Download Ambulatory Telemonitoring of Physiological Data: A Systematic

MOBILE SYSTEMS FOR CHRONIC DISEASES TELEMONITORING: CURRENT STATUS
Authors: ALVES, José Pedro Figueiral Oliva Soares; CAMPOS, Marta Sofia Gomes; DATA, Tânia
Rodrigues; ESTEVES, Alexandra Sofia Moreira; FARIA, Carlos Augusto da Silva; FERNANDES,
Diana da Silva; GUEDES, Paulo Renato Moreira; MACHADO, Marino João Pinto; MAGALHÃES, Ana
Isabel Pereira; MARQUES, Pedro Seabra; MATOS, José Pedro Rodrigues; MELO, Inês Marisa
Tribuzi de Magalhães; MOREIRA, Pedro Manuel Costa; NASCIMENTO, João António Santos;
PEREIRA, Maria Francisca Azevedo Marques; SILVA, Ana Rita Carneiro.
Authors’ e-mail: [email protected]
Adviser: RODRIGUES, Pedro Pereira.
Class Number: 05
ABSTRACT
Background: Chronic diseases telemonitoring is a result of recent technological breakthroughs
which allows clinicians to make use of electronic equipment with the intent to record physiological
processes while the patients undergo normal daily activities, becoming a more efficient process of
chronic diseases management and early detection of abnormal health parameters.
Aim: Expose scientific evidence which supports the use of mobile telemonitoring systems in different
chronic diseases, as well as the advantages to patients, physicians and healthcare institutions.
Methods: A comprehensive literature search was conducted in Pubmed and ISI Web of Knowledge,
to identify relevant published articles which were, then, submitted to a process of quality assessment
according to the established criteria. The results of individual studies were synthesized and
statistically analyzed.
Results: A total of 13 studies were found in the literature (5 Diabetes, 5 cardiac disease and 3
hypertension). Most articles (76.9 %) described potential benefits for the patient. Telemonitoring has
a high level of acceptance (23%) and provides a larger amount of information available about the
patient’s condition (23%). It influences patient and physician attitudes and behaviours (54%), leading
to an apparent better disease self-management (23%). The costs (15%), lack of physical contact
(15%) and difficulties in using computer technology (15%) are the main reported disadvantages.
Conclusion: Mobile Telemonitoring systems are likely to be a useful tool for chronic diseases
management since they are well-accepted, increase patients’ compliance and enable to diagnose
and apply treatment at distance. An adaptation of clinical guidelines for the implemantation of this
technology is needed as well as further research to assess its cost-effectiveness.
1
KEY-WORDS: telemonitoring, physiological data, telemedicine, self monitoring, chronic diseases,
cardiovascular disease, diabetes, hypertension, mobile telemonitoring, mobile devices and their
synonyms.
INTRODUCTION
supervision, observation or care[17]. Many of
In this new century, medicine is facing a new
these patients – who are often elderly people –
challenge called telemonitoring[1], which will
need regular monitoring because of the length
revolutionize healthcare delivery processes by
of their disease, the nature of their health
changing some of the long-held assumptions
condition and the drugs that they are using.
and creating innovative alternative models[2].
Therefore telemonitoring is also a way of
Telemonitoring of physiological data consists
responding to the new needs of home care in
on the collection, record and transmission of
an ageing population.
clinical data between a patient at a distant
location and a healthcare provider through
electronic
information
processing
technologies[34] . This implies that the patient
undergoes normal daily activities and is
provided on an outpatient basis[34]. Hence,
healthcare services are delivered via remote
telecommunications. The so-called "objective
technological monitoring" is no longer the only
way
to
monitor
physiological
data
from
patients[3], and a wide range of telemonitoring
devices
is
available
nowadays,
enabling
several diseases monitoring.
The
most
ambulatory
promising
Fig. 1 Benefits of mobile telemonitoring systems for both
the patient and healthcare providers[4].
