Home health monitoring: critical success factors for implementation · 2016-04-14 · Key Points...
Transcript of Home health monitoring: critical success factors for implementation · 2016-04-14 · Key Points...
Home health monitoring: critical success factors for implementation A narrative synthesis of evidence
Definitions Critical success factors
Critical success factors have been explained as ‘those few things that must go well to ensure
success for a manager or organisation’(1).
Large scale (or ‘at scale’)
For the purposes of this report, the agreed definition of ‘large-scale’ implementations was those
relating to over 100 people.
Telehealth
Telehealth has been defined as follows: ‘the provision of health services at a distance using a
range of digital and mobile technologies. This includes the capture and relay of physiological
measurements from the home/community for clinical review and early intervention, often in
support of self management; and “teleconsultations” where technology such as email,
telephone, telemetry, video conferencing, digital imaging, web and digital television are used to
support consultations between professional to professional, clinicians and patients, or between
groups of clinicians’(2).
Home health monitoring
‘Home and mobile health monitoring supports patients to digitally receive or capture information
on their condition. If required, physiological and symptom information can be relayed from the
home/community setting for clinical review and remote monitoring by health and care
staff’(3).For the purposes of this report, home health monitoring was defined as a patient self-
measuring specified physiological data and transmitting this data to an external professional.
Long-term conditions
The Scottish government has defined long term conditions as ‘health conditions that last a year
or longer, impact on a person’s life, and may require ongoing care and support. The definition
does not relate to any one condition, care-group or age category’(4).
Implementation
Implementation has been defined as ‘the process of putting a decision or plan in to effect’(5).
Key Points
Whilst the evidence was very heterogeneous, a number of critical success factors were
commonly suggested in the literature, including:
implementation should be considered within the context of current care processes and with
relevant stakeholders,
home health monitoring technology resources should ideally be intuitive, reliable and ‘fit in’
with patients and care processes,
there are changes to activities, so patients and professionals may require support and training
to adjust,
patients and professionals need clarity and definition and a shared understanding regarding
each other’s changed responsibilities, and
home health monitoring programmes should be evaluated and monitored by patients and
professionals.
Strategic context of the report
The Scottish government’s vision is that by 2020, everyone is able to live longer, healthier lives
at home, or in a homely setting. As part of this vision, telehealth (and telecare) has been
identified as a quality approach which will reduce costs by supporting more people at home to
achieve better outcomes at less cost(6). A national telehealth and telecare delivery plan for
Scotland has been in place since 2012 and outlines an intention to spread ‘at scale’,
technology-enabled service redesign(2). The £30 million Scotland-wide Technology Enabled
Care (TEC) Programme is a three-year initiative to 2018, underpinning the national delivery
programme, with the aim of supporting the expansion of technology uptake, and supporting the
national health and wellbeing outcomes.
Purpose and scope of the report
The Scottish Centre for Telehealth and Telecare (SCTT), through the TEC programme,
commissioned a synthesis of the critical success factors relating to previous large-scale home
health monitoring programme implementations to inform future guidance. By describing reported
critical success factors which could relate to the successful implementation of home health
monitoring, it is intended that this report will be of use during planning for implementation .
This report was guided by the following research question:
What are the critical success factors of service models that have been used to implement
home-health monitoring for people with long-term conditions at scale across Scotland,
the UK and developed countries?
This is not an exhaustive synthesis and there will be many other factors which affect the
success of implementation of home health monitoring. International and national evidence may
not be generalisable to local Scottish contexts.
What evidence was searched for?
Initial scoping work suggested there was a lack of literature specifically relating to
implementation, so quantitative and qualitative evidence was searched for in both secondary
and primary literature. A systematic search of the secondary literature was carried out between
18/03/2015 and 25/03/2015 to identify systematic reviews, health technology assessments and
other evidence based reports. Medline, Medline in process, Embase, Cinahl, Health
Management Information Consortium databases were also searched for systematic reviews and
meta-analyses. The primary literature was systematically searched between 18/03/2015 and
25/03/2015 using the following databases: Medline, Medline in process, Embase, Cinahl, Health
Management Information Consortium. Results were limited to Europe, North America, Australia
and New Zealand. Key websites were searched for guidelines, policy documents, clinical
summaries, economic studies. Websites of organisations related to this topic, for example
Scottish Telehealth & Telecare Community, Shifting the Balance of Care, were also searched.
Concepts used in all searches included: Telehealth, telemonitoring, telemedicine, home health
monitoring. A full list of resources searched and terms used are available on request.
Where did the evidence relate to and what methodology was used?
Evidence was included in this report where it related to patients in Scotland, the UK and
developed countries, involved an ‘at-scale’ home health monitoring intervention and reported at
least one outcome or factor related to home health monitoring implementation. Most of the
studies related to patient experience in Scotland and the UK. Eleven papers were examined for
the final analysis. No review of critical success factors related to the implementation of home
health monitoring was found. Where HHM was referred to as telemonitoring the same term is
used in this report, for consistency. Many of the studies were intervention trials rather than
evaluations of exisiting services.
Scottish context
Three qualitative studies were undertaken in Scotland. Two related to the Lothian region and
explored the experiences of patients and professionals in separate trials of home health
monitoring for COPD and Heart Failure using semi-structured interviews (7, 8). The other
related to the Highland region and aimed to describe the implementation and outcomes of a
telehealth initiative for COPD using a questionnaire and some semi-structured interviews (9).
UK context Four qualitative papers related to England, with two in the West Midlands: a service evaluation
in the Stoke on Trent area which explored the experiences of hypertension patients across 10
GP practices through a telephone-administered questionnaire(10), and a study across 24 GP
practices in the region which explored patient and staff experiences of self-monitoring of blood-
pressure and self-titration of anti-hypertensive medication through semi-structured interviews
(11). Another study related to the Oxford area and explored COPD patients’ views of using a
mobile health application through semi-structured interviews (12). The remaining study related
to West London and involved in-depth interviews with patients with heart failure to explore the
potential for telemonitoring to empower patients to self – care (13).
Outside of the UK
One qualitative paper related to semi-structured interviews with patients and family members to
explore Swedish patients with hypertension’s perceptions of transmitting body weight data (14).
Another study appeared to relate to Canada and described the development of a rule-based
heart failure telemonitoring system through semi-structured interviews with clinicians (15).
The two systematic reviews) (16, 17) included published evidence related to various countries,
including the UK
How was the evidence synthesized and why?
Home health monitoring is recognised as a complex programme which needs to be integrated in
to clinical practice (8, 16). Contribution analysis(18) (CA) is a theory based analysis process
which is designed to assist planning, monitoring and evaluation of the outcomes of programmes
operating in complex contexts (19). In this report, CA was used as a framework to group the
reported factors and develop and identify common themes across the studies. Factors reported
in the literature which appeared to relate to implementation were noted and arranged into
categories for further analysis. Where a factor was reported more than once (i.e. it appeared to
be a common factor between at least two papers) it was developed in to a theme and tabulated.
The use of logic models (such as those used in CA) to capture complexity when synthesising
evidence has previously been advocated in relation to systematic reviews(20). CA considers
that a long term outcome (programme aim) cannot be achieved before a change in behaviour
(medium term outcome) happens and that change in behaviour (medium term outcome) cannot
be achieved before a change in awareness or knowledge (short-term outcome) happens. In
turn, a change in awareness or knowledge (short term outcome) cannot be achieved before a
person is reached (reach), a person cannot be reached unless you produce something (output)
or do (activity) something, and you cannot do something (activity) without input (resources). This
is known as a ‘results chain’. Figure 1 shows a simple example of a theoretical results chain.
Some potential risk and mitigating factors to this chain are illustrated to the left and right
respectively.
Resources
Medium term
outcome
Reach
Activities
Short term
outcome
Long term outcome
Staff and patients are
knowledgeable about
HHM
Staff and patients can
use HHM in practice
Patient receives care
closer to home
technology
is easy to
use
Key:
Potential risk factor
Potential mitigating factor
HHM technology
and equipment
resources
Discuss using the
HHM system with
patientspatients may
misunderstand
what they need
to do
ongoing
support and
learning needs
addressed
patients may
have problems
using
technology
Reach staff and
suitable patients
patients may
mistakenly think they
are continuously
monitored
patients have a
trusted
relationship
with healthcare
professional
staff may have
concerns about
increased workload
potential
patients are
carefully
selected
patients take
and interpret
their own
measurements
patients may not
follow advice of
professional
Figure 1: Simple results chain example
In this way, the purpose of using the CA framework in this report was to consider apparent
‘critical success factors’ as addressing potential risk factors and encompassing mitigating
factors within the results chain stages.
Findings
Whilst the evidence was very diverse in terms of patient population, intervention and care
setting, nearly 40 factors were reported in at least two studies. The Scottish and UK studies
overall were of good quality and therefore findings are of sufficient robustness to be considered
useful in contributing to initial preparations for implementation of home health monitoring. Table
1 provides details of the factors reported, arranged by results chain stage. Appendix 1
summarises study details, and Appendix 2 provides original source data for reference.
Table 1: Factors reported in the literature, organised by results chain stage (asterisk indicates factor reported in Scottish research: see appendices)
factors to consider when planning for
resources
examples
reported in the literature
potential risk factors
*connectivity or reliability problems could deter users
broadband provision was unreliable (9)
measuring equipment was unreliable(14)
*patients may have problems using the technology
devices malfunctioned(7)
some patients had difficulty collecting their data (10)
some patients had difficulty using digital technology to send data(10)
*technology does not link up with existing patient record
where the monitoring system was independent of an existing administrative system, staff had to manually input received data(9)
potential mitigating factors
*the technology is used as part of a routine
elderly patients integrated measurements in to a daily routine(13)
monitoring may become part of a wider routine for example alongside taking medication(9)
the technology reminds patients to take measurements
mobile phones and tablets provided reminders to patients to take measurements(10, 12)
*the technology is easy to use
patients found the technology easy to use (or were able to learn to use easily)(7, 12)
the technology provides timely feedback or receipt after patient transmits data
patients received feedback when they transmitted data to let them know that the data had been received(13) and if the reading was ‘normal’(14)
the technology is able to be personalised to patients
technology was able to be personalised to suit patients preferences and clinical needs, for example frequency/timing of data collection and level of support given to the patient(17)
factors to consider when planning for
activities
examples
reported in the literature
potential risk factors
patients may not be confident to self-manage or adjust medication
some patients recognized a change in their data, but weren’t sure what action to take as a result(13)
*patients may feel anxious about an aspect of home health monitoring such as having more responsibility or using the
some patients felt initially anxious or unsure of their new responsibility or using the equipment (7, 10)
technology competently
*patients perceived professionals retain primary responsibility for their home health monitoring
patients relied on professional decision-making(13)
some patients perceived that they were collecting data to help the professionals to manage their condition(7)
potential mitigating factors
patient learning and support needs relevant to home health monitoring are identified and addressed on an ongoing basis
patients may require support and appropriate training to use the systems (17, 21)
*patients are adequately trained in self-management
it is useful to assess how patients understand the concept of self-management(12)
professionals felt that patient training may support self-management (7)
*professionals are competent in supporting self-management
patients may require professional support to self-manage,(7) and professionals may differ in their preferences of involvement(9)
a sufficiently skilled practitioner reviews data and provides feedback
nurses provided clinical review and timely feedback as required(13)
*a joint self-management plan is developed between patient and health care professional outlining their new responsibilities
a jointly agreed management plan should be documented for reference(8)
factors to consider when planning for
reach
examples
reported in the literature
potential risk factors
*the patient-clinician relationship or interaction changes
incorporating telehealth in to disease management, and self-management, alters interactions between the patient and clinician(9, 21)
home health monitoring is not suitable for all patients
it would not be clinically appropriate to use home health monitoring for all
patients (11) and for some it may be appropriate clinically but they would prefer not to participate(10)
*there may be concerns that patients will see themselves as sick or patients may become more dependent
professionals were concerned that focus on measurement would lead patients to consider themselves as ill(8)
*professionals have concerns about increased workload as a result
professionals voiced concerns about impact of telemonitoring on workload(7)
*professionals have concerns that patients will become more dependent on them
