Telemonitoring

Listen to this as a podcast courtesy of the IFMiL or Catalan Institute of Medical Education and Leadership.

What is it?

Telemonitoring has been defined as “the distance monitoring of components of a patient’s health as part of a larger chronic care model” as recently as 2016 (1). It is clear, however, that real-time telemonitoring is now opening up the possibility to manage acute illness too.

Types of devices.

Many telemonitoring devices are available. From weight to oxygen saturation, to heart rate and rhythm, it is important to choose the parameters which will affect your management. In an acute setting, this may be the parameters of a NEWS or early warning score such as blood pressure, oxygen saturation and heart rate among others. For more chronic patients, it may be recording weight variations a way of evaluating fluid balance.

Patients own

A recent article in the BMJ noted that “it may be possible to get the patient to take readings from instruments they have at home—for example, temperature, pulse, blood pressure, blood glucose, peak expiratory flow rate, and oxygen saturation”(2). Many patients also have wearables, such as Fitbits and Apple watches. These wearables can measure biomarkers such as heart rate and, in the case of the apple watch, heart rhythm. Although the FDA approval for heart rhythm came out to great fanfare, there was also a backlash from cardiologists against the identification of asymptomatic atrial fibrillation for example. And the worried well using and wanting consultations about the information from their home monitoring can be a challenge in a stretched health care system.

Official

Some home monitoring has been FDA approved for information transfer and sharing with health care professionals. CGMs or continuous glucose monitoring is increasingly available to people with diabetes, enabling them to alter carbohydrate intake, lifestyle and medications in real-time. Not having CGM has been likened to a block of cheese with holes. Even if you do eight pinprick blood glucose checks a day, you will still have only a very limited picture as to what is going on. CGM not only provides a continuous blood glucose measurement, but it also gives tendencies. Knowing you have a BM of 100 stable or 100 going down fast will lead to very different decisions as to how much insulin to inject. Commercial CGM sensors all have FDA approval.

#wearenotwaiting

Sometimes the FDA approved technology is not enough. This is the case in people with type 1 diabetes who can have significant and dangerously low blood sugar levels, especially at night. The need to be able to share this information with other family members who can act if the person with diabetes does not react in time led to the #wearenotwaiting and nightscout movement. Using opensource technology, people with diabetes can upload their CGM readings to the cloud. They can set up alerts and share their blood glucose in a way which was not initially offered by the manufacturers and is still not available for all the CGMs on the market. As this is opensource, it does require a level of commitment that is not needed with out of the box commercial solutions. There is also a disclaimer that the movement is not liable for any safety issues. However, users say it is safe, much more so than the commercial solutions for enabling parents to keep an eye on their children at a distance and for adults to live independently alone.

Pros

Like any technology or therapeutic intervention, there are pros and cons. Advantages include the fact that patients using telemonitoring can be in their own home. This is especially relevant when hospitals are at capacity. Cost is generally, but not always, agreed to be decreased with telemonitoring. The devices themselves have an initial and maintenance cost which has to be absorbed. Depending on the value placed on health care professional time, telemonitoring may be more or less cost-effective. In the case of less expensive monitoring such as BP measurement for hypertension management, telemonitoring and self-monitoring are more cost-effective than clinic care(3). Telemonitoring information can easily be shared across several professionals enabling real multidisciplinary decisions. Another advantage is that patients are empowered by having real-time information and acting reactively or proactively. They can work with their HCP on medication but also lifestyle changes. Studies have shown that telemonitoring of patients with diabetes leads to better blood glucose control, a positive impact on comorbidities and better treatment and hygiene-dietary adherence(4). Elderly or frail patients in whom transfer to a health care centre can be challenging can particularly benefit from telemonitoring. A Swedish team showed that in elderly patients with advanced HF and COPD, telemonitoring decreased the need for hospitalisation without increasing the overall health costs(5).

