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e-Health/m-Health applications for telemonitoring of outpatients with Cardiac Arrhythmia and Arterial Hypertension

e-Health/m-Health applications for telemonitoring of outpatients with Cardiac Arrhythmia and Arterial Hypertension. Zviad Kirtava 1,2,3 , Gaiane Simonia 1 , Irina Andronikashvili 1 , Tea Gegenava 1,3 , Maka Gegenava 1,3

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e-Health/m-Health applications for telemonitoring of outpatients with Cardiac Arrhythmia and Arterial Hypertension

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  1. e-Health/m-Health applications for telemonitoring of outpatients with Cardiac Arrhythmia and Arterial Hypertension Zviad Kirtava 1,2,3, GaianeSimonia1, Irina Andronikashvili1, Tea Gegenava 1,3, Maka Gegenava1,3 1 – Tbilisi State Medical University; 2 – eHealth Dept, Chapidze Heart Center; 3 – Partners for Health NGO; Tbilisi, GEORGIA. zkirtava@NILC.org.ge 8th QPS Congress, Antalya, April 24-27, 2014

  2. eHealth In last decade, new term - eHealth – has received more widespread use, than previously used Health Telematicsor simply Telemedicine. eHealth has been defined as - Technology-enabled health, which offers a new route to better public health, a better quality of life and increased life expectancy. eHealth includes (but may not be limited to): • Health Information Systems (HIS) and EMR; • Telemedicine; • eLearning of Health Professionals; • Consumer health informatics; • Health knowledge management; • mHealth; (mobile telemedicine & mobile telelearning) 8th QPS Congress, Antalya, April 24-27, 2014

  3. mHealth • mHealth (mobile health, m-telemedicine) - sub-segment of eHealth and a rapidly growing branch of telemedicine, which covers the practice of medical and public health, supported by mobile devices, (mobile phones,PDAs, smartphones) for health services & information. • mHealth - broadband mobile connectivity (GPRS/3G/4G) is used as communication means to transfer data between medical professionals and patients. • With - • rapid development, • wide coverage • good accessibility • Improved bandwidth and • affordable broadband rates of mobile communication mHealth became most advantageous mode of eHealth for population in developing economies 8th QPS Congress, Antalya, April 24-27, 2014

  4. mHealth benefits for developing economies mHealth projects throughout the developing world are demonstrating concrete benefits, including: • Increased access to healthcare and health-related information, particularly for hard-to-reach populations • Improved ability to diagnose and track diseases – anywhere, anytime • Timelier, more actionable consumer health information • Expanded access to ongoing medical education and training for health workers • More chances for cost-efficient solutions. 8th QPS Congress, Antalya, April 24-27, 2014

  5. Integrated Healthcare (WHO) WHO’s notion of integrated healthcare • cost containment (shortening of hospital stay, reduction of inappropriate hospitalizations), • creating conditions for seamless and timely referral of a patient from PHC system hospital whenever needed. Integrated healthcare is based on continuity of care, which is often subdivided in 4 components: 1. Continuity of information (through electronic medical records), 2. Primary-Secondary-Tertiary care interaction (vertical integration), 3. Multidisciplinary teams approach (horizontal integration), 4. Provider continuity. All these can be better realized with the emergence and implementation of e-Health and mHealth 8th QPS Congress, Antalya, April 24-27, 2014

  6. MTM-1 Cardiac Arrhythmia Telemonitoring 8th QPS Congress, Antalya, April 24-27, 2014

  7. Objectives and Patients/Controls • Objectives: to define usefulness, limitations and cost-efficiency of e-Health and/or m-Health applications for outpatients with Cardiac Arrhythmia (CArr) or Arterial Hypertension (AH). • 61 outpatients with different types of Cardiac Arrhythmia (CArr) (M/F=32/25, age – 12-80 y), • among them: • 10 patients with concomitant Epilepsy, • 6 patients after radiofrequency catheter ablation, • 4 patients after aorto-coronary bypass graft surgery (CABG) • 10 patients with unexplained syncope. • Control group - 7 clinically healthy sportsmen – soccer players (all – men, 15-17 y), during 30 min veloergometer stress-test. 8th QPS Congress, Antalya, April 24-27, 2014

  8. Technical Advantage of MTM for Arrhythmia patients • Vitaphone (www.vitaphone.de) equipment produced in Germany and tested, approved and widely used in EU. • Czech company MDT s.r.o. provides LRMA software adjustment for mobile telemedicine • mobile remote monitoring: anytime, anywhere • lightweight and secure • reliable connection to doctor • immediate, personalized feedback • long-term operation • remote supervision • timely intervention • adjustability to user-need/requirements 8th QPS Congress, Antalya, April 24-27, 2014