professionals were concerned that patients’ increased access to healthcare could lead to increased dependence and workload(9) could, 2013 #8}
*professionals may be concerned that patients will not self-manage
professionals found that some patients did not display self-management behaviours(8)
*changes required for patients to self-manage and patients and professionals to assume their new roles and responsibilities are complex
there was a recognition that staff would need to adapt interaction styles(9)
potential mitigating factors
*professionals felt leadership was important to developing services
professionals highlighted the role of service development leaders (7) and clinical champions(15)
*potential patients are carefully selected
patients’ physical and cognitive abilities can be assessed(10) as well as their views on self-management (17)
*patients feel reassured as they perceive that their health is being closely monitored
patients described a feeling of being ‘watched over’ and observed(9, 14)
factors to consider when planning for
outcomes
examples
reported in the literature
potential risk factors
patients may not implement advice as suggested
some patients did not act on the advice given to them by the telemonitoring nurse(13)
*patients may mistakenly believe their data is being monitored continuously
patients expected professionals to monitor their data more frequently than was actually the case(7)
lack of appreciation of the complexity of telemonitoring
decision makers and professionals need to consider the complexity of the intervention (16)
potential mitigating factors
patients take and interpret their own measurements
patients took measurements and were aware of deteriorations(14)
*patients gain increased knowledge of their condition
patients were able to learn about their normal range and how their symptoms varied(12)
patients are less anxious when they take their own blood pressure and so avoid inaccurate readings
many patients reported being less anxious to take readings at home(10)
*patients have a trusted relationship with the health professional who is providing advice
many patients wanted to be monitored by a professional who already knew them(7)
*patients make decisions about their care and when to contact professionals based on the data they collect
patients had access to data, which they may not have had before, to help them to understand their condition(8)
overarching factors
not easily attributed to results chain
examples
reported in the literature
potential risk factors
*self-management impacts on existing systems of care
community and district workloads were affected(9)
potential mitigating factors
*important to plan the project with stakeholders and undertake ongoing evaluation with staff and patients
there should be continuous feedback from patients and professionals about new working practices(7)
*telemonitoring is integrated in to an established clinical context
new systems should be complementary to current care pathways(12)
Conclusion
Home health monitoring is complex, and the evidence associated with implementation was
highly heterogeneous. However, a number of common critical success factors were suggested
in the literature, for example that implementation should be considered within the context of
current care processes and with relevant stakeholders, and technology resources should ideally
be intuitive, reliable and ‘fit in’ with patients and care processes. In addition, it was reported that
patients and professionals may require support and training and support to adjust to changes in
their roles, responsibilities and activities, and that ultimately, home health monitoring should be
evaluated by patients and professionals.
The majority of qualitative studies identified related to patient experience in Scotland and the UK
and their findings are therefore expected to be very relevant to the current context. The
synthesis of the available literature suggests that there are a number of critical success factors
which relate to the implementation of home health monitoring. The studies used mostly
appeared to be of good quality and therefore the findings are sufficiently robust to be useful to
consider as part of initial preparation for more detailed planning of large-scale implementation.
References
1. Boynton ACZRW. An Assessment of Critical Success Factors
Sloan Management Review (pre-1986) [Internet]. Summer 1984;25(4):[17-27 pp.]. Available from: http://as.nida.ac.th/~waraporn/resource/704-1-50/Readings/6-Assessment%20CSF-Boynton-Zmud.pdf. 2. Government S. A National Telehealth and Telecare Delivery Plan for Scotland to 2015. 2012. Available from: http://www.gov.scot/resource/0041/00411586.pdf. 3. Telecare SCfTa. Home and Mobile Health Monitoring 2015. Available from: http://www.sctt.scot.nhs.uk/programmes/community/home-based-health-monitoring/. 4. Government S. Long Term Conditions 2013 [cited 2015]. Available from: http://www.gov.scot/Topics/Health/Services/Long-Term-Conditions. 5. Press OU. Oxford Dictionaries. 2015.
6. Government S. The Healthcare Quality Strategy for NHSScotland 2010 [cited 2015]. Available from: http://www.gov.scot/Resource/Doc/311667/0098354.pdf. 7. Fairbrother P, Ure J, Hanley J, McCloughan L, Denvir M, Sheikh A, et al. Telemonitoring for chronic heart failure: the views of patients and healthcare professionals - a qualitative study. Journal of Clinical Nursing. 2014;23(1-2):132-44. 8. Fairbrother P, Pinnock H, Hanley J, McCloughan L, Sheikh A, Pagliari C, et al. Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: a qualitative study embedded in a randomized controlled trial. Patient Education & Counseling. 2013;93(3):403-10. 9. Roberts A, Garrett L, Godden DJ. Can telehealth deliver for rural Scotland? Lessons from the Argyll & Bute Telehealth Programme. Scottish Medical Journal. 2012;57(1):33-7. 10. Cottrell E, McMillan K, Chambers R. A cross-sectional survey and service evaluation of simple telehealth in primary care: What do patients think? BMJ Open. 2012;2(6). 11. Jones M. Patients' experiences of self-monitoring blood pressure and self titration of medication: the TASMINH2 trial qualitative study. 2012. 12. Williams V, Price J, Hardinge M, Tarassenko L, Farmer A. Using a mobile health application to support self-management in COPD: a qualitative study. British Journal of General Practice. 2014;64(624):e392-400. 13. Riley JP, Gabe JPN, Cowie MR. Does telemonitoring in heart failure empower patients for self-care? A qualitative study. Journal of Clinical Nursing. 2013;22(17/18):2444-55. 14. Lynga P, Fridlund B, Langius-Eklof A, Bohm K. Perceptions of transmission of body weight and telemonitoring in patients with heart failure? International Journal of Qualitative Studies on Health and Well-being. 2013;8:21524. 15. Seto E, Leonard KJ, Cafazzo JA, Barnsley J, Masino C, Ross HJ. Developing healthcare rule-based expert systems: Case study of a heart failure telemonitoring system. Int J Med Inform. 2012;81(8):556-65. 16. Kitsiou S, Pare G, Jaana M. Effects of Home Telemonitoring Interventions on Patients With Chronic Heart Failure: An Overview of Systematic Reviews. J Med Internet Res. 2015;17(3):e63. 17. Cruz J, Brooks D, Marques A. Home telemonitoring in COPD: a systematic review of methodologies and patients' adherence. Int J Med Inform. 2014;83(4):249-63. 18. Mayne, J. Addressing attribution through contribution analysis: using performance measures sensibly. Canadian Journal of Programme Evaluation. 2001;16:1-24. 19. Connolly JM, S. Guidance for Healthcare Improvement Scotland. 2014. 20. Laurie M. Anderson MP, Eva Rehfuess, Rebecca Armstrong, Erin Ueffing, Phillip Baker, Daniel Francis and Peter Tugwel. Using logic models to capture complexity in systematic reviews. Research Synthesis Methods. 2011;2(1):33-42. 21. Jones MI, Greenfield SM, Bray EP, Baral-Grant S, Hobbs FD, Holder R, et al. Patients' experiences of self-monitoring blood pressure and self-titration of medication: the TASMINH2 trial qualitative study. Br J Gen Pract. 2012;62(595):e135-42.
