Implementing telemonitoring in heart failure care: barriers from the perspectives of patients, healthcare professionals and healthcare organizations.

The increasing prevalence of chronic diseases, such as heart failure, presents a substantial challenge to healthcare systems. Telemonitoring is believed to be a useful instrument in the delivery of heart failure care. However, a widespread use of telemonitoring is currently failing for various reasons. This article provides an overview of the barriers for the implementation of telemonitoring in heart failure patients from the perspectives of its users: patients, healthcare professionals and healthcare organisations. In doing so, identified barriers are grouped according to the perceived attributes of innovation by Rogers. Recommendations are provided as to how research can improve the implementation of telemonitoring in heart failure.

Specific health status has an impact on the willingness to use telemonitoring: data from a 2009 health survey in north rhine-westphalia, Germany.

OBJECTIVE: Demographic changes in Germany are expected to cause a rising need for medical care and therapy while capacities are declining. Telemedicine offers the option of minimizing some aspects of these problems, but so far, many telemedicine projects in Germany (including telemonitoring projects) are not applied to the clinical routine. This study was done to assess the influence of health factors on potential willingness to use telemonitoring devices at home. MATERIALS AND METHODS: Health status and other health-relevant factors were determined using individual and medical factors (e.g., reported diseases). Principal-component analysis was used to identify groups with a specific response behavior. This study was based on a representative telephone survey conducted in the German state of North Rhine-Westphalia in 2009. RESULTS: Willingness to use telemonitoring was high in North Rhine-Westphalia but decreased with age. Men showed a significantly greater willingness to use telemonitoring than did women. Also, there was an effect associated with the subjects' health status (e.g., cardiovascular diseases caused a decrease of 9.7% in the level of acceptance, whereas musculoskeletal disorders caused a decrease of 5.1%). CONCLUSIONS: The target groups for telemonitoring consisted mainly of elderly persons and those with certain diseases. This study showed that being diseased lowered the willingness to use telemonitoring. People need to understand better how telemonitoring can help to improve controlling their health status and coping with the disease. It is necessary to reflect on these specific needs if telemonitoring is to become routine in the German healthcare system.

Patients' experiences of remote communication after pacemaker implant: The NORDLAND study.

BACKGROUND: The concept of 'patient experience' has become central to how to improve healthcare. Remote communication with patients is today a frequent practice in healthcare services, showing similar outcomes to standard outpatient care while enabling cost reduction in both formal and informal care. The purpose of this study was to analyse the experiences of people with telemonitoring pacemakers. METHODS: Patients were randomly allocated to either the telemonitoring or hospital monitoring follow-ups. Using the 'Generic Short Patient Experiences Questionnaire' (GS-PEQ), as well as an ad-hoc survey from the 'telehealth patient satisfaction survey' and 'costs survey', patients' experiences were measured six months after the pacemaker implant in a cohort of 50 consecutive patients. The mean age was 74.8 (± 11.75) years and 26 (52%) patients were male of which 1 was lost in follow-up. Finally, 24 patients were followed up with standard hospital monitoring, while 25 used the telemonitoring system. Differences in baseline characteristics between groups were not found. RESULTS: Findings showed overall positive and similar experiences in patients living with telemonitoring and hospital monitoring pacemakers. Significant differences were found in GS-PEQ concerning how telemonitoring patients received less information about their diagnosis/afflictions (p = 0.046). We did not find significant differences in other items such as 'confidence in the clinicians' professional skills', 'treatment perception adapted to their situation', 'involvement in decisions regarding the treatment', 'perception of hospital organisation', 'waiting before admission', 'satisfaction of help and treatment received', 'benefit received', and 'incorrect treatment'. CONCLUSIONS: The remote communication of pacemakers was met with positive levels of patients' experiences similarly to patients in the hospital monitoring follow-up. However, telemonitoring patients received less information. Thus, improving the quality and timing of information is required in telemonitoring patients in the planning and organisation of future remote communication healthcare services for people living with a pacemaker implant.

