Maternal mortality in the United States is a public health crisis and national emergency. Missed or delayed recognition of preventable life-threatening symptoms and untimely treatment of preventable high-risk medical conditions have been cited as key contributors to the nation’s worsening mortality rates. Effective strategies are urgently needed to address this maternal health crisis, particularly for Black birthing populations. Morbidity and Mortality Assessment: Lifting Outcomes Via Education (MAMA LOVE) is a web-based platform that focuses on the identification of maternal morbidity and mortality risk factors.The purpose of this paper is to present the conceptualization, development, heuristics, and utility evaluation of the web-based maternal mortality risk assessment and educational tool MAMA LOVE.A user-centered design approach was used to gain feedback from clinical experts and potential end users to ensure that the tool would be effective among groups most at risk for maternal morbidity and mortality. A heuristic evaluation was conducted to evaluate usability and need within the current market. Algorithms describing key clinical, mental health, and social conditions were designed using digital canvas software (Miro) and incorporated into the final wireframes of the revised prototype. The completed version of MAMA LOVE was designed in Figma and built with the SurveyJS platform.The creation of the MAMA LOVE tool followed three distinct phases: (1) the content development and creation of an initial prototype; (2) the feedback gathering and usability assessment of the prototype; and (3) the design, development, and testing of the final tool. The tool determines the corresponding course of action using the algorithm developed by the authors. A total of 38 issues were found in the heuristic evaluation of the web tool’s initial prototype.Maternal morbidity and mortality is a public health crisis needing immediate effective interventions. In the current market, there are few digital resources available that focus specifically on the identification of dangerous symptoms and risk factors. MAMA LOVE is a tool that can address that need by increasing knowledge and providing resources and information that can be shared with health care professionals. Maternal mortality in the United States is a public health crisis and national emergency -3. AccorThe leading pregnancy-related causes of death among Black populations include cardiovascular conditions, hypertensive disorders, hemorrhage, and infection, conditions in which the timeliness of patient reporting and subsequent medical intervention are critical ,4,6. AddBlack women consistently report feeling ignored and unheard by providers when expressing concerns about health symptoms and the necessary resources to address them ,17. The There is limited research on the development, testing, and use of maternal mHealth apps that specifically address serious maternal morbidity and mortality risk for birthing people of color . HoweverTaken together, these findings suggest that mHealth apps, when developed in collaboration with target demographic communities, appear to be an effective way to communicate information related to knowledge about maternal physical and mental health to birthing people. However, existing platforms do not currently address symptoms related to the high-risk conditions that contribute most to maternal morbidity and mortality, and those that do are not tailored toward communities of color, the population at greatest risk of experiencing adverse perinatal outcomes.We conducted a market analysis in October 2021 looking at the availability and quality of evidence-based tools that provide customized symptom resources for Black female peripartum consumers. The market analysis was performed through a keyword search of the Apple App Store and Google Play Store, public websites, and PubMed. Our main findings included the Believe Her app  , the IrtMorbidity and Mortality Assessment: Lifting Outcomes Via Education (MAMA LOVE) is a web-based platform that focuses on the identification of maternal morbidity and mortality risk factors, a feature not identified during our market search. The platform has been designed to address the leading medical conditions associated with maternal morbidity and mortality with an additional focus on mental health conditions and social determinants of health. Specifically, the platform provides the following: options for users to select symptoms associated with each category ; feedback and recommendations on follow-up timelines for selected symptoms; tailored educational and resource links for selected symptoms; and a downloadable document of all physical, mental health, and social factors selected, which can be presented to health care providers as a communication tool. Tools that provide education for birthing people on perinatal urgent warning signs are needed to equip and empower them to seek care and communicate effectively with care providers. A key benefit provided by MAMA LOVE is the ability to tailor resources based on user-entered information, as evidenced by the market analysis. Given this capability, there may be regulatory implications in future versions of the tool. For example, Food and Drug Administration clearance would be required if the app were to make clinical recommendations based on the results of the survey.The purpose of this paper is to present the conceptualization, development, heuristics, and utility evaluation of the web-based maternal mortality risk assessment and educational tool, MAMA LOVE. Specifically, in this paper, a detailed description of the content development process, feedback and end user recommendations, heuristic evaluation of the platform components, and final tool are presented along with a discussion about implications for future directions.The creation of the MAMA LOVE tool followed three distinct phases : (1) theInternational Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnosis and procedure codes to create a list of the 21 most common severe maternal morbidity conditions; these created the foundation for the symptom screening component of the app [The initial conceptualization of the tool was guided by information identified in clinical practice guidelines, publicly available data, and maternal mortality review reports related to the leading maternal health conditions contributing to morbidity and mortality, both in the United States and globally ,8,31-33.The WHO Application of ICD-10 to Deaths During Pregnancy, Childbirth and the Puerperium: ICD-MM report was consulted as a resource to ensure that the full range of most common causes of maternal death were incorporated into the physical screening portion of the tool [Additionally, the World Health Organization’s the tool .Health disparities are driven by multiple interrelated medical, social, and societal factors that promote susceptibility to disease ,12-14. WEducational resources were collected on each associated physical condition from reputable academic , governmental , and nonprofit/community-based organizations  to create customized educational reports based on the symptoms selected by the user.From the information identified in the literature, clinical practice guidelines, and public reports about the leading contributors to maternal morbidity and mortality, a prototype was built. This initial prototype of the tool (not shown) was developed via a collaboration between nurse midwifery researchers, community experts, and a software engineer at a private institution in Atlanta, Georgia. The initial prototype was developed with a third party with the guidance of the clinical authors over a period of 1 year. The format of the tool included an introduction to the MAMA LOVE platform; sociodemographic questions; symptom options for physical, mental health, and social factors; sample recommendations for a course of action options; and examples of resources that could be included. The goal of the prototype design was to validate whether the tool captured the most common symptoms and risk factors associated with high-risk perinatal conditions and to explore if the conditions and resources included in the tool were relevant to end users. Due to limitations in the software, the inability to make changes easily, and difficulty in addressing the heuristic evaluation results, a second tool was developed that allowed for more robust algorithm development and seamless transition between selected items, recommendations, and resources.Given the persistent racial and geographic disparities in maternal mortality risk, a robust approach inclusive of the community and social environment in which Black women reside may prove effective in ameliorating maternal mortality risk. As such, five focus group sessions (n=19) were conducted on the initial prototype with a mix of Black birthing parents (n=3) as well as doulas (n=6), community organization representatives (n=4), and health care providers (n=6) to assess initial impressions of the tool and to validate the concept. A rapid analysis of the focus group sessions was conducted to quickly identify key areas for feedback and revision of the tool . The EmoA heuristic evaluation is a qualitative assessment in which a usability expert measures a user interface against a set of principles to find usability issues. The heuristic evaluation was conducted on the initial prototype independently by five experts using Nielsen and Norman’s 10 Usability Heuristics, and the number of evaluators was determined using heuristic evaluation principles . The expThe algorithm development followed an iterative approach in the translation from the clinicians to the developers. First, the clinician would list the symptoms related to a given condition and the suggested recommendation for the user. The developer partners would then review that representation and, with the clinicians, verify that the symptoms map properly to the condition. Common computer nomenclature was used to facilitate implementation and testing. Due to the algorithm’s complexity and many mappings between symptoms and conditions, a visual approach to organizing the information was used. Miro is a digital canvas tool that allows for real-time collaboration and facilitates mind mapping, which made it ideal for this use case. Symptoms in the algorithm were arranged head to toe and then mapped to select conditions see . Lastly,Limitations in the first prototype tool related to software, the inability to make changes easily, and difficulty in addressing the heuristic evaluation results prompted the development of a second and final tool that allowed for more robust algorithm development and seamless transition between selected items, recommendations, and resources.The second tool was designed in Figma (Adobe), developed with the SurveyJS framework, and carried out by AppHatchery. AppHatchery is a National Institutes of Health–funded team part of the Georgia Clinical and Translation Science Alliance that creates patient-centered digital tools for health care through strategy, user research, design, software development, and clinical studies. The design and development of the tool took 6 months from August 2022 to January 2023, during which weekly meetings were held between the AppHatchery team and the clinical experts. Additionally, the collection of use metrics (Pendo.io) and survey responses (Firebase) was set up to validate the tool’s usability and intervention’s feasibility; this will be reported in a future paper.Once the tool was finalized and made available on MAMA LOVE, it was tested by the authors and 3 nurse midwifery experts from Emory University prior to public promotion of the platform. The aim was to find issues with the algorithm recommendations and to ensure the data collection was accurately capturing users’ behavior in the tool and their submitted responses. During this iterative testing process, inaccuracies were identified and corrected.Ethical considerations and safety were evaluated and approved via the Emory Institutional Review Board’s review process (IRB STUDY00002618).The tool was primarily developed to screen for symptoms related to the most common conditions associated with severe maternal morbidity and mortality. From this list of conditions, clinician experts created symptom panels that map a user’s reported symptom