Can telehealth monitors in the home help nurses and doctors care for more patients with chronic conditions? Preliminary results from the country’s second telehealth research project – ASSET – indicate the answer is probably “yes”. FIONA CASSIE reports.
With telehealth, nurses can encourage patients to be more hands-on with their care, while the nurses themselves literally can be more hands-off. And according tow Matthew Parsons, one of the co-principal investigators of the telehealth ASSET (Application of Self-management Systems Trial), patients and nurses have responded positively to it.
The research project’s purpose was to see whether home telemonitoring could help more people with long-term conditions continue to live well at home.
In the just-completed trial, more than 90 heart failure, respiratory and patients with multiple chronic conditions were trained to measure their own “vital obs” and then send the results via the internet to their nurse’s computer screen using a hand-held hub device.
The health professional group found telemonitoring to be effective (by freeing up time) and it altered their practice so they could manage a higher-need client group. “Which was exactly what we were hoping to achieve,” says Parsons, who last year became the country’s first professor of gerontology nursing, a joint appointment between The University of Auckland and Waikato District Health Board.
ASSET was a joint initiative between The University of Auckland, working with Auckland District Health Board’s heart failure team, Counties Manukau DHB’s respiratory team and rural East Coast iwi health provider Ngāti Porou Hauora. Funding for the trial was provided by the Primary Health Care Innovations Fund. Parsons says the rationale for the trial was the rapidly ageing population and the resulting increase in demand for chronic care management.
Using telehealth technology is seen as a way of promoting self-management and improving the case management of chronic care patients, while at the same time making better use of limited health professional resources.
He says the two DHB specialist services were chosen for the randomised, controlled trial as their “usual care” standards were basically at the “cutting edge of evidence-based practice”. “If you were looking for the perfect services these were the perfect services.”
There was a need for a rural primary health study, and Ngāti Porou Hauora was seen as an obvious choice because of its strong rural nursing model.
The trial was clinician-directed, with the health professionals selecting the equipment and developing the clinical processes for gathering and monitoring patient data.
Some initial hiccups with the chosen technology saw some participants pull out and some trust lost, but Parsons repeats that qualitative results showed that patients and health professionals had responded positively to the telemonitoring intervention.
He says in some large overseas studies the standard of the care service is poor, and therefore telemonitoring meets with a positive reaction that is highly statistically significant.
For ASSET, the baseline standard of care was high. Parson says the “raw data is tending in the right direction”, indicating a positive impact overall, but the most significant finding for Parsons is that telemonitoring appears to allow health professionals to work with more clients with no detrimental impact on the clients already under their care.
“Let’s say the intervention has no impact on hospitalisation rates, the satisfaction levels for the clients are the same and there’s no difference between the (control and telemonitoring) groups. However, a nurse practitioner or nurse specialist worked with 80 or 90 clients instead of 40 or 50 clients. “If we had no difference all in the outcomes but we could use staff more efficiently, then that would be a positive outcome.”
Telehealth cutting rural health barriers
Living with a chronic health condition is never easy, and this is not improved by being in an isolated rural community with no public transport, sometimes dodgy fuel supplies and many people on low incomes.
Rural East Coast health provider Ngāti Porou Hauora was keen to be part of ASSET to see what impact telemonitoring might have on rural clients’ self-management of their chronic conditions.
The trial was run for 12 months during 2010/11 from the Uawa (Tolaga Bay) Community Health Centre, 45 minutes’ drive from Gisborne. Uawa is one of eight health centres run by the iwi health provider.
Hinemoa McLelland, research nurse for the Ngāti Porou Hauora trial, says the community’s isolation brings problems, yet this is also the source of some of its strengths, with strong whānau support, marae-based networks and a rich cultural identity.
It didn’t take long for the centre’s GP and nurse team to select 25 people to invite to trial the telemonitoring equipment. McLelland says people were keen to try the technology. The hauora greatly appreciated the Uawa community’s willingness to support the local trial.
The community’s predominantly Māori population was reflected in the 88 per cent of trial participants who were Māori. Most of the participants were also younger than their urban trial counterparts and were busy people, so self-managing their health conditions had to fit in with balancing family, work and community commitments.
McLelland says participants were quick to pick up how to regularly measure their own blood pressure and oxygen saturation and send the results down the line using the hub.
The hub software allowed participants and the clinic nurse monitoring the results to ask and answer questions in Māori – like a ‘txt’ conversation in te reo. This was ‘a plus’ as te reo Māori is an everyday language in the Uawa clinic and community.
Finding meaning in flashing numbers and bathroom scales
Analysis of the trial results is continuing (see sidebar). McLelland says from her personal observations the biggest impact was nurses and doctors handing over the power and responsibility to people to measure and record their own “vital obs”.
“When you do your own blood pressure for the first time, suddenly you’ve got these numbers flashing and you are going to be thinking – what does that mean? Is that good or bad?” After years of being told their results as a passive patient, people who are measuring their own blood pressure are keen to understand what the results actually mean for their health. Establishing a regular routine was also a frequently reported “positive” by trial patients. Patient feedback included:
“It helps me keep focused on my wellbeing”
“Keeps me close to the problem – keeps me aware of what is going on in the body”
“Those machines that you’ve given us have given us a better appreciation of where we are at in life”
“It’s given me a routine – so I now check my blood sugars more consistently”
Patients also reported that seeing their own immediate results at the same time as sending them to the clinic gave them a sense of reassurance and safety. And for nurses at the other end of the hub or telephone line it was an opportune time for discussing more health information with a patient and whānau.
It was made clear to people that if they did not feel well they still needed to get in direct touch with the clinic.
McLelland says answering the daily hub question “How are you feeling today?” was particularly important. The telecare results can be within a person’s normal parameters but people can still be feeling unwell and the only way to find out is to ask the person at the other end of the telemonitoring link.
Giving the measuring equipment to one member of the household also had a ripple effect across the whole whānau, says McLelland. Participants made comments like:
“It’s good for the whole family because it helps us watch our blood pressure”
“My grandchildren think it’s a buzz – they like to get involved”
“It brought home to me how important it was having access to equipment like a scale,” McLelland says. “Having scales in the house gives you instant feedback.” People were weighing themselves and making choices to change.
“They didn’t think about it – they did it, because they had something to work with… some people started to do exercises and lose weight simply because they had scales.”
Blown phone lines and households without landlines
McLelland sees telehealth as the way of future, particularly in isolated rural areas, where people living hours away from their nearest township on back-country farms, can lose a half day or more of work driving in for a test they could do themselves at home.
She also believes joining the trial was a wonderful opportunity to learn the realities of applying innovative technology in a rural region like the East Coast. “Rather than it being a roaring success in Auckland and then rolling it out around the country and finding it start to fall apart in our neck of the woods.”
For instance, some people were excluded from the Tolaga Bay trial as they didn’t have access to a telephone landline. “It’s important to be mindful of your target population as you could be hindering access if people don’t have a phone. And people managing on limited incomes find it easier with a cell phone,” says McLelland.
Inroducing new technology to an existing telephone line might also interfere with phone and internet services. And there’s no guarantee that rural telephone lines that crackle and hum during heavy rain or when electric fences nearby are on, are up to handling extra loading.
However, telehealth can be a very useful tool for rural areas with the funding, infrastructure and health worker training to support it.
She believes technology that helps patients and whānau to become more active participants in their own health management has to be the way to go in the future. “And hopefully sooner, rather than later.”
Heart failure patients don’t miss a beat
The oldest heart failure patient in the Auckland trial was well over ninety, while the youngest was around 20.
Research trial nurse Mariska ter Bals says mindset was more of a barrier than age when it came to using the technology. Most found it pretty straightforward. A more significant issue was whether some people were too fragile to stand on a set of scales to weigh themselves each day without the risk of falling off and hurting themselves.
