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The question
Remote monitoring is meant to catch early signs of heart failure decompensation, such as weight gain or worsening symptoms, so treatment can be adjusted before a patient needs the hospital. Yet trials have produced conflicting results. A health system considering a remote monitoring program needs to understand why.
Two large trials
Tele-HF (Chaudhry et al., 2010). In the United States, 1,653 patients recently hospitalized for heart failure were randomly assigned to telemonitoring or usual care. Telemonitoring used a telephone-based interactive voice-response system that collected daily information on symptoms and weight, which the patients' own clinicians reviewed. Readmission or death within 180 days occurred in 52.3% of the telemonitoring group and 51.5% of the usual-care group, a difference that was not significant. Readmission and death rates were similar, and telemonitoring did not improve outcomes.
TIM-HF2 (Koehler et al., 2018). In Germany, 1,571 patients with New York Heart Association class II or III heart failure and a heart failure hospitalization in the previous 12 months were randomly assigned to remote patient management plus usual care or usual care alone. Patients with major depression were excluded. The percentage of days lost to unplanned cardiovascular hospital admissions or death from any cause was 4.88% with remote management and 6.64% with usual care (ratio 0.80). All-cause mortality was 7.86 versus 11.34 per 100 person-years (hazard ratio 0.70). The difference in cardiovascular mortality was not significant.
Comparing the interventions through a sociotechnical lens
Sittig and Singh (2010) describe eight interacting dimensions that determine whether health information technology works in real health care settings: hardware and software; clinical content; the human–computer interface; people; workflow and communication; internal organizational policies, procedures and culture; external rules, regulations and pressures; and system measurement and monitoring. Seen this way, the two trials tested different systems, not just different devices.
| Dimension | Tele-HF | TIM-HF2 |
|---|---|---|
| Hardware and software | Telephone voice-response system | Devices transmitting measurements to a telemedical center |
| People and workflow | Data reviewed by patients' own clinicians alongside their usual work | A dedicated telemedical center reviewed data and acted on it, in coordination with patients' physicians |
| Patient selection | Patients recently hospitalized for heart failure | A narrower group, recently hospitalized, with major depression excluded |
| Monitoring and response | Depended on clinicians noticing and acting on alerts | A structured process for responding to abnormal data |
The comparison suggests that the technology alone does not change outcomes. What may matter is a reliable team and workflow that turns data into timely action, and careful selection of patients likely to benefit.
Implications for a health system
- Design the response, not just the data feed. Define who reviews data, how quickly and what actions they can take, including diuretic adjustment protocols.
- Select patients thoughtfully, for example those with recent hospitalizations who can engage with monitoring, and screen for depression, which can affect engagement.
- Plan for workload. Staff the monitoring role rather than adding alerts to busy clinic inboxes.
- Measure across dimensions, including patient adherence to transmitting data, response times, hospitalizations and mortality.
Conclusion
The two trials are a reminder that informatics interventions are sociotechnical systems. A DNP-prepared nurse leading a remote monitoring program should evaluate the whole system, the people, workflow and organization as well as the device, before expecting better outcomes.
References
Chaudhry, S. I., Mattera, J. A., Curtis, J. P., Spertus, J. A., Herrin, J., Lin, Z., Phillips, C. O., Hodshon, B. V., Cooper, L. S., & Krumholz, H. M. (2010). Telemonitoring in patients with heart failure. New England Journal of Medicine, 363(24), 2301–2309. https://doi.org/10.1056/NEJMoa1010029
Koehler, F., Koehler, K., Deckwart, O., Prescher, S., Wegscheider, K., Kirwan, B.-A., Winkler, S., Vettorazzi, E., Bruch, L., Oeff, M., Zugck, C., Doerr, G., Naegele, H., Störk, S., Butter, C., Sechtem, U., Angermann, C., Gola, G., Prondzinsky, R., . . . Stangl, K. (2018). Efficacy of telemedical interventional management in patients with heart failure (TIM-HF2): A randomised, controlled, parallel-group, unmasked trial. The Lancet, 392(10152), 1047–1057. https://doi.org/10.1016/S0140-6736(18)31880-4
Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Quality and Safety in Health Care, 19(Suppl. 3), i68–i74. https://doi.org/10.1136/qshc.2010.042085
