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Introduction

Remote monitoring, or telemonitoring, can be regarded

as a subdivision of telemedicine - the use of electronic

and telecommunications technologies to provide and

support health care when distance separates the

participants [1]. Telemonitoring involves the use of audio,

video, and other telecommunications and electronic

information processing technologies to monitor patient

status at a distance. Th e patient and the carer/system

surveying, analysing or interpreting the data could be a

few feet apart, but more often they will be in diff erent

areas of the same building, diff erent buildings or diff erent

towns. In theory, they could even be in diff erent countries

or continents. Th e fi rst case of direct transmission of a

patient variable was that of an electrocardiograph (ECG)

in 1905 by the inventor of the ECG, Einthoven [2].

However, the routine use of telemonitoring began in 1961

when the ECG, respiratory rate, electro-oculogram and

galvanic skin response of the fi rst human in space, Yuri

Gagarin, were continuously monitored by doctors on

earth. Figure 1 shows typical ECG tracings from Neil

Armstrong, Buzz Aldrin and Michael Collins, received at

the Mission Control Center approximately 384,467

kilometres away, during various periods of the Apollo 11

mission to the moon in 1969.

Th is review will provide a broad overview of this

resurgent fi eld of medical remote monitoring and will

describe the components of telemedicine, the current

clinical utilisation and the fi eld’s obvious challenges.

Where possible, the article provides the appropriate

references to allow the interested reader to obtain

additional information.

Components of telemonitoring

At its simplest, the monitoring of a person’s vital signs

involves an observer (usually a clinician) using their own

senses directly (that is, without any intervening

technology) to determine pulse rate, breathing rate, and

so on. Added sophistication is produced by introducing

simple technology such as a sphygmomanometer, stetho-

scope or thermometer, but still the act of monitoring is

Abstract

Recent developments in communications

technologies and associated computing and digital

electronics now permit patient data, including routine

vital signs, to be surveyed at a distance. Remote

monitoring, or telemonitoring, can be regarded as

a subdivision of telemedicine - the use of electronic

and telecommunications technologies to provide

and support health care when distance separates

the participants. Depending on environment and

purpose, the patient and the carer/system surveying,

analysing or interpreting the data could be separated

by as little as a few feet or be on diff erent continents.

Most telemonitoring systems will incorporate fi ve

components: data acquisition using an appropriate

sensor; transmission of data from patient to clinician;

integration of data with other data describing the

state of the patient; synthesis of an appropriate action,

or response or escalation in the care of the patient,

and associated decision support; and storage of data.

Telemonitoring is currently being used in community-

based healthcare, at the scene of medical emergencies,

by ambulance services and in hospitals. Current

challenges in telemonitoring include: the lack of a full

range of appropriate sensors, the bulk weight and

size of the whole system or its components, battery

life, available bandwidth, network coverage, and

the costs of data transmission via public networks.

Telemonitoring also has the ability to produce a mass

of data - but this requires interpretation to be of clinical

use and much necessary research work remains to be

done.

Health technology assessment review: Remote monitoring of vital signs - current status and future challenges Vishal Nangalia1, David R Prytherch2 and Gary B Smith3,4*

R E V I E W

*Correspondence: [email protected] 3TEAMS Centre, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK

Full list of author information is available at the end of the article

Nangalia et al. Critical Care 2010, 14:233 http://ccforum.com/content/14/5/233

performed directly by the clinician. All remaining

processes, up to and including synthesising the appro-

priate response, occur in the clinician’s brain. Th e

advance of technology, with the fi nal stage of remote

monitoring, has separated the various links in the chain

between measuring and acting, and made explicit the

chain of events, actions, processing and decisions linking

the patient and the clinician.

Th e various links in this chain may include the

following: data acquisition using an appropriate sensor;

transmission of these data from patient to clinician;

integration of the data with other data describing the

state of the patient; synthesis of an appropriate action, or

response or escalation in the care of the patient, and

associated decision support; and data storage. Th e

second, third and fourth items can occur in any order and

may be repeated at diff erent stages. Th ese stages will now

be considered in detail.

