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Heathcare technologies

Examining the implications of analytical and remote monitoring in pharmacy practice

Abstract
Remote patient monitoring (RPM) incorporates digital technology that collects health data from individuals in one location and electronically transmits secure data to healthcare providers in a different location for review and assessment. This allows healthcare professionals to make recommendations to optimise patient care without the patient having to be in the healthcare setting. With the implementation of RPM, pharmacists can use objective data obtained by remote devices to monitor patients and provide recommendations, medication therapy management, adherence counselling, and education for patients or their caregivers on ways to optimise clinical outcomes. Whether engaging in telemedicine or telepharmacy, pharmacists are integral members of interdisciplinary patient care. This article provides an overview of various RPM applications reported in the literature and highlights areas with pharmacist involvement, as well as areas in which pharmacists could integrate in the future.
Keywords: Clinical outcomes, pharmacist, remote monitoring, remote patient monitoring, telehealth, telemedicine, telemonitoring
Original submitted: 03 November 2016; Revised submitted: 13 March 2017; Accepted for publication: 22 March 2017.

Telepharmacy, pharmacist in front of computer screen

Source: Aaron Jennissen

Although no universal definition of telemedicine exists, telepharmacy can be described as “a full-service operation that includes prescription medications, remote pharmacists, pharmaceutical utilisation review, patient education, and counselling provided to a remote site using a range of technologies”. Whether engaging in telemedicine or telepharmacy, pharmacists are integral members of the healthcare team, providing interdisciplinary patient care.

Key points:

  • The field of telehealth is rapidly emerging and should be embraced for its ease of use and operability in various settings (including a patient’s home);
  • Chronic disease states make for an ideal setting to implement remote monitoring devices;
  • Remote monitoring devices may be used by pharmacists to assess objective data and medication adherence, as well as as a venue to provide patient education and clinical recommendations to providers involved in a patient’s care.

Introduction

To date, there is no universal definition of telemedicine, indicating the constant evolution of telemedicine and its respective information and communications technology (ICT). The World Health Organization (WHO) describes telemedicine as: “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.”[1] But while this description is effective in summarising the purpose and use of telemedicine, it does not reflect recent innovations in technology that continue to change what the term encompasses.

The growth of telemedicine has often coincided with developments in ICT. The first recorded use of telemedicine, in its most rudimentary form, involved a ship-to-shore method of radio communication in the 1920s[2]. In this scenario, medical information was transmitted in real-time from on-shore physicians to those at sea. A decade later, radiology and cardiology specialties would take advantage of the telephone wire to transmit electrocardiogram (ECG) information remotely[2].

The advent of technologies, such as television, and improved telecommunication infrastructure are the defining factors that established the significance of telemedicine in contemporary society. In the late 20th century, the use of interactive videoconferencing began to be more widespread. This allowed for real-time interaction between medical professionals and patients in greater detail than what was previously offered, with the potential for more holistic treatment. However, these telemedicine programmes proved costly, so initiatives to find an alternative method of telemedicine delivery began. The objective to lower expenses, along with the rise of the internet, would expedite the development of improved store-and-forward technology (see below)[2].

Telemedicine can be categorised into two forms: store-and-forward technology and real-time interactive services.

Store-and-forward technology involves the “transmission of packets of data relating to investigations”, where a specialist would later review the data and provide clinical input from a distance. A common example of store-and-forward includes the use of digital images for radiology, pathology and dermatology[3].

Real-time interactive services involve the use of an interactive video modality, in which the parties involved can interact and receive feedback instantaneously. They are often used when direct patient care is needed and in chronic disease states such as asthma or diabetes[4],[5]. Medical specialties that commonly use real-time services are psychiatry, surgery and emergency medicine[2],[6]. Furthermore, the provision of real-time telemedicine clinical pharmacy services has been described in multiple disease states, including: HIV[7], hepatitis C, type 2 diabetes mellitus (T2DM)[8], coagulopathies[9] and chronic cardiovascular diseases[10].

Although slightly different than telemedicine, it is worth mentioning telepharmacy, which is described as “a full service operation that includes prescription medications, remote pharmacists, pharmaceutical utilisation review, patient education and counselling provided to a remote site using a range of technologies”[6].

The first successful telepharmacy project originated from North Dakota State University College of Pharmacy, United States, in 2002, to prevent rural pharmacies from closing throughout the state[11]. Another successful example of telepharmacy is a model from Washington, United States, that incorporates automated drug dispensing system units and webcams to provide full pharmacy services, including order processing, patient counselling, refill authorisation, and an on-site telepharmacy technician available to mediate transactions with patients[12].

Remote patient monitoring (RPM) incorporates digital technology that collects health data from individuals in one location and electronically transmits secure data to healthcare providers in a different location for review, assessment and recommendations to optimise patient care without having to be in the healthcare setting[13]. It is estimated that by 2018, RPM will result in cost savings of nearly US$36bn (£28bn) worldwide[14].

