Wearables Take On New Meaning in Cardiovascular Care

The onset of the COVID-19 pandemic changed medicine forever, particularly in the way care is managed and delivered. While masking up and social distancing was enforced to prevent the spread of the disease, a separation was created between family and friends, but it also had a significant impact on the relationship between patient and clinician.

Quickly, the innovative and quickly-adopted use of telemedicine seemingly narrowed that gap, where the 4 walls of a doctor’s office could be anywhere, at any time. As time went on, the seemingly novel method of care became a conventional factor and the potential stigma of telemedicine disappeared.

However, there was still more work to be done, with the fields of technology and medicine colliding in more ways than one.

In cardiovascular care, wearable technology helped shift the narrative away from the doctor’s office into the virtual care center. The high-technology devices, including wearables and body sensors, can provide real-time data on the patient’s metrics including blood pressure, weight, oxygen, and heart rates with complex algorithms then were then fed into an electronic health record (EHR).

Some devices can be direct-to-consumer, including fitness trackers such as an Apple Watch, while others are considered medical-grade, with wearable devices including digital blood pressure cuffs, EKG monitoring, and arrhythmia monitoring systems.

There are still open-ended questions regarding if the onslaught of data reported by the patient ultimately serves as a benefit, or overwhelms workload, if not reported correctly. However, clinicians remain optimistic on both its uptake and their subsequent potential.

“I think in light of the pandemic, and the landscape that has followed, the devices that we rely upon historically, will only grow in their importance and increasingly mobile health, virtual care delivery, telemedicine will become a key driver for us in the years to come,” said Ty Gluckman, Medical Director, Center for Cardiovascular Analytics, Research, and Data Science at Providence St. Joseph Health.

The Role of Wearables

While the boundaries of medicine grew beyond the physical walls of the hospital, Seth Shay Martin, MD, Director, Co-Director, Johns Hopkins Center for Health Technology and Innovation, Johns Hopkins Medicine, saw wearables as the balance between traditional care and the future of medicine.

With data reporting on such measures as heart rate, blood pressure, and physical activity, clinicians can care for patients while the patient is able to stay home. Martin noted that a major goal of wearables is to meet patients wherever they are to deliver care, as well as have them take a more active role in their cardiovascular care.

“The future of cardiovascular care is one in which we truly meet people where they are, and mobile health and wearable devices are enabling that future,” Martin said. “It’s not just about collecting data, but it is about how that data then helps patients better understand what’s going on with their health.”

Further still, Martin pointed out that he continued to view wearables as a novel approach to improve the delivery of care for patients in a growing field of care, not necessarily the end-all be-all.

“It needs to be thoughtfully designed, and really to serve the needs of our end users,” Martin said. “As these technologies are developed, really meeting those needs, in an equitable way, needs to be closely considered.”

Although wearables have gained traction year over year, Gluckman pointed out the increasing visibility of remote patient monitoring (RPM), due to institutions and care centers seeking to lower the rate of hospital readmission.

The tool of wearables became particularly valuable for this reason, in order to monitor patients related to acute hospitalizations or post-procedure.

It allowed in certain conditions such as heart failure, Gluckman noted, to ask questions on the stability of the patient, or to see the data if their condition continued on a worsening trajectory post-hospitalization.

Another larger idea of mobile health is that this crucial information could be shared in a bidirectional fashion, between patient and caregiver, so that each has a clear understanding of the health patterns they undergo.

Once more, Gluckman called to mind the impact of conditions on the patients themselves, where the strategic use of the devices can also work to collect patient reported outcomes on how the patient is doing, or in what ways they may be struggling.

“The area, I think of key importance, is it allows for an activation and engagement tool,” Gluckman said. “Theoretically, you could provide educational material, this isn't just about collecting data.”

The Past 2 Years

Before the onset of the COVID-19 pandemic, studies such as the Apple Heart study represented landmark findings on atrial fibrillation through the use of wearables. It benefited the field of healthcare, which began to realize the importance of large population data in treating individual patients.

“I think in advance of the pandemic, there was an increased recognition that as we shift into population health, value based reimbursement, the ability to collect information from patients that informs their care delivery, could be particularly important,” Gluckman said.

Then, at the onset of the COVID-19 pandemic, as medicine shifted to a hybrid model, technology and care could not be separated even if clinicians may have wanted it to stay separate.

