Cyrille Herkert’s PhD project is a collaboration between the Máxima Medical Center (MMC) and TU/e. Her PhD supervisor Hareld Kemps, a part-time professor at TU/e and cardiologist at MMC, had been engaged in this topic for some time and inspired her to undertake this doctoral research. “He bridges the gap between the hospital and TU/e,” says Herkert.

In addition to pursuing her PhD, she is training as a cardiologist at the Catharina Hospital in Eindhoven. This was quite a challenging combination, she says: “I often had to work on my research in my spare time.”

Difficult to predict

Heart failure is a chronic condition in which the heart is unable to pump blood around efficiently. This can lead to fluid build-up, causing symptoms such as shortness of breath and swollen legs. “Unfortunately, this often requires patients to be admitted to the hospital,” says Herkert. To discharge the excess fluid, they are given diuretic medication via IV.

“The big problem in current care is that it’s difficult to foresee these admissions,” she continues. Although patients periodically visit the outpatient clinic, they may not show any symptoms at that time. If their condition deteriorates between appointments, they still need to be admitted. “It’s currently difficult for doctors to predict when this will happen,” she points out.

Timely intervention

In her research, Herkert explored the possibilities of telemonitoring – remote care – to better monitor patients. This allows doctors to detect early signs of a patient’s condition deteriorating and intervene immediately. At the same time, it spares stable patients unnecessary hospital visits, making healthcare more efficient and improving comfort and quality of care for patients.

Telemonitoring means that patients measure their own data such as weight, heart rate and blood pressure at home. They also complete a short questionnaire about heart failure-related physical symptoms. They share this data with healthcare professionals, often through an app. By monitoring these values, doctors can adjust medication if necessary to help prevent fluid build-up. Currently, this monitoring is done manually, with healthcare personnel reviewing the data. “Hopefully, this process can be more automated in the future with the help of AI,” says Herkert. “That would make telemonitoring even more efficient.”

A new care path

As part of her doctoral research, Herkert developed a care path for telemonitoring of patients with heart failure and COPD (a chronic lung condition). “These two diseases often occur together and usually aggravate at the same time,” she explains. The patients in her study are monitored remotely via telemonitoring and only attend the outpatient clinic if the measurements warrant it. “So that means no more standard outpatient checkups. This is unique compared to previous studies,” says Herkert.

According to Herkert, the greatest challenge in introducing telemonitoring is integrating it into traditional hospital care, which is rigidly structured. “It takes a lot of effort to introduce such a major change,” she says. New work procedures need to be established and responsibilities must be clearly defined.

In outlining the care path, Herkert also took patients’ experiences with current care into account. “The study has only just been completed, so we still need to carefully analyze the results,” she says. “We will mainly look at whether it improves the quality of life for these patients.” Of course, the care path must also be practically feasible and cost-effective.

Accurate measuring devices

In addition to its practical implementation, Herkert also examined the technical aspect. For example, she investigated whether existing measuring devices are suitable for telemonitoring this patient group. “There are lots of different activity trackers and smartwatches that have potential for remote patient monitoring, but those devices were developed for healthy people and the question is whether their measurements are accurate enough for cardiac patients,” she explains.

Her tests showed, for example, that the two commercially available activity trackers are not accurate enough to monitor physical activity in heart patients. “There’s an urgent need for a better wristband with algorithms that are better tailored to heart patients and produce more accurate results,” she concludes.

Telemonitoring in space

Additionally, Herkert conducted two studies using a relatively new device that was previously used to monitor the heart condition of astronauts in space. “That’s another form of remote monitoring,” she says, laughing. With its sensors, which are attached to the chest and back, the device measures vibrations caused by the contraction of the heart muscle. Herkert wondered if this device would also be suitable for monitoring heart patients.

One of her studies showed that the device is able to detect changes in physical activity in heart failure patients. In another study, she examined how the device responds when patients with fluid build-up receive diuretic medication via IV. The device proved capable of measuring the decrease in fluid. “They are relatively small studies, but they offer hope for the future.”

The experiences Herkert gained during her doctoral period have contributed to telemonitoring becoming part of the standard healthcare practice at MMC. Nevertheless, she believes there is still room for improvement when it comes to remote care. “Step one is developing reliable measuring devices that allow us to collect better data,” she says.  She also stresses the importance of better algorithms to process and assess data more efficiently. “We’ve observed that the values change just before a patient needs to be hospitalized. With better measuring devices and algorithms, we would be able to predict deterioration at an earlier stage and intervene faster.”