In addition to the economic benefit, RPM can assist in obtaining objective data to provide closer monitoring of patients’ clinical disease states. Examples of collected data range from vital signs to blood sugar, ECG readings and point-of-care INR monitoring. RPM can allow clinical outcomes to be optimised, geographical barriers reduced, and patients empowered to take control of managing and monitoring their own health. This in turn can enable early detection and/or prevention of worsening clinical symptoms, the monitoring of medication adherence, and engagement in personalised health management. Furthermore, for at-risk patients who are chronically ill and are often directed to urgent care or emergency departments, RPM may reduce unnecessary hospitalisations or readmissions.

With the implementation of RPM, pharmacists can use objective data obtained by remote devices to monitor patients and provide recommendations, medication therapy management (MTM), adherence counselling and education for patients or their caregivers on ways to optimise clinical outcomes.

Whether engaging in telemedicine or telepharmacy, pharmacists are integral members of the healthcare team providing interdisciplinary patient care. This article offers an overview of various RPM applications reported in the literature. It is not intended to serve as a comprehensive review on this topic, but to highlight data and services in which pharmacists are and have been involved, as well as models that could be integrated in other healthcare settings.

Sources and selection criteria

Literature searches of PubMed/Medline (1946–2017) and Google Scholar databases were performed, along with a review of the bibliographies of retrieved articles to identify additional references. Key terms that were searched included remote monitoring, remote patient monitoring, telehealth, telemedicine, telemonitoring, clinical outcomes and clinical pharmacist. Only English language articles were included. In addition, currently available or in-development remote monitoring devices or practices involving a pharmacist, or that could be adapted to incorporate a pharmacist, were included in this review.

Telemedicine to support medication adherence

Through the use of telemedicine, Hale et al.[15] conducted a randomised controlled pilot study to investigate the effect of a remote medication monitoring system (MedSentry Medication Management System, MedSentry Inc, Westborough, Massachusetts, United States) on medication adherence in patients with chronic heart failure (HF). The device alerted patients when it was time to take medications and contacted the patient through a monitoring centre if doses were missed (see table 1)[15]. This device did not afford the portability of other medication-monitoring systems, such as Kraken from iMPack Health (Neptune, New Jersey, United States)[16] or oreCAP from Information Mediary Corporation (Ottawa, Ontario, Canada)[17]; however, these portable devices did not contact patients in the event of missed doses.

In the study[15], 29 older HF patients who recently completed a HF telemonitoring programme were randomised to the remote medication monitoring system (intervention) or usual care (control) for 90 days. Final data analysis included 11 and 13 patients in the intervention and control groups, respectively. The groups were well matched, with the exception of statistically significant differences in New York Heart Association (NYHA) functional class and health-related quality of life (HRQoL) physical score, as assessed by the Minnesota Living with Heart Failure Questionnaire, which were both worse in the intervention group (P =0.001, 0.03, respectively). There were no differences in HF-related, non HF-related or all-cause emergency department (ED) visits between the two groups at 90 days or study closeout.

The intervention group experienced significantly fewer all-cause hospitalisations compared with the control group at 90 days (P =0.04) but not at study closeout, and HF-related and non-HF-related hospitalisations were similar between the two groups at both time points. No significant difference at study closeout in self-reported adherence, based on the Morisky Medication Adherence Scale, was observed between the two groups. Adherence data derived from the device revealed around 97% total adherence over the 90-day study period for the intervention group. No objective adherence data were collected from the control group for comparison.

There was no difference between groups with self-reported health status; however, the intervention group experienced a significant decline in total, physical and emotional HRQoL compared with the control group (P =0.002, 0.001, 0.03), which the authors attributed to poorer baseline heart function and HRQoL. At least 50% of the patients ranked each device feature as ‘mostly’ or ‘extremely’ useful. Based on these results, telehealth technology for medication adherence shows promise for improving patient self-management and quality of care, while reducing healthcare use and costs for HF and other complex disease states[15]. One major limitation of this study is the small sample size. Therefore, the data should be interpreted cautiously because an adequate power was not achieved to detect a difference from baseline to the end of the study.

