How to improve disease management of chronically ill patients? Perception of telemetric ECG recording and a novel software application

Full text

Research Article
Clinical Research and Trials
Clin Res Trials, 2019 doi: 10.15761/CRT.1000266
ISSN: 2059-0377
Volume 5: 1-6
How to improve disease management of chronically ill
patients? Perception of telemetric ECG recording and a
novel software application
Michael Lang*, Stefan Ringbauer, Martin Mayr and Lukas Cepek
Nervenfachärztliche Gemeinschaftspraxis Ulm Pfauengasse 8, 89073 Ulm, Germany
Abstract
Background and Objective: During the last years, mobile applications and telemetry have been discussed to become an attractive tool to support and monitor patients
with chronic diseases. is study aimed to evaluate the usability and perception of both telemetry and a novel app in MS patients scheduled for an ECG due to
medication adjustment or follow-up.
Methods: In 211 neurological centers throughout Germany, telemetric 2-channel ECG was applied in 1082 patients with ngolimod prescriptions, who have to be
subjected to ECG recording as a mandatory monitoring step. In a second approach, patients were oered to use the PatientConcept app, an application designed
to ease patient-physician contact and to support patients in their daily life. Patients as well as physicians from the participating centers were surveyed to evaluate
handling, acceptance and utility of both devices.
Results: e majority of patients perceived telemetric ECG recording as an interesting tool and appreciated shorter waiting times. 95%, 95% and 98% of the centers
believed that using telemetric ECG recording eliminates waiting times, accelerates medical reporting and provides a relief for test persons, respectively. Both, patients
and physicians perceived the use of PatientConcept app as useful.
Conclusion: Being both well accepted, telemetric ECG recording and the use of a mobile app might provide new concepts to improve patient care. e positive
results gained in this study may help to develop new perspectives for using these tools in the future, which may constitute a relief for the complex management of
chronic diseases.
*Correspondence to: Michael Lang, Nervenfachärztliche Gemeinschaspraxis
Ulm Pfauengasse 8, 89073 Ulm, Germany, Tel: 0049 731 65 66 5; Fax 0049 731
65 42 0; E-mail: lang@neurologie-ulm.de
Key words: adherence, chronic disease, disease management, mHealth, monitoring,
telemetry
Received: July 01, 2019; Accepted: July 09, 2019; Published: July 11, 2019
Introduction
Representing the most common cause of death and disability
worldwide, chronic diseases are associated with a high need for
patient care [1]. Management of most chronic diseases usually
requires extensive patient education and long periods of supervision,
including regular monitoring and routine visits to observe disease
progress or complications [2]. ese time- and cost-consuming
demands place a considerable strain on patients, physicians and
health service resources.
One example is the necessity of frequent electrocardiograms
(ECG), representing one of the most important non-invasive tools for
the diagnosis of cardiac diseases [3]. Patients treated with medications
that potentially interfere with cardiac function have to be monitored
regularly through an ECG. For instance, multiple sclerosis patients
receiving ngolimod (Gilenya®) have to be subjected to an ECG prior
to and 6 hours aer the rst or adjusted dose of ngolimod. Telemetric
monitoring systems oer the opportunity of recording ECGs outside
of the cardiologist’s practice and transmitting patients’ physiologic
parameters to a specialist for assessment. Telemetry ECG devices
thereby allow easy and fast ECG monitoring of patients with suspected
cardiac issues [3].
During the last years, also the use of mobile applications has gained
importance and has been discussed to become an attractive tool to
support and monitor patients [4,5]. Recently, the PatientConcept
App was implemented into clinical routine. With the intention to
support chronically ill patients in their daily life and to intensify the
contact between patient and physician, the app facilitates monitoring
and disease management [6]. Delivering healthcare via telemetry and
mobile health (mHealth) devices might thus be a promising and cost-
saving tool to improve health outcomes and to relieve patients and
physicians.
Obtaining physicians’ and patients’ perception constitutes an
essential step in understanding the feasibility and long-term values
when applying telemetric ECG or using PatientConcept App. erefore,
the FASTER study aimed to evaluate the acceptance of telemetric ECG
measurement in MS patients scheduled for an ECG due to medication
adjustment or follow-up. Furthermore, the study was initiated to
address the perception of employing a soware application in order to
support patients in a comprehensive manner.

Lang M (2019) How to improve disease management of chronically ill patients? Perception of telemetric ECG recording and a novel software application
Volume 5: 2-6
Clin Res Trials, 2019 doi: 10.15761/CRT.1000266
center (ExCard Research GmbH) within a dened time frame (9 a.m.
