Telemonitoring strategies

This category includes the articles that describe the tools available in the telemonitoring, making a total of (12) articles; the studies were selected in the databases CINAHL and PubMed.

The health services adopt the strategies according to pre-defined programs, in which the remote consultation can be done by telephone or through electronic equipment. The information is transmitted via web and / or bluetooth; it is necessary to provide fixed or mobile telephone lines for the transmission and monitoring of data through electronic resources such as video monitors, Tablets, alarm boxes, digital scales and wristwatches ^{10 11}.

The instruments of clinical evaluation and health guidelines have variations according to the remote consultation programs. Health professionals perform monitoring of weight, vital signs, signs and symptoms of clinical decompensation of heart failure (HF); the evaluation of functional capacity for daily life activities and health-related quality of life (HRQoL); besides offering support for the patient with HF ¹².

The user's poor understanding of discharge readiness has been identified as one of the leading causes of re-hospitalization within 30 days. The patient may find it difficult to assimilate discharge guidelines referring to home self-care due to their clinical conditions and the family, based on factors such as stress, work and home care planning for the patient. Lack of understanding of information provided during hospital discharge can cause uncertainties and make adherence difficult. Effective communication can contribute significantly to the success of transitional care ¹³.

The remote consultation has been used by nurses as a tool for the educational process, management of the signs and symptoms of decompensation of HF and support for the search of emergency and emergency care. Information on the clinical conditions and pharmacological and non-pharmacological treatment offered to the patient contributes to health promotion, with increased knowledge and improved self-care ¹⁴.

The development of new studies is of great value, with a description of the approach taken in the remote consultation and of the applied teaching-learning process, with the analysis of knowledge and self-care variables in HF and the possible clinical outcomes such as re- hospitalization and death, leading to new randomized clinical trials due to their shortage in Brazil ¹⁴.

In a study ¹⁵who used the Interactive Voice System to answer questions related to physical condition (dyspnea, edema and changes in appetite) and adherence to pharmacological treatment, the weight was monitored by Bluetooth. The sample comprised 541 patients and showed a 23% reduction in admission chances, a 44% chance of readmission in 30 days and a 38% chance of readmission in 90 days. The cost of treatment reduced by 11% during the use of this system.

Another study ¹⁶quasi-experimental study, with non-randomized selection, applied to elderly patients with heart failure and life expectancy from 02 to 03 years, a system was developed using text messages and videophone, transmitting patients data on vital signs and clinical parameters for a team of health professionals. The data submitted were analyzed based on evidence medicine. Studies before and after the implementation of telehealth have shown a decrease in total costs with care, visits to the emergency department and hospitalization.

Management of care is addressed in another retrospective cohort study ¹⁷integrated by 1767 patients. The Buddy Health System developed in the USA consists of an electronic equipment with screen that captures information related to symptoms, vital signs, behavior and knowledge about health. The information obtained is sent to a software through a secure web portal. The data of the program showed a positive impact on the self-management, contributing to the adherence to the pharmacological treatment, exercises, diets and direct communication with the health professionals.

Managing care associated with the Buddy Health program provides healthcare professionals with the information they need to support clients in reinforcing positive treatment behaviors. The study ¹⁷17 identified a decrease in the mortality rate of 15% of the controls in relation to the group in relation to the propensity rate, also including a decrease in the admission rate of 18%.

Corroborating with the above surveys, a cohort study ¹⁸performed with 141 patients during one year, focusing on the evolution of the remote referral service, monitored the weight, vital signs and signs and symptoms of cardiac decompensation. The data obtained regarding weight were transmitted to a central and electronic medical record. The research showed a rapid feed-back by the medical professional when patients presented changes in weight. Patients who did not respond to furosemide were directed to an evaluation by a general practitioner. And, the patients with a clinical worsening were oriented to look for an emergency service.

In the same study ¹⁸cited above, the application of the Minnesota Quality of Life Instrument score showed a gradual improvement in the parameters on a quarterly basis; this in turn may be related to an increase in confidence in your health care due to tele-monitoring or in relation to an improvement in physical vigor due to weight control. Another relevant parameter was the decrease in hospitalization rate per person (4.7 to 2.6 p <0.001).

The evaluation of health-related quality of life (HRQL) makes it possible to understand several aspects of the individual's well-being, related to the presence of the disease and / or therapeutics. HF reduces patients' functional capacity and ability to perform activities of daily living, leading to a decrease in HRQL ¹⁹.

In another study applied in a multidisciplinary telemonitoring program ¹², composed of nurses and physiotherapists, the Physical Activity Scale of the Elderly (PASE) and the Minnesota instrument that evaluates Health-Related Quality of Life (HRQL) were used. The randomized study comprised a sample of 50 to 60 patients over a period of 6 months. The follow-up by telephone contact served to verify adherence to therapy, maintain motivation for exercise, educate for the early recognition of signs and symptoms of cardiac decompensation, and evaluate acquired skills.

The aforementioned research ¹²was implemented to know the efficacy of this technology in patients with HF and chronic obstructive pulmonary disease (COPD) due to the existence of few studies addressing HF and comorbidities. Data from the study were obtained from the Physical Activity Scale of the Elderly (PASE) and from the Minnesota instrument that evaluates Health-Related Quality of Life (HRQL). The quality of life evaluation is an important indicator of the home program; but, it is little applied in the investigations of telemonitoring. Most studies with the Minnesota instrument focus on hospitalizations and mortality; however, there is a lack of studies that address the efficacy of the programs, physical performance and quality of life.

In another research²⁰, the telemonitoring was implemented with an interactive web-based video monitor with support from medical professionals and nurses for patients with HF, COPD, diabetes and wounds. Among the relevant aspects, it is important to highlight the transmission of vital signs and summaries to electronic medical records, facilitating communication among health professionals. Another important parameter was the performance of the physicians in the task group using the diuretic protocol, to avoid the hospitalizations of patients with HF in the terminal phase, evidencing the efficacy of this treatment at home.

The above study shows that the implementation of home care, telehealth and the application of the diuretic protocol ²⁰the following benefits: a) the provision of quality health care; b) reduction of hospitalizations and care in the emergency services, through early interventions such as monitoring of vital signs, use of appropriate medications and consultations with health professionals; c) greater patient compliance through contact with health professionals and informal caregivers; d) e, the decrease of the stress of the patients and improvement of the quality of life, contributing to the autonomy of the patients.

The remote consultation facilitates the patient's access to technology without leaving home, the nurse has the ability to communicate, in this way, a support is offered with the health information, which maintains the standard of attendance of the physical consultations. Consequently, there is a decrease in the search for emergency services by patients, since their needs are met remotely ⁴.

A retrospective study ²¹from 11 medical records, brought important data for the deepening of the use of remote consultation, indicating the need for further studies on this form of care. The study analyzed the number of emergency services, admissions, length of stay, scheduled and unscheduled home visits.

The data from the above study ²¹, showed that the average number of unplanned home visits pre-screened was lower than the average number of unplanned home visits post-tele-monitoring. In addition, the average number of visits to the emergency service during the remote consultation was less than the average number of visits to the emergency service after the remote consultation. It is likely that the increase in the number of post-tele-monitoring consultations is related to the decline in the health of these patients who have chronic diseases, and there is no failure in the telemonitoring.

The remote consultation allows the follow-up of patients with HF through parameters such as vital signs, weight, signs and symptoms of HF decompensation and, through health guidelines. The studies showed that telemonitoring is an efficient and effective strategy for the patient with HF. However, it is emphasized that the transmission of knowledge to the users in an isolated way does not contribute to identify their adherence to the treatment. To achieve this goal, it is essential to base the educational actions with Orem's Theories of Motivation, Self-Determination and Self-Care Deficit, including also the Motivational Interview and Decision-Making Model ²².

Similar study reported the adherence and usability to a remote system by elderly people with chronic diseases or not in an extended period of time. The results showed that the elderly can benefit from a health monitoring system for a long period in order to follow their chronic conditions and stay longer in their homes ¹⁰.