Table 1. Devices used to support medication adherence, support disease monitoring, and to collect patient experience and support symptom management
DeviceDescriptionAvailability
Telemedicine to support medication adherence
MedSentry medication management system (MedSentry Inc, Westborough, Massachusetts, United States)Device alerts patients when it is time to take medications and transmits data via the internet when doses are missed so the monitoring centre can contact patients and/or caregivers. Patients are responsible for refilling the device and communicating medication changes. A weekly picture is transmitted to the monitoring centre to ensure medications are filled correctly.http://0355903.netsolhost.com/medsentry
Telemedicine to support disease monitoring
Cardiology  
Bluetooth-enabled electronic equipment (Bluetooth SIG Inc, Kirkland, Washington, United States)Device displays/sends texts and is integrated with a wireless transmission pod, weight scale, and blood pressure (BP) and heart rate monitors. Data (daily weight, BP, heart rate and responses to three symptom questions) are transmitted and reviewed by nurses in a call centre who contact patients for out-of-range data and scheduled coaching.https://www.bluetooth.com
Electronic, uploadable BP monitor, model UA-767PC (A&D Medical, San Jose, California, United States)A device that uploads BP readings via USB onto a home computer. Readings are not uploaded in real time and the patient is not able to edit the readings. If the patient does not have a home computer, they can upload readings by logging into a kiosk located in the transplant clinic and use the Good Health Gateway (Abacaus Health Solutions, Cranston, Rhode Island, United States) patient portal. Monitoring is done via a platform that requires a minimum of six BP readings per 30 days to calculate average systolic BP and diastolic BP. Automated feedback is provided via mail and text to reinforce active participation. Tailored prompts are sent to patients not providing the required readings. Telephone support is also available for those with technical issues.http://www.andonline.com/medical/products/details.php?catname=&product_num=UA-767PC
Validated Omron Hem-705CP oscillometric automated manometer (Omron Healthcare UK Ltd, UK)Omron has various BP devices that measure systolic and diastolic BP and heart rate remotely.  Some devices have Bluetooth technology allowing for data to be directly uploaded to a patient portal or an app.http://www.omron-healthcare.com/en-gb
CoaguChek XS point-of-care test system to measure INR (Roche Diagnostics Ltd, UK)/CoaguChek INRange System (Roche Diagnostics Ltd, UK)The CoaguChek XS system is similar to a blood glucometer. It is a battery-operated device that requires testing strips and a drop of blood to test INR from 0.8 to 8 and stores up to 300 readings that can be manually written in the testing log book. The CoaguChek INRange system is a remote monitoring self-testing meter with Bluetooth technology that allows for wireless transmission of PT/INR results.http://www.coaguchek.com/coaguchek_patient/en/home/products/xs-system.html
Respiratory
Electronic medication sensorThe investigational electronic medication sensor is attached to the inhaler monitors and wirelessly transmits the time and location of the inhaler each time it is used. A summary on inhaler use as well as feedback on asthma control and advice on improving asthma self-management, based on the National Asthma Education and Prevention Program (NAEPP) guidelines, is provided to patients via weekly email reports. Patients also complete monthly questionnaires to assess asthma control.Investigational
TeleMedCare System (Medcare, Sydney, Australia)A laptop computer with digitally integrated devices (BP cuff and stethoscope, pulse oximeter, pneumotachography, electrocardiogram [ECG] touch plate, thermometer and scales) guides patients through measurements and allows them to input symptoms and changes in medication use. Data were reviewed by nurses with per-protocol responses for abnormal trends.http://www.telemedcare.com
Endocrine
OneTouch Verio Flex blood glucose (BG) monitoring system with Coloursure technologySimple colour range indicator that tells if a BG result is in or out of range with a storage capacity up to 500 tests with date and time stamps.https://www.lifescan.co.uk
Diabetes remote monitoring and management system (MedAdherence LLC, Norwalk, Connecticut, United States)Patients were reminded via text message or phone call to test BG and report results in the automated system. Only severe hypo- or hyperglycaemia prompted human interaction from a healthcare provider. Providers could monitor patients through a web-based portal.http://www.circlelinkhealth.com
Intel-GE Care Innovations web portal (Intel-GE Care Innovations, Roseville, California, United States)A tablet computer was connected to a glucometer and an online portal that transmitted glucose data and facilitated a complete feedback loop. Data from patient glucose testing were analysed via software and certified diabetes educators (CDEs) provided feedback to patients via virtual visits. In urgent situations, CDEs telephoned patients.http://www.careinnovations.com
Renal
LifeView, American TeleCare Inc (Eden Prairie, Minnesota, United States)A touchscreen computer with peripherals (BP cuff, scale, glucometer, pulse oximeter, stethoscope and web camera) measures and transmits vital signs, delivers a customised education programme and conducts video visits.Company website not available
Telemedicine to collect patient experience and support symptom management
Neurology  
Kinesia One (Great Lakes Neurotechnologies, Cleveland, Ohio, United States)Measures and reports Parkinson’s-related symptoms (tremor, bradykinesia and dyskinesia) while wearing a sensor on the finger that transmits data wirelessly via Bluetooth® to an iPad application. Clinicians can access data through the Kinesia web portal.http://glneurotech.com/kinesia/products/kinesia-one
Kinesia 360 (Great Lakes Neurotechnologies, Cleveland, Ohio, United States)Measures and reports Parkinson’s-related symptoms while wearing two sensor bands that transmit data wirelessly via Bluetooth® to an iPad application. Patients are also able to enter symptoms and medication administration times.  Clinicians can access data through the Kinesia web portal.http://glneurotech.com/kinesia/products/kinesia-360
Oncology
7-inch Android tablet with a remote monitoring software applicationA touchscreen Android tablet with remote monitoring software prompts patients on a twice-daily basis (more frequently if they feel unwell) to complete an assessment concerning chemotherapy-induced side effects as well as activities of daily living (ADLs). Once weekly, patients are asked about their level of anxiety, depression and psychological stress. Encrypted data are automatically uploaded to a secure server, where algorithms are derived to send email alerts to dedicated clinical staff in the event of a life-threatening-urgent issue (must be addressed in 15 minutes) or a moderate-non-life-threatening issue (should be addressed in 8 hours). Trained nurses contact the patient by telephone to provide further assessment and management.Software application not specified

