SWOT-analysis: Remote monitoring of blood pressure

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INTRODUCTION

Healthcare systems are currently under great strain due to sociodemographic (e.g., decreasing working-age population, population aging, and increasing population with chronic noncommunicable disease risk factors) and economic (e.g., economic volatility and understaffing of healthcare facilities) factors [1–4].

Scientific and technological advancements in medicine and healthcare systems allows finding solutions to some existing problems. Digital transformation in healthcare requires innovative approaches for providing medical care [5]. Remote monitoring based on automatic reporting of the patient’s health status is a key technology for personalized medicine [6]. The wide clinical use of innovative remote monitoring technologies is crucial in healthcare as it can determine the risk factors of chronic noncommunicable diseases [7–11].

Strengths, weaknesses, opportunities, and threats (SWOT) analysis is a universal tool for strategic analysis. It is applied in all sectors of the economy (commercial, nonprofit, and governmental organizations) to assess brands, products, and projects. A benefit of SWOT analysis is the ability to examine external and internal factors, determine the relationship between strengths and weaknesses, and evaluate external threats and opportunities [12].

Hypertension is a common health condition and significant modifiable cardiovascular risk factor [4]. According to research, in Russia, the prevalence of hypertension is constantly high, reaching 40%–45%. The current population aging in Russia can further increase the number of hypertension patients [3]. Epidemiological studies of hypertension performed in Russia between 2010 and 2020 revealed several unresolved challenges in providing medical care, including unwillingness of patients to take medicines, failure to reach the target blood pressure (BP) on antihypertensive therapy, and low motivation and BP control in rural areas [2].

Successful BP control is an effective preventive strategy in cardiovascular diseases¹. A meta-analysis of 61 randomized clinical studies showed that a decrease in BP even by 2 mmHg resulted in a decreased mortality due to stroke and coronary heart disease; moreover, effective and timely hypertension therapy could be life-saving for approximately 30% of patients [13].

Suboptimal BP control by patients is a global concern [14]. In most countries, poor compliance and irregular or nonexistent physician visits for hypertension management are believed to be the main reasons for unsatisfactory control of the disease [15]. Low compliance with antihypertensive therapy prevents from reaching target BP levels and raises hospitalization rate and duration, thus increasing healthcare system expenses [8].

Currently, Russia is undertaking large-scale initiatives to implement remote BP monitoring. Therefore, a SWOT analysis of this strategic task is critical.

S: STRENGTHS

Remote monitoring of patients with cardiovascular diseases using wearable devices is regarded feasible, because these devices are efficient, readily available, small-sized, and user-friendly for prolonged use. Moreover, they enable remote monitoring of patients in a comfortable environment (at home) and provide prompt alerts on events that require emergency care or hospitalization [7]. Some wearable devices do not require hospital visits for maintenance. Their operation can be controlled remotely, which is critical for patients living far from large cities with a well-organized cardiovascular care service, including in rural areas [9]. Telemedicine solutions provide several benefits, including easy planning of monitoring and treatment [16] and easier communication between patients and physicians [17].

Patients who use remote technologies can better observe and understand the association between their daily behaviors, such as diet, sleeping habits, and adherence to medication, and health. Telemedicine technologies allow patients to monitor and record their health parameters. This raises awareness and encourages patients to take better care of their health [18, 19]. Patients benefit from telemedicine because it allows for long-term monitoring, long-term disease control by physicians, greater patient health literacy, and convenient communication without the need for hospital visits [20, 21].

Furthermore, remote monitoring increases access to healthcare in remote areas [22]. A healthcare professional (physician or physician assistant) can assess the patient’s daily activities and behaviors, allowing for timely treatment plan adjustments [23]. Moreover, a study showed that BP levels measured at home are closer to actual levels, because stress caused by hospital visits and the white coat effect are avoided [24].

Healthcare facilities using remote technologies have various advantages, such as more patients enrolled in care, improved satisfaction with treatment, and more capacity in the facility owing to effective remote consultations. A direct short-term economic effect remains to be demonstrated; nevertheless, the long-term cost-effectiveness of these solutions is clear [19, 24, 25].

Several foreign studies have shown the cost-effectiveness of telemetric reporting of BP self-monitoring [26–29]. Russian studies have assessed the potential socioeconomic effect of remote technologies in patients with elevated BP. According to mathematical estimates, in a region with a population of 1 million, with 30% involved in remote monitoring, over 600 patients could be spared over 5 years, and with 90% involved in remote monitoring, about 2,000 lives could be saved [30].

