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Does Telemonitoring Have a Place in Oncology?

Michael A. Thompson, MD, PhD

03 May 2012 12:15 PM

Does telemonitoring (remote monitoring of patient vitals or other biometric data) have a role in oncology?

Telemedicine
Telemonitoring is a specific form of "telemedicine," which is the use of telecommunication to provide health care at a distance. That can include sending images, video (e.g., for dermatology consults in rural areas), or person-to-person discussions such as via Skype. Remote monitoring devices and companies are proliferating rapidly since many individuals have sophisticated computers with Bluetooth and WiFi capabilities with them all the time—i.e., smartphones. These may be linked with biologic monitors such as watches with HR monitors, dedicated blood pressure monitors, or even biologically integrated sensors in the skin or deeper tissue to transmit information.

Oncology
I imagined the ability to monitor for biologic parameters such as heart rate and temperature in high-risk patients after chemotherapy to improve neutropenic fever care. This might be helpful after outpatient stem cell transplants. Also, remote monitors could evaluate adherence to oral medications on or off study. Other applications might be monitoring well-being, pain control, nausea, or other patient-centered outcomes to improve the continuum of care.

Mayo Telemedicine Study = no drop in readmissions, ED visits
I was alerted to an interesting study on telemonitoring by the following tweet (HT @medskep): RT @jessiegruman: Telemonitored pnts: no drop in readmissions, ED visits. Time to re-think breathless marketing? [study. Arch Int Med]: bit.ly/Io30wQ

In the study by Takahashi and colleagues, "A Randomized Controlled Trial of Telemonitoring in Older Adults With Multiple Health Issues to Prevent Hospitalizations and Emergency Department Visits," published in the Archives of Internal Medicine (online April 16, 2012), the authors found that "Among older patients, telemonitoring did not result in fewer hospitalizations or ED visits."

 

The manuscript noted that, "Efficiently caring for frail older adults will become an increasingly important part of health care reform; telemonitoring within homes may be an answer to improve outcomes." The study was a randomized controlled trial in patients older than 60 years at high risk for rehospitalization. The 205 study participants were randomized to telemonitoring or usual care. Telemonitoring was accomplished by daily biometrics, symptom reporting, and video conference. 
 

As noted in the AMA Medical News: “‘We’re trying to change our care model for sick and older people, and we know this technology’s been out there, and the question is: Will it help?’ said Paul Y. Takahashi, MD, MPH, lead author of the study. ‘We went into it with the thought that this would provide some assistance. . . . It didn’t help at all.’”

The study was performed by a great team with a leader (Paul Y. Takahashi, MD, MPH, was my attending when I was a resident at Mayo) who understands the potential to merge medicine and technology. The study was performed at a well-recognized center that is engaged in innovation. What went wrong? I don't think this study "kills" the concept of telemonitoring. However, it is cautionary that technological innovation cannot solve all problems in human medicine. Just as anti-VEGF therapy didn't cure all cancer, new technology has great potential, but may need additional effort or fine tuning of population, etc. I think this and future prospective studies will provide more real data as opposed to the theoretical speculation of how this remote monitoring might help.

What are your thoughts?

Posted in: Interests, Practice

Comments

Number of Comments: 17
Michael A. Thompson, MD, PhD

Tuesday, May 22, 2012 1:53 PM

Cross referencing to Bryan Vartabedian, MD (@Doctor_V) comments...
http://33charts.com/2012/05/real-time-doctors-visit.html

The Real-Time Doctor's Visit - 33 Charts

Time for a human "check engine light" #mhealth API 
Michael A. Thompson, MD, PhD

Thursday, July 19, 2012 11:24 AM

A JOP article demonstrates this has potential utility in cancer... http://jop.ascopubs.org/content/8/4/205.abstract?cmpid=jop_etoc_1July2012

Cost Effectiveness of Integrated Medicine in Patients With Cancer Receiving Anticancer Chemotherapy

Conclusion:
  The hospital-home monitoring program is a cost-effective strategy for offering ambulatory chemotherapy treatment to patients with cancer. This program has become our standard procedure for ambulatory chemotherapy in patients with cancer. What are your thoughts? How can this be extended with other telemonitoring technologies? 
Michael A. Thompson, MD, PhD