Year Author(s) Location Condition Aim of study Types of participants Scale Technology Methodology Data (often measured
‘symptoms’ as well
measured but for rapid
review these are not
tabulated)
Frequency of
patient data
transmission
Clinical reviewer of
data (frequency of
review)
Data feedback
2013 Fairbrother et
al.
Scotland
(Lothian)
COPD To explore patient and
professional views on
telemonitoring for
COPD
Patients: 47% male,
mean age 67.5 years
70 participants (38
patients, 32 healthcare
professionals) relating
to a trial of 256 people
Tablet Semi-structured
interviews with patients
(n=38) and healthcare
professionals (n=32)
Peak flow and oxygen
saturation
Daily Clinical team (daily) Team contacted
patients if expected
data did not arrive or
data received was not
within expected range.
2012 Roberts et al. Scotland
(Argyll and
Bute)
COPD To describe the
implementation and
outcomes of a
telehealth initiative
(2009)
Patients: age range 61-
102 years
10 participants relating
to a trial within NHS
Highland at home and
in the community (17
people at home, total
number of people
unknown)
Home 'pod' with touch
screen.
Questionnaire to
patients, staff and
carers (n=?) Semi
structured interviews
with healthcare
professionals (n=10)
Oxygen saturation Daily Community nursing
team (daily)
Not stated
2013 Fairbrother et
al.
Scotland
(Lothian)
Heart Failure To understand the views
of patients and
professionals on
telemonitoring for
chronic heart failure
Patients: 61% male, age
range 50-80, mean age
75 years
23 (18 patients, 5
healthcare
professionals)
participants relating to
a trial within NHS
Lothian (number of
people unknown)
Device l inked via
bluetooth to pulse
oximeter, electronic
sphygmomanometer
and electronic weighing
scales.
Semi-structured
interviews with patients
(n=18) and healthcare
professionals (n=5)
Pulse rate, oxygen
saturation, blood
pressure, weight
Daily Initially a single GP.
Later, specialist nurses
( daily on weekdays)
and Lothian
Unscheduled Care
Service (daily at
weekends)
An algorithm was used
to process data. Values
which breached pre-set
levels flagged up. The
clincian then contacted
the patient.
2013 Riley et al England
(West London)
Heart Failure To explore whether
telemonitoring
empowers patients to
self-care
Patients: mostly male,
age range (mean) 44-86
years (74), mostly with
a new diagnosis of
heart failure, mostly
symptomatic on
moderate activity,
mostly white British,
mostly retired, mostly
l ived alone
15 participants relating
to a trial of 182
patients
Standalone
telemonitoring system
to take daily
measurements using a
weighing scale,
automated blood
pressure cuff and a
pulse oximeter.
In depth interviews with
patients (n=15)
Pulse rate, oxygen
saturation, blood
pressure, weight
Daily Specialist Nurse (daily) Any variation outwith a
predefined range
triggered an alert. The
clincian then contacted
the patient.
2012 Cottrell et al. England
(Stoke on
Trent)
Hypertension To determine the patient
experience of using the
telehealth service
Patients: chronic
kidney disease (CKD)
Stages 3 or 4 with BP
persistently >130/85
mm Hg or patient is >50
years old and
hypertensive
Participants relating to
a trial of 124 people
Patients took home
home electronic blood
pressure (BP)
measurements using a
electronic
sphygmomanometer
and sent results via the
patient's mobile phone
to a secure server.
Questionnaire
completed via
telephone interview
(n=124)
Blood pressure Daily GP or Nurse (at least
weekly)
The system sent
automatic responses
and instructions for
action to patients as
appropriate to each
reading. Messages can
be sent back to the
patient by the
healthcare team.
2014 Williams et
al.
England
(Oxford)
COPD To explore patients'
expectations and
experiences and the
impact of using a
mobile health
applocation
Patients: 57% male, age
range (mean) 50-85
(67), 84% stage 2 and 3
COPD, 57% living with
spouse or family)
19 patients relating to a
pilot study of 23 people
(pilot study relates to a
future trial* which aims
to recruit 186 people)
Computer and bluetooth-
enabled pulse oximeter
with finger probe.
Semi-structured
interviews with patients
(n=19)
Pulse rate and oxygen
saturation*
Daily* Clinican (at no less
than 4 day intervals)*
Oxygen saturation or
symptom scores of
concern (within a
individualised range)
for more than 4 days
are followed up.
2012 Jones et al. England
(West
Midlands)
Hypertension To explore patients'
views of self-monitoring
blood pressure and self-
titration of
antihypertensive
medication
Patients: 57% male, age
range (mean) 49-
84years (70), mean
blood pressure at
baseline 159/84, 91%
married or cohabiting,
57% professsional
occupation
23 participants relating
to a trial of 527
patients
Participant given a
blood pressure monitor
and a modem to send
readings.
Semi-structured
interviews with patients
(n=18) and healthcare
professionals (n=5)
Blood Pressure Daily for the
first week of
each month.
Participant
took two
measurements
and the second
was
considered.
Participant (asked to
code each reading). A
monthly summary of
readings was also sent
to the GP (further action
by GP not stated).
A traffic l ight system
was used by
participants to code
each reading- if patient
had 2 consecutive
months of reading
above target they were
asked to make
medication changes by
requesting a new
precription (the
potential changes had
been agreed by the
doctor when starting
the trial).