Telemonitoring can bring benefits for patients,
applications
telemonitoring
healthcare
professionals
and
intitutions[4].
chronic
Its use can allow symptoms and abnormal
illnesses, such as cardiopulmonary disease,
health parameters to be detected earlier than
asthma, heart failure and diabetes[1]. Chronic
during a routine or emergency consultation,
diseases
are
residual
and corrective measures can be taken before
disability,
are
nonreversible
more serious complications appear. It may also
pathological alteration, require special training
result in less frequent visits to healthcare
of the patient for rehabilitation, or may be
facilities, thereby increasing the quality of life
expected
for patients[5]. Furthermore, it seems to be
to
are
for
permanent,
caused
require
leave
by
a
long
period
of
2
[5].
cost-effective
This may also be a useful method, for
clinicians, to gather more information with less
Fig. 2 Growth in the number of published articles about
Ambulatory
Telemonitoring,
indexed
in
Pubmed,
between 1990 and 2007.
effort and, moreover, healthcare professionals
Despite the fact that the domains in which
are able to follow the patients closely spending
telemonitoring has been used remain slightly
[6-
unclear, the creation in 2002 of a project called
Despite its potential, most telemonitoring
MobiHealth for the development of mobile
services are still limited to the status of
health services, funded by the European
temporary projects without clear prospects for
Commission, only reinforces the above results
wider
[15].
less time, through ambulatory telemonitoring
10].
use
and
healthcare system
proper
[11-13].
integration
into
There is limited
In 2008, the global market for telemedicine
is estimated to be worth €4.7bilion increasing
cost-
to over €11.2 billion by 2012, an average
effectiveness of telemedicine services on a
annual growth rate of 19%[16]. This reveals not
large
only how recent this matter is, but also its
evidence
of
scale.
the
effectiveness
Awareness,
and
confidence
and
acceptance by health authorities, professionals
emerging relevance.
and patients still needs to be strengthened[17].
This
The advantages telemonitoring may possibly
supporting the use of mobile systems for
bring for patients make it an important and
chronic diseases telemonitoring, by means of a
relevant problem to be investigated. A simple
systematic review, identifying which chronic
and not very restricted search at Pubmed
diseases have been targeted, analysing the
about ambulatory telemonitoring found more
types of physiological data monitored and the
than 500 articles, and 93% of those were
advantages
published between 2000 and 2008.
healthcare intervenients, namely the patient,
article
exposes
and
scientific
disadvantages
evidence
for
the
the physician and the healthcare institution.
METHODS
A
comprehensive
literature
conducted in Pubmed
Knowledge
[33]
[32]
search
was
and ISI Web of
to identify relevant published
articles, using keywords such as: ambulatory,
physiological
data,
telemonitoring
and
synonymous .
The research was limited to articles with
abstract available in English and about human
telemonitoring.
3
The 502 articles obtained were submitted to a
examined the outcomes of telemonitoring
process of critical appraising according to its
using mobile systems.
quality in order to select potential articles using
Study variables are the types of chronic
the following inclusion criteria: (1) studies
disease and physiological data monitored as
which involve direct data collection from
well as the benefits and drawbacks mobile
human patients, (2) using outdoor-usable
telemonitoring systems can bring for the
devices and (3) which document scientific
patient, clinician and the healthcare institution
evidence of telemonitoring effects (health
(health improvement, system usability, cost-
improvement,
We
effectiveness, etc.), which were extracted
excluded articles which: (1) were focused on
through an extensive analysis of the articles.
athletes telemonitoring (2) address monitoring
The statistical study was carried out in SPSS®.
system
usability,
etc.).
which does not make use of mobile systems,
(3) were general reviews or (4) conference and
RESULTS
poster abstracts.
General Overview
After abstract revision, 174 articles were
The majority of the studies included were
included (34.7%).
conducted in the United States (46.1%) and
Then, an extensive analysis of the full-text took
92.3% were reported in the past five years
place using the additional criteria: we included
(Table 1).
articles: (1) with full-text available (2) written in
A similar number of articles related to mobile
English
diseases
telemonitoring systems were found for each
mobile
one of the three chronic illnesses: diabetes
telemonitoring systems. We excluded articles
(n=5), cardiac diseases (n=5) and hypertension
which: (1) do not present a detailed description
(n=3), involving both adult and child patients.