Data acquisition using an appropriate sensor

Sensors, their modes of action, and the signals (vital

signs) they measure are well known and are beyond the

scope of this article. However, it is worth noting that

newer modalities of measurement are emerging [3]. Any

physiological parameter that can be measured can

theoretically be telemonitored. Table 1 lists those

variables for which this has been successfully achieved

[4]. Measurements from sensors may be continuous or

intermittent. Th e time to the next measurement may be

determined by the last value. Th e sensor may be remote

from the patient (for example, using Doppler radar to

count breathing rate) [3] or intermittently used by the

patient [5] or even continuously worn by the patient (for

example, the remote patient monitoring system is inte-

grated within a ‘smart garment’) [6]. Th e measurement

and collection of the data may be entirely automatic, or

may involve a human (usually a clinician or the patient)

in invoking the measurement or in performing it (for

example, nurses entering vital signs data into a handheld

computer) [7].

The transmission of data from patient to clinician

Depending on the setting, transmission of data can be by

wired or wireless connections. Modalities include both

wired and wireless computer networks, telephone net-

works and mobile phone networks. Systems that identify

the available modalities and use them accordingly for the

transmission of data are being developed. Th e trans-

mission technology is the essential glue in the various

possible chain topologies. Its capabilities (bandwidth,

coverage, cost of use, and so on) predicate the functions

and capabilities of the other components. Transmission

Figure 1. Electrocardiograph signal received at Mission Control during various periods of the Apollo 11 mission (NASA). (http://history.

nasa.gov/SP-368/p492b.htm)

Nangalia et al. Critical Care 2010, 14:233 http://ccforum.com/content/14/5/233

Page 2 of 8

technologies will need to be chosen according to the

particular use envisaged. Transmission of data from

patient to clinician may be continuous or may only occur

when a pre-defi ned exception state has occurred (for

example, when a potentially dangerous heart rhythm is

detected) [8] or when connectivity is available.

Currently, diff erent systems tend to use proprietary

standards for transmission of data. As such systems

become more common place, standards such as HL7 will

become more widely used to allow integration and total

systems building. Governments have set aside portions of

the electromagnetic spectrum for the specifi c use of

wireless telemetry, though these are not always

standardised across international regions and there are

severe bandwidth limitations and interference issues.

Th erefore, most medical device companies develop for

the internationally agreed 2.4 to 2.5 GHz industrial,

scientifi c and medical band (ISM) [9], though, since this

is not medicine-specifi c, it is open to possible inter-

ference and overcrowding.

Wireless transmission protocols in use include wi-fi

(802.11 a/b/g/n) at 2.45 GHz and 5.8 GHz, and Bluetooth

at approximately 2.45 GHz. Newer low-power, though

lower-bandwidth, protocols that are also gaining favour

include ANT [10] and Zigbee [11]. Th e Continua Health

Alliance [12] has been formed to standardise both the

protocols for transmission of medical data and the

devices themselves, so devices can securely and reliably

communicate with each other but this is at an early stage.

Integration of the data with other data describing the state

of the patient

Th is may be done by a computer or a clinician, or both.

Computer integration and/or analysis of data and their

synthesis into information on which to act can happen

anywhere in the chain and may be distributed across it.

Amongst other things, this depends upon what data are

being transmitted along the chain, which itself depends

on the available bandwidth and its cost. Raw data could

be transmitted (for example, three-lead ECG) or simply

the heart rate; a full set of vital signs could be transmitted

or simply a derived value such as an early warning score

[13] or other index of patient severity of illness [14].

Th e detection of a particular patient state as a result of

computer integration and/or analysis of data and their

synthesis may be used to trigger transmission of the data

themselves [8]. Th ese are all inter-related engineering

decisions specifi c to a particular application.

Synthesis of an appropriate action, or response or escalation

in the care of the patient, and associated decision support

Th is depends on context. In hospital, it might be a

decision to admit to an ICU or to call a rapid response

team; in the community, the action could be to arrange a

visit by a community nurse. Such a decision could be

made by an ‘intelligent’ system but at present would

certainly involve human input. Importantly, though, such

‘systems’ could push the data to the responsible clinician

for a decision to be made when pre-determined criteria

had been satisfi ed, removing the need for continuous

human monitoring. What such escalation (or de-

escalation) criteria should be is both context-dependent

and probably unknown. Th e extent of synthesis and

decision support ranges from applying the above criteria

for escalating clinical input to simply making background

contextual information available to the responsible

clinician to reduce diagnostic and decision errors, and

improve patient safety and quality of care [15].

