Challenges and Barriers of Remote Patient Monitoring (RPM) Systems on Hypertension

by Marjorie Melendres

Roison Andro Narvaez, MSN RN CMCS CLDP LGBH

Citation: Melendres, M., & Narvaez, R. A. (2024). Challenges and barriers of remote patient monitoring (RPM) systems on hypertension. Canadian Journal of Nursing Informatics, 19(3). https://cjni.net/journal/?p=13479

Abstract

Background: The integration of Remote Patient Monitoring (RPM) systems in healthcare, particularly for managing hypertension, has been recognized for its potential to enhance patient care through continuous, real-time health data collection and analysis. However, the implementation and efficacy of RPM face various challenges and barriers that need comprehensive exploration.

Objective: This study aims to systematically review and identify the primary challenges and barriers associated with the use of RPM systems in the management of hypertension.

.Methods: An integrative review was conducted, encompassing eight studies that met stringent inclusion criteria from a search across multiple databases including PubMed, Google Scholar, Scopus, and Science Direct. The review focused on studies published between 2010 and 2022, ensuring the inclusion of up-to-date and relevant data.

Results: The review identified three main themes impacting the efficacy of RPM: cost, adherence, and feedback. RPM has been shown to potentially reduce overall healthcare costs by decreasing hospital admissions and clinic visits. Adherence to RPM protocols and effective feedback mechanisms were critical in achieving successful hypertension management. However, challenges such as the initial high costs of technology adoption, integration with existing healthcare systems, and patient anxiety related to self-monitoring were significant barriers.

Conclusion: While RPM systems offer a promising approach to managing hypertension, particularly in reducing costs and improving patient outcomes through early detection and intervention, their widespread adoption is hindered by several barriers. Addressing these challenges, especially those related to cost and patient anxiety, is essential for the successful integration of RPM into routine hypertension care.

Implications for Practice: To maximize the benefits of RPM, providers must consider both the economic and psychological impacts on patients. Effective strategies for integrating RPM into existing healthcare frameworks and involving patients in decision-making processes are crucial for enhancing adherence and improving overall hypertension management.

What is known about this topic:

1. Remote patient monitoring (RPM) is effective in managing hypertension by providing continuous, real-time health data.
2. RPM systems are generally safe and can enhance patient care by reducing hospital admissions and clinic visits.
3. Despite its benefits, RPM can variably impact healthcare costs and is associated with increased patient anxiety during self-monitoring.

What this paper adds:

1. This paper identifies critical challenges such as high initial costs, integration difficulties with existing healthcare systems, and patient anxiety.
2. Adherence to RPM protocols and effective feedback mechanisms are essential for successful hypertension management.
3. Emphasizing patient involvement in decision-making processes can significantly improve adherence and overall management outcomes in RPM for hypertension.

Background

Elevated blood pressure or hypertension means the pressure against the blood vessel walls in the body is consistently too high and is often called the “silent killer” (Cleveland Clinic, 2021; Pokharel et al., 2022). Hypertension was the main or contributing cause of more than 7.5 million fatalities globally, as being hypertensive increases the risk of developing heart disease and stroke (World Health Organization [WHO], 2022). It is essential that patients have the tools necessary to manage their hypertension such as Remote Patient Monitoring (RPM) systems (Muller, 2022a).

Unprecedented morbidity and mortality brought on by the COVID-19 pandemic have put a strain on healthcare systems all around the world. Hospitals began to drastically restrict in-person contact by postponing routine patient appointments and cancelling elective treatments to stop the virus from spreading, forcing providers to adopt telehealth solutions (Mantena & Keshavjee, 2021). The COVID-19 pandemic has propelled telemedicine into the mainstream of healthcare. It was also used and was proven to be an effective approach in managing COVID-19 symptoms at home (Annis et al., 2020). RPM is another area of telehealth that has experienced significant growth during the pandemic (Siwicki, 2022).

RPM gathers patient health and medical data using networked electronic instruments in one location, where it is subsequently analyzed by a healthcare professional in another location (Vaidya, 2022). RPM has improved practitioners’ capability to observe and handle patients in unconventional healthcare settings (Vegesna et al., 2017). Devices for RPM encourage regular interaction and assist patients to comprehend their condition. Blood pressure cuffs, glucometers, pulse oximeters, ECG with a stethoscope, wearables/activity trackers, thermometers, and scales are the seven most often employed instruments for RPM (Muller, 2022b).  Patients with chronic illnesses, those with mobility problems or other disabilities, those who have recently undergone surgery, neonates, and elderly patients are just a few of the patient subgroups that are the focus of RPM (Malasinghe et al., 2017). It has also been found that RPM can reduce acute care use for patients with COPD and cardiovascular diseases (Taylor et al., 2021), cancer (Pritchett et al., 2021), and it also helps improve glycemic control among patients with Type II diabetes (Amante et al., 2021).