experiences to a list of potential health conditions. Symptoms were arranged head to toe and then mapped to potential conditions that include the symptoms selected. Additionally, mental health conditions were included in the design prototype to further contextualize risk factors that may increase the risk for maternal morbidity or mortality. Recent findings indicate that mental and social conditions such as substance use disorder, suicide, and homicide are the leading contributors to serious maternal morbidity, particularly in the later postpartum period ,35,38. OWhen ascertaining which social determinants of health to include in the tool, several modalities were leveraged. The first was expert clinician brainstorming sessions to identify the most common social determinants of health that have the potential to contribute to maternal morbidity and mortality. The search was then expanded to include, from an epidemiological perspective, the social determinants of health found to most commonly predict maternal morbidity and mortality at a large scale. The final conditions included in the tool were determined by the clinical authors in consultation with health care providers who participated in focus group sessions to assess the initial features of the tool. Additional feedback was gathered from other end users including community organizations, doulas, and Black women with experiences of high-risk morbidity conditions who participated in focus group sessions. The Area Deprivation Index was found to be a strong predictor of adverse perinatal outcomes -41. ThusDelayed reporting of concerning symptoms can result in ineffective and untimely management of potentially deadly conditions. The development of interventions that empower and educate pregnant populations to accurately recognize life-threatening symptoms, provide access to necessary resources, and promote effective communication with providers are needed to mitigate the maternal mortality risk among high-risk populations. It is essential that users are directed to reliable educational resources that consistently use the most up-to-date available evidence. Additionally, resources for mental health and other social determinants of health were included with a particular focus on including culturally focused content from groups like the Black Mamas Matter Alliance and Every Mother Counts organizations. Mental health resources were obtained primarily from Postpartum Support International (PSI), which is a leading nonprofit organization with a focus on perinatal mental health conditions . In addiTo ensure that MAMA LOVE would be effective, feedback on the first prototype was sought from Black birthing people and community stakeholder experts . Key aspects identified in the rapid analysis of the focus group sessions included simplification of the terminology used across the platform, incorporation of examples to describe conditions, features to show the end user how far along they are in the platform, grouping of demographics questions, use of more images and fewer words, and expansion of resources lists to include more content from diverse groups that serve Black pregnant populations. A more robust thematic analysis of the focus group sessions is reported elsewhere (manuscript in submission). These preliminary findings were used to inform the development of the second tool.Following a heuristic evaluation with 5 usability experts, a total of 38 issues were found in the initial prototype of the web tool. Sample comments for each usability factor related to the website are reported in The annotations in The addition of a navigation menu allowed users to easily navigate to any section of the tool they want to revisit. This provides users with more freedom and improves the visibility of system status by highlighting the section they are currently on.Removal of redundant elements, such as empty content, and the reorganization of the information architecture helps visually prioritize urgency. This means that potential conditions are listed first, so users can immediately see what is important without having to scroll.Changing the format of the download button and presenting it by itself can help users locate the button and avoid confusion over its purpose.The resource section only includes necessary information, and URL links are formatted following web standards to improve user understanding and expectations of their behavior.The addition of a back button allows users to go back and change their choices if they wish, while the finish button ensures that the user knows there is no more content to interact with.Overall, the changes made to the tool were designed to make it more user-friendly and improve the user experience. The annotations on the figure provide a clear visual representation of the changes that were made, making it easy for readers to understand how the updated version of the tool differs from the original version. However, there were more changes that were implemented to improve usability, such as saving user selections on previous pages, using consistent colors and standards, increasing the tapping targets so clicking is easier, reducing the amount of text on the screen to the strictly necessary, and making the website mobile responsive.The tool determines the corresponding course of action using the algorithm developed by the authors. Following the decision to create a second tool, the algorithm to determine the corresponding course of action was developed between the clinician and developer partner. Examples of algorithms from each of the three categories included in MAMA LOVE are outlined in MAMA LOVE is a web-based tool designed to support Black birthing populations by providing guidance and resources on the leading high-risk conditions. The tool follows a survey structure . It begiPrior to public release, the research team of midwives and AppHatchery experts encountered several issues related to the mapping of symptoms to conditions. For example, the algorithm for symptoms that link to pre-eclampsia also includes those that overlap with the stroke algorithm. During the evaluation, it was noted that the end output was only identifying stroke as a potential condition. The team identified that the language used by the lead midwife researcher on the visual algorithm platform was being read differently by the design team. Once this difference was identified, the issue was corrected, thus resulting in the desired end conditions appearing in the output. Each section of the tool was carefully evaluated and tested in this manner.There is limited research on the development, testing, and use of maternal mHealth apps that specifically address serious maternal morbidity and mortality for birthing people of color. Of those evaluated in a recent meta-analysis of 15 randomized controlled trials of mobile technology addressing peripartum physical and mental health behaviors, none specifically focused on the identification of symptoms and risk factors for morbidity and mortality in the general population nor among populations of color .MAMA LOVE is designed to address the leading physical, mental health, and social risk factors that increase the risk for maternal morbidity and mortality. The leading pregnancy-related causes of death among Black women include cardiovascular conditions, hypertensive disorders, hemorrhage, and infection, conditions in which the timeliness of patient reporting and subsequent medical intervention are critical, as many of these deaths are deemed preventable . The addResources are included in the tool that direct users to well-known, community-led, and state- and national-level academic, governmental, and nonprofit resources. However, there is a need for more robust culturally tailored educational and social support resources. There was an effort to include resources from community groups caring for people of color; however, those resources were not plentiful. The need for culturally designed resources is particularly important for those most at risk for severe maternal morbidity and mortality. Using this cultural perspective, we worked with the development group during the design process to ensure that the imagery, language, and functionalities of the tool were designed with the end user in mind.There is limited research available regarding the use of mHealth apps and their effectiveness in mitigating maternal mortality risk. As previously discussed, there are apps available that provide quality content around health behaviors in pregnancy. However, they do not adequately represent people of color. It has been shown that Black women are willing to use their smartphones to access health promotion content and to participate in mHealth research . AlthougWhile other studies detailed the development and testing of mHealth apps for pregnant people of color, they focused on topics other than serious maternal morbidity and mortality, such as postpartum fitness and weight loss (BeFAB) , physicaThe tool is limited in its scope as it identifies symptoms or social conditions after they have already occurred. In the quest to prevent maternal morbidity and mortality, this may be too late. There is a need for a tool or resource that captures data and information in real time so that interventions can be instituted earlier in the pregnancy or postpartum period. Additionally, the resources that are included in the tool will have to be continually revised to ensure accuracy and relevance to the population. Additionally, the tool has been developed by researchers and app developers in the southeastern United States; as such, the types of resources included were naturally influenced by this geographic lens.The development group responsible for building the tool consisted of individuals with diverse backgrounds, including in product management, design, and development. The team had prior experience working on other technology projects aimed at African American minorities, which provided a strong foundation for their work on this tool. The group was composed of individuals from African Black, Hispanic, and White backgrounds, which helped ensure a broad perspective and inclusivity during the design and development process.In addition, the group leveraged specific design methodologies to navigate cultural values and paternalism during the development of the tool. These methodologies included incorporating common visual styles and themes from other tools aimed at Black birthing parents, such as using visuals of birthing parents throughout the tool. The team also sought to avoid paternalistic and critical language in the tool, which could be perceived as condescending or dismissive. By taking these measures, the development group aimed to create a tool that was culturally sensitive and inclusive while also providing accurate and useful information to users.Despite the outcomes of the heuristic evaluation and design changes implemented, it is important to acknowledge the limitations. Although the conceptualization of the project and creative design of the tool was led by a Black researcher, the evaluation of the tool was conducted by a team of designers who were not specialized in website design for Black birthing parents. While the team had experience in evaluating and designing digital tools, they may not have been fully attuned to the specific cultural and experiential needs of this population. As such, it is possible that certain design issues or cultural considerations were not fully captured by the evaluation, and additional research by specialized user experience–specific experts may be warranted to further refine the tool.Maternal morbidity and mortality is a public health crisis needing immediate effective interventions. Comprehensive models and strategies that improve the ability of at-risk groups to better identify their risk are needed. MAMA LOVE seeks to empower pregnant populations with knowledge and resources to encourage self-advocacy, particularly among Black populations who have the greatest risk of dying during the perinatal period. Given that many pregnant populations have identified that they often do not feel heard or are not taken seriously when presenting with concerning symptoms, MAMA LOVE is a tool that has the potential to address that need by increasing knowledge and providing information that can be shared with health care professionals.