Additionally, economic benefits to patients have been confirmed. BP self-monitoring is more effective than standard therapy in both men and women (assuming the effect of lowered BP was maintained for at least 2 years in men and 5 years in women) [20]. Notably, long-term monitoring was not associated with reduced quality of life [31]. Furthermore, other studies demonstrated a varying economic effect of short-term use of remote technologies; however, this effect becomes apparent starting from 2 years of use [19, 20].

Thus, the advantages of remote monitoring in patients with hypertension include the possibility of BP control and improved access to healthcare in remote areas, providing long-term economic benefits both for patients and healthcare facilities.

W: WEAKNESSES

Despite the advantages of remote monitoring, several weaknesses have been discovered when using digital technologies for BP monitoring in clinical practice, which should be considered when upscaling ongoing and future projects.

Low technology literacy of patients is a limiting factor for remote monitoring. Many patients are unfamiliar with new possibilities and hence unable to integrate them in their everyday life [32]. This is especially true for older patients and requires training to extend the group of patients who comprehend and actively use remote monitoring systems [31].

Personal characteristics and emotional profile of patients considerably affect the efficacy of implementing innovative technologies [33]. A study conducted at the University of Pennsylvania investigated patient interaction phenotypes with a remote BP monitoring system. Three main patterns of engagement style were observed:

• The enthusiast, who tended to submit unprompted messages with high word counts (10.9%)
• The student, who inconsistently engaged with the remote monitoring system (22.6%)
• The minimalist, who engaged only when prompted (66.5%)

A significant association between the communication pattern and reaching the target BP was observed only in the group of patients demonstrating the minimalist communication style (P < 0.001) [34].

A study conducted in Belgium examined the effect of anxiety and depression on adherence to remote monitoring in women with pregnancy-induced hypertension using PHQ-9 and ECR-R questionnaires. The moderate adherence group showed significantly higher anxiety and depression levels, whereas no such association was observed in patients with good adherence and over-adherence [35].

Many patients are concerned about personal data safety; hence, some patients refuse to employ biometric data monitoring devices. Some of these patients, who finally consent to use monitoring devices, show high anxiety and depression levels [36].

According to some studies, the absence of interpersonal interaction could hinder the widespread use of remote monitoring [37]. A previous study found that patients valued such communication components as the ability to visit a hospital, meet a physician personally, and ask questions [38]. Moreover, the patient’s passive role in remote monitoring is a risk factor, as evidenced by the absence of adequate and timely responses from physicians to suboptimal BP control [39].

The duration of remote monitoring has a significant effect on compliance. Short-term programs showed good adherence to monitoring in approximately 80% of 1,662 patients; 87% of patients found this monitoring option useful and convenient [40]. In long-term follow-up, the number of active patients decreased: an observational clinical trial using the Hello Heart software found that nearly half of patients ceased keeping the electronic diary between 3 months and 1 year [41]. Russian studies revealed similar tendencies: manual reporting of measurements is associated with low adherence to remote monitoring [42, 43]. More than 50% of patients in these studies discontinued monitoring, with most of these cases observed during the first 1.5–3 months of monitoring.

Research showed that patients require extensive support from healthcare professionals to use telemedicine technologies independently and regularly [16]. Moreover, some patients struggle to understand and follow the rules of remote monitoring [44] and resort to self-medication, which poses significant health risks [24].

In addition to the patient-related limitations of remote monitoring, weaknesses associated with the processes and staff management in healthcare systems were noted.

Russian studies revealed that outpatient physicians are hesitant about the widespread use of remote monitoring because of a lack of practical experience. For example, Kalinina et al. conducted a survey of 93 physicians from 6 outpatient clinics in Bryansk [45]. The survey found that respondents struggled the most with questions on the organizational structure of remote monitoring. More than 34.4% of physicians were unable to convey their opinions on the feasibility of establishing a separate system for follow-up remote monitoring, despite this topic being widely discussed presently. Thus, practitioners today cannot comprehend the functions of such an organizational structure. Further, the survey highlighted the ideas of physicians on potential barriers to the implementation of remote monitoring in follow-up care. The majority of respondents (80.6%) indicated insufficient time for monitoring as a barrier; economic reasons (cost of equipment) were mentioned by 44.1%, technical issues by 45.2%, and challenges in patient training and uncertain reliability of data collection and reporting tools by 39.8%.

