rdiology 29 (2013) 579e585

Canadian Journal of Ca

Review

Transforming Hypertension Management Using MobileHealth Technology for Telemonitoring and Self-Care Support

Alexander G. Logan, MD, FRCPCProsserman Centre for Health Research, Samuel Lunenfeld Research Institute of the Mount Sinai Hospital, Department of Medicine of the Mount Sinai Hospital and the

University of Toronto, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada

ABSTRACTAchieving and sustaining good blood pressure control continues to bea challenge for many reasons including nonadherence with prescribedtreatment and lifestyle measures, shortage of primary care physiciansespecially in less populated areas, and variations in physicians’ prac-tice behaviour. Many strategies have been advocated to improveoutcomes with the greatest success being achieved using nurse orpharmacist-led interventions in which they were given the authority toprescribe or alter antihypertensive treatment. However, this treatmentapproach, which historically involved 1-on-1 visits to a doctor’s office orpharmacy, proved costly, was not scalable, and did not actively engagepatients in treatment decision-making. Several electronic healthinterventions have been designed to overcome these limitations.Though more patient-centred and often effective, they required wiredconnections and a personal computer, and logging on for Internetaccess and navigating computer screens greatly reduced access formany older patients. Furthermore, it is unclear whether the benefitswere related to better case management or technological advances.Mobile health (mHealth) technology circumvents the technical chal-lenges of electronic health systems and provides a more flexibleplatform to enhance patient self-care. mHealth applications areparticularly appropriate for interventions that depend on patients’sustained adherence to monitoring schedules and prescribed treat-ments. Studies from our group in hypertension and other chronicconditions have shown improved health outcomes using mHealth

Received for publication February 9, 2013. Accepted February 26, 2013.

Corresponding author: Dr Alexander G. Logan, Mount Sinai Hospital,435-600 University Ave, Toronto, Ontario, Canada. Tel.: þ1-416-586-5187;fax: þ1-416-586-5039.

E-mail: logan@lunenfeld.caSee page 584 for disclosure information.

0828-282X/$ - see front matter � 2013 Canadian Cardiovascular Society. Publishehttp://dx.doi.org/10.1016/j.cjca.2013.02.024

R�ESUM�EL’atteinte et le maintien d’une bonne maîtrise de la pression art�eriellecontinue de poser des difficult�es pour diverses raisons incluant la non-observance du traitement prescrit et des mesures li�ees au mode devie, la p�enurie de m�edecins de premier recours, particulièrement dansles r�egions moins peupl�ees, et les variations dans le comportement li�eà la pratique des m�edecins. Plusieurs strat�egies ont �et�erecommand�ees pour am�eliorer les r�esultats à la suite du grand succèsobtenu en utilisant les interventions des infirmiers ou des pharmaciensqui ont reçu l’autorisation de prescrire ou de modifier le traitementantihypertenseur. Cependant, cette approche de traitement, qui sup-posait historiquement des visites individuelles, r�ev�el�ees coûteuses, àun cabinet m�edical ou à la pharmacie, n’�etait pas �evolutive et n’en-gageait pas activement les patients dans la prise de d�ecision à l’�egarddu traitement. Plusieurs interventions ont �et�e conçues pour surmonterces limites. Bien que plus ax�ees sur le patient et souvent efficaces,elles ont n�ecessit�e des connexions fil�ees et un ordinateur personnel, etl’ouverture de session pour l’accès à Internet et la navigation sur des�ecrans d’ordinateur r�eduisaient grandement l’accès à plusieurspatients plus âg�es. De plus, on ignore si les avantages �etaient li�es àune meilleure prise en charge coordonn�ee ou aux progrès tech-nologiques. La technologie mobile en sant�e (m-sant�e) contourne lesdifficult�es techniques des systèmes de sant�e �electroniques et offreune plateforme plus flexible pour am�eliorer les soins autoadministr�espar le patient. Les applications de la m-sant�e sont particulièrement

IntroductionHypertension is a highly prevalent chronic condition affectingup to 23% of Canadian adults according to a recent population-based survey.1 It accelerates arterial aging and is a leading riskfactor for cardiovascular disease. Clinical events such as stroke,myocardial infarction, or end-stage renal disease, the finalchapter of this devastating condition, dramatically change the

daily life of patients, impose a major burden on families, and areenormously expensive to manage.2