of the study, (2) describes a project of a new
The type of study design, samples size and
instrument and (3) general reviews. Despite
study duration varied according to the chronic
the change in the inclusion and exclusion
disease and the study in question. Overall,
criteria, none of the articles excluded in the first
more than half (54%) of the studies were
revision would have been included in the
nonrandomized trials without control group,
second revision since the new criteria is a
while 46% involved randomization with (31%)
restriction of the previous one. Moreover, no
and without (15%) control group. Contrarily to
heterogeneity between reviewers was found
diabetes and heart disease telemonitoring
regarding the number of included/excluded
studies,
articles (Chi-Squared test: p=0.668). As shown
nonrandomized trials, 66% of hypertension
in Table 1, a total of 13 studies were found in
studies were randomized trials with control
the
groups. (Table 2)
(3)
telemonitoring
scientific
addressing
and
(3)
literature
chronic
using
(1996–2008)
that
most
of
which
(66%)
were
4
The size of the experimental group varied
control group (80). In terms of proportion of the
between 10 for Diabetes and 750 for cardiac
control group in relation to the experimental
diseases with heart diseases telemonitoring
group, diabetes has the highest percentage
having the largest average samples of patients
(50%). The study duration varied among the
(236), followed by hypertension (168) and
three groups. It ranged from a minimum of 3
diabetes (55). The control group varied from 10
days for Diabetes to a maximum of 18 months
to 150 patients with hypertension having a
for hypertension and cardiac diseases (Table
considerably larger average of patients in
2).
Table 1 – Profile of mobile telemonitoring systems studies – Number of studies, country and date of
publication and type of patient sample for each chronic disease
How many?
Total numbers of studies
Where?
USA
Australia
Canada
UK
Norway
When?
1996
2004
2005
2006
2007
2008
With whom?
Patients with cardiovascular disease
- Adults hospitalized with heart failure.
- Enrolled in health centers.
- Recently implanted with CRT-D.
- With symptomatic chronic heart failure
and left ventricular ejection.
- Undergoing cardiac rehabilitation.
Patients with Diabetes
- Young patients and their parents.
- Young patients using insulin for at
least one year.
- Wide-ranging patients with type I Diabetes
-
Adult patients with type II Diabetes and
uncontrolled blood pressure.
Patients with uncontrolled hypertension
DIABETES
CARDIAC
DISEASES
HYPERTENSION
TOTAL
5
5
3
13
3
1
1
1
2
1
1
-
2
1
-
6
3
2
1
1
2
2
1
-
1
1
2
1
3
1
2
3
1
5
1
-
5
1
1
1
1
-
3
1
1
1
-
-
-
1
-
-
-
-
1
-
-
2
CRT-D - cardiac resynchronization therapy defibrillator
5
Table 2 – Overview of research designs – Type of study design, size of experimental and control groups and
study duration
DIABETES
CARDIAC
DISEASE
HYPERTENSION
TOTAL
5
5
3
13
Randomized trial with control group
1 (20)
1 (20)
2 (66)
4
Randomized trial without control group
1 (20)
1 (20)
Nonrandomized trial without control group
3 (60)
3 (60)
1 (33)
7
Maximum
200
750
450
750
Minimum
10
30
20
10
Mean
55
236
168
Median
18
81,5
33
Maximum
18 (50)
54 (44)
150 (25)
150
Minimum
18 (50)
54 (44)
10 (33)
10
Mean
18 (50)
54 (44)
80 (29)
18
54
80
Maximum
6 months
18 months
18 months
18 months
Minimum
3 days
6 weeks
4 months
3 days
3,82
months
4 months
7,9
months
6 months
11,3 months
Number of studies
Type of design, n (% within disease)
2
Size of experimental group
Size of control group, n (% within the respective experimental group)
Median
Study duration
Mean
Median
12 months
Table 3 – Types of data transferred in chronic diseases telemonitoring and frequency of data transmission to
healthcare provider
DIABETES
HYPERTENSION
TOTAL
5
CARDIAC
DISEASE
5
3
13
Heart Rate
-
3
1
4
Blood pressure
-
1
3
4
Heart electrical activity
-
2
-
2
5
-
-
5
Number of studies
Main types of data transferred
Blood glucose
Frequency of data transmission to health care provider
More than once a day
3
-
1
4
Once a day
-
2
-
2
A few times a week
-
2
1
3
Once a week
1
-
-
1
Once a month
1
-
-
1
Once every three months
-
-
1
1
Once every six months
-
-
1
1
6
Moreover, every telemonitoring study involved
disease (4 out of 5 articles), stating whether
collection and transference of clinical data
the system was cost-effective or not for the
about the patient’s health parameters. Blood
patient and the hospital. However, it remains
glucose was the parameter transferred most
inconsistent across the studies since some
frequently (38% of the studies) and was
report contradictory results. Almost every
exclusive for diabetes telemonitoring. Heart
article did not present any cost extensive
rate (31%) and blood pressure (31%) was
analysis.