Personalized tele-monitoring can aid in the prevention of heart failure decompensation, facilitating patient self-care and providing greater adherence to treatment ¹¹. The education of patients with heart failure is an essential part of controlling the disease. Thus, it is very important to increase the investment in actions that help the diffusion of the knowledge and the education of these patients ^23,24. The success of non-pharmacological treatment requires repeated and frequent efforts, enabling the health team to approach the patients with HF and family, consolidating information on HF and self-care ²⁵.

The perception of health professionals and users about telemonitoring

The second category that covers the perception of health professionals and users about telemonitoring, emerged from (04) articles listed in the CINAHL AND PUBMED databases, with emphasis on knowledge, information technology, communication and support for the implementation and development of the consultation remote.

In a study²⁶developed from semi-structured interviews, a group of 16 telemonitoring nurses was asked about this tool, the training, equipment, barriers and repercussions of the strategy on users' health. The findings in the study described the difficult aspects for the remote consultation as: the lack of resources and organizational support, restrictive criteria for patients' enrollment in the remote consultation program and the lack of technical support.

The implementation of a telemonitoring service ²⁶in the professionals, a resistance. To overcome this barrier imposed by professionals, it is necessary to develop strategic planning and the use of communication between the manager and health professionals. Other attributes that strengthen the use of this technology are the training, the collaboration and the support aiming to overcome the obstacles existing for this type of assistance.

In the United Kingdom, a case study ²⁷was developed with eighty-four (84) nurses and professionals who participate in health services and others who do not participate, twenty-one (21) managers and stakeholders. The case study was conducted at four community health services in England to understand how patients were being monitored remotely.

Research data ²⁷show the barriers and facilitating aspects for remote consultation. Among the barriers mentioned, are the acceptance of telemonitoring by the team of professionals, aspects related to the configuration of the services; the lack of clarity regarding the application and efficacy of the technology and the paradigm change regarding the physician's performance in relation to these patients, since other professionals would participate in this care.

With regard to the facilitator aspects ²⁷, the data point out the incentive to trust in technological innovation, the sharing of knowledge and the early identification of barriers by the team with the objective of overcoming them, including also the acquisition of resources for the sustainability of the process.

Health professionals should participate in the planning and construction of an uninterrupted and interactive counseling protocol for patients with chronic illnesses, taking into account necessary changes such as information technology and health technology. The health service will undergo changes based on the patients' demands, in order to meet their needs ⁴.

Regarding users' views on remote consultation, two studies developed with an indigenous population in Australia were elaborated: based on their cultural characteristics. A research ²⁸had five participants aged 61.6 ± 10 years and class III or IV IC (NYHA). The mixed method was applied, in the first phase the action research contributed to the construction of an electronic resource (Tablet) that evaluated the indigenous population in a safe way. In the second phase, the new resource was tested to verify the acceptability and viability of the indigenous population.

From this study ²⁸two themes emerged: identity (the resource showed the local people's robes, skin tone and voice) and understanding (simple images and text in the first person). Patients reported a high level of satisfaction with the electronic resource 83%. Knowledge about HF increased (percentage of correct answers) from 48.00 plus or minus 6.7% to 58.00 plus or minus 9.7%, an increase of 20.8%, there was a 95% increase in the self-care (46.7 ± 16.0 to 91.1 ± 11.5). Changes in management and maintenance scores varied among patients.

In another study²⁹with the indigenous population, the sample had 102 patients who were divided into eighteen focal groups followed at eleven Aboriginal Health Services. Seven focus groups were performed for people who had already used the HMR program (n = 23) and 11 focus groups were performed for people who did not use an HMR program (n = 79). All the participants realized that the lack of awareness and promotion of the HMR program were factors that contributed to the low adherence to the program. Most users reported that the HMR interview was very helpful in learning more about their medications. However, many reported that they found the process confusing and confronting. The study showed that in the patients' perception, health professionals should develop communication, knowledge transmission, referral and follow-up satisfactorily.

Limitations of the Study

The integrative review was developed under the careful analysis and evaluation of four reviewers, this action does not rule out the risk of bias occurrence. The bias includes any distortion during the search for scientific evidence, which can occur in any type of design. The types of bias can be classified in the following forms: selection bias, information bias and confounding bias. The occurrence of these can be limiting factors for the study ³⁰.