To slow the rate of vascular deterioration and preventcardiovascular events related to uncontrolled hypertension,there has been a wide array of initiatives to detect, treat, andcontrol this condition. The Canadian Hypertension Educa-tion Program has been at the vanguard of producing guide-lines that have shaped the practice behaviour of frontlinephysicians in Canada.3 The approach to managing hyper-tension has been based largely on the traditional medicalmodel in which physicians identify health problems, prescribeappropriate therapy, and monitor the treatment response infollow-up office visits. Trend analysis has shown considerableimprovement in achieving good blood pressure control fora substantial proportion of the hypertensive population.4

d by Elsevier Inc. All rights reserved.

Figure 1. Domains of care under patients’ control.

applications that have undergone rigourous usability testing. None-theless, the inability of most electronic medical record systems toreceive and process information from mobile devices continues to bea major impediment in realizing the full potential of mHealthtechnology.

appropri�ees aux interventions qui d�ependent du maintien de l’ob-servance par les patients aux calendriers de surveillance et auxtraitements prescrits. Les �etudes de notre groupe sur l’hypertension etautres affections chroniques ont montr�e une am�elioration desr�esultats de sant�e par l’utilisation d’applications de la m-sant�e ayantsubi un examen de convivialit�e rigoureux. N�eanmoins, l’incapacit�e dela plupart des systèmes de dossiers m�edicaux informatis�es à recevoiret à traiter l’information à partir d’appareils mobiles demeure unobstacle majeur à la r�ealisation du plein potentiel de la technologie dela m-sant�e.

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Nonetheless, success has not been uniform with poorer ratesof control being observed in subsets of hypertensive patientssuch as those with diabetes and those aged 60 years or older.

Many quality improvement strategies have been studiedincluding self-monitoring of blood pressure, education ofpatients and health professionals, clinical decision supportsystems, practice audits and feedback, appointment remindersystems, and the use of nurses or pharmacists as first-linecaregivers.5 There was considerable variation in their effec-tiveness with the greatest success being achieved using nurseor pharmacist-led interventions in which they were given theauthority to prescribe or alter antihypertensive treatment.Historically the successful nurse- or pharmacist-led interven-tions followed the traditional medical care model of 1-on-1patient and provider encounters generally in a health clinic orpharmacy.6 As such, this approach proved costly, was notscalable, and did not actively engage patients in treatmentdecision-making. Newer team-based interventions haveadopted a more patient-centred approach to treatment withcontinued good success.7 Nonetheless, this approach tomanaging hypertension has not been widely adopted withinthe Canadian health care system.

Personalized health care

Personalized medicine, commonly viewed as plying molec-ular genetics to identify disease risk and guide treatment, cantake many forms. In health care delivery it involves individu-alized treatment, active engagement of patients in the process ofcare, and enhanced communication between patients and theirhealth care providers. The development of personalized healthcare has arisen in response to the rapidly growing burden ofchronic diseases and the well-recognized need to find betterways of delivering care to chronically ill patients.8 In recognitionof these changes and the rapid growth of patient empowermentmovement, the Ontario Ministry of Health and Long-TermCare revamped the infrastructure of the provincial healthcare delivery care system to create a knowledge-based, patient-centred framework to facilitate chronic care management. Inthe revised system, patients are encouraged to assume greaterownership in managing their health and work in partnershipwith their health care providers to solve problems and achievetreatment goals.9

Shared care arrangements are heavily influenced by theseverity of the patients’ medical problems. For people who arewell, the prime responsibility for maintaining good health andpreventing illness rests squarely in their hands. For those withchronic illnesses, they shoulder most of the responsibility formanaging their health problems.10 This might take several

forms such as becoming better informed, adopting a healthierlifestyle, and adhering to professionally prescribed treatments.It is only in complex illnesses, which constitutes a very smallfraction of medical problems, where professional skills andexperience dominate. Even in these instances, patients can stillbe responsible for many aspects of their care when they havebeen explicitly defined.