Home monitoring reduces healthcare costs while improving understanding of a patients’ regular blood pressure readings without adding to the strain placed on either patients or physicians (Champion et al., 2018). By 2024, 30 million US patients, or 11.2% of the population, are anticipated to utilize RPM equipment, up 28.2% from the 23.4 million patients who used them in 2020 (Samet, 2022). A review concluded that, despite the complexity of RPM interventions, they are more likely to be effective at reducing acute hospital events if they are properly designed with the factors, providers, and patients in mind (Thomas et al., 2021). There are numerous studies that show how RPM can be used to manage hypertension, but there are none that specifically focus on the challenges and barriers of RPM on hypertension. The aim of this research is to systematically explore and identify the primary challenges and barriers associated with the implementation and effectiveness of Remote Patient Monitoring (RPM) systems in the management of hypertension.

Method

Design

To analyze and synthesize the literature on hypertension, this study employed an integrated review design since it is a technique that takes into account diverse points of view and types of information (Massey et al., 2016). The most recent explanation of integrated review methodology in nursing was by Whittemore and Knafl (2005). Since that time, nursing researchers have consistently employed the five stages of the technique as the fundamental conceptual framework for their integrative reviews (Hopia et al., 2016).  The five stages include: (1) Problem identification; (2) Literature search; (3) Data evaluation; (4) Data analysis and (5) Results presentation (Whittemore & Knafl, 2005).

Search Strategy

A search of the literature on the online databases: PubMed, Google Scholar, Scopus, and Science Direct was conducted using a combination of terms: Remote Patient Monitoring, Hypertension, Remote Patient Monitoring Challenges, Remote Patient Monitoring barriers in order to generate and identify eligible articles published from the years 2010 to 2022. After generating the initial articles, inclusion and exclusion criteria were then applied, and the level of evidence of the generated studies were also identified.

Inclusion and Exclusion Criteria

The inclusion criteria for this study were: Free full access, published in English, focused on RPM as well as hypertension, and involved an actual study. Only studies published from 2010 to 2022 were included to ensure up-to-date data with regards to the topic.

The excluded papers were either duplicates or were not relevant to the purpose of this review, the research was conducted or published before 2010, and lastly were not a scoping, expert opinions, literature, or integrative review. As shown in Figure 1, PRISMA diagram, the number of included and excluded identified records are presented, as well as the reason for exclusions.

Figure 1.

PRISMA Flow Diagram

Literature evaluation

Only studies that met the following criteria were included: Free access, an English paper, published from 2010-2022, tackles RPM as well as hypertension, involves an actual study (Trials, Cohort, Quantitative, or Qualitative). The initial literature generated had undergone checking and evaluated using the set of inclusion and exclusion criteria, and the level of evidence (LOE) of the studies were also identified.

Results

As shown in Table 1, eight (8) studies were included that used a variety of research designs including: Randomized controlled trials (n=5), Cohort studies (n=2), and a Case control study (n=1). There were three (3) studies which focused on pregnancy-related hypertension, such as pre-eclampsia, and one (1) study specifically aimed to analyze costs. The studies included were conducted in different settings including primary care, multi-centre care, and academic/university hospitals. Two (2) trials were monitored by nurses and doctors (McKinstry et al., 2013; McManus et al., 2021), one (1) was watched over by nurses (Hoppe et al., 2018), and another by doctors, nurses, nutritionists, and fitness trainers (Kim et al., 2015), and  three (3) were coordinated with a doctor (Logan et al., 2012; Mujisers et al., 2022; van den Heuvel et al., 2021), and one (1) by a pharmacist and a nurse ( Clark et al., 2021).

A total of 2,098 participants in the eight included studies with ages ranging from 18 to 95 years old, which were conducted in different places, one (1) in South Korea, one (1) in Toronto, Canada, two (2) in the Netherlands, one (1) in Scotland, one (1) in Wisconsin, USA, one (1) in Mississippi, USA, and lastly, one (1) in the United Kingdom. In the included studies, there were five (5) studies with a LOE of II, and three (3) with a LOE of IV. In terms of the research designs, five (5) studies utilized Randomized control trial, one (1) case control study, and two (2) cohort studies.

Table 1:

Summary of Articles

Discussion

The goal of this review was to explore and identify the primary challenges and barriers associated with the implementation and effectiveness of Remote Patient Monitoring (RPM) systems in the management of hypertension. Three main themes emerged from the eight included articles in this study: Cost, Adherence, and Feedback.

Theme 1: Cost

According to estimates, people with hypertension spend nearly $2,000 more per year on healthcare than people without the condition. Over the past 12 years, this trend has remained largely stable. Hypertension-related medical expenses total about $131 billion USD (Kirkland et al., 2018).  Compared with usual care, RPM was cost-effective for hypertension, where longer-term cost reductions may be greater due to the prevention of expensive health events (De Guzman et al., 2022), this finding was also noted in another study (El-Rashidy et al., 2021). It was also seen-as cost effective in any different program involving remote monitoring in lowering blood pressure and in providing earlier diagnosis and prompt treatment of severe postpartum hypertension thus improving maternal status and decreasing costs of readmission (Hoppe et al., 2019; McManus et al., 2020; Mujiser et al., 2022).

In another study that used a pathway for antenatal care, cost was reduced primarily due to a decrease in clinic visits and a change in the type of care provided by professionals during these visits, as well as a decrease in antenatal admissions, which together accounted for a 19.7% reduction (median cost difference: €888) (van den Heuvel, 2021). It was also determined to be practical in a rural and low-income community and was linked to a considerable reduction in blood pressure (Clark et al., 2021). In contrast, one study found a link between RPM and and an increased usage of national health resources (McKinstry et al., 2013).

RPM was thrust into the mainstream as a result of the financial burden caused by hypertension and the restrictions caused by COVID-19, such as social isolation. Despite being effective, RPM has not yet been extensively adopted since the expenses associated with the first adoption of new technology are high (McKinstry et al., 2013).

The studies reviewed indicated that RPM can significantly reduce healthcare costs by preventing expensive health events, decreasing hospital admissions, and minimizing clinic visits. To overcome the initial financial barriers, several strategies can be employed. For instance, phased implementation of RPM systems can help distribute costs over time, making it more manageable for healthcare providers. Additionally, seeking funding from government programs, grants, and private sector partnerships can alleviate the financial burden. Investing in scalable and interoperable RPM technologies can also enhance cost-effectiveness by allowing seamless integration with existing healthcare infrastructure, reducing redundancy and operational costs.  Overall, while RPM promises cost-effectiveness in the long run, healthcare systems must address the initial financial barriers to support widespread implementation.

Theme 2: Adherence

In managing hypertension, one critical factor is the adherence of the patient to the treatment and one way to improve compliance was self-measurement of blood pressure, which also showed a 92% drug compliance rate (Marquez-Contreras et al., 2006), improvement in compliance was also noted in another study (Parati et al, 2009). According to a study by Niiranen and colleagues, home blood pressure monitoring gives doctors more accurate readings of patients’ actual blood pressure than traditional office readings. Home blood pressure monitoring should replace traditional methods for diagnosing and treating hypertension because it is a practical, reliable, and widely accessible option with no risk of white-coat and masked hypertension (Niiranen et al., 2010). 

RPM was shown to reduce antihypertensive medication use (Kim et al., 2015; Verberk et al., 2007). In one study, there was a significant increase in depression scores and was associated with the possibility of increasing a patient’s attention to their hypertension, making it one of the reasons why providers cannot fully endorse its use, and the over-time decline of reports from patients suggested a fatigue effect with this intervention (Logan et al., 2012).  Anxiety was also reported in a study as a result of self-monitoring (McKinstry et al., 2013).  Self-monitoring at home may improve treatment compliance and blood pressure control, but there are barriers to its use in everyday clinical practice (Parati et al., 2009). One study showed the value of using home BP monitoring in conjunction with online pharmacy care to lower blood pressure in patients with essential hypertension (Green et al., 2009). Self-monitoring coupled with various interventions resulted in reduction of blood pressure but it is also important that patients will adhere with the stated treatment plan as to properly manage or control their blood pressure.

Adherence to RPM protocols is crucial for the successful management of hypertension. This theme explored the factors influencing patient compliance with RPM, the benefits of adherence, and the barriers that may hinder consistent use. Understanding these aspects is essential for healthcare providers to develop strategies that enhance patient adherence and optimize the effectiveness of RPM systems. Adherence to RPM protocols is vital for the effective management of hypertension. Factors such as ease of use, patient education, continuous support, and addressing psychological barriers are crucial in ensuring consistent use of RPM systems. By understanding and addressing these factors, healthcare providers can enhance patient adherence, leading to better health outcomes and more efficient management of hypertension. Investing in technology and personalized care approaches will further support patients in maintaining adherence and optimizing the benefits of RPM systems.

