Current Status of Home Telemonitoring for Older Patients: A Brief Review for Healthcare Providers
The contemporary definition of telemedicine is a broad concept, encompassing any aspect of medical care that is provided without direct face-to-face patient and healthcare provider contact. Rudimentary iterations were initially described as early as 1905, when electrocardiograms (ECGs) were first transmitted via telephone lines. Modern telemedicine can include remote consultation either between two physicians or between a patient and a healthcare provider. Clinical applications of virtual technology since the 1990s have paralleled the rapid growth of the Internet and the World Wide Web.1 Home telehealth is a category of telemedicine that refers specifically to remote provision of care for a patient at his or her residence, and is generally subdivided into home telemonitoring and telephone support. Telemonitoring, the focus of this article, describes the remote collection of multiple data parameters through peripheral equipment, while telephone support is the direct interaction between the patient and the healthcare professional on either a scheduled or acute basis to discuss symptomatology and provide instruction and education. This article discusses the different aspects of telemonitoring with specific emphasis on the evidence for application in elderly persons with common chronic disease conditions.
Home Telemonitoring Technology
Home telemonitoring consists of an ongoing collection of clinical data in a patient’s home, which is relayed to healthcare personnel for review and interpretation. Typically, one can obtain many different parameters through the use of telemonitoring, including blood pressure, heart rate, pulse oximetry, peak flow measurements, glucometer readings, digital stethoscopy, ECG tracings, fetal heart tones, and infant cardiopulmonary monitoring (ie, “home apnea monitor”).1 More advanced variables such as ocular pressure,2 electroencephalography, electromyography, intracranial pressure, basal metabolic rate, intrauterine pressure, and intravesical pressure can also be transmitted.1
Data acquired by home telemonitoring have been demonstrated to be reliable and comparable to that obtained in a physician’s office.3 Studies have shown a high rate of patient satisfaction and compliance with home telemonitoring, including in the elderly population.3-5 Most published reports have described monitoring for ≤ 12-month intervals; however, one study was able to demonstrate sustainability of telemonitoring over a 5-year period.6
Telemonitoring can include real-time video monitoring, both for activity surveillance and to simulate an actual face-to-face visit. Video can be utilized for patient educational purposes and to obtain visual information such as an evaluation of general appearance and for monitoring of wound care. Additionally, troubleshooting malfunctions of equipment and guidance (or retraining) on the use of equipment can be performed via videoconferencing.
Transmission of data can occur either synchronously (real-time technology) or asynchronously (store-and-forward technology). Many telemonitoring systems are now Internet-based, but “plain old telephone service” (POTS) and 3G/4G technologies can also be used to transmit data. To ensure compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a telemonitoring network must take reasonable precautions to prevent interception of data by unauthorized third parties; this can be accomplished through the use of a password-protected secure server networked to reception equipment. The HIPAA privacy rule explicitly allows providers to communicate electronically with patients, provided reasonable safeguards are in place.
Practice Design and Implementation
As with the introduction of any technology, practical applications must be user-friendly, especially for elderly patients who may be easily intimidated by complex new processes. Home telemonitoring systems can include digital or touch screen technology, which allows patients to answer simple, binary “yes/no” symptom-related questions, and peripheral devices, which can be fully automated. Filtering software to alert providers of potential abnormal clinical values is the key factor to the daily monitoring of numerous patients. Monitoring systems can be designed to triage patient data based on preset global parameters, which may be modified as appropriate for an individual patient. Data can further be triaged into “zones” of prioritization. For example, patient responses can be triaged into a green zone (all data within preset parameters), a yellow zone (data moderately out of range), and a red zone (data significantly out of range). Ranges can be determined by a clinician who is familiar with the individual patient and targeted accordingly. Thus, a blood pressure reading that may fall in a green zone for one patient may fall in a yellow zone for another patient. As an individual’s clinical condition changes over time, relevant parameters can be adjusted accordingly. This triage system simplifies a provider’s ability to telemonitor large groups of patients simultaneously and intervene on only those patients who require attention. Data can be integrated directly into an electronic medical record system or stored separately within an encrypted database, which is then accessed by the clinical monitoring team. These data can be interpreted by a chronic disease nurse care manager or a midlevel provider, with involvement of the primary care provider as needed, to manage patients’ chronic medical conditions. A change in the clinical condition of the patient can be addressed either through a phone call, a videoconference, an office visit with the primary care provider, or an emergency department visit according to the level of care that is needed.