Self-management of hypertension

For hypertensive patients, self-care activities can play amajorrole in achieving good blood pressure control. There are manydomains of care that are under their direct control (Fig. 1). Twomajor components are making appropriate lifestyle choices andadhering to prescribed treatments. Equally important arehaving access to their own health record and self-monitoring ofblood pressure to assess response to treatment and improveadherence. An overarching consideration in enhancing self-management skills is to make patients better informed andstrengthening self-confidence inmanaging key elements of theirown care (self-efficacy).10 The effectiveness of different diseasemanagement programs for patients with chronic illnesses hasbeen evaluated in several meta-analyses. In general, patienteducation, reminders, and financial incentives are associatedwith better patient outcomes.11 In hypertension specifically,promotion of self-management activities lead to small butclinically important reductions in blood pressure, althoughthere is considerable heterogeneity among the trials.5,12,13

Health From a DistanceAdvances in telecommunication technologies have been

instrumental in allowing patients tomove away from face-to-face

Alexander G. Logan 581Telemonitoring Using mHealth Technology

visits in the doctor’s office to using the Internet for continuousaccess to care, a development encouraged in the Institute ofMedicine’s Crossing the Quality Chasm report.14,15 Using high-speed communication systems, patients and family memberscan easily access a wide array of educational resources includinginformation on disease-specific topics and general self-management tools. Institutional portals allow patients to viewrelevant sections of their electronic medical records, accessinformation about their medications or illness, and communi-cate with their health care providers through a Web messagingsystem. Some portals also allow patients to update demographicinformation, request an appointment or referral, and renewa prescription. Structured home surveillance of vital physiolog-ical parameters has proven to be a useful way to establish baselinevalues, aid in setting treatment goals, assess response to therapy,and detect drifts from control.16 Such information also becomesa motivational tool for maintaining adherence to treatment,a starting point for better patient-provider communication, anda means for patients to become actively engaged in treatmentdecision-making. Finally, computer-mediated communicationtechnologies (online support groups, Web 2.0, and online socialnetwork sites) have opened new frontiers for patients to shareand adopt successful experiences with peers worldwide.15 Ingeneral these developments have greatly improved chronicdisease management. Nonetheless, there are concerns about theso-called ‘digital divide,’ whereby affordability, availability, andcomplexity of operation might affect access.

Electronic Health Solutions to ManageHypertension

Over the past 2 decades a variety of electronic health(eHealth) solutions for improving the management ofhypertension from afar have been evaluated. One of the firstsuccessful innovations was a totally automated interactivetelecommunication system that used computer-controlledspeech to converse with patients by telephone.17 Patientswere asked weekly to provide the system with results of self-measured blood pressure readings and to answer a seriesof questions about their treatment (medication regimen,adherence, side effects) using the touch-tone keypad on theirtelephone. The system provided management tips and moti-vational counselling on medication adherence. In a random-ized controlled trial, the system improved adherence withtreatment, and lowered diastolic blood pressure among non-adherent subjects. In a study using a similar telecommunica-tion system but with an added nursing interventioncomponent, the telemonitoring group achieved better bloodpressure control, which was attributed to intensified antihy-pertensive drug treatment.18

Other programs sought different solutions. In a study byGreen and colleagues from the United States, pharmacistsused secure e-mail that was integrated into a health careorganization’s Web site to deliver care to hypertensivepatients.19 The intervention was a care plan created by thepharmacist in collaboration with assigned patients and theirphysician. The plan called for patients to choose a lifestyleactivity to work on and to measure their blood pressure twiceat least 2 days a week and transmit the readings by e-mail tothe pharmacist. It also allowed the pharmacist to makemedication changes according to an approved protocol, order

