Review
Transforming Hypertension Management Using Mobile Health Technology for Telemonitoring and Self-Care Support

https://doi.org/10.1016/j.cjca.2013.02.024Get rights and content

Abstract

Achieving and sustaining good blood pressure control continues to be a challenge for many reasons including nonadherence with prescribed treatment and lifestyle measures, shortage of primary care physicians especially in less populated areas, and variations in physicians’ practice behaviour. Many strategies have been advocated to improve outcomes with the greatest success being achieved using nurse or pharmacist-led interventions in which they were given the authority to prescribe or alter antihypertensive treatment. However, this treatment approach, which historically involved 1-on-1 visits to a doctor’s office or pharmacy, proved costly, was not scalable, and did not actively engage patients in treatment decision-making. Several electronic health interventions have been designed to overcome these limitations. Though more patient-centred and often effective, they required wired connections and a personal computer, and logging on for Internet access and navigating computer screens greatly reduced access for many older patients. Furthermore, it is unclear whether the benefits were related to better case management or technological advances. Mobile health (mHealth) technology circumvents the technical challenges of electronic health systems and provides a more flexible platform to enhance patient self-care. mHealth applications are particularly appropriate for interventions that depend on patients' sustained adherence to monitoring schedules and prescribed treatments. Studies from our group in hypertension and other chronic conditions have shown improved health outcomes using mHealth applications that have undergone rigourous usability testing. Nonetheless, the inability of most electronic medical record systems to receive and process information from mobile devices continues to be a major impediment in realizing the full potential of mHealth technology.

Résumé

L’atteinte et le maintien d’une bonne maîtrise de la pression artérielle continue de poser des difficultés pour diverses raisons incluant la non-observance du traitement prescrit et des mesures liées au mode de vie, la pénurie de médecins de premier recours, particulièrement dans les régions moins peuplées, et les variations dans le comportement lié à la pratique des médecins. Plusieurs stratégies ont été recommandées pour améliorer les résultats à la suite du grand succès obtenu en utilisant les interventions des infirmiers ou des pharmaciens qui ont reçu l’autorisation de prescrire ou de modifier le traitement antihypertenseur. Cependant, cette approche de traitement, qui supposait historiquement des visites individuelles, révélées coûteuses, à un cabinet médical ou à la pharmacie, n’était pas évolutive et n’engageait pas activement les patients dans la prise de décision à l’égard du traitement. Plusieurs interventions ont été conçues pour surmonter ces limites. Bien que plus axées sur le patient et souvent efficaces, elles ont nécessité des connexions filées et un ordinateur personnel, et l’ouverture de session pour l’accès à Internet et la navigation sur des écrans d’ordinateur réduisaient grandement l’accès à plusieurs patients plus âgés. De plus, on ignore si les avantages étaient liés à une meilleure prise en charge coordonnée ou aux progrès technologiques. La technologie mobile en santé (m-santé) contourne les difficultés techniques des systèmes de santé électroniques et offre une plateforme plus flexible pour améliorer les soins autoadministrés par le patient. Les applications de la m-santé sont particulièrement appropriées aux interventions qui dépendent du maintien de l’observance par les patients aux calendriers de surveillance et aux traitements prescrits. Les études de notre groupe sur l’hypertension et autres affections chroniques ont montré une amélioration des résultats de santé par l’utilisation d’applications de la m-santé ayant subi un examen de convivialité rigoureux. Néanmoins, l’incapacité de la plupart des systèmes de dossiers médicaux informatisés à recevoir et à traiter l’information à partir d’appareils mobiles demeure un obstacle majeur à la réalisation du plein potentiel de la technologie de la m-santé.

Introduction

Hypertension is a highly prevalent chronic condition affecting up to 23% of Canadian adults according to a recent population-based survey.1 It accelerates arterial aging and is a leading risk factor for cardiovascular disease. Clinical events such as stroke, myocardial infarction, or end-stage renal disease, the final chapter of this devastating condition, dramatically change the daily life of patients, impose a major burden on families, and are enormously expensive to manage.2

To slow the rate of vascular deterioration and prevent cardiovascular events related to uncontrolled hypertension, there has been a wide array of initiatives to detect, treat, and control this condition. The Canadian Hypertension Education Program has been at the vanguard of producing guidelines that have shaped the practice behaviour of frontline physicians in Canada.3 The approach to managing hypertension has been based largely on the traditional medical model in which physicians identify health problems, prescribe appropriate therapy, and monitor the treatment response in follow-up office visits. Trend analysis has shown considerable improvement in achieving good blood pressure control for a substantial proportion of the hypertensive population.4 Nonetheless, success has not been uniform with poorer rates of control being observed in subsets of hypertensive patients such as those with diabetes and those aged 60 years or older.

