A .gov website belongs to an official government organization in the United States. A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality, the Department of Veterans Affairs, or the U.S. Background: Prior telemonitoring trials of blood pressure and blood glucose have shown improvements in GlycoCares Blood Sugar Guideinsulin sensitivity support pressure and glycemic targets. However, implementation of telemonitoring in primary care practices may not yield the same results as research trials with extra resources and rigid protocols. In this study we examined the process of implementing home telemonitoring of blood glucose and blood pressure for patients with diabetes in six primary care practices. Materials and Methods: Grounded theory qualitative analysis was conducted in parallel with a randomized controlled effectiveness trial of home telemonitoring.
Data included semistructured interviews with 6 nurse Glyco Care review coordinators and 12 physicians in six participating practices and field notes from exit interviews with 93 of 108 randomized patients. Results: The three stakeholder groups (patients, nurse care coordinators, and physicians) exhibited some shared themes and some unique to the particular stakeholder group. Major themes were that practices should (1) understand the capabilities and limitations of the technology and the willingness of patient and physician stakeholders to use it, (2) understand the workflow, flow of information, and human factors needed to optimize use of the technology, (3) engage and prepare the physicians, and (4) involve the patient in the process. Although there was enthusiasm for a patient-centered medical home model that included between-visit telemonitoring, there was concern about the support and resources needed to provide this service to patients. Conclusions: As with many technology interventions, careful consideration of workflow and information flow will help enable effective implementations. The chronic care model emphasizes clinical care management and self-management support for complex patients.1 For patients with type 2 diabetes, home monitoring of blood pressure (BP) and blood glucose (BG) may be part of a disease self-management program.
Between-visit communication about these data by the patient-healthcare team may facilitate the interaction of an informed, activated patient with a prepared, proactive team, which is an integral part of the chronic care model.1 This interaction may also help overcome "clinical inertia" that leads to treatment intensification delays.2 Capabilities for uploading home BP and BG data using the Internet and mobile technologies are proliferating. Most investigations of BG and BP telemonitoring show some improvement in BP and glycemic control,3-11 but they generally occurred within the context of a structured research protocol with research personnel acting as intermediaries. Little information is available about how to incorporate these activities into real-world primary care practice.12 Practices that seek to use telemonitoring to improve care need to know who should receive these data and in what form, how data should flow to the patient's provider, how much time office personnel will spend troubleshooting technical problems, and how burdensome these activities will be to members of the healthcare team.
Many previous models have used nurses to review home telemonitoring BP and BG data rather than having the raw data go directly to the physician.13 Previous research shows a distinct possibility of low physician attendance to these data.3,14 In our 3-month randomized trial of BP and BG telemonitoring among patients with diabetes attending six primary care practices, practice nurses received, reviewed, and communicated with physicians and patients about transmitted data. To address the need for information about telemonitoring implementation in clinical practice, we focus here on the experiences of the nurses, physicians, and patients who submitted, received, and reviewed these home BG and BP data. The clinical trial that is the background for this work was very much an effectiveness trial. While a research assistant enrolled patients and collected data, all other functions of the telemedicine implementation were performed by existing personnel in these six internal medicine and family medicine practices.
We present a 360° qualitative examination of implementation from the perspective of practice nurses, physicians, and patients. These practical considerations can inform "real-world" primary care practices considering telemonitoring implementations. We conducted this qualitative inquiry in parallel with a randomized controlled trial of electronic transmission of home BG and BP measurements to the practices. 8.0% (see our accompanying article23). Patients randomized to the intervention were asked to measure their BG and BP at least once a day, or at greater frequency if directed by their physician, and to transmit BG and BP values to a secure server at least every other day. The transmission device could be attached to an analog telephone line or via USB to a computer for upload to a secure server and associated Web site. Control patients were asked to monitor every day and bring a list of values to any clinic visits occurring during the study but were not given the ability to upload data electronically.