Remote Telemonitoring Research Articles

Monitorização à distância no seguimento de portadores de dispositivos cardíacos implantados

With a widening of indications for cardiac devices, especially in view of the clinical benefits of implantable cardioverter-defibrillators and cardiac resynchronization therapy, the number of patients with such devices is growing steadily. However, the resources required, and the need for long-term regular interrogation in dedicated clinics, represent a significant burden for already overstretched electrophysiology teams and hospital services. Remote telemonitoring is increasingly used for such follow-up, as it is a safe and effective alternative to conventional follow-up programs in outpatient clinics. This technology has been shown to be technically reliable, enabling early identification of device malfunction, arrhythmic events and heart failure decompensation, while reducing the risk of under-reporting, the number of outpatient clinic visits and hospitalizations due to cardiac events, and healthcare costs. Further studies are needed to determine how best to implement this new technology in a cost-effective manner, and what new legislation governing the use of remote monitoring in clinical practice may be required. In this article, we describe current systems, review the technical and clinical evidence in the literature regarding remote monitoring of implantable cardiac devices, and expand on outstanding questions.

Pilot Study of Remote Telemonitoring in COPD

Remote in-home monitoring (RM) of symptoms and physiological variables may allow early detection and treatment of exacerbations of chronic obstructive pulmonary disease (COPD). It is unclear whether RM improves patient outcomes or healthcare resource utilization. This study determined whether RM is feasible in patients with COPD and if RM reduces hospital admissions or length of stay (LOS) or improves health-related quality of life (HRQOL). Forty-four patients were randomized to standard best practice care (SBP) (n=22) or SBP+RM (n=22). RM involved daily recording of physiological variables, symptoms, and medication usage. There were no differences (mean±SD, SBP versus SBP+RM) in age (68±8 versus 70±9 years), gender (male:female 10:12 in both groups), or previous computer familiarity (59% versus 50%) between groups. The SBP group had a lower forced expiratory volume in 1 s (0.66±0.24 versus 0.91±0.34 L, p<0.01) and more current smokers (six versus none, p<0.05). There were no differences in number of COPD-related admissions/year (1.5±1.8 versus 1.3±1.7, p=0.76), COPD-related LOS days/year (15.6±19.4 versus 11.4±19.6, p=0.66), total admissions/year (2.2±2.1 versus 2.0±2.3, p=0.86), total LOS days/year (22.1±29.9 versus 21.6±30.4, p=0.88), or HRQOL between the two groups. The addition of RM to SBP was feasible but did not reduce healthcare utilization or improve quality of life in this group of patients already receiving comprehensive respiratory care.

A critical review on telemonitoring in heart failure

Morbidity and mortality remain high in heart failure despite considerable progress achieved with medical therapy and electrical devices. A multidisciplinary approach is actually strongly recommended. In order to provide optimal care to the ever-growing population of patients with heart failure, telemonitoring has been proposed as a modality to improve usual care. The aim of this review is to provide an overview of the existing evidence on telemonitoring in HF. Despite two major meta-analyses with favourable results, two recent, large, multicentre, randomized controlled trials, one with a sophisticated technical remote telemonitoring approach (TIM-HF) in stable chronic HF and the other with a comprehensive telephone-based interactive voice-response monitoring (Tele-HF) in patients recently hospitalized for heart failure, have been performed and both failed to demonstrate a clinical benefi t for telemonitoring. Newer technologies or other modalities, such as collaboration between a general practitioner and a heart failure clinic facilitated by telemonitoring should be further evaluated. Dedicated telemonitoring for heart failure may be a practical adjunct in selective centres and patients, on top of usual care, including education and a multidisciplinary approach. However, prior to being accepted as a standard of care, more evidence from large, randomized clinical trials is required.

