User-Centered Adaptation of an Existing Heart Failure Telemonitoring Program to Ensure Sustainability and Scalability: Qualitative Study (Preprint)

Abstract

Background: Telemonitoring (TM) interventions for the management of heart failure (HF) has seen limited adoption in Canadian health systems but isolated examples of TM programs do exist. An example of such a program was launched in a specialty HF clinic in Toronto, Canada and a recent implementation evaluation concluded that reducing the cost of delivering the program is necessary to ensure its sustainability and scalability. Objectives: The objectives of this study are (1) to understand which components of the TM program could be modified to reduce costs and adapted to other contexts while maintaining program fidelity; and (2) to describe the changes made to the TM program to enable its sustainability within the initial implementation site and scalability to other health organizations. Methods: Semi-structured interviews probed the experiences of patients (n=23) and clinicians (n=8) involved in the TM program to identify opportunities for cost reduction and resource optimization. Ideas for adapting the program were informed by the interview results and prioritized based on: (1) potential impact for sustainability and scalability; (2) feasibility; and (3) perceived risks to negatively impacting the program's ability to yield desired health outcomes. Results: Five themes representing opportunities for cost reduction were discussed, including: (1) Bring Your Own Device (BYOD); (2) technical support; (3) clinician role; (4) duration of enrollment; and (5) intensity of monitoring. The hardware used for the TM system and the modalities of providing technical support were found to be highly adaptable which supported the decision to implement a BYOD model, whereby patients use their own smartphone, weight scale and blood pressure cuff as well as the development of a website aimed at reducing the burden on a technical support telehealth analyst (THA). In addition, the interviews suggested that, while it is important to have a clinician who is part of a patient's circle of care monitoring TM alerts, the skill level and experience was moderately adaptable. Thus, a Registered Nurse was determined to be more cost-effective and was hired to replace the existing nurse practitioners in the frontline management of TM alerts as well as taking over the technical support role from a THA. Conclusion: This paper provides a user-centred example of how necessary cost-reduction actions can be taken to ensure the sustainability and scalability of TM programs. In addition, the findings offer insights into what components of a TM program can be safely adapted to ensure its integration in various clinical settings.