Tuesday, August 07, 2012 2:05 PM

update from a tweet today:

@DrDave01 Market for embedded health monitoring-gadgets to hit 170M devices by 2017 - FierceMobileHealthcare:

http://www.fiercemobilehealthcare.com/story/market-embedded-health-monitoring-gadgets-hit-170m-devices-2017/2012-08-03?utm_campaign=twitter-Share-Web#.UCFVDBJdrOE.twitter

From article:

A "different cast of characters" might dominate the health wearables market, combining "big-data analytics with wearables and a broader ecosystem of platforms that dominate across the fitness app, personal-health-record and self-tracking spaces."
Michael A. Thompson, MD, PhD

Friday, December 07, 2012 8:47 AM

Here is an elegant, crowdfunded, consumer wearable telemonitoring device.
I ordered one for myself and as a gift.

Some tweets on it: 

Misfit Wearables debuts first wearable sensor Shine using IndieGoGoimedicalapps.com/2012/11/misfit… via @iMedicalApps

"Lean Hardware Movement" -- Misfit Shine: an elegant, wireless activity tracker ow.ly/fTjGG Cool video!

RT @medcitynews: How a sleek, quarter-sized activity tracker hit its $100,000 crowdfunding goal in under a day bit.ly/11MSZU3 
John Holland

Friday, December 07, 2012 10:42 AM

The Mayo study has been a puzzle to most people with experience in telemonitoring, because it contradicts the bulk of the literature. Just this week, Alan Snell, M.D., chief medical informatics officer at Indianapolis-based St. Vincent Healthpresented results at the mHealth/HIMSS conference of the Central Indiana Beacon Community remote monitoring program. 30-day readmission rates were 5% in the telemonitoring group versus 20% in the control group! That is just one example. The Geisinger Health Research Foundation analyzed 30-day readmissions for nearly 3,000 patients with all diagnoses. Telemonitoring added to existing case management reduced the risk of readmission an additional 44% versus case management alone. The small number of studies with negative results get a lot of air time, but they should be balanced with the large body of supportive evidence. Full disclosure-- I am Senior VP for Research at AMC Health, a telemonitoring services provider.
Michael A. Thompson, MD, PhD

Friday, December 07, 2012 3:55 PM

Great comments.
I agree this is a ripe area for exploration -- especially in oncology patients -- and especially as a mechanism to bring expertise to more areas.
This has potential implication for both the US and globally.
But it will take some work and iterative approaches to patient selection, hardware, software, integaration, and developing systems with IT competent nurses, NPs, MDs, etc. 
Do you have any links to the data above? Would love to review more of this.

Mike 
Ben Creelan

Saturday, December 15, 2012 2:31 AM

I agree it is important that this issue is being studied. Odd that mortality was higher in the telemonitor arm (p =0.008), but this was just a secondary endpoint.
It may be a small point, but perhaps this study received particular attention because it is level 1 evidence. I wonder if there are other published randomized, controlled trials that have examined this.
Michael A. Thompson, MD, PhD

Saturday, December 15, 2012 3:46 PM

Ben -
Thank you for the comments.
Feel free to share any links to other data on telemonitoring in medicine or especially in oncology. 

This data from:
Telemonitored patients show no drop in readmissions and ED visits
http://www.ama-assn.org/amednews/2012/04/30/prsd0501.htm
An Aug. 4, 2010, systematic review of 25 studies of telemonitoring and phone-based interventions conducted by The Cochrane Collaboration found that they reduced mortality, heart failure readmissions and costs while improving quality of life." 

...is old and could (and likely has been) refreshed since 2010.
I think recently we have much better monitoring devices and integration abilities. 
I suspect that studies planned now and in the future will have differences. 
Michael A. Thompson, MD, PhD

Tuesday, December 18, 2012 8:23 AM

How long until used in Tele-Oncology for trials or normal monitoring (eg post-BMT or other "higher risk" condition)? From a tweet this morning: medcitynews7:07am via twitterfeed

FDA gives go ahead for Phase 2 trial using remote monitoring for multiple sclerosis drug bit.ly/V1SYEN

For the 12-month study, data will be collected from the homes of 180 participants’ homes, using wearable monitors to collect vital signs. 
Secure video interaction between investigators and trial participants will facilitate communication between them, according to a statement from AMC Health. Patients will see clinical trial personnel in person twice — once at the beginning and once at the end of the trial.