Telemedicine to support disease monitoring

Heart failure 

According to the British Heart Foundation, nearly 500,000 patients are currently living with HF in the UK, where there were around 160,000 inpatient episodes for HF between 2013 and 2014. Additionally, nearly 41,000 premature deaths were due to cardiovascular disease. Most of these deaths were due to coronary heart disease and stroke, with the remaining deaths attributed to HF, pulmonary heart diseases and stroke[18].

Ong et al.[19] conducted a randomised multicentre study (BEAT-HF) to investigate remote monitoring in transition of care in older patients hospitalised for decompensated HF. Patients in the intervention group used Bluetooth-enabled electronic equipment (Bluetooth SIG Inc, Kirkland, Washington, United States) to transmit daily data to call centre nurses, who contacted patients for out-of-range values and scheduled coaching (see table 1). This device uses automatic transmission of data, which eliminates the need for patients to input their own values into the system. However, it is non-invasive, so patients need to allocate time for daily measurements (unlike invasive devices that continually send data), which could represent a barrier for poorly adherent patients.

More than 1,400 patients were randomised to either remote monitoring (intervention) or usual care (control). Final data analysis included 715 patients in the intervention group and 722 patients in the control group. No statistically significant differences were observed between the groups based on demographic data, 30-day or 180-day all-cause readmissions, 30-day or 180-day mortality, or combined 30-day or 180-day readmission or mortality. A significant improvement in quality of life was found in the intervention group at 180 days compared with the control (P =0.02). During the study period, 82.7% of patients in the intervention group used the remote monitoring equipment. The remote monitoring and telephone coaching adherence of patients for greater than 50% of days were 55.4% and 61.4% at 30 days, and 51.7% and 68% at 180 days, respectively[19].

RPM as part of transition-of-care management in this study did not reduce all-cause readmissions, but a significant improvement in quality of life was demonstrated. While more than 50% of the patients were adherent to remote monitoring and telephone coaching for more than 50% of the study, it remains to be seen if improved adherence could produce more favourable results.

Pharmacists have proven to be valuable members of HF healthcare teams, with improvements in outcomes such as adherence and hospitalisations[20],[21],[22]. They could have an active role in a monitoring centre, such as the one described in the study by Hale et al., reviewing adherence data and providing feedback to improve adherence. Pharmacists could also be responsible for checking images to ensure the MedSentry Medication Management System device is filled correctly, and reviewing and recommending medication changes[15]. Although registered nurses monitored and called patients in the study by Ong et al., the authors admit that the use of other healthcare providers in the study could affect health outcomes[19]. Additional studies are needed to investigate if pharmacists could impact outcomes using that same model.

Coupled with medication adherence data, although definitive data do not yet exist, overall quality-of-life outcomes may improve with the use of telehealth, along with healthcare utilisation and costs associated with HF.

Hypertension 

It is estimated that hypertension (HTN) costs the NHS more than £2bn annually with five million people unaware of their diagnosis. HTN is estimated to affect more than one in four adults, yet, in England between 2003 and 2012, around 5%–9% of men and women achieved blood pressure (BP) goals and had controlled HTN[23]. The use of home-based BP readings, compared with clinic-based readings, has been shown to improve BP control; however, it has been suggested that home BP measurements alone, without active monitoring by a healthcare professional, may not be adequate to improve outcomes[24],[25]. The use of remote monitoring with intensive clinical pharmacist case management may assist in improving outcomes.

Remote management for HTN was first described in 2008 by Green et al.[26]. Three groups were randomised to group 1 (usual care), group 2 (home BP monitoring, where results were uploaded to a patient portal [Group Health has a comprehensive electronic medical record, Epic Systems Corporation’s EpicCare]), or group 3 (home BP monitoring, where results were uploaded to a patient portal, plus clinical pharmacist case management). The main outcome was the percentage of patients achieving controlled BP (<140/90mmHg) at 12 months.

A total of 730 participants completed the study. Groups 1 and 2 did not have a significant increase in BP control (36% [95% CI: 25%–37%] vs 31% [95% CI: 30%–42%]; P =0.21). When adding a clinical pharmacist to BP management, the percentage of participants meeting the primary outcome increased to 56% [95% CI: 49%–62%] compared with groups 1 and 2 (P <0.001). The authors established that when adding clinical pharmacists to remote BP management, BP control was improved in participants with HTN[26].