A Multidisciplinary Evaluation of a Virtually Supervised Home-Based High-Intensity Interval Training Intervention in People With Type 1 Diabetes.

OBJECTIVE: Adopt a multidisciplinary approach to evaluate a virtually supervised home-based high-intensity interval training (Home-HIT) intervention in people with type 1 diabetes. RESEARCH DESIGN AND METHODS: Eleven individuals with type 1 diabetes (seven women; age 30 ± 3 years; [Formula: see text] 2.5 ± 0.2 L/min; duration of diabetes 10 ± 2 years) completed 6 weeks of Home-HIT. A heart rate monitor and mobile phone application were used to provide feedback to the participants and research team on exercise intensity (compliance) and adherence. RESULTS: Training adherence was 95 ± 2%, and compliance was 99 ± 1%. Home-HIT increased [Formula: see text] by 7% (P = 0.017) and decreased insulin dose by 13% (P = 0.012). Blood glucose concentration did not change from baseline to immediately or 1 h post Home-HIT. Qualitative perceptions of Home-HIT and the virtual-monitoring system were positive, supporting that the intervention successfully removed exercise barriers in people with type 1 diabetes. CONCLUSIONS: Virtually monitored Home-HIT resulted in high adherence alongside increased [Formula: see text] and decreased insulin dose.

The two facets of electronic care surveillance: an exploration of the views of older people who live with monitoring devices.

Scholars are increasingly questioning the notion that electronic surveillance merely constrains individuals' liberty and privacy. However, illustrations of alternative perspectives are few and there is a need for empirical research exploring the actual experience of surveilled subjects. This study, carried out in Sweden, seeks to offer a nuanced account of how senior citizens experience electronic care surveillance in relation to their privacy. It is based on in-depth interviews with 17 seniors who have participated in a telemonitoring project and who have experience of being continuously activity monitored in their own homes. The findings suggest that senior citizens can perceive electronic care surveillance as freeing and as protecting their privacy, as it enables them to continue living in their own home rather than moving to a nursing home. One individual, however, experienced a privacy violation and the surveillance service was interrupted at her request. This illustrates the importance of built-in possibilities for subjects to exit such services. In general, the study highlights that e-surveillance can be not only constraining but also enabling. Hence, it supports the view of the dual nature of surveillance. The study also illustrates the agency of the surveilled subject, extending the argument that various agents actually participate in the construction of surveillance practices. It analyzes the indirect role and responsibility of the surveilled subject, and thereby questions the traditional roles ascribed to the agents and targets of surveillance.

Findings from a participatory evaluation of a smart home application for older adults.

The aim of this paper is to present a participatory evaluation of an actual "smart home" project implemented in an independent retirement facility. Using the participatory evaluation process, residents guided the research team through development and implementation of the initial phase of a smart home project designed to assist residents to remain functionally independent and age in place. We recruited nine residents who provided permission to install the technology in their apartments. We conducted a total of 75 interviews and three observational sessions. Residents expressed overall positive perceptions of the sensor technologies and did not feel that these interfered with their daily activities. The process of adoption and acceptance of the sensors included three phases, familiarization, adjustment and curiosity, and full integration. Residents did not express privacy concerns. They provided detailed feedback and suggestions that were integrated into the redesign of the system. They also reported a sense of control resulting from their active involvement in the evaluation process. Observational sessions confirmed that the sensors were not noticeable and residents did not change their routines. The participatory evaluation approach not only empowers end-users but it also allows for the implementation of smart home systems that address residents' needs.

Veteran Preferences Regarding Wireless Management of Positive Airway Pressure for Obstructive Sleep Apnea at a Tertiary Health-Care System.

