‘My Home Hemo’ app — a new telehealth tool for remote monitoring of patients on home haemodialysis Mary Ann Nicdao, Jinman Kim, Tanya Baldacchino, Youn Hyun Jung, Mary Mikaheal, Abhijit Patekar & Kamal Sud Submitted: 24 November 2015, Accepted: 16 March 2016

Abstract As opposed to institutional and satellite dialysis, home dialysis is advocated as the preferred and cost-effective alternative to provide dialysis to a rising number of patients with end-stage kidney failure. Ongoing support to ensure success of a home dialysis program can be challenging because of limited nursing resources to visit patients who are often distributed over large geographical areas. Since patients on home haemodialysis (HHD) are reviewed much less frequently compared to those on institutional or satellite haemodialysis, we developed a telehealth information system, the Home Haemodialysis Remote Monitoring System (HHD-RMS), comprising of a mobile device application named ‘My Home Hemo’ app and a web portal for remote monitoring of patients’ dialysis parameters. This study reports our findings from analysing the dialysis data from the app, collected and reviewed on 74 patients over 21 weeks. Using this data increased occasions of patient review by 270% as compared to the previous two years, with an average of 12 patients’ dialysis data being remotely reviewed per week, resulting in 26 changes to dialysis prescriptions during the study period, and significant reduction in nursing and patient times associated with consultations and travel. Both patients and nursing staff reported high levels of satisfaction and ease of use. We conclude that this remote monitoring telehealth tool enabled nurses to remotely monitor dialysis parameters of patients on HHD, resulting in improved nursing efficiencies. The data allowed changes to be made to haemodialysis prescriptions and led to savings associated with patient and nursing time from the reduced need for travel. Anecdotally, the app also improved patient and staff satisfaction. This system has the potential for major health benefits to patients and cost savings to health services.

Keywords Home haemodialysis, telehealth, mobile app, remote monitoring

Mary Ann Nicdao, BN, Grad Cert (Renal), Clinical Nurse Consultant, Home Haemodialysis Training and Support Unit, Western Renal Service, Blacktown, NSW 2148, Australia.

Jinman Kim, PhD, Nepean Telehealth and Technology Centre; Institute of Biomedical Engineering and Technology, University of Sydney, NSW, Australia.

Tanya Baldacchino, BN, Grad Cert (Clinical Studies), Diploma in Project Management, District Telehealth Program Manager, Nepean Blue Mountains Local Health District, Kingswood, NSW 2750, Australia.

Youn Hyun Jung, PhD, Institute of Biomedical Engineering and Technology, University of Sydney, NSW, Australia. Mary Mikaheal, RN, Grad Cert (Renal), Clinical Nurse Specialist, Home Haemodialysis Training and Support Unit, Western Renal Service, Blacktown, NSW 2148, Australia

Abhijit Patekar, Network Centred Software Engineer, Dip Pharm, Data Analyst, Transplantation Medical Unit, Westmead Hospital, NSW, Australia

Kamal Sud, MBBS, MD, DM, DNB, FISN, FRACP, Senior Staff Specialist in Renal Medicine, Western Renal Service; Clinical Associate Professor, University of Sydney, Nepean Clinical School, Kingswood, NSW 2750, Australia Correspondence to: Mary Ann Nicdao, CNC — Home Haemodialysis, Regional Dialysis Centre, Marcel Crescent, Blacktown NSW 2148, Australia Email: [email protected]

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‘My Home Hemo’ app — a new telehealth tool for remote monitoring of patients on home haemodialysis

