Vision is everything when one is developing a new product, starting a new company, or devising policy. The engineer, business person, health policy advisor, academician, patient, consumer advocate, or healthcare provider interested in mHealth have their own idea of what the technology will look like in practice. I’d like to provide you with my personal vision of the ideal wireless solution for the post-discharge cardiac patient. I choose the patient with heart disease as an example for a few reasons. I was a practicing cardiac electrophysiologist for many years, the cardiac patient usually has comorbidities, heart disease is the country’s (and Western world’s number one killer), and cardiac disease eats up a huge amount of the healthcare dollar.
The ideal wireless solution for a patient leaving the hospital would be one which is programmed or activated prior to discharge. The patient’s diagnosis and comorbidities which have the potential to be managed with wireless solutions automatically populate an order set that arranges for the solution to be programmed and arranged for. This plan is transmitted electronically to the hospital and outpatient EHRs, payer, patient, and if applicable, caregiver. The technologies would operate on an actionable alert basis, and be supplemented with occasional teleconferencing (phone or visual conferencing (to check a surgical wound for example). This organizational blueprint is a closed loop system that minimizes visiting nurses, cost of time and expense to the patient and caregiver, and provides customized follow-up better that the traditional post-hospital visits. This should not be construed as a substitute for all office visits, but as a way of closer follow-up with a proactive philosophy, which has been shown to decrease rehospitalizations.
1. The first important issue is medication adherence. Medication non-adherence is a significant factor in rehospitalizations. The ideal medication adherence monitoring process is seamless and involves minimal patient effort. Medication changes in the EHR via the provider or prompted by the patient or caregiver would automatically populate the adherence app. Alerts of non-adherence would be sent automatically to a caregiver or provider. For a more detailed discussion of compliance please see http://davidleescher.com/2011/10/12/mobile-health-technology-solution-to-medication-non-adherence/.
2. Clinical monitoring of heart failure is important. One Meta analysis study of 25 clinical trials examined the effectiveness of home monitoring of post-discharge heart failure patients, which was presented at the 2011 Heart Failure Society meeting in Boston. It was found that both human interactive telephone monitoring (requiring the most patient interaction) and “complex device-oriented telemonitoring” (requiring the least patient participation) resulted in statistically significant decreases in all-cause mortality, all-cause hospitalizations, and heart failure hospitalizations. Interestingly, voice-recognition telephone automated interaction was least preferred by patients and did not result in any significant improvement in any of the three endpoints. (http://www.theheart.org/article/1284715.do).
3. A team approach is necessary. A post-cardiac surgical patient will need wireless follow-up with the surgical and medical cardiac teams. Mobile examination of surgical wounds may be done more frequently than the traditional follow-up, possibly preventing superficial infections from becoming more serious ones. Wireless monitoring of vital signs (heart rate, respiratory rate, blood oxygen level, temperature may be done with vests with sensors, or technologies that will be available on smart phones. Weight and blood pressure may also be monitored via wireless technology. Patients with implanted cardiac devices (pacemakers, defibrillators, other types of monitors) can have the function of the device system itself as well as their rhythms evaluated wirelessly. Implanted devices including those and valves, stents, and others will have unique identifiers which can be wirelessly identified and followed in case of defect or recall. The primary care provider will have the patient’s glucose and other blood chemistries monitored with wireless technology.
This article is not meant to be a comprehensive overview. It is a brief vision of how wireless health might be applied to a world I know very well. It’s a world that encompasses significant morbidity, mortality, and cost to society. Let’s look forward to my vision.