“And then the pandemic hit, many of us had to morph having never done a telehealth virtual visit into that world, and remote patient monitoring, virtual visits, and virtual care delivery became that much more important,” Gluckman said.

Issues immediately become apparent when a patient and clinician may not have been prepared for a virtual visit, or when there are challenges in the preferred platform or application for the care delivery. It was quick to realize that there is not a one-size fits all option. However, ways to overcome these issues with wearable and tele-technology are possible, despite physical exams notably becoming more important for some conditions.

“We talked about telehealth or telemedicine visits as being a sort of one size fits all,” Gluckman continued. “But I would make the argument that they probably lend themselves more to some conditions rather than others.”

Patient Population

Widespread effects of the COVID-19 pandemic shone a light on inequities in cardiovascular care, including the control of risk factors such as high blood pressure or high cholesterol. It also had lingering impacts on future outcomes for patients, where access to care may play a big role in the ability to remedy them.

Specifically, advancements in cardiac rehabilitation, where an organized program in a medical center aims to help patients who have a post-cardiac event or procedure, were impacted during the pandemic.

The majority of these programs were in-person and had to shut down as a result of social distancing. Prior to the pandemic, there were difficulties in these programs, including lower participation of patients with lower income and educational levels as well as ethnic minorities.

Martin called cardiac rehabilitation as a critical service in the field of cardiology that is currently highly underutilized, but hybrid models with wearables may change that narrative.

Recently, a case study of his was published in the BMJ Case Reports, describing a patient enrolled in a heart attack cardiac rehab program who utilized his institution’s mobile health program, with an Apple Watch and Bluetooth-connected blood pressure monitor.

He explained a single patient could not afford the copayment that was necessary for the program, but they were able to perform their own cardiac rehabilitation program concurrently and learn more about heart health behaviors, including tracking blood pressure, heart rate, and learning about their medication regimen.

“The role of mobile and wearable technologies is really starting to take off, where we're seeing that they could empower patients to participate in similar behaviors and receive similar education at home where we meet patients where they are, rather than needing to come into the center,” Martin said.

While these virtual programs highlight flexibility and personalization of care, it is a matter of increasing access, not replacing the model already in place. A goal of these programs is to one day merge the in-person and virtual offerings to create synergy and expand access.

“We think that patients participating using the mobile and wearable devices can also increase the degree to which they're inspired and excited by the program and participate in the program, so there'll be even greater adherence to coming into the center as well,” he continued.

Data Overload

A potential complication stemming from the use of wearables or mobile health technology is the idea that there is actually too much data being collected, which may not take the end goals of the patients into account. If a clinical team is suddenly overwhelmed with data, the accuracy of the data or if it is even actionable may be affected.

Moreso, if there is not a workflow in place to act on the data, with a 24/7 data stream, there could be complications in the care method.

“If you just don't have the workflow in place related to that, the way that the patients and clinicians can effectively collaborate to modify their treatment plan, and for patients to be able to move forward, that could be problematic,” Martin said.

On the other hand, Gluckman opined that the field of medicine will consistently play catch up, when technology moves faster than clinicians can determine how to operationalize mobile technology and its findings.

“I think that's a cycle that will persist,” he said, “But, having that information done in a more rigorous fashion, will allow us for boots on the ground clinicians to understand how to utilize the technology.”

What comes next?

The evolution of the technologies will most likely work to push this field forward, where innovation drives their use and leads to critical clinical guidelines and a higher level of adoption in care.

As Martin sees it, the culture of innovation in wearables will soon be welcomed into the clinical practice in order to improve that collaboration between patient and clinician, but the evolution is still ongoing.

“It's not all going to happen in the next year, but I think we're going to be one step closer, and we're going to be carrying forth this momentum that has been building up,” he said.

Moreso, he pointed out that as companies invest more into digital health meetings and create synergistic marketplaces, the collaboration between technology and healthcare will work to meet the needs of patients.

Speaking specifically to virtual health, Gluckman concluded that while they are still nascent to the process, the importance of hospital at-home care delivery will increasingly become more crucial to the field.

“I would say, I'm sure we're going to be having these same conversations 1, 3, 5 and 10 years from now and we'll have greater technology and advancements to help inform that,” Gluckman said. “Hopefully, we can keep up with technology on both an operational and implementation side.”