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  • TEC2: What kind of qualification and quality assurance processes are needed for the use or maintenance of Structured telephone support (STS) for adult patients with chronic heart failure?
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What kind of qualification and quality assurance processes are needed for the use or maintenance of Structured telephone support (STS) for adult patients with chronic heart failure?

Authors: Ingrid Wilbacher, Valentina Prevolnik Rupel

Internal reviewers: Alessandra LoScalco, Antonio Migliore, Christina Mototolea, Silvia Gabriela Scintee

Additionally to the basic literature search a qualitative handsearch (google; keywords: telemonitoring, telemedicine, qualification) was done adding two studies, the results are provided in descriptive way.

Literature included for this AE: Whellan 2005 {66}, Jaarsma 2013 {37}, Radhakrishnan 2012 {52}, MAST report {47}, Wakefield 2013 {65}, Clark 2011 {72}, Grustam 2014 {28}, Chaudhry 2007 {6}, Cleland 2010 {12}, BUDYCH {70}.

The answer was created out of statements in eight of the included studies from the general literature search and an additional handsearch in google for more information.

The studies providing information about the staff qualification mainly contains information on:

-management according to a multidisciplinary/ physicians care plan

-provision of monitoring and reaction in case of abnormities by nurses

The results of the survey with 15 experts in Germany {70} provide a conclusive overview of Expected skills:

-methodological competence (analytical thinking, ability of reflexion, autonomy, linguistic, anamnestic competence, ability of abstraction, ability of reaction)

-social competence (empathy, communication skills, politeness, social sensitivity, authority, motivation skills, kindness)

-professionality (basic medical knowledge, secure technical skills, practical medical experience, knwoledge of basic health legislation, knowledge about the health system, psychological motivational skills, knowledge in quality management)

personal competence (self-knowledge, psychical capacity, steadiness, distress-resistancy, learning motivation, professional distance, IT-skills. The quality assurance seems to be lacking.

Structural quality:

-How telemonitoring or telemedicine is implemented and to whom varies (see also CUR and LEG domain).

-Process quality:Marketing authorisation and licensing is partly provided (and discussed in CUR and LEG domains) and differs among health systems and continents. A regulative norm should be able to distinguish between technical and staff-related quality aspects. {15}

Technological usability, responsible innovation, health literacy, behaviour change, caregiver perspectives and motivational issues of professionals influence the efficient use of telemedicine. {47}

 

The professional knowledge about how and when to react on monitored data is a crucial aspect within telemonitoring (and monitoring at all).

The healthcare professional should not over-react to the risk identification, as this could lead to increased clinical activity and hospitalization without improving outcome.  High quality professional education should lead to a  sufficient rather than just a more frequent decision-making. {15}

Some expect that over the next decades the number of patients with heart failure increases, and the number of cardiologists decreases.{57},{24}Study results are discussed with a focus on a possible bias if only cardiologists or primary health care physiscians supervised the call-center and disease management interventions. In the review of Whellan {66} it is stated, that the outcomes of the postdischarge interventions depend on the type of provider, providing supervision: number of hospitalisationsin case of  cardiologist supervision decrease, which is not true for those supervised by primary health care physicians. The author himself is a cardiologist. The Heart Failure Association of European Society of Cardiology also addressed the need for appropriate education and training of healthcare professionals recently. {72}{66}Telemonitoring produces a lot of data, if a large number of patients transmit quantities of data daily. Resources to deal with the high amount of data adequately and process them automatically have to be provided.The final goal of remote monitoring is likely to be further empowerment of the patient. Primary care physicians are described as being responsible, cardiologist as to supervise the drug prescription and titration, in some cases nurses adjust diuretics, angiotensin-converting enzyme inhibitors, or beta blockers under the supervision of a cardiologist. Patient education to patients (and families) is provided by nurses or in some cases pharmacists. {72}.

In the WHARF trial, cardiac nurses reviewed data whereas the patients' physicians took the  responsibility for acting on the regularly updated information. {6}

Specific training for nurses is mostly described{37} in general terms such as for example:

  • "a specific HF programme based on AHCPR guidelines","trained nurses",

  • "advanced practice nurse",

  • "one day training course".

  • "Nurses underwent brief training programme regarding problems and treatment options associated with this particular group of patients".

The way how to train practitioners (nurses) is described varying {37} between

  • „interactive“,

  • “ role playing and audio taping“,

  • “ increase the skills in communicating“ and

  • „motivating the patients to treatment instructions adherence“,

  • „2-months orientation and training programme“,

  • „developing competences related to detection of deterioration in HF in elderly patients“,

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    „optimal therapeutic management“,

  • „educational and behavioural strategies in the home“,

  • „address patients and caregivers unique learning skills“.

