Download Home health monitoring: critical success factors for implementation

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 selfmeasuring 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 bloodpressure 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.
Long term
outcome
Medium term
outcome
Short term
outcome
Reach
Patient receives care
closer to home
patients may not
follow advice of
professional
patients may
mistakenly think they
are continuously
monitored
staff may have
concerns about
increased workload
Activities
patients may
misunderstand
what they need
to do
Resources
patients may
have problems
using
technology
patients have a
trusted
relationship
with healthcare
professional
Staff and patients can
use HHM in practice
patients take
and interpret
their own
measurements
Staff and patients are
knowledgeable about
HHM
potential
patients are
carefully
selected
Reach staff and
suitable patients
ongoing
support and
learning needs
addressed
Discuss using the
HHM system with
patients
HHM technology
and equipment
resources
Figure 1: Simple results chain example
technology
is easy to
use
Key:
Potential risk factor
Potential mitigating
factor
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


*patients may have problems using the
technology



*technology does not link up with existing patient
record

broadband provision was unreliable
(9)
measuring equipment was
unreliable(14)
devices malfunctioned(7)
some patients had difficulty collecting
their data (10)
some patients had difficulty using
digital technology to send data(10)
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)
factors to consider when planning for
examples
activities
potential risk factors
patients may not be confident to self-manage or
adjust medication
*patients may feel anxious about an aspect of
home health monitoring such as
having more responsibility or using the
reported in the literature

some patients recognized a change in
their data, but weren’t sure what
action to take as a result(13)

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


potential mitigating factors
patient learning and support needs relevant to
home health monitoring are identified and
addressed on an ongoing basis
*patients are adequately trained in selfmanagement
patients relied on professional
decision-making(13)
some patients perceived that they
were collecting data to help the
professionals to manage their
condition(7)

patients may require support and
appropriate training to use the
systems (17, 21)

it is useful to assess how patients
understand the concept of selfmanagement(12)
professionals felt that patient training
may support self-management (7)

*professionals are competent in supporting selfmanagement

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)
factors to consider when planning for
examples
reach
reported in the literature
potential risk factors
*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 selfmanagement 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)
potential mitigating factors
*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)
factors to consider when planning for
outcomes
potential risk factors
examples
reported in the literature
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 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
*patients have a trusted relationship with the
health professional who is providing advice

many patients reported being less
anxious to take readings at home(10)

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)
potential mitigating factors
patients take and interpret their own
measurements
overarching
factors
examples
reported in the literature
not easily attributed to results chain
potential risk factors
*self-management impacts on existing systems
of care
potential mitigating factors

community and district workloads
were affected(9)
*important to plan the project with stakeholders
and undertake ongoing evaluation with staff and
patients
*telemonitoring is integrated in to an established
clinical context