This paper proposes a method for CNN-based fault detection of the scan-matching algorithm for accurate SLAM in dynamic environments. When there are dynamic objects in an environment, the environment that is detected by a LiDAR sensor changes. Thus, the scan matching of laser scans is likely to fail. Therefore, a more robust scan-matching algorithm to overcome the faults of scan matching is needed for 2D SLAM. The proposed method first receives raw scan data in an unknown environment and executes ICP (Iterative Closest Points) scan matching of laser scans from a 2D LiDAR. Then, the matched scans are converted into images, which are fed into a CNN model for its training to detect the faults of scan matching. Finally, the trained model detects the faults when new scan data are provided. The training and evaluation are performed in various dynamic environments, taking real-world scenarios into account. Experimental results showed that the proposed method accurately detects the faults of scan matching in every experimental environment. SLAM  is a method which allows a mobile robot to build a map and estimate its location simultaneously in an unknown environment ,2,3. DesSLAM problems in dynamic environments have been explored with various solutions. The authors of Ref.  proposedAs described previously, most of the existing SLAM solutions in dynamic environments or those which are deep learning-based require vision sensors to perform object detection for visual SLAM. An undesirable consequence of this is that the image data have a large data size and take much more time to process than laser scan data. In this regard, solutions for SLAM problems in dynamic environments with only a LiDAR, while not using vision sensors, are worth further exploration. Additionally, deep learning applications for 2D SLAM are still open to be thoroughly studied.The main contributions of this paper are as follows.An online process which includes raw scan data acquisition, scan matching, matched scan image generation, and the fault detection of the scan matching has been proposed and performed successfully, as shown in A method to form the training images which represent two consecutive laser scans, thereby taking advantage of the effective CNN-model training, has been proposed for the first time.The fault detection of scan matching has been conducted with high accuracy in various dynamic real environments.The remainder of this paper is organized as follows: In Various 2D SLAM algorithms with a LiDAR have been developed. This work has utilized the GMapping algorithm, one of the widely used SLAM algorithms based on RBPF (Rao-Blackwellized Particle Filter), to build a 2D grid map and a robot trajectory ,18. DuriHowever, in dynamic environments, the sensor data for the computations of the two posterior probabilities of the robot trajectory and the map are disrupted, resulting in bad SLAM performance. To improve this situation, our proposed method detects the faults of scan matching for the final decision to reflect the resulting scans from scan matching or otherwise on the computations as described in In 2D SLAM, a new laser scan is matched to a previous scan. To take the results of matching, the matched scans are converted into scan images. When the trained CNN model confirms that the scan matching is successful, the new laser scan is used for updates of the robot position and the map. If the scan matching is predicted to be faulty, the new laser scan is discarded, but only the odometer data at the time are used. Not using the unaligned scan points prevents an incorrect estimation of the map and the robot trajectory. ICP is a scan-matching method that iteratively matches two consecutive laser scans. A transformation matrix that minimizes the distance between two scans is needed to align the current scan with the previous scan.K is defined as:The closest points Then, to find the rotation elements in the transformation matrix, Scan matching is an important technique which allows SLAM to match the current scan to the previous scan of two consecutive laser scans by searching the overlapping parts . ICP  scan matching. The matched scans are converted into scan images to be fed as training data for the CNN model for fault detection. When new scan data are acquired, the trained model detects faults in scan matching. The sequential tasks of acquisition of raw scan data, scan matching, conversion of matched scans into images, and fault detection are performed in a single process. To obtain a large amount of laser scan data for the training of the CNN model, raw scan data from a high-resolution LiDAR are received in ROS (Robot Operating System) sensor messages. The raw scan data include ranges values of dynamic objects and their scan occlusions, as shown in To conduct effective training of the CNN model, the scan points are converted into simple scan-matching images with clear features. To generate scan-matching images, two consecutive scans in the raw scan data are scan matched at each timestamp using ICP.The matched scans with Cartesian values are plotted as point graphs, as shown in For the preprocessing of plotted images, the unnecessary edge parts of scales are eliminated, and the sizes are reduced by about 1/16, to a final total of 256 × 256 pixels. The images are reduced in size for fast CNN model training while maintaining the features of scan matching. The processed images are automatically saved, then classified into binary class labels of normal and fault, as shown in The CNN model used to perform the fault detection of scan matching has an architecture shown in The environments for the experiments are set with multiple dynamic scenarios for an adaptive CNN model, as shown in The mobile robot used for experiments is Omorobot R1, which has a maximum speed of 1.2 m/s and an odometer for the control information, as shown in The results of scan matching in Environments 1, 2, 3, 4, and 5 are shown in For training and testing, among 20,830 images in total, 13,254 normal images and 7576 faulty images are used at a ratio of three (training) to one (testing). For the validation of the prediction, 2969 normal images and 1283 faulty images of 4252 images are used. Data from all environments described in 4.1 are used for the training and testing, and the validations of label prediction are conducted using the total data of all environments and the respective data of each environment. Environment 1 shows the highest accuracy in detecting faults of 99.6%. This is because the images in this environment more clearly show whether the two consecutive scans are aligned or not, compared to other environments. For the fault detection of the trained model, the mismatch of scans results in more red points of the previous scan in an image. That is, since the mismatched red points in Environment 1 are clearly shown in faulty scan-matching images, the fault detection is successful. Comparatively, in Environment 2, the fault detection has 99.3% accuracy, which is the lowest accuracy. Because the faults of scan matching in the environment are mostly linearly unaligned, the current scan in blue covers the most of the previous scan in red, but the two scans are not yet matched. These faults less clearly show the unconformity of the scans on images than faults in other environments, making the fault detection of the CNN model confusing. However, these errors are reduced by feeding a large number of linearly faulty images; thereby, the trained model is still robust in its predictions. Environment 3 shows good results, except for four incorrectly labeled predictions among 998 images, resulting in 99.5% accuracy. Due to the windows and mirrors, as well as dynamic objects, the red previous scan points partially decrease. The scan matching errors in this situation are wrongly predicted, but they are handled by training data from different trajectories and environments. Likewise, in Environment 4, the scan points of two laser scans are reduced by its spacious structure and objects. The images of this matching error contain fewer features, which demonstrates the quality of scan matching. Still, the trained model predicts it with an accuracy of 99.5%. Only a few slightly unaligned scan images are incorrectly predicted. Environment 5 is used only to test the trained model, and is never used for the fault detection training. Even though the images reduce features as a result of the objects, 98.9% accuracy is achieved due to the large dataset taken from Environments 1–4.The results are also presented as ROC (receiver operating characteristic) curves in We have proposed an applicable CNN model for the fault detection of scan matching to complement SLAM in dynamic environments. For fault detection, as soon as the raw scan data are received, scan matching, the conversion of matched scans into images, and the fault detection by the trained CNN model are performed sequentially at each time step. The scan data for the training of the model are acquired under various dynamic scenarios to compare the model’s performances in real-world environments. As the training data for a CNN model, the form of images that represent consecutive scan data in Cartesian coordinates are used for the first time and demonstrate efficiency in the model training. The validation of the trained model shows accuracy of over 99% in the detection of faults of scan matching in every experimental environment.For future work, the method can be extended to various SLAM frameworks in real time. Depending on the methods of scan matching, mapping, and robot pose estimation of different SLAM algorithms, the steps of scan matching and the application of fault detection in the proposed method can be adapted to enhance existing SLAM and scan registration systems.