BACKGROUND: Timely monitoring of obstructive sleep apnea (OSA) therapy can be a challenge amid conflicting pressures of rising patient volume and shortage of sleep medicine providers. Positive airway pressure (PAP) devices with wireless modem technology have the potential to improve patient access to care and streamline work load, yet little is known about patient attitudes toward telehealth integration among veterans with sleep apnea. As part of a larger quality improvement initiative at the Veterans Affairs (VA) Puget Sound Health Care System, we elicited veterans' preferences toward modem versus traditional PAP data download, including patient attitudes and factors affecting those preferences. METHODS: We conducted an anonymous survey of veterans without previous CPAP experience presenting for initial device setup and training at VA Puget Sound PAP clinics. Surveys assessed subject demographics, PAP download preferences (modem vs mail), and Likert-type scale ratings of importance placed on factors including convenience and information privacy. Using multinomial logistic regression, we examined the association between convenience rating and download preference, adjusting for information privacy rating, age, and commute time. RESULTS: Of 444 surveys analyzed, respondents were primarily male with a mean age of 52 y. Most respondents reported taking ≥ 30 min to commute to the PAP clinic. Convenience was rated as the most important factor affecting download preferences. Veteran preferences regarding PAP download method were mixed, with 47% preferring modem, 38% preferring memory card mail-in, and 15% undecided. A higher rating of convenience was significantly associated with modem preference, both before and after adjustment for information privacy rating, commute time, and veteran age (adjusted relative risk ratio 1.67, P < .001, 95% CI 1.40-1.99). CONCLUSIONS: PAP data download preferences were mixed among new veteran users. Veterans placed a high value on the potentially competing concerns of convenience and information privacy. Veterans preferring modem factored convenience as important in their decision making, independent of privacy concerns.

Current attitudes on cardiac devices in heart failure: a review.

PURPOSE: Despite significant advances in optimizing drug therapy, heart failure-related mortality and morbidity remain high. There has been great progression with regard to device therapy in heart failure, and device use continues to increase. The aims of this review were to critically re-examine the evidence base and to highlight recent refinements in device therapy in heart failure. METHODS: Significant contemporary clinical trials and registries of device therapy in heart failure were examined and critically reviewed to draw conclusions on the clinical applications of implantable cardioverter-defibrillators, cardiac resynchronization therapy, remote monitoring of devices, and hemodynamic monitoring. FINDINGS: Advances regarding patient selection, technology, and implementation for the use of devices in heart failure have significantly improved outcomes. IMPLICATIONS: This review article provides a contemporary guide to the current attitudes toward the use of devices in heart failure. Device therapy is an important adjuvant to optimal pharmacologic therapy. The role of devices continues to increase, and devices have a positive impact on patients' quality of life and survival.

Patient and nurse-related implications of remote cardiac telemetry.

The purposes of this study were (a) to determine the frequency of rhythm disturbance events among patients on remote cardiac telemetry, (b) to identify how many of these events were detected by the telemetry nurses, and (c) to explore the impact of managing telemetry on nurses' workload This prospective observational study took place in a nine-bed Coronary Respiratory Care Unit (CRCU) in a tertiary Canadian University Hospital. No lethal arrhythmias were detected during 420 hours of observation. There were a high number of remote telemetry warning arrhythmias, the vast majority of which were artifact (80.2%). A warning alarm occurred every 2.1 to 6.2 minutes. Nurses detected between 60% to 100% of valid warning alarms. Remote cardiac telemetry without a dedicated monitor-watcher places unnecessary demand on CRCU nurses' time because the vast majority of arrhythmia alarms are inconsequential. The addition of monitoring remote telemetry to the CRCU nurse's workload has the potential to negatively influence the care provided to CRCU patients.

Teaching telemetry.

For patients on telemetry monitoring, knowledge is power--and comfort. You can develop informative tools to help critical care nurses put these patients at ease.

Patient adaptation to technology: an application of the Roy model to nursing research.