Additionally, several foreign countries have observed low digital literacy and reluctance among healthcare professionals. Shaw et al. highlighted the factors reducing technology acceptance by nurses, including additional workload, the need for integration into existing work processes, additional contacts with patients, and understaffing [25]. Moreover, physicians expect the use of telemedicine to increase the workload in the long term [19, 24, 46]. Practitioners are concerned that the cost of remote monitoring will exceed the insurance amount [46], leveling off the economic benefit [21]. Moreover, implementing this technology may make the professional roles in healthcare less clear [18].

In addition to staff-related limitations, economic factors significantly impede future development of information technology in follow-up care.

For example, when incorporating remote technologies into clinical practice, the high cost of devices and the need to train healthcare professionals in their use may become a barrier. Furthermore, the limitations of regulatory documents and the lack of general guidelines for the use of remote monitoring should be considered [10]. Another weakness is low engagement of insurance companies in the field of telemedicine for BP monitoring [39].

The development of remote monitoring technology demands attention to another poorly addressed issue, namely, the time and effort required for the physician to regularly assess the measurements obtained by patients at home and provide remote consultations during monitoring. Moreover, physician labor costs increase, because patients need to be trained on how to use applications. This issue requires adjustments in working time management and modifications in the compulsory/voluntary healthcare insurance system or the introduction of new sources of funding by a healthcare facility [22].

The third group of weaknesses of remote monitoring in hypertension includes methodology-related issues. The most significant unresolved difficulty is the diagnosis of white coat and masked hypertension based on office or home BP measurement. The PAMELA study found similar BP levels when measured at home and during ambulatory blood pressure monitoring [47]. Another study found variations in the diagnosis of white coat hypertension based on home BP measurement and ambulatory monitoring in 13% of participants [48]. Regarding masked hypertension, only 57% and 45% of patients with hypertension confirmed by elevated systolic and diastolic BP, respectively, had similar BP levels during home monitoring. However, the systolic and diastolic BP levels varied in 23% and 30% of patients, respectively [49]. Therefore, home BP monitoring confirms the diagnosis in the case of elevated office BP, whereas ambulatory monitoring is most effective in the diagnosis of masked or white coat hypertension [49]. The disparity in findings does not imply that one method is inferior to the other. Despite appearing similar, the methods address different aspects of the BP profile [50, 51]. According to Barochiner et al., the diagnosis of masked hypertension based on home monitoring can be rarely established owing to low reproducibility of office measurements (Cohen’s kappa coefficient κ = 0.19; 95% confidence interval: 0.0002, 0.38; P = 0.02) [52].

Currently, no clear guidelines for addressing variations between office and home BP measurements have been established; thus, overtreatment and undertreatment are possible. This is not a limitation of telemedicine, but rather a methodological feature of hypertension detection. Home BP monitoring and reporting should be standardized to prevent bias in the assessment of findings and data misrepresentation [53].

When making therapeutic decisions, reliability of home BP measurements is critical. Technical errors or blood pressure monitor malfunction may result in inaccurate BP measurements. Hence, BP monitors should be validated and tested for accuracy. Furthermore, the data should be compared to measurements taken by a qualified healthcare professional. In addition to the technical serviceability of the BP monitor, a properly sized cuff is required. According to NHANES, 51% of adults in the USA, including 65% of patients aged 18–34 years and 84% of patients with obesity, required large or very large cuffs [54–56].

Thus, remote monitoring technology for hypertension is not free of weaknesses. Low digital literacy, distrust of innovative technologies, and the desire to maintain current patient–physician interaction style hinder the widespread use of this technique. Moreover, healthcare professionals show a certain degree of reluctance: a potential increase in time and labor input due to additional work results in a hesitation over the widespread use of remote monitoring. The methodological and technical challenges of remote monitoring in patients with hypertension result in a less than enthusiastic attitude toward this technology in the medical community.

O: OPPORTUNITIES

Despite its weaknesses, remote BP monitoring in patients with cardiovascular diseases has shown favorable outcomes, including a significant reduction in hospitalization rate and duration, a decrease in mortality, and improved BP control compared to standard therapy and follow-up. In the TEN-HMS study (UK, Germany, and the Netherlands), the 1-year mortality in the control, remote monitoring, and structured telephone support groups was 45%, 29%, and 27%, respectively [10]. A meta-analysis of 46 randomized clinical studies assessed the efficacy of remote BP monitoring compared to standard hypertension management. Remote monitoring was associated with a decrease in office systolic and diastolic BP by 3.99 mmHg (P < 0.001) [11]. The Home BP study (UK) demonstrated improved systolic BP control when using a remote monitoring system. The mean difference in systolic BP was 3.4 mmHg (95% confidence interval: 6.1, 0.8; P < 0.05) [57].

