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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. 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%20CSFBoynton-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. 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. 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) HYPERTENSION HEART FAILURE ENGLAND INTERNATIONAL HYPERTENSION ENGLAND COPD ENGLAND COPD SCOTLAND HEART FAILURE HEART FAILURE HYPERTENSION EUROPE COPD INTERNATIONAL HEART FAILURE SCOTLAND COPD SCOTLAND COPD SCOTLAND HYPERTENSION ENGLAND 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) COPD HYPERTENSION SCOTLAND ENGLAND p.407: Many [staff] expressed concern about creating dependence on the technology and/or COPD SCOTLAND 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) HEART FAILURE SCOTLAND COPD SCOTLAND HEART FAILURE HEART FAILURE COPD HEART FAILURE COPD HEART FAILURE COPD HYPERTENSION COPD INTERNATIONAL HEART FAILURE COPD HEART FAILURE HYPERTENSION HEART FAILURE HEART FAILURE HYPERTENSION EUROPE HEART FAILURE INTERNATIONAL COPD INTERNATIONAL SCOTLAND SCOTLAND INTERNATIONAL SCOTLAND SCOTLAND SCOTLAND ENGLAND ENGLAND INTERNATIONAL ENGLAND ENGLAND INTERNATIONAL EUROPE ENGLAND 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) HEART FAILURE COPD SCOTLAND HYPERTENSION ENGLAND COPD ENGLAND HEART FAILURE HEART FAILURE INTERNATIONAL HEART FAILURE SCOTLAND HEART FAILURE HYPERTENSION ENGLAND HYPERTENSION ENGLAND HEART FAILURE SCOTLAND HYPERTENSION ENGLAND HEART FAILURE EUROPE 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) COPD SCOTLAND COPD SCOTLAND SCOTLAND INTERNATIONAL ENGLAND 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) COPD SCOTLAND HEART FAILURE ENGLAND HYPERTENSION ENGLAND 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 HEART FAILURE HEART FAILURE HEART FAILURE HYPERTENSION SCOTLAND COPD INTERNATIONAL HEART FAILURE HEART FAILURE COPD INTERNATIONAL HEART FAILURE SCOTLAND COPD SCOTLAND HYPERTENSION ENGLAND ENGLAND INTERNATIONAL ENGLAND SCOTLAND ENGLAND 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) HEART FAILURE HEART FAILURE HEART FAILURE HEART FAILURE ENGLAND HEART FAILURE EUROPE HYPERTENSION HYPERTENSION ENGLAND ENGLAND HEART FAILURE SCOTLAND HEART FAILURE HYPERTENSION ENGLAND COPD ENGLAND COPD INTERNATIONAL COPD SCOTLAND HEART FAILURE HEART FAILURE SCOTLAND EUROPE ENGLAND INTERNATIONAL ENGLAND SCOTLAND 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) HEART FAILURE COPD EUROPE HYPERTENSION ENGLAND COPD SCOTLAND HEART FAILURE SCOTLAND HEART FAILURE COPD ENGLAND HEART FAILURE EUROPE COPD SCOTLAND HEART FAILURE COPD SCOTLAND HYPERTENSION ENGLAND HEART FAILURE COPD HEART FAILURE ENGLAND COPD INTERNATIONAL COPD SCOTLAND SCOTLAND ENGLAND SCOTLAND ENGLAND EUROPE 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) HEART FAILURE HYPERTENSION SCOTLAND COPD SCOTLAND HEART FAILURE HYPERTENSION EUROPE HEART FAILURE HYPERTENSION ENGLAND HEART FAILURE HYPERTENSION ENGLAND COPD HEART FAILURE HYPERTENSION HEART FAILURE HEART FAILURE HYPERTENSION SCOTLAND EUROPE HYPERTENSION ENGLAND HEART FAILURE HEART FAILURE SCOTLAND ENGLAND ENGLAND ENGLAND ENGLAND ENGLAND ENGLAND EUROPE ENGLAND INTERNATIONAL 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) HEART FAILURE SCOTLAND HYPERTENSION ENGLAND HEART FAILURE COPD INTERNATIONAL HEART FAILURE ENGLAND SCOTLAND