  9. Arrhythmia monitoring scheme • Design: Arrhythmia 24-h monitoring by means of ECG loop recording (Holter), which records arrhythmia events automatically, recognizing R-R interval irregularities. • Then loop recorder transfers event ECGs through Bluetooth to mobile phone. • Special LRMA software then allows phone to send by 3G communication data to server in Hemnitz (Germany). • In less then 1 min the patient’s ECG (.pdf file) is received by physician at corporate secured e-mail. • All ECGs could be transferred and safely stored for patient data dynamics review. 8th QPS Congress, Antalya, April 24-27, 2014

  10. ECG report example 8th QPS Congress, Antalya, April 24-27, 2014

  11. Results Arrhythmias (CArr) were registered/monitored during 7-68 hours of observation. Automatically recorded ECG events varied from 3 to 170 per observation or 0.4-10.7 hourly. Cases of sinus brady- and tachyarrhythmia, sick sinus syndrome, atrial fibrillation (AF), supraventricular tachycardia (SVT), supraventricular premature complexes (SVPCs) and ventricular premature complexes (VPCs) have been correctly recognized by automatic recognition software and recorded. Arrhythmia relapse (SVT or SVPCs) was detected in 50% (3/6) of patients who underwent RFA, mostly - asymptomatic. Asymptomatic VPCs were often (50%) detected after CABG surgery. 52% of arrhythmia episodes were asymptomatic. From n=10 patients with epilepsy 30% had SVT, 20% - sinus tachycardia (ST). Among n=10 patients with unexplained syncope, 20% revealed ST, 20% - SVT and 10% - sick-sinus syndrome. In 7 patients (13%) the diagnosis was modified/clarified based on MTM findings. 8th QPS Congress, Antalya, April 24-27, 2014

  12. Telemonitoring Scenarios - 1 Scenario #1:Natia is 32 year old young mother of 2.5-year old twin boys. Being medical doctor herself she is not working currently with limited chance both to find the job and also to have somebody to provide care for kids, whom she lovely calls “bandits”. During last year she often had heart palpitation and dizziness, which lasts around 30-120 sec and then stops, sometimes, a feeling of strong heartbeats, after which “the heart stops”. She made regular ECG twice, which has shown no abnormalities. She was advised to have inpatient care at cardiac ward, but that was expensive, besides she couldn’t leave the kids. We have discovered by mHealth telemonitoring (45 hours observation) that Natia rarely has episodes of Sinus Tachycardia and non-frequent SVPCs, mainly during night times or during home work (laundry). She was given medication and was advised to check thyroid hormones (which proved to be normal). She was very happy by having chance of m-telemonitoring and said she was always worried that she could have had something really serious, but was unable to go to the hospital. It was very convenient to be at home with kids, walking them around and doing usual work and at the same time being confident that her health status is being observed – Natia said after investigation. 8th QPS Congress, Antalya, April 24-27, 2014

  13. Telemonitoring Scenarios – cont’d • Scenario #2: Natela is a 77 year old pensioner, on post-ER rehab at home after strong 3rd episode of Ischemic stroke for last 1.5 years. As previous treatment with Aspirin proved ineffective, now on Fraxiparin and then Warfarin anticoagulation treatment. She has speech impairment and left-hand motor deficiency, uses notepad for communication with the hired caregiver. With last two stroke episodes she had persistent atrial fibrillation (AF), which was transformed by Amiodarone treatment back to sinus rhythm (SR). At 2nd day of Warfarin she again developed AF and as cardioversion invasive treatment was dangerous at this stage with risk of recurrent emboli and stroke, we started m-telemonitoring which has shown tachysystolic AF with risk or paroxysmal flatter. Beta-blocker treatment was started and we carefully monitored her heart rate going down from avg. 136 to avg. 56. After that dosage of b-blocker was halved and after 2 weeks SR was restored. In this situation it was risky to move patient back to hospital, but she certainly needed an extended monitoring. Thorough m-telemonitoring was investigation of choice. 8th QPS Congress, Antalya, April 24-27, 2014