Bubnova et al. conducted a study in 342 hypertension patients and found that remote monitoring provided significant benefits regarding the number of emergency calls, hospitalization rate, and time on sick leave. After 12 months, 92.2% of patients in the treatment group and 43.3% of patients in the control group achieved the target BP level [58].

Remote monitoring enables the collection of large amounts of patient data. Big data and intelligent computer systems have an increasing effect on conventional approaches in medicine [59, 60]. Data collection and integration and feedback to a physician will be automated. Big data collection from various devices, trend prediction via machine learning, and long-term analysis of vital and geographical characteristics will help improve our understanding of cardiovascular disease development on a population level [61].

Improvements to remote monitoring systems may make them more adaptive and flexible. For example, if a patient struggles to follow the remote monitoring protocol, a behavioral module will activate, adapting to the patient’s needs to help overcome the challenges. Drug prescription algorithms can also be automated: large datasets allow for case-by-case analysis and real-time decision-making [62].

Remote monitoring has been widely used in healthcare systems of the USA and Europe, confirming its long-term economic and clinical efficacy. Telemedicine allows for more effective health management and efficient utilization of limited medical resources:

• Less time spent on follow-up visits and selecting effective antihypertensive therapy
• Improved BP control in hypertension and the resulting decrease in complication rates
• Shorter hospital stay for complications of hypertension
• Implementation of the technology in remote areas and consistently understaffed healthcare facilities
• Improved availability and quality of medical care for patients with disabilities [40]

T: THREATS

In the implementation of remote monitoring, several threats were identified that limit its wide clinical use.

The development of remote monitoring requires wide implementation of advanced solutions and modern technologies in healthcare systems. However, the current geopolitical environment has its own rules. Previously, most information technology (IT) products and their components were imported, which was significantly more convenient than developing domestic solutions with a long pay-off period. Thus, Russia became severely disadvantaged by sanctions due to weak domestic IT infrastructure. Major western IT companies, such as Microsoft, Oracle, Cisco, IBM, Adobe, SAP, Intel, and AMD², have limited their activities or stopped operating in Russia. According to Dmitry Pshichenko, lecturer of the IT Management School of the Russian Presidential Academy of National Economy and Public Administration, the main risks are currently associated with data security and server maintenance, because the majority of western software is cloud-based, and purchasing components for maintenance is difficult. This affects the development of digital technology in medicine³.

In addition to software issues, the Russian IT industry faces a shortage of expertise. According to Vice Prime Minister Dmitry Chernyshenko, the deficit of IT specialists currently stands at 1 million people⁴, with projections of 2 million by 2027. This impedes the rapid development of the IT industry, particularly in healthcare.

Furthermore, economic issues and resource shortages may cause delays in digitization. According to the HSE University, the healthcare industry spent 39.5 billion rubles on the development, distribution, and use of digital technologies and related products and services in 2019, which accounted for 1.6% of the total industry gross added value. When compared to total expenses, the share of expenses for digitization does not exceed 0.6%–0.7% [63].

In 2021, healthcare digitization expenses accounted for 2.6% of the total economic activity. When considering the expenses of Russian companies for digitization, the share of healthcare has increased insignificantly over the last 2 years: 1.6% in 2019 and 2.2% in 2020.

Cybersecurity concerns add to the doubts in the use of remote monitoring systems. Telemedicine involves the collection of large amounts of data, which should be stored in a specific manner to prevent them from being leaked into open sources. Fraudsters may gain access to patient data and use it for criminal purposes⁵.

According to Kaspersky Lab, 54% of healthcare facilities use outdated software, because of the high cost of updates and issues with old and new system compatibility. A lack of updates makes a system more vulnerable to cyberattacks; attackers can break into the corporate system and use the databases for their own gain. According to statistics, owing to increased vulnerability of Russian medical systems, 32%, 32%, and 30% have experienced data leaks, DDoS attacks, and ransomware attacks, respectively⁶. A study by Buldakova et al. identified potential threats to information security: data leaks can occur at almost any point, from sensors and cloud-based medical information systems to healthcare professionals and patients [64]. Furthermore, the rapid development of mobile technologies and m-Health has resulted in numerous mobile applications and ready-made wireless devices. The majority of them have not been certified [65, 66] and thus cannot be used as medical devices, because of noncompliance with cybersecurity rules (such applications are only suitable for use by patients) [67].