Data storage

At one extreme this may be local storage of data in the

sensing device to allow, for example, a breathing rate to

be determined prior to transmission or the short-term

storage of data to allow the data prior to a critical event

to be transmitted as supporting information along with

notifi cation of the critical event [8]. At the other extreme,

it could be the formation of a large database of vital signs

to determine and validate calling criteria for rapid

response team activation [7]. Such data are almost certain

Table 1. Physiological parameters that have been

successfully telemonitored [5]

Heart rate

Blood pressure

Respiratory rate

Temperature

Pulse oximetry

Heart sounds

Electrocardiograph (ECG)

Pacemaker parameters

Electroencephalogram (EEG)

Electromyograph (EMG)

Spirometry

Body weight physical activity

Fetal heart rate

Basal metabolic rate

O 2 consumption

CO 2 production

Blood glucose

Blood lactate

Blood ethanol

Intracranial pressure

Intravesical pressure

Intrauterine pressure

Nangalia et al. Critical Care 2010, 14:233 http://ccforum.com/content/14/5/233

Page 3 of 8

to become an essential part of the electronic patient

record. Medico-legal as well as contractual and billing

issues will demand the storage of the majority of these

data.

Clinical use of telemonitoring

Telemonitoring is being used in the home, at the scene of

a medical emergency, in transit via the ambulance service

and in the hospital.

Home

In the home, telemonitoring is characterised by a patient

being monitored by a number of devices and the

subsequent, real time or delayed transmission of derived

data via the domestic or mobile telephone service to a

remote monitoring service or healthcare provider. Th ese

devices may monitor physiological data (for example,

pulse, blood pressure, SpO 2 , blood glucose) or the per for-

mance of equipment such as implantable defi brillators or

pacemakers [16,17]. Most commonly, telemonitoring is

used for the distant surveil lance of patients with chronic

disease, such as chronic heart failure, chronic obstructive

pulmonary disease and diabetes mellitus. However, fetal

heart rates and the level of activity of elderly people have

also been monitored [4,18]. Th e same type of technology

may also be used to record a patient’s subjective response

to specifi c pre-set questions about their health [5].

Table 2 lists a selection of studies with positive outcomes

attributed to telemonitoring. It has been estimated that

the use of remote monitoring of chronic disease to

prevent deterioration by early detection and intervention

in the community could save approximately $197 billion

in the USA over the next 25 years [19].

However, other studies have not shown any change in

measured parameters with home-based monitoring and

intervention for asthma [20] or hypertension [21].

Systematic reviews on chronic disease management and

telemonitoring, although acknowledging the potential

benefi t of telemonitoring, highlight the need for further

research [22-24]. Interpretation of the signifi cance of the

reported results of most pre-hospital telemonitoring

studies is diffi cult because not only has the frequency of

vital sign measurement been arbitrarily chosen - ranging

from continuous to symptom-based [21,25-36] - but

medical review and intervention based on the collected

data also varied from immediately based on alarms to

monthly [21,27-30,34,36-38].

Disaster medicine

Systems are being developed that would enable emer-

gency medical services to tag and physiologically monitor

large numbers of patients at a remote site, that is, the site

of the disaster or a triage centre [39]. Such systems would

provide fi rst responders, disaster command centres and

supporting hospitals with medical data to track and

monitor the condition of up to thousands of victims on a

moment-to-moment basis using vital signs monitoring

and location tagging (similar to global positioning system

tagging).

Ambulance services

Use of telemedicine in ambulances has so far focussed

primarily on patients suspected of suff ering a myocardial

infarction. ECG data from these patients has been

transmitted to a designated hospital and a decision is

then for either pre-hospital thrombolysis [40] or redirect-

ing the ambulance to a centre for primary angioplasty

[41], both of which have been shown to reduce the time

to treatment compared to traditional in-hospital assess-

ment. Other parameters transmitted from ambulances

include non-invasive blood pressure, arterial oxygen

satura tion, blood glucose concentration and body

temperature [42].