Cons

However, telemonitoring does have some negatives. The transfer of monitoring to a home context has been shown to place a high burden on patients. The patient has to be able to carry out these measurements correctly. There is also evidence, perhaps surprisingly, of an increase in clinician and nurse workloads as telemonitoring services expanded(1). Another consideration is the inability to calibrate home apparatus. Several authors recommend specifying in the medical notes if the values reported by the patient are not consistent with the HCP’s wider assessment(2). Hacking and security breaches can also happen. The consequences can be lethal, especially if that information is used to change treatment without human input, as in the case of insulin pumps.

Case Studies

Heart failure.

Heart failure is one of the pathologies which has had the most interest when it comes to home monitoring(6). Telemonitoring has existed for a long time in this domain, as far back as 1966 in the form of phone calls(7). Now it includes smart scales and BP monitoring which is transferred directly via the patient’s smartphone. There seems to be a reduction in all-cause mortality and HF-related hospitalisations, especially in the case of recently discharged patients(6). A Cochrane review and a more recent Basque review also noted that participants in the heart failure studies reported improvements in quality of life and self-care behaviours(8)(9).

COVID-19

Doctivi

The COVID-19 pandemic has accelerated the adaptation of telemedicine but also that of telemonitoring as a way of keeping patients out of hospitals which are already at capacity. In Barcelona, a recently implemented telemonitoring project for chronic patients, Doctivi, was quickly adapted to include stable COVID-19 patients under the Hospital del Mar. Integrated technology provided by the hospital means that parameters such as blood pressure, oxygen saturation, heart rate and even steps can be monitored at a distance. Alerts are set up if out of range values are picked up. As this technology includes video calls, this can lead to a medical consultation and review of the management plan. 

Conclusion.

Telemonitoring is already with us, and costs will continue to come down. Patients themselves can sometimes be ahead of the health care professionals, and in these cases, you can learn a lot from your patients about the digital health solutions available. Every patient and pathology will need different parameters to be monitored. The ability to filter the parameters of interest and get rid of the excess information noise in order will be paramount. This is where the practice of the health care professional will be augmented, and the patient empowered.

1.        Bashshur RL, Howell JD, Krupinski EA, Harms KM, Bashshur N, Doarn CR. The Empirical Foundations of Telemedicine Interventions in Primary Care. Telemed e-Health. 2016;

2.        Greenhalgh Trisha, Koh Gerald Choon Huat CJC-19: a remote assessment in primary care B 2020; 368 :m1182. Covid-19: a remote assessment in primary care. BMJ. 2020;368:m1182.

3.        Monahan M, Jowett S, Nickless A, Franssen M, Grant S, Greenfield S, et al. Cost-Effectiveness of Telemonitoring and Self-Monitoring of Blood Pressure for Antihypertensive Titration in Primary Care (TASMINH4). Hypertens (Dallas, Tex  1979). 2019;

4.        Andrès E, Meyer L, Zulfiqar AA, Hajjam M, Talha S, Bahougne T, et al. Telemonitoring in diabetes: evolution of concepts and technologies, with a focus on results of the more recent studies. Journal of medicine and life. 2019.

5.        Lyth J, Lind L, Persson HL, Wiréhn AB. Can a telemonitoring system lead to decreased hospitalisation in elderly patients? J Telemed Telecare. 2019;

6.        Kitsiou S, Paré G, Jaana M. Effects of home telemonitoring interventions on patients with chronic heart failure: An overview of systematic reviews. Journal of Medical Internet Research. 2015.

7.        Louis AA, Turner T, Gretton M, Baksh A, Cleland JGF. A systematic review of telemonitoring for the management of heart failure. European Journal of Heart Failure. 2003.

8.        Inglis SC, Clark RA, Dierckx R, Prieto-Merino D, Cleland JGF. Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database of Systematic Reviews. 2015.

9.        Güemes Careaga I. Telemonitorización en pacientes con insuficiencia cardiaca o enfermedad obstructiva crónica. Revisión sistemática de la literatura. Inf Evaluación Tecnol Sanit. 2012;

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Telemedicine – a brief introduction.

Listen to this post as a podcast instead.

What is it?