Mobile Telemonitoring for Arrhythmias in Outpatients in the Republic of Georgia: A Brief Report of a Pilot Study

As the very first trial of mobile telemedicine in the Republic of Georgia, in June-December 2010 we investigated 35 outpatients with different types of arrhythmia (male/female ratio=16/19; 12-80 years old), among them 5 patients with concomitant epilepsy. The control group comprised 7 clinically healthy sportsmen (soccer players, all men; 15-17 years old), during a 30-min velo ergometer stress test. A three-lead electrocardiogram (ECG) loop recorder (Vitaphone BT 3300; Vitasystems GmbH, Mannheim, Germany) was used in automatic mode, using special LRMA software (MDT, Lázně Bohdaneč, Czech Republic) and a Nokia (Espoo, Finland) model 6730 Symbian phone. Automatically recorded arrhythmia events were transmitted from the loop recorder by Bluetooth(®) (Bluetooth SIG, Inc., Kirkland, WA) to a phone and then by 3G (through our partner mobile operator, MagtiCom Ltd. [Tbilsi, Georgia]) to the Vitasystems server in Germany and were available to Georgian physicians via e-mail/Internet. Arrhythmias were recorded/monitored during 7-68 h of observation. The number of automatically recorded ECG events varied between 3 and 170 per observation, or 0.4-10.7 hourly. Cases of sinus brady- and tachyarrhythmia, sinus node weakness syndrome, atrial fibrillation, supraventricular tachycardia, supraventricular premature complexes, and ventricular premature complexes were correctly recognized by automatic recognition software and recorded. In 3 patients and 1 sportsman previously unspecified (despite multiple investigations), arrhythmias were recorded: paroxysmal tachycardia (n=1), sinus node weakness syndrome (n=1), and ventricular premature complexes (n=2). In 3 cases (all women) light insomnia and nervousness were reported. In 2 patients with neurosis (both elderly men, 1 with epilepsy) we had to stop investigation prematurely because of anxiety/agitation. Mobile telecardiology represents feasible methodology to monitor arrhythmias in outpatients in Georgia, promoting earlier discharge of non-life-threatening cases, improving patients' comfort of life, and increasing their mobility with enhanced safety. Mobile telehealth might also represent significant cost-saving for insurance companies (this is an ongoing study). Finally, in remote areas mobile telemonitoring of patients will improve quality of care by timely provision of a second opinion in cases when local expertise is not sufficient.

Security of Telemedical Applications over the Internet using Programmable Cellular Automata

As the increasing number of telemedical applications over the Internet using mobile devices (PDAs, Tablet PC, various medical devices, and so on), for access of medical data in terms of telemedicine and remote patient telemonitoring, the necessity of new powerful encryption techniques becomes a crucial issue. In this paper is presented a fully functional software encryption system based on a combination of a one-dimensional hybrid cellular automaton (CA) and a programmable cellular automaton (PCA) used for securing of medical data sent over the internet. The experimental results are based on the powerful of cellular automata based encryption systems, already validated in my previously works. The proposed algorithm belongs to the class of symmetric key systems.

Telehomecare Communication and Self‐Care in Chronic Conditions: Moving Toward a Shared Understanding

Remote telemonitoring of patients' vital signs is a rapidly increasing practice. Although methods of communication in remote electronic monitoring differ from those in traditional home health care, the understanding shared by the nurse, patient, and family members remains the same: patients' self-care behaviors affect exacerbations of chronic health conditions. The purpose of this paper is to examine the relationship between communication and information integration into the daily lives of patients with chronic illnesses and offer best practice recommendations for telehomecare nurses (THN). The original study used the Social Relations Model to examine relationships within 43 triads composed of patients with chronic conditions, home helpers, and their nurse involved in telehomecare at three Veterans Health Administration sites. This secondary descriptive and correlational analysis compared 43 patients' and nine THNs' ratings of themselves and each other on communication (frequency, timeliness, and understanding) and the use of patients' daily telemonitored information. There was almost no correlation between patients' perception of THNs' communication (frequency [r=0.05], timeliness [r=0.09], and understandability [r=0.03]) and patients' integration of information into daily health practices. However, significant correlations were found between the THNs' perception of patients' communication frequency and timeliness, and integration, (p=0.02; p<0.001) respectively. This study suggests that frequent phone communication may lead the remote THN to believe patients are integrating blood pressure, weight, and other information into daily self-care behaviors, when in fact the patient reports that they are not. The influence of a halo effect on the THN may cloud an accurate perception of what is actually occurring. Remote communication may require more attention to THNs educating patients about shared understandings when using telemonitoring. Best practices for THN should include explicit goals and intentions for telemonitored home care with individualized instructions about how to use the information for self-care.