In hospital

In hospital, the interest in telemonitoring has been driven

by the need to balance the confl icting requirements

posed by increased population age, increased patient

severity of illness, increased incidence of concurrent

illness, reduced staffi ng levels and raised patient expec-

tation regarding patient safety. Telemonitoring could be

used in any area of a hospital, but is perhaps most

pertinent in critical care areas and the general wards.

Critical care areas In the USA, VISICU, a Philips healthcare company, has

implemented over 30 remote ICU programmes, in which

intensivists and physicians provide supplemental moni-

tor ing and management of ICU patients at workstations

in an off -site, centralized facility (the eICU). Bedside

monitor data, lab results, patient treatment charts,

ventilator and other equipment settings and outputs

from audiovisual equipment in the ICU patient rooms

are available to the eICU staff , who also have access to

physician note- and order-writing applications. When

the eICU team is allowed full and direct management of

the patient, these systems have been reported to reduce

mortality by up to 33% [43], number of ventilator days by

up to 25% [43] and length of stay in the ICU by up to 17%

[44]. A criticism of the eICU is that these benefi ts may

only be apparent in an environment where there is a

shortage in the number of intensivists to adequately

provide an onsite 24/7 specialist-led service. Other

descriptions of the use of telemonitoring in critical care

include the provision of support for patients requiring

mechanical venti lation at home [45], which has proved to

be success ful in the weaning of a patient from home

mechanical ventilation without onsite specialist help [46].

Nangalia et al. Critical Care 2010, 14:233 http://ccforum.com/content/14/5/233

Page 4 of 8

Systems that monitor patients’ physiological parameters

during home hemodialysis also exist [47].

Remote monitoring of vital signs of ward patients

provides the possibility of obtaining pre-ICU data - even

to the point of using these data to decide if ICU

admission is required. It may also allow earlier, safe dis-

charge of patients from the ICU as they can be reliably

remotely monitored by ICU staff . Perhaps, most interest-

ingly, it potentially allows ICU staff to survey the whole

population of monitored in-patients and to intervene as

necessary - a technology-enabled pro-active outreach

service [7].

Ward patients Many hospitalised patients suff ering adverse events (for

example, in-hospital cardiac arrest, unanticipated ICU

admission or death) exhibit physiological deterioration in

the period before the event [48-50]. Sometimes this is

detected, but often there is insuffi cient monitoring

[51-55]. For example, the 2007 National Confi dential

Enquiry into Patient Outcome and Death report [54]

noted that ‘not only are appropriate observations

performed less often than is desirable, when they are

performed, their frequency is inappropriately low in a

signifi cant proportion of patients’. Other failures in the

Table 2. Telemonitoring studies with a positive outcome

Paper Setting Disease

Parameters measured (frequency)

Transmission frequency

Review frequency Outcome

Breslow

2007

[43,44]

In hospital -

ICU

Multiple - all

critically ill

patients

Multiple

continuously;

all measured

parameters +

video monitoring

Continuously Continuously Reduced mortality by up to 33%, number of ventilator

days by up to 25%, length of stay by up to 17%

Antonicelli

et al. 2008

[30]

Community Chronic heart

failure (CHF)

BP (daily), ECG

(weekly), body

weight (weekly),

24-h urine output

(weekly)

Daily Weekly Telecare versus usual care: decreased hospital

readmission 9 versus 26 (P < 0.01); trend towards

decreased mortality 3 versus 5; total patients 28 versus

29 (N = 57)

Fursse et al.

2008 [29]

Community Diabetes,

hypertension,

CHF

Blood glucose

(daily), BP (daily),

SpO 2 (daily)

Daily On alerts,

regularly -

not specifi ed

Mean reductions of 11 mmHg systolic and 2 mmHg

diastolic in patients with CHF, 0.4% HbA1c in those with

diabetes, and 12 mmHg systolic and 2 mmHg diastolic

in those with hypertension (no control group; N = 29)

Green et al.

2008 [31]

Community Hypertension BP (twice weekly) Twice weekly Fortnightly Higher proportion of patients (after 12 months) whose

BP was controlled (<140/90); telemonitored group 56%

versus usual care 31% (80% increase; N = 778)

Kisner et al.