Telemedicine is, as its name explains, medicine at a distance. This can be synchronised in time with both doctor and patient being in contact at the same time or asynchronous with a time lag. Telemedicine has existed in one form or another as long as doctors have. Currently, telemedicine is usually understood to mean phone, email and video calls. A local example within the Catalan EHR is the e-consults where patients can email their doctor and receive a response within 48h working hours.

Advantages and disadvantages.

Like all technologies, there are pros and cons. In these times, especially, the lack of direct face to face contact is a basic infection control measure. A recent Cochrane review concluded that there were probably economic savings to be made, although there is generally a lack of evidence at this point(1). Savings can also be non-monetary. A Michigan geriatric service went from 0 to 91% of their visits virtually in the space of 5 weeks. They calculated that during this time that over 1135 travel miles had been saved with an average of 24 miles per virtual visit which probably reflects the geography they practise in(2).

However, telemedicine does have its detractors or at least those who point out that we should exercise a certain level of caution. The first point is the same as our first cited advantage, the fact that there is no contact.  Many physicians feel that the face to face and indeed hand to body part of their interaction is fundamental. They struggle with the thought of not having this part of the consult available. In another podcast, we will look at the digital health tools which are available to overcome at least in part this aspect.

Another negative which has been spoken about widely recently with people working from home is the fact that video calling is tiring. Video consultations are dependent on the availability and stability of the internet connection which, even at it’s best, will always have a slight lag. As Philippa Perry points out, video calling “is tiring because of the delay of the spoken word and gestures and expressions. So you have to listen to words and notice body language in two separate streams in your poor head”. She also points out that you get distracted by your own face. Video calling takes more concentration than our usual conversations.

There is also a perceived elitism that telemedicine is for young and smart technology-savvy patients, not for the older or patients with accessibility issues. However, the University of Chicago reports that 1 in 5 of people over 70 have had a telehealth visit since the pandemic started. 49% of these over 70s said that the experience was about the same as an in-person visit with only 4% saying it was much worse.

Resources.

Telemedicine is a new skill that has to be learnt for everyone. But there are resources out there to help both physicians and patients deal with the challenges. When it comes to breaking bad news remotely, the BMJ provides guidance which includes thinking about your tone of voice when you don’t have non-verbal communication to help you(3). The palliative care team at Chelsea and Westminster hospital have also produced a useful infographic, dealing with bad news. The NHS have produced infographics, videos and leaflets to help patients with video consultations. The NHS resources specifically recognise the varying demographics and possible challenges of all patients.

Another aspect is patient confidentiality. Clinicians have to bear in mind that they may not be able to see who else is listening in to the video consultation and that in situations of domestic abuse the patient’s freedom to give all the information may be limited. At the same time, a video consultation gives you a privileged view into someone’s life. There has been much discussion recently about what your zoom background says about you and when it comes to patients, it can help you decide if you feel they can cope at home or need extra help.

Regulatory aspects.

This leads us on to regulatory aspects of telemedicine. It goes without saying that the method of communication used needs to be compliant with data protection regulations. You can listen to previous podcasts dealing with health data and the GDPR.

However, regulation goes beyond the purely technical. Back as early as 2002, the Barcelona College of Physicians emitted a statement about the use of email and other types of electronic means for interacting with patients. Telemedicine was defined then as a complement to the interpersonal physician-patient relationship with a patient who had previously been seen in person. The current COVID-19 pandemic has accelerated the use of telemedicine, and the Madrid College of Physicians emitted new guidance in March 2020 saying that in the context of the current health emergency, a previous face to face visit may no longer be necessary.

COVID-19

COVID-19 has changed the world we live and practise in. Telemedicine, which was on the cusp of being mainstream, has now been implemented across the board. Concurrently, research has been undertaken looking at the validity of telemedicine in the COVID-19 pandemic context.

Phone triage.

Prof Greenhalgh produced an infographic for the primary care phone triage of COVID-19 and concluded that most patients with COVID-19 could be managed remotely, with advice on symptomatic management and self-isolation (4). Phone triage was found to be sufficient in many cases, but video would provide additional visual cues and a therapeutic presence. Breathlessness was highlighted as a concerning symptom with, for this team, there being no currently validated tool for assessing breathlessness remotely.