laboratory tests, and schedule follow-up visits. The patientsunderwent proficiency training in the use of the health careorganization’s Web site so that they could view their personalmedical records, refill their medications, and correspond usinge-mail with their health care providers. The pharmacist con-tacted patients every 2 weeks until home blood pressure wascontrolled, and less frequently thereafter. In a randomizedcontrolled trial of 778 patients with uncontrolled hyperten-sion, Green et al. compared the effectiveness of the Web-pharmacist care with usual care, described as patients usingthe health care organization’s Web site without any specifictraining and receiving treatment in the standard fashion, andwith a second group that received training on home bloodpressure monitoring and Web portal use to access all servicesavailable to the Web-pharmacist group, except communica-tion with a pharmacist.19 Blood pressure control, the primaryoutcome measure, improved dramatically in the Web-pharmacist care group compared with usual care (56% vs31%), albeit with significantly increased number of antihy-pertensive medication classes filled. On the other hand, therewas no significant difference in blood pressure controlbetween patients assigned to the home blood pressure moni-toring and Web training only group and those in the usualcare group. Blood pressure outcomes were not related tochanges in lifestyle measures (body mass index and physicalactivity), which did not differ among the 3 groups. Medica-tion adherence was not reported. The results suggested thataggressive application of antihypertensive treatment ratherthan enhanced patient self-management support was thecritical element in improving blood pressure control.

McManus and colleagues in the United Kingdom devel-oped a telemonitoring intervention to self-titrate antihyper-tensive medications based on daily home blood pressuremeasurements, a colour traffic light system to code readings,and a titration schedule developed collaboratively with thepatients’ family doctor.20 In a randomized controlled clinicaltrial of 12 months duration, the reduction in systolic bloodpressure, the primary outcome measure assessed in the patients’general practice using a validated electronic automated sphyg-momanometer applied by a member of the research team, wassignificantly greater in the home-titration group compared withthe control group at the end of the study. The home-titrationgroup also used more antihypertensive medications and hadmore frequent side effects. Data on blood pressure control werenot reported nor was there any information on lifestyle changesor medication adherence. Importantly, self-management didnot induce anxiety among participants.

Two recent meta-analyses and systematic reviews havesummarized the results of all telemonitoring studies withhome blood pressure measurements.21,22 Omboni et al. re-ported that patients randomized to home telemonitoring hadsignificantly greater reduction in blood pressure, achievedbetter blood pressure control, and used more antihypertensivemedications compared with care based on office measure-ments.21 Home telemonitoring was also more expensive,although only 1 study undertook a formal economic analysis.In most studies the major cost drivers were salaries of healthproviders and telemonitoring equipment. In the study byAgarwal et al., telemonitoring was associated with a greaterreduction in systolic blood pressure compared with homeblood pressure monitoring without a telecommunication

Figure 2. Structure of smartphone blood pressure telemonitoring system. 1x, packet based billing; BP, blood pressure; GPRS, General PacketRadio Service; SSL, Secure Sockets Layer.

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component.22 Thus, blood pressure telemonitoring holdsgreat promise in improving the treatment of hypertension.

There are many limitations to the use of eHealth systemsto improve chronic disease management. User acceptance isa major issue. In a heart failure study only 85.6% of subjectsrandomly assigned to home telemonitoring actually used thesystem, and by week 26, only 55.1% adhered to the recom-mended monitoring schedule.23 Complexity of operation canalso affect usage. eHealth systems require wired connectionsand a personal computer to access electronic personal healthrecords and patient Web portals. Users have to log on forInternet access and navigate computer screens, which canoften flummox older patients, generally the population ofinterest in chronic disease management.24 Affordability andavailability are major issues for people with limited financialresources who often rely on using a computer in public areassuch as a library or community centre for Internet access.Publically available computers might also compromise securityof personal health information. Currently eHealth solutionsfor home surveillance of vital parameters require qualifiedpersonnel to process and evaluate transmitted informationbefore the patient is contacted to change therapy. Apart fromcost, such a configuration greatly reduces timeliness ofcommunication and increases uncertainty among patientsawaiting a response. Furthermore such tight supervision mightnot actually be necessary because patients with diabetes havebeen adjusting insulin doses based on home blood glucosereadings for decades and many patients with end-stage renal

disease set up their equipment unsupervised and self-cannulate for vascular access to undergo home hemodialysisoften at night while sleeping.25

