In December 2010, an article describing a telehealth remote monitoring program for heart failure patients concluded that telemonitoring did not improve patient outcomes. The paper, Telemonitoring in Patients with Heart Failure, written by Sarwat I. Chaudhry, M.D, and nine other authors, analyzed 1,653 CHF patients, 826 of whom participated in a remote health intervention: a telephone-based interactive voice-response system that patients dialed into on a daily basis to report symptoms and weight; this was designed to occur every day over six months. These data were then reviewed by patients’ clinicians who could contact patients when data pointed to the clinical need to adjust patients’ medications and other parameters.
As that peer-reviewed article appeared in my weekly electronically delivered issue of the New England Journal of Medicine, the draft of my paper, The Connected Patient, was undergoing final edits by the California HealthCare Foundation. In the paper, I assembled a broad range of research into remote health monitoring, sampling from a long list of trials that have tested telehealth programs connecting patients and providers using various methods. The one clinical area that has been studied more than any other in the remote health literature is heart disease, and among all areas reviewed, there was more evidence support RHM for the heart than any other condition studied.
The March 17, 2011, issue of NEJM has published several letters that critique the study, contesting issues of methodology:
- Swedburg, et. al., point to the fact that the study focused on data collection and not patient self-care. They write, “Telemonitoring needs to focus on patients’ self-care instead of reporting data…it is important that professionals and patients develop a partnership to achieve commonly agreed-on goals….We suggest that modern mobile-phone technology can advance person-centered telemonitoring.”
- Inglis, et. al., believe that, “Monitoring alone is unlikely to improve outcomes but may do so when it improves prescription of or adherence to lifesaving treatments. Given enough resources, traditional methods for delivering care may render an interactive voice-response system or a home telemonitoring system ineffective.”
- Everett, Kvedar and Nesbit, write that, “home telemonitoring programs that used more advanced forms of technology to support patient education and health care for patients with congestive heart failure have been shown to be successful in reducing unnecessary hospitalizations. These systems require daily, real-time monitoring of physiological data, direct patient feedback and coaching, and a high level of patient-clinician interaction to achieve positive results.”
The authors of the original paper respond to these three letters by defending their study, saying “Patients’ self-care efforts were individually supported as needed.”
Health Populi’s Hot Points: In the course of conducting research for The Connected Patient, I reviewed over 50 remote health monitoring studies performed in the U.S. (both in the private sector and in the Veterans’ Administration health system, which has arguably the most experience of any provider in the world with remote health monitoring), Europe and Japan. I’m also deeply immersed into health information technology and emerging mobile, home-based and personal (wearable) platforms that support health management and monitoring.
My assessment is that for telemonitoring to be most effective, several conditions must be in place: a patient must be health-engaged and activated; a provider must be willing to partner with the patient in accessing the data generated by the telemonitoring system, analyzing the data, and feeding actionable advice back to the patient; and the device itself, optimally, should populate the clinician’s health records automatically. Asking a patient to dial in on a daily basis, using an interactive voice response system, is destined to yield poor outcomes. Even the most engaged patient can miss a day of reporting, and that data isn’t easily recordable into a digital health record. This interrupts clinician and staff workflow, and adds administrative hassle to a physician practice that is already stressed.
This coming together of patient and clinician/health coach is the DNA of participatory medicine.
Patient-centered monitoring means that the device is highly usable, even engaging, and of course, elegantly designed to work well with the patient’s personal “life flow” (the citizen’s version of physician “work flow”).
As bundled payments and accountable care morph into the next payment models in U.S. health care, telehalth makes sense as a tool and ethos to keep people well at home. Furthermore the Affordable Care Act will provide incentives to keep patients home once discharged — most particularly, discharged patients with heart failure.
What I’ve learned in the past several years, and punctuated by my fresh experience coming out of SXSW Interactive 2011 in Austin, is this: that home is the new hub of health. Watch out for cable TV, consumer electronics, branded telecommunications, and other consumer-facing companies to support and also disrupt this space.