Certain issues with remote monitoring are related to remote patient identification. Accurate and reliable identification of the patient being monitored is challenging. Hence, remote monitoring cannot be used in expert settings or in problematic situations, and the patient is solely accountable for the appropriate use of devices [68].

CONCLUSION

The widespread use of remote monitoring technologies in Russia requires large-scale threat analysis, which is not limited to healthcare. In our country, medicine advances at the same rate as IT. Digitization in medicine cannot be considered a standalone industry; it is linked to external and internal factors and political, economic, and social considerations. Certainly, healthcare-specific aspects (personal data and patient confidentiality) should be considered. However, the foundation for the development of IT solutions in Russia is consistent.

SWOT analysis involves developing a further strategy. To accomplish this, the Weihrich model is used to predict the interaction of factors from different squares:

• Strengths—opportunities
• Strengths—threats
• Weaknesses—opportunities
• Weaknesses—threats

A comprehensive approach enables seamless integration of remote monitoring technologies into healthcare systems, making the benefits of digital medicine available to all.

ADDITIONAL INFORMATION

Funding source. This article was prepared by a group of authors as a part of the research and development effort titled “Scientific evidence for using telemedicine-based models and methods for organization and delivery of medical care” (USIS No.: 123031400008-4) in accordance with the Order No. 1196 dated December 21, 2022 “On approval of state assignments funded by means of allocations from the budget of the city of Moscow to the state budgetary (autonomous) institutions subordinate to the Moscow Health Care Department, for 2023 and the planned period of 2024 and 2025” issued by the Moscow Health Care Department.

Competing interests. The authors declare that they have no competing interests.

Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. A.E. Demkina — the concept of the study, writing the text of the manuscript, manuscript’s text editing; A.N. Korobeynikova — collection of materials, writing the text of the manuscript; A.N. Rogova — writing the text of the manuscript, manuscript’s text editing; A.V. Vladzymyrskyy — manuscript’s text editing.

¹ WHO. Global report on hypertension. The race against a silent killer. Geneva, 2013. URL: http://apps.who.int/iris/bitstream/handle/10665/79059/WHO_DCO_WHD_2013.2_rus.pdf Last accessed: February 13, 2023

² Gone for good: IT companies that have exited Russia. URL: https://hightech.fm/2022/05/26/it-companies-went-away. Last accessed: March 1, 2023

³ Major risks in IT stem from a shortage of expertise. URL: https://rg.ru/2023/02/17/vitaiut-v-oblakah.html. Last accessed: March 1, 2023

⁴ This year, the number of certified IT companies in Russia has grown sevenfold. URL: https://www.ixbt.com/news/2022/10/24/v-jetom-godu-akkreditovannyh-itkompanij-v-rossii-stalo-v-sem-raz-bolshe.html. Last accessed: March 1, 2023

⁵ The risks, threats, and lack of systemic approach in digitization. URL: https://www.infowatch.ru/resources/blog/tochka-zreniya-kasperskoy/o-riskakh-ugrozakh-i-otsutstvii-sistemnosti-v-tsifrovizatsii. Last accessed: March 1, 2023

About the authors

Alexandra E. Demkina

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies

Email: ademkina@bk.ru
SPIN-code: 4657-5501

MD, Cand. Sci (Medicine)

Russian Federation, Moscow

Anna N. Korobeynikova

Center of Cardiology and Neurology

Author for correspondence.
Email: anna_best2004@mail.ru
ORCID iD: 0000-0002-8934-7021
SPIN-code: 9728-9583

MD, Cand. Sci. (Medicine)

Russian Federation, Kirov

Anatoliy N. Rogoza

National Medical Research Centre of Cardiology Named After Academician E.I. Chazov

Email: anrogoza@gmail.com
ORCID iD: 0000-0002-4829-0954
SPIN-code: 9362-3496

Dr. Sci. (Biology), Professor

Russian Federation, Moscow

Anton V. Vladzimirskiy

Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies

Email: a.vladzimirskiy@npcmr.ru
ORCID iD: 0000-0002-2990-7736
SPIN-code: 3602-7120

MD, Dr. Sci. (Medicine)

Russian Federation, Moscow

References

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