 For other healthcare providers, specific training is even less well described {37} such as:

  • " a highly scripted training process"

  • " combined experience and completed a one-year clinical residency in home care". {37}

Provided  services (by nurses) include:

  • reviewing transmitted clinical data {52}

  • assessing individuals, coaching, and installing telehealth. { 52}

  • supervising automatic patient data transmission by means of telemonitoring devices {8}

  • providing telephone support and education. {28}

  • playing a coordinating or leading role {37}

  • telephone based monitoring and education {6}

  • using a software program to determine call frequency {6}

  • using a standardized algorithm to adjust diuretic doses or recommend urgent medical visits {6}

  • making the phone calls could adjust the medication over the phone or organized clinic appointments {15}

  • visiting and monitored patients' clinical status and educating them about heart failure and pharmacologic management {6}

  • initiating and regulating medications for heart failure {6}

The telemedicine providers were  described {37} as:

  • homecare nurses, {37}

  • hospital nurses, {37}

  • HF nurses, {37}

  • cardiac rehabilitation nurses, {37}

  • research nurses, {37}

  • practice nurses{37}

  • district nurses {37}

  • registered nurses {65}

  • advanced practice nurses who were considered specialists for HF patients {65}

  • cardiologist {37}

  • primary care physicians {37}

  • other specialists such as geriatricians or internists {37}

  • teams with different profiles like „collaboration between the primary care physician and cardiologist, trained doctor's assistant and a primary care physician or physician, physiotherapist, ECG technician and a psychologist“ {37}

  • additional involvement of other professionals (psychologist, dietician, physical therapist, social worker, pharmacist) {37}

  • nurses trained in management of heart failure {6}

The description of the specialization or clinical background are lacking within the studies. {37},  {15}

Physicians were rarely directly involved in intervention delivery. Furthermore, information about patient progress during the study was sent to physicians in fewer than half of the studies.“ {65} {15}„In TIM-HF trial monitoring was done by call centres that were otherwise not directly involved with the patients' care.“ {12}

Qualification requirements found in the handsearch:

Qualification

Requirements from

source

„Qualified providers are home health agencies enrolled with Vermont Medicaid.

Qualified providers must follow data parameters established by a licensed physician’s plan of care.

Qualified providers must use the following licensed health care professionals to review data: registered nurse (RN), nurse practitioner (NP), clinical nurse specialist (CNS), licensed practical nurse (LPN) under the supervision of a RN, or physician assistant (PA). In the event of a measurement outside of the established individual’s parameteres, the provider shall use the health care professionals noted above to be responsible for reporting the data to a physician.

The data transmission must comply with standards set by the Health Insurance Protability and Accountability Act (HIPAA).“

Vermont Medicaid, USA. Contract status.

Part 7702.2 Qualified providers (10/29/2014, 14-05P) available at: http://dvha.vermont.gov/budget-legislative/dvha-bulletin-14-05p-adopted-rule-for-website-13oct14.pdf (2014-01-08)

„Nursing staff monitor data readings twice daily and abnormalities are escalated based on the severity of the concern to patients and caregivers via SMS and email.

All parties are able to view the data and nurses are able to advise appropriate actions to keep the patient on track and in good health.“

HCF, Telstra launch health telemonitoring program, Australia; Website information

http://www.itnews.com.au/News/390532,hcf-and-telstra-launch-large-scale-health-telemonitoring-program.aspx

„Required competences:

  • methodological competence (analytical thinking, ability of reflexion, autonomy, linguistic, anamnestic competence, ability of abstraction, ability of reaction)
  • social competence (empathy, communication skills, politeness, social sensitivity, authority, motivation skills, kindness)
  • professionality (basic medical knowledge, secure technical skills, practical medicinal experience, knwoledge of basic health legislation, knwoledge about the health system, psychological motivational skills, knowledge in quality management)
  • personal competence (self-knowledge, psychical capacity, steadiness, distress-resistancy, learning motivation, professional distance, IT-skills)“

Results of a study based on a questionnaire to 15 experts in the telemedicine branche 2009-2010 in Germany.

http://www.telemed-berlin.de/telemed/2010/beitrag/beitrag_budych317_391.pdf


Critical
Partially
Wilbacher I, Rupel V Result Card TEC2 In: Wilbacher I, Rupel V Description and technical characteristics of technology In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=305

References