Prof. Giuseppe Boriani,
E-health is a new dimension of medicine and represents a new perspective, able to modify in the future the way we deliver health care, with clinical, organizational, financial and legal implications. E-health encompasses many branches, but remote monitoring of data retrieved from implantable devices is surely one of the fields of greatest interest, as discussed in a session of the ESC Congress in Munich, on August 28th, 2012. In this session Carsten Israel from Bielefeld (DE), Robert Hatala from Bratislava (SK), Lieselot Van Erven from Leiden (NL) and Panos Vardas from Heraklion (GR), new President of ESC, reported on current developments, the expected clinical benefits and the economic and legal issues of telemonitoring for patients implanted with a pacemaker, a cardioverter-defibrillator or a device for cardiac resynchronization therapy. Remote monitoring of implanted devices now covers multiple aspects; first of all checking of technical features related to appropriate device system functioning (can + leads) and checking of device-patient interactions (treatment of brady- and tachyarrhythmias), in line with what is called “remote follow up”. The second aspect is related to surveillance of the patient’s clinical status and specifically, detection of signs of decompensation suggesting worsening heart failure, so called “remote disease management”. The need to implement remote follow up as an alternative to conventional in-office checks can easily be appreciated by considering the increasing number of patients implanted with electrical devices across Europe, leading to an impressive number of in-office follow ups (more than 2 million per year). This burden can no longer be afforded, especially in larger centers. Through remote monitoring, it is possible to obtain timely information on system functioning and reliability, with early detection of lead failure, as well as timely information on the occurrence of ventricular and atrial tachyarrhythmias, including atrial fibrillation. Detection of “silent” atrial fibrillation may prompt appropriate clinical decisions, including prescription of oral anticoagulants to reduce the occurrence of stroke. A series of controlled studies have confirmed that remote follow-up is non-inferior to in-office follow up and may also allow a reduction of dedicated resources, thus increasing the efficiency of the process. The perspective of remote disease management is also attracting increasing interest, since detection of signs of worsening heart failure, linked to transmitted alarms, may allow early management of decompensation, with reduction of the number of visits and the number of days spent in hospital. A series of studies are ongoing in order to assess to what extent and in what settings disease management may be beneficial and what is its cost-effectiveness profile. Adoption of this approach requires specific organizational settings, adaptation of reimbursement practices, clarification of the legal aspects and education of patients, nurses and physicians. In this period of economic downturn, it may appear inappropriate to adopt a “high-tech” approach to medicine, but it has to be considered that remote monitoring may be an important way to improve the efficiency of health care delivery, with a favorable cost-effectiveness profile, suggesting good value for money. The revolution of e-health is ongoing... it is time to organize in a different way the interaction of patients nurses, physicians, policy makers and industry in order to obtain the full spectrum of advantages potentially linked to this new approach!
e-health and remote monitoring using implantable devices
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