Structured interviews were used to explore 75 medical-surgical patients' reactions to intravenous (invasive) and telemetry (noninvasive) attachment. Dependent variables operationalizing constructs of comfort, self-esteem, patient role, and social relationships derived from Roy's four effector modes were organized into 19 adaptation items. It was hypothesized that patients attached to invasive technology would report more stimuli and need for behavioral responses than those attached to noninvasive technology. In keeping with the exploratory nature of the study and use of a new adaptation interview tool, item-by-item analysis was used to test the hypotheses. Most support for the hypotheses occurred when patients were attached to only one invasive device and for less than 3 days. Findings also provide new insights on how technology connections might put patients at risk for coping difficulties.

Elder acceptance of health monitoring devices in the home.

This study examined frail elders' acceptance of the concept of home monitoring devices. With the potential of such devices to ultimately assist many older persons, acceptance of the device in the individual's home is a critical component. Elders who view devices negatively--as unnecessary, unattractive, or intrusive--may be less likely to use the device if installed or less likely to allow them to be installed. For the participants in the current study, the results suggest strong acceptance of the concept of home health monitoring and the devices to make the system work. When questioned on device appearance a majority of the subjects felt that the devices would be acceptable in their homes, and initial reactions to the devices were primarily favorable. Equipment characteristics have been identified as one of the determining factors of perceived intrusiveness of home monitoring devices (Fisk, 1997). Study participants made several suggestions pertaining to device features and appearance. A common criticism related to device size, especially concerning the blood pressure cuff which was referred to as "gaudy" by one study participant. Participants offered suggestions such as making devices smaller, providing control for volume adjustment, and providing voice activation. At least one participant expressed a concern over device functioning in the event of distance traveling. Subjective comments such as "I think it would help many people," "It's very reasonable and important in several ways," and "...people would be more independent and safe," provided anecdotal support of device acceptance. Although a majority of the study participants had favorable responses to the devices and monitoring systems, many of their subjective comments reflected positive views regarding use by others as opposed to personal use. This finding may suggest that the participants did not personally identify with the need to use such devices but rather viewed the devices as relevant and acceptable for "the person who absolutely needs it." However, a majority of the participants identified "relieving personal worry" as a possible benefit of the home monitoring system which suggests personal identification with the potential benefits. The findings of study participants' willingness to pay, and a desire to maintain communications on a consistent basis with monitoring services, may demonstrate overall acceptance of the idea of home monitoring devices/services and establishes a need for continued research in product development. During the interviews, many of the subjects expressed enthusiasm and interest over the prospect of the home monitoring devices and systems with which they were relatively unfamiliar. This suggests a need for further consumer education regarding use of home monitoring devices and systems. Aside from the relatively small sample size, one limitation of this study relates to the study participants' understanding of the devices in relation to their current needs. The questionnaire results provided hypothetical acceptance of devices from a usefulness and aesthetic point of view. However, the findings may not totally reflect the study participants' actual willingness or desire to utilize the applicable devices in their homes. Further research is suggested in the area of assessment of potential consumer groups' perceptions of their current health status, functional limitations and needs, and more extensive research regarding perceptions of the potential benefits of using home monitoring devices. Further research in product development and clinical trials of existing home monitoring devices is also recommended.

[Will telemonitoring be adopted by patients with chronic heart failure?]. / Wird Telemonitoring von Patienten mit chronischer Herzinsuffizienz angenommen?

BACKGROUND: Remote Patient Management for chronic heart failure (CHF) is gaining increasing importance in health care. Telemonitoring is defined as daily measuring of health parameters by the patient and their transmission to a telemedical centre. The adherence of this action by the patient can be considered as a measure for RPM adoption. METHODS: The randomized controlled clinical trial TIM-HF (NCT 00543881) was conducted between 2008 and 2010 with 710 CHF patients with the primary endpoint total mortality for a mean follow-up of 21.5 ± 7.2 months. The non-prespecified analysis of adherence to daily measuring of ECG, blood pressure, weight and self-assessment was focused on sociodemographic and disease-related factors of the 354 RPM patients. RESULTS: The mean adherence to telemonitoring was more than 80% (absolute adherence: 81.8 ± 22.8%, relative adherence: 88.9 ± 21.5%). From the beginning of treatment 6.5% of the patients (23/354) have shown an adherence below average. The high adherence of the majority of the patients was stable for the entire study duration and irrespective of age, sex, severity of the disease and the presence of mild to moderate depression. CONCLUSION: A high adherence can be achieved by individual training of the patient regarding the handling of his disease, the use of telemedical devices and an easy-to-use telemonitoring system. The majority of the informed self-determined CHF patients NYHA class II/III are adopting telemonitoring and are adherent in the long term.