A key component of home telemonitoring is that the collection of clinical data is performed by a patient or caregiver without a healthcare provider present. Trained clinical personnel can visit patients’ homes and instruct them in the use of the monitoring equipment. Troubleshooting of technical issues can be resolved with either a follow-up home visit, videoconferencing, online correspondence, or via telephone. Patients are also informed that telemonitoring equipment is not intended to substitute for local emergency medical services and should not be activated in the event of a life-threatening situation.
Common barriers to implementation include both patient acceptance and technical factors such as significant visual impairment, dementia, super obesity (exceeding weight limits of devices), significant mobility or balance problems (leading to difficulty using a scale and other monitoring equipment), and language barriers (when monitors are configured in an unfamiliar language). Additionally, lack of reliable telephone lines or a grounded electrical outlet in the home are technical factors that can preclude telemonitoring.
Although intuitively appealing, the economic viability of home telemonitoring remains to be convincingly demonstrated, as few trials have performed rigorous cost analysis. A small observational trial conducted in patients with chronic obstructive pulmonary disease (COPD) demonstrated cost savings over a 6-month period when compared to standard care.7 A report from the Canadian Agency for Drugs and Technologies in Health (CADTH) found that economic evaluations of telemedicine are rare and incomplete,3 a view that was echoed in a review by Dávalos et al.8 However, if the use of telemonitoring can be shown to decrease the use of high-acuity healthcare such as emergency department visits and hospitalizations, there would seem to be a potential for significant cost savings. It is unclear how payment systems will change with the use of telemonitoring for the Medicare population; however, if the Centers for Medicare & Medicaid Services increases the emphasis on bundled payments, the use of telemonitoring may dramatically increase.
Indications and Target Populations
There are a myriad of potential applications of home telemonitoring; however, much of the current literature focuses on the treatment of chronic disease conditions commonly found in older adults. Current forecasts predict that patients over 65 years of age will comprise approximately 16% of the U.S. population by 2020, with a concurrent increase in chronic disease conditions9; likely, this will be mirrored on a global scale. Home telehealth can be used for multiple aspects of chronic disease management, including site-specific and disease-specific uses. Specifically for rural settings, patient education can be done via videoconferencing by a remotely located healthcare provider, and additional disease-specific education can be programmed directly into an in-home monitor. Telemonitoring can be used to increase patients’ ability to self-monitor their medical condition(s) and to increase their personal sense of self-efficacy with regard to their disease(s).3 Perhaps most promising, longitudinal data can be used to objectively assess for a decline in health status, with the goal of instituting early interventions and thus preventing emergency department visits and hospital admissions. Healthcare providers can guide medication adjustments and remotely monitor physiologic responses to changes in a medication regimen. Finally, telemonitoring systems can provide gentle reminders to patients to take their prescribed medications, and this can potentially increase medication compliance.
The majority of the evidence-based literature on home telemonitoring of patients with chronic diseases explores its use in the management of congestive heart failure (CHF), COPD, and diabetes mellitus. Many of the original pilot studies were limited to small, nonrandomized populations. Outcome data between populations have often been inconsistent, and direct comparison of different studies is difficult since randomized trials have been heterogeneous in terms of specific patient characteristics (age, severity of underlying illness, chronic disease in isolation vs chronic disease with multiple comorbidities), frequency of monitoring (twice daily to once a month), and category of intervention (type of monitoring system, specific clinical data that are monitored). The duration of studies has generally ranged from 3 to 12 months. As with all technology, the capabilities of telemonitoring continue to evolve. This evolution hinders the applicability of some studies because the technology used during a trial is obsolete by the time the study is completed.6 However, the general concepts of clinical improvement with telemonitoring must be considered despite differing technologies.
