Towards A Framework for Implementing Remote Patient Monitoring From an Integrated Care Perspective: A Scoping Review

Document Type : Review Article


1 Centro de Estudos de Gestão do Instituto Superior Técnico (CEG-IST), Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal

2 Enterprise Services, Siemens Healthineers Portugal, Lisboa, Portugal

3 iBB - Institute for Bioengineering and Biosciences and i4HB - Associate Laboratory Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisboa, Portugal

4 Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal

5 Comprehensive Health Research Center (CHRC), Universidade NOVA de Lisboa, Lisboa, Portugal


Remote patient monitoring (RPM) has been increasingly adopted over the last decade, with the COVID-19 pandemic fostering its rapid development. As RPM implementation is recognised as complex and highly demanding in terms of resources and processes, there are multiple challenges in providing RPM in an integrated logic.

To examine the structural elements that are relevant for implementing RPM integrated care, a scoping review was conducted in PubMed, Scopus, and Web of Science, leveraging a search strategy that combines terms relative to (1) conceptual models and real-life initiatives; (2) RPM; and (3) care integration.

28 articles were included, covering nine conceptual models and 19 real-life initiatives. Eighteen structural elements of RPM integrated care implementation were identified among conceptual models, defining a structure for assessing real-life initiatives. 78.9% of those initiatives referred to at least ten structural elements, with patient education and self-monitoring promotion, multidisciplinary core workforce, ICTs (information and communications technologies) and telemonitoring (TM) devices, and health indicators measurement being present in all studies, and therefore being core elements to the design of RPM initiatives.

RPM goes far beyond technology, with underlying processes and involved actors playing a central role in care provision. The structural elements identified can guide RPM implementation and promote maturity in adoption. Future research may focus on assessing design completeness, evaluating impacts, and analysing related financial arrangements.