Social defeat and isolation induce clear signs of a depression-like state, but modest cardiac alterations in wild-type rats.

Adverse social environments play a relevant role in the onset and progression of mood disorders. On the other hand, depression is an independent risk factor for cardiovascular morbidity. This study was aimed at (i) corroborating the validity of a rat model of depression based on a negative social episode followed by social isolation and (ii) verifying its impact on cardiac function and structure. Pair housed, wild-type Groningen rats (Rattus norvegicus) were implanted with radiotransmitters for ECG, temperature and activity recordings. They were either exposed to a social defeat episode followed by 4-week isolation or left undisturbed with their female partners. The social challenge induced a series of biological changes that are commonly taken as markers of depression in rats, including decreased body weight gain and reduced preference for sucrose consumption, functional and structural changes of the hypothalamic-pituitary-adrenocortical axis, increased anxiety in the elevated plus maze test. The cardiovascular alterations consisted in (i) transitory heart rate circadian rhythm alterations, (ii) lack of habituation of cardiac autonomic responsivity (tachycardia and vagal withdrawal) to an acute stressor, and (iii) moderate hypertrophy affecting the right ventricle of the heart. These results indicate that a depression-like state induced via this model of social challenge was associated with a few modest cardiovascular changes. Further studies are required to confirm the validity of this rat model of depression as a valid preclinical approach to the comprehension of the biological substrates underlying depression-cardiovascular comorbidity.

An intelligent videomonitoring system for fall detection at home: perceptions of elderly people.

We explored the perception and receptivity of elderly people regarding the introduction of an intelligent videomonitoring system (IVS) at home. Using a mixed methods design, 25 elderly people with a history of falls completed a structured interview (two questionnaires). In the year preceding the interview, 72% of the participants fell as many as seven times. Open-ended questions (qualitative data) were used to supplement the quantitative data. A content analysis (qualitative data) and a descriptive analysis (quantitative data) were carried out. The participants were 84% favourable or partially favourable to technologies which ensured home security and 96% favourable or partially favourable to the IVS. About half (48%) said that they would use it. The other participants did not wish to use it unless they had been left to live alone or if their health condition worsened. Thus the living conditions of the elderly appear to influence their perception and receptivity regarding the acceptance and use of an IVS.

[Possibilities of telemedicine in arterial hypertension]. / Möglichkeiten der Telemedizin bei Hochdruckpatienten.

Telemetric blood pressure measurement opens a new dimension of cooperation between physician and patient. It requires clearly defined therapeutic target values. Telemonitoring is judged positively by 93% of patients treated this way for its exact and long-lasting observation mode by the treating physician. A better control of hypertension is possible due to adaption of therapy over a long observation period and exact blood pressure data by the treating physician and a better adherence to therapy by the patients. Besides good technical and logistic feasibility, published studies show a high acceptance both on the part of patients and treating physicians. Randomized, controlled and prospective studies showed significantly better blood pressure control of telemetrically observed patients compared to standard care. Telemedicine was exceptionally effective when combined with regular individualized interventions like phone calls. These data have to be confirmed by large prospective studies including "hard" endpoints and economic aspects. Of special interest is the telemetric observation in high-risk hypertensive patients like those with coronary artery disease, heart failure, cerebrovascular complications, or hypertension in pregnancy.