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"Tele-Management of Diabetic Hypertension: The Use of the Digital Medical Diary

More than 1.5 million Canadians suffer from diabetes. Of those, about half are hypertensive. The coexistence of diabetes mellitus and hypertension has serious health consequences. Lowering blood pressure (BP) markedly decreases the rate of cardiovascular events and renal deterioration in these patients. A recent study revealed that only 15% of hypertensive diabetic patients reached their goal BP, even when treated by physicians in hypertension management. While there are many patient and health system related factors that contribute to poor BP control, it is becoming increasingly apparent that major improvements in outcomes will likely require changes in the manner that care itself is delivered.

We hypothesize that in the primary health care setting a tele-management system will improve BP control in diabetic patients with uncontrolled hypertension compared to usual care and the intervention will be feasible, acceptable to the users and cost-effective.

The system under development uses Bluetooth-enabled homecare devices such as BP monitors and weight scales to transmit data to a PDA or smartphone. The device acts a conduit to transmit data back to a data repository, where rules can be applied and alerts generated as necessary. These alerts can be communicated back to the family physician by a variety of methods, including email or fax.

For the patient, the PDA acts as personal medical diary, logging all of the BP and weight measurements and displaying trends. Given the sophistication of modern PDAs, rules can also be applied to this local data and alerts and recommendations be displayed to patient immediately.

Using a user-centred approach, careful consideration of design issues relating to elderly patients has been taken. The small form factor of PDAs and smartphones may limit their ability to read the screen. Many may have little or no experience with such technology.

For such patients, the system can simply sit unattended on a nightstand, all the while it receives data from the Bluetooth homecare devices, logging the information, and transmitting wirelessly to the data repository for later review. For patients more comfortable with the technology, the device could serve them by displaying trending data, providing them with alerts, recommendations, and related health information. This largely precludes the need for a personal PC, unlike existing system available.

Focus groups with family physicians indicate a concern about receiving regular automated reports generated by the system. Most physicians feel that, in the absence of scheduled visit to their office, they do not have the ability to act on these reports.

To address this, the system will have the ability to generate a report at the time of the patient’s visit. The patient simply brings their device to their visit and the system can automatically generate the report and output wirelessly to the physician’s Bluetooth-enabled printer. The physician and patient can then go over their information together during the visit. These focus groups have indicated that this “sneaker-net” approach, coupled with automated alerts for readings that are trending seriously, will help them better manage their hypertension.

There is evidence that for an ever-increasing population of these patients, the automated recording of BP measurements, with trending and alerts, will act as a “cue to action” for the patient to comply with prescribed health regiment. “Cue to action” is an element of the Health Belief Model, used for predicting health behaviour in patients.

It is hypothesized that this user-centred approach, utilizing focus groups, iterative design and human factors methods of evaluation, will lead to the next-generation of home tele-monitoring applications that are more intuitive, less cumbersome, and ultimately bring about greater patient compliance and better physician management.

Investigator(s) or Project Sponsor(s):

Alexander Logan, Joseph Cafazzo, Peter Rossos, Denice Feig, Jane Irvine, Warren McIsaac, Kerrayem Al Suwaida, Carlos Rizo, Melinda McLean, Peter Picton, Jack Lam, Walter Igharas, Andrea Dunai, Tony Easty Funding organizations

Ministry of Health and Long Term Care - Primary Care Transition Fund Organizations

Medical Device Informatics and Telehealth, Centre for Global eHealth Innovation, University Health Network and Mount Sinai Hospital Research Institute Contact information

Joseph Cafazzo