Can oral anticoagulation be managed using telemedicine and patient self-testing? A pilot study

We report a feasibility study of patient self-testing telemedicine for anticoagulant management using TOPCARE (Telematic Homecare Platform in Cooperative Health Care Provider Networks, developed by the European Commission for a user-friendly information society). TOPCARE comprises a Home Telematic Box (TOPCARE BOX), a central database held on a remote server and secure computer terminals in the anticoagulant clinic. The TOPCARE BOX transmits encrypted International Normalized Ratio (INR) results from the CoaguChek S monitor (Roche Diagnostics) via the patient's telephone line to the database, which is accessed by health-care professionals via the Internet. The database displays the patient's anticoagulant record, highlighting out of range results, overdue tests and quality control results. The database can also send information back to the TOPCARE box, although currently only the next test date can be transmitted. 23 patients, on long-term oral anticoagulation were recruited from the hospital anticoagulant clinic. After completing a nurse-led training course, patients tested their INR weekly on a CoaguChek S and transmitted their results via the TOPCARE BOX. The nurse specialist accessed the patient's results, electronically entered the date of the next test. Changes in warfarin dose were telephoned. Four patients dropped out early in the study and 19 patients received TOPCARE BOXs of which nine were fully functional. Unintentional software misconfiguration meant that remaining 10 TOPCARE BOXs were nonfunctional (these were later reconfigured but not reintroduced into the study). Patients successfully transmitted 222 results over a 5-month period using the TOPCARE system. Early server problems were resolved, but intermittent problems with database access persisted and five results were not received by the server. Although concerns were raised regarding technical problems, feedback from patients and staff was favourable and the system thought to be user-friendly. In conclusion, this pilot study showed that telemedicine is a feasible option for anticoagulant management, but that the technology requires thorough testing prior to installation.