However, a recent New England Journal of Medicine article spoke of the Roth Score to evaluate shortness of breath and hypoxia(5) via telemedicine. The Roth Score is described as simply having the patient take a deep breath and count out loud to 20 as rapidly as possible while timing the time before the next breath. Being unable to count to 7 has a sensitivity of 100% for oxygenation less than 95%. Being unable to count for 5 seconds has a 91% sensitivity for an oxygenation saturation of less than 95%. I would argue that if the patient is that compromised normal conversation would already be alerting you to the fact that the patient has severe shortness of breath anyway. The team behind this article explain that COVID patients needing transfer to hospital were often not able to count to 7 in one breath.

Video consultations.

Oxford University professionals have also produced guidance on the use of videocalls for COVID-19 related consultations. Specifically, video consultations may be appropriate if the clinician or patient is self-isolating. This would also be the case for patients who have symptoms which could be due to COVID-19 or if the patient is well but needs additional reassurance. Patients in care homes may also benefit from video consultations if staff are on hand to give them the support they may need. Video consultations were deemed not to be appropriate for a series of patients, including assessing patients with potentially serious, high-risk conditions likely to need a physical examination. This included high-risk groups for poor outcomes from COVID-19 who are unwell. Situations where internal examinations, for example, gynaecological examinations, can not be deferred also mean that a video consultation would not be appropriate. It was also pointed out that some deaf and hard-of-hearing patients may find video difficult, but if they can lip-read and/or use the chat function, video may be better than telephone.

1.        Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S. Interactive telemedicine: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2015.

2.        Dewar S, Lee PG, Suh TT, Min L. Uptake of Virtual Visits in A Geriatric Primary Care Clinic During the COVID-19 Pandemic. J Am Geriatr Soc [Internet]. n/a(n/a). Available from: https://doi.org/10.1111/jgs.16534

3.        Rimmer A. How can I break bad news remotely? BMJ [Internet]. 2020;369. Available from: https://www.bmj.com/content/369/bmj.m1876

4.        Greenhalgh Trisha, Koh Gerald Choon Huat CJC-19: a remote assessment in primary care B 2020; 368 :m1182. Covid-19: a remote assessment in primary care. BMJ. 2020;368:m1182.

5.        Hollander JE, Sites FD. The Transition from Reimagining to Recreating Health Care Is Now. NEJM Catal. 2020;

Straight from the horse’s mouth – or where to go for verified information about #coronavirus or any other medical topics.

Over the past years, months and days, we’ve all been exposed to #fakenews in one form or another. Some of it is obvious and maybe even funny. Other fake news maybe less obvious, especially if it comes through a friend or colleague. #coronavirus has led to many fast circulating examples of misinformation so here is a quick guide to how to make sure you have up to date validated information and a list of specific #COVID19 resources.

Yet, we often don’t know where to go in the middle of so much available information. Newspapers often get their information second hand and report , as is their function, on ever changing situations early on. Blog posts can look surprisingly well referenced but if you go into the references maybe citing animal studies or non peer-reviewed articles. Did you know that many journals now ask authors to pay for their article to be published, knowing they have a willing market in researchers needing to publish a certain amount of articles a year?

Other sources of potentially biased information due to having vested interests are patient information webpages which appear at the top of google. Often pharmaceutical companies or pressure groups have invested a lot of money in making sure that their page appears first when you type in their name. It may take a while to find out who is behind the page – a red flag in itself.

So where should you look?

The best sources are official, have an obligation to be updated regularly and have been reviewed by someone other than the author. Looking at the site where the information is hosted is one of the first steps.

  1. .ac.uk – university sites in the UK
  2. .gov – official government sites
  3. .nhs.uk – the National Health Service in the United Kingdom
    1. NHS Patient Info
    2. NHS Specialist Info
  4. .org – if combined with it being the national college of a medical speciality, it should be a reliable if not always very easy to use source of specific medical information
  5. .edu – a educational institution which may be a university hospital with information for healthcare professionals and patients.