Margolis et al.[27] set out to determine whether BP home telemonitoring, combined with pharmacist case management, achieved better BP control compared with usual care, and to assess whether BP control was sustained beyond intervention. In total, 450 individuals with uncontrolled HTN (>140/90mmHg during a minimum of the two most recent primary care visits) were randomised to the intervention (n=228) or usual care (n=222) groups.

The intervention group received A&D Medical 767PC automated oscillometric BP monitors (San Jose, California, United States) that stored and transmitted data to a secure website (AMC Health, New York, United States). A live, one-hour face-to-face visit occurred between the pharmacist and patient, where a thorough medical and medication history was obtained, along with education on HTN goals and training on the telemonitoring device.

Patients were expected to transmit at least six BP readings weekly during the first six months of the intervention. The pharmacist and patient reviewed results every two weeks by telephone until BP was controlled, for a minimum of six weeks. At that point, the frequency was reduced to monthly. Phone visits occurred every two months during months 7–12. During the phone calls, pharmacists focused on lifestyle changes and medication adherence, and evaluated and adjusted antihypertensive therapy based on an algorithm. After 12 months, patients returned the devices and pharmacist support ceased.

Patients randomised to the usual care group continued receiving care under their primary care provider but could have been referred to a medication therapy management (MTM) pharmacist for consultation, or participate in conventional home BP measurement. BP monitoring with telemonitoring and pharmacist case management achieved higher rates of goal BP in all groups compared with usual care (6 months: 71.8% vs 45.2%, P <0.0001; 12 months: 71.2% vs 52.8%, P =0.005; 18 months: 71.8% vs 57.1%, P =0.003), respectively. Through its large sample size, the study revealed that home BP telemonitoring and pharmacist management achieved better BP control compared with usual care throughout the 12-month intervention and was sustained for six months post-intervention[27].

Another study performed by Aberger et al.[28] described a collaborative practice agreement for HTN management between a physician and transplant clinical pharmacist, using a convenience sample from 66 participants, to evaluate home electronic BP monitoring with a web-enabled device in renal transplant recipients. Participants were given A&D Medical 767PC automated oscillometric BP monitors (San Jose, California, United States, that stored and uploaded BP readings via USB on to their home computer. Results were not uploaded in real time and the participants were unable to augment their readings. Alternatively, if the participant was unable to upload the information or did not have a home computer, they were able to upload their results on to a device located in the transplant clinic through the Good Health Gateway (Abacus Health Solutions, Cranston, Rhode Island, United States) patient portal.

The transplant clinical pharmacist educated the patient on the importance of BP health as well as goal BP readings, reviewed medications and identified any barriers to medication adherence. Participants were required to obtain at least six BP readings over a 30-day period to calculate an average. The Good Health Gateway portal provided individual participant goals and feedback on whether these goals were met. This portal interfaced with an MTM platform to allow the clinical pharmacist to monitor and review the patient’s adherence, and barriers to adherence, as well as BP readings. Automated messages were derived through mail and text to positively reinforce those who were actively monitoring and individualised messages were sent to participants not meeting monitoring goals to calculate a monthly average. If antihypertensive medication therapy required modification, the pharmacist communicated the data along with a recommendation to the participant’s primary care provider.

Preliminary results revealed that average systolic BP and diastolic BP were significantly lower 30 days after enrolment compared with baseline (systolic BP=–6mmHg and diastolic BP= –3mmHg, P <0.01). The authors concluded that there was a great need to optimise BP control, especially in the transplant population, which may improve graft outcomes and survival. The use of telemonitoring may improve these outcomes, but more studies with longer durations of follow-up are needed[28].

Anticoagulation

Oral anticoagulants (ACs) are prescribed for around 1.25 million people annually in the UK, with warfarin being the most commonly prescribed agent. This estimate is expected to rise as the ageing population increases[29]. Time constraints of managing warfarin may be problematic if frequent visits to an anticoagulation clinic (ATC) are required, especially for those with full-time employment or if the patient is unable to travel there. The use of remote monitoring and management with clinical pharmacy services may be useful in the setting of oral ACs as it has been well documented in practice[30],[31],[32] and through telemedicine[9].

CoaguChek INRange and CoaguChek XS are remote monitoring devices available globally to measure the INR of patients receiving warfarin (see table 1)[33]. A study of 140 patients receiving lifelong anticoagulation for at least six months was conducted by physicians at an ATC at a county hospital in Denmark[34]. Patients with access to a home computer with internet access and a willingness and ability to use point-of-care INR testing were randomised to one of three groups: A, INR measurement at home once weekly; B, measurement at home twice weekly; or C, usual care with routine ATC visits (maximum interval every four weeks) for the next year.

A two-hour training on the CoaguChek XS point-of-care test system (Roche Diagnostics A/S, Hvidovre, Denmark) and computer interface were required. INR readings were interpreted and the medication dose was adjusted by ATC staff within four hours of the reading. If a patient reported problems or had a question through the electronic system, the ATC staff contacted the patient via telephone. Patients with INR readings less than 1.5 or above 5.0 were alerted through the system to contact the ATC staff immediately. Every six months, patients in groups A and B returned to the ATC to calibrate their device to a maximum difference of 0.5 INR. Groups A and B experienced significantly better time in therapeutic range (TTR) compared with group C (P <2.2 x 10-16), where group A experienced 79.7% [95% CI 79.0–80.3] of TTR, group B 80.2% [95% CI 79.4–80.9], and group C 72.7% [95% CI 71.9–73.4]. No significant difference was observed between groups A and B.

Although adverse events were recorded, the number was too infrequent to be of value. During the trial, one patient was admitted to the hospital for a supratherapeutic INR greater than 9, but upon repeat analysis the following day, the INR was 5.1 and the patient did not experience any bleeding events. Unfortunately, the authors did not document which group this patient belonged to.

The findings from this study established that remote monitoring of anticoagulation is safe and resulted in more TTR[34]. Pharmacist involvement has been well documented for anticoagulation management both in person and through clinical video telehealth (CVT) technology[9]. This model has the potential to be adapted and incorporated into a clinical pharmacy model.

Respiratory

Asthma and chronic obstructive pulmonary disease (COPD) are the two most common respiratory diseases in the UK, with 8 million individuals (12% of the population) with an asthma diagnosis and 1.2 million (2% of the population) with COPD[35]. It is estimated that only 5.4 million patients receive treatment for their asthma, which accounts for 60,000 hospital admissions and 200,000 bed days per year[36]. There is a clear need for closer monitoring and intervention in individuals with respiratory illnesses. One solution to improve outcomes could be RPM. Two studies examining remote monitoring, one in asthma and one in COPD, are discussed below. For a more in-depth look at available inhaler monitoring devices, Chan et al.[37] provide an excellent review.

Van Sickle et al.[38] prospectively evaluated a cohort of 30 patients with asthma using an investigational electronic medication sensor attached to their inhaled, short-acting bronchodilators over a four-month period. Patients received weekly reports summarising inhaler use and providing feedback (see Table 1). During the first month, patients did not receive weekly reports. At the end of the first month, there were no significant differences in Asthma Control Test (ACT) scores, daytime or night-time symptoms, or activity limitations. After receiving weekly reports, there was a significant decrease in daytime (95% CI: –2.65, –0.04) and night-time symptoms (95% CI: –1.25, –0.44), and a significant increase in ACT scores (95% CI: 0.61, 2.18), but no difference in activity limitations. Based on ACT scores, 75% of patients had controlled asthma at the conclusion of the study versus 38% upon entry. All patients, with the exception of one, rated the weekly reports as either very, or somewhat, useful in improving asthma management, and 80% were interested in continued use of the device. This study proved that weekly e-mail reports of asthma management guidance and inhaler use reports were associated with improved asthma control measures[38]. Pharmacists can be a valuable educational resource for patients with asthma[39], and could be integrated into this model by reviewing inhaler use and providing feedback to patients via the weekly reports.

Antoniades et al.[40] conducted a randomised pilot study to investigate feasibility and outcomes of a remote monitoring system (TeleMedCare System, Medcare, Sydney, Australia) in COPD patients over 12 months. The TeleMedCare System consisted of a laptop computer and integrated monitoring devices, and transmitted data to nurses for review and follow-up (see Table 1). Forty-four patients were randomised to remote monitoring plus standard best practice (RM+SBP) or standard best practice (SBP). Final data analysis included 16 and 20 patients in the RM+SBP and SBP groups, respectively.

Baseline characteristics were similar between the groups with the exception of incidence of active smoking and severity of airflow obstruction; both higher in the SBP group (P <0.05 for both). No statistically significant differences were observed between the groups for any of the primary or secondary outcomes, hospital admissions (COPD-related or total), length-of-stay days (COPD-related or total), or HRQoL, as assessed by the Chronic Respiratory Disease Questionnaire, Short Form 36 (SF-36) questionnaire, or a six-minute walk’s distance. Regarding feasibility of remote management, there was around 80% median adherence for all daily measurements; 94% found the system easy to use; 82% felt it helped manage their COPD better; and the overall satisfaction rate was 88%.

Based on these findings, remote monitoring, as studied in this trial, may not be better than standard care but it is unknown if other remote monitoring approaches for COPD may provide benefit[40]. While nurses were responsible for data monitoring and follow-up in this study, this model could be adapted to a pharmacist-centred practice.

Endocrine

Globally, it is estimated that diabetes affects 415 million individuals, with 4 million patients with diabetes living in the UK. It is also estimated that one in two adults with T2DM is undiagnosed[41]. Furthermore, 7.5% of individuals with type 1 diabetes mellitus (T1DM) had a haemoglobin A1c (HbA1c) below 6.5% and 26.4% with T2DM achieved goal HbA1c[41]. There is an increased need for more intensive diabetes management to prevent complications secondary to diabetes.