  14. Telemonitoring Scenarios – cont’d • Scenario #3:Zurabis 12 year old boy from Western Georgian village. He has epilepsy and due to nodular tachycardia (NT) has passed radiofrequency catheter ablation 2 years ago. Recently he has started to have episodes of palpitation and chest pain again. m-telemonitoring has revealed recidive of NT, which means he either needs to pass RFA again, or to reconsider his main treatment (antiepileptic drugs are often causing CArr). This was one of the first m-telemonitoring in Georgian rural district. 8th QPS Congress, Antalya, April 24-27, 2014

  15. Side Effects: in 13% • 5 cases – 9.3% (4 – women, 1 - man) light insomnia and nervousness (expecting signal during night). • In 2 patients – (3.7%) with neurosis (both – elderly men, one – with concomitant epilepsy) we had to stop the investigation due to patients’ anxiety/agitation related with technology fear and/or idea of constant monitoring. 8th QPS Congress, Antalya, April 24-27, 2014

  16. Technical faults • Bluetooth miscommunication - 19 events out of 2751 (0.7%). • Minor artifacts (mainly at first minutes of recording) - in 9%, or during vigorous physical exercise (around 12%, mainly - in sportsmen group). • Low voltage in one of 3 recorded channels (mainly during night-time, in 3 patients - <6%) – presumably due to loose contact of electrode during sleep. • Stop of recording due to electrode detachment - 6 pts (11%, night-time 4/6). • Loop recorder cannot register all events of arrhythmia, because after recording (25 sec before and 15 sec after the event) equipment is “deaf” for another 40 sec, therefore it can only register maximum 30-40 events hourly. • Besides, software might miss the event, which is then recorded in the next “pre-event” period. Noted in approximately 10%. • Event recognition rate is even lower in AtrialFibrilation(due to R-R constant change). • (problems 5-7 are in acceptable range and doesn’t crucially affect system’s operability and usefulness) 8th QPS Congress, Antalya, April 24-27, 2014

  17. QoS data MTM cycle – in average 47-51 sec. 3G/3.5G communication time (incl. 80-90% authorization) with server 5-6 sec. Sent information size – 11-13 Kb. GPRS/EDGE – 30-250 kb/s and HSDPA – 0.8-6.4 Mb/s (insignificant difference for small data transfer) Feedback pdf report size - 120-138 Kb, so the main challenges and delays happened at this part of the route – to physician’s laptop, or particularly – Smartphone. 8th QPS Congress, Antalya, April 24-27, 2014

  18. QoE Survey results (patients) 8th QPS Congress, Antalya, April 24-27, 2014

  19. QoE Survey results (doctors) 8th QPS Congress, Antalya, April 24-27, 2014

  20. Competition: Alternatives for m-telemonitoring for Arrhythmia patients(Physicians survey results) 8th QPS Congress, Antalya, April 24-27, 2014

  21. Cost-Efficiency of Arrhythmia m-Telemonitoring – in average on 206% cheaper (daily cost calculations, 1 € = 2.2 GEL) 8th QPS Congress, Antalya, April 24-27, 2014

  22. mHealth marketing value for Arrhythmia Market share Among approximately 73,500 Arrhythmia cases in Georgia at least 7,000-10,000 are hospital cases annually and of them at least 10% need post-hospital telemonitoring. Besides another 10-20% cases the treatment regiments are changed and that needs also careful telemonitoring, if not inpatient monitoring. • MTM Target users: • Health/Medical Insurance Companies • Advanced multiprofile or Cardiology Hospitals • Regional Hospitals • So far implemented in 2 major hospitals and 3 Cardiac clinics. 8th QPS Congress, Antalya, April 24-27, 2014

  23. Patient and control group studies 8th QPS Congress, Antalya, April 24-27, 2014

  24. Hypertension mobile telemonitoring 8th QPS Congress, Antalya, April 24-27, 2014

  25. Patients and Control group for AH telemonitoring m-Health telemonitoring - 12 elderly patients (F/M = 7/5, age – 56-77 y) with AH using Stabil-O-Graph (IEM, Germany) monitor with SMS function through the same Huawei smartphone. e-Health telemonitoring of 20 outpatients with AH (F/M = 8/12, age – 38-69 y) for evaluation of circadian rhythms, using Microlife BP03 (Switzerland) e-Health monitoring device. Control – 7 persons with no AH from the Internal medicine faculty and residents (F/M – 5/2, age – 26-56) 8th QPS Congress, Antalya, April 24-27, 2014

  26. BP monitoring equipment m-Telemonitoring– IEM Stabil-O-graph + Huawei IDEOS (Android) - with MDT LRMA software e-Telemonitoring – Microlife Watch BP03 8th QPS Congress, Antalya, April 24-27, 2014

