Coordination of a remote mHealth infrastructure for atrial fibrillation management during COVID-19 and beyond: TeleCheck-AF

Background

Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia, associated with increased morbidity such as heart failure, thromboembolic complications, and mortality. Management of AF is a multifaceted process that goes beyond the treatment of the arrhythmia alone. In addition to controlling the arrhythmia (heart rate and rhythm control), assessment of stroke risk and the administration of appropriate anticoagulation to prevent strokes, the management of concomitant risk factors represents an important component of AF treatment as it can reduce AF symptom burden and may reverse the type and natural progression of AF. ¹ A multidisciplinary team approach involving cardiologists, electrophysiologists, nurses, allied health professionals as well as primary care physicians, amongst others, should be in place, following a patient-centred approach which places the patient in a central role in decision-making. Integrated care has been identified as a suitable approach to implement comprehensive AF care within specialised AF outpatient clinics through face-to-face contacts.^2,3 Significant improvements in the quality of care delivery ⁴ as well as in patient outcomes have been demonstrated when applying such specialized AF-Clinics in clinical practice.^5–8

During the coronavirus 2019 (COVID-19) pandemic, traditional face-to-face consultations in AF outpatient clinics were constrainedly converted into teleconsultations. At the Maastricht University Medical Centre+ (MUMC+), Maastricht, the Netherlands, we developed a mobile health (mHealth) infrastructure to support teleconsultations with AF patients to guarantee the continuity of comprehensive AF management through teleconsultations during COVID-19: The TeleCheck-AF approach.^9,10 In this article, we explain the coordination of the TeleCheck-AF approach and the implementation of this mHealth intervention in European centres.

TeleCheck-AF

TeleCheck-AF incorporates three important components (Figure 1): 1) a structured teleconsultation, which allows health care professionals to conduct remote patient consultations (‘Tele’), 2) an app-based on-demand heart rate and rhythm monitoring infrastructure based on a CE-marked mobile phone app: www.fibricheck.com (‘Check’) and 3) comprehensive AF management (‘AF’) consisting of four main domains: i) rate control for symptom management and preservation of left ventricular function, ii) rhythm control to improve symptoms, iii) prescribing appropriate oral anticoagulation according to stroke risk to prevent thromboembolic complications, and iv) management of precipitating factors (i.e. underlying cardiovascular conditions and modifiable risk factors) to reduce the cardiovascular burden. ¹¹ The TeleCheck-AF approach is an on-demand mHealth intervention which is provided to patients for seven days prior to a scheduled teleconsultation. Patients are instructed to measure heart rate and rhythm and symptoms, three times a day and in case of symptoms using the FibriCheck® app. This app is based on photoplethysmography (PPG) technology using the built-in camera on the smartphone, allowing semi-continuously heart rate and rhythm monitoring of AF patients prior to the teleconsultation. This on-demand mHealth approach provides vital parameters and enables physicians to use heart rate and rhythm data for the decision-making process related to treatment and management AF patients.

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Figure 1.

Multi-level care coordination within the TeleCheck-AF approach.

Care coordination

Coordination of patients’ self-management

TeleCheck-AF calls upon the responsibility of patients: this means that coordination of performing measures lies mainly with the patients themselves. Patients’ adherence and willingness to participate and perform the measures as prescribed is essential for the collection of measurements. In fact, a short intervention for only seven days may increase commitment and prevent mHealth fatigue. Clear education and empowerment by the case coordinator on the importance of the proper use of the mHealth prescription seems to be effective for most patients. In addition, the user-friendliness, daily notifications provided by the app, and the support of carers may increase adherence as well. The use of the mHealth intervention stimulates patients to take an active role in their self-management of AF. Moreover, patient experiences have been very positive, and some patients even register comments , or try to seek out situations in which they normally experience symptoms. They are eager to discuss these results with their physician and thereby take on a more active role during consultation. This provides an excellent opportunity for shared decision making, as the patients may feel more involved in their own care. The vast majority of patients indicates during teleconsultation that they would like to use the mHealth prescription for a longer period of time, since they find it comforting to be able to check their heart rhythm in case of symptoms.

An online webinar for patients and those interested, was organized to provide in-depth information about the TeleCheck-AF approach, but also to answer questions of attendees. ¹⁵ This ‘’Hart&Vaat Café’’ (Heart&Vascular Cafe) is normally hosted in a local café, where patients can get together to meet fellow patients. However, due to the COVID-19 pandemic the Café was organized online, which was the first time in the 10 year existence of this local initiative (Figure 2).

