Skip to main content

Telemonitoring: Sounds Great. But it doesn't work.

Telemonitoring is a novel disease management strategy that sounds wonderful. But just because something sounds wonderful does not mean it works. Sometimes new technologies are implemented into clinical practice just because we think they should work. But wishful thinking should not be good enough for our patients. New technologies should be subjected to rigorous evaluation before they are widely implemented

Telemonitoring in theory that should improve outcomes for patients with chronic illness. Patients are given devices for use at home that allow them to transmit information via the phone or internet to their providers. This often includes information about vital signs such as blood presssure and weight, symptoms, or other parameters such as blood sugar. The theory is that this information will allow providers to detect problems early, intervene, and prevent clinical deterioration. It sounds so good that many health systems have implemented telemonitoring for a number of conditions. For example, the VA health has made a huge investment in telemonitoring, and within the VA there are major efforts underway to increase the number of Veterans who get telemonitoring.

However, a rigorous study has just been published in the New England Journal of Medicine that throws big doubts on the usefullness of telemonitoring. The study was led by Dr. Sarwat Chaudhry of Yale University. Chaudhry randomized 1653 patients with heart failure as they were discharged from the hospital. This was an excellent test for telemonitoring, as heart failure defines a condition for which telemonitoring should work, and the time after hospital discharge is a very high risk period as many patients decompensate shortly after they go home and need to be readmitted.

Patients randomized to telemonitorinng received a device that allowed them to report weight and heart failure symptoms on a daily basis via a toll free number. The information was transmitted to their clinicians for review. Concerning information (variances) were flagged for attention.

The benefits of the intervention? Absolutely nothing. Those who got telemonitoring had the same rate of mortality and readmission as those who got usual care.

There are many possible reasons for the ineffectiveness of telemonitoring in heart failure. It may be that collecting lots of data on patients and feeding it back to providers is not as useful as we want to believe. Perhaps what's needed is a lesser flood of information and more sophisticated thinking about how to use this information.

But the bigger question: Is all this enthusiasm for telemonitoring justified? I don't think so. This study certainly should raise major concerns in the VA, which now needs to consider the possibility that its investment in telemonitoring is not the wisest use of resources.

Is it possible that other approaches to telemonitoring might be more effective? Certainly. But the burden of proof is now on the advocates of those approaches. Medical practice should be driven by evidence, not wishful thinking.

This study is an important example of why new technologies need to be subjected to rigorous evaluation before they undergo widespread implementation.

by: [Ken Covinsky]

Comments

Much as I love technology, I agree that technology for it's own sake is probably a waste of time. I would like to know more about the support systems around the telemonitoring. Technology does not exist in a vacuum.

The North Shore of Long Island Jewish Health System presented at NAHC in 2009 on their low literacy telehealth program. They had a great station set up in the home with a video camera and a touchscreen monitor (no keyboarding required. This really was for low literacy folks.) There was lots of follow-up and interaction. Not just simple reporting of values.

Their randomized control trial showed significant clinical and financial improvements.

I'm also thinking of the Care Transitions Intervention by Eric Coleman at University of Colorado. Their intervention involved very active coaching to teach patients/families advocacy techniques as well as knowing when to invoke "Plan B" and when to go to the ER. They also had an interactive record, which I believe involved patient access to home monitored values and the ability to communicate with the coach about it.

Tech in a vacuum, is just a lot of toys. Tech as a tool to facilitate interaction, education and empowerment, I suspect has loads of value. I think it's about matching the technology with the human factor.

Popular posts from this blog

Practical Advice for the End of Life: A Podcast with BJ Miller

This week we talk with BJ Miller, hospice and palliative care physician, public speaker, and now author with Shoshana Berger of the book "A Beginner's Guide to the End."

As we note on the podcast, BJ is about as close as we get to a celebrity in Hospice and Palliative Care.  His TED Talk "What Really Matters at the End of Life" has been viewed more than 9 million times.  As we discuss on the Podcast, this has changed BJ's life, and he spends most of his working time engaged in public speaking, being the public "face" of the hospice and palliative care movement.

The book he and Berger wrote is filled to the brim with practical advice.  I mean, nuts and bolts practical advice.  Things like:
How to clean out not only your emotional house but your physical house (turns out there are services for that!)Posting about your illness on social media (should you post to Facebook)What is the difference between a funeral home and mortuaryCan I afford to die?  …

Improving Advance Care Planning for Latinos with Cancer: A Podcast with Fischer and Fink

In this week's GeriPal podcast we talk with Stacy Fischer, MD and Regina Fink, RN, PhD, both from the University of Colorado, about a lay health navigator intervention to improve advance care planning with Latinos with advanced cancer.  The issue of lay health navigators raises several issues that we discuss, including:
What is a lay health navigator?What do they do?  How are they trained?What do lay health navigators offer that specialized palliative care doesn't?  Are they replacing us?What makes the health navigator intervention particularly appropriate for Latinos and rural individuals?  For advance care planning? Eric and I had fun singing in French (yes French, not Spanish, listen to the podcast to learn why).
Enjoy! -@AlexSmithMD




You can also find us onYoutube!



Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher

Transcript

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, I'm really excited about toda…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …