NE PHROLOGY
tend to experience better health, have better health outcomes and engage in healthier behaviours. Working with this platform in the manner described promotes ‘supported’ self-management. The patient is required to engage in their healthcare by being entrusted to perform their own clinical observations and symptom reports. A majority of our cohort reported feeling more engaged in their care while using the platform than prior and many reported a better understanding of their management.
A concern is that web-based monitoring
via a smartphone or computer may introduce health inequalities – not everyone is so enabled. However, this possibility needs to be considered in context. The internet is now widely used by the UK public for everyday needs, some of which involve the transfer of highly confidential information (e.g. online banking and shopping). UK Government data show that 96% of UK adults are internet users (80% in people over 65 years).8
In
2019, 87% of adults aged 25-64 used a smartphone to access the internet.9 The great majority of patients could therefore access healthcare via digital means and this number is certain to grow in future. A few individuals may not be able to use these technologies, but it is likely that they too will derive benefit from greater access to the clinic capacity which remote monitoring creates. It is therefore possible that adoption of remote monitoring, where it is appropriate, may help reduce health inequalities across the service as a whole.
Are healthcare professionals ready for remote monitoring? We offered the option of remote monitoring to a selected cohort who, in our opinion, stood to benefit from it. We regarded remote monitoring as an adjunct to, rather than a wholesale replacement for, clinic-based care. Importantly, clinicians and patients retained the freedom to decide what kind of review was most appropriate for a given clinical circumstance. Failure to appreciate this hybrid model causes problems for some clinicians, who fear a wholescale takeover of traditional care by impersonal technology. We noted some resistance from clinicians to the introduction this system to our unit. Some were of the opinion that “proper” medicine cannot be delivered remotely. They felt that physical contact with patients is the essence of the care a doctor should provide and that patients value this contact. Others were sceptical that patients could be trusted to take responsibility for their care without face-to-face professional oversight. Our evidence, derived from the patients themselves, does not support these views. We have shown that those who opted to use remote monitoring found it convenient and reassuring; they told us that they did
not miss routine face-to-face consultations. We did not identify a single instance when a using remote monitoring led to outcomes which were inferior to those attained with clinic attendance. Remote monitoring is not for everyone, but it is wrong for clinicians to assume that it is only suitable for computer-savvy youngsters. For internet-based monitoring to be used appropriately in clinical practice, professionals need to learn to identify those patients who are likely to benefit. This requires unprejudiced judgement of a patient’s physical attributes (eyesight, manual dexterity) cognitive function, psychological health and clinical suitability (the expected natural history of their disease). Clinicians must also learn to identify users of remote monitoring who are no longer benefiting and require a change to face-to-face surveillance. These skills are not yet fully developed in the clinical workforce but are important if the ambitions of the Topol review, which aims to prepare the workforce for the digital age, are to be realised.10
Conclusions We have shown that a selected cohort of patients with CKD prefer remote, web-based, shared management to traditional clinic-based care for routine surveillance when they felt well. When used for such routine monitoring, it enabled an interaction with clinicians which met the needs of patients. The resulting reduction in demand for clinic space improved access for patients who needed a face-to-face interaction. From our experience, the major barrier to realising the benefits of guided self-management using this technology is not the preference or capability of patients, but rather the willingness of clinicians to embrace its introduction and of organisations to create conditions which enable its use. Widespread acceptance of these systems by healthcare providers will depend on the provision of a body of peer-reviewed evidence which confirms the benefits we have seen during our experience. There is therefore a need for large clinical trials examining the role of new technologies in modern healthcare delivery. Now is the time.
CSJ
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WWW.CLINICALSERVICESJOURNAL.COM About the Author
Dr. Robert Lewis MD FRCP was appointed as a consultant nephrologist at the Wessex Kidney Centre in 1997 after completing his renal training and MD thesis at Guy’s Hospital London. He has previously been head of department and is now head of research and innovation. He is an honorary senior lecturer at the University of Portsmouth and renal specialty lead for the Wessex Clinical Research Network.
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