Appendix 1: Summary table of included studies
Year Author(s) Location Condition Aim of study Types of participants Scale Technology Methodology Data (often measured
‘symptoms’ as well
measured but for rapid
review these are not
tabulated)
Frequency of
patient data
transmission
Clinical reviewer of
data (frequency of
review)
Data feedback
2012 Seto et al. Not specified
but
presumably
Canada
Heart Failure To develop a rule-based
expert system for a
heart failure mobile
phone based
telemonitoring system
Clinicians 10 participants relating
to a trial of 100
patients
Wireless medical
device sent data via
Bluetooth to patient
mobile phone.
Research team carried
out semi-structured
interviews with
clinicians (n=10) to
inform the development
of a draft heart failure
rule set for patient
alerts and
instructions.The draft
rule set was validated
by heart failure
clincians and then
trialled and evaluated
with 100 patients in a
randomised controlled
trial.
Heart rate, blood
pressure, weight and
single lead
electrocardiogram
(ECG)
Daily and if
patient noticed
a change in
their
symptoms.
Each time an alert
message or instruction
was sent to the patient ,
the on-call clinician
received an email alert
which were stratified by
priority.
If appropriate to the
data an alert might be
sent to the patient's
mobile phone. An email
was simultaneously
sent to the mobile
phone of the on-call
clincian
2013 Lynga et al. Sweden Heart Failure To explore and describe
patients' perceptions of
transmission of body
weight
Patients: 65% male, age
range (mean) 61-86
years (74), 65% co-
habiting
29 participants relating
to a trial of 179
patients
Participants given a
weighing scale, weight
measurments were sent
from the scale via
wireless to the patient's
phone.
Semi-structured
interviews with patients
(n=23) amd family
members (n=6)
Weight Daily Heart Failure Nurses
(usually Mon, Wed, Fri).
Data always checked
within 4 days.
The system sent an
alarm if patients
showed a weight gain of
>2kg from target or an
upward trend of weight
increase of >2kg in 3
days.
2014 Cruz et al. 3 papers
relating to UK
trials (17 in
total )
COPD To comprehensively
describe the
methodologies used in
home telemonitoring for
COPD and explore
patients' adherence and
satisfaction
Age range described as
mostly older people. 10
studies related to
advanced COPD
severity.
Number of participants
in included papers
ranged from 20-165
Variable, defined as
patients/carers had to
periodically record
clinical data and
transmit these data
from home to a
monitoring centre.
Summary of findings
tables created and
quality of review
methodologies
assessed
Mostly oxygen
saturation, spirometric
parameters,
medication, heart rate,
temperature, weight
Mostly daily Mostly healthcare
professional on a daily
basis
In half of studies,
transmitted data was
automatically analysed
and alerts were sent to
healthcare
professionals or
research team when the
data value was outwith
a pre-defined
acceptable range.
2015 Kitsiou et al. 15 review
papers
reviewed from
various
countries
Heart Failure To synthesise existing
evidence on the
effectiveness of home
telemonitoring
interventions for
patients with chronic
Range of mean age in
studies from mean= 45
to mean= 85. Range of
New York Heart
Association (NYHA )
class in studies from I
Number of total
participants in included
reviews ranged from
774-6561
A taxonomy was
devised to classify
interventions and
technologies.
Summary of findings
tables created and
quality of review
methodologies
assessed
Aterial blood pressure,
weight, cardiac rate
Variable Variable Variable
Appendix 2: Reference table of source data
Factor Evidence Condition Context Complex intervention
p.140:[The self-management intervention] is complex in nature(11) HYPERTENSION ENGLAND
p.32:'Health care decision makers and practitioners who are faced with implementing home telemonitoring programs in community settings need to consider the complexity of these programs…'(16)
HEART FAILURE
INTERNATIONAL
Technology reminds patients to take measurements
p.5:'[A patient] monitored his blood pressure twice per week and found the texts useful as they reminded him to take his blood pressure'(10)
HYPERTENSION ENGLAND
p.396:'Patients also perceived the tablet computer [supported] their self-management behaviour. It reminded patients of the need to engage in self management'(12)
COPD ENGLAND
Connectivity or reliability problems could deter users
p.36:'Broadband provision in Scotland's rural areas remains poor (citing Mason 2009) ...in this project, broadband linkage was initially unreliable, a major potential disincentive to new users of the system'(9)
COPD SCOTLAND
p.4:'There were also indications that when the system did not work as expected, the patients' enthusiasm decreased and they got weary of using the electronic scale'(14)
HEART FAILURE
EUROPE
Patients may have problems using the technology
p.6:'Patients and professionals reported experiencing technical problems with the equipment, notably recurrent malfunctions with the peripheral devices'(7)
HEART FAILURE
SCOTLAND
p.6:'Four[patients]reported problems sending or receiving text messages…and one had a problem taking their own blood pressure due [to] the resultant effects of having a previous stroke'(10)
HYPERTENSION ENGLAND
p.260:'Most patients did not provide systems with options to personalise them, making the use of those systems difficult'(17)
COPD INTERNATIONAL
Technology does not link up with existing patient record system
p.7: 'Professionals described problems arising from the perceived lack of interoperability between the 'stand-alone' telemonitoring patient information system and existing information systems in both primary and secondary care'(7)
HEART FAILURE
SCOTLAND
'p.36:Delays in linking [to the electronic patient record system] meant that data had to be transferred manually between systems [at first]'(9)
COPD SCOTLAND
The patient-clinician relationship or interaction changes
p.36:'Managing chronic disease while incorporating telehealth alters the interaction between patients and healthcare workers' (9)
COPD SCOTLAND
p.141:'Self management impacts on patients, their interactions with clinicians'(11) HYPERTENSION ENGLAND
Self-management impacts on existing systems of care
p.35:'The home COPD pods affected community and district workload in particular'(9) COPD SCOTLAND
p.141:'Self management impacts on…the current professional led system of hypertension care'(11) HYPERTENSION ENGLAND
Professionals p.407: Many [staff] expressed concern about creating dependence on the technology and/or COPD SCOTLAND
have concerns that patients will become more dependent on them
practitioner support, particularly among patients with severe COPD'(8)
p.5: Many professionals considered that patients' [increased accessibility... [to telemonitoring data and healthcare professionals] increased the depth and frequency of communication between patients and professionals.(7)
HEART FAILURE
SCOTLAND