there should be continuous feedback
from patients and professionals about
new working practices(7)
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.
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Appendix 1: Summary table of included studies
Year
Author(s)
Location
Condition
Aim of study
Types of participants Scale
Technology
Methodology
Data (often measured Frequency of Clinical reviewer of
‘symptoms’ as well
patient data data (frequency of
measured but for rapid transmission review)
Data feedback
review these are not
tabulated)
2013 Fairbrother et Scotland
al.
(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
2012 Roberts et al. Scotland
(Argyll and
Bute)
COPD
To describe the
implementation and
outcomes of a
telehealth initiative
(2009)
Patients: age range 61- 10 participants relating Home 'pod' with touch
102 years
to a trial within NHS
screen.
Highland at home and
in the community (17
people at home, total
number of people
unknown)
2013 Fairbrother et Scotland
al.
(Lothian)
Heart Failure
To understand the views Patients: 61% male, age
of patients and
range 50-80, mean age
professionals on
75 years
telemonitoring for
chronic heart failure
23 (18 patients, 5
healthcare
professionals)
participants relating to
a trial within NHS
Lothian (number of
people unknown)
Patients: mostly male, 15 participants relating
age range (mean) 44-86 to a trial of 182
years (74), mostly with patients
a new diagnosis of
heart failure, mostly
symptomatic on
moderate activity,
mostly white British,
mostly retired, mostly
lived alone
2013 Riley et al
England
Heart Failure
(West London)
To explore whether
telemonitoring
empowers patients to
self-care
2012 Cottrell et al.
England
(Stoke on
Trent)
Hypertension
To determine the patient Patients: chronic
Participants relating to
experience of using the kidney disease (CKD)
a trial of 124 people
telehealth service
Stages 3 or 4 with BP
persistently >130/85
mm Hg or patient is >50
years old and
hypertensive
2014 Williams et
al.
England
(Oxford)
COPD
To explore patients'
expectations and
experiences and the
impact of using a
mobile health
applocation
Patients: 57% male, age
range (mean) 50-85
(67), 84% stage 2 and 3
COPD, 57% living with
spouse or family)
2012 Jones et al.
England
(West
Midlands)
Hypertension
To explore patients'
views of self-monitoring
blood pressure and selftitration of
antihypertensive
medication
Patients: 57% male, age 23 participants relating
range (mean) 49to a trial of 527
84years (70), mean
patients
blood pressure at
baseline 159/84, 91%
married or cohabiting,
57% professsional
occupation
Tablet
Semi-structured
Peak flow and oxygen
interviews with patients saturation
(n=38) and healthcare
professionals (n=32)
Daily
Clinical team (daily)
Questionnaire to
patients, staff and
carers (n=?) Semi
structured interviews
with healthcare
professionals (n=10)
Oxygen saturation
Daily
Community nursing
team
(daily)
Device linked via
bluetooth to pulse
oximeter, electronic
sphygmomanometer
and electronic weighing
scales.
Semi-structured
Pulse rate, oxygen
interviews with patients saturation, blood
(n=18) and healthcare pressure, weight
professionals (n=5)
Daily
An algorithm was used
to process data. Values
which breached pre-set
levels flagged up. The
clincian then contacted
the patient.
Standalone
telemonitoring system
to take daily
measurements using a
weighing scale,
automated blood
pressure cuff and a
pulse oximeter.
In depth interviews with Pulse rate, oxygen
patients (n=15)
saturation, blood
pressure, weight
Daily
Initially a single GP.
Later, specialist nurses
( daily on weekdays)
and Lothian
Unscheduled Care
Service (daily at
weekends)
Specialist Nurse (daily)
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)
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.
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.
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 light 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).
Blood pressure
19 patients relating to a Computer and bluetooth- Semi-structured
Pulse rate and oxygen
pilot study of 23 people enabled pulse oximeter interviews with patients saturation*
(pilot study relates to a with finger probe.
(n=19)
future trial* which aims
to recruit 186 people)
Participant given a
blood pressure monitor
and a modem to send
readings.
Semi-structured
Blood Pressure
interviews with patients
(n=18) and healthcare
professionals (n=5)
Team contacted
patients if expected
data did not arrive or
data received was not
within expected range.
Not stated
Any variation outwith a
predefined range
triggered an alert. The
clincian then contacted
the patient.
Year
Author(s)
Location
Condition
Aim of study
Types of participants Scale
Technology
Methodology
Data (often measured Frequency of Clinical reviewer of
‘symptoms’ as well
patient data data (frequency of
measured but for rapid transmission review)
Data feedback
review these are not
tabulated)
2012 Seto et al.
Not specified
but
presumably
Canada
Heart Failure
To develop a rule-based Clinicians
expert system for a
heart failure mobile
phone based
telemonitoring system
10 participants relating Wireless medical
to a trial of 100
device sent data via
patients
Bluetooth to patient
mobile phone.
2013 Lynga et al.
Sweden
Heart Failure
To explore and describe
patients' perceptions of
transmission of body
weight
Patients: 65% male, age 29 participants relating
range (mean) 61-86
to a trial of 179
years (74), 65% copatients
habiting
Participants given a
weighing scale, weight
measurments were sent
from the scale via
wireless to the patient's
phone.
Semi-structured
Weight
interviews with patients
(n=23) amd family
members (n=6)
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 Number of participants
mostly older people. 10 in included papers
studies related to
ranged from 20-165
advanced COPD
severity.
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
Mostly daily
saturation, spirometric
parameters,
medication, heart rate,
temperature, weight
2015 Kitsiou et al.
15 review
Heart Failure
papers
reviewed from
various
countries
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
A taxonomy was
devised to classify
interventions and
technologies.
Summary of findings
tables created and
quality of review
methodologies
assessed
Aterial blood pressure, Variable
weight, cardiac rate
Number of total
participants in included
reviews ranged from
774-6561
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.
Daily
Heart Failure Nurses
(usually Mon, Wed, Fri).
Data always checked
within 4 days.
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
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.
Mostly healthcare
In half of studies,
professional on a daily transmitted data was
basis
automatically analysed
and alerts were sent to
healthcare
professionals or
research team when the
data value was outwith
a pre-defined
acceptable range.
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)
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)
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)
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)
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)
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)
p.6:'Patients and professionals reported experiencing technical problems with the equipment,
notably recurrent malfunctions with the peripheral devices'(7)
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)
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)
'p.36:Delays in linking [to the electronic patient record system] meant that data had to be transferred
manually between systems [at first]'(9)
p.36:'Managing chronic disease while incorporating telehealth alters the interaction between
patients and healthcare workers' (9)
p.141:'Self management impacts on patients, their interactions with clinicians'(11)
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p.35:'The home COPD pods affected community and district workload in particular'(9)
p.141:'Self management impacts on…the current professional led system of hypertension care'(11)
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p.407: Many [staff] expressed concern about creating dependence on the technology and/or
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Technology
reminds patients
to take
measurements
Connectivity or
reliability
problems could
deter users
Patients may have
problems using
the technology
Technology does
not link up with
existing patient
record system
The patientclinician
relationship or
interaction
changes
Self-management
impacts on
existing systems
of care
Professionals
SCOTLAND
ENGLAND
have concerns
that patients will
become more
dependent on
them
Professionals
have concerns
about increased
workload as a
result
Technology is
easy to use
Technology
provides timely
feedback /receipt
after patient
transmits data
The technology is
able to be
personalised to
patients (see text
for
characteristics)
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)
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)
p.560:'[Professionals] were concerned the alerts would be false positives and would result in patients
going to the emergency department unnecessarily'(15)
p.7:'The impact of telemonitoring on home visits and existing practice was of particular concern to
professionals'(7)
p.35:'Most [staff] respondents had concerns about impact on their current and future workload'(8)
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)
p.407:Many patients found the technology easy to use'(8)
p.5:'All of the respondents found the technology easy to use'(7)
p.35:'The technology was described as straightforward and easy to use'(9)
p.3:'Patients found Florence easy to use'(10)
p.394:'Patients [transitioned] from being uncertain about their ability to use the technology to being
confident to use it'(12)
p.3:'[For some patients] the transmission of body weight and the daily weighing was easy to do…'
(14)
p.257:'Overall, patients found the technology easy to learn and/or use"(17)
p.2449:'Effective telemonitoring also required the equipment to function accurately and patients
learnt quickly if their telemonitoring data were successfully transmitted'(13)
p.3:'Patients were satisfied with the feedback they obtained from Florence'(10)
p.561:'Each time [a patient reading was completed] an alert message/instruction was sent to the
patient [and clinician]'(15)
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)
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)
p.261:'The frequency of data collection and transmission should be flexible to improve adherence to
telemonitoring interventions'(17)
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Telemonitoring is
integrated in to
an established
clinical context
Patients may
believe their data
is monitored
continuously
Patients may not
be confident to
self-titrate
Patients may feel
anxious about an
aspect of home
health monitoring
such as having
more
responsibility or
technical
competence
Changes required
for patients to
self-manage and
patients and
professionals to
assume their new
p.8: '[Professionals] considered integration of telemetric provision with local practitioner services
preferable to 'call-centre' type provision'(7)
p.35:' A number of 'normalisation' issues concerning training, communication and integration with
existing professional work patterns were identified’(9)
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)
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)
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)
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)
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)
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)
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)
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)
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p.408:'Professionals acknowledged the challenges in adapting established attitudes, behaviours and
practices to address the challenges of telemonitoring-supported self-management'(8)
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)
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roles and
responsibilities
are complex
A joint
management
document is
developed
between patient
and health care
professional
outlining their
new roles
Patients have a
trust and
relationship with
the health
professional who
is providing advice
Patient learning
and support
needs relevant to
home health
monitoring are
identified and
addressed
Patients are
trained in selfmanagement
Professionals are
competent in
supporting selfmanagement