There has been increasing interest in green and recyclable materials to promote the circular economy. Moreover, the climate change of the last decades has led to an increase in the range of temperatures and energy consumption, which entails more energy expenditure for heating and cooling buildings. In this review, the properties of hemp stalk as an insulating material are analyzed to obtain recyclable materials with green solutions to reduce energy consumption and reduce noise to increase the comfort of buildings. Hemp stalks are a low-value by-product of hemp crops; however, they are a lightweight material with a high insulating property. This study aims to summarize the research progress in materials based on hemp stalks and to study the properties and characteristics of the different vegetable binders that could be used to produce a bio-insulating material. The material itself and its microstructural and physical aspects that affect the insulating properties are discussed, as is their influence on durability, moisture resistance, and fungi growth. Research suggests using lignin-based or recyclable cardboard fiber to develop a bio-composite material from hemp stalk, but long-term stability requires further investigation. Energy consumption has been increasing in recent decades, as has its consequent increase in greenhouse gas emissions into the atmosphere. In the building sector, climate conditioning consumes 45% of the total energy consumption in the building . This efA technique that can be explored in this field of research is the improvement of the performance of insulating materials based on green materials ,5 with acannabis sativa L., is a crop that can grow rapidly and yield up to four harvests in a single year. It is mainly produced for industrial or food purposes and is available in different varieties, each suited for specific applications. Hemp is a multi-functional crop with diverse applications across several fields. Despite its versatility, hemp cultivation declined globally in the 20th century due to the emergence of synthetic fibers that were cheaper to produce and possessed superior properties [Hemp, operties .In recent years of the 21st century, hemp has aroused interest in the scientific community, considerably increasing the number of related publications in recent years . The figAlthough it is primarily used in the textile industry, with the advent of the industrial era, other parts of the plant have been utilized in the market, leading to an increased range of products and applications . These aThe remarkable versatility of hemp, increased farming productivity, rising demand resulting from emerging applications, and the growing need for eco-friendly materials have led to a surge in hemp farming in recent years. Despite the great farming tradition, new studies are still important to optimize the farming of hemp due to the numerous varieties of the crop. It is important to note that the usage and production of natural fibers are influenced by the customs and traditions of specific countries and regions. For example, China and Bangladesh, both located in Asia, have a rich history of the use of natural fibers, particularly jute, sisal, and coconut. Conversely, France and Belgium are renowned for being major producers of flax, whereas North America, despite its significant economic impact, does not possess the same level of prominence in relation to natural fibers. West Africa, Latin American countries, and India are the major oil palm cultivating countries ,11,12,132 emissions can also involve the use of hemp, which can be utilized for its negative carbon footprint. Moreover, hemp biomass can also be processed into biochar, which has the ability to absorb various types of organic and inorganic pollutants in an environmentally friendly manner [In addition to the innovations in the production of hemp, there are others related to less widespread applications, such as the use of fibers not only in the manufacture of textiles but also in construction, due to their mechanical properties when composite materials are manufactured from hemp fibers, obtaining a substitute material for synthetic fibers ,23. It ay manner .However, currently, there is a part of the plant that does not have a specific application, and most of such material is treated as a low-value by-product of hemp crop or crop waste. Despite the fact that hemp stalk is used in building applications or to breed animals, those applications do not cover all the offers of the material . The hemThe objective is to revalue a hemp by-product, hemp stalk  as the mThe main focus of this review is to cover the properties of hemp stalks and different green materials that can be used as a binder to develop a green insulating material based on hemp stalks. Recently published papers indicate that lignin-based resin, bio-epoxy resin , and recThermal/sound-insulating materials are materials that prevent the transfer of heat or sound. In the case of a building, the insulating materials improve the performance of energy consumption and provide a more comfortable area. The most used materials are rock wool and EPS (Expanded Polystyrene).One of the most attractive properties of hemp is its insulating properties . MoreoveHemp possesses exceptional insulating qualities, which are retained in the stalk. One of the primary advantages of using hemp stalk is its affordability, coupled with its insulation performance. However, ensuring its long-term stability as well as its chemical compatibility with various binders is crucial . Since hIn the case of acoustic properties, the parameters of the hemp particles that influence its acoustic properties are the density of the particles, the bulk density, the thickness of the particles, and the shape factor ; this re3.Decreasing the stalk particle size improves the acoustic properties, the best case being those with an average length of 4 mm. Furthermore, the internal porosity can be predicted from the density of the particles ,46. At aIn the case of thermal insulation, it increases energy efficiency by reducing heat transfer with the outside and saving energy in the air conditioning of buildings. The porosity also contributes to its high thermal properties, although in this case, the properties of the matrix composite material are more influential properties for the final property of the biomaterial composite.According to the hemp stalk’s insulating properties, .98–0.99 ,52  depends on its position in the stem of the plant according to the height at which it is located ,57. HoweThe properties shown by the stalk are suitable for use as both thermal and acoustic insulating material. However, it is a particle material, so it is necessary to use a vegetal binder to manufacture green composite material. In this insulating application, the mechanical resistance of the material is not a critical value; it is only necessary that it satisfy the minimum requirements and be a stable material.This review focuses on green materials; however, there are not many studies with a 100% green material, so some results of non-green binder will be presented to study the behavior of the material and find out which green materials can obtain the best performance.2 storage. Nevertheless, the mechanical properties decrease (maximum stress is reduced up to 30% when adding 8% hemp) [Different applications are being studied to use hemp stalk, taking advantage of its low price, such as using it as insulation in buildings and adding lime to form non-structural blocks ,59. Seek8% hemp) ,63,64. A8% hemp) . In hot-8% hemp) . Moreove8% hemp) . While c8% hemp) .Hemp stalk particles are also used as raw materials for compounds that are made up of wood particles. In this way, the manufacturing process mixes it with a binder to fabricate a material similar to a chipboard. The manufacture of this type of material consists of mixing the stalk with the binder material and applying pressure and temperature in a mold, then the adhesive cures and the material obtains the shape of the mold. The most commonly used binders are currently based on formaldehyde because of its mechanical properties, dynamic properties, abrasion resistance, and affordability . NeverthAnother alternative is to completely eliminate formaldehyde-based resins by using synthetic ones. Although studies are being carried out to obtain vegetable resins that can achieve the regulatory requirements of the different applications, such as lignin-based wood adhesives ,77, obtaDifferent innovative fabrication methods and renewable materials for thermal insulating applications are studied. However, the technology still needs more research to have a competitive price and solve different technical difficulties in using materials like vacuum insulating panels, aerogels, or nanocellulose. The research also proposes the use of recycled paper fiber as an insulating material based on cellulose . To bindWhen a surface is contacted by sound waves, the energy is distributed into three categories: incident, reflected, and absorbed energy. In architectural acoustic design, it is helpful to utilize an average absorption coefficient that is assumed to rely solely on the physical attributes of the material. The sound absorption coefficient of any material is determined by the angle at which the sound wave hits the material and the frequency of the sound .In the case of a composite material based on hemp stalks. The mechanism by which the materials absorb sound energy mainly involves three physical processes. Sound-absorbing composite materials have small holes that allow sound waves to access their interior, causing gas flow and friction. It triggers the conversion of a portion of the sound energy into heat energy, which leads to sound absorption. In the case of hemp stalks, when sound waves hit them, the viscous effects between air cavities attenuate some of the sound energy, converting it into heat. Moreover, the sound-absorbing composite materials have the ability to