Congestive Heart Failure
Studies of telemonitoring in patients with CHF have been varied with regard to New York Heart Association (NYHA) class and type, frequency, and duration of intervention. Most trials have included remote monitoring of weight, blood pressure, pulse oximetry, and cardiopulmonary symptoms. Investigators have shown mixed outcomes, with some finding a decrease in mortality,10-14 and others finding no difference.15,16 Goldberg et al12 showed a significant 56% decrease in mortality in persons from the telemonitored group. The Trans-European Network-Home-Care Management System (TEN-HMS) was closed early due to a similar significant decrease in mortality in the telemonitored group.10 For the elderly in particular, preservation or improvement of functional status, maintenance of independent living, and avoidance of preventable emergency department visits and hospitalizations become more important end points than mortality alone. Telemonitoring in CHF has been demonstrated to decrease hospital readmission rates,3,11,13-15 with one study showing a 50% reduction,15 and another showing fewer bed-days of care.13 It has been reported that quality-of-life scores have improved in telemonitored groups.3,11 Another study showed an improvement in NYHA functional class in the telemonitored group, but not in the standard care group, over the duration of the study.17
Chronic Obstructive Pulmonary Disease
Studies of telemonitoring in persons with COPD have generally included supervision of symptoms, peak flow measurements, and episodic pulse oximetry. Reduction in hospital readmissions,18 emergency department visits, and disease exacerbations19 has been found with the implementation of telemonitoring in persons with COPD. As previously mentioned, a small, randomized study showed a cost reduction of Can$355 (Canadian dollars) over a 6-month period in telemonitored patients with COPD.7
The Informatics for Diabetes Education and Telemedicine (IDEATel) study was a large (N = 1665 patients), randomized trial of telemonitoring versus standard care in an elderly U.S. Medicare population with diabetes.6 Over a 5-year period, this study demonstrated significant sustained decreases in serum hemoglobin A1c (HbA1c) and low-density lipoprotein values, as well as improved blood pressure control and improved diabetes self-efficacy.6 The CADTH report also found that HbA1c levels were significantly lower in telemonitored groups when compared to standard care groups.3
Mixed Chronic Diseases
Several home telemonitoring studies have been performed in populations with multiple comorbid disease conditions. These mixed chronic disease trials usually have focused on patients with CHF, COPD, and/or diabetes mellitus. Although there is a lack of rigorous, randomized controlled trials in patients with mixed chronic diseases, in general, patients have demonstrated a high degree of satisfaction and acceptance of telemonitoring, showing an increase in their knowledge of their disease,5 a decrease in bed-days of care during hospitalization, and a reduction in emergency department visits.20
Veterans Health Administration Experience
The U.S. Veterans Health Administration (VHA) provides healthcare for veterans of the United States armed forces. Since the VHA population is largely capitated, emphasis is on preventative care. In 2003, the VHA Office of Telehealth Services deployed a nationwide telehealth program called Care Coordination/Home Telehealth (CCHT).21 This program provides care for approximately 31,000 veterans with various chronic diseases, and, due to the large scale of operation, it serves as an important model for the estimation of requirements for implementing a telemonitoring program in other populations. Some specific details of the CCHT experience are as follows21:
1. Training of clinical personnel involves 12 hours of online training and 2 to 4 weeks of hands-on training.
2. Approximately 90% of patients are accepting of this modality of care.
3. A single care manager can feasibly oversee the care of 100 to 150 patients with chronic medical illness or 90 patients with psychiatric illness.
4. Cost of this program is $1600 per patient on a yearly basis.
To date, this system has resulted in decreased hospital admissions and bed-days of care, and in 2008 it was awarded the American Telemedicine Association President’s Innovation Award (www.americantelemed.org/i4a/pages/index.cfm?pageID=3518).
Home telemonitoring will likely become increasingly utilized in the coming years, particularly given the recent national emphasis on reduction in costs through healthcare reform. However, optimal utilization of telemonitoring for chronic disease remains to be defined. Unanswered questions include identifying which populations would most benefit and determining if certain stages of chronic illness are particularly amenable to telemonitoring. The optimal duration, type, and frequency of telemonitoring for specific disease states will need to be clarified. Perhaps most importantly, robust cost-analysis studies are needed to evaluate the economic validity. Despite limitations in the current available evidence for home telemonitoring, this technology appears to show considerable promise for reducing morbidity and mortality in chronic disease management for older patients.
The authors have received research support from Intel and General Electric for an ongoing study of telemonitoring at the Mayo Clinic; however, the authors do not receive any personal compensation nor have any stock in the companies. No funding was provided in relation to this article.
Dr. Pecina is Senior Associate Consultant, Department of Family Medicine, Dr. Takahashi is Associate Professor of Medicine, Department of Primary Care Internal Medicine, and Dr. Hanson is Assistant Professor of Medicine, Department of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN.
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