- 5 p.m.). Time stamps and patient data could only be allocated by the
center performing the ECG. Experts / cardiologists of the analyzing
center promptly analyzed the received ECG records. e medical report
was sent back to the treating neurologist / treatment center by email
within a maximum of 1 hour (Figure 1A). As the neurologist received
the medical report from the experts / cardiologist, this monitoring
setup required no additional personal appointment of the patient with
the cardiologist.
Evaluation of ECG functionality and acceptance
To evaluate the functionality of the applied ECG, the total and
evaluable number of ECGs was documented by the participating
neurological centers. In addition, the necessity to repeat the
transmission of ECG data, quality of data transfer and ECG records,
processing time and occurring adverse events were assessed. Using a
standardized printed questionnaire (yes/no questions), physicians
and patients evaluated whether telemetric ECG was perceived as an
interesting tool and a general relief, and whether it can reduce waiting
hours and accelerate medical reporting.
PatientConcept app
e Patient Concept app has been recently implemented into
clinical routine. It is available for free download via the German app
store (for both iOS and android smartphones or tablets, usable in a
multilingual manner) [6]. Patients included in the study were oered
Methods
Study design
e non-interventional FASTER (Focus on therapy associated
monitoring and evaluation of telemedicine in real world setting) study
was conducted between March 2016 and September 2017 in up to
300 practices and clinics in Germany. Multiple sclerosis patients with
ngolimod prescriptions were included in the study. e primary goal
was to investigate the feasibility and acceptance of telemetric 2-channel
ECG measurements as a part of the mandatory monitoring requirements
by both, patients and physicians. In a second approach, acceptance of
an individualized mobile application was evaluated. Age and EDSS
were also documented. e study was conducted in accordance with
the 1964 Helsinki declaration and its later amendments or comparable
ethical standards. e study design was approved by the local ethics
committee of the Landesärztekammer Baden-Württemberg (F-2016-
013) Informed consent was obtained from all participants prior to
study inclusion.
Telemetric ECG
During a visit at the neurologist / MS treatment center, telemetric
ECGs (2-channel, four electrodes, 40 seconds) were performed on
site using PhysioMem® PM 100. External nurses (ying nurses) could
be requested by the treatment center to support telemetric measures.
ECG records were pseudonymized by applying time stamps (date and
time of day) and immediately transmitted wirelessly to the analyzing
Report
CardiologistNeurologist Neurologist receives records
Dura�on: 30 min
ECG and pa�ent care Telemedical diagnosis Pa�ent interview and
pa�ent discharge
NeurologistPa�ent
data safety
A
B
Figure 1. Study design

Lang M (2019) How to improve disease management of chronically ill patients? Perception of telemetric ECG recording and a novel software application
Volume 5: 3-6
Clin Res Trials, 2019 doi: 10.15761/CRT.1000266
to use the app during the last 6 months of the investigation period
(due to developmental reasons the app was not available at an earlier
timepoint). Patients were allowed to make use of all available modules
and to employ the app at their own discretion. Webcast-trainings were
oered to educate physicians and patients on the usage of the app and
the corresponding backend.
Evaluation of the acceptance of app usage
Patients as well as physicians from the participating centers
completed standardized questionnaires (yes/no questions) to evaluate
the use of PatientConcept app. Patients assessed whether app usage
was benecial or useful to communicate with the center, whether it
may reduce consultations, and whether patients were satised with the
available app features. Physicians evaluated whether they perceived the
app as useful to increase adherence and whether they showed interest
in testing the application. Patients answered questionnaires via their
smartphone, physicians via the backend (dashboard of the application).
Statistics
Data were analyzed descriptively using the program R. For
categorial variables, percentages in relation to the total number were
provided. For metric variables, mean values were provided.
Results
Quality of telemetric ECG
Telemetric ECG was applied to 1082 test persons with a median age
of 39 years (range 16-71) and a median EDSS of 2 (range 0-8) in 211
participating centers throughout Germany. 1538 ECGs were recorded
(in parts, patients received repeated recording, 5.1% of records were
not evaluable). On average, the medical report was available in the
recording center aer 12 minutes.
Support by ying nurses
During the study, 197 nurses were requested to support ECG
measurements for a minimum of 1 to a maximum of 7 hours. 17% of
treating centers requested a nurse. e reasons for external request
included limited capacities due to lacking sta or lacking willingness
for education of sta (50%). Overall, the use of external nurses was
regarded as very positive (score 1.3 on a 6-step scale from 1=very
good to 6=insucient). Only 1.8% reported delays or communication
problems when requesting a nurse.
