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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 122-126

Televital signs monitoring compliance trial in Singapore

Lotus Eldercare Pte Ltd, Singapore

Date of Web Publication18-Oct-2018

Correspondence Address:
Jit Seng Tan
Lotus Eldercare Pte Ltd., 16 Collyer Quay, Level 20, Singapore 049318
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_18_18

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Background and Objectives: The Singapore population is aging rapidly, with increased prevalence of chronic diseases and healthcare demand. Telemonitoring of vital signs will enable better care of the patient. However, daily monitoring requires a change in lifestyle and compliance may be an issue. Materials and Methods: A total of 18 patients in 4 demographics were identified. Telemonitoring equipment was deployed to them for 3 months. Results: After 3 months, the well individual did not use the monitoring devices. 50% of the patients with chronic medical disease <65 years old continued the use of the devices. 2 out of 7 activities of daily living (ADL) independent individuals >65 years old continued the daily monitoring and almost all (5 out of 6) ADL dependent patients continued daily routine monitoring. The dropout may be due to technical issues, user fatigue, change in caregiver or resistance to technology. Conclusions: Remote monitoring will be more successful if the individual already is doing routine self-monitoring or has a life-threatening health-related event. Technical support is also important to help retrain the person in using the devices and for troubleshooting.

Keywords: Telemonitoring, televital signs monitoring, vital signs monitoring

How to cite this article:
Tan JS, Teo SY. Televital signs monitoring compliance trial in Singapore. Digit Med 2018;4:122-6

How to cite this URL:
Tan JS, Teo SY. Televital signs monitoring compliance trial in Singapore. Digit Med [serial online] 2018 [cited 2023 Mar 24];4:122-6. Available from: http://www.digitmedicine.com/text.asp?2018/4/3/122/243634

  Introduction Top

Population is aging in Singapore and worldwide.[1] With an aging population, chronic disease prevalence increases[2] and healthcare demand increases likewise. Poor control of chronic diseases, such as hypertension, dyslipidemia, and diabetes mellitus, can lead to complications and end organ damages, requiring further intensive and expensive healthcare demand. This will lead to escalating the costs for the individual and the society.

Empowering each individual with the knowledge and skills to care for oneself will enable the individual to have good control of the chronic diseases. Self-monitoring is one of the key cornerstones in empowering everyone to manage their chronic diseases, giving everyone the objective guidance to control their chronic diseases.

Telehealth has been one of the revolutions in healthcare services since the introduction of the internet. Under the World Health Organization definition,[3] Telehealth involves the use of telecommunications and virtual technology to deliver healthcare outside of traditional health-care facilities. Telehealth, which requires access only to telecommunications, is the most basic element of “eHealth,” which uses a wider range of information and communication technologies (ICTs). There are many instances of Telehealth, for example, telemedicine, being used in online platforms and through pharmacies in recent years. Remote home telemonitoring is part of a telehealth ecosystem that involves vital signs being recorded in an online platform, which is then presented real time to the physician in charge doing the consultation. It is basically being used as a day-to-day monitoring system, with certain inbuilt alarm systems which can alert the caregivers or the healthcare professional when abnormal readings are detected.

Many reviews on home telemonitoring were done and systemic reviews of the some of these published articles have been published.[4] Unfortunately, most of these studies were done in the United States of America and Europe. There are few such studies in the Asian population.

Daily monitoring of vital signs requires a small change in lifestyle and the motivation to do such tasks repeatedly. We know that medication compliance issue is a gigantic challenge,[5] hence, getting individuals to do monitoring daily may pose an even greater challenge.

With improved and cheaper connectivity, cheaper devices and improvement in overall technologies and its usage, telemonitoring is increasing becoming a viable option for many individuals or family clinics alike.

This paper describes our experience in rolling out such services and the various dropout and usage rates after a period of 3 months from February to May of 2016.

  Materials and Methods Top

Ethical consideration

Verbal consent was given by patient or their caregivers.

Selection and description of participants

At the start, we questioned the need for such monitoring. Who would utilize such services and how would they benefit?

After the initial brainstorming, we identified four demographics to roll out this remote monitoring pilot:

The first group was the chronically sick elderly patients who were dependent on others for their activities of daily living (ADLs). This is also the largest group, and many of these patients already had their vital signs routinely monitored by their respective caregivers. Vital signs are recorded in physical diaries in their homes by the caregivers daily.

The second group was active agers above 65 with zero to only a few chronic medical conditions. These individuals are generally well and ADL independent, able to still live an active and full life without any support. This is also the group that agencies such as the Health Promotion Broad and Population Health services are targeting to prevent complications and hospitalizations. By managing their stable chronic medical conditions well, the goal is to maintain their independence for as long as possible.