  1. Healthcare and Life Sciences Predictions 2020. A Bold Future? Deloitte Center for Health Solutions; 2014. p. 48.
  2. Xu S, Glenn S, Sy L, et al. Impact of the COVID-19 pandemic on health care utilization in a large integrated health care system: retrospective cohort study. J Med Internet Res. 2021;23(4):e26558. doi:2196/26558
  3. Kumpunen S, Webb E, Permanand G, et al. Transformations in the landscape of primary health care during COVID-19: themes from the European region. Health Policy. 2022;126(5):391-397. doi:1016/j.healthpol.2021.08.002
  4. Smith EM, Toro Hernandez ML, Ebuenyi ID, et al. Assistive technology use and provision during COVID-19: results from a rapid global survey. Int J Health Policy Manag. 2022;11(6):747-756. doi:34172/ijhpm.2020.210
  5. Azevedo S, Rodrigues TC, Londral AR. Domains and methods used to assess home telemonitoring scalability: systematic review. JMIR Mhealth Uhealth. 2021;9(8):e29381. doi:2196/29381
  6. Schlieter H, Marsch LA, Whitehouse D, et al. Scale-up of digital innovations in health care: expert commentary on enablers and barriers. J Med Internet Res. 2022;24(3):e24582. doi:2196/24582
  7. Gülmezoglu AM, Ammerdorffer A, Narasimhan M, et al. Self-care and remote care during pregnancy: a new paradigm? Health Res Policy Syst. 2020;18(1):107. doi:1186/s12961-020-00627-4
  8. Kronenfeld JP, Penedo FJ. Novel coronavirus (COVID-19): telemedicine and remote care delivery in a time of medical crisis, implementation, and challenges. Transl Behav Med. 2021;11(2):659-663. doi:1093/tbm/ibaa105
  9. Newhouse N, Farmer A, Whelan ME. COVID-19: needs-led implementation and the immediate potential of remote monitoring. BJGP Open. 2020;4(2):bjgpopen20X101093. doi:3399/bjgpopen20X101093
  10. Tersalvi G, Winterton D, Cioffi GM, et al. Telemedicine in heart failure during COVID-19: a step into the future. Front Cardiovasc Med. 2020;7:612818. doi:3389/fcvm.2020.612818
  11. Casale PN, Vyavahare M, Coyne S, et al. The promise of remote patient monitoring: lessons learned during the COVID-19 surge in New York City. Am J Med Qual. 2021;36(3):139-144. doi:1097/01.JMQ.0000741968.61211.2b
  12. Annis T, Pleasants S, Hultman G, et al. Rapid implementation of a COVID-19 remote patient monitoring program. J Am Med Inform Assoc. 2020;27(8):1326-1330. doi:1093/jamia/ocaa097
  13. Castelnuovo G, Pietrabissa G, Manzoni GM, Sicurello F, Zoppis I, Molinari E. Fighting the COVID-19 pandemic using the technology-based second-line in Italy and Lombardy: the urgent need of home-based remote monitoring systems to avoid the collapse of the hospital-centred first line. J Glob Health. 2020;10(2):010371. doi:7189/jogh.10.020371
  14. Krenitsky NM, Spiegelman J, Sutton D, Syeda S, Moroz L. Primed for a pandemic: implementation of telehealth outpatient monitoring for women with mild COVID-19. Semin Perinatol. 2020;44(7):151285. doi:1016/j.semperi.2020.151285
  15. Watson AR, Wah R, Thamman R. The value of remote monitoring for the COVID-19 pandemic. Telemed J E Health. 2020;26(9):1110-1112. doi:1089/tmj.2020.0134
  16. Vegesna A, Tran M, Angelaccio M, Arcona S. Remote patient monitoring via non-invasive digital technologies: a systematic review. Telemed J E Health. 2017;23(1):3-17. doi:1089/tmj.2016.0051
  17. George LA, Cross RK. Remote monitoring and telemedicine in IBD: are we there yet? Curr Gastroenterol Rep. 2020;22(3):12. doi:1007/s11894-020-0751-0
  18. Jain S, Agarwal A, Bhardwaj A, et al. Remote monitoring and holistic care of home-isolated COVID-19 positive healthcare workers through digital technology during the omicron (B1.1.529) wave: a prospective cohort study from India. Front Public Health. 2022;10:936000. doi:3389/fpubh.2022.936000
  19. Amorim P, Brito D, Castelo-Branco M, et al. Telehealth opportunities in the COVID-19 pandemic early days: what happened, did not happen, should have happened, and must happen in the near future? Telemed J E Health. 2021;27(10):1194-1199. doi:1089/tmj.2020.0386
  20. Doraiswamy S, Abraham A, Mamtani R, Cheema S. Use of telehealth during the COVID-19 pandemic: scoping review. J Med Internet Res. 2020;22(12):e24087. doi:2196/24087
  21. Hincapié MA, Gallego JC, Gempeler A, Piñeros JA, Nasner D, Escobar MF. Implementation and usefulness of telemedicine during the COVID-19 pandemic: a scoping review. J Prim Care Community Health. 2020;11:2150132720980612. doi:1177/2150132720980612
  22. Struckmann V, Leijten FRM, van Ginneken E, et al. Relevant models and elements of integrated care for multi-morbidity: results of a scoping review. Health Policy. 2018;122(1):23-35. doi:1016/j.healthpol.2017.08.008