Mobile Health RevolutionIn developed countries mobile access is almost ubiquitous,

adoption of smartphones is increasing rapidly with sales nowoutnumbering cell phones and the increasing availability of3G and 4G networks enables video calling and high-speeddata transfer.26 The explosion of mobile health (mHealth)care devices and software has greatly extended self-care capa-bilities across the spectrum of health care activities. Today’shigh-end smartphones allows patients and their families toeasily access a wide range of health educational materials andservices anywhere anytime. For people interested in main-taining or improving their health there are many self-helpwellness and fitness programs. There are also a wide rangeof mobile services and solutions for the prevention, diagnosis,and treatment of diseases. However the greatest strength ofmHealth solutions for patients might be disease monitoring.mHealth applications running on smartphones or otherportable devices enable remote monitoring of vital parametersto diagnose health problems, track responses to treatment ofchronic illnesses, detect drifts from control, and provide earlywarning signals of potentially dangerous changes in patients’health status. As such mHealth is poised to become theindispensible healthcare tool of the future and has thepotential to greatly enhance patient autonomy.

Alexander G. Logan 583Telemonitoring Using mHealth Technology

Over the past 8 years our group has been developingmHealth applications to engage patients in self-managementactivities based on the belief that enhancing self-relianceimproves health outcomes.24,27-31 In hypertension ourefforts centred on developing an application for remotemonitoring of blood pressure. In focus-group meetings withhypertensive patients, we learned that they preferred a systemwhich did not require computer literacy for Internet accessand operation.23,27 In addition, patients preferred a systemthat provides feedback in real time on how they are doing.With this information, we designed an mHealth blood pres-sure monitoring system that used a commercially availableBluetooth-enabled blood pressure measuring device for datainput, a central server for data processing, communication,and storage, and a preprogrammed smartphone for datatransmission and receipt of messages and reminders (Fig. 2).27

All electronic transmissions were encrypted and deidentifiedto ensure confidentiality. Immediately after each blood pres-sure measurement, the blood pressure reading and a textmessage appeared automatically on the screen of the patients’smartphone. The message provided context for the reading byindicating the 2-week running average of blood pressurereadings and encouraged adherence to treatment recommen-dations and lifestyle measures. Blood pressure alerts weretriggered whenever the running 2-week average was too highor too low. In such instances patients were asked to measuretheir blood pressure more often with the frequency beingdetermined according to the degree of deviation from thenormal range. If the readings continued to exceed preset limitspatients were advised via automated messaging to contact theirdoctor’s office for an appointment with the urgency beingdictated by the magnitude of the deviation. All patientmessages were derived from predefined care paths, which tookinto account the results of previously transmitted readings.Voice messages to the patients’ home phone were limited toqueries about possible operational difficulties with the tele-monitoring equipment and in the case of critical alerts, askingpatients to check their smartphone for messages.

Nonadherence to the preset home blood pressuremeasurement schedule triggered an automated remindersystem, and critical (safety) alerts for physicians were auto-matically sent to their office by fax. On the day precedingtheir doctor’s office visit, patients called a dedicated telephonenumber to initiate the automated process of generating a 1-page patient summary report. The report containeda graphic presentation of readings with dates, the average ofa patient’s blood pressure readings over the past 30 days, theprevious 30-day average, and the number of readings used toderive the averages. It did not contain any treatment recom-mendations. In a pilot study the system was highly effectivein lowering the blood pressure of hypertensive diabeticpatients.27

Based on the encouraging initial results we undertooka randomized controlled trial in which 110 diabetic patientswith uncontrolled hypertension were randomly assigned tothe mHealth-monitored group or home blood pressuremonitoring without mHealth support.31 One year afterrandomization, the mean daytime ambulatory blood pressurefell significantly in the mHealth group with no change in thecontrol group, and the mean between-group differences of 7.1� 2.3 (standard error) mm Hg for systolic blood pressure and

3.9 � 1.3 mm Hg for diastolic blood pressure were clinicallyand statistically significant. Furthermore, 51% of patients inthe mHealth group achieved the guideline-recommendedtarget of < 130/80 mm Hg compared with 31% of controlgroup subjects. Unlike previous telemonitoring studies,21 thesignificant improvements were achieved without theprescription of more antihypertensive medications. Further-more, there were no additional clinic visits to physicians in themHealth group. Patients’ acceptance was also extraordinarywith 100% uptake and 65% weekly full adherence rate (� 8readings per week) to the recommended blood pressuremonitoring schedule. In keeping with other studies of remoteblood pressure monitoring, the users of our telemonitoringsystem did not become more anxious,20 although theirdepression score on formal testing did increase. The clinicalsignificance of that finding, however, is unclear because noprevious study has reported the psychological consequences ofpromoting self-care activities. Finally, we did not undertakea formal cost-effectiveness analysis. Nonetheless we achievedmajor cost savings using relatively inexpensive commerciallyavailable hardware and bypassing the need for a healthprofessional to vet and respond to transmitted readings.27