Acceptance of telemetric ECG recording
731 patients from 166 centers participated in the survey. e
necessity of digital communication between patients and physicians was
valued with a mean score of 2.5 (on a 6-step scale from 1 representing
high need to 6 representing no need). 80% of participants stated that
usage of telemedicine tools is benecial. 73% and 19% of participants
rated the oer of telemetric ECG recording in the treatment center as
very good and good, respectively.
e vast majority of patients perceived telemetric ECG recording as
an interesting tool and appreciated fast medical reporting and shorter
waiting times for ECG measurements (Figures 2A, B and E). Patients
also experienced a general relief due to telemetric ECG recording
(Figure 2D). Rating levels regarding usability were independent of
increasing age. A minimum of 93% of patients armed the use of
telemetric ECG.
Patients also assessed whether telemetry may enrich
communication, displaying a largely positive evaluation throughout
the patient cohort (Figure 2C). In contrast to telemetry usability, utility
of telemetry for communication purposes was less well accepted with
increasing age. While more than 80% of patients younger than 40 years
recognized telemetric tools as enrichment for communication, older
patients showed reduced acceptance.
In addition, 211 physicians from the participating centers
evaluated the application of telemetric ECG recording with regard
to usability, quality and benet. 98% of treating centers classied
this device as an interesting supporting tool (Figure 3). 95%, 95%
and 98% of the centers believed that using telemetric ECG recording
eliminates waiting times, accelerates medical reporting and provides a
relief for test persons, respectively. In only 6% of cases waiting times or
communication problems were reported, while technical procedures by
the involved companies were assessed positive by 96% of the patients.
e quality of data sets was considered high and was rated with a
mean score of 2.5 (on a 6-step scale from 1 representing excellent to 6
representing insucient).
Acceptance of app usage
e perception of app usage was analyzed in a cohort of 92
patients (Figure 4A). 51% of users stated that the app was a useful tool
to communicate with the treatment center (Figure 4A). 36% of users
believed that the app might reduce the number of consultations. 92%
of patients were satised with currently available features and did
not propose any particular requests regarding further app functions.
Most commonly used modules included ‘medication (pill) alarm’,
‘appointment request’ and ‘information’. Analyses of the nature of the
use by 92 MS patients revealed that 64% of these patients used more than
one and 30% four or more modules. For instance, 59%, 56% and 44% of
patients using the module ‘opening hours’ also employed the modules
‘appointment inquiry’, ‘follow-up prescription’ and ‘medication alarm’,
respectively. Patients using the module ‘therapy control’ also employed
the modules ‘news’ (79%), ‘seminars’ (71%), ‘medication alarm’ (71%),
‘laboratory values’ (57%) and ‘memory function’ (50%).
In general, elderly patients showed less interest in communications
via app (Figure 2F), while 53.4% of patients aged younger than 40 years
were interested in using an app to communicate with their treating
physician.
Based on the experiences gained when using this soware
application, 50% of the centers believed that this novel application
might represent a useful tool to increase adherence.
Discussion
Physicians’ and patients’ acceptance of an intervention or the
use of a particular device is an essential prerequisite for its successful
application. is study analyzed the acceptance of applying telemetric
ECG for mandatory monitoring and of using a recently developed
supportive app. Usage of telemetric ECG recording was well recognized
by physicians as well as patients that have to be subjected to an ECG
due to monitoring requirements. Participating patients and centers
considered this approach as an overall relief and perceived telemetric
ECG as useful and time-saving. is result is supported by studies
reporting that telemetric follow-up of implantable electronic cardiac
devices had a high degree of acceptance among both, patients as well as
health care professionals, and carried the potential to reduce health care
costs [7,8]. Also home-monitoring of implantable cardiac devices with
telemetric functionalities is becoming increasingly popular because
it allows remote diagnosis of proper device functionality and also
optimization of the device settings. us, telemetric ECG measures can

Lang M (2019) How to improve disease management of chronically ill patients? Perception of telemetric ECG recording and a novel software application
Volume 5: 4-6
Clin Res Trials, 2019 doi: 10.15761/CRT.1000266
Figure 2: Patients‘ evaluation of telemetric ECG measurement
0
20
40
60
80
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120
Number of patients
Age (years)
Interesting tool
0
20
40
60
80
100
120
Number of patients
Age (years)
General relief
0
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Number of patients
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Fast medical reporting
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Shorter waiting times for ECG recording
Agreement
Disagreement
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Telemetry enriches communication
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A
B C
D E F
Figure 2. Patients‘evaluation of telemetric ECG measurement
Figure 4: Evaluation of app usage
0
20
40
60
80
100
Beneficial Useful to
communicate
with center
Might reduce
consultations
Satisfied with
features
Patients (%)
Evaluation by patients (n=92)
0
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100
Useful to increase
adherence
Interest in testing
the app
Physicians (%)
Evaluation by physicians (n=211)
Agreement
Disagreement
AB
Figure 4. Evaluation of app usage
Figure 3: Physicians‘ evaluation of telemetric ECG measurement
0
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100
Interesting
tool
Reduced
waiting
times
Faster
medical
reporting
General
relief
Physicians (%)
Evaluation of telemetric ECG (n=211)
Agreement Disagreement
Figure 3. Physicians‘ evaluation of telemetric ECG measurement

Lang M (2019) How to improve disease management of chronically ill patients? Perception of telemetric ECG recording and a novel software application
Volume 5: 5-6
Clin Res Trials, 2019 doi: 10.15761/CRT.1000266
be helpful for monitoring purposes and may facilitate implementation
of complex therapy regimens, emphasizing the growing interest in
digital health of physicians, patients, and technology companies [9].