Introduction Home haemodialysis (HHD) is the preferred haemodialysis modality for patients with end-stage renal failure as it is associated with better patient outcomes at lower health care costs (Lewicki et al., 2015). Western Renal Service (WRS) is one of the largest HHD programs in Australia that has experienced a 24% growth in patient numbers over the past three years. In October 2015, the service looked after 125 patients on HHD residing in 84 different suburbs which are spread across 9950 km2 between two local health districts in New South Wales (NSW). Once patients are at home on dialysis, ongoing support and best practice are essential to sustain its success (Fortnum et al., 2012), but this is resourceintensive, and nursing resources are often limited in their ability to visit patients spread across many geographical locations. Here we describe and introduce our newly developed and innovative telehealth information system, the Home Haemodialysis Remote Monitoring System (HHD-RMS), comprising of a mobile device application, named ‘My Home Hemo’ app and a web portal for remote monitoring of patients’ dialysis parameters to support our patients. We report the

district and surrounding areas, with an aim to improve patient outcomes and access to care, regardless of their geographical location. Partnership between NBMLHD and the Institute of Biomedical Engineering and Technology, University of Sydney, resulted in the establishment of the Nepean Telehealth and Technology Centre (NTTC), which allowed the development of several projects including one for remote monitoring of patients on HHD. Since the renal services in Western Sydney Local Health District (WSLHD) are networked with NBMLHD (as WRS), the HHD Unit at Blacktown Hospital was able to participate in the telehealth initiative for patients on HHD. Initial brainstorming to justify the use of information technology for HHD patients commenced in September 2012 and resulted in a proposal in June 2013 to create an HHD-RMS, including a smartphone app. Content and design planning started in early 2014 between the NTTC, medical and nursing staff of WRS, and a user agreement covering patient consent, confidentiality and scope of the system was developed. The app was designed and launched on the Android platform (supporting smartphones and tablets) in May 2014, with a two-week trial on 10 selected patients to test the app’s functionality and

preliminary results of an audit, looking at the ability of this tool

implementation to the clinical work flow. Use of the app was

in providing adequate information to allow changes to dialysis

restricted to patients on HHD within the WRS through the use

prescriptions, and its effects on efficiencies in the delivery of

of a unit-specific password. Improvements were made based

care. We also relate some of the feedbacks received from the

on feedback received from patients and nurses from the trial,

patients and the nursing staff using the HHD-RMS.

and an updated version of the HHD-RMS was launched in November 2014, supporting both Android and iOS mobile

Background Patients within WRS typically perform their first HHD after receiving a minimum of six weeks’ training at the HHD training unit. Unlike patients on satellite or hospital-based haemodialysis, where contact with health care professionals with dialysis training and experience occurs at least three times a week during haemodialysis sessions, HHD patients in WRS are reviewed by nursing staff only 4–5 times a year,

devices (for iPhones and iPads). These updates included recording patients’ mood at the end of their treatments and separate fields to record their medications list and additional notes. Alerts were built into the app to remind patients when their next HHD session was due, when their blood pressure readings exceeded set parameters, or when their ultrafiltration goals are above 3.0 litres for the index dialysis session.

and at variable intervals by their nephrologists for routine

Methods

consultations. Outside these planned reviews, they would

The “Telehealth for Home Dialysis Population in Western Renal

seek clinical attention only when they develop issues with their

Service” project was approved as a telehealth initiative at the

dialysis treatments. HHD patients are taught to record their

NBMLHD Telehealth Steering Committee. The application

dialysis treatment parameters in a logbook, which should be

outlined the description of the project, description of the

available for review by the nursing staff during home or unit

sample, analysis of the approach, methodology of the data to

visits and specialist physician appointments. Often, these

be collected and the expected outcomes. The correctness of

logbooks are unavailable at the time of these reviews and

patients’ digital entry of treatment parameters using the app,

interpreting data can be time-consuming and difficult. In view of

the value of having web-based access to patients’ home HD

the infrequent reviews and consultations, a need was identified

data, and the technical issues identified from using the app

for a timely and ongoing access to accurate and easy to

were to be analysed. The expected outcome was to collect

interpret dialysis data.

statistically significant amounts of data to measure the value

The Nepean Blue Mountains Local Health District (NBMLHD)

from the use of telehealth technology for WRS home patients.

received a four-year funding grant in 2011 to develop, evaluate

With the availability of the app on two most-commonly used

and implement best practice telehealth technology in the

mobile device platforms, 74 of 124 prevalent patients were

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Renal Society of Australasia Journal I Vol 12 I No. 2 I July 2016