absorb certain sound waves through their own vibrations. Due to the force between chain segments, unique hollow structure, and large specific surface of hemp stalks, sound energy is attenuated and converted into heat and mechanical energy during propagation, resulting in an effective sound-absorbing effect ,93,94. TThe acoustic absorption values in Based on the results presented in The main objective of thermal insulation is to enhance energy efficiency by limiting the transfer of heat through the building envelope. Insulation materials are designed to conduct heat poorly in order to minimize heat loss . Heat coIn addition to acoustic insulation, the hemp stalk also has high thermal insulation properties, obtaining a coefficient of thermal conductivity of 0.05 W/m K . In Eurosulators . Moreovesulators .There are studies on that topic to develop new biomaterials using starch as a binder . Straw aIn addition to using vegetable resins, it is also proposed to replace the particles of pine and other common trees with crop waste, such as hemp stalk. The influence of the starch-stalk ratio on the properties of the material is studied, and it shows that by increasing the hemp particle ratio, the mechanical properties are reduced due to the increase in porosity, which decreases the load transfer capacity. Nevertheless, it improves thermal performance . The theAt a mean temperature of 24 °C, the apparent thermal conductivity of hemp stalk was tested for various densities and found to increase with rising temperature. While wood-based fiberboards are utilized as thermal insulation materials due to their low density and high thermal resistance, their porous internal structures make them sensitive to environmental changes . ConsequAn increase in relative moisture in materials can lead to a decrease in their thermal conductivity and make them more prone to mold formation. For composites made of jute, flax, hemp shives, and fibers, a relative air humidity of 70% leads to a relative material humidity of 5–10%. Additionally, it has been demonstrated that an increase in material moisture from 0–10% results in an increase in thermal conductivity .2 accumulators [Although the different studies show high insulating properties, they are not the only important characteristic of these materials. Developing a biomaterial based on hemp stalk can increase the value of the hemp crop, produce more environmentally friendly materials, and also result in materials that act as CO2; meanwhile, it is growing through the photosynthesis process. Moreover, due to very rapid growth, the biomass accumulated by hemp crops has a significant effect in absorbing atmospheric CO2; however some of the carbon stored in this biomass is turned back into the atmosphere as CO2 due to the biodegradation of leaves and roots. Assuming a concentration of 0.5 kg of carbon per kg of dry matter, it can be calculated that 1.84 kg of CO2 is sequestered per kg of dry hemp through photosynthesis during the plant’s growth. This means that a ton of dry hemp can store 325 kg of CO2, taking into account the amount of emissions during the farming as the diesel consumption, transportation of the seeds, etc [The hemp absorbs COeds, etc .2 sequestration due to the carbonation process of the lime. During the carbonation process, the lime reacts with the CO2 present in the air, resulting in the conversion of calcium hydroxide (Ca(OH)2) into calcium carbonate (CaCO3) [2 during this process can have significant implications for the environmental impact of this product [2 per m3 [2, obtaining a material that would passively help to obtain buildings with zero emissions [Hempcrete is a sustainable building material made from hemp stalks, lime, and water, and the lime in the material also takes part in the CO (CaCO3) . The car product . Hempcre2 per m3 ,123,124.missions .Based on these examples, it can be concluded that the binder used in the composite material has a significant impact on its carbon footprint. The use of recyclable materials with low impact on the carbon footprint is proposed for the binder material.In order to develop new biocomposite insulating materials, it is necessary to ensure the durability conditions to ensure the commercial product can be reached. However, there are only a few papers that study the durability of long-term tests in those materials. The longevity of bio-composites can be impacted by various forms of biological degradation, such as mold growth, as well as environmental factors like fluctuations in temperature and humidity .Investigating the water absorption characteristics of biocomposites is crucial, given the weak water resistance of biomaterial. For biocomposites used outdoors in construction applications, their water absorbency is a critical factor affecting their mechanical properties and dimensional stability .Hemp fibers also present low stability against contact with water, which sees their Young’s modulus reduced by 50% after immersion in water . Moreove2 during cement hydration. The calcium adsorption is pH dependent, and the pectin contained in fibers can react with calcium ions in an alkaline environment [2 treated hemp stalks compared to untreated ones [2O3 and SiO2 can mitigate the degradation of the hemp fibers. This material should have the ability to consume Ca(OH)2 during mortar hydration [In the case of VFRCM , the issue arises from the alkaline hydrolysis resulting from the production of Ca(OH)ironment . Moreoveted ones ,130. To ydration . AlternaTo prevent the degradation of the biomaterials, a solution is to introduce a coating in order to protect the material against environmental effects. To increase the water resistance of these materials, surface coatings such as NaOH, silane, and epoxy have been studied, which reduce the moisture absorption of the fibers ,134,135.In one research work, a vegetal coating is proposed by coating a bamboo particle with pine resin, obtaining a hydrophobic material after treatment; in addition, after the coating, bamboo particles become a stable material against the environment . NeverthThe coating would not only have the function of protecting the material, but also of stabilizing the interior moisture. Since moisture has a great impact on the insulating properties, as seen in the previous sections.According to the results presented in the different studies of the last decades, hemp is positioned as a green material with great insulating properties that could replace some inorganic commercial materials to improve the insulating performance of buildings and build green buildings. These data can be corroborated by the increase in interest in the scientific community, with the increase in research each year, and also with the increase in the hemp industry in the business sector.Varieties and positions on the stem can cause differences in the elastic modulus of the hemp stalk of up to 60%. However, no studies have been found to confirm whether these differences in cell size impact the insulating properties of hemp.This research gap presents an interesting opportunity for future studies to explore ways to enhance the performance of hemp as a raw material for insulating applications. With the farming of the different varieties of hemp, it is necessary to study which variety produces the hemp stalk with the best insulating properties and in which part of the stem it is localized.It is suggested to use a binder that aids in creating a low-density and porous material as the microstructure of the composite material plays a significant role in determining its insulating properties.It is still necessary to delve into some issues in order to develop new green insulating materials, such as the study of more green binders that do not need to apply pressure or temperature during the manufacturing process. In this way, the manufacturing cost is reduced, and lightweight materials with high porosity would be produced that would stimulate the insulating properties of the composite material.In this way, paper pulp-based binder shows great opportunities for the development of future research.Despite all the studies, further research is still needed on the use of a 100% plant-based composite material, including the binder. However, among those presented, starch stands out.By using starch as a binder, an acoustic absorption (It has been observed that only a few studies have investigated the acoustic properties, fire resistance, fungi growth, and long-term durability of 100% green composite materials.2.A ton of dry hemp can store 325 kg of CO2 and producing a renewable material with a circular economy. The binder also affects the carbon footprint of the composite material. To prioritize the carbon footprint, a recycled biomaterial such as cardboard fiber can be chosen as a binder.Hemp is exhibited as a material capable of storing COIt is necessary to protect the biomaterial against ambient conditions.The main problem for a biocomposite material is degradation over time. So in order to produce a commercial product it will be necessary to ensure the stability of the material in ambient conditions. Nevertheless, no research has been found that investigates the influence of using an eco-friendly coating on the insulation properties of a composite material.To protect the biocomposite material against ambient degradation, some vegetable coating, such as colophony, shows a great performance. Arabic gum is proposed as an effective solution for fire protection, but it only provides protection against moisture and not direct contact with water.In this review, a large amount of research related to the development of new hemp stalk-based composite materials has been compiled. Much research has been done, and it is arousing increasing interest in the scientific community for its performance and sustainability reasons. Therefore, it is recommended that these issues continue to be investigated in order to develop a new competitive material capable of replacing current inorganic materials.