In the runup to the FDA approval for the trial, Transparency Life Sciences had obtained insights from patients and and healthcare professionals to strengthen the protocol for the Phase 2 trial, such as primary and secondary endpoints, inclusion and exclusion criteria and remote monitoring strategies.Read more: http://medcitynews.com/2012/12/fda-gives-go-ahead-for-phase-2-trial-using-remote-monitoring-for-multiple-sclerosis-drug/#ixzz2FPQFCC75
Michael A. Thompson, MD, PhD

Saturday, January 26, 2013 11:04 AM

A positive study from Mayo Clinc, from tweet: RT @JackWestMD: @MayoClinic pilot#telemedicine program on high risk #BreastCancer successful bit.ly/XHFwrt This has enormous potential!

“Successful Implementation of a Telemedicine-Based Counseling Program for High-Risk Patients With Breast Cancer” Sandhya Pruthi, et al.

http://www.mayoclinicproceedings.org/article/S0025-6196(12)01040-3/abstract

Abstract An interactive audio and video telemedicine feasibility program was established to provide counseling on breast cancer risk-reducing strategies for underserved, high-risk Alaskan native women through a collaboration among the Alaska Native Medical Center, the Mayo Clinic Breast Clinic, Mayo’s Center for Innovation, and the Alaska Federal Health Care Access Network. The telemedicine model included a navigator to facilitate patient encounters (referrals, electronic records, and scheduling) and a subscription billing contract.

Between January 1 and December 31, 2011, 60 consultations were provided to the Alaska Native Medical Center. A survey of a sample of 15 women demonstrated overall patient satisfaction of 98% pertaining to the experience, technology, and medical consultation.

The referring physician satisfaction, from 11 visit surveys and 8 referring physicians, revealed 99% satisfaction with the service. In this telemedicine pilot study, we demonstrated the feasibility of a telemedicine program to provide integrated specialty care that resulted in a positive effect on patient satisfaction.

This program has a sustainable business model, thus creating a new modality for health care delivery.

Michael A. Thompson, MD, PhD

Monday, April 15, 2013 9:06 AM

More wrinkles to the concept of telemonitoring, albeit in a different population and setting... New York Times(Health) - 4/14/13, "The Doctor Is In, but Hundreds of Miles Away," by Nina Bernstein. This article debates the effectiveness of remotely monitoring intensive care patients: 
Michael A. Thompson, MD, PhD

Thursday, July 18, 2013 6:39 AM

Remote patient monitoring to save $36B by 2018



HT @JohnNosta


“With accountable care the delivery of healthcare funding is linked more directly to the health of the patient or individual, rather than being based upon the cost of treatment,” the firm writes in a whitepaper. “Even though remote patient monitoring, particularly for chronic diseases, is still at a very early stage in the development cycle, it fits well with new healthcare practices and the goal of keeping patients out of hospital.” 
David L. Graham, MD

Saturday, July 20, 2013 5:21 PM

An underutilized aspect of telemedicine is the access it can provide to resources that are difficult to maintain widely. The best example that springs to my mind is allowing patients at distant sites to undergo a genetics evaluation. Geneticists are in short enough supply that many facilities cannot have one. Making a geneticist available via telemedicine can be easy and a great benefit.
Michael A. Thompson, MD, PhD

Wednesday, July 24, 2013 12:37 PM

David -

Great comment. I hadn't though of genetic counselors, but it makes sense.
This is especially important in large geographically dispersed health systems and/or in rural areas. However, it could even be reasonable in large metro areas where getting around is difficult. I recall well patient transportation issues at LBJ Hospital in Houston when it was raining (people didn't want to wait in flash floods at bus stops).

Mike 
Peter Lems

Saturday, November 02, 2013 5:53 AM

Dear Mike,

There are several Lancet publications (2010 and 2012) in the area of home blood pressure measurement and INR self management in combination with telemonitorig, showing a significant reduction in the risk of stroke, coronary heart disease and thromboembolic events. The diseases described here all lead to long term haspitalisation. 

Peter Lems, The Netherlands 
Michael A. Thompson, MD, PhD

Sunday, November 03, 2013 7:57 PM

Thanks for the info.
I'll check them out. 

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