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)


activities

examples



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)


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)


reach

examples



*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)


*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)


outcomes

examples



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)


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



*self-management impacts on existing systems of care

community and district workloads were affected(9)


*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.

http://as.nida.ac.th/~waraporn/resource/704-1-50/Readings/6-Assessment%20CSF-Boynton-Zmud.pdf

http://as.nida.ac.th/~waraporn/resource/704-1-50/Readings/6-Assessment%20CSF-Boynton-Zmud.pdf

http://www.gov.scot/resource/0041/00411586.pdf

http://www.sctt.scot.nhs.uk/programmes/community/home-based-health-monitoring/

http://www.gov.scot/Topics/Health/Services/Long-Term-Conditions

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.

http://www.gov.scot/Resource/Doc/311667/0098354.pdf

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



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


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


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


(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


range (mean) 49-

84years (70), mean

blood pressure at

baseline 159/84, 91%

married or cohabiting,

57% professsional

occupation


to a trial of 527

patients

Participant given a

blood pressure monitor

and a modem to send

readings.

Semi-structured



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


range (mean) 61-86

years (74), 65% co-

habiting


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


(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)


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)


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)


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)


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)


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)


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)


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)


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


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)


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)


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)


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)


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)


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)


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)


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)


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)


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)


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)


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

home health monitoring: critical success factors for implementation · 2016-04-14 · key points...

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