Integration of telemedicine into clinical gastroenterology and hepatology practice

Enhanced monitoring and self-care through use of telemedicine technologies

Several groups have implemented telemedicine to improve monitoring and self-care in patients with IBD. Our group at the University of Maryland, Baltimore, has developed several systems to improve care as part of research protocols. Our first telemedicine system included a laptop computer and electronic weight scale connected telephonically to a server. Patients were asked questions about bowel symptoms, medication use, side effects, and body weight measurements. They also received educational messages. This system, IBD Home Automated Telemanagement (HAT), required installation in the patient’s home by a technical team. Our preliminary results demonstrated that patients were very receptive of the technology.⁶ In a small pilot study (n = 34), we demonstrated that 88% of patients were adherent to self-assessment during a period of 6 months. In addition, patients experienced a reduction in disease activity, improved quality of life, and increased disease state awareness.⁷ In a small, randomized, controlled follow-up trial, we demonstrated that use of an ulcerative colitis (UC) telemanagement system (UC HAT) resulted in improved quality of life and decreased disease activity from baseline during 1 year compared with controls. The UC HAT system was enhanced to include self-care plans that were based on patient reporting of symptoms. Fewer participants completed the study in the UC HAT, compared with the control, group (56% vs 72%).⁸ We theorized that participant dropout was higher in the UC HAT group because of the requirement for a technician to visit the home to install or service the system. Hence, as part of a randomized controlled trial, our group has collaborated with the University of Pittsburgh and Vanderbilt University to assess a new telemedicine system that monitors patients by using text messaging.⁹ Three hundred forty-eight patients were recruited for this ongoing clinical trial. Thus far, 83%–84% of participants in the intervention arms have completed the 1-year study.

Elkjaer et al. evaluated the impact of a web-based treatment program and patient education center in a convenience sample of patients with UC.¹⁰ All 21 patients reported the ability to initiate a self-care plan. Furthermore, participants experienced improvements in knowledge after interaction with the patient education center.¹⁰ The web-based self-management and treatment approach was compared with standard of care in 333 patients with mild-to-moderate UC from Ireland and Denmark.¹¹ Only 135 patients (41%) completed the 1-year study. Web subjects were more adherent with acute treatment, demonstrated improved disease knowledge and quality of life, experienced shorter relapses, and had fewer office and urgent care visits. Conversely, web group patients generated more emails and telephone calls. In the Irish arm, the results were similar; however, there was no difference in quality of life between groups, and the relapse rate was higher in the web group, compared with controls.¹¹ A 2012 study by the same group investigated the efficacy of web-based monitoring of Crohn’s disease activity for individualized dosing of infliximab maintenance therapy. Twenty-seven patients were enrolled; 17 completed 52 weeks and 6 completed 26 weeks of follow-up. Patients recorded their symptoms weekly via a web-based portal; on the basis of symptom scores, patients were instructed to contact their physician for an infliximab infusion. Fifty percent of the patients were able to tolerate intervals greater than 8 weeks, whereas 36% required shorter intervals.¹² This concept of web-based personalized treatment was further investigated in a 2014 study evaluating 86 patients with mild-to-moderate UC. Mesalamine treatment was individualized on the basis of a composite index of clinical symptoms and fecal calprotectin levels. Use of the web application was associated with decreased disease activity scores and lower fecal calprotectin levels despite dose reduction in 88% of patients at week 12.¹³

The eIBD program developed at the University of California, Los Angeles, also uses a web-based platform to monitor patients. After an initial training session with an IBD nurse specialist, patients are able to view clinical results and view and update their disease activity status, quality of life, and work productivity remotely. Patients interact with the eIBD program by using a tablet or home computer. Self-monitoring was found to correlate well with an in-person assessment of symptoms and disease activity.¹⁴ Patient care is organized into evidence-based pathways on the basis of disease status and the medication regimen. Each pathway has a defined number of clinic and electronic visits and laboratory sets. Patients can also access support programs such as My Academy, My Work, My Coach, My Physical Fitness, and My Diet. When University of California, Los Angeles, IBD patients were compared with matched controls by using an administrative claims database, they were significantly less likely to use steroids and had fewer hospitalizations and emergency department visits.¹⁵

HealthPROMISE is an application developed at Mount Sinai to collect patient-reported outcomes and to provide decision support. Patient-reported symptoms and quality of life are integrated into the electronic medical records system; providers can view the information in real time to better manage their panel of patients. HealthPROMISE is currently being evaluated as part of a pragmatic, multicenter, randomized controlled trial.¹⁶ EncephalApp is a mobile phone application used to assess patients for hepatic encephalopathy. The application was tested in 167 cirrhotic patients, 38% of whom had overt encephalopathy, and 114 controls. The application was shown to have excellent discriminant ability to detect encephalopathy, and importantly, EnecphalApp times correlated with motor vehicle accidents and illegal turns in a driving simulation test.¹⁷ A number of other mobile applications have been developed to support patients with chronic illnesses. These applications can be integrated with wearable devices, and some have been approved by the Food and Drug Administration.¹⁸