  23. Melchiorre MG, Papa R, Rijken M, van Ginneken E, Hujala A, Barbabella F. eHealth in integrated care programs for people with multimorbidity in Europe: insights from the ICARE4EU project. Health Policy. 2018;122(1):53-63. doi:1016/j.healthpol.2017.08.006
  24. Lluch M, Abadie F. Exploring the role of ICT in the provision of integrated care--evidence from eight countries. Health Policy. 2013;111(1):1-13. doi:1016/j.healthpol.2013.03.005
  25. Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-473. doi:7326/m18-0850
  26. Leijten FRM, Struckmann V, van Ginneken E, et al. The SELFIE framework for integrated care for multi-morbidity: development and description. Health Policy. 2018;122(1):12-22. doi:1016/j.healthpol.2017.06.002
  27. Müller A, Cau A, Muhammed S, et al. Digital mHealth and virtual care use during COVID-19 in 4 countries: rapid landscape review. JMIR Form Res. 2022;6(11):e26041. doi:2196/26041
  28. Armstrong R, Hall BJ, Doyle J, Waters E. 'Scoping the scope' of a Cochrane review. J Public Health (Oxf). 2011;33(1):147-150. doi:1093/pubmed/fdr015
  29. Black JT, Romano PS, Sadeghi B, et al. A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized controlled trial. Trials. 2014;15:124. doi:1186/1745-6215-15-124
  30. Chen H, Levkoff SE. Delivering telemonitoring care to digitally disadvantaged older adults: human-computer interaction (HCI) design recommendations. In: Zhou J, Salvendy G, eds. Human Aspects of IT for the Aged Population. Design for Everyday Life. Vol 9194. Cham: Springer; 2015. p. 50-60. doi: 1007/978-3-319-20913-5_5.
  31. Singh R, Mathiassen L, Stachura ME, Astapova EV. Dynamic capabilities in home health: IT-enabled transformation of post-acute care. J Assoc Inf Syst. 2011;12(2):163-188. doi:17705/1jais.00257
  32. Sheeran T, Rabinowitz T, Lotterman J, et al. Feasibility and impact of telemonitor-based depression care management for geriatric homecare patients. Telemed J E Health. 2011;17(8):620-626. doi:1089/tmj.2011.0011
  33. Pelletier AC, Jethwani K, Bello H, Kvedar J, Grant RW. Implementing a web-based home monitoring system within an academic health care network: barriers and facilitators to innovation diffusion. J Diabetes Sci Technol. 2011;5(1):32-38. doi:1177/193229681100500105
  34. Foster CC, Steltzer M, Snyder A, et al. Integrated multimodality telemedicine to enhance in-home care of infants during the interstage period. Pediatr Cardiol. 2021;42(2):349-360. doi:1007/s00246-020-02489-7
  35. Brooks E, Novins DK, Noe T, et al. Reaching rural communities with culturally appropriate care: a model for adapting remote monitoring to American Indian veterans with posttraumatic stress disorder. Telemed J E Health. 2013;19(4):272-277. doi:1089/tmj.2012.0117
  36. Dimengo J, Stegall G. Team-based care for external telemonitoring in patients with heart failure. Heart Fail Clin. 2015;11(3):451-465. doi:1016/j.hfc.2015.03.008
  37. Cheville AL, Moynihan T, Basford JR, et al. The rationale, design, and methods of a randomized, controlled trial to evaluate the effectiveness of collaborative telecare in preserving function among patients with late stage cancer and hematologic conditions. Contemp Clin Trials. 2018;64:254-264. doi:1016/j.cct.2017.08.021
  38. Schenkel FA, Barr ML, McCloskey CC, et al. Use of a Bluetooth tablet-based technology to improve outcomes in lung transplantation: a pilot study. Am J Transplant. 2020;20(12):3649-3657. doi:1111/ajt.16154
  39. Aronoff-Spencer E, McComsey M, Chih MY, et al. Designing a framework for remote cancer care through community co-design: participatory development study. J Med Internet Res. 2022;24(4):e29492. doi:2196/29492
  40. Donner CF, Raskin J, ZuWallack R, et al. Incorporating telemedicine into the integrated care of the COPD patient a summary of an interdisciplinary workshop held in Stresa, Italy, 7-8 September 2017. Respir Med. 2018;143:91-102. doi:1016/j.rmed.2018.09.003
  41. Realdon O, Rossetto F, Nalin M, Baroni I, Romano M, Catania F, et al. The technology-enhanced ability continuum-of-care home program for people with cognitive disorders: concept design and scenario of use. In: Cipresso P, Serino S, Ostrovsky Y, Baker J, eds. Pervasive Computing Paradigms for Mental Health. Vol 253. Cham: Springer; 2018. p. 64-73. doi: 1007/978-3-030-01093-5_9.
  42. Ricci RP, Morichelli L. Workflow, time and patient satisfaction from the perspectives of home monitoring. Europace. 2013;15 Suppl 1:i49-i53. doi:1093/europace/eut113