Clinical guidelines and updates are often published by national societies but there are also a few other places to look:

FDA: The U.S Food and Drug Administration website has a lot of regulatory information but also updates on current events such as donating plasma if you have recovered from COVID-19. Use the search option to find information about your topic of interest.

NICE : The National Institute for Health and Clinical Excellence is a UK based organisation on which clinical protocols are based. if you want to check what is the is the latest guidance on a specific health issue, including coronavirus, then this is a good place to start. Don’t be put off by the sometimes dense text, there is always a summary option available.

For research papers you can look at PubMed where almost all research papers are collated, with links out to the originals and links to other articles citing the information provided in your chosen article. You can specify how recent you want the article to be and whether you are interested in just humans or also animals. Using the “review” filter means that you will get an article looking at all the research on a particular topic. This can be very useful for the general public or non-specialists. You can also set up alerts so that you receive an email every time someone publishes something in your field of interest.

If you do receive a whatsapp or facebook message purporting to come from Stamford University for example, copy and paste the first line into google and you will quickly find out if it is a scam or not. Even videos with an MD explaining something may not be validated information. Always fact check anything you receive.

Specific COVID-19 or #coronavirus resources.

In view of the fast changing events it really is best to go straight to the horse’s mouth, or the specific #COVID-19 pages of the ones informing the experts and the general public:

  1. World Health Organisation
  2. British Medical Journal – Best Practise
  3. John Hopkins Coronavirus Dashboard.
  4. KnowledgeShare compilation of articles and guidelines coming out.

If you want to hear it from those on the ground.

Front-line health workers whether doctors, nursed or paramedics have taken to podcasts as the way of reflecting on their experiences and how it fits in with the evidence. They are ahead of the official guidelines especially in fast-changing situations such as the current coronavirus pandemic.

EMCrit – USA based emergency physician and guests.

The Good GP – Australian Family Medicine Doctors talk about their experiences and latest updates.

Emergency Medicine College explains how to deal with COVID19 for non-EM doctors.

Pondermed – talks about the reality for radiographers amongst other COVID-19 topics.

Paramedic podcasts – prehospital health workers are the first people on the scene and have a unique view on what actually works and is really going on.

10 minute podcast updates

Sometimes reading a blog post or an article is hard to fit in. Try getting your updates with these podcasts in ENGLISH.

An introduction to the GDPR for doctors.

The difference between anonymisation and pseudoanonymisation in health data – stay compliant with GDPR.

Polypharmacy.

Communicating with patients.

Podcasts by MHW medical health writing.

Why your #healthtech pizza can’t have too many toppings.

Have you ever been so exhausted with making decisions at work that you decide you just want pizza for dinner (any pizza, as long as someone else decides the toppings)? This decision fatigue (1) is a very real experience for all types of doctors and health professionals who spend their day taking important decisions with life or death consequences immediately or in the future. There has even been a scale developed to assess how health professionals are affected by this (2).

So when you present your amazing healthtech product with its many multiple options to clinicians, don’t feel offended that their eyes glaze over, or even droop. It’s not a case of reducing your offer of special functions available exclusive to your digital health product. Instead, tailor your product to the needs of the health professional in front of you.

What you really need to do is to know which functions will change their practise, decrease their levels of frustration with IT and set it up for them. Of course, they can do it themselves (this and a few more complicated procedures such as saving lives), but if you do it for them, you get a foot in the door. Leave it to them, and it will be pushed to the bottom of the non-urgent pile, and that is how digital health products end up not being implemented.

You can rail against health professionals pushing back against tech, but the reality is that if it doesn’t work for them, you are going to be the one left on the outside.

1. Linder JA, Doctor JN, Friedberg MW, et al. Time of Day and the Decision to Prescribe Antibiotics. JAMA Intern Med. 2014;174(12):2029–2031. doi:10.1001/jamainternmed.2014.5225 

2. Hickman RL, Pignatiello GA, Tahir S. Evaluation of the Decisional Fatigue Scale Among Surrogate Decision Makers of the Critically Ill. West J Nurs Res. 2018;