‘My Home Hemo’ app — a new telehealth tool for remote monitoring of patients on home haemodialysis recruited to record their HHD treatment-related data into the

The data from all the patients is presented according to the

HHD-RMS from January 2015 onwards. Similar to the data

patient’s mood immediately following their treatments (lowest

that would have been recorded into conventional logbooks,

mood at the top of the list) for nursing reviews (Figure 2).

patients were trained to record their treatment parameters and medications digitally into the app in real time for each dialysis session that they performed at home. The data entered by patients from home were uploaded from their mobile devices and stored onto a secure cloud-based database server (Microsoft Azure). The data was available for review by nursing staff in real time via a web portal (Internet

Nurses can remotely monitor an individual patient’s number and length of treatments, weight and blood pressure readings before and after dialysis, dry weight, ultrafiltration goals, blood flow rates and arterial/venous pressures. The data is serially available for review to allow for historical assessment of treatment parameters (Figure 3). The app also allows for

browser) at the HHD unit (Figure 1). Using their unique

graphic representation of trends on patients’ weight, blood

access credentials, nurses logged into the web portal at the

pressure and arterial/venous pressure readings over a period of

workstation, or off-site during after-hours for the on-call nurse.

time (Figure 4).

Figure 1.

Figure 2.

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‘My Home Hemo’ app — a new telehealth tool for remote monitoring of patients on home haemodialysis

Figure 3.

Figure 4.

44

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‘My Home Hemo’ app — a new telehealth tool for remote monitoring of patients on home haemodialysis and recorded. In addition, remote reviews of patients’ dialysis data recorded with the app were also counted and recorded. There were on average 12 patients remotely reviewed per week (Table 1), resulting in 26 changes to dialysis prescriptions, mainly related to adjustments in patients’ dry weight. These remote reviews resulted in savings of seven hours of nursing and patient times each from the avoidance of conducting home and/or unit visits, equating to a total saving of 11 hours of travel time and 544 kilometres of travel distance. As compared to the preceding two years, addition of the HHD-RMS increased the occasions of patient reviews by 270% per week (Figure 5). This resulted in improved efficiencies, measured in terms of number of patients reviewed; significant

Figure 5.

reduction in nursing and patient times associated with

Nursing staff reviewed dialysis data available at the HHD

consultations and travels; and cost savings from these gains.

unit on a daily basis, and made phone calls or sent emails

Literature review

to patients if there were concerns. Patients expressing a low mood were reviewed as a priority. On average, each nurse

The World Health Organization defines telemedicine as the:

reviewed data on three–four patients per day regardless of

... delivery of health care services, where distance is a critical

patients’ expressed mood. As per the user agreement of the HHD-RMS, patients were still required to contact the HHD unit by telephone if they had any concerns. The nursing staff were

factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention

not obliged to review data on every home HD session on a

of diseases and injuries, research and evaluation, and for

daily basis, and the patients were not mandated to upload the information from each HHD session.

the continuing education of healthcare providers, all in the

An audit of occasions of web-based access to patient data,

communities (WHO, 2010).

interest of advancing the health of individuals and their

changes to dialysis prescriptions, number of home or unit visits, travel distance and time saved were charted. Travel distance

include remote non-clinical services, is becoming globally vital

and time saved by patients and nursing staff were calculated

in the delivery of health care in many settings, by increasing

at two times the distance and travel time between the HHD unit and patients’ homes depicted on Google maps to account for return travel. Total occasions of patient reviews per week during the study period were compared with data on occasions of patient reviews in the preceding two years. Finally, patient feedback was obtained on a standardised questionnaire and

Telehealth, which refers to the extension of telemedicine to

access to health care, improving efficiencies and reducing health care costs (Bashshur & Shannon, 2009). Originally aimed to improve health care access for geographically isolated patients, telehealth in the past decade has extended into many areas of health care, regardless of patients’ geographical

patients’ comments were tabulated.