p.408:'[Professionals] placed emphasis on their role in supporting 'patient preparedness' to selfmanage through the provision of self-management plans, through coaching and advice and through
the dispensing of information materials'(8)
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)
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)
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p.7:'Many patients expressed a preference for being telemonitored by professionals with whom they
had an existing association'(7)
p.2451:'Our findings confirm the importance of the relationship between the patient and
telemonitoring nurse'(13)
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)
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)
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)
p.6:'The importance of formalised education and training in supporting patient self-management
was discussed by professionals'(7)
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)
p.6:'Practitioners queried the utility of the telemonitoring technology in supporting selfmanagement…some [staff questioned] whether patients would identify responsibility for selfmanagement without [staff] support'(7)
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)
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
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A sufficiently
skilled
practitioner
reviews data and
provides feedback
Home health
monitoring is not
suitable for all
patients
Potential patients
are carefully
selected (see text
for
characteristics)
Professionals may
be concerned that
patients will not
self-manage
There may be
concerns that
patients will see
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)
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)
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)
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)
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)
p.140:(citing main trial) 'Self-management will not be appropriate for all patients'(11)
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)
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)
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)
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)
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)
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)
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)
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)
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themselves as sick
or dependent
(Contradictory
findings)
Patients perceived
professionals
retain primary
responsibility for
their home health
monitoring
Patients gain
increased
knowledge of
their condition
Patients feel
reassured as they
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)
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)
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)
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)
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)
p.2450:The majority [of patients] relied on the decision making of a telemonitoring nurse'(13)
p.396:'They [some patients] appeared to rely more on healthcare professionals to make decisions
about treating exacerbations'(12)
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)
p.407:'Many [patients] found it helpful to know their oxygen saturation and to learn their 'normal'
range'(8)
p.5:'Patients also expressed the view that they felt better informed and knowledgeable about their
condition'(7)
p.35:'Most [staff] felt that it was appropriate for rural patients to be monitored at home and that
telemonitoring promoted self-management.'(9)
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)
p.395:'Patients also indicated an increased awareness of the variability of their symptoms'(12)
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)
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)
p.407:''Most patients appreciated the accessibility of the telemonitoring service and the reassurance
of feeling constantly 'watched over' by telemonitoring professionals'(8)
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perceive that their
health is being
closely monitored
Patients may not
implement advice
as suggested
Technology is
used as part of a
routine
Patients take and
interpret their
own
measurements
Patients are less
anxious when
they take their
own blood
pressure and so
avoid inaccurate
readings
Professionals felt
leadership was
important to
developing
p.6:'Many [patients] thought the service was designed to increase practitioner support, rather than
to foster greater personal responsibility'(7)
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)
p.4:'Descriptions of being looked after and [a] sense of security... emerged [from the interviews]' (14)
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)
p.5:'One patient highlighted that despite improved understanding, patients remain free to exert their
autonomy'(10)
p.2451:'We also found that this elderly population used the telemonitoring daily and integrated it in
to their everyday lives'(13)
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)
p.3:'[Telemonitoring] became a routine often done without reflection…'(14)
p.140:'Some patients [relished] the opportunity to manipulate their own treatment'(11)
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)
p.5:'There were patients who closely followed their weights, being aware when something was
beginning to go wrong'(14)
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)
p.9:'Professionals stressed the importance of effective leadership and project management in the
development of future telemetric service provision'(7)
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)
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services
Important to plan
the project with
stakeholders and
undertake
ongoing
evaluation with
staff and patients
Patients make
decisions about
their care and
when to contact
professionals
based on the data
they collect
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)
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)
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)
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)
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