common to heart disease and hypertension
Third, patient attitudes and behaviors were
studies while heart electrical activity (15%) was
mentioned in 46% of the articles (every article
only monitored in heart diseases (Table 3).
about hypertension, 2 out of 5 articles about
Finally, the information collected from the
diabetes, and 1 out of 5 about cardiac
mobile system was then transmitted to the
diseases). Overall, there was a high level of
healthcare provider. The frequency of data
patient’s acceptance and satisfaction (23%),
transmission varied throughout the studies, yet
the system was easily integrated into everyday
most studies reported several times a day
life (23%) and increased patient’s responsibility
(31%), once a day (15%) and a few times a
and compliance with the medication and
week (23%), mainly for diabetes and heart
treatment (31%).
diseases,
data
Fourth, physician facilities (38%), attitudes and
transmission. A few studies (31%) considered
behaviors (23%) were referred only in cardiac
data transmission over longer periods of time
diseases and hypertension, specifically the fact
and
that telemonitoring allows clinical discussion
this
as
the
was
regularity
particularly
of
common
in
hypertension. (Table 3)
between the physicians (31%) as well as a
As shown in Table 4, different types of effects
larger amount of information about the patient
were observed in the studies regarding mobile
condition (23%).
telemonitoring
then
Fifth, data quality (31%) was found in 3 out of 5
divided into seven categories: data quality,
articles about diabetes and in 1 article about
patient
heart disease, but it was not referred in
systems
conditions,
which
patient
were
attitudes
and
behaviors, physician attitudes and behaviors,
hypertension
studies.
The
accuracy
and
physician facilities, clinical effectiveness and
reliability of data transmitted was referred to be
economic viability. First, it should be noticed
the same of those traditional monitoring
that clinical effectiveness and structural effects
systems. However, sometimes the system
was the most focused aspect in studies found
warned the patient and the healthcare provider
in the literature (77%).
without necessity, specially in case of diabetes.
Second, assessment of economic viability was
Finally, 31% of the studies discussed the
referred in 54% of the articles, mainly in heart
patient condition (1 out of 5 about diabetes and
7
all
about
hypertension)
referring
that
a
significant improvement in blood pressure and
glucose was achieved.
Table 4 – Frequencies of types of effects observed in mobile telemonitoring systems studies.
DIABETES
CARDIAC
DISEASE
HYPERTENSION
TOTAL
5
3
1
2
4
2
5
1
1
1
2
3
4
3
3
3
2
3
3
1
13
4
4
6
3
5
10
7
Number of studies
Data quality
Patient condition
Patient attitudes and behaviors
Physician attitudes and behaviors
Physician facilities
Clinical efectiveness/ structural effects
Economic viability
Table 5 – Frequencies of advantages and disadvantages observed in mobile telemonitoring systems studies.
DIABETES
CARDIAC
DISEASE
HYPERTENSION
TOTAL
5
5
3
13
4
1
3
3
3
2
3
2
1
10
6
6
1
1
-
1
1
-
2
2
-
4
4
-
Number of studies
Advantages to:
Patient
Physician
Health care institutions
Disadvantages to:
Patient
Physician
Health care institutions
In terms of advantages and disadvantages,
this revolutionary technology were reported.
every article referring to hypertension, 80% of
First, 6 out of 13 studies stated an increase in
the diabetes and 60% of the heart diseases
patients’ responsibility and awareness of their
articles describe potential benefits for the
health condition as well as a more active role
patient. Nevertheless, it is important to point
in their disease self-management. Second,
out that 28.6% and 36% of studies stated
alerts sent to patient by the mobile device are
considerable
disadvantages
refered in 4 out of 13 studies and they can play
patient
the
and
healthcare
both
for
the
professionals,
an
essential
role
to
overcome
memory
respectively (Table 5).
problems with the purpose of a better control
Despite the variability of telemonitoring effects,
and increased compliance with the treatment
several positive and negative aspects about
(Table 6). The physician work can be facilitated
8
by realtime discussions between specialists in
condition enabling the physician to follow up
primary and secondary care (31%). 21% of the
the patient on a daily basis rather than just on
articles
the day of the medical exam or consultation
mentioned
information
the
available
larger
about
amount of
the
patient’s
(Table7).
