicine 2 Improving palliative care with deep learning The case for home based telehealth in pediatric palliative care: a systematic review Effectiveness of eHealth interventions and information needs in palliative care: a systematic literature review Telehealth in palliative care in the UK: a review of the evidence A systematic review of the evidence base for telehospice A Systematic Review of Telehealth in Palliative Care: Caregiver Outcomes The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions Telemedicine in palliative care: a review of systematic reviews Patient and carer involvement in palliative care research: An integrative qualitative evidence synthesis review The effect of weekly specialist palliative care teleconsultations in patients with advanced cancer -a randomized clinical trial Clinician-Targeted Mobile Apps in Palliative Care: A Systematic Review e-Health in palliative care: review of literature, Google Play and App Store Can video consultations replace face-to-face interviews? Palliative medicine and the Covid-19 pandemic: rapid review Patients' Experiences of Telehealth in Palliative Home Care: Scoping Review WHO guidance for digital health: What it means for researchers What do we know about different models of providing palliative care? Findings from a systematic review of reviews Effectiveness of telemedicine: A systematic review of reviews Effectiveness and Cost-Effectiveness of eHealth Interventions in Somatic Diseases: A Systematic Review of Systematic Reviews and Meta-Analyses The Impact of eHealth on the Quality and Safety of Health Care : A Systematic Overview What is the economic evidence for mHealth? A systematic review of economic evaluations of mHealth solutions.(Report) Electronic consultations (E-consults) and their outcomes: a systematic review Implementation science approaches for integrating eHealth research into practice and policy Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update) Results of a transparent expert consultation on patient and public involvement in palliative care research Applying M-Health to Palliative Care: A Systematic Review on the Use of M-Health in Monitoring Patients With Chronic Diseases and its Transposition in Palliative Care Artificial intelligence-enabled healthcare delivery Improving palliative care with deep learning. bmc medical informatics and decision making 18 Robotic technology for palliative and supportive care: Strengths, weaknesses, opportunities and threats World Health Organization. Classification of digital health interventions. (World Health Organization Telehealth: A quarter-trillion-dollar post-COVID-19 reality? Telemedicine in the Time of Coronavirus Effects of eHealth for patients and informal caregivers confronted with cancer: A meta-review A systematic review of reasons for gatekeeping in palliative care research Patient, caregiver, health professional and researcher views and experiences of participating in research at the end of life: a critical interpretive synthesis of the literature Symptom Control Trials in Patients With Advanced Cancer: A Qualitative Study Utilization of the PICO framework to improve searching PubMed for clinical questions Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings An AMSTAR assessment of the methodological quality of systematic reviews of oral healthcare interventions published in the Studies generally identified benefits of using home telehealth in palliative care and overall evidence was judged moderate to high quality. However, research on DHIs in paediatric palliative care is challenging. More research is needed to assess what influences acceptance of these DHIs, including ease of utilizing the technology and care goals 21 studies included * descriptive (n=9) * pilot (n=3) * service evaluation (n=1) * system report (n=1) * web resource (n=1) * mixed methods (n=1) *prospective cohort (n=1) * qualitative (n=1) * case study (n=1) * not given (n=2) * videoconferencing * hand-held personal computer *mobile phone * website * electronic records * e-learning resource *out-of-hours telephone advice and support services * computer-based screening system * computerised system * NHS intranet Simulation-based learning experience are being used to teach palliative and end-of-life communication skills to nursing students and clinicians. Lack of standardization, poor evaluation methods, and limited exposure to the entire interprofessional team makes it difficult to identify and disseminate validated best practices. Further research is needed employing rigorous evaluation methods and measures that link the SBLE to the training objectives and desired clinician practice behaviours and patient outcomes. As quality assessment was not undertaken, the strength of evidence reported is not known. 6 None Not assessed *The most common EHR interventions described were documentation templates, followed by prompts and electronic order sets. *Documentation templates can reduce variability in documentation and gather information associated with high quality ACP *All studies reporting efficacy (n=7) reported an improvement in one or more ACP outcomes.EHR interventions, such as documentation templates, order sets, and prompts, may improve the incidence and quality of ACP and may improve ACP completion and availability at the point of care. As quality assessment was not undertaken, the strength of evidence reported is not known. Limited evidence suggests electronic medical records could be used to help address advance directive documentation challenges but may also create additional problems. Stronger evidence is needed to determine how electronic medical records more conclusively may assist in population approaches to improving advance directive documentation.