Remote Monitoring of Heart Failure Patients Treatment

Programme: Customer Experience, Expectations, Barriers and

Conditions

Annamaija Paunu and Nina Helander

Information and Knowledge Management, Tampere University, Tampere, Finland

Keywords: Knowledge Management, Healthcare, Telecare, Experiences, Expectations, Case Study.

Abstract: Telemedicine in health care is becoming more important as digitalization continues to spread in all areas of

our everyday life. The ageing population, not only in Finland, but all over the world, and the shortage of

health care personnel forces to develop new solutions. This case study investigates the effectiveness of the

telecare programme from the perspective of patients' service experiences and identifies barriers and conditions

that should be taken into account in the wider introduction of a new type of telecare service. Empirical study

points out the patients' expectations of the new telehealth service model and presents benefits and challenges

that may occur in new telehealth services. Self-monitoring of health through the device portfolio seems to be

an interesting possibility for several respondents in the study. The patient experience in regards to health care

and health care personnel was satisfactory and participants had a positive view of remote monitoring of heart

failure through the device portfolio.

1 INTRODUCTION

Health care is facing major challenges from different

directions: ageing population and increasing

prevalence of chronic diseases (Lim et al. 2017,

Christensen et al. 2009), at a time when the

demographic dependency ratio is declining and the

funding base for tax-funded health systems is

shrinking. Alongside these challenges, there are many

new opportunities for health systems. Medical

advances are making it possible to address an

increasing number of ailments and to cure more and

more diseases. Technological advances also make it

possible to do things in a whole new way.

Healthcare is still largely based on traditional

appointment-based mode in which physical visits and

services are centralised in physical buildings (e.g.

hospitals and health centres) where patient care takes

place (McKee et al, 2020). However, current

technological solutions mean that in the future an

increasing proportion of patients will be able to

benefit from digital solutions based on continuous

data collection and exchange between patients and

healthcare professionals, alongside or replacing

traditional service models. According to the

literature, remote monitoring has the potential to

improve patients' quality of life, prevent unnecessary

office visits, reduce costs and enable timely and early

treatment intervention in situations where the

patient's need for care is increasing with advancing

illness (Scalvini et al 2020, Walker, Tong et al 2019).

In the Finnish context, we know relatively little about

how remote monitoring affects the patient's

experience of care and what barriers or conditions are

associated with the use of this new type of service.

However, these are key factors influencing patients'

engagement in and ability to benefit from treatment.

Mapping patients' experiences is also important to

enable health service providers to better identify those

people who are most likely to benefit from remote

monitoring.

The purpose of this study was to investigate the

effectiveness of the telecare programme from the

perspective of patients' service experiences and to

identify the barriers and conditions that should be

taken into account in the wider introduction of a new

type of telecare service. It also explored patients'

expectations of the new telehealth service model and

how the new service was perceived in relation to

traditional appointment-based, physical outpatient

clinic visits.

Paunu, A. and Helander, N.

Remote Monitoring of Heart Failure Patients Treatment Programme: Customer Experience, Expectations, Barriers and Conditions.

DOI: 10.5220/0012195800003598

In Proceedings of the 15th International Joint Conference on Knowledge Discovery, Knowledge Engineering and Knowledge Management (IC3K 2023) - Volume 3: KMIS, pages 213-218

ISBN: 978-989-758-671-2; ISSN: 2184-3228

213

Research questions

1. What are patients' expectations of using

telehealth and how do they differ from their

expectations of traditional outpatient services?

2. What are the effects of implementing telehealth

on patients' quality of life and perceived well-being?

3. What factors contribute to the uptake and

adherence to telehealth?

4. What are the barriers to telehealth adoption

and engagement?

The remain of the paper is organized as following.

Theoretical base is first introduced shortly. Research

method and the case is introduced and followed by

the description of the key results of the empirical

study. The paper is finalized by the conclusions and

discussion section.

2 TOWARDS

PATIENT-ORIENTED

TELECARE

Digitalization is inducing an important shift in the

division of labour in healthcare, with telemedicine-

based patient self-care (Borries et al., 2019) and

remote care (Queirós et al., 2018) that are becoming

increasingly prevalent and more important.

According to Akhlaghi & Asadi (2002) in the area of

telecare there is great potential due to the ageing

populations throughout the world. However, more

work needs to be done on making equipment easy to

use and moreover, succeeding in the continuously

evolving digital technologies require more in-depth

knowledge about the customer experience on digital

technology and the ways the data from multiple

sources can be empowered to create impactful

solutions and development of new kinds of digital

services (Khodadad-Saryazdi, 2021), such as telecare

(Akhlaghi & Asadi, 2002).

Telecare includes a promise towards more cost-

efficient care that is free of the limitations of physical

distance and strict office hours (Queirós et al., 2018).

For example, remote monitoring makes it possible to

improve the patient's quality of life, to prevent

unnecessary reception visits, reduce costs and enable

timely and early therapeutic intervention in situations

where the patient's need for treatment is increasing

(see e.g., Tortorella et al. 2020, Goodridge &

Marciniuk, 2016). Even though the potential of

telecare has been well recognized, many healthcare

activities are still largely based on traditional

appointments, physical reception visits and services

are centralised in physical buildings (e.g., hospitals)

where the patient's treatment takes place. In

healthcare, it is traditionally used to the fact that the

service provider and the patient meet physically.

However, through digitalization, this is no longer the

case. Because there is an immense number of digital

services and opportunities available nowadays also in

healthcare, you have to think about it in advance how

they are perceived by the patients and what is their

impact on patient care (Hermes et al, 2020). This

makes it easier to find the right tools, target groups

and services. Thus, to leverage telecare use in

practice, more information is needed from the patient

point of view.

3 RESEARCH METHODS AND

CASE STUDY DESCRIPTION

One of the strategic goals of the case hospital has been

to establish a digital care pathway for heart failure

patients and to implement a related telehealth

programme. Based on preliminary studies, the case

hospital started piloting a new service for heart failure

patients in October 2020, with 47 patients already

enrolled (December 2021). The programme of care

service includes a guiding visit and introduction to the

digital system for the heart failure patient, the tools

needed by the patient (alternatively a mobile app

provided on the patient's smartphone or a complete

monitoring toolkit including a tablet computer,

mobile connection, scales and device instructions), a

daily assessment of the treatment balance by the case

hospitals nurse and remote interventions for heart

failure treatment. In this case study a total of 15

patients were interviewed, of which 13 were

interviewed twice according to the study design.

Interviewees were recruited between May and

October 2022 and the first interviews took place

during the same period. The interviews were

conducted as semi-structured thematic interviews by

one researcher. Semi-structured thematic interviews

allow for a conversational atmosphere and provide

still the opportunity to delve deeper and ask questions

like why, what and how. The method is particularly

well suited to studying a phenomenon where there are

several variables, and the phenomenon is not yet fully

understood. The interviews were conducted by

telephone and recorded with a separate recorder and

later transcribed. All materials were stored securely

by the research organizations data administration.

The interviews were conducted in two stages:

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1) as soon as possible after the start of the

telecare programme, in order to identify the

baseline situation and expectations for the

telecare programme, and

2) during the course of the telecare programme,

at 3-12 months, to gather experiences of

using telecare and to highlight barriers and

enablers

The study also included a group interview with

nurses in the heart unit of the hospital. This interview

was conducted as a semi-structured thematic

interview by two researchers. The interview was a

live event and was recorded on a recorder. The

interview was transcribed, and all materials were

equally securely stored.

The empirical study on patients' experiences,

expectations and barriers/conditions to use was

conducted as a qualitative interview study. The

transcribed interview data was examined using the

content analysis method. The interview data was

coded to identify key words from each interview and

categorise these under broader themes. The themes

identified from individual interviews were in turn

aggregated together, paying particular attention to

convergent and divergent empirical findings. Content

analysis as a method is particularly well suited to the

analysis of data collected through thematic

interviews, as it allows for a genuinely data-driven

identification of the interviewees' views and

experiences of the phenomenon under study.

4 CASE STUDY RESULTS

4.1 Expectations, Feeling and

Technology

The first round of interviews was conducted with

participants soon after the orientation and

introduction of the telemonitoring portfolio for heart

failure, in order to get a sense of their actual

expectations and feelings and to get a snapshot of the

situation. The expectations of several respondents

were neutral and the comment "no expectations" was

repeated in the responses. Being continuously

monitored by the device portfolio seemed to provide

participants with a sense of security and safety in

terms of their health and care. Self-monitoring of

health through the portfolio also seemed an

interesting possibility for several respondents.

Overall, participants had a positive view of remote

monitoring of heart failure through the device

portfolio and the monitoring through the device

portfolio created a sense of security for participants.

The patient experience at the hospital was largely

very satisfactory. The staff is perceived as

knowledgeable, competent and thorough. The

induction and guidance on the equipment portfolio

and remote monitoring of heart failure received

positive feedback. The guidance was adequate,

unhurried and comprehensive. The interviews also

revealed that good care and patient experience

requires good interpersonal skills and a people-

oriented and holistic approach. Especially in a new

health situation, it is important that the patient and his

or her awareness of the situation is taken into account

and that the health situation, and the treatment plan

are presented in a way that the patient is sure to

understand.

Interaction with the nursing staff was generally

perceived positive in both rounds of interviews, i.e. at

the time of implementation and during

implementation. Interaction and communication with

the care staff via the mobile device was also largely

perceived as effective; questions were answered and

contact was actively taken if there were any

discrepancies in answers or values. On the other hand,

it was also noted that if everything goes according to

plan, e.g. no deviations in the weight, the feedback is

mainly a daily acknowledgement message on the

mobile device. Some participants had no interaction

at all with the care staff because the care was

balanced. This may have resulted in participants

becoming slightly unmotivated with remote

monitoring and lead to some level of boredom.

Overall, the expectations and feelings in the first

round of the interviews were both positive and

neutral. Expectations included the consolidation of

self-monitoring and the ease of technology-enabled

monitoring. Several respondents mentioned the

feeling of security that comes with remote

monitoring; the medical staff seems to be closer or at

least easier to reach. In both rounds, interviewees

mostly described monitoring as a routine activity.

According to the interviewees, measuring weight and

answering questions is not an effort, mostly a minor

inconvenience, but it is notable that the monotonous

situation in the follow-up, as good as it really is, also

seems frustrating and can lower the motivation to do

this routine in the beginning of each day. The

questions are repeated in the same way and when the

state of health is under control, feedback may not be

received.

The interviewees felt that good care was provided

during the remote monitoring. A few interviewees

had used remote monitoring to balance their

Remote Monitoring of Heart Failure Patients Treatment Programme: Customer Experience, Expectations, Barriers and Conditions

215

medication and felt that this approach was effective.

Most interviewees had had pre-arranged outpatient

clinic visits and did not feel the need for additional

visits. For most interviewees, nothing unexpected had

happened during the telemonitoring and the

telemonitoring had worked routinely. However, a few

interviewees had discontinued the telemonitoring on

their own initiative. The interviewees who had done

so were not contacted by the nursing staff to find out

why the remote monitoring had stopped.

In summary, the level of engagement from all

parties, that took place during the remote monitoring,

whether it was the use of the patient's device or, for

example, communication with the patient, was

perceived as quite adequate and in some places even

abundant. (Table 1).

Table 1: Expectations and performance of remote

monitoring of heart failure.

ectations Performance

- More efficient

information sharing

- Monitoring and

treatment nearby

- Closer monitoring of

your own health

- A positive feeling

- Routine measure

- Easy to use

- Nothing

unexpected/surprises

happened

- Questions are repetitive,

simple

With regard to the technology itself i.e. the device

portfolio, the interviewees felt that the initial training

was sufficient and thorough. The second round of

interviews asked about the functioning of the device,

its drawbacks and problems, and its ease of use.

Basically, the device was easy to use. Almost all

interviewees had experienced problems with the login

update in the beginning, when a new log-in procedure

was introduced. Almost all had needed to take a

contact with hospital personnel or needed to try to log

into the mobile device several times on their own. In

a few cases, the device had not been restarted and

remote monitoring had stopped as a result. All in all,

the update to the log-in (four-digit code) was

perceived as an improvement, logging in was initially

more difficult. Currently, technical support is

provided by nursing staff, who should not be

performing this type of task. These contacts place an

unnecessary burden on nursing staff, who should be

able to concentrate on their actual nursing duties.

Technical issues related to the operation of the device

should be referred to a separate technical support

service. This wish was also expressed in the

interviews.

4.2 Benefits and Challenges

When planning the introduction of a new approach, it

is important to identify the benefits to be gained,

while at the same time identifying the potential

challenges. It is also particularly important to get

feedback on the benefits and challenges from users

and staff during the implementation process. The

survey asked both the nursing staff and the patients

for their experiences and thoughts on the benefits of

remote monitoring of heart failure and also asked

them to reflect on any challenges or drawbacks. Table

2 below shows the benefits of remote monitoring

from patient and healthcare professionals’

perspective while table 3 shows the challenges for

patient and health care personnel.

Table 2: Benefits of remote monitoring of heart failure for

patients and healthcare professionals.

Patients Health care personnel

Balance of care;

medication, well-being,

ability to work

Improved monitoring of

one’s own health

Interaction and ease of

contact (mobile contact

versus waiting in line on the

phone)

Mental well-being - feeling

of security

Easy to use and hassle-free

(digital/manual))

Patient activity: better

engagement in treatment

and better monitoring of

their own health

For health care

professionals, easier

monitoring of the

patient's condition -

regular data collection

Increased

communication,

interaction and contact

In terms of benefits, both the patient interviewees

and the nursing staff consider that the patient's own

activity and monitoring of their own health status is

enhanced. The importance of communication and

interaction is also highlighted by both groups of

respondents. For the patient group, the ease of contact

is emphasized, and this is reflected in increased

contact from the nursing staff. For the patient group,

the sense of security, the emotional well-being of

having "someone watching" is significant, and for the

nursing staff this can be interpreted as an indication

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of the nursing staff's experience of facilitating the

monitoring of the patient's condition - data is

accumulated daily, the system processes the data

according to set limits and reports deviations.

Table 3: Challenges of remote monitoring of heart failure

from the perspective of patients and healthcare

professionals.

Patients Health care personnel

Simultaneous use of other

devices with a remote

monitoring mobile device

does not work

Absent-mindedness in

using the device, not a

routine activity

Boredom due to the

monotonous proceedings,

lack of motivation

Implementation requires a

customer visit and

guidance

Increased communication

and contacts: sufficiency

of resources

False or unwarranted

contacts: technical issues,

non-urgent care

Awareness of remote

monitoring of heart failure

among other medical staff

Compatibility of

information systems – still

manual recording of data

System does not support

e.g. automatic feedback to

the patient

Challenges for patient interviewees included

boredom with routine procedures or distraction from

remote monitoring. On the one hand, telemonitoring

had become a routine every morning, but was almost

as easily forgotten by some of the interviewees, who

were more likely to telemonitor a few times a week

rather than daily. This was also influenced by the lack

of motivation that emerged as a challenge; if the data

and answers are the same every day and there is no

feedback on the answers, in the longer run remote

monitoring can also be perceived as a useless and

even futile exercise. The same phenomenon emerged

in interviews with the nursing staff who called for the

system to enable automatic feedback to the patient,

especially in cases where the balance of care is good,

and which therefore do not appear as ‘red flags’ in the

nursing staff's system. The nursing staff expressed the

wish that it would be possible to send some kind of

positive feedback to those who consistently

performed well. A major challenge, particularly for

the nursing staff, is the incompatibility of information

systems, with data currently being recorded in

multiple locations and copied from one location or

system to another. There is a risk of data

fragmentation and errors in the data.

5 CONCLUSIONS AND

DISCUSSION

This case study shows that remote monitoring of heart

failure generally works well with the current

approach. Suggestions for improvement from the

patient and health care personnel included the

integration of other devices into the mobile heart

failure telemonitoring device, such as the

measurement of glucose levels and blood pressure.

These were currently delivered manually to the

mobile device by self-recording. Also there seems to

be a need for variability in the question set. The

questions were repetitive, and this was perceived as a

factor reducing motivation. The question set should

be made more variable, e.g., new question or at least

rephrased questions at certain intervals. Adding

questions that measure the quality of life would

provide important and useful information for health

care staff. It can also be concluded from the

interviewees' answers that some positive,

encouraging feedback through the technology device

from time to time would better maintain motivation

for remote monitoring. To be able to give feedback

via the system also emerged in the interviews with the

nursing staff. In the future, it would be good to

explore with the equipment supplier the possibility of

a partially or fully automated feedback system, e.g.,

monthly reports from the Oura ring with "crowns" or

Apple health reports in the corresponding

applications. It would also be advisable to develop a

feedback system for patients on a mobile device, e.g.,

a happy or not -type feedback questionnaire, for

example a few questions per week, which would

provide up-to-date information on users' feelings and

the impact of remote monitoring. Combining these

user feedback questions with the quality-of-life

questions proposed above would allow for a

reasonably easy collection of data that could be

analysed to meet patient needs and to give important

and useful infomation for the social and welfare staff.

Providing functional and timely technical support

for the device, both for patient users and medical

staff, is of paramount importance. At present,

technical support for patient users is in practice

provided by nursing staff, whose duties do not include

Remote Monitoring of Heart Failure Patients Treatment Programme: Customer Experience, Expectations, Barriers and Conditions

217

this. It would be important for users and medical staff

alike to make a clear distinction between technical

support and contact for heart failure care. Nursing

staff should be able to concentrate on nursing care and

answering related questions and messages. This is

also important for the future, as remote monitoring of

heart failure will expand and patient numbers will

increase, with a corresponding increase in the number

of contacts for nursing staff. Technical support should

address the problems of both patient users and

medical staff in a comprehensive manner. At present,

it is very difficult to make changes to the system, e.g.

to edit questions.

This study has several limitations. The empirical

data is gathered only from one case, representing

Finnish health care hospital. The empirical data was

gathered only by qualitative means, thus the study is

lacking quantitative evidence. However, this study

was able to provide initial empirical insights of the

patients experiences and feelings on new telecare

procedure. It also highlights some benefits and

challenges from two perspectives; patients and health

care personnels. Further empirical studies are needed.

ACKNOWLEDGEMENTS

This research was supported by Tampere Heart

Hospital.

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