Use of remote telemonitoring in chronic heart failure

Use of remote telemonitoring in chronic heart failure

Sympathetically Mediated Changes in Capacitance

“To be accepted as a paradigm, a theory must seem better than its competitors, but it need not, and in fact never does, explain all the facts with which it can be confronted.” Thomas Kuhn, The Structure of Scientific Revolutions ### Heard on Rounds “A 57-year-old patient with a history of heart failure states that she began experiencing worsening shortness of breath 4 days prior to admission, with lower extremity edema developing 1 day prior to admission. She is compliant with her medications, though has had similar admissions previously. She states that her weight at home increased by “a couple of pounds” 2 days ago and that she increased her diuretic dose but her symptoms worsened. She says that she generally adheres to her low salt diet, but admits to eating pretzels 5 days ago. The physical examination showed BP 136/84, HR 94, weight 3 lbs above baseline, elevated JVP, basilar rales, and 1+ pedal edema.” As the intern finishes the presentation, the Senior expresses surprise that the patient's weight had increased only 3 pounds, and comments about salt and volume overload leading to acute decompensated heart failure (ADHF). The Attending adds that recent data reveal that many patients presenting with ADHF have minimal or no weight gain, but that there is no clear mechanism to explain this phenomenon. They set in place plans for diuresis, increasing vasodilators, and further patient education. On the surface, there is nothing remarkable about this case, and the usual approaches to treat this entity have remained remarkably consistent since the advent of loop diuretics over 50 years ago: salt restriction, patient education, uptitration of medications if not already at optimal doses, and diuresis. However, approximately 1 in 4 such patients are readmitted to the hospital within 30 days,1 and the disease continues to progress. It is clear …

Device Therapy in Advanced Heart Failure: What to Put In and What to Turn Off

Despite evidence based medical and pharmacologic advances the management of heart failure remains challenging, especially in the ambulatory setting. There is an urgent need to develop strategies to reduce hospitalizations and re-admission rates for heart failure in general. This focused review illustrates the potential role for remote telemonitoring and implantable hemodynamic devices to address this significant issue. We also explore the growth of cardiac resynchronization therapy and how it has evolved into another tool in our armamentarium for hemodynamic monitoring.

Remote Telemonitoring Technology Will Expand, But Progress Depends on More Research and Federal Support

Remote Telemonitoring Technology Will Expand, But Progress Depends on More Research and Federal Support

Noninvasive Remote Telemonitoring for Ambulatory Patients With Heart Failure: Effect on Number of Hospitalizations, Days in Hospital, and Quality of Life. CARME (CAtalan Remote Management Evaluation) Study

Introduction and objectives Multidisciplinary strategies for the management of heart failure (HF) improve outcomes. We aimed to evaluate the effectiveness of noninvasive home telemonitoring in ambulatory patients with HF already included in a structured multidisciplinary HF program. Methods Prospective intervention study with before/after comparison design of an interactive telemedicine platform in HF patients, randomized 1:1 into two groups: A) Motiva System with educational videos, motivational messages, and questionnaires, and B) Motiva System + self monitoring of blood pressure, heart rate, and weight. Hospitalizations were compared over 12 months prior to and post study inclusion. Quality of life was evaluated using the generic EuroQoL visual analogue scale and the specific questionnaire Minnesota Living With Heart Failure Questionnaire. Results There were 92 patients included (71% male; 66.3 ± 11.5 years; 71% ischemic aetiology). During real-time telemonitoring over 11.8 months (interquartile range, 8.6-12), 14,730 questionnaires were administered with 89% median response rate. Hospitalizations for HF decreased by 67.8% ( P = .010) and for other cardiac causes by 57.6% ( P = .028). The number of days in hospital for HF decreased by 73.3% ( P = .036), without statistically significant differences between groups, and for other cardiac causes by 82.9% ( P = .008). The perception of quality of life improved significantly both for the generic scale ( P < .001) and for the HF specific questionnaire ( P = .005). Conclusions HF patients who used an interactive telehealth system with motivational support tools at home spent less time in hospital and felt their quality of life had significantly improved. No significant differences were observed between groups.

Role of home blood pressure telemonitoring in hypertension management

Despite the increasing use of home blood pressure monitoring (HBPM) in daily practice and the growing awareness in the scientific community about its positive impact on the diagnostic and therapeutic management of patients with high blood pressure (BP), the potential advantages offered by HBPM have not yet been fully exploited. Indeed, use of the information offered by HBPM is often incomplete and imprecise, with the BP values reported by patients in handwritten logbooks being frequently inaccurate, illegible to physicians, or unreliable. Although a practical solution for improvement may come from the use of devices equipped with a storage memory, a step forward in this regard has been taken more recently with the introduction and refinement of systems for the remote telemonitoring of BP values measured at home. However, although several studies have provided evidence on the clinical usefulness of HBPM, only limited data are available on the clinical impact of home blood pressure (HBP) telemonitoring, because of a number of reasons. First, most of the available studies are characterized by a small sample size, and in some cases, the patients were neither randomized nor even matched with a control group. Moreover, technological solutions used in the different studies carried out so far are often heterogeneous, some of them being particularly difficult to use for the patients, thus limiting the effectiveness of the results. BP monitoring programmes, number of BP readings and transmission schedules are often different among the various studies. In addition, patient selection criteria are different from study to study. Finally, different study objectives and important diversities in the types of centres involved (ranging from general practices, to specialists' offices, hospitals or university centres) may have also influenced the quality of results. Large-scale randomized controlled studies, based on easy-to-use technologies, are thus still needed to show the superiority and clinical usefulness of HBP telemonitoring as compared with conventional HBPM. This study summarizes the evidence available on the clinical usefulness and current limitations of this approach, highlighting the results of meta-analyses and randomized controlled trials on this issue. The role of HBP teletransmission in the context of integrated patients' management programmes is also addressed, with indications for further progress in this field.

Remote Patient Monitoring: A Human Factors Assessment

The Study Context Telehealth remote patient monitoring applications are being used increasingly in chronic disease management because patients are leaving the hospital after acute episodes still needing care. Monitoring applications may have several purposes, but two are typical: to provide continuing care to patients and to educate patients, enabling them to better manage their condition and avoid hospital readmission and costly visits to emergency rooms. Some of these applications are quite sophisticated from a clinical perspective; some are much simpler. Western Michigan University, in collaboration with a local visiting nurse agency, conducted a longitudinal randomized control trial of the Health Buddy (Bosch Healthcare)i remote telemonitoring and patient education system, via funding support from the Health Resources and Services Administration (Grant 1 D1B TH 0374401) from 2006 to 2008. Subjects were patients with heart failure (HF) or chronic obstructive pulmonary disease (COPD) who had just been discharged to homecare after hospitalization for an acute episode. Those patients who were eligible for the study, based on both diagnostic criteria and criteria for telehealth, were randomly assigned to receive standard homecare alone or standard homecare with a 60-day telehealth program specific to their illness (either an HF or COPD program). In all, a total of 19 patients participated in the telemonitoring group, and 27 in the control group. Subjects were followed for one year post-discharge and many clinical and non-clinical outcomes were assessed at various points in this one-year period. (See Table 1 for a list of outcome measures and assessment tools used in the study.) Not unlike many Remote Patient Monitoring: A Human Factors Assessment

Integrated clinical and laboratory databases

Many clinical laboratories routinely provide electronic reporting of laboratory results, and there is an increasing trend for users to capture these data in their own departments' clinical information system. This allows laboratory data to be interpreted in the context of the rest of the patients' electronic healthcare record. Integration of clinical data from various sources (e.g., clinical, laboratory, and radiology systems) combats fragmentation of healthcare, facilitates audit, and can lead to improved patient outcomes. The development of international standards such as Health Level 7 for clinical data interchange has facilitated this process. Also, the availability of evidence-based guidelines and integrated care pathways in clinical domains where laboratory data are critical has given a further stimulus to integration. Decision support systems and clinical data mining techniques may also be used to interrogate or search large data ‘warehouses' containing integrated clinical and laboratory data. In this presentation, the benefits and some limitations of integrating laboratory data with clinical information systems in selected clinical domains such as diabetes will be reviewed. International developments and selected applications from primary and secondary care will be reviewed, including the role of laboratory data in online personal health records, in remote telemonitoring, and in virtual clinics (‘e-clinics').