2008 [61]

In hospital -

ward

Atrial fi brillation

post CABG

SpO 2

(continuously)

Continuously On alerts Incidence of atrial fi brillation in telemonitored group

was 14% versus 26% (prior to telemonitoring; P = 0.016;

N = 119; control cohort = 238)

Morguet

et al. 2008

[33]

Community CHF Weight (daily), BP

(daily), pulse rate

(daily), ECG (on

request)

Daily Twice weekly,

on alerts

50% reduction in hospital admissions (38 versus 77/100

patient years, P = 0.034), 54% reduction in hospital

length of stay (317 versus 693 days/100 patient years;

P < 0.0001) (N = 128)

Nakamoto

et al. 2008

[63]

Community Hypertension:

drug trial of

temlisartan versus

amlodipine

BP (twice daily) Twice daily End of study Evening systolic BP reductions higher in telmisartan

versus amlodipine group (13 ± 3 versus 6 ± 3 mmHg);

non-signifi cant diff erences in morning BP reduction

between both groups; better daytime normalisation

with telmisartan (N = 40)

Nielsen et

al. 2008

[27]

Community ICD, pacemaker ECG (continuously) Daily, on alerts On alerts 26% of unplanned clinic visits initiated by

telemonitored data (N = 260)

Ricci et al.

2008 [28]

Community ICD, pacemaker ECG (continuously) Daily, on alerts Fortnightly,

on alerts

37% of patients had changes to their medication,

device reprogramming, or were called in for further

investigations (N = 117)

Woodend

et al. 2008

[34]

Community Angina, heart

failure

BP (daily), weight

(daily), ECG (not

specifi ed)

Daily Weekly 32% reduction in hospital admission (0.4 versus 0.59

hospital readmission rate per patient, P = 0.048); 46%

reduction in length of stay in hospital if readmitted

(2.11 versus 3.93 days, P = 0.038) (N = 249)

Parati et al.

2009 [35]

Community Hypertension BP (not specifi ed) Not specifi ed On alerts Increased daytime BP normalization (<130/90), 62%

versus 50% (P < 0.05); less frequent treatment changes,

9% versus 14% (P < 0.05) (N = 228)

BP, blood pressure; CABG, coronary artery bypass graft; CHF, chronic heart failure; ECG, electrocardiograph; ICD, implantable cardioverter-defi brillator.

Nangalia et al. Critical Care 2010, 14:233 http://ccforum.com/content/14/5/233

Page 5 of 8

system of recognising and responding to patient

deterioration include a failure to call for experienced help

and a failure of responders to respond [48-51].

Outreach/medical emergency team data appear to

indicate that early identifi cation and intervention of

deteriorating patients reduces the incidence of adverse

events. In one multicentre study Chen and colleagues

[56] analyzed 11,242 serious adverse events and 3,700

emergency team calls and found for every 10% of increase

in the proportion of early emergency team calls there was

a 2.0 reduction per 10,000 admissions in unexpected

cardiac arrests (95% confi dence interval (CI) 2.6 to 1.4), a

2.2 reduction in overall cardiac arrests (95% CI 2.9 to

1.6), and a 0.94 reduction in unexpected deaths (95% CI

1.4 to 0.5).

It is now advised that a clear physiological monitoring

plan, which details the parameters to be monitored and

the frequency of observations, should be made for each

patient, and that there should be a graded response to

patient severity of illness [7,53]. Other recent reports also

recommend an increase in the range and frequency of

physiological parameters monitored in general ward

patients [51-55]. Th is could be achieved by increasing

levels of nurse staffi ng, as this has been shown to reduce

adverse outcomes [57], but there are limits to the extent

to which nursing numbers can be increased. However,

technology can enable the continuous capture and

transmission of physiological parameters and the advent

of early warning systems allows for a mechanism of

automatic analysis of these signals, theoretically enabling

the clinical expertise of medical professionals to be

focussed on those patients who are at greatest risk of

deterioration. Telemonitoring technology therefore has

the potential to increase patient care and is thus regarded

as an integral part of the UK National Health Service

Connecting for Health Programme [58].

