Where are we going?

Distance technologies for patient monitoring

E Andrew Balas, Weil distinguished professor of health policy ^a,  Ilias Iakovidis, scientific officer ^b. 

^a Center for Health Care Quality, University of Missouri, Columbia, MO 65211, USA, ^b Health Telematics Unit, European Commission, Brussels, B-1049, Belgium

Correspondence to: E A Balas Abalas{at}health.missouri.edu

Medical technology once used exclusively in hospitals and general practices is now available for use in the home. A growing selection of innovative electronic monitoring devices is available, but meaningful communication and decision supports are also needed for both patients and clinicians. Several randomised clinical trials of home distance monitoring of glucose concentrations by computer found improved outcomes in diabetes care. Likewise, trials of home distance monitoring of blood pressure show enhanced efficiency. Failure to improve outcomes of high risk pregnancies through home distance monitoring illustrates the difficulties in certain clinical applications. Overall, electronic monitoring at home promises cost effective health services, more active involvement of patients in their own care, and a new sense of realism in making a diagnosis.

	Distance technologies

Top Distance technologies The gamut of home... Controlled trials of home... Conclusions References

With access to home monitoring devices, computers, and communication networks, patients can become more active in their own health care. This review lists available technologies for home distance monitoring, assesses its clinical value, and identifies criteria for its appropriate use. Some of the articles included in this review were already in place as part of the Columbia registrya systematic collection of trials of information and utilisation management at the University of Missouri's school of medicine.¹

	The gamut of home distance monitoring

Top Distance technologies The gamut of home... Controlled trials of home... Conclusions References

Home distance monitoring often requires the creative use of not just various measurements or monitoring devices but also communication technologies and organisational support services.

Electronic monitoring devices for home use
Medical technology is now available for use in the home (box). Numerous studies have explored the clinical application of novel monitoring devices, for example, a whole blood prothrombin time monitor,² a portable sleep monitor,³ an electronic spirometer. ^{4 5} Telephone and videoconferencing equipment can be used for the measurement of mobility, sleep patterns, and self care behaviours, such as cooking, washing, and toileting, and can properly identify changes in the functional health status of patients at home.⁶

Communication and computerised decision support
Communication tools are needed for patients in their home and also for clinicians receiving information from a multitude of sources (for example, interactive telephone based systems and computer networks). Often store forward techniques (data collected and transported later) work better than live communication. In a group of infants who were either premature, had had apparent life threatening episodes, or had siblings who had died from sudden infant death syndrome, monitors recorded all episodes of apnoea greater than 15 seconds and bradycardia episodes less than 80 beats/min.⁸ Information was transferred at regular intervals, and the recordings could validate parental reports of apnoea episodes at home and could assist in the evaluation of the patients.

Patient care policies and procedures
Several studies illustrate how home monitoring can be combined with treatment. Pierratos et al reported on nocturnal haemodialysis over 3 years.¹² Nocturnal haemodialysis, a new modality of renal replacement therapy, entails dialysis for 6 to 7 nights per week during sleep at home. The functions of the dialysis are monitored through a modem at a nocturnal haemodialysis centre. The patient must take special precautions to prevent accidental disconnection during sleep and air embolisation. Twelve patients have completed training and successfully performed nocturnal haemodialysis for up to 34 months.¹² Blood pressure control was achieved with fewer drugs, subjective improvement was significant, and complications were infrequent. Nocturnal haemodialysis seems to present an efficient form of dialysis at low cost.

(Credit: SUE SHARPLES)

	Controlled trials of home distance monitoring

Top Distance technologies The gamut of home... Controlled trials of home... Conclusions References

Randomised controlled clinical trials represent the planned experimental approach of evaluation, and they can provide the most reliable information about the clinical value of home distance monitoring. Fortunately, a growing number of randomised controlled trials in health services research, including evaluations of home distance monitoring, have been reported in recent years.¹³

Better outcomes
Several studies of computerised home distance monitoring in the management of diabetes found improved outcome effects.^14-17 In one study a significant improvement in glycohaemoglobin concentrations was found in a group of 56 diabetic patients sending details of their glucose concentrations through a modem to their physicians compared with a control group entering their glucose concentrations in diaries (8.9 v 9.3; P<0.05).¹⁴ Two other studies also found that glucose monitoring by telemedicine led to significant reductions in glucose concentrations in the modem group (22 patients; 13.2% improvement) compared with the control group (20 patients; 8.9% improvement). ^{15 16} In one of these trials¹⁵ a follow up questionnaire showed that patients in the modem group had developed a better understanding of blood glucose control and an improved motivation for self management. Evaluation of remote access to Diabeto, a computer assisted diet education system, found that it significantly improved dietetic knowledge (8% v 2% improvement; P<0.0005), dietetic habits, and metabolic balance as opposed to no access for 105 patients in a crossover trial.¹⁷

Difficulties in achieving better health
Home monitoring of pregnant women at risk of preterm labour and fetal mortality illustrates the difficulty of researchers in some clinical applications. To achieve appropriate blood glucose control in diabetic women during pregnancy frequent admission to hospital has been recommended, particularly in the third trimester. Numerous randomised controlled clinical trials evaluated the effect of home care on outcome of high risk pregnancies.^18-20 Patients in the intervention group were instructed to perform self monitoring at homefor example, for blood glucose concentration, uterine activity, and fetal heart rate. The frequency of pregnancy complications, likelihood of preterm delivery before the 36th week of gestation, problems of blood glucose control, and prenatal death rates were not significantly different between mothers who were monitored at home and those who were admitted to hospital or received visits by nurses during the same period.

Equal care promises cost saving
In a prospective randomised controlled clinical trial at four medical centres 31 patients in the intervention group were asked to measure their blood pressure twice weekly and to send a record of their blood pressure readings, changes in antihypertensive drugs, and any possible side effects by post every 4 weeks. The recorded data were transferred to a clinical computer, and reports were generated for each patient's physician. Patients who did not submit blood pressure readings on time were contacted by telephone. The 31 patients in the intervention group had 1.5 visits to their physician during the study year whereas the 31 patients in the control group (usual care) had 2.7 visits per year. According to one study doctors' prescribing decisions may also be influenced by evidence from self measurement of blood pressure.²¹

	Conclusions

Top Distance technologies The gamut of home... Controlled trials of home... Conclusions References

Distance monitoring should extend beyond data collection and generate feedback, prompt preventive care, and support patient education. Future telehealth applications are likely to combine initial screening, measurement devices, patient education, decision support, appropriate telephone and video contacts, home visits, emergency support services, and physician access.

Available studies are unspecific about the impact of increased technical sophistication on patient access to quality health care. The role of computer literacy and the need for training clinicians particularly need clarification in future studies. Evidence based healthcare policies could facilitate the development of home care technologies and also accelerate the introduction of these technologies in patient care. Observations from randomised controlled clinical trials show that millions of physician visits could be avoided annually. As expectations are growing the European Commission wants more research on the application of distance care technologies.

	Footnotes

Funding: This research was supported in part by a National Library of Medicine grant (LM05545).

Competing interests: None declared.

	References

Top Distance technologies The gamut of home... Controlled trials of home... Conclusions References

1.	Balas EA, Stockham MG, Mitchell JA, Austin SM, West DA, Ewigman BG. The Columbia registry of information and utilization management trials. J Am Med Inf Assoc 1995; 2: 307-315[Abstract/Free Full Text].
2.	Massicotte P, Marzinotto V, Vegh P, Adams M, Andrew M. Home monitoring of warfarin therapy in children with a whole blood prothrombin time monitor. J Pediatr 1995; 127: 389-394[Medline].
3.	Mykytyn IJ, Sajkov D, Neill AM, McEvoy RD. Portable computerized polysomnography in attended and unattended settings. Chest 1999; 115: 114-122[Abstract/Free Full Text].
4.	Lindgren BR, Finkelstein SM, Prasad B, Dutta P, Killoren T, Scherber J, et al. Determination of reliability and validity in home monitoring data of pulmonary function tests following lung transplantation. Res Nurs Health 1997; 20: 539-550[Medline].
5.	Finkelstein SM, Snyder C, Edinstibbe C, Chlan L, Prasad B, Dutta P, et al. Monitoring progress after lung transplantation from home-patient adherence. J Med Eng Technol 1996; 20: 203-210[Medline].
6.	Nakamura K, Takano T, Akao C. The effectiveness of videophones in home healthcare for the elderly. Med Care 1999; 37: 117-125[Medline].
7.	Jacob SV, Morielli A, Mograss MA, Ducharme FM, Schloss MD, Brouillette RT. Home testing for pediatric obstructive sleep apnea syndrome secondary to adenotonsillar hypertrophy. Pediatr Pulmonol 1995; 20: 241-252[Medline].
8.	Gibson E, Spinner S, Cullen JA, Wrobel HA, Spitzer AR. Documented home apnea monitoringeffect on compliance, duration of monitoring, and validation of alarm reporting. Clin Pediatr 1996; 35: 505-513[Abstract/Free Full Text].
9.	Magrabi F, Lovel NH, Celler BG. A web-based approach for electrocardiogram monitoring in the home. Int J Med Inf 1999; 54: 145-153[Medline].
10.	Fayn J, Conti L, Fareh S, Maison-Blanche P, Nony P, Rubel P. Interactive and dynamic ECG analysis. Is it just an IDEA or a clinically relevant approach? J Electrocardiol 1996; 29: 21-5S.
11.	Hernando ME, Gomes EJ, Delpozo F, Corcoy R. Diabneta qualitative model-based advisory system for therapy planning in gestational diabetes. Med Inf 1996; 21: 359-374.
12.	Pierratos A, Ouwendyk M, Francoeur R, Vas S, Raj DSC, Ecclestone AM, et al. Nocturnal hemodialysisthree year experience. J Am Soc Nephrol 1998; 9: 859-868[Abstract].
13.	Balas EA, Jaffrey F, Kuperman GJ, Austin Boren S, Brown GD, Pinciroli F, et al. Electronic communication with patients: evaluation of distance medicine technologies. JAMA 1997; 278: 152-159[Abstract].
14.	Rosenfalck AM, Bendtson I. The Diva system, a computerized diary, used in young type 1 diabetic patients. Diabete Metabolisme 1993; 19: 25-29[Medline].
15.	Ahring KK, Joyce C, Ahring JPK, Farid NR. Telephone modem access improves diabetes control in those with insulin-requiring diabetes. Diabetes Care 1992; 15: 971-975[Abstract].
16.	Billiard A. Rohmer V, Roques M, Joseph MG, Suraniti S, Giraud P, et al. Telematic transmission of computerized blood glucose profiles for IDDM patients. Diabetes Care 1991; 14: 130-134[Abstract].
17.	Turin MF, Beddok RH, Clottes J, Martini PF, Abadie RG, Buisson JC, et al. Telematic expert system Diabeto: new tool for diet self-monitoring for diabetic patients. Diabetes Care 1992; 15: 204-212[Abstract].
18.	Brown HL, Britton KA, Brizendine EJ, Hiett AK, Ingram D, Turnquest MA, et al. A randomized comparison of home uterine activity monitoring in the outpatient management of women treated for preterm labor. Am J Obstet Gynecol 1999; 180: 798-803[Medline].
19.	Monincx WM, Zondervan HA, Birnie E, Ris M, Bossuyt PMM. High-risk pregnancy monitored antenatally at home. Eur J Obstet Gynecol Reprod Biol 1997; 75: 147-153[Medline].
20.	Dyson DC, Danbe KH, Bamber JA, Crites YM, Field DR, Maier JA, et al. Monitoring women at risk for preterm labor. N Engl J Med 1998; 338: 15-19[Abstract/Free Full Text].
21.	Bailey B, Carney SL, Gillies AAH, Smith AJ. Antihypertensive drug treatment: a comparison of usual care with self blood pressure measurement. J Human Hypertens 1999; 13: 147-150[Medline].
22.	Fry JM, Diphillipo MA, Curran K, Goldberg R, Baran AS. Full polysomnography in the home. Sleep 1998; 21: 635-642[Medline].