Theme 3. Feedback

Researchers postulate that giving feedback in terms of the patients’ blood pressure, diet, and exercise patterns might be beneficial in reducing BP (Kim et al., 2015).  Better hypertension controls can be achieved when patients were included in the decision making. It was also discovered that interventions conducted in collaboration with healthcare professionals yielded positive results because patients were notified or contacted with a management plan (Duan et al., 2017; Logan et al., 2012). These findings was also seen in another study which showed that patients gained more access to their providers, thus making more equitable and informed decisions; in some cases, this feedback was deemed annoying, but others felt more engaged with the process (McKinstry et al., 2013). In the same study, researchers reported that efficiencies might be realized if a better integration of telehealth data to the current system was available.

Self-monitoring of blood pressure may be beneficial by allowing physicians to tailor treatment to a person’s blood pressure abnormality, thus avoiding overtreatment as well as undertreatment (Uhlig et al., 2013). When compared to standard care, home BP telemonitoring and pharmacist case management improved blood pressure control over the course of 12 months and continued during the post intervention follow-up of six months (Margolis et al., 2013). Telemedicine, in fact, can reinforce and empower the physician-patient relationship, and even individualise this relationship, thus further ameliorating BP control and reducing the risk of major cardiovascular outcomes (Citoni et al., 2022).

Effective feedback mechanisms are pivotal for the success of RPM systems in managing hypertension. This theme examined the importance of feedback, the ways in which it enhances patient outcomes, the challenges associated with providing effective feedback, and strategies for integrating feedback into RPM systems. This analysis indicated that robust feedback mechanisms, when well-integrated, can empower patients and enhance the overall effectiveness of RPM systems. While challenges exist in providing effective feedback, strategies such as real-time data analytics, personalized feedback, automated systems, patient education, collaborative care models, and user-friendly interfaces can address these issues. By integrating effective feedback mechanisms into RPM systems, healthcare providers can support patients in managing their hypertension more effectively, leading to improved health outcomes and overall quality of care.

An integrated perspective on cost, adherence, and feedback reveals that these themes are interconnected and must be addressed holistically. The initial financial investment in RPM systems can be justified by the long-term savings and improved health outcomes resulting from better adherence and effective feedback. Enhancing patient adherence through user-friendly devices, continuous support, and addressing psychological barriers ensures that RPM systems are utilized effectively. Moreover, integrating comprehensive feedback mechanisms reinforces patient engagement and provides valuable insights for personalized care.

Implications for Practice

RPM offers various benefits such as being cost effective over time and the convenience it offers in being monitored 24/7 by healthcare professionals in the comfort of one’s home. It was also proven to be effective in helping to manage or lower blood pressure among hypertensive patients. This could prove to help improve the quality of life of many Filipinos but despite its proposed benefits or advantages, the Philippines still has no existing legal framework for the implementation of telehealth (Macariola et al., 2021). In one systematic review, it was stated that additional support such as medication management, behavioural interventions, and home visits was linked with greater reductions in BP compared to usual care (Uhlig et al., 2013). It is also worthy to note that patients’ inclusion in the decision making with regards to their condition could help improve or manage their hypertension.

Limitations and Recommendations    

The only aim of this paper was to identify challenges and barriers of RPM on a single condition, hypertension. During the search of the literature, there were other studies that could have possibly been included for this review but had restricted access, or were conducted before 2010, thus did not meet the inclusion criteria. Aside from the access, there were also other relevant studies that did not meet the stated inclusion criteria. However, these studies were still used as a reference in completing this paper. There also no specific studies that directly provided an answer for the objectives of this study, but by analysing the included studies, the three themes were generated.

Aside from hypertension, there are other conditions for which RPM is used, such as cancer and diabetes. With the economic burden of hypertension increasing, multiple studies acknowledged RPM as one way to reduce the cost. There is still inhibition in terms of its usage and RPM is yet to still be fully utilized as it will take more time to integrate it into the usual care framework, in all countries. There are challenges encountered in remote monitoring patients with hypertension and one of them was the behavioural impacts of monitoring. Providers should take into consideration the current status or disposition of their patient in having them do RPM. With the threat of COVID-19 still looming, implementation or the integration of the RPM into current health care should be considered even if not convenient since it was proven to reduce costs in the long run and also lessens possible exposure to COVID-19 and other infectious diseases.

Conclusion

In conclusion, the successful implementation of RPM systems for hypertension management requires a multifaceted approach that addresses the financial, psychological, and operational challenges identified in the themes of cost, adherence, and feedback. By developing strategies to mitigate initial costs, fostering environments that support patient adherence, and integrating effective feedback mechanisms, healthcare providers can enhance the overall effectiveness and adoption of RPM systems. This holistic approach will lead to better health outcomes for patients, more efficient resource utilization, and ultimately, a more sustainable and effective model for managing hypertension in diverse healthcare settings.

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