p.36:'Staff reported concerns that telemonitoring could impact on their conventional workload, since patients were empowered to make more frequent contacts with their healthcare providers'(9)
COPD SCOTLAND
p.560:'[Professionals] were concerned the alerts would be false positives and would result in patients going to the emergency department unnecessarily'(15)
HEART FAILURE
INTERNATIONAL
Professionals have concerns about increased workload as a result
p.7:'The impact of telemonitoring on home visits and existing practice was of particular concern to professionals'(7)
HEART FAILURE
SCOTLAND
p.35:'Most [staff] respondents had concerns about impact on their current and future workload'(8) COPD SCOTLAND
p.560:'One of the most common concerns was clinicians would not have the time to follow up with all the alerts being generated'(15)
HEART FAILURE
INTERNATIONAL
Technology is easy to use
p.407:Many patients found the technology easy to use'(8) COPD SCOTLAND
p.5:'All of the respondents found the technology easy to use'(7) HEART FAILURE
SCOTLAND
p.35:'The technology was described as straightforward and easy to use'(9) COPD SCOTLAND
p.3:'Patients found Florence easy to use'(10) HYPERTENSION ENGLAND
p.394:'Patients [transitioned] from being uncertain about their ability to use the technology to being confident to use it'(12)
COPD ENGLAND
p.3:'[For some patients] the transmission of body weight and the daily weighing was easy to do…' (14)
HEART FAILURE
EUROPE
p.257:'Overall, patients found the technology easy to learn and/or use"(17) COPD INTERNATIONAL
Technology provides timely feedback /receipt after patient transmits data
p.2449:'Effective telemonitoring also required the equipment to function accurately and patients learnt quickly if their telemonitoring data were successfully transmitted'(13)
HEART FAILURE
ENGLAND
p.3:'Patients were satisfied with the feedback they obtained from Florence'(10) HYPERTENSION ENGLAND
p.561:'Each time [a patient reading was completed] an alert message/instruction was sent to the patient [and clinician]'(15)
HEART FAILURE
INTERNATIONAL
p.6:'(citing Seto et al. 2012) Patients received a feedback message if everything was within normal parameters, information which patients identified as important'(14)
HEART FAILURE
EUROPE
The technology is able to be personalised to patients (see text for characteristics)
p.4:'A key benefit highlighted by patients and fed back was [flexibility]...blood pressure readings could be taken and submitted at any time of the day or night'(10)
HYPERTENSION ENGLAND
p.563:'Patients have varying self-care capabilities, medical histories and preferences…for instance, sending automatic reminders to take an extra dose of medication under certain circumstances was appropriate for some patients and not for others…'(15)
HEART FAILURE
INTERNATIONAL
p.261:'The frequency of data collection and transmission should be flexible to improve adherence to telemonitoring interventions'(17)
COPD INTERNATIONAL
Telemonitoring is integrated in to an established clinical context
p.8: '[Professionals] considered integration of telemetric provision with local practitioner services preferable to 'call-centre' type provision'(7)
HEART FAILURE
SCOTLAND
p.35:' A number of 'normalisation' issues concerning training, communication and integration with existing professional work patterns were identified’(9)
COPD SCOTLAND
p.138:'Several patients pointed out that they were not actually changing their own medication, as they were following medication plans predetermined by their doctor'(11)
HYPERTENSION ENGLAND
p.398: 'It appears crucial that any telehealth application complements rather than replaces current care'(12)
COPD ENGLAND
p.560:'[A matrix of all possible outcomes was developed and] accounted for all scenarios by specifying the alerts and instructions for all possible combinations'(15)
HEART FAILURE
INTERNATIONAL
p.32:'The key to the success of these programs is not the technology itself, but the coordination of care that needs to be in place along the continuum of health services delivered for heart failure patients'(16)
HEART FAILURE
INTERNATIONAL
Patients may believe their data is monitored continuously
p.8:'The misalignment generated by the patients' expectations of the extent and frequency of telemonitoring and the reality of actual monitoring activity undertaken by professionals providing the service caused some practitioners concern'(7)
HEART FAILURE
SCOTLAND
p.2449:'[Patient transcript: There was one day when my pulse was 122. I waited all day to see if anybody would get in touch with me and nobody did'](13)
HEART FAILURE
ENGLAND
Patients may not be confident to self-titrate
p.140:'[Some patients required] continued medical input in making prearranged medication changes.' (11)
HYPERTENSION ENGLAND
p.2450:'At the first interview, all patients recognised change in their monitoring data, but did not necessarily know how to interpret or act on such a change.'(13)
HYPERTENSION ENGLAND
Patients may feel anxious about an aspect of home health monitoring such as having more responsibility or technical competence
p.6:'Some [patients were] expressing anxiety and trepidation at the prospect of being required to exercise greater personal responsibility although, [an example suggests] that confidence may grown with longer term support'(7)
HEART FAILURE
SCOTLAND
p.5:'One [patient] reported having a problem taking their own blood pressure but this was due to them being 'too anxious'’(10)
HYPERTENSION ENGLAND
p.3:The procedure was described as stressful because of concerns that they would forget to weigh themselves each morning; however this was a temporary condition that transformed and turned in to a routine'(14)
HEART FAILURE
EUROPE
Changes required for patients to self-manage and patients and professionals to assume their new
p.408:'Professionals acknowledged the challenges in adapting established attitudes, behaviours and practices to address the challenges of telemonitoring-supported self-management'(8)
COPD SCOTLAND
p.36:'[Telehealth] changes responsibilities for staff...Training in the technology and the revised mode of interaction is essential, especially for those staff more peripherally involved in telehealth'(9)
COPD SCOTLAND
roles and responsibilities are complex
A joint management document is developed between patient and health care professional outlining their new roles
p.408:'[Professionals] placed emphasis on their role in supporting 'patient preparedness' to self- manage through the provision of self-management plans, through coaching and advice and through the dispensing of information materials'(8)
COPD SCOTLAND
p.2451:'(citing Rogers et al., 2000) Effective self-care support requires a collaborative approach between the patient and healthcare professional that meets patients' need for information and promotes their active role '(13)
HEART FAILURE
ENGLAND
p.7:'Patient concordance with jointly agreed management strategies between the patient and their responsible health professional is essential in maximising the health benefits obtained'(10)