  43. Grustam AS, Vrijhoef H, Cordella A, Koymans R, Severens JL. Care coordination in a business-to-business and a business-to-consumer model for telemonitoring patients with chronic diseases. Int J Care Coord. 2017;20(4):135-147. doi:1177/2053434517747908
  44. Dontje ML, Kruitwagen-van Reenen E, Visser-Meily JMA, Beelen A. Implementation and evaluation of an e-health innovation for personalized care for patients with amyotrophic lateral sclerosis (ALS): protocol for a participatory action research study. Implement Sci Commun. 2021;2(1):25. doi:1186/s43058-021-00130-z
  45. Herkert C, Kraal JJ, Spee RF, Serier A, Graat-Verboom L, Kemps HMC. Quality assessment of an integrated care pathway using telemonitoring in patients with chronic heart failure and chronic obstructive pulmonary disease: protocol for a quasi-experimental study. JMIR Res Protoc. 2020;9(11):e20571. doi:2196/20571
  46. Gordon K, Steele Gray C, Dainty KN, DeLacy J, Ware P, Seto E. Exploring an innovative care model and telemonitoring for the management of patients with complex chronic needs: qualitative description study. JMIR Nurs. 2020;3(1):e15691. doi:2196/15691
  47. Agarwal P, Mukerji G, Laur C, et al. Adoption, feasibility and safety of a family medicine-led remote monitoring program for patients with COVID-19: a descriptive study. CMAJ Open. 2021;9(2):E324-E330. doi:9778/cmajo.20200174
  48. Ferrua M, Minvielle E, Fourcade A, et al. How to design a remote patient monitoring system? A French case study. BMC Health Serv Res. 2020;20(1):434. doi:1186/s12913-020-05293-4
  49. Bourret R, Bousquet J. An integrated approach to telemonitoring noncommunicable diseases: best practice from the European innovation partnership on active and healthy ageing. World Hosp Health Serv. 2013;49(3):25-28.
  50. Modre-Osprian R, Pölzl G, Von Der Heidt A, Kastner P. Closed-loop healthcare monitoring in a collaborative heart failure network. In: Hörbst A, Hayn D, Schreier G, Ammenwerth E, eds. eHealth 2014. Vol 198. Netherlands: IOS Press; 2014. p. 17-24. doi: 3233/978-1-61499-397-1-17.
  51. Vuorinen AL, Leppänen J, Kaijanranta H, et al. Use of home telemonitoring to support multidisciplinary care of heart failure patients in Finland: randomized controlled trial. J Med Internet Res. 2014;16(12):e282. doi:2196/jmir.3651
  52. Schmidt C, Öner A, Mann M, et al. A novel integrated care concept (NICC) versus standard care in the treatment of chronic cardiovascular diseases: protocol for the randomized controlled trial CardioCare MV. Trials. 2018;19(1):120. doi:1186/s13063-018-2502-1
  53. Smaradottir BF, Fensli R, Aas IA, Gallefoss F. Telemedicine follow up of chronic obstructive pulmonary disease integrated into a patient-centered health care team-setting impacts on patient empowerment and safety. In: Arabnia HR, Deligiannidis L, Tinetti FG, Tran QN, Yang M, eds. 2017 International Conference on Computational Science and Computational Intelligence (CSCI). Las Vegas, NV: IEEE; 2017. p. 1779-1781. doi: 1109/csci.2017.311.
  54. Fairbrother P, Ure J, Hanley J, et al. Telemonitoring for chronic heart failure: the views of patients and healthcare professionals–a qualitative study. J Clin Nurs. 2014;23(1-2):132-144. doi:1111/jocn.12137
  55. Gordon K, Seto E, Dainty KN, Steele Gray C, DeLacy J. Normalizing telemonitoring in nurse-led care models for complex chronic patient populations: case study. JMIR Nurs. 2022;5(1):e36346. doi:2196/36346
  56. Binder AF, Handley NR, Wilde L, Palmisiano N, Lopez AM. Treating hematologic malignancies during a pandemic: utilizing telehealth and digital technology to optimize care. Front Oncol. 2020;10:1183. doi:3389/fonc.2020.01183
  57. Davis SM, Jones A, Jaynes ME, et al. Designing a multifaceted telehealth intervention for a rural population using a model for developing complex interventions in nursing. BMC Nurs. 2020;19:9. doi:1186/s12912-020-0400-9
  58. Tahan HM. Essential case management practices amidst the novel coronavirus disease 2019 (COVID-19) crisis: part 1: tele-case management, surge capacity, discharge planning, and transitions of care. Prof Case Manag. 2020;25(5):248-266. doi:1097/ncm.0000000000000454
  59. O'Mara B, Monani D, Carey G. Telehealth, COVID-19 and refugees and migrants in Australia: policy and related barriers and opportunities for more inclusive health and technology systems. Int J Health Policy Manag. 2021;11(10):2368-2372. doi:10.34172/ijhpm.2021.31
  • Receive Date: 31 March 2022
  • Revise Date: 22 October 2022
  • Accept Date: 28 January 2023
  • First Publish Date: 30 January 2023