The economics of an mHealth application for remotemonitoring of blood pressure has not yet been undertaken.Nonetheless, the study by Madsen et al. that used personaldigital assistants, the forerunner of smartphones, for tele-communication can provide some insights into costs.32 Intheir study, the single major expense was the 1-time cost ofpurchasing the telemonitoring equipment that could beamortized over many years. The ongoing cost for daily use ofthe equipment was low, being less than $100 (Canadian) perperson annually. Furthermore this expense was offset by thelower cost of medication and consultation visits to thepatients’ physician in the telemonitoring group. Thus, tele-monitoring does not need to be more costly than usual care,especially when its beneficial effects are taken into account.

Our group has been exploring other applications ofmHealth technology. For patients with heart failure because ofpoor systolic function we developed an mHealth monitoringsystem for transmitting weight, blood pressure readings, andanswers to symptom questions daily, and electrocardiographicrecordings weekly.28 In a 6-month randomized controlled trialof 100 subjects, patients randomly assigned to the mHealthgroup demonstrated greater self-care maintenance as measuredwith the Self-Care of Heart Failure Index compared withcontrol subjects. For those who were followed for more than6 months the mHealth group had a significant lower meanbrain natriuretic peptide level, an increase in left ventricularejection fraction, and better self-care maintenance andmanagement, and the control group did not. The study wasunderpowered to detect between-group differences in hospitalreadmissions, number of nights in hospital, and mortality. Wehave also applied mHealth monitoring to improve glycemiccontrol in type 2 diabetes mellitus and in teenagers with type1 diabetes mellitus.29,30

The rapid growth of mHealth technology has brought intofocus the challenges facing its integration into the health caresystem.26 Currently most electronic medical record systems donot have the capability of receiving information from mobiledevices. For those that do, there are restrictions on the amountof data that can be stored in electronic medical record systems

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and subsequently made available for clinical use. Furthermore,the ability to exchange information among diverse systems,organizations, and users is another limitation. ContinuaHealth Alliance, an international not-for-profit industryorganization, has developed standards-based interoperabilityguidelines to facilitate data sharing between differentcomponents of a personal teleHealth system without restric-tion to access or implementation. Mobile technology has thepotential to shift the information hub away from immobilecomputer-based workstations to points of care, but the currentsystems require major restructuring to provide greater flexi-bility. Finally, authoritative bodies are now requiring designersof mHealth applications to engage consumers throughout thedevelopment process and undertake usability testing. Studieshave shown that mHealth applications meeting consumers’expectations are more likely to be used long-term and improvehealth outcomes.

ConclusionSustaining effective antihypertensive treatment has been

a challenge for those involved in the chronic management ofhypertension. A variety of quality improvement strategies havebeen advocated with the greatest success being achieved usinga nurse- or pharmacist-led intervention in which they havebeen given the authority to prescribe or alter antihypertensivetreatment. Historically, this approach to care involved 1-to-1patient-provider encounters generally in a health clinic orpharmacy. As such, it proved costly, was not scalable, and didnot actively engage patients in treatment decision-making.Advances in mHealth technology has led to the develop-ment of products and platforms that are versatile, robust, andhighly flexible and enhance patient self-care. mHealth appli-cations are particularly appropriate for interventions thatdepend on patients’ sustained adherence to monitoringschedules and prescribed treatments. Studies from our groupin hypertension and other chronic conditions have shownimproved health outcomes using mHealth applications thathave undergone rigourous usability testing. Nonetheless, thereare many challenges still ahead to successfully incorporatemHealth technology into the health care delivery system.

Funding SourcesThe 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.

DisclosuresThe author has no conflicts of interest to disclose.

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