HIMSS: Remote monitoring shown to be ineffective, time-consuming in PCP setting
 |
“Simultaneous control of blood glucose and blood pressure is complex and difficult to achieve, but could help to improve outcomes with costly illnesses like diabetes and hypertension,” wrote lead authors Bonnie J. Wakefield, PhD, RN, research associate professor at Sinclair School of Nursing at the University of Missouri, and Richelle J. Koopman, MD, assistant professor of family and community medicine at the University of Missouri School of Medicine, both in Columbia. “Thus, the use of remote monitoring programs can shift some responsibility for patient management from the patient’s primary physician to other clinicians, such as nurses or pharmacists.”
Self-managed support can be provided by using home-based technologies that enable healthcare professionals to monitor patients more routinely than is possible through face-to-face office visits. This monitoring, according to the authors, may facilitate earlier medication intensification and partially address the phenomenon called “clinical inertia,” wherein providers are hesitant to increase medication dosages for fear of adverse events. But, with remote monitoring, the providers can possibly receive real-time data, which will allow them to adjust the treatment plan more often.
The purpose of the study was to evaluate the effectiveness of short-term use of remote data transmission of blood glucose (BG) and blood pressure (BP) to the clinic in adult patients with diabetes.
For this study, which included 108 participants, patients assigned to the intervention group (53) measured their BP daily and BG as often as currently advised by their provider. Using a telephone or PC, the patients uploaded their data to a web portal for three months. Data from the intervention group were reviewed by the clinic nurse, who later reviewed the data with the physician if needed.
Patients in the control group (55 patients) tested their BP and BG at the same frequency as the intervention group, and manually recorded their readings in a diary. All treatment changes were individualized according to the patient’s needs, and changes in therapy were usually communicated by telephone call to the clinic.
The outcomes assessed during the trial were the proportion of patients with the BG goal of A1c less than 7 percent and the BP goal of less than 130/80 at the end of three months in two primary care practices.
The participants in the study had established type 2 diabetes or hypertension, whose BG or BP were not in control—with an A1c greater than 8 percent or a systolic BP greater than 130. Also, all the patients were on oral medication or insulin.
Of the 108 participants—with a mean age of 60 years—56 percent were female, 87 percent were Caucasian and 11 percent were black, and 63 percent were married while 30 percent were divorced or single. In the two clinics, there were 11 clinicians (10 family medicine/one internal medicine) and six nurses.
At the end of three months, there were no significant differences between the two groups in getting the patients’ A1c or systolic BP under control. Thus, the authors concluded that “the remote monitoring program did not improve patients’ diabetes or blood pressure control, as the program was implemented.”
In the primary care setting, Wakefield and Koopman found that the implementation facilitators were supportive of the intervention and “did not find it too bothersome,” and the electronic transmission vendor was responsive to requests for technical troubleshooting when a problem fell outside the clinic staff’s expertise.
However, they also found that barriers to implementation were the lack of integration of the system and website with the EHR, meaning nurses had to transcribe data from the EHR to the website. This also meant that the nurses had to communicate by telephone, rather than use the functionality of the personal health record—which likely took more time. Finally, the physicians noted the lack of reimbursement strategy for this between-visit work in a fee-for-service reimbursement model as another barrier.
“Most physicians felt that new models of reimbursement would be needed before this type of remote monitoring system could become standard in practice,” the authors summed. The physicians also were disappointed with the evidence of benefit to the patient in this study.
Specifically, for workload in this study, nurses spent an average of 32 minutes per day in tasks related to the transmitted data. The most time-consuming task was reviewing patient data on the website—an average of 9.8 minutes per day, followed by providing feedback to patients at 6.6 minutes per day. Also, it was noted that the lack of integration of the website with the EHR increased nurses' workload and made workflow more complex, according to surveyed nurses.
Wakefield and Koopman concluded that in order for a practice to adopt this technology, they should first:
- Understand the capabilities and limitations of the technology;
- Design and understand the workflow, flow of information and human side of the equation;
- Involve the patient in the process; and
- Integrate the data transmission system with the EHR and the electronic personal health record, if one is available.