The third group was younger patients below age of 65 who have already had chronic conditions and are still in the workforce. They may be on medications for chronic conditions but still lead a busy and hectic life. Some of them may have a previous life-threatening condition such as an acute myocardial infection or an intracranial hemorrhage from persistent uncontrolled hypertension.

Finally, the fourth group was those above 40 with no chronic medical conditions. Those who are undiagnosed or who refuse to accept prior diagnosis also fall into this group. Performing health screening among these people could potentially pick up previously undiagnosed conditions.

The vital signs that were monitored in this pilot were:

  • Blood pressure
  • Heart rate
  • Blood glucose
  • Weight.

All four groups of individuals were given blood pressure machines and those with diabetes were handed glucometer. A physical syncing gateway equipment connected to the Internet was set up by our technical team in the homes. Each patient or their caregiver was taught to use the monitoring devices, and all the readings were sync directly from the devices into the cloud platform via bluetooth through the secured gateway. All the telemonitoring devices were approved by the Health Science Authority,[6] Singapore, for their intended uses.

  Results Top

In total, 18 patients were enrolled into the 3-month study.

As shown in [Figure 1], there were 1 well individual >40 years old, 4 individuals <65 years old with chronic medical conditions on active treatment, 6 ADL dependent patients and 7 ADL independent individuals >65 years old taken into the study.
Figure 1: Proportion of number of individuals in each category

Click here to view

As shown in [Figure 2], the well individual did not use the monitoring devices after 3 months. 50% of the patients with chronic medical disease <65 years old continued the use of the devices after 3 months. Two out of 7 ADL independent individuals >65 years' old continued the daily monitoring after 3 months and almost all (5 out of 6) ADL dependent patient continued daily routine monitoring.
Figure 2: Number of individussals initially and at the end of 3 months

Click here to view

It was easy for the individuals who were already doing daily routine monitoring. It was hard to ask a new user to change their lifestyle habits and do daily monitoring, unless they had a life-changing health event recently. We have in total about 18 users in our pilot group, divided into the four different profiles as listed above. After 3 months of usage, only nine users continued the daily monitoring. There are various reasons why patients encountered technical difficulties or decided to stop.

Here are some of those reasons:

  1. Technical issue 1: The monitoring device used bluetooth to a gateway connected to the modem/router. If the distance between the gateway and the device was too far, the data could not sync. This happened to one of my patients whose family routinely did monitoring at home, but I was unable to get the readings
  2. Technical issue 2: For monitoring of 2 or more patients in the same household, one needs to tap a card to the gateway first to identify him or herself before doing self-monitoring. This additional step might not go well with some active elderly. While they did their daily monitoring, they did not tap their cards on the gateway and hence, I was unable to get the readings remotely as well
  3. After a few weeks, there is user fatigue, especially for those active and functionally capable ones. If the reading does not fluctuate much week after week, the tendency to stop monitoring will be high for those doing self-monitoring
  4. Change of caregiver, and with the new care giver not knowing how to use the devices, the monitoring devices were left untouched
  5. There were two seniors who, being healthy and well, did not even bother to start the monitoring after the equipment were set up!

Apart from the negatives, there were some positives. One bed bound uncommunicative elderly was diagnosed to have a dislocated joint after her heart rate and pulse rate were suddenly raised. After a period of self-monitoring, a middle age hypertensive executive was convinced of his diagnosis of hypertension and is willing to start medications for treatment. His blood pressure now is well controlled.

  Discussion Top

There are many advantages that an effective remote monitoring service can be for patients. Many studies were done for specific groups of patients with cardiac failures,[7] chronic obstructive lungs disease,[8] hypertension,[9] etc.

My patients in hospital transitional care services are a prime example. Frequently, their medications are adjusted, started or stopped while they are warded in the hospital due to a change in physiology during treatment. More intensive monitoring is needed when this group of patients goes home to ensure medications can be restarted or stopped when the clinical conditions change.

For example, a patient coming in for septic shock with low blood pressure will have all his antihypertensive medications stopped. During treatment and recovery in the hospital, these medications may still be withheld due to the patient exhibiting normal blood pressure. After the patient returns home, he goes back to his routine life and blood pressure will begin to creep upwards as well. How can the clinician know to restart the medications in a timely manner? Remote monitoring in transitional care services will be very helping in such situations.

For patients followed up in normal general practitioner clinics or polyclinics for primary care services, remote monitoring allows clinicians to establish a baseline of their vital signs. This is important as the patient's vital signs might be elevated due to “white-coat hypertension.” Patients might have raised blood pressures consistently in clinic setting but back home; it might be normal or slightly raised. On the other hand, it can also be a good tool for diagnosing those with prehypertension,[10] which then earlier management strategies such as lifestyle modification and stress management may be effective.