Due to the complexities of advanced illnesses and their treatments, it can be difficult for patients in palliative care to maintain their quality of life. Telemedicine interventions in chronic disease management engage patients in their care, provide continuous follow-up by their health care providers, identify symptoms earlier, and allow a quick response to illness-related decline.We aimed to detail and reflect on the design of an app and evaluate its feasibility to monitor the clinical situation of patients with advanced illnesses.This study used a mixed methods design using qualitative methods to inform app development and design and quantitative methods for data collection and analysis of patient evaluations. Palliative care units in 2 Spanish university hospitals  carried out a literature review, designed the study protocol, and obtained approval from the Ethics Committee from June to December 2020. In addition, focus group meetings were held, and the design and technical development of the app were elaborated on and subsequently presented in the participating palliative care units. From January to March 2021, the app was made public on the App Store and Play Store, and a pilot study with patients was carried out in April to September 2021.Six focus group meetings were held that included doctors, nurses, app developers, technology consultants, and sponsors. In addition, the technology consultants presented their results 3 times in the participating palliative care units to obtain feedback. After the app’s final design, it was possible to publish it on the usual servers and begin its evaluation in patients . Sixty percent (n=36) of the participants were women and 40% (n=24) were men. The most prevalent advanced pathology was cancer , followed by other diseases  and amyotrophic lateral sclerosis . Seventy percent (n=42) of the patients were already in follow-up prior to the start of the study, while 30% (n=18) were included at the start of their follow-up. The information in the app was collected and entered by relatives or caregivers in 60% (n=36) of the cases. The median follow-up was 52 (IQR 14-104) days. In all, 69% (n=41) had a follow-up >30 days (10 were deceased and 9 were missing data). The use of the different sections of the app ranged from 37% (n=22) for the glycemic record to 90% (n=54) for the constipation scale). Patients and caregivers were delighted with its ease of use and usefulness.Incorporating an intelligent remote patient monitoring system in clinical practice for patients in palliative care can improve access to health services and provide more information to professionals. Palliative care supports patients with life-threatening illnesses with a focus on disease management and overall quality of life improvement . The neeSpecific to palliative care, Lundereng et al  point ouThe following definition of telemedicine is a starting point: “the provision of medical care at a distance through a variety of telecommunications tools.” This suggests that there are various possible solutions to implement in palliative care. This variety offers the possibility of selecting the most appropriate modality: synchronous or asynchronous; media such as voice, videoconference, and chat; and whether the operating system environment should be computers, mobile phones, or tablets. The main conditions for the success of an initiative related to telemedicine will be whether the project’s design can be adequately implemented with the characteristics and actual needs of patients and professionals. Thus, acceptance will be related to the project’s ability to facilitate clinical management, increase accessibility, improve health outcomes without increasing the burden of care, and provide continuous, high-quality care and follow-up in the location desired by patients and families . Specific to an intervention targeting patients with advanced illnesses, the development team would ideally comprise health personnel members who attend to these patients’ clinical needs alongside programmers with training and expertise in designing and adapting models based on telemedicine. It would also be of great value to obtain feedback on user experience from the patients and their families or caregivers for the optimal final design. However, it is important to note that heterogeneity in the team’s professional background can result in slower project development, as differing expectations and comprehension of clinical needs and strengths or limitations of technologies intersect ,7.Here we share the personalization of the HumanITcare platform to the palliative care setting. Emphasis is placed on the developers’ perspectives and workflows for feasibility testing; these results have been reported elsewhere by Castillo-Padrós et al . We beliThe difficulties in using smart technology by the elderly population have not been the subject of many studies. However, Busch et al , in theiHarris et al  followedThe design of this study allowed for data collection by the patients themselves or by their relatives or caregivers to ensure that participating in the project was not an inconvenience. Although it was not evaluated in this study due to its design characteristics, it could be interesting to further assess the difficulties that older or dependent patients have with smart technology in future studies.This study is based on the HumanITcare platform. HumanITcare is an intelligent remote patient monitoring system  that canWritten informed consent was obtained from each participant after a complete study description. The patients’ data were coded in dissociated databases and could only be accessed by the health care team. The study was approved by the Human Research Ethics Committee of Santa Cruz de Tenerife (2020-217-1) under the Ethical Principles for Medical Research Involving Human Subjects adopted in the Declaration of Helsinki by the World Medical Association (WMA) at the 64th WMA General Assembly in Fortaleza, Brazil, October 2013 and Spanish data protection regulations . Neither the researchers nor the study subjects received financial compensation for their participation.Each participant in the study was assigned an ID consisting of 8 random characters , and participant data could only be reviewed using this ID, which ensured data anonymization.Participant data were also encrypted on the access platform for the researchers, technical administrators, and servers. The platform server is in Ireland and complies with the General Data Protection Regulation of May 25, 2018, and the Data Protection Law .When the patient registered on the platform through the app, the following legal notice regarding data protection appeared on the screen to obtain consent from the patient for data processing:“This tool does not provide medical advice. It is only intended for information purposes for healthcare professionals. Do not use it as a substitute for professional medical advice, diagnosis, or treatment. Your doctor will review your responses and contact you, if necessary. Confidentiality of your data is important to us. Therefore, we have complied with the established data protection regulations. For more information, please read the detailed legal terms and conditions.”This remote monitoring platform has 3 primary components: an app, integrated devices, and a web portal.The app is available for Android and iOS systems to achieve maximum compatibility. Users register with a secure ID and temporary password. Once registered, the app appears personalized according to the follow-up care plan to which they belong. Depending on the program, users can complete different tasks  to collect data related to their health and well-being. They can consult all this data collected in a personal area available in the app. Communication channels  are also available to improve accessibility between patients and their health teams.Wearables and medical devices, such as pulse oximeters, blood pressure monitors, activity trackers, and smart scales, can connect via Bluetooth to the patient’s app to measure vital signs and other medical indicators , thus providing an automatic data collection tool. In addition, HumanITcare has different brands of devices integrated into the platform to be device-agnostic and offer the patient the possibility to connect their own devices.Professionals can access a website to manage remote patient monitoring. They can define which (and how often) variables should be monitored depending on each illness and each patient, set alarms when the monitored variables exceed a specific range, choose the connected devices, and customize the questionnaires each participant must answer at a specific time. Once all these parameters have been configured, professionals can view the data through the platform, receive alerts by email when patients report any symptoms or abnormal vital signs from home, communicate with them through the available channels , and record the medical data of the visits in the patient’s profile.The methodology to adapt the platform to patients in palliative care, as described above, was carried out in January to March 2021 and divided into three stages.A total of 6 focus groups were held with palliative care physicians from 2 different hospitals, including methodologists, system developers, and sponsors, with the collaboration of Grupo Ferrer International SA and FollowHealth SL holding multidisciplinary discussions on what should be the best solution for patients in palliative care .After reviewing the literature and other apps or similar initiatives already developed for other patient populations and considering the results of the discussion groups, a proposal was developed for the app’s content.Once the app’s content was discussed and analyzed, an initial proposal was drawn up, considering ease of use by patients and relatives or caregivers as a central premise for optimal data collection and feedback on variables needed for effective tracking by the population of interest .Based on the analysis carried out in the first phase, a new app version was created to improve the user experience and functionalities. We selected the following characteristics to determine the health status of patients with advanced illnesses remotely: a registry for clinical variables, a registry for questionnaires, alarms for registered clinical variables, a personal area to review the data of the registered clinical variables, and communication channels, including chat and video calls.We sought to adapt the HumanITcare platform specifically to patients in palliative care based on the previously identified requirements and, subsequently, carried out a pilot test among 60 patients from Hospital de la Candelaria (Canary Islands) and Hospital de Ferrol . The study was approved by the drug research ethics committees of the hospitals participating in the study .Most important was that the app be complete and precise, so that professionals could extract the necessary information quickly and easily without adding a burden to their professional duties.The content of the app for patients was structured into 4 main sections: clinical measures, questionnaires, a personal area, and chat.The first section is clinical measures , which iThe second section was questionnaires . Online This digital solution also had a section prepared to display the data entered in the app as a diary, so patients and carers could review the values entered to improve their compliance and support their self-monitoring . PatientPatients and professionals can exchange messages about their needs, situation, or clinical process. By downloading the HumanITcare solution, symptoms, vital signs, and medication management can be remotely monitored. In addition, patients, family members, and caregivers could respond to the app’s questionnaires and measurements once a day as they saw fit .The doctors or health care personnel responsible for the patients checked the values entered by the participants daily. They received an alarm if the reference values deviated from normal. In these cases, the patient was contacted as soon as possible by chat or phone .After receiving the protocol approval, pilot testing was conducted from April to September 2021 among 60 patients from Hospital de la Candelaria (Canary Islands) and Hospital de Ferrol . The following data were collected: demographics, including age, recorded pathology, time of inclusion in the pilot study, and who was responsible for data collection; clinical measurements, including blood pressure, temperature, heart rate, oxygen saturation, and blood glucose; symptom