Clinical validation of a wearable system for emotional recognition based on biosignals

The AUBADE system can be trained to classify a subject's feelings into six different emotional classes, derived from three of the basic emotions (happiness, disgust and fear). The performance of different classifiers was examined. Biosignals were recorded from 24 healthy subjects who viewed pictures designed to invoke different emotional responses. A psychologist evaluated the emotional status of the subjects by looking at their faces. During the training stage, information from 15 subjects was used to teach the system how to discriminate the emotional status of the subject based on the biosignals provided as input. A subset of the data was used for comparing the performance of four different classifiers. They were evaluated using three different metrics: sensitivity, positive predictive accuracy and accuracy. Using the SVM classifier, the AUBADE system provided sensitivities in the range 63-81%. The positive predictive accuracy was in the range 71-95%. The accuracy was in the range 63-83%, depending on the emotional class considered. The work paves the way for remote telemonitoring of patients suffering from neurological diseases.

RESIDENT PERCEPTION OF THE EDUCATIONAL AND PATIENT CARE VALUE FROM REMOTE TELEMONITORING IN A MEDICAL INTENSIVE CARE UNIT

PURPOSE: To assess residents’ perception of remote telemonitoring with regard to the educational value it may contribute in their residency training and to improved patient care.

TEMPORAL VARIABILITY OF REMOTE ELECTRONIC TELEMONITORING UNIT INTERVENTIONS BETWEEN WEEKDAYS AND WEEKENDS

PURPOSE: Studies suggest higher mortality for patients admitted to the hospital during weekends and weeknights. Remote telemonitoring units interventions in the ICU should be greater in severity and quantity during weekends and weeknights.

The formal specification of an electrocardiogram compressor.

Remote telemonitoring of physiological parameters is being used increasingly both for medical research and for clinical management. However, the technique entails the collection of large volumes of information for transmission and storage which necessitates efficient means of data compression. This paper presents a simple mathematical model of the lossy compression of physiological signals. The model is developed in a top-down style making design decisions progressively. First a general model of lossy compression is developed and some lemmas presented. Then the model is refined to take advantage of inherent cyclicity in many types of physiological signal. Finally the model is specialized to the compression of electrocardiograms. An algorithm is described for implementing the model. The algorithm is a table-based method capable of achieving very low output bit rates (50 bps) with reasonable fidelity. This compares favourably with the results obtained by other workers and holds promise for further evaluation. The generality of the model should ultimately allow a coherent approach to the compression of the various types of physiological signal currently being recorded.

Tearing down the barriers to daily home hemodialysis and achieving the highest value renal therapy through holistic product design.

Renal therapy value can be defined as the ratio of outcomes achieved by a dialytic therapy to the total cost of providing that therapy. One desirable goal of any dialysis modality would be the achievement of maximum value. Unfortunately, with conventional hemodialysis and peritoneal dialysis modalities, improving outcomes has always been linked to a simultaneous increase in costs, thereby leaving value relatively unchanged. However, a new modality, daily home hemodialysis, finally may allow this linkage to be broken. The outcomes are dramatically improved as a result of a higher quantity and quality of dialysis dose resulting from the greater frequency of treatments. The costs can be reduced by minimizing the consumed items, avoiding the labor and overhead of dialysis clinics, and reducing the costs associated with morbidity. Provision of this therapy is, however, predicated on the availability of instrumentation designed specifically for it because conventional equipment designed for in-center use is not suitable. By starting with a clean sheet of paper and incorporating such features as insitu reuse of the entire extracorporeal circuit, remote telemonitoring, automated system disinfection, and integrated water purification, most of the impediments to performing this modality can be overcome.