Hybrid comprehensive cardiac telerehabilitation allows supervise and implement comprehensive rehabilitation through the use of advanced medical and telecommunications technologies.

Hybrid comprehensive telerehabilitation program consisting of two stages: 

• an initial stage - conducted at hospital or ambulatory and 
• a basic stage - home-based telerehabilitation five times weekly. 

Telerehabilitation is carried out by a medical team and advanced monitoring systems are used.               
A telerehabilitation medical team is composed of: 

• physicians
• physiotherapists 
• nurses
• psychologist. 

The monitoring system includs: 

• a special remote device for tele-ECG monitoring and to supervise of an exercise training - telerehabilitation device set (manufactured by Pro-PLUS SA, Poland), which consists of EHO-MINI device, blood pressure monitor and weighing scale (Figure 1)
• data transmission set via a mobile phone
• a monitoring centre capable of receiving and storing patients’ medical data (specialized hardware and software are necessary).

The EHO-MINI device is able to record ECG data from three pre-cordial leads and transmit them via a mobile phone network to the monitoring center. An EHO-MINI device has training sessions preprogrammed individually for each patient (defined exercise duration, breaks, timing of ECG recording). The moments of automatic ECG registration are preset and coordinated with the exercise training. The planned training sessions are executed with the device indicating what needed to be done with sound and light signals. There are sound signals in the form of bleeps and light signals from color emitting diodes. Bleeps and green diode blinking meant that the patient has to perform exercise. Another set of bleeps and red diode blinking meant “stop exercise”. The timing of automatic ECG recordings correspond to peak exercise.

An EHO-MINI device has a tele-event-Holter ECG feature as well. It enables a patient, whenever a worrying symptom occurs, to register and immediately send the ECG recording via mobile phone network to the telemonitoring center. 

Figure. Telerehabilitation set — a weighing machine, the EHO-MINI device, a manometer. 

 Figure . Telerehabilitation device set – the EHO-MINI device, a blood pressure monitor, a weighing scale

The initial stage of the hybrid comprehensive telerehabilitation

The goals of the initial stage are: 

• a baseline clinical examination, 
• optimization of treatment, 
• individual planning of exercise training, 
• performing five monitored educational training sessions,
• education.

Patients and their partners are taught: 

• how to operate a telerehabilitation set,
• how to measure heart rate, blood pressure, body mass
• how to self-evaluate worrying signs and symptoms                                                                           
• how to prepare healthy diet        
• how to give first aid in case of an emergency - how to perform the exercise training                                                                                               
• how to self-evaluate the level of perceived exertion according to the Borg scale during training session
• how to perform relaxation training and decrease depressive symptoms and anxiety.

The basic stage of the hybrid comprehensive telerehabilitation

The basic telerehabilitation stage consist of two parts performed prior to each training session: 

• the training consent procedure required to access each training session; 
• the training session.

Patient, before the each training session, answers a series of questions regarding his present condition and medication(s) taken via mobile phone. Subsequently patient transmits resting ECG, blood pressure and body mass data to the monitoring centre. If no contraindications to exercise are identified,  patients can receive consent to start the training session

Exercise training is performed in accordance with the guidelines for heart failure patients. 

Three different training modalities have been proposed to improve exercise capacity:

• aerobic endurance training (walking, Nordic walking, cycling)
• respiratory muscle training 
• resistance and strength training

Telerehabilitation  set is used to monitor and control training in anywhere the patient has elected to exercise. If the training session is completed uneventfully, the patient transmits ECG recording via a mobile phone to the monitoring centre immediately after the end of every training session. 

The data are stored in a computer and are analyzed by telerehabilitation team at the monitoring centre, and the safety, efficacy, and accuracy of a particular patient rehabilitation programme are assessed.

Using the data on heart rate during exercise and the patient’s subjective evaluation of the perceived exertion, consultants are able to adjust the training workload appropriately or,         if necessary, to discontinue the session.

The telephone contact is also used for psychological support. 

We recommend the presence of another person who always accompanied the patient during exercise and was able to provide first aid and call professional medical help in case of an emergency.

After completing all scheduled home telemonitoring training sessions, the patient undergoes  a final medical examination and tests and receives further medical recommendations. 

Device features:

• modern medical smartphone dedicated for comprehensive handling of the cardiac rehabilitation process
• Color 3,5’’ touchscreen
• GSM, Bluetooth and WiFi communicationa enables quick transmission of medical data and wireless communication with external devices such as: weighing scale, blood pressure monitor, pulse oximeter, blood glucose meter
• physical activity monitoring, patient geolocalization (GPS), fall detection, route monitoring during the training

Device functionality:

• built-in R-R detection algorithm and quality of ECG signal evaluation algorithm
• implemented support for interval and continuous training with the possibility of standard or sequential monitoring
• built-in voice messages, text messages and haptic alerts
• clear and understandable messages and instructions displays on the touchscreen
• convenient voice communication system for patient and doctor
• patient rating of perceived exertion using Borg scale

User interface benefits:

• Easy and user-friendly interface
• on-screen training instructions supporting the process of patient education
• the device allows to guide the patient through the cardiac telerehabilitation process and provides comprehensive supervision and control capabilities at every stage of the process

Patient benefits:

• heart rate value monitoring during cardiac telerehabilitation – buil-in control of set alert threshold values for heart rate pulsoximeter
• implemented medical algorithms
• implemented electrode fastening detection with visualization
• remotely configurable alert threshold values for all types of monitoring parameters at a procedure of training permission and during a session
• Voice assist and user aid throughout the rehabilitation process
• Event monitoring function, or automatic detection of cardiac rhythm abnormality after rehabilitation session

Medical personnel benefits:

• safety - comprehensive supervision and control capabilities at every stage of the process
• device autonomy - after programming, the device independently guides the patient through the telerehabilitation process, without need for medical staff involvement, at the same time ensuring a high level of safety
• data transmission right after measurement (quasi on-line) during a cardiac rehabilitation session
• Possibility to adapt the rehabilitation process to the patient – the procedure is fully configurable remotely via the telemedicinal platform
• Optimization of work for medical personnel by reducing the number of tasks

The telemedicine platform (cardiologic.pl) is an internet portal supporting the implementation of the hybrid comprehensive cardiac telerehabilitation procedure.

The cardiologic.pl platform has been modernized in accordance with the latest technological trends taking into account access to it from both stationary and mobile stations using any web browser compatible with HTML5 and CSS3.

User communication with the platform is implemented in the client-server mode using the encrypted HTTPS protocol, which, together with TLS support, prevents the interception and change of transmitted data.

The telemedicine platform (cardiologic.pl) supports the functions associated with operating the medical procedure - hybrid comprehensive telerehabilitation implemented in a telemedicine system using the Pro-PLUS SA EHO-MINI-LCD device operating in the GSM network. The telemedicine platform enables collecting, managing, describing, analyzing and archiving data related to the process of conducting hybrid comprehensive telerehabilitation. The result of this procedure is a rational model of data exchange between the physician / nurse / physiotherapist and the patient. Rational, in this case, means an attempt to minimize contact with the patient (optimizing costs) while maintaining a high level of telerehabilitation process for heart failure patients.