intensity, including monitoring the presence and intensity of the most frequent symptoms (using the revised version of the ESAS); functional status, using an adaptation of the contents of the PPS scale; medication reminders, to assess whether the usual treatment was sufficient for the patient; stools (the presence of constipation was explicitly assessed using an adaptation of the Rome IV criteria); satisfaction questionnaires, including the Post-Study System Usability Questionnaire (PSSUQ); and the use of chat, which provided a new communication channel between professionals and patients or relatives in a secure information environment.Preliminary results from the data collected have been previously published . The aveThe application’s design is simple, although in all cases, it was ensured that the patient had a family member or caregiver who could help them complete what they could not.Overall, very positive responses were received, mainly related to the perceived usefulness of the application. One problem mentioned by participants was the length of the PSSUQ and the repetition of items. There was thus a need for feedback, as patients and caregivers only selected items related to overall satisfaction, ease of use, and perceived usefulness. The study focused on acceptance and usability by patients, caregivers, and professionals. However, more research is needed to demonstrate that using the app helps achieve specific care goals, such as improved symptom control and reduced urgent visits.In order to respond to the needs and deficiencies detected in the clinical care of patients with advanced illnesses, the HumanITcare platform was started with a singular style of shared development.The HumanITcare solution, characterized by its customization, was adapted to the app based on a review of previous scientific initiatives and the clinical experience of professionals who care for patients with advanced illnesses . Our proThe technical development for the personalization of the HumanITcare platform was possible due to preexisting familiarity with these applications among the professionals who oversaw it, the response to the needs of the health care workers, and thought about their needs and those of the patients. In addition, having a technical team that continuously monitored the proper functioning of the app and could quickly and effectively resolve doubts and problems raised by patients and professionals contributed significantly to the success of this project.Most previous initiatives have focused solely on monitoring isolated data, but the HumanITcare platform is comprehensive and consistent. It collects all the data considered especially important for the follow-up of these patients in an intuitive and easy-to-use way for all audiences, thus better controlling each patient’s clinical evolution ,7. UntilAt a qualitative level, the experience and usability data of the patients were very positive. This innovative project aims to complement and help the structures and resources of existing palliative care units to improve effective home care programs that provide comprehensive and coordinated care closely tailored to each patient’s needs.There are still several steps to take before implementing the systematic integration of this experience in the usual care of this type of patient. Murray et al  describeHere we highlight the HumanITcare platform solution, as it brought together the clinical constants usually evaluated in face-to-face consultations and some of the most-used questionnaires by professionals working with patients with advanced illnesses. The clinical constants are essential for the future development of effective mHealth systems that support remote monitoring of symptoms through wearable devices combined with proactive care for patients at constant risk of rapid or unexpected deterioration of health status. Continuous assessment and critical review of symptoms by patient and physician are the cornerstones of effective outpatient palliative care. Numerous technology-related applications have proven their benefits in engaging patients in their care, promoting treatment adherence, focusing face-to-face assessments on the most critical issues, and improving overall health outcomes.The results of this project support the conclusions of other studies that patients with advanced illnesses could be the ideal beneficiaries of an intervention focused on telemedicine, and that such intervention can be a helpful complement to their care, so that they can remain in their homes for as long as possible while receiving optimal care -19. The Even in a population with extreme frailty and high needs, such as patients with advanced illnesses, initiatives based on telemedicine can be successfully developed and enthusiastically accepted . HoweverThe care and design/technical support teams must be in contact from the beginning of the study to uncover the specific needs of the patients and professionals to be addressed by the app or platform. There must be continuous feedback that quickly incorporates the changes that are considered necessary to resolve the problems that arise. Changes to the overall functions of health care structures and professions are complex, so incorporating these new forms of health monitoring must not add burdens and must show clear benefits. For the incorporation of this app to be sustainable over time, the implemented solution must provide improvements in the health outcomes of patients and, in turn, facilitate the work of professionals. The patients with advanced-stage illnesses and their caregivers or relatives were delighted to participate in this initiative related to new technologies based specifically on mobile phones and handled this technology in a wholly normalized way, so it seems appropriate to continue exploring this line of research and clinical assistance with this population.This study had limitations. First, although the app was designed to be as straightforward as possible and accessible to anyone, it was introduced as something to be used interchangeably by patients and caregivers. Thus, we could not assess if patients directly experienced problems entering data or with the general use of the app or if they needed a family member or caregiver to assist them in its use. Also, we did not explicitly evaluate, as it was not the aim of the study, whether people with physical or cognitive disabilities or deficits could use the app.Second, given that the study focused on the acceptability and usability of the app by patients, caregivers, and professionals, the sample size did not provide sufficient power to analyze whether specific care objectives were achieved with the use of the app, such as better symptom control or reduced hospital visits. In line with this, a final limitation was that the pilot testing was only done in 2 hospital units with few patients. However, to recommend its use in other centers or settings , it would be helpful to demonstrate its role in improving health outcomes. Therefore, future work should aim for a more extensive study with a more significant number of patients across multiple centers.The HumanITcare digital solution is proposed as a clinical monitoring tool based on ICT and focused on patients with advanced illnesses. This digital solution optimizes and coordinates activities through intelligent planning, anticipation, and prevention of critical events through its alarm system management. In addition, it automates manual tasks and procedures, facilitates the mutual coordination of medical personnel and patients, carers, and families, and uses a personalized care plan derived from direct monitoring of each patient’s daily signs and symptoms.Among patients who completed their follow-up study using their mobile phone, more than 80% highlighted the app’s use as an effective form of communication. This app demonstrates that the digital divide is narrowing and that technologies such as those provided by HumanITcare can add value to patient services. Nevertheless, there is some future work to do on this particular platform, including increasing the use of integrated medical devices via Bluetooth to improve usability instead of using manual registration, a function that HumanITcare already has; using voice and image recognition to monitor patients without medical devices at home, using artificial intelligence processes; increasing the use of the video call functionality available on the platform to improve communication between medical professionals and patients from home; and continuing to integrate HumanITcare through an application programming interface with electronic health records  using the Fast Healthcare Interoperability Resource interoperability standard developed by Health Level 7 to enable the electronic exchange of health care data between different systems in the health care industry.


The current epidemic of Coronavirus Disease 2019 (COVID-19) has become a public health event worldwide. Through ethical analysis of a series of epidemic prevention phenomena and epidemic prevention measures taken by the Chinese (and other countries) government and medical institutions during the COVID-19 pandemic, this paper discusses a series of ethical difficulties in hospital emergency triage caused by the COVID-19, including the autonomy limitation of patients and waste of epidemic prevention resources due to over-triage, the safety problem of patients because of inaccurate feedback information from intelligent epidemic prevention technology, and conflicts between individual interests of patients and public interests due to the “strict” implementation of the pandemic prevention and control system. In addition, we also discuss the solution path and strategy of these ethical issues from the perspective of system design and implementation based on the Care Ethics theory. Cases of breakthrough infections have occurred due to the emergence of mutant strains of SARS-CoV-2, the virus that causes COVID-19, as a result of ongoing genetic mutations . COVID-1Before the outbreak of COVID-19, emergency departments (EDs) have been facing a series of challenges around the world, overcrowding, dramatic increases in patient volume, insufficient numbers of experienced medical staff, resulting in longer emergency wait times and inaccurate triage, negatively impacting the overall operational efficiency of emergency departments (EDs), increased patient safety risks and decreased satisfaction, and staff satisfaction burnout . The epi2.2.1.There are numerous emergency triage scales that are commonly utilized, among which the Emergency Severity Index (ESI) scale was developed in the United States (U.S.) and is now used by an increasing number of EDs worldwide . During Moreover, as the spread of the epidemic continues to change, the timeliness and proximity of the triage system is also insufficient. During the epidemic, triage nurses need to not only classify patients with critically ill patients but also perform epidemiologic screening and screen for patients infected with COVID-19. Currently, real-time reverse transcription–polymerase chain reaction (rRT-PCR) is considered the COVID-19 standard for most diagnostic studies, but there are data suggesting that the sensitivity of a single test ranges from 60 to 78% . ClinicaThe need for epidemic prevention and control has led to a “nursing shortage” in a lot of countries, so the hiring of “new nurses” has elevated to meet the growing and changing needs of the epidemic . However2.2.Hospital EDs worldwide are notoriously overcrowded. A key feature of overcrowding is that when demand exceeds capacity, the various parts of the system form queues, which leads to an extended average ED length of stay (ED LOS) . In factHowever, critically ill patients do not think so much and often choose to go to the ED as soon as possible or be transported by ambulance to the ED because of the urgency and suddenness of their disease. Although the number of ED visits reduces during the initial phase of the epidemic for all of these reasons, it does not mean that ED crowding is relieved because the ensuing epidemic prevention measures complicate the triage process, resulting in longer triage times for individual patients. Emergency crowding was not improved through the reduction in the number of visits due to the epidemic and may have even increased after the number of emergency patients resumed. In addition, in pEDs, children are exposed to a high frequency of triage errors because they involve asking their guardians for relevant information and often involve emergency classification of high-risk children in complex and stressful environments . If the 2.3.Tele-medicine refers to a medical technology that uses electronic information and telecommunication technologies to achieve a remote clinical diagnosis, health education, and public health management . Tele-trMeanwhile, with the development of the epidemic and the prolongation of epidemic time, various social institutions  are increasingly employing fever examination as a mechanism to measure whether the population, travelers, employees, and patients are infected with COVID-19 . In Chin3.The nursing ethical principles include autonomy, non-maleficence, beneficence, justice, fidelity, and veracity . Nurses Indeed, inaccuracies in triage, ED crowding, and inaccurate assessment of tele-triage information existed before the epidemic but were exacerbated by the COVID-19 epidemic. The COVID-19 epidemic constantly facilitates the informatization and intelligence of all medical means  and also impacts the emergency triage system. All the medical institutions are forced to take such measures urgently because of the epidemic prevention work, while the possible ethical issues induced by these measures are generally ignored. It may also be difficult for nurses to practice nursing values because of multiple factors . 