Frequently, when a family physician starts an antihypertensive medication, the physician may worry that the patient's blood pressure could drop too fast and too much, causing light-headedness and resulting in falls, especially in elderly patients. Remote monitoring will establish the premedication blood pressure readings, and also allow the physician to monitor the post-medication effects, whether the decrease in blood pressure is too drastic. This holds very true for diabetic monitoring and treatment as well.

For chronic care, remote monitoring can also aid a physician in determining when the patient needs to return for review, to replenish the medications for their chronic illness. Instead of reviewing monthly, 2-monthly or even 3-monthly for medications, patients on remote monitoring services can be given 6-monthly or even longer appointment dates. In future, if there are blood-taking points in the community, patient might not even have to visit doctors to obtain new prescriptions for their chronic conditions! There are also research papers on such self-monitoring efforts which can achieve a better control of chronic medical conditions such as hypertension.[11] The patient can be empowered by the remote monitoring system as it provides the best clinical evidence whether to continue treatment. This empowerment plus technology use will probably be able to cut the number of visits to polyclinics or hospital's specialist outpatient clinics.

For those who have been diagnosed but resistant to start therapy, remote monitoring is a good way to start these group on seeing their vital signs daily and if need be, start therapy. Remote monitoring can provide them all the objective data they need to convince themselves.

On the population health side, monitoring equipment place in strategic areas can allow the population to take measurement anytime and still be recorded into systems such as Health Hub. This will allow the nation to be very “smart” and provides everyone a venue to have some basic health checks.

  Conclusions Top

From what we have learnt in these 3 months, remote monitoring will be more successful if the individual already is doing routine self-monitoring.

Technical support is important as well, to constantly retrain the individuals in doing the monitoring work so that they are more confident. The technology itself must also work, since in some situation, the distance of the devices and the gateway can pose as a limiting issue.

Those who have a life-threatening health-related event – for example, a new stroke, a heart attack etc. – will be more willing to change and embrace remote monitoring. Those who are still well and do not have any serious health issues will be very much more resistant in switching a small part of their lifestyle to do remote monitoring.

I believe that continually educating the people and empowering them with such technologies will be a key to future healthcare models.

Financial support and sponsorship

Equipment and platform from NCS Pte Ltd.

Conflicts of interest

There are no conflicts of interest.

  References Top

World Population Ageing – UN Report. Available from: http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf. [Last accessed on 2018 Aug 07].  Back to cited text no. 1
Global Health and Ageing – WHO Report. Available from: http://www.who.int/ageing/publications/global_health.pdf. [Last accessed on 2018 Aug 07].  Back to cited text no. 2
Definition of Tele Health – WHO Article. Available from: http://www.who.int/sustainable-development/health-sector/strategies/telehealth/en/. [Last accessed on 2018 Aug 07].  Back to cited text no. 3
Paré G, Jaana M, Sicotte C. Systematic review of home telemonitoring for chronic diseases: The evidence base. J Am Med Inform Assoc 2007;14:269-77. [Last accessed on 2018 Aug 07].  Back to cited text no. 4
Medication Adherence: WHO Report. Available from: http://www.who.int/chp/knowledge/publications/adherence_Section1.pdf. [Last accessed on 2018 Aug 07].  Back to cited text no. 5
Health Science Authority, Singapore. Available from: http://www.hsa.gov.sg/content/hsa/en.html. [Last accessed on 2018 Aug 07].  Back to cited text no. 6
Atkin P, Barrett D. Benefits of telemonitoring in the care of patients with heart failure. Nurs Stand 2012;27:44-8.  Back to cited text no. 7
Miłkowska-Dymanowska J, Białas AJ, Obrębski W, Górski P, Piotrowski WJ. A pilot study of daily telemonitoring to predict acute exacerbation in chronic obstructive pulmonary disease. Int J Med Inform 2018;116:46-51.  Back to cited text no. 8
Beran M, Asche SE, Bergdall AR, Crabtree B, Green BB, Groen SE, et al. Key components of success in a randomized trial of blood pressure telemonitoring with medication therapy management pharmacists. J Am Pharm Assoc (2003) 2018. pii: S1544-3191(18)30337-6.  Back to cited text no. 9
Chen Y, Zhang DY, Li Y, Wang JG. The role of out-of-clinic blood pressure measurements in preventing hypertension. Curr Hypertens Rep 2018;20:85.  Back to cited text no. 10
Stergiou GS, Kario K, Kollias A, McManus RJ, Ohkubo T, Parati G, et al. Home blood pressure monitoring in the 21st century. J Clin Hypertens (Greenwich) 2018;20:1116-21.  Back to cited text no. 11


  [Figure 1], [Figure 2]


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