Telemonitoring of patients with advanced COPD and heart failure within specialised home care - based on digital pen technology and a health diary form (“the eHealth Diary”)

The eHealth Diary, a 4 year long research study, aims at supporting patients with heart failure (HF) and/or chronic obstructive pulmonary disease (COPD) and their professional caregivers in specialised homecare through the use of a telehealth system based on digital pen technology. In the study, elderly, multi-morbid patients with COPD or HF exacerbations are admitted to specialised homecare and telemonitored by a multi-professional team at the clinic. Patients included in the study have at least two hospital admissions during the year preceding inclusion and planned study participation for twelve months. 

The  telehealth  system  provides  the  professional  caregivers  with  frequent  patient-reported  outcome measures  (PROMs)  on  various  symptoms  and  measurement  data  for  the  detection  of  early  signs  of deterioration. In the home, patients with advanced HF and/or COPD use the digital pen and paper health-diary  forms  daily  to  fill  in  symptom  assessments,  intake  of  p.r.n.  (“as  needed”)  medications,  and measurement data, e.g., weight, blood pressure, body temperature and oxygen saturation. 

The  study  will  evaluate  if  the  method  and  system  can  contribute  to  earlier  detection  of  patients’ deterioration and thereby prevent acute hospital admission. Further, the study will evaluate quality of life, costs, and differences between COPD and HF patients. 

Background and earlier research by this group 

COPD is an underdiagnosed but rather common illness. There are around 400-700 000 persons with COPD in Sweden [Läkemedelsverket, 2009]. Severe acute exacerbations have a negative effect on the prognosis [Soler et al, 2005] with increasing mortality, especially if hospital care is required. It is therefore important to follow up COPD patients after they have been discharged from hospital care. The National Guidelines for asthma and COPD [The National Board of Health and Welfare, 2015-11-3] state that better follow ups lead to better disease control and less exacerbations, which lead to less hospital admissions for COPD patients. Ten per cent reduction in exacerbations means an annual saving of ~50 M€ for Swedish Healthcare. 

The prevalence for HF is >= 10 % among those 70 years and older [ESC, 2012]. It is associated with hospital admissions, comorbidities, poor quality of life, and high mortality [Thorvaldsen et al, 2013]. The costs for the management of HF have been calculated to be approximately 2% of the Swedish health care budget [Cline et al, 2002]. 

Due to patients’ high age and advanced illness, the remote monitoring equipment must be possible to use effortlessly for the patients. Since less than 50 % of individuals 75 years and older use computers and internet in Sweden [Davidsson & Findahl, 2016], our choice is to use other technologies than computers, tablet PCs or smartphones. In addition, the equipment should be easy to install and there should be no need for fixed broadband in the patient’s home.  

Digital pen technology has been evaluated in three earlier research studies in specialised homecare; two studies including palliative cancer patients in the end of their lives [Lind et al, 2008; Lind & Karlsson, 2013a], and one study – the Health Diary pilot – including 14 patients with advanced HF, NYHA functional class (II)III-IV [Lind et al, 2011; Lind & Karlsson, 2013b, 2014; Lind et al, 2016].

Results from these studies showed that the patients managed to handle the equipment and method in spite of severe illness and difficulties in comprehending the technology and system intervention. Both cancer and HF patients participated more in their own care and had a sense of increased security. The medical records showed that there had been a swift response in the medical treatment [Lind et al, 2007; Lind et al, 2008]. In the Health Diary pilot study the clinicians checked the system daily, and thereby prevented hospital readmissions through detection of HF-related deteriorations at an early stage. None of the patients was admitted to hospital during the study. 

Research collaboration

The project is a collaboration between the RISE SICS East, the Department of Biomedical Engineering, Linköping University, Division of Pulmonary Medicine, Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University, Department of Respiratory Medicine UHL, Centre for Surgery and Oncology, and, the Local Health Care Research and Development Unit, Region Östergötland, Sweden. The study started November 2013 at the Hospital-Based Home Care clinic, Linköping University Hospital and will end in December 2017. 

Project leader: Leili Lind, PhD, RISE SICS East and the Department of Biomedical Engineering, Medical 
informatics, Linköping University. 

Shared scientific responsibility between: RISE SICS East, the Department of Biomedical Engineering and 
the Department of Medical and Health Sciences, Faculty of Health Sciences, Linköping University. 

Funding: Region Östergötland, RISE, NovaMedTech 

References

 

Cline, C.M.J., Boman, K., Holst, M., Erhardt, L.R. The management of heart failure in Sweden. National report. Eur J Heart Fail. 2002 Jun;4(3):373-6. 

ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur J Heart Fail (2012), 14(8): 803-869. 

Davidsson, P & Findahl O. 2016. Svenskarna och internet 2016. Internetstiftelsen i Sverige, IIS.  

Lind L, Karlsson D and Fridlund B. 2007. Digital pens and pain diaries in palliative home health care: professional caregivers' experiences. Medical Informatics and the Internet in Medicine 2007 Dec;32(4):287-96.

Lind L, Karlsson D, Fridlund B. 2008. Patients' use of digital pens for pain assessment in advanced palliative home healthcare. International Journal of Medical Informatics, 2008 Feb;77(2):129-36.
 
Lind, L. & Karlsson, D. 2013a. Electronic patient-reported symptom assessment in palliative end-of-life home care. Health Systems, advance online publication 17 May 2013. 

Lind L, Klompstra L, Jaarsma T, Strömberg A. 2011. Implementation and testing of the digital pen to support patients with heart failure and their health care providers in detecting early signs of deterioration and monitor adherence - a pilot study, Heart Failure Congress 2011, 21 May 2011 - 24 May 2011 , Gothenburg – Sweden, 2011. 

Lind, L. & Karlsson, D. 2013b. Digital pen-based telemonitoring of elderly heart failure patients. Studies in Health Technology and Informatics. 2013;192:1062. 

Lind, L & Karlsson, D. 2014. Telehealth for “the digital illiterate” – elderly heart failure patients’ experiences. Studies in Health Technology and Informatics. 2014;205:353-7 

Lind L, Carlgren G, Karlsson D. Old-and With Severe Heart Failure: Telemonitoring by Using Digital Pen Technology in Specialized Homecare: System Description, Implementation, and Early Results. Comput Inform Nurs. 2016 Aug;34(8):360-8.  

Läkemedelsverket nr 2: 2009 https://lakemedelsverket.se/malgrupp/Halso---sjukvard/Behandlings--rekom...  

Nationella riktlinjer för vård vid astma och KOL – stöd för styrning och ledning 
http://www.socialstyrelsen.se/publikationer2015/2015-11-3  

Soler-Cataluña JJ, Martínez-García MA, Román Sánchez P, et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax. 2005;60:925–931 

Thorvaldsen T., Benson L., Ståhlberg M., Dahlström U., Edner M., Lund L.H. 2013. Triage of Patients with Moderate to Severe Heart Failure: Who Should be Referred to a Heart Failure Center?, J Am Coll Cardiol , doi: 10.1016/j.jacc.2013.10.017.