3.1.The World Health Organization defines patient safety as the absence of preventable harm to patients and the prevention of unnecessary harm by health care professionals . In GrouTele-triage (via the Internet or telephone) has emerged as a means of reducing ED crowding and cross-infection. The inaccuracy of tele-triage predisposes to delayed untimely treatment for acute patients. A Paris study reported that 1% of misdiagnosis of tele-triage in a primary and secondary ophthalmic emergency office contributed to delayed emergency care during COVID-19 lockdown . This suBesides, face recognition temperature measurement devices still have the inaccuracy of temperature measurement although their extensive utilization does open a novel way to diminish the burden of epidemic prevention work. In Honduras, relevant research designs manifested 82% of accuracy and 14% of error for face recognition and temperature measurement devices . It has 3.2.The implementation of an epidemic prevention and control system commonly plunges triage nurses into a moral dilemma: they are fearful of being reprimanded for inadequate implementation of epidemic prevention measures, yet the admission of patients infected with COVID-19 may culminate in the occurrence of nosocomial infections. When a triage nurse encounters a critically ill patient with suspected COVID-19, will it threaten the safety of other patients attending the ED if the patient is accepted? If this patient is rejected, the safety of other patients in the ED will be guaranteed, but who will safeguard the life safety of this patient? How should the triage nurse make an ethical choice?With the intensification of epidemic prevention measures, triage nurses shoulder increased responsibilities and are likely to engage in negative defensive medical behaviors for fear of making mistakes or taking responsibility. A report  exhibiteIn addition, ED crowding is probable to exacerbate the spread of the epidemic and likewise endanger the lives of emergency patients. As per the report of the Daily mail, Werribee Mercy Hospital, one of the busiest hospitals in Melbourne of Australia, refused to admit emergency patients due to a shortage of doctors and nurses caused by the impact of the epidemic . The ED 3.3.The new Code of Ethics for Nurses (2021) points out that nurses need to ensure informed consent for nursing and/or medical care, which includes the right to choose or refuse treatments . RestricDuring the epidemic prevention and control, medical institution managers introduced a series of epidemic prevention and control measures to protect the safety of medical staff and most patients and for fear of nosocomial infections of COVID-19. In Italy, for example, one of the first epicenters of the COVID-19 pandemic, hospital emergency departments were forced to constantly adapt their space layout to improve safety and comfort for medical staff, including the creation of temporary spaces, buffer zones, “dirty” paths and spaces for medical staff . In ChinAsymmetric nurse–patient information can also contribute to the limitation of informed consent and autonomy for patients. During epidemic prevention and control, triage nurses are likely to engage in positive defensive medical behaviors, that is, they include all emergency patients into the scope of potential COVID-19 infection, which is not immoral in terms of their purpose but finally leads to the limited autonomy of patients. Patients, especially patients with lower-level education, may be at a disadvantage when deciding on treatment  due to t3.4.Overt-triage often leads to wasted resources for vaccination. The nucleic acid test is taken as an example. The strict triage system and intensive workload may induce overstress of triage nurses during the epidemic, which in turn leads to positive defensive medical triage behaviors. As a result, these behaviors may shift their goal from protecting patients and preventing the COVID-19 infection of patients to preventing nosocomial infections and protecting themselves from leadership reprimands. Abuse of nucleic acid tests caused by over-triage undoubtedly brings about a waste of limited resources for epidemic prevention. Importantly, there are a large number of economically underdeveloped countries in the world that are still unable to conduct universal nucleic acid testing and realize the requirement of ensuring that “all those in need are tested.” Over-triage out of self-preservation is irresponsible in terms of both behaviors and purpose, which does not follow the service concept and principle of “patients’ interests first” for patients and causes a gratuitous waste of restricted epidemic prevention resources for the country.In the meantime, abuse of nucleic acid tests also give rise to “forced” competition for epidemic prevention resources. That is to say, limited resources for epidemic prevention are meant to serve the patient population that needs nucleic acid tests. Nonetheless, because of over-triage, patients who do not need nucleic acid tests “seize” the finite epidemic prevention resources of those who do need them. This “forced” competition for epidemic prevention resources ultimately results in a “crowding-out” effect, that is, groups in need of nucleic acid tests are crowded out and not effectively tested as a result of the “competition and preemption “for resources.In addition, there is competition for bed resources among emergency patients. During the emergency phase of the outbreak, there were also challenging decisions to be made by the emergency department staff - new criteria for admission to the emergency intensive care unit (EICU)  and the 4.EDs in hospitals are in need of a triage system that can comfortably handle major public health events. The triage system should be rebuilt not only to respond to the current epidemic of COVID-19 but also to deal with future public health events that may occur. In the face of a global epidemic, the design of the triage system may not be perfect by considering only the traditional ethical principles of autonomy, beneficence, non-maleficence, and justice . On thisCaring is not only a value but also a practice. Specifically, carers should be committed to fulfilling the needs of the cared-for. For medical services, all actions are motivated by caring and cause caring results with the needs of patients as the goal. A triage system that aims at caring and practices caring is a system of kindness and good. Because motivation is the subjective will and the guide to action, the motivation must be good for the development of a triage system. Nevertheless, good motives do not necessarily trigger good actions and do not imply good results. Therefore, the system should be formulated with the consideration that the implementation and the results both are good and kindness. Harm to patients can only be minimized when the epidemic prevention triage system is one that is caring in nature.4.1.Although utilitarians advocate the principle of maximizing interests, there still exists the possibility that maximizing benefits overlooks the interests of a small group of patients. Therefore, the interests and needs of individual patients need to be taken into account while safeguarding the interests and needs of patients as a whole. According to the care ethicist Virgina Held, the ethics of care is suggested to be a sense of moral urgency and to serve and be responsible for meeting the needs of surrounding people, with a primary emphasis on satisfying the needs of dependents . She pre4.2.In some special situations, it is difficult to predict whether the implementation of a system conflicts with the interests of patients. Moreover, how to ensure that the interests and needs are not infringed? Nel Noddings argues that the one-caring is other-focused and has a motivation shift. The motivation for caring is directed at the well-being and protection of the cared-for. Our focus is on the cared-for, not on ourselves by acting in the interests of the cared-for and with reference to his angle of thinking, objective needs, expectations for us, and the objective components of the problematic dilemma . As per 4.3.Nel Noddings believes that caring is primarily about the actions adopted by the one-caring that benefit the cared-for or appear reasonable, with flexibility in these actions, and that the actions of the one-caring are based on the interests of the cared-for without being constrained by rules and regulations . The des4.4.Balancing the common objectives of medical institutions and patients is extremely complex. Therefore, in order to bridge the objective gap between both parties and ensure that both parties have the same objective as possible, system design should leave a certain operating space for system implementers. On the one hand, triage systems should be designed in combination with epidemic prevention and control requirements, policy environment, facility and equipment conditions, and other management systems to ensure their actionability. On the other hand, the design of the triage system should take into account the issue of appropriate empowerment of triage nurses in emergency situations , i.e., providing nurses with certain decision-making authority in triage to increase operability. However, the degree of empowerment in decision-making should be grasped, and the bottom line must be not to harm the interests of others. Triage nurses must make decisions with the life safety of patients as the premise. For instance, if a special event occurs and triage nurses have difficulty in making decisions, they should immediately report to superior managers and make decisions through joint discussion under the premise of ensuring the life safety of patients.4.5.The waste of all resources should be curbed in terms of appropriateness and moderateness in the use of epidemic prevention medical resources. Michael Slote suggests that caring is not only for surrounding people but also for strangers or people in remote areas to some extent . The adv5.The COVID-19 epidemic raises unique ethical issues about emergency triage, with key issues of patient safety, patient autonomy, and application of epidemic prevention resources. The outbreak and epidemic of COVID-19 provide a crucial opportunity to consider some of the ethical issues exposed by the current emergency triage system. The ethical issues of emergency triage in epidemic situations are unique compared to emergency triage in normalized medical scenarios. The paths to solve these ethical issues can be discussed from the perspectives of system design and implementation with the ethics of care as a theoretical basis, which can provide an idea for the adjustment and the reconfiguration of emergency triage systems in related institutions. Meanwhile, although the discussion of these ethical issues is based on the emergency triage work during the current epidemic prevention and control period, this paper also has key implications for how to improve and refine the emergency triage work in hospitals when major public health events occur in the future.LW made a substantial contribution to data analysis and wrote the first draft of the article. XK contributed to the conceptualization, data collecting, and contributed to revising the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.