App shows success in monitoring heart failure patients

TORONTO – The Centre for Global eHealth Innovation is on the verge of releasing a new version of its Medly app that can monitor patients with two or more chronic conditions. Medly was first designed and released for heart failure patients.

However, the system was designed as a general platform, and a single Medly app will soon be able to support patients with multiple chronic conditions, including chronic obstructive pulmonary disease, diabetes, hypertension, and chronic kidney disease.

“We know that over 50 percent of people who are 65 and older have two or more chronic conditions,” said Emily Seto, an assistant professor at the University of Toronto, who chaired the Mobile Health Summit in January. The conference was held in Toronto and was organized by the Strategy Institute.

Seto works closely with the Centre for Global eHealth, and described some of the work being done there on monitoring chronic care patients through the use of apps to improve outcomes and to reduce costs and pressure on acute-care hospitals.

Patients using the apps typically take readings of various vital signs; in some instances, such as when they step on a Bluetooth weight-scale in the morning, the data is automatically uploaded via Bluetooth to the patient’s smartphone. Data from the smartphone is then uploaded to servers.

In the randomized controlled trial, alerts about abnormal readings were sent directly to the patient’s cardiologist via e-mail. The message included the patient’s phone number, so the physician could simply click on the phone number to quickly get in touch.

“We didn’t want them to have to open the electronic patient record to start searching additional clinical information and for phone numbers,” said Seto.

A six-month randomized controlled trial of the Medly app that involved 100 patients was a major success. The patients were all enrolled in the University Health Network’s (UHN’s) heart function clinic, and compliance with the program was very high.

One patient even went to Florida for four of the six months and still took his measurements and uploaded them.

In the trial, many of the patients learned to modify their own diets and exercise. Some learned, for example, not to drink too much water, as it is not healthy for heart failure patients.

Overall, said Seto, the patients experienced improvements in quality of life and self-care. BNP fell significantly, and LVEF levels increased by notable amounts as found through a sub-group analysis.

BNP is a substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable.

Left ventricular ejection fraction (LVEF) is the measurement of how much blood is being pumped out of the left ventricle of the heart (the main pumping chamber) with each contraction.

Seto said that one reason the clinical trial was successful was that it had the backing of a clinical champion. Dr. Heather Ross, who heads the heart failure clinic, is a proponent of the Medly app and its benefits for patients and the hospital.

By keeping closer tabs on HF patients at home, Dr. Ross and the creators of Medly believe they can keep them out of hospital.

Indeed, the most common reason for hospitalization in Canada and the United States is heart failure. There are 500,000 HF patients in Canada, and about 5 million in the U.S.

Moreover, up to 60 percent of the hospitalizations are preventable, with better patient management, said Seto.

While the clinical trial, with its 50 clinic patients, sent alerts right to the smartphones of cardiologists, it’s unlikely that physicians will be ready and able to field these alerts and make call-backs in the future.

That’s because the plan is expand the use of Medly to thousands of patients, and to other hospitals. In fact, a remote monitoring program using Medly will be launched as standard of care to UHN heart failure patients in Spring 2016. An analogous remote monitoring program will also be launched this year to UHN chronic kidney disease patients.

“We envision a shift to nurse practitioners supervising the alerts,” said Seto. Nurse practitioners will in some cases be able to handle the alerts on their own. They will also know when to escalate the problem to a physician.

The Centre for Global eHealth Innovation is now testing new ways of expanding the use of telemetry, apps and smartphones into the community. It is in partnership with Paramed, a visiting nurse and community healthcare company, and CellTrak, which devises software for visiting nurses.

However, it has proven harder to recruit patients in the community than at the UHN’s hospital clinic. As well, nurses are not currently able to bill for their ‘telephone visits’ which is a barrier to implementation.

Nurses that did participate in a field trial of Medly in the community found, in addition, that it was difficult to get in touch with patient’s physician when additional advice was required. “Physicians were often off duty, or busy with other patients,” said Seto.

Seto and her colleagues are working on solutions to these problems. In the near future, the remote monitoring system may be more useful for patients tied to hospital cardiac clinics, especially those whose clinicians are salaried.

Still, the continually falling cost of medical equipment and phones makes remote management of chronic care patients easily affordable.

Moreover, new sensors are being developed that will make remote monitoring even more effective. Seto described a bandaid-like sensor that can be placed on the chest to take ECG readings. A headband that can monitor EEG waves is also being tested.

But Seto said that when it comes to apps and remote monitoring, technology is the easy part. “Implementation of the technology including finding funding models and managing workflow is the hard part,” she said.