HYPERTENSION ENGLAND
Patients have a trust and relationship with the health professional who is providing advice
p.7:'Many patients expressed a preference for being telemonitored by professionals with whom they had an existing association'(7)
HEART FAILURE
SCOTLAND
p.2451:'Our findings confirm the importance of the relationship between the patient and telemonitoring nurse'(13)
HEART FAILURE
ENGLAND
p.560:'[A clinician said]'the only fear I have is that you've got people making decisions who may not know the patient and that is going to reflect on outcomes in patients'(15)
HEART FAILURE
INTERNATIONAL
Patient learning and support needs relevant to home health monitoring are identified and addressed
p.141:'Some patients required significant input from their GPs, despite having been trained and equipped for self-management. Understanding the additional support that such participants need will be important in the wider implementation of self-management'(11)
HYPERTENSION ENGLAND
p.260:'The inclusion of more training sessions may facilitate patient's education on the use of the systems'.(17)
COPD INTERNATIONAL
p.32: 'The effects of home telemonitoring will most likely be better when the technology is used as part of a comprehensive and integrated care package…for example involving patient education..'(16)
HEART FAILURE
INTERNATIONAL
Patients are trained in self-management
p.6:'The importance of formalised education and training in supporting patient self-management was discussed by professionals'(7)
HEART FAILURE
SCOTLAND
p.398:'The perceived benefits…could be further improved by assessing patients' knowledge about clinical parameters, health behaviours and self-management approach when implementing such interventions'(12)
COPD ENGLAND
Professionals are competent in supporting self-management
p.6:'Practitioners queried the utility of the telemonitoring technology in supporting self-management…some [staff questioned] whether patients would identify responsibility for self-management without [staff] support'(7)
HEART FAILURE
SCOTLAND
p.35:'Some [staff] did not want to take on the extra responsibility of checking patient readings. Staff reported that training could be improved to enhance confidence'(9)
COPD SCOTLAND
p.141:'Maximising [effectiveness] requires careful integration of this novel method in to daily practice with particular attention to providing a supportive environment for self-management without losing
HYPERTENSION ENGLAND
sight of patient's preferences'(11)
p.2452:'The competency of the professional in developing a supportive patient-professional relationship is likely to be more important than where they are based'(13)
HEART FAILURE
ENGLAND
p.5:'It has been suggested that the co-operation between patients and specially trained nurses, within the concept of telemonitoring is helpful in this process [of self care]'(14)
HEART FAILURE
EUROPE
A sufficiently skilled practitioner reviews data and provides feedback
p.2452:'Our findings suggest the importance of a knowledgeable and skilled nurse to review the telemonitoring data and provide timely feedback when necessary'(13)
HEART FAILURE
ENGLAND
p.561:'The intent was to have nurse practitioners as the on-call clinicians for any future implementation of the telemonitoring system because they would personally know the patients and they already closely follow high-risk patients'(15)
HEART FAILURE
INTERNATIONAL
p.4:'Being under the control of healthcare professionals in a chronic situation influenced the patient's situation in a positive manner… [some] patients wanted more contact with the heart failure clinic, wishing to be told that everything is fine...'(14)
HEART FAILURE
EUROPE
Home health monitoring is not suitable for all patients
p.140:(citing main trial) 'Self-management will not be appropriate for all patients'(11) HYPERTENSION ENGLAND
p.6:'This management approach just does not seem to suit some patients' preferences, who would rather see a doctor and/or are concerned about using home blood pressure machines or mobile phones.'(10)
HYPERTENSION ENGLAND
Potential patients are carefully selected (see text for characteristics)
p.7:'Professionals emphasised the importance of selecting suitable patients for telemonitoring. They considered that telemonitoring would be best used to support those with advanced heart failure and/or those non-compliant with medication'(7)
HEART FAILURE
SCOTLAND
p.2451:'In this study, we found age and gender made no difference to the extent to which telemonitoring supported patients self-care actions'(13)
HEART FAILURE
ENGLAND
p.8:'Our results indicate that careful selection and counselling of patients is required at recruitment ... and that they are physically and cognitively able to operate the simple equipment'(10)
HYPERTENSION ENGLAND
p.398:'Some participants found the use of [telemonitoring] less beneficial…and these participants appeared to be less engaged in self-management behaviour'(12)
COPD ENGLAND
p.260:'Assessment of patient's needs, characteristics and acceptance of the telemonitoring technology should be considered prior to its implementation, as it may help adjusting the intervention to the target population'(17)
COPD INTERNATIONAL
Professionals may be concerned that patients will not self-manage
p.407: 'Some [staff] questioned whether the presence of telemonitoring technology in the home would be sufficient on its own to facilitate (re)consideration of self-management attitudes and behaviours among patients'(8)
COPD SCOTLAND
p.6:Practitioner attempts to encourage involvement in self-management (for example, in attempts to encourage patient participation in self-directed medication) received a mixed response'(7)
HEART FAILURE
SCOTLAND
There may be concerns that patients will see
p.6:'Whilst [increased communication with patients] was often considered a good thing [supporting early intervention and health], professionals also expressed concern regarding perceived greater dependence on practitioner support'(7)
HEART FAILURE
SCOTLAND
themselves as sick or dependent
p.5:'A perception of fear caused concerns among patients that the transmission of body weight might remind the patients of illness and further deterioration in their health'(14)
HEART FAILURE
EUROPE
p.407: 'Professionals worried that patients 'fixated' on oxygen saturation levels as a health indicator above all else and that this reinforced a 'sick model'.’(8)
COPD SCOTLAND
(Contradictory findings)
p.141:'There was no evidence that patients became preoccupied with monitoring their blood pressure when they self-monitored, despite this being suggested as a potential disadvantage of home monitoring, particularly health professionals'(11)
HYPERTENSION ENGLAND
Patients perceived professionals retain primary responsibility for their home health monitoring