A cloud-based web application, OneTouch Reveal (OTR), has the ability to pool blood glucose (BG) data from glucometers or insulin pumps to allow for remote monitoring and/or consultation. One study evaluated 23 participants with T1DM and 17 participants with T2DM over 12 weeks with OneTouch Verio (OTV) glucometers to assess changes in glycaemic control. Healthcare professionals (HCPs) remotely monitored participant progress using OTR and engaged in telephone consultation at weeks four and eight based on OTR data. Mean HbA1c decreased by 0.4% (P <0.001) and 25% of the participants experienced > 1.0% HbA1c reduction at 12 weeks. For participants with T2DM, mean BG reduction was 175 to 161mg/dL (P <0.001), with the percentage of above-range BG readings also decreasing (33% to 24%). Based on these findings, remote monitoring and real-time data may assist in providing focused and effective remote consultations[42].

Other models implementing remote monitoring devices and web-based portals to assist in improving diabetes control have been described[43],[44], yet none describe pharmacist involvement. A single-centre, prospective, pre-post pilot study evaluated the impact of a pharmacist-led telehealth clinic on diabetes-related goals of therapy in 26 veterans. After six months of evaluation, HbA1c significantly decreased by 2% from baseline (9.6 + 1.9 to 7.6 + 1.3, P =0.0002). In addition, participants meeting goal HbA1c increased from 0% at baseline to 38% at six months (P =0.0007). Overall patient satisfaction was high among participants where the median score was 39.5 out of 40. This demonstrates that pharmacist intervention coupled with remote monitoring capabilities has the potential to positively impact diabetes management[8].

Renal

The mean prevalence of all stages of chronic kidney disease (CKD) was recently estimated to be 18.38% [95% CI: 11.57–25.20] in Europe and 15.45% [95% CI: 11.71–19.20] in the United States and Canada. CKD is associated with high economic costs globally and increased risk of cardiovascular disease, premature mortality and decreased quality of life[45]. Early referral to nephrology specialists has been shown to improve outcomes. Solutions to improve outcomes and increase access to care for patients with CKD are needed to solve this global healthcare challenge. Telemedicine may represent one solution[46],[47].

Ishani et al.[48] conducted a randomised study in a veterans affairs healthcare system to investigate outcomes of patients with CKD cared for by an interprofessional team, including a nephrologist and a clinical pharmacy specialist, using a telehealth device (LifeView, American TeleCare Inc, Eden Prairie, Minnesota, United States) over one year. The device was used to measure and transmit patient data, deliver a customised education programme and conduct video visits (see table 1). Periodic clinic visits were conducted in certain situations.

Patients were randomised to receive interprofessional telehealth care (intervention) or usual care (control). Final data analysis included 450 patients in the intervention group and 150 patients in the control group. Baseline characteristics were well matched between the two groups with the exception of race and systolic BP, with the intervention group having more white patients and higher systolic BP (P <0.05 for both). The mean age was approximately 75 years and mean glomerular filtration rate (GFR) was 37 ml/min/1.73m2.

There was no difference between the telehealth and usual care groups for the composite endpoint of death, hospitalisation, ED visits, admission to a skilled nursing facility, or any of the individual components. Regarding intervention adherence; 96.2% of patients in the intervention group completed at least one video visit. Therefore, an interprofessional team was feasible but not superior to usual care for patients with CKD. Although alternative interventions to improve outcomes are needed, interprofessional telehealth could be an option for patients[48], especially those with geographic or other barriers who may not access nephrology specialty care otherwise.

HIV

It is estimated that almost 37 million individuals are living with HIV or AIDS globally, and new infections continued to occur in 2.1 million individuals worldwide in 2015[49]. Complete virological suppression is the goal of antiretroviral therapy (ART), yet in the United States, just 30% of HIV-positive individuals achieved virological suppression. Rates of virological suppression in the UK are double that, at 61%, and Switzerland demonstrated the highest rates of virological suppression, at 68%[50]. Although HIV is now deemed a chronic disease state, continued challenges to engagement, linkage and continuity of care exist.

A multidisciplinary, homecare telemedicine intervention (Virtual Hospital) was developed in Barcelona to provide complete management of chronic HIV to patients[51]. This was a prospective, randomised study occurring over a two-year period comparing the virtual hospital intervention (group one) to standard care at the day hospital (group two) by monitoring HIV remotely (group one) or on-site (group two).

After one year of follow-up, the patients were switched to the other group. The patients in the Virtual Hospital group had access to virtual consultations (appointments/consultation via videoconferencing and chat session or message exchanges for emergency or unscheduled consultations), telepharmacy (pharmacists received electronic prescriptions to perform virtual consultations regarding compliance, adverse events or interactions, and delivery of ART to the patient’s home via courier), a virtual library (stored validated HIV information and links to webpages), and a virtual community (allowed for the exchange of information about the disease and the project as well as other opinions about articles and news). This system offered integrated patient monitoring by a multidisciplinary team as well as patient access to clinical and pharmaceutical files.

Patients were eligible for enrolment if they had a CD4 >250 cells/mm3 for at least three months prior to the intervention, along with computer and broadband access. Patients excluded from the study were those with a CD4 <250 cells/mm3, those with an opportunistic infection, a tumour, or those who were pregnant. Of the 83 patients in this study, 42 patients were enrolled in group 1 and 41 in group 2 for the first year. Patient satisfaction using the virtual system was high; 85% of patients felt that the Virtual Hospital improved their access to clinical data and they felt comfortable using the videoconferencing system. No difference relating to CD4 counts, proportion of virological suppression (P =0.21), medication adherence (P =0.58), or quality of life was detected between groups. The study demonstrated that the virtual hospital intervention was a viable and safe option for multidisciplinary homecare of HIV patients[51].

Telemedicine to collect patient experience and support symptom management

Neurology

Although pharmacist monitoring or intervention using remote monitoring has not been detailed, Kinesia One is a monitoring tablet device used to manage symptoms associated with Parkinson’s disease. The device is programmed to an individual patient’s symptoms and treatments. The device instructs the patient to complete a variety of motor tests throughout the day to assess tremor, upper extremity bradykinesia, and dyskinesia through a finger sensor, where data are uploaded directly from the tablet to be viewed by the clinician. The data reveal severity scoring and symptom changes during the day in response to treatment[52].

Kinesia 360 is another remote device used to evaluate Parkinson’s disease symptoms. Similar to Kinesia One, the device is programmable based on specific patient symptoms to assess tremor and dyskinesia. In addition, the patient is able to enter how they are feeling, and when medications are taken, through touchscreen technology. Again, clinicians can review the patient’s data and make recommendations remotely. Motion sensor bands measure 3D movements and are rechargeable with a USB cable. These bands are designed for patients to wear as they go about their normal daily activities[53].

Oncology

Pharmacists are at the centre of the monitoring of side effects, and could play a vital role in optimising supportive care and evaluating tolerability or presence of side effects in patients receiving chemotherapy. A study is under way in Australia that uses telehealth to evaluate the development of chemotherapy side effects in adult patients with chronic lymphocytic leukaemia, Hodgkin lymphoma or non-Hodgkin lymphoma. Patients recruited from two hospitals will be randomised to a control group (usual care) or an intervention group who will receive usual care in addition to a remote monitoring device (Patient Remote Intervention and Symptom Management System [PRISMS]) that assesses the development of chemotherapy-induced side effects along with psychological health. Patients will be evaluated twice daily, or when they feel unwell, for up to four cycles of chemotherapy. An email alert is generated and prioritised based on severity any time a concern is raised by the patient, and a nurse specialist reviews the information and contacts the patient by telephone to provide clinical intervention[54]. Although this concept is provided by a nurse specialist, this can easily be adapted into a clinical pharmacist model of care and expanded to other malignancies.

Discussion and conclusions

This article provides an overview of various RPM applications reported in the literature, highlighting areas where pharmacists are involved or could be integrated into the model. Telehealth and RPM can be used to support medication adherence and disease monitoring, and to collect patient experiences and support symptom management. In many chronic disease states, these applications are expanding and can improve patient outcomes. Despite innovations in technology and its increased use with the evidence to support it, reimbursement and funding concerns may hinder growth of RPM and telemedicine. Reimbursement regulations are inconsistent, with great variations from country to country and, in the United States, from state to state. In addition, different insurance payers may have different regulations[55].

There are no national reimbursement mechanisms for RPM in the UK[55] or the United States. Reimbursement regulations in Maine and Mississippi are vastly different, for example. In Maine, two-way video services must be used and difficulty with in-person services must be demonstrated to receive reimbursement. In Mississippi, the law is much broader, allowing for reimbursement of store-and-forward technology. Funding for programme infrastructure, including technology and personnel, is often limited. Typically, funding must come from an existing budget within the health system or external sources (such as grant or governmental support)[56].

In England, as an example, funding for RPM is decided at a regional level by clinical commissioning groups, with other funding available at a national level[55]. Pharmacists may face the biggest challenge regarding reimbursement. The only state in the United States where pharmacists are eligible for reimbursement of telemedicine services is New Mexico, with the caveat that they are licensed and enrolled as Medicaid providers. And, as in Maine, the interaction must be via two-way, real-time video services[57].

Telehealth and remote monitoring technologies are rapidly expanding and may be used in various chronic disease states. A variety of remote monitoring devices have demonstrated value equal or above standard care when applied across diverse chronic disease states. Pharmacists are well positioned to assess data obtained from remote monitoring devices and provide recommendations to both patients and other healthcare providers to optimise patient outcomes.

Author disclosures and conflicts of interest:

The authors have no relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. No writing assistance was used in the production of this manuscript. 

Citation: Clinical Pharmacist DOI: 10.1211/CP.2017.20202516

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