Th ere are many publications from ICUs, high

dependency units or cardiac care units that describe data

telemetry from a bed-bound patient to the nurses’

station. However, descriptions of the use of such tech-

nology in the general wards of hospitals are rare. Cale

[59] has described the hospital-wide implementation of a

wireless telemonitoring system in a Californian hospital

that transmits patient parameters to a ‘war room’, where

these are monitored by biomedical technicians 24 hours

a day. Th e use of a wireless pulse oximeter in a Zurich

hospital [60,61] is claimed to reduce the incidence of

atrial fi brillation (14% versus 26% prior to telemonitoring,

P = 0.016) in coronary artery bypass graft patients by

early detection of desaturation and implementation of

oxygen therapy. A unique characteristic of this system is

that it either pages the doctor directly or sends an SMS

text message to their mobile phone alerting them of the

desaturation and providing a history of the event. In the

UK, nurses in some hospitals use the VitalPAC system for

collecting routine vital signs data at the bedside using

standard personal digital assistants (PDAs) wirelessly

linked to the hospital’s intranet system. Here raw and

derived data are integrated with patient demographic and

laboratory information, allowing raw physiology data,

early warning scores, vital signs charts and oxygen

therapy records to be made instantaneously available to

any member of the hospital healthcare team [7].

Some obvious challenges

Currently, the technology for telemonitoring is far from

mature and there are still technological issues to be

addressed. Th ese include: the lack of a full range of

appropriate sensors; the bulk weight and size of the

whole system or its components (particularly in relation

to patient-worn systems); the identifi cation of invalid

data (for example, from sensors that become detached/

displaced); battery life; available bandwidth; network

coverage; and the costs of data transmission via public

networks.

Th ere will also be challenges for adoption of such

systems because individuals may see constant

physiological surveillance as intrusive. As with genetics

testing, there may even be insurance-related issues [62].

Th ere are also potential cultural problems to be tackled

in relation to the deployment of such technology in

health care organisations, as they produce requirements

for new ways of working. Another major problem is that

telemonitoring has the ability to produce a mass of data

that require interpretation to be of use. New data analysis

methods therefore need to be devised and validated.

Mistakes in this analysis could have medico-legal

conse quences.

However, despite all the potential hurdles, it is likely to

be only a matter of time before smart systems continu-

ously monitor every patient from the moment they are

admitted to the point of discharge from hospital (and

possibly beyond).

Abbreviations

CI = confi dence interval; ECG = electrocardiograph.

Competing interests

VitalPACTM is a collaborative development of The Learning Clinic Ltd and

Portsmouth Hospitals NHS Trust. Professor Gary Smith’s wife and Dr David

Prytherch’s wife are shareholders in The Learning Clinic Ltd. Professor Smith

and Dr Prytherch are engaged in research with McLaren Applied Technologies

and Laerdal Medical who both manufacture patient monitoring devices.

Author details 1Academic Clinical Fellow, Centre for Anaesthesia, University College London

Hospital, Room 436, 4th fl oor, 74 Huntley St, London WC1E 6AU, UK. 2Clinical

Scientist, Portsmouth Hospitals NHS Trust, TEAMS Centre, Queen Alexandra

Hospital Portsmouth PO6 3LY, UK. 3Professor, Portsmouth Hospitals NHS Trust,

TEAMS Centre, Queen Alexandra Hospital Portsmouth PO6 3LY. 4Professor, The

School of Health & Social Care, Bournemouth University, Royal London House,

Christchurch Road, Bournemouth, Dorset BH1 3LT, UK

Nangalia et al. Critical Care 2010, 14:233 http://ccforum.com/content/14/5/233

Page 6 of 8

Published: 24 September 2010

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doi:10.1186/cc9208 Cite this article as: Nangalia V, et al.: Health technology assessment review: Remote monitoring of vital signs - current status and future challenges. Critical Care 2010, 14:233.

Nangalia et al. Critical Care 2010, 14:233 http://ccforum.com/content/14/5/233

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documents suitable for reliable viewing and printing of business documents. Created PDF documents can be opened with Acrobat and Adobe Reader 6.0 and later.) >> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice