Health services in the developed world are faced with unprecedented challenges over the coming years. The ageing population and increased prevalence of long-term conditions have been factors for some time, but the pressure on resources has been exacerbated by the economic turmoil of recent years.
Increasing healthcare costs and expectations, coupled with the growing need for restraint in healthcare spending – particularly in publicly funded systems such as the National Health Service (NHS) in the UK – have led to increased emphasis on providing ‘better for less’. This quest for efficiency is particularly apparent in cardiovascular care, where enhanced management is paradoxically increasing the prevalence of patients with long-term cardiac conditions.
Technology provides just one solution to the problems faced by healthcare providers in the future. In particular, innovations such as telehealth and telecare give practitioners the opportunity to provide enhanced care with the same – or fewer – resources. These technologies may also enable patients to become much more active participants in the provision of healthcare. Indeed, innovative and well-planned deployment of technology may be the only method of delivering personalised, affordable, high-quality healthcare in the future. This article provides an overview of the current status of telehealth in cardiovascular care, and offers some possibilities for the next steps to be taken in this exciting and innovative area of practice.
Current Models of Telehealth Utilisation In Cardiac Care
Before exploring the current status of telehealth, it is important to clarify the nomenclature. Terms such as telemedicine, telehealth, telemonitoring and telecare are often used interchangeably, leading to some confusion. For the purposes of this article, telehealth will be used to describe any use of technology to remotely promote wellbeing, assess health status or manage disease. Under this umbrella term, a number of more specific applications exist. Telemedicine utilises two-way video consultation technology to allow remote discussion between practitioners and patients or between collaborating practitioners. Telemedicine can also be used to describe the transmission of healthcare data such as radiological investigations or 12-lead electrocardiograms (ECGs). Telemonitoring is the use of technology to remotely monitor vital signs or symptoms, and teletriage is the remote assessment and prioritisation of patient needs using technology. Other terms such as tele- or cyber-therapy will be required as telehealth technologies evolve from relatively passive systems to become methods for actually delivering healthcare interventions.
Over the past few years a number of telehealth applications have been developed for patients with cardiovascular disorders. As part of the more generalised move towards teletriage in many regions and countries, the first port of call for patients with cardiac symptoms may be a call centre, such as NHS Direct in the UK or the Canadian Telehealth Service. A recent review of activity patterns within a large call centre (Ask Mayo Clinic within the US) identified that 4% of calls were from patients with chest pain or discomfort.1 Although this figure may be proportionally small, it represents a substantial number of patients who may have acute coronary syndromes when extrapolated to a service such as the NHS Direct health advice service, which receives over five million telephone calls per year.2
Telemedicine services for patients with cardiac (or suspected cardiac) conditions exist in a number of different centres. These services generally use videoconferencing technologies, sometimes supplemented with the transmission of physiological data (such as 12-lead ECGs), to allow remote assessment of patients. In the UK, a recent pilot of a telemedicine service utilising only 12-lead ECG transmission demonstrated the potential for substantial reductions in hospital attendances and financial cost.3
In the broader field of cardiovascular medicine, telemedicine is also being deployed to assist with the immediate assessment of stroke patients – sometimes referred to as ‘telestroke’. Telestroke systems usually provide the opportunity for remote physical assessment of patients with stroke symptoms, coupled with access to radiology results. This allows decisions to be made regarding a patient’s suitability for thrombolysis even if a specialist stroke physician is not available on-site. A number of stroke telemedicine services exist worldwide, with services appearing to improve access to thrombolysis and enhance decision-making in certain populations.4,5 Indeed, the American Stroke Association has stated that in the acute setting, a telemedicine-facilitated assessment by a stroke specialist is recommended when a bedside assessment is not immediately available.6
For patients with mechanical heart valves, atrial fibrillation or history of embolic stroke, anticoagulation with warfarin remains the mainstay of thromboembolic prophylaxis. The introduction of near-patient testing technologies for anticoagulation monitoring has enabled a move towards self-monitoring supported by warfarin dosage calculation software. Home anticoagulation monitoring appears to be feasible, safe and effective in selected patient groups.7
In principle, telemonitoring of anticoagulation should be technologically and operationally feasible: self-monitoring technology with the ability to transmit findings remotely has been commercially available for some time. However, although the feasibility of anticoagulation telemonitoring has been demonstrated, a number of technical problems have been identified and the benefits are uncertain.8
Of all the areas of telehealth related to cardiology, the greatest wealth of research evidence relates to the use of telemonitoring for patients with heart failure (HF). In addition to the human cost of HF – it has a prevalence of 2–3% and a four-year mortality rate of approximately 50%9 – the financial cost to healthcare providers is substantial and growing. A number of randomised controlled trials (RCTs) and cohort studies have demonstrated that telemonitoring for HF patients – with vital signs, weight and symptom reporting automatically uploaded to a server where it can be viewed and acted upon by a practitioner – has substantial clinical benefits. The Trans-European Network Home Care Management System (TEN-HMS) study demonstrated a significant decrease in one-year mortality with telemonitoring compared with usual care (29 versus 45%), while the HOME-HF study suggested that telemonitoring could reduce unplanned HF hospital admissions.10,11 Recent meta-analyses have also demonstrated that remote monitoring for HF patients reduces mortality and hospital admissions.12,13
Many pacemakers and implantable cardioverter–defibrillators (ICDs) now have the capacity to remotely transmit information on device function – and malfunction – on a daily basis, allowing problems to be detected and corrected much more quickly.14,15 Implanted systems have also been developed to monitor patient physiology, including heart rate and rhythm, heart rate variability, activity, respiratory rate and fluid accumulation in the lung. These can be used to identify patients who are deteriorating before severe symptoms develop and, often, to identify the cause of the worsening condition. Given that device implantation is now considered standard therapy for many HF patients, the move towards integrated device and patient monitoring is intuitive and relatively straightforward. Indeed, the ability to couple device surveillance with enhanced patient monitoring has been described as providing a ‘win–win’ solution for patients and practitioners.16 The INfluence of Home Monitoring on The clinIcal Management of heart failurE patients with impaired left ventricular function (IN-TIME) study – due to report in late 2010 – will evaluate the impact of home monitoring for HF patients with either ICD or cardiac resynchronisation therapy (CRT) with ICD backup.17
Future Developments in Telehealth for Cardiovascular Disease
As technologies become more affordable and the evidence base less equivocal, it is likely that telehealth innovations such as telestroke and telemonitoring for HF will be adopted into mainstream healthcare. However, the speed of technological development means that new service innovations will also come on-stream within the next few years.
The embedding of telehealth services into routine clinical practice – previously described as normalisation18 – has been slow to develop. This is due to a number of factors, including a lack of clarity with regard to cost and reimbursement, difficulties in developing a comprehensive and consistent technology infrastructure, concerns over clinical governance issues and the need for enhanced workforce education.19 Arguably, the greatest barrier to the development of telehealth has been excessive focus on the technology itself rather than the service in which it should be embedded. Once the concept of what telehealth can deliver is realised, it is likely to be adopted as routine care for many long-term conditions. Telemonitoring for HF should become standard practice within the next decade,20 anticoagulation should be managed remotely wherever possible and patients in rural or hard-to-reach areas should receive teleconsultations to support their care.
Embedding telehealth solutions into the fabric of healthcare is not simply about inventing gadgets that work. It requires telehealth services that are designed around patient need, that are properly evaluated to ensure effectiveness and safety and that are delivered by a workforce with the necessary knowledge and skills. In addition, efforts must be made to enhance the level of intelligence exhibited by telehealth technologies. For example, telemonitoring services – such as those operational for HF patients – are often made less efficient by the occurrence of false alarms. These may be due to technical issues (such as weighing scales not working) or unsophisticated decision-making algorithms that deliver many false-positive clinical alerts. In addition to enhancements in technology, a better understanding of what constitutes a significant clinical change will also allow for more intelligent and effective telemonitoring systems. For example, moving from simple rule-of-thumb calculations towards a more sophisticated moving average convergence divergence algorithm related to weight gain provides a more specific (though less sensitive) model for predicting episodes of worsening heart failure.21
As telehealth becomes more commonplace, it will inevitably develop in a number of different directions. Telemedicine solutions will become more sophisticated and applicable in a wider range of settings. It may in certain cases be deemed useful to deploy video links within a patient’s own home, allowing for direct consultation between the patient and his or her carer without the need to visit a healthcare setting. However, this should be undertaken with care. One of the potential benefits of telehealth is to reduce the intercessionary role of the health professional and make the patient more independent. Reducing the demands on health professionals by dealing with mundane, routine and repetitious questions and tasks – ideally suited to computers and automated systems – is one of the major ways in which telehealth can improve the quality of care in an affordable way. Overuse of video links has the potential to undermine this, so it is important that deployment of, and access to, this technology is carefully structured.
The use of telehealth will evolve from a process of monitoring patients remotely to one of personalising care and further empowering patients to take control of their own management. The provision of educational and motivational material via telehealth platforms will grow, and reliance on healthcare professionals will lessen. One particular example of utilising telehealth technologies to empower patients is in the area of cardiac rehabilitation (occasionally leading to the use of the term telerehabilitation). Piotrowicz and colleagues recently reported on their experience of delivering and monitoring a rehabilitation programme for HF patients. The study demonstrated that telemonitoring could provide an effective platform for supporting home-based rehabilitation,22 and it is likely that similar service models will grow in prevalence over the next few years. Similarly, success has been reported in the delivery of remote cardiac rehabilitation for patients following myocardial infarction or cardiac revascularisation.23,24
Understandably, there has to date been a focus on the value of telehealth solutions in the reduction of hospital admissions among patients with long-term cardiac conditions. However, the potential for technology in the management of acute cardiac care is also substantial. The use of telestroke and teletriage has already been discussed, but telemonitoring also carries the potential of helping to facilitate the early discharge of patients from acute care.
There are many political drivers for facilitated discharge, notably the need to reduce length of hospital stay and avert readmission. One of the barriers to discharge home after an acute cardiac event may be concerns about the lack of clinical or social support available. However, telemonitoring equipment that enables telemetry of cardiac rate and rhythm and other physiological indicators may enable hospitals to discharge patients earlier with the clinical support required to prevent readmission.
The existing and potential monitoring capabilities of therapeutic devices such as pacemakers and ICDs have been discussed earlier. However, the future may herald the increasing utilisation of devices implanted purely for their telemonitoring capabilities. For example, the Pulmonary Artery Pressure by Implantable device Responding to Ultrasonic Signal (PAPIRUS) II study evaluated the feasibility and safety of remotely monitoring pulmonary artery pressures in HF patients utilising a miniature implantable device. The study demonstrated feasibility, safety and acceptability, and randomised controlled trials have been advocated to assess clinical benefits.25
Although devices can be introduced percutaneously, the inherently invasive nature of implantable monitors will to some degree limit their utilisation. Non-invasive monitoring technologies are also advancing quickly. Adhesive patch technologies, such as the Corventis PiiX™, provide systems that allow remote monitoring of physiological status with the added benefits of portability and easy application.26 Looking slightly further into the future, remote monitoring technology will be coupled with ‘intelligent tablets’ that can detect and report their own ingestion; products such as the Proteus Raisin™ already demonstrate the feasibility of such an idea.27 Technology such as this not only presents opportunities for optimised medication compliance, but also will allow for evaluation of the physiological impact of medication on individual patients.
Existing telehealth solutions tend to focus on patients who have already been identified with cardiovascular disease. In the future, telehealth technologies have the potential to serve as powerful screening tools for members of the public. The introduction of community-based ‘telekiosks’ will allow members of the public to test vital signs and identify their risk status, and, if necessary, provide a portal into healthcare services and primary prevention.
Telehealth carries with it huge potential to revolutionise the delivery of healthcare. Through remote monitoring, teleconsultation, education and motivation and cybertherapy, patients can be empowered to take control of their disease and reduce their reliance on carers. The most under-utilised resources in cardiology are the patients themselves; with the targeted utilisation of technology, we can harness the potential of self-care and enhance the lives of those for whom we care.