ECG recording requires the clinician to be well trained in the
technical use of the equipment [10]. In order to overcome a potential
lack of adequately trained personnel in the MS centers, trained ying
nurses were available to technically support the treating centers. Every
h center requested support by a nurse, and the support was rated
positively throughout.
Besides telemetric measurements, mobile health devices have
gained importance in disease management [5]. Entitled as the new
edge on healthcare innovation, mHealth potentially may deliver
healthcare regardless of time and place, evading not only geographical
and temporal, but also organizational barriers [11,12]. In this study,
patients were oered to use and evaluate a novel and innovative
soware application [6]. Patients used the app in a multifunctional
manner. Half of the patients testing the app felt that it is a useful tool
to communicate with the treating center, whereby younger users were
less skeptical than older patients. According to a survey by a German
health insurance company, every second patient would appreciate
the opportunity to contact or communicate with their physician
online [13]. Enhanced communication may help to increase patients’
commitment to the practice and thereby facilitate continuous support
of chronically ill patients. ese patients in particular, facing long-term
medication are known to have low adherence rates [14]. As medication
adherence is critical to achieving improved health outcomes, quality of
life, and cost-eective health care [1], there is a high need for innovative
approaches to improve adherence. In this context, intensied patient
support via patient support programs (through patient academy,
MS nurse or physicians) has already been shown to be benecial for
improving adherence in earlier studies [15]. Furthermore, a positive
inuence of mHealth-concepts on adherence [16,17] with high
usability and acceptability for mobile interventions has been reported
[18]. A similar tendency is reected in the presented study with 50%
of participating centers considering the application as a useful tool to
increase adherence. Given the general annual increase in mobile phone
users [19], the importance of mHealth is likely to increase in the future.
Limitations of the study include the small number of patients
evaluating the use of PatientConcept App, which can be explained by
the late availability of the application only in the last months of the
investigation period. erefore, further studies should investigate app
acceptance, usability and its impact on adherence in a larger patient
population covering a longer time period.
In conclusion, this study implies that new concepts of telemetric
ECG recording and the use of a mobile app might improve patient
management. Applied approaches were well recognized and perceived
as useful in the practice by both, patients and physicians. e positive
results gained in this study can help to develop new perspectives for
future use of these tools, which may constitute a relief for patient
monitoring and complex management of chronic diseases.
Authorship
M. Lang and L. Cepek substantially contributed to conception and
design, acquisition and interpretation of data. S. Ringbauer substantially
contributed to interpretation of data. M. Mayr substantially contributed
to conception and design and analysis of data. All authors revised the
article critically for important intellectual content, gave their nal
approval of the version to be published, and take public responsibility
for appropriate portions of the content.
Acknowledgments
Editorial support (writing assistance, based on authors’ detailed
directions) was provided by Katrin Blumbach (med:unit GmbH).
Funding
e study was supported by Novartis Pharma. Patient Concept
system has received nancial support from the Bavarian state,
Neuropoint Patient Academy and Systemhaus Ulm, Bayer and Sano
Genzyme.
Competing interest
M. Lang and L. Cepek have received travel grants, speaker’s
honoraria, nancial research support, consultancy fees from Teva,
Merck Serono, Genzyme -Sano, Novartis, Bayer, Biogen, Roche. S.
Ringbauer and M. Mayr have nothing to disclose.
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Volume 5: 6-6
Clin Res Trials, 2019 doi: 10.15761/CRT.1000266
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Copyright: ©2019 Lang M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use,
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