p.407:'Often [staff] observed that patients actively deferred responsibility for the medical management of their condition to healthcare professionals during periods of ill health' (8)
COPD SCOTLAND
p.6:'Whilst [patients] perceived that telemonitoring supported existing efforts to monitor weight and blood pressure, they considered that healthcare professionals held primary responsibility for the management of their condition'(7)
HEART FAILURE
SCOTLAND
p.2450:The majority [of patients] relied on the decision making of a telemonitoring nurse'(13) HEART FAILURE
ENGLAND
p.396:'They [some patients] appeared to rely more on healthcare professionals to make decisions about treating exacerbations'(12)
COPD ENGLAND
p.4:'[Patients wished] to be told that everything was fine and there was no deterioration…[A patient said] "when everything was fine you did not get any feedback that: now you're really doing well…I thought that was wrong"'(14)
HEART FAILURE
EUROPE
Patients gain increased knowledge of their condition
p.407:'Many [patients] found it helpful to know their oxygen saturation and to learn their 'normal' range'(8)
COPD SCOTLAND
p.5:'Patients also expressed the view that they felt better informed and knowledgeable about their condition'(7)
HEART FAILURE
SCOTLAND
p.35:'Most [staff] felt that it was appropriate for rural patients to be monitored at home and that telemonitoring promoted self-management.'(9)
COPD SCOTLAND
p.140:'This interview study found that the intervention was acceptable [and] improved patients' own knowledge of their own blood pressure'(11)
HYPERTENSION ENGLAND
p.2450:[Patients] knew when their data were suggestive of a clinically significant change and sought professional help'(13)
HEART FAILURE
ENGLAND
p.395:'Patients also indicated an increased awareness of the variability of their symptoms'(12) COPD ENGLAND
p.5:'The main finding was that the patients perceived that their self-care was supported and encouraged…through the telemonitoring system…this helped them keep abreast of their condition'(14)
HEART FAILURE
EUROPE
p.260:'By helping patients to be aware of their symptoms and act in case of exacerbations, home tele-monitoring may have facilitated patient's self-management'(17)
COPD INTERNATIONAL
Patients feel reassured as they
p.407:''Most patients appreciated the accessibility of the telemonitoring service and the reassurance of feeling constantly 'watched over' by telemonitoring professionals'(8)
COPD SCOTLAND
perceive that their health is being closely monitored
p.6:'Many [patients] thought the service was designed to increase practitioner support, rather than to foster greater personal responsibility'(7)
HEART FAILURE
SCOTLAND
p.6:'Patients liked feeling increased levels of support and Florence had a role as a companion, in promoting patients to educate themselves further…'(10)
HYPERTENSION ENGLAND
p.395:'[Sharing of self-monitoring data with the research nurse] underpinned [a sense of continuity of care] even though this was infrequent and did not replace current care'(9)
COPD SCOTLAND
p.4:'Descriptions of being looked after and [a] sense of security... emerged [from the interviews]' (14) HEART FAILURE
EUROPE
Patients may not implement advice as suggested
p.139:'[A patient] felt a fourth change might not be necessary and did not agree with his GP's recommendation to increase his medication'(11)
HYPERTENSION ENGLAND
p.2450:'[Some patients] did not necessarily act on the advice they received from the telemonitoring nurse'(13)
HEART FAILURE
ENGLAND
p.5:'One patient highlighted that despite improved understanding, patients remain free to exert their autonomy'(10)
HYPERTENSION ENGLAND
Technology is used as part of a routine
p.2451:'We also found that this elderly population used the telemonitoring daily and integrated it in to their everyday lives'(13)
HEART FAILURE
ENGLAND
p.5:'[A patient]reported that 'getting texts from Flo has given him a break in his daily routine, as it feels that he has someone to talk to'(10)
HYPERTENSION ENGLAND
p.396:'[The tablet] also reinforced routines that included adherence to regular medication'(9) COPD SCOTLAND
p.3:'[Telemonitoring] became a routine often done without reflection…'(14) HEART FAILURE
EUROPE
Patients take and interpret their own measurements
p.140:'Some patients [relished] the opportunity to manipulate their own treatment'(11) HYPERTENSION ENGLAND
p.2449:'Patients described a range of heart failure self-monitoring actions. They used equipment to monitor their weight, blood pressure, pulse rate and oxygen saturation'.(13)
HEART FAILURE
ENGLAND
p.5:'There were patients who closely followed their weights, being aware when something was beginning to go wrong'(14)
HEART FAILURE
EUROPE
Patients are less anxious when they take their own blood pressure and so avoid inaccurate readings
p.137:'Patients felt that home blood pressure readings were more 'natural' than surgery readings, as they were more relaxed at home and readings were taken more carefully and under controlled conditions'(11)
HYPERTENSION ENGLAND
p.4:'The theme of being more relaxed or less anxious when taking home blood pressure and submitting them to Florence was repeated by a number of patients'(10)
HYPERTENSION ENGLAND
Professionals felt leadership was important to developing
p.9:'Professionals stressed the importance of effective leadership and project management in the development of future telemetric service provision'(7)
HEART FAILURE
SCOTLAND
p.561:'When conflicting information was obtained (usually related to health provider preferences)... the clinical champion of the project was asked to make an executive clinical decision'(15)
HEART FAILURE
INTERNATIONAL
services
Important to plan the project with stakeholders and undertake ongoing evaluation with staff and patients
p.9:'It is important that the development of future telemetric provision retains the active involvement and engagement of stakeholders groups. New ways of working [should enable] continuous feedback and evaluation from patients and professionals'(7)
HEART FAILURE
SCOTLAND
p.141:'Patients in this study appeared to understand [a multistep variable monitoring intensity model]…but perhaps a more flexible model is needed for the longer term, with periodic monitoring only reverting to self-titration where control is lost'(11)
HYPERTENSION ENGLAND
p.564:'Lessons learned…include the need …to validate each draft rule set with the end users, to ensure all corner cases are included…and to account for the workflow and policies…'(15)
HEART FAILURE
INTERNATIONAL
Patients make decisions about their care and when to contact professionals based on the data they collect
p.407: 'Often for the first time [patients] had access to clinical data about their condition which they considered beneficial in determining their state of health and recognising illness'(8)
COPD SCOTLAND
p.2449:'The majority [of patients] quoted these numerical data and appeared to develop knowledge of their 'normal' vital signs from viewing such telemonitoring data'(13)
HEART FAILURE
ENGLAND