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Figure 2.

Coordination of communication to patients and multidisciplinary team

Discussion

The TeleCheck-AF mHealth infrastructure has been developed to remotely assess information on heart rate and rhythm in patients with AF, to support teleconsultations during the COVID-19 pandemic. The approach has been rapidly embedded in the clinical setting and has been well adopted by patients and health care professionals. In fact, the TeleCeck-AF approach has been integrated in a way that it will remain even after the COVID-19 restrictions. However, it is crucial to evaluate the mHealth infrastructure and determine further utilization in the clinical pathway for arrhythmia patients. ¹⁷ The approach has potential to improve patient outcomes, increase access to health care providers whilst reducing health care utilization (i.e. outpatient visits and presentations to the emergency department) and decrease the burden on the health care system and cost. Despite these advantages, areas for improvement have been identified that should be considered in refining the TeleCheck-AF approach as part of the standard AF care.

Reimbursement is a barrier to more widespread adoption of mHealth in general. During the COVID-19 pandemic, technology and companies provided temporary support. Nevertheless, such support has limits and without a coherent funding system to cover such services, the application will be limited to those patients who may be willing to pay out-of-pocket for telemedicine solutions. In collaboration with the Healthcare Innovation Lab, Maastricht University Medical Centre+, discussions with government and health care insurers are ongoing to secure funding for the approach. Privacy and security of patient data is legitimate since patients may not exactly know who will be responding to and sharing their personal medical information. Reliable security and privacy legislation should be in place, and a robust privacy and security plan with identification of the data controller company (FibriCheck®) is essential. This should be communicated with patients and may increase patient confidence and reassurance.

As technology is advancing quickly, alternative media, e.g. short messages instead of email contact, may extend the communication between the case coordinator and the patient. In addition to just solving app-related technical problems and providing support, the coordinator’s role could be extended into coordination of the care process by means of collecting and assessing risk factors and provide additional material for lifestyle advices and disease self-management. This would ensure patient empowerment through engagement and providing personalised care.

After the COVID-19 pandemic, teleconsultations supported by the TeleCheck-AF approach could be provided as an alternative to traditional face-to-face visits in the outpatient department. Depending on patient preferences, the optimal strategy for each individual patient should be discussed between health care professional and patient and then selected in a shared decision making process. ¹⁸

The availability of new mHealth technologies and infrastructures such as the TeleCheck-AF approach may help to improve the quality of care, to increase access to the most optimal treatment tailored to the individual patient and to overcome equity issues related to demographics and socioeconomic status. More research is needed to develop and validate novel care pathways incorporating existing mHealth tools. One of the main requirements of future mHealth applications will be a flexible cloud infrastructure around it. This will allow the adaptation of the mHealth infrastructure to support the optimal care pathway instead of adapting the care pathways around an inflexible mHealth tool and infrastructure. Additionally, the mHealth end users, e.g. physicians and patients, should be involved from the early stages in the development and finetuning of future technologies. The TeleCheck-AF approach was initially developed in an AF outpatient clinic by close collaboration of a multidisciplinary team, including physicians and specialised AF-nurses together with secretaries who served as case coordinators. Along the track further development and refinement was undertaken based on valuable feedback from physicians, nurses, secretaries and patients, demonstrating the importance of a multidisciplinary approach. TeleCheck-AF represents an example of an on-demand health monitoring which can be tailored to the patient’s needs, values and preferences, and as such contributed significantly to the strengthening of AF services in responding to COVID-19.

Although the TeleCheck-AF approach is specifically designed for the management of AF, it has potential to be extended to comprehensive management of other conditions. As an example, it may be helpful to assess heart rate control in the treatment of heart failure. Moreover, the on-demand mHealth approach may serve as a basic principle which can be translated and tailored to the requirements of chronic conditions in which it is conceivable that the fundamental aspects of the approach will remain.

Conclusion

The TeleCheck-AF approach has been developed in the heat of the COVID-19 pandemic and was a significant source of support and reassurance for both patients and health care providers. Coordination appeared to be a key concept, intertwined with numerous aspects of the mHealth infrastructure: from empowering patients to self-manage the on-demand application, to implementation of the approach in clinical centres, aiming to strengthening the health system response to COVID-19. Nevertheless, despite the modes of care delivery, coordination of care will remain crucial to provide care that is responsive to individual patient values and preferences and aligns with evidence-based recommendations.