distance to a health facility (Blinkhorn, 2012). Several studies

Results

Table 2: Nursing staff and patient feedback

show that care delivered based on telehealth applications

Dialysis data was collected among 74 patients over 21 weeks from February to June 2015. The number of conventional patient reviews at home or during clinic visits were counted Table 1: Occasions of patient reviews during study period

Month

Home or clinic visits

App reviews

Total reviews

Feb

27

48

75

Mar

24

60

84

Apr

37

59

96

May

25

54

79

Jun

19

35

54

Total

132

256

388

Patients

Nurses

Easy to use

Easy to navigate web application

Charts and alerts are useful

Increased job satisfaction

“I am more relaxed to know that I am being monitored”

“Decreased feelings of frustration as we are now able to ‘reach out’ to more patients”

“Motivated to keep my dialysis schedule”

Getting a glimpse of patients’ emotional status through the happy/sad faces is reassuring.

“Comforting, I don’t feel so alone”

Time-saving tool

“Useful in sending info to my Proud to be one of the first to use nurses whilst I dialysed overseas” technology for ongoing care provision.

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‘My Home Hemo’ app — a new telehealth tool for remote monitoring of patients on home haemodialysis is comparable to face-to-face visits with health practitioners

system specifically designed for patients on HHD. It has three

(Dellifraine and Dansky, 2008).

major components, as illustrated in Figure 1:

Some of the examples of telehealth applications include the

• A ‘My Home Hemo’ app for smartphones or other hand-

use of video conferencing between the hospital and nursing

held devices operated on either iOS or Android platforms.

homes for geriatric care (Baldacchino et al., 2014), and remote

The app can be downloaded by the patients to their

diagnosis of clinical images for stroke patients (Demaerschalk

own devices to record their treatment parameters and

et al., 2012). Of late, the potential for telehealth applications

medications.

in the area of dialysis has also been documented in peritoneal dialysis (PD) through the use of video consultations for patients

• A secure cloud-based web database server to host all the patient data.

in remote areas, increasing communication pathways between doctors and patients (Harrington, et al., 2014). In India, an internet-based remote monitoring system was created for

• A web portal providing real-time data for nurses to evaluate patients’ treatment parameters remotely, which may also be

PD patients to integrate services and facilitate real-time

printed into customised format for doctors.

communication between patients and primary health providers (Nayak, et al., 2012). In Japan, a telemedicine system reduced

Reviewing the HHD-RMS data on a daily basis added minimally

outpatient clinic visits for elderly and handicapped patients on

to the nursing workload, but with the patients’ HHD data being

PD (Nakamoto, 2007). In supporting frail haemodialysis patients

available on computer screens upon logging in, nursing staff

at home, Bernman et al., (2011) found that telemonitoring

found the system to be a highly efficient way of evaluating

using video consultations was successful in reducing hospital

patient data and prioritising their workloads. In totality, this

presentations by 68%, and hospital stays by 78%.

telehealth initiative resulted in significant savings to nursing and

Another area in telehealth is telemonitoring, which enables real-time automated transmission of data on a patient’s health status (such as vital signs) from a patient to a health care facility that has the capability to monitor and take action on the data to improve outcomes (Pare et al., 2007; McLean et al., 2011). The system may utilise sensors or other applications to monitor vital signs and wireless technology to convey clinical

patient times. We further report that using data from the HHDRMS provided the nursing staff the ability to change dialysis prescriptions. Both patients and nurses reported ease of use and high levels of satisfaction in using the app. In addition, patient feedback was positive, with increased feeling of being connected, and higher levels of motivation to keep up with their HHD schedules.

information to a health professional at a distant location. The

With documented improvements in efficiencies, the HHD-

information is assessed and treatment changes are remotely

RMS has the potential to reduce health care costs in HHD. In

advised to the patient. The data is usually securely stored and

addition, our results indicate that using the system can lead to

is available for review by the health professional to ensure

early diagnosis and management of complications related to

effectiveness of clinical recommendations (McLean et al., 2011;