Many quality improvement strategies have been studied including self-monitoring of blood pressure, education of patients and health professionals, clinical decision support systems, practice audits and feedback, appointment reminder systems, and the use of nurses or pharmacists as first-line caregivers.5 There was considerable variation in their effectiveness with the greatest success being achieved using nurse or pharmacist-led interventions in which they were given the authority to prescribe or alter antihypertensive treatment. Historically the successful nurse- or pharmacist-led interventions followed the traditional medical care model of 1-on-1 patient and provider encounters generally in a health clinic or pharmacy.6 As such, this approach proved costly, was not scalable, and did not actively engage patients in treatment decision-making. Newer team-based interventions have adopted a more patient-centred approach to treatment with continued good success.7 Nonetheless, this approach to managing hypertension has not been widely adopted within the Canadian health care system.

Personalized medicine, commonly viewed as plying molecular genetics to identify disease risk and guide treatment, can take many forms. In health care delivery it involves individualized treatment, active engagement of patients in the process of care, and enhanced communication between patients and their health care providers. The development of personalized health care has arisen in response to the rapidly growing burden of chronic diseases and the well-recognized need to find better ways of delivering care to chronically ill patients.8 In recognition of these changes and the rapid growth of patient empowerment movement, the Ontario Ministry of Health and Long-Term Care revamped the infrastructure of the provincial health care delivery care system to create a knowledge-based, patient-centred framework to facilitate chronic care management. In the revised system, patients are encouraged to assume greater ownership in managing their health and work in partnership with their health care providers to solve problems and achieve treatment goals.9

Shared care arrangements are heavily influenced by the severity of the patients’ medical problems. For people who are well, the prime responsibility for maintaining good health and preventing illness rests squarely in their hands. For those with chronic illnesses, they shoulder most of the responsibility for managing their health problems.10 This might take several forms such as becoming better informed, adopting a healthier lifestyle, and adhering to professionally prescribed treatments. It is only in complex illnesses, which constitutes a very small fraction of medical problems, where professional skills and experience dominate. Even in these instances, patients can still be responsible for many aspects of their care when they have been explicitly defined.

For hypertensive patients, self-care activities can play a major role in achieving good blood pressure control. There are many domains of care that are under their direct control (Fig. 1). Two major components are making appropriate lifestyle choices and adhering to prescribed treatments. Equally important are having access to their own health record and self-monitoring of blood pressure to assess response to treatment and improve adherence. An overarching consideration in enhancing self-management skills is to make patients better informed and strengthening self-confidence in managing key elements of their own care (self-efficacy).10 The effectiveness of different disease management programs for patients with chronic illnesses has been evaluated in several meta-analyses. In general, patient education, reminders, and financial incentives are associated with better patient outcomes.11 In hypertension specifically, promotion of self-management activities lead to small but clinically important reductions in blood pressure, although there is considerable heterogeneity among the trials.5, 12, 13

Section snippets

Health From a Distance

Advances in telecommunication technologies have been instrumental in allowing patients to move away from face-to-face visits in the doctor’s office to using the Internet for continuous access to care, a development encouraged in the Institute of Medicine’s Crossing the Quality Chasm report.14, 15 Using high-speed communication systems, patients and family members can easily access a wide array of educational resources including information on disease-specific topics and general self-management

Electronic Health Solutions to Manage Hypertension

Over the past 2 decades a variety of electronic health (eHealth) solutions for improving the management of hypertension from afar have been evaluated. One of the first successful innovations was a totally automated interactive telecommunication system that used computer-controlled speech to converse with patients by telephone.17 Patients were asked weekly to provide the system with results of self-measured blood pressure readings and to answer a series of questions about their treatment

Mobile Health Revolution

In developed countries mobile access is almost ubiquitous, adoption of smartphones is increasing rapidly with sales now outnumbering cell phones and the increasing availability of 3G and 4G networks enables video calling and high-speed data transfer.26 The explosion of mobile health (mHealth) care devices and software has greatly extended self-care capabilities across the spectrum of health care activities. Today’s high-end smartphones allows patients and their families to easily access a wide

Conclusion

Sustaining effective antihypertensive treatment has been a challenge for those involved in the chronic management of hypertension. A variety of quality improvement strategies have been advocated with the greatest success being achieved using a nurse- or pharmacist-led intervention in which they have been given the authority to prescribe or alter antihypertensive treatment. Historically, this approach to care involved 1-to-1 patient-provider encounters generally in a health clinic or pharmacy.

Funding Sources

The Ontario Ministry of Health and Long-Term Care and the Heart and Stroke Foundation of Ontario (ESA 5970) funded the work on blood pressure telemonitoring.

Disclosures

The author has no conflicts of interest to disclose.

References (32)

  • T. Fahey et al.

    Educational and organisational interventions used to improve the management of hypertension in primary care: a systematic review

    Br J Gen Pract

    (2005)
  • C.E. Clark et al.

    Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis

    BMJ

    (2010)
  • Health Council of Canada. Why health care renewal matters: learning from Canadians with chronic health conditions....
  • V.J. Barr et al.

    The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model

    Hosp Quart

    (2003)
  • T. Bodenheimer et al.

    Patient self-management of chronic disease in primary care

    JAMA

    (2002)
  • S.R. Weingarten et al.

    Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports

    BMJ

    (2002)
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