Nurses feature prominently in interventions that use home telehealth for heart failure. They are usually the first point of contact for the patient and are generally responsible for follow-up as well. Follow-up may include referral to a physician, but there is considerable variation in the extent to which physicians are direct users of the home telehealth system. In some cases, a specialist or a patient’s personal physician helps in determining treatment goals and outlining management plans. Their involvement thereafter is minimal. At other times, the nurse consults a physician whenever the content of a patient’s data transmissions deviate from pre-determined values.
The clinical and administrative burden of home telehealth interventions for heart failure patients is uncertain. Details on how home telehealth duties are incorporated into existing workload are scarce. The design of the intervention is clearly a factor: some interventions may require providers to respond to each instance of patient contact, while others may only demand periodic monitoring and selective response. The sensitivity of the remote monitoring technology and the clinical status of patients are also factors. Frequent alerts can increase provider workload.
There are signs that provider uptake and satisfaction with home telehealth for heart failure are lower than one would desire. Although it would be inadvisable to draw definite conclusions without more systematic studies of provider experiences, several descriptions of program implementations recount challenges. These include problems with incorporating new responsibilities into workload, frustration with technical failures, and difficulties maintaining communication with patients. Care coordination was a source of conflict in one instance. Another study reported a ‘steep learning curve’ in interpreting patient data transmissions, and noted that education is vital if providers are to develop appropriate response habits. This study was retrieved in a final scan of 2011-2012 literature and was not subject to the same level of analysis as the other studies included in this review. Details can be found in Acosta et al. (2011).
Provider outcomes were reported in 11 studies (Bowles et al., 2009; Gambetta et al., 2007; Kashem et al., 2008; Kulshreshtha et al., 2010; Myers et al., 2006; Scalvini et al., 2005a, b; Schmidt et al., 2008; Schwarz et al., 2008; Soran et al., 2008; Wakefield, et al., 2008a, b, 2009; Woodend et al., 2008).
Uptake and Use of Technology
Summary: Uptake and use of technology outcomes were reported in 4 studies. There are signs that provider uptake and satisfaction with home telehealth for heart failure are lower than one might wish. The studies retrieved described difficulties encountered by providers in using technologies to communicate with patients and other health providers.
Study Details: Bowles et al. (2009) wrote that study nurses found it difficult to complete the required number of telemonitoring contacts (4) by the end of the 2-month study. Challenges in consulting with the study physicians were also reported (Bowles et al., 2009). In Kulshreshtha et al. (2010), 16 of 84 patients who were approached to take part in the intervention did not do so due to physician refusal to participate. The most frequently cited reasons were ”dislike of technology, fear of information overload, and doubt that their patient would cooperate” (p. 3). Woodend et al. (2008) reported that study nurses frequently encountered problems with the videoconferencing technologies and resorted to using regular telephone lines to meet with their patients. Wakefield et al. (2008b) described provider difficulties with scheduling and completing planned contacts with patients.
No data on provider perceptions are reported in the remaining 19 studies. This is a significant limitation of the research in this area, particularly given the challenges that are described in the studies that do report this information. Members of the research team frequently lead interventions. This creates significant potential for bias, as their attitudes toward telehealth and perception of related work might be expected to differ from that of the average provider. Without more frequent and systematic measurements of provider experience, it is not possible to draw any firm conclusions in this area.
Effects on Practice and Patient Care
Summary: Effects on practice and patient care were reported in 3 studies. These data do not lend themselves to any obvious conclusions. Details on how intervention duties were incorporated into existing workload are scarce. It can be observed, however, that some interventions may require providers to respond to each instance of patient contact, while others may only demand periodic monitoring and selective response.
Study Details: One study found that providers made significantly more changes to patients’ medications after 90 days of the telehealth intervention (Wakefield et al., 2009). However, this difference was no longer significant at 180-day follow-up. In addition, significant differences between groups existed at enrollment. In Myers et al. (2006), patients in the telehealth group were more likely to be prescribed diuretics though there were no significant differences in the likelihood of being prescribed other medications, such as beta blockers, ACE inhibitors, anticoagulants, digoxin, or antidepressants. Scalvini et al. (2005b) did not report absolute numbers, but indicated that roughly 35% of patients’ data transmissions were used as the basis for medication changes, suggested consultations with primary care providers, and hospital admissions. Transmissions of ECG recordings allowed for the detection of a wide range of adverse events.
Wakefield et al. (2008a) report greater numbers of ‘other closed-ended questions’ communicated by the study participants than the control group. However, they found no statistically significant differences in communication across time, mean number of utterances across time, or nurses’ perceptions of interactions.
Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 2 additional studies that addressed effects of practice and patient care (Acosta et al., 2011; Wade et al., 2011). Both found cause for caution in implementing home telehealth. Wade et al. (2011) found that frequent alerts from the telehealth system increased provider workload. Acosta et al. (2011) reported a ‘steep learning curve’ in interpreting patient data transmissions, and noted that education is vital if providers are to develop appropriate response habits. See Acosta et al. (2011) and Wade et al. (2011) for more details.
Cost and Time Savings
No studies reported on cost or time savings directly, although 1 study did find that patients in the intervention group received significantly fewer medical home visits per month: 58 home visits versus 8 for a historical control group (Myers et al., 2006).