HHD and thus has the potential to improve patient outcomes,

Ng et al., 2006; Blinkhorn, 2012).

including reducing presentations to emergency departments

Although home dialysis is one area where telemonitoring

and hospital admissions.

of dialysis data from patients’ home to a dialysis unit could

This study, however, has several limitations. This is a

be useful, this area has not been explored to date. Despite

retrospective, single-centre audit on a small number of patients

multiple advancements in dialysis technology over the last

who decided to use the HHD-RMS to record their HHD-

decades, there have not been major changes in the way patients on HHD are monitored and their dialysis data recorded or reviewed. Whilst telemedicine initiatives around video consultations for patients on haemodialysis in remote settings have been successfully used, there have been no attempts on remote recording and real-time monitoring of HHD data.

Discussion

related data. The reasons for non-acceptance of this telehealth initiative by patients who did not participate in the initiative are not known. The increase in nursing workloads, which may be offset by gains in efficiencies and reduced travel time for nurses and patients, was not measured. In addition, a formal survey would be required to measure levels of satisfaction for patients, nursing staff and nephrologists who used the HHD-RMS. The safety of HHD prescription changes made by reviewing data

The HHD-RMS has characteristics to allow telemonitoring, in

online has not been formally evaluated, although anecdotally,

that the dialysis treatment parameters are transmitted from a

no adverse events were reported by patients during this study

patient’s personal device and are assessed remotely by health

period that later necessitated reversal of such changes. Since it

care professionals at a dialysis unit. Prescription changes

is an initial audit of a novel telehealth initiative, its impact, if any,

are introduced based on this data. It is the first telemedicine

on any hard clinical outcomes including blood pressure control,

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Renal Society of Australasia Journal I Vol 12 I No. 2 I July 2016

‘My Home Hemo’ app — a new telehealth tool for remote monitoring of patients on home haemodialysis vascular access outcomes, hospitalisations and mortality have

with patient and nursing time related to travel, and enhanced

not been evaluated in this study.

patients’ clinical decision making. Anecdotally, the app also improved patient and staff satisfaction.

The proportion of patients on HHD across Australia has been largely static at 9% from 2009 to 2013 (ANZDATA, 2015).

With this collaborative project being sustained by nursing,

By improving patient motivations and the feeling of being

information technology and medical experts, the HHD-RMS

monitored and connected to their units at all times, the system

and the app has evolved into an easy-to-use version with

can empower patients to enhance their health outcomes, and

abundant potential for research, health benefits to patients and

has the potential to improve patient intake and retention on

cost savings to health services globally.

HHD. In 2013, there were 1095 patients on home dialysis in Australia

Australia & New Zealand Dialysis & Transplant Registry (2015). ANZDATA Registry. 37th Report (2014). Retrieved from: http://www.anzdata.org.au/ anzdata/AnzdataReport/37thReport/c06_home_print_20150929.pdf

(ANZDATA, 2015). While the HHD-RMS has been successfully implemented within WRS in Western Sydney, the system is transferable to the wider renal community across the country.

Baldacchino, T., Kim, J., Sharma, A., Scanlon, K., Kakkat, M., & Khadra, M. (2014). Hand in Hand: Connecting Acute Aged Care Service with Residential Aged Care Facilities Using Telehealth. Presented at the 5th Annual Conference of the Australasian Telehealth Society, 17–18 November 2014, Adelaide, South Australia.

Further studies are needed to evaluate the impact of its wider implementation to document if the benefits observed in WRS can be carried over to other renal services.

Bashbur, R. L., & Shannon, G. W. (2009). History of Telemedicine: Evolution, Context, and Transformation. Mary Ann Liebert, Inc.: New Rochelle (NY).

Other potential areas of research include measuring the safety of using the system in recommending changes to dialysis

Berman, S. J., Halliday, T., Jordan, P., Lindo, J., Minatodani, F., & Miyamoto, R. (2011). Home-based preventative care in high risk dialysis patients: a pilot study. Telehealth Journal and eHealth, 17(4), 283.

prescriptions; and qualitative research based on pre-set questionnaires to critically evaluate feedback from patients, nursing staff and physicians. Qualitative usability study of the

Blinkhorn T. M. (2012). Telehealth in nephrology health care: a review. Renal Society of Australasia Journal, 8(3), 132–139.

HHD-RMS will also provide insights into the human computer interaction and industrial design considerations.

Dellifraine, J. L., & Dansky, K. H. (2008). Home-based telehealth: a review and meta-analysis. Journal of Telemedicine and Telecare, 14(2), 62–6.

There are several future scopes to improve the functionality of

Demaerschalk, B. M., Bobrow, B. J., Raman, R., Ernstrom, K., Hoxworth, J. M., Patel, A. C., Kiernan, T. E., Aguilar, M. I., Ingall, T. J., Dodick, D. W., & Meyer, B. C. (2012). CT interpretation in a telestroke network: agreement among a spoke radiologist, hub vascular neurologist, and hub neuroradiologist. Stroke, 43(11), 3095–7.

the HHD-RMS, including incorporating video conferencing for remote consultations, remote assessment of vascular access, treatment monitoring feedback via mobile device notifications, as well as introducing similar system for remote monitoring

Fortnum. D., Mathew, T., & Johnson, K. (2012). A Model for Home Dialysis, Australia. Kidney Health Australia. ISBN 978-08596-6-9 (web version). Available: www.kidney.org.au

of patients on PD. Lastly, capabilities to link HHD-RMS with patients’ electronic medical records (EMR) need to be investigated.

Harrington, D. M., Myers, L., Eisenman, K., Bhise, V., Nayak, K. S., & Rosner, M. H. (2014). The use of a tablet computer platform to optimize the care of patients receiving peritoneal dialysis: a pilot study, Blood Purification, 37(4), 311–5.

Conclusion

Lewicki M. C., Polkinghorne, K. R., & Kerr, P. G. (2015). Debate: Should dialysis at home be mandatory for all suitable ESRD patients?: Home-based dialysis therapies are the second choice after transplantation. Seminars in Dialysis, 28, 147–54.

HHD patients typically perform at least three unsupervised treatments a week or 156 unsupervised treatments a year. Although known to be the healthier dialysis consumer group, patients on HHD are exposed to the same health risks as other dialysis patients. Without a structured monitoring process,

McLean, S., Protti, D., & Sheikh, A. (2011). Telehealthcare for long term conditions. The British Medical Journal, 342, 7793. Nakamoto, H. (2007). Telemedicine system for patients on continuous ambulatory peritoneal dialysis. Peritoneal Dialysis International, 27(Suppl 2), S21–6.

important aspects of care for HHD patients may often be overlooked. Patients may feel isolated and discouraged to

Nayak, A., Karopadi, A., Antony, S., Sreepada, S., & Nayak, K. S. (2012). Use of Peritoneal Dialysis Remote Monitoring System in India. Peritoneal Dialysis International, 32(2), 200–204.

continue with the modality due to limited contact with clinical staff.

Ng, H. S., Sim, M. L., Tan, C. M., & Wong, C. C. (2006). Wireless technologies for telemedicine. BT Technology Journal, 24(2).

The HHD-RMS (My Home Hemo app) enabled nurses to monitor patients in multiple locations from the dialysis unit, overcoming boundaries of time and distance, which traditionally limit ongoing patient monitoring and support. It opened communication between nurses and patients, allowed changes to haemodialysis prescriptions, led to savings associated

References

Pare, G., Jaana, M., & Sicotte, C. (2007). Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base. Journal of the American Medical Informatics Association, 14(3), 269–277. World Health Organization (WHO). (2010). Telemedicine: opportunities and developments in member states. Report on the Second Global Survey of Ehealth. Global Observatory for Ehealth Services, 2, 8–9. Geneva, Switzerland: WHO.

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