Table 6 – Advantages and disadvantages of mobile telemonitoring systems for the patient
DIABETES
CARDIAC
DISEASE
HYPERTENSION
TOTAL
5
5
3
13
Advantages
- Ability to overcome the problems.
- Increased level of patients’ responsibility.
- Helps in disease self-management.
- Patients received an alert everytime the values of blood
pressure are lower or higher than the normal-
1
2
1
1
-
1
2
2
1
2
3
4
- Patient enthusiam and acceptance.
- System easily integrated into everyday life.
- Child independence while being monitored by their parents.
2
3
1
-
1
-
3
3
1
- Allows patients with memory problems to remember to take
medication.
- Allows the introduction of healthy habits of practice of
physical exercise and alimentation in patients.
1
-
1
2
-
-
1
1
1
1
1
-
1
2
1
1
1
1
-
1
2
2
1
1
1
1
1
Number of studies
Patient
Disadvantages
- Costs.
- Difficulty in using Internet.
- Difficulty in accepting new technologies.
- No physical contact with the doctor.
- Problems of integration of other diseases.
- Problems of adaptation in the routine.
- Warns unnecessarily in situations of low levels of glucose,
especially during the night.
clinician (66% of articles about hypertension)
Regarding the disadvantages, 20% of the
and the necessity of clinician availability to
articles
analyze patient data (20% Cardiac diseases
about
Hypertension
Diabetes
articles
and
referred
33%
costs
of
and
and
33%
Hypertension)
were
the
most
economical issues as one of the drawbacks for
reported negative aspects for the physician
the patient. Difficulty in using the internet by
(Table 7). No negative impact on the hospital
elderly people was also reported in 66% of
was referred in any of the included articles
articles about hypertension (Table 6). The lack
(Table 8).
of physical contact between the patient and the
9
Table 7 – Advantages and disadvantages of mobile telemonitoring systems for the physician
DIABETES
CARDIAC
DISEASE
HYPERTENSION
TOTAL
5
5
3
13
Number of studies
Physician
Advantages
- Facilitates realtime discussions between physicians in
primary and secondary care.
2
2
-
4
- Less acute care needs when admitted.
- More accurate decision regarding the treatment of BP.
1
-
-
1
1
1
1
1
1
3
-
-
1
1
1
-
-
1
- Larger amount of information about the patient’s condition
enabling the patients’ follow-up the patient on a daily basis
rather than just on the day of the medical exam.
- Shows when the medication has adverse effects.
- Integration of physician in the patient routine.
Disadvantages
- No longer able to contact the patient directly.
- Has to adapt its guidelines to the new technology.
- Availability of the physician to analyze patient data.
- Failure in detection of low blood glucose values.
1
1
-
2
1
1
-
2
1
2
1
Table 8 – Advantages and disadvantages of mobile telemonitoring systems for the healthcare institution
Number of studies
DIABETES
CARDIAC
DISEASE
HYPERTENSION
TOTAL
5
5
3
13
2
1
-
2
-
4
1
-
1
-
1
Hospital
Advantages
- Reduction of hospitalization
- Automatically generated historical graphics transferred to
the healthcare provider, feasibility of the system.
- Reduction of hospital overcrowding.
to the fact that a sensitive but not so specific
DISCUSSION
query was used in order to prevent interesting
With this systematic review we intended to
articles from being excluded. Although our
synthesize and analyze information from a
research was focused in all chronic diseases
group of studies regarding chronic diseases
only articles about Diabetes, Cardiac Diseases
telemonitoring and assemble the results of
and Hypertension were found, contrarily to
these studies. This review aims at finding out
Paré et al.
on
mobile
pulmonary disease telemonitoring. Perhaps
telemonitoring systems have been used, a
pulmonary health parameters can only be
recent subject with emerging relevance. The
measured by home-telemonitoring systems,
large number of articles found (502) was due
which is in agreement with Paré et al. and the
which
chronic
diseases
[7]
who also made reference to
10
articles
excluded
regarding
pulmonary
diseases in our initial research.
systems.
According to
the included articles, USA is the country which
Advantages and Disadvantages
has
Patient
most
explored
the
use
of
mobile
technology to follow up chronic patients,
Despite rare exceptions, all the studies seem
followed
and
to confirm the accuracy and reliability of the
Canada. The date of publication of the articles
transferred data, which supports the success
ranges between from 1996 to 2008. No articles
of the use of this emerging technology. The
between 1996 and 2004 were found which
findings presented in this review are in favor of
could be explained by the fact that the article
the idea that, in general, it brings advantages
by
UK,
Australia,
Norway
any
to the patients enabling a better quality of life.
technological breakthrough since it is based on
It allows active participation in the process of
a
healthcare, increased patient’s independence
1996[18]
from
does
pre-existent
not
present
telemonitoring
(electrocardiograph).