  27. BP m-telemonitoring data (MDT) 8th QPS Congress, Antalya, April 24-27, 2014

  28. BP m-telemonitoring: Pros and Cons • BP mobile-monitoring seems not cost-efficient for the moment due to high cost of the IEM equipment and easiness of BP interpetation, compared to arrhythmia m-telemonitoring; • BP m-telemonitoring has advantage for elderly lonely patients; • 76% of AH patients assessed BP m-telemonitoring positively, emphasizing better self-assurance, however rest 24% (mainly - younger ones) have doubted its added value. • Cost-efficiency could be achieved in case of cheaper equipment. (currently – around 850 Euros). • Main disadvantage – this equipment is only for office/home (indoor) usage, not – for mobile outdoor monitoring. 8th QPS Congress, Antalya, April 24-27, 2014

  29. BP e-Health Monitoring (Microlife BP03) 8th QPS Congress, Antalya, April 24-27, 2014

  30. BP e-Health telemonitoring report 8th QPS Congress, Antalya, April 24-27, 2014

  31. Night time circadian rhythms for AH patients (systolic BP data) 8th QPS Congress, Antalya, April 24-27, 2014

  32. BP - Circadian rhythms of Normal Controls 8th QPS Congress, Antalya, April 24-27, 2014

  33. BP e-Health telemonitoring results • Mean arterial pressure (MAP) by mobile monitoring in hypertensive patients significantly exceeded that of healthy controls (121 ± 7.21 mm Hg vs. 89±6.13 mm Hg, p<0.05). • Ambulatory blood pressure night-time monitoring in hypertensive patients revealed inversed circadian rhythm of blood pressure, mostly in elderly persons. In contrary to healthy controls elevated blood pressure was registered at night (starting mainly at 4:00 AM) with further elevation in daytime. In controls maximum BP – since noon. • Main advantage of BP e-Health monitoring – establishment of individual circadian rhythms and adjustment of individualized treatment for AH. • Provision of bluetooth /mobile connectivity would enhance usefulness of Microlife BP03 and similar equipment – from e-Health to – m-health and ubiquitous monitoring. 8th QPS Congress, Antalya, April 24-27, 2014

  34. MTM-2 PROJECT - M-Telemonitoring for improving decision-making and integrated care for remote cardiac patients • Project aims: • to develop guidelines and assess cost-efficiency of the model for integrated care provision to cardiac patients in 2 regions of Georgia based on • m-telemonitoring, • teleconsultation, • evidenced-based decision-making and • tertiary level/interventional cardiology support either at nearest certified point-of-care or – at central university clinics in Tbilisi with organized transportation by the State Referral Service. • 3 major life-threatening cardiac conditions are chosen for m-health monitoring: • Ischemic Heart Disease (IHD) and particularly – Coronary Artery Disease (CAD) – CA/CABG interventions is thought, • Cardiac Arrhythmia (CArr) – with vision of potential Radiofrequency Catheter Ablation (RFA); • Arterial Hypertension (AH) – with vision to administer Hypertension Individualized Treatment Schemes (HITS). 8th QPS Congress, Antalya, April 24-27, 2014

  35. Conclusions • Our study confirmed that mHealth represents feasible methodology to monitor Cardiac Arrhythmia cases, improving patients’ comfort of life and increasing their mobility with enhanced safety. 2) m-Health telemonitoring oh Arterial Hypertension patients with home/office-based equipment represents limited advantage due to non-complexity of measurement and results readings, as well as – of relative high cost of equipment. However, night-time automatic measurements provide useful information for hypertension treatment adjustment to individual circadian rhythms. 8th QPS Congress, Antalya, April 24-27, 2014

  36. Presentations at: • ESF–COST High Level conference “Future Internet and Society - Complex Networks Prospectives” (AcquafreddadiMaratea, Italy, October 2-7, 2010) • Mobile Health Expo (Las Vegas, NV, USA, Oct 19-21, 2010) • COST 605 Project – “Economics of Telecommunication” Final Public Workshop (Budapest, Hungary, September, 2011) • Dagstuhl seminar on “Future Internet for eHealth” (Wadern, Germany, June 3-6, 2012) • IEEE HealthCom 2013 (Lisbon, Oct 9-12, 2013) 8th QPS Congress, Antalya, April 24-27, 2014

  37. Projects funding by: Shota Rustaveli National Science Foundation (SRNSF) www.rustaveli.org.ge And CRDF-Global / GRDF www.crdfglobal.orgwww.grdf.ge 8th QPS Congress, Antalya, April 24-27, 2014

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