In all, there were 98 patients on the Auckland DHB trial, all referred to the board’s heart failure service following a diagnosis of decompensated heart failure. Just fewer than 50 of them were randomised to the telemonitoring intervention for three months.
The secondary and community service has one dedicated nurse practitioner and two clinical nurse specialists, one of whom is Jane Hannah. Hannah says it is customary for the service to teach its patients to self-manage their care, including weighing themselves daily and checking changes in their breathing. “So telemonitoring helped reinforce what we were already doing.”
She says they found that the routine measuring and reporting helped people grasp some of the concepts better, including fluid balance. “We all hop on the scales and think we are looking for fat, but in fact in these patients we are looking for fluid,” says Hannah. “You get little old ladies desperately trying to put on weight because they are just 40 kilos, so it can be quite a confusing concept.”
She says the service had been part of an earlier telehealth pilot, so they were used to telemonitoring heart failure patients.
In this trial they went to the ASSET website, clicked on their patients’ observations and checked out whether anybody’s weight had gone up, they were reporting they were more tired, or whether they had problems with their breathing, or if there was swelling. “Then we could decide whether we would activate phoning them or not.”
She views telemonitoring as a way of helping patient’s self-manage their condition, and allows nurses to remotely monitor patients.
Telemonitoring came into its own when the service sought to increase or optimise a heart patient’s drug dose. The patient’s blood pressure and heart rate could be monitored daily, and their dose could be changed to suit.
Hannah says being able to remotely monitor patients also effectively meant they could see more patients. “It (telemonitoring) doesn’t take long to do.”
Overall she thinks telemonitoring is extra technology that could help to guide care. “I don’t think it’s a stand-alone. I still think eyeballing a patient and doing a whole physical assessment (is needed), and being with a patient you definitely see a lot more.”
But telemonitoring meant they could intervene a lot quicker when results were deteriorating. “So we weren’t relying on a patient to phone us to say ‘my weight’s gone up by two kilos’. You could see the results every day.”
Facts at a glance about ASSET (Application of Self-management Systems Trial)
Primary Health Care Innovations Fund joint research project by
The University of Auckland in league with:
• Auckland DHB: 98 heart failure patients (48 randomised to telemonitoring intervention for up to three months).
• Counties Manukau DHB: 8 respiratory failure patients (24 randomised to telemonitoring for up to four months).
• Ngāti Porou Hauora:25 patients with multiple conditions (the majority with diabetes). Post design so no control group and all using telemonitoring (19 using equipment for six months or more.)
• High-quality weight scales
• Blood pressure and heart-rate monitor
• Oxygen saturation probe
• Blood sugar monitor for diabetics
• Hub to record and transfer data through phone line to website
Participants regularly measured observations relevant to their condition including:
• oxygen saturation rates;
• blood pressure and heart rates;
• blood sugar results.
Results (and answers to three to four open questions pertinent to their condition) were sent via the hub to be monitored during the week by the patient’s clinical team. Results were reviewed as falling into either “green” (stable and requiring no action), or “red” (results outside set parameters), or “black” (no results recorded) and requiring nurse follow-up.
Sample open questions on the hub
• How are you feeling today? Same as/better than/worse than yesterday?
• Have you taken your medication today?
• Is your breathing more difficult today?
• Have you got more swelling?
• Is your blood sugar high? What do you think contributed to that?
• Are you more tired?
Quantitative research data collected
Baseline surveys of patients followed up at three months and six months, including Hospital Anxiety and Depression Scale (HADS), Self-efficacy Survey, Self Care of Heart Failure (SCFI) index, Saint George’s Respiratory Questionnaire (SGRQ) and Self Care of Diabetes Index (SCDI).
Preliminary analysis indicated trends toward modest or no improvement for telemonitoring over the “usual care” control group.
Costs: initial findings showed potential to increase client caseload caseload and potentially lower hospital-based costs while the client was using the equipment, but technological issues reduced trust in telecare equipment.
Still to come is in-depth analysis of first and second trial results, costs, health-related quality of life, plus hospital admission and ED attendance data.