Otherwise,
system
the
other
and responsibility
[19, 20, 21].
General satisfaction
articles included reveal the development of
and a high level of acceptance of the system
original new devices. By assembling the
was also reported
articles into three groups according to the type
articles presented an automated telemonitoring
of disease, it was evident that the majority of
system
articles were addressing type I Diabetes,
intervention in the collection and transference
revealing it is the disease for which most
of data, reducing bias and subjectivity. This
telemonitoring systems have been developed,
system has an identical level of effectiveness
due to the importance to closely monitor and
when compared to the traditional monitoring
control the levels of blood glucose on a daily
systems
basis.
promote
In
addition,
cardiac
diseases
were
also
which
[23].
[19, 20, 21, 22].
allows
One of the
minimal
patient
It was also mentioned that it can
a
healthy
lifestyle
with
an
improvement in physical exercise practice and
frequently targeted by mobile telemonitoring
balanced
systems, since the adoption of a western diet
awareness of their health condition
allied to increased sedentary behavior leads to
few
weight gain, hypertension and hyperlipidaemia,
compliance with the treatment, medication and
factors which in turn combine to amplify the
telemonitoring which is a result of a tighter
chances of getting heart disease and Diabetes
control achieved by an alarm system warning
[25].
the patient
Thereby, these two have a high level of
incidence and prevalence in population in
general
[31,],
development
diet
articles
as
stated
[19, 25].
it
increases
increased
patient
[24, 25].
A
patients’
On the other hand, problems
related to the usage and access to the internet
justifying the need for the
were often referred especially among elderly
of
people since they are not used to deal with
appropriate
telemonitoring
11
computer
[19,20].
technology
The
cost-
Health care institutions
effectiveness is quite controversial. Although it
Little evidence was found on the telemonitoring
requires an initial investment in the equipment
effects on the hospital and additional research
purchase, it may compensate in the long run,
is required to further investigate and analyze
since it decreases future expenditures in
the impact of chronic disease telemonitoring on
healthcare services
[18,20].
Besides, undesirable
healthcare institutions. Anyway, there seems
changes in the daily routine may happen as a
to be an agreement across a few studies
result of the permanent monitoring which leads
included, namely less frequent visits to the
to dependency towards the equipment and,
healthcare facilities, shorter hospital stays and
consequently
poorer
quality
of
life
[20].
decrease of hospital admissions
[28, 26, 23, 20].
Healthcare professionals
Study limitations
This kind of telemonitoring can also bring
After several literature revisions only 13
benefits to the healthcare professionals. It
studies were included in this article. Since it is
promotes the knowledge integration from the
a
different
healthcare
encouraging
generalizations or solid conclusions can be
discussion
[18, 20].
Moreover, the physician has
taken into account. The majority of the
[19, 26],
included articles included were nonrandomized
and can be warned through an alarm system
trials without control groups and very few were
every time the patients health parameters are
randomized trials with control group. It would
areas,
easier access to the patient information
not normal
[25, 27].
reduced
amount
of
evidence
no
Emergency situations can be
be recommended that future studies draw on
detected earlier preventing the occurrence of
randomized trials with control groups similar in
more serious complications. It is possible to
size to the experimental groups and over
follow closely the evolution of a patient health
longer periods of time. In addition, it was not
condition [28] and consequently to diagnose and
clearly stated whether the improvement shown
apply
distance.
in the patient health condition is due to over
However, a few limitations were found across
supervision or to the telemonitoring itself so
the studies, namely the lack of physical contact
future
treatment
with the patients
at
[20, 19],
adaptation of clinical
guidelines to this new way of healthcare
studies
are needed
to
accurately
evaluate the influence of all the variables in the
observed outcome.
delivery service [19] and it requires availability of
the
physician
in
order
to
ensure
the
maintenance of the equipment, as well as to
analyze
the
patient
data
[20].
CONCLUSION
Major Findings
Despite being a recent subject, there is a
growing body of knowledge about mobile
12
telemonitoring
systems.
According
to
the
results of this review, there is a general
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