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Remote patient monitoring - Wikipedia

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<div class="vector-body-before-content"> <div class="mw-indicators"> </div> <div id="siteSub" class="noprint">From Wikipedia, the free encyclopedia</div> </div> <div id="contentSub"><div id="mw-content-subtitle"></div></div> <div id="mw-content-text" class="mw-body-content"><div class="mw-content-ltr mw-parser-output" lang="en" dir="ltr"><div class="shortdescription nomobile noexcerpt noprint searchaux" style="display:none">Technology to monitor patients outside of conventional clinical settings</div> <style data-mw-deduplicate="TemplateStyles:r1251242444">.mw-parser-output .ambox{border:1px solid #a2a9b1;border-left:10px solid #36c;background-color:#fbfbfb;box-sizing:border-box}.mw-parser-output .ambox+link+.ambox,.mw-parser-output .ambox+link+style+.ambox,.mw-parser-output .ambox+link+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+style+.ambox,.mw-parser-output .ambox+.mw-empty-elt+link+link+.ambox{margin-top:-1px}html body.mediawiki .mw-parser-output .ambox.mbox-small-left{margin:4px 1em 4px 0;overflow:hidden;width:238px;border-collapse:collapse;font-size:88%;line-height:1.25em}.mw-parser-output .ambox-speedy{border-left:10px solid #b32424;background-color:#fee7e6}.mw-parser-output .ambox-delete{border-left:10px solid #b32424}.mw-parser-output .ambox-content{border-left:10px solid #f28500}.mw-parser-output .ambox-style{border-left:10px solid #fc3}.mw-parser-output .ambox-move{border-left:10px solid #9932cc}.mw-parser-output .ambox-protection{border-left:10px solid #a2a9b1}.mw-parser-output .ambox .mbox-text{border:none;padding:0.25em 0.5em;width:100%}.mw-parser-output .ambox .mbox-image{border:none;padding:2px 0 2px 0.5em;text-align:center}.mw-parser-output .ambox .mbox-imageright{border:none;padding:2px 0.5em 2px 0;text-align:center}.mw-parser-output .ambox .mbox-empty-cell{border:none;padding:0;width:1px}.mw-parser-output .ambox .mbox-image-div{width:52px}@media(min-width:720px){.mw-parser-output .ambox{margin:0 10%}}@media print{body.ns-0 .mw-parser-output .ambox{display:none!important}}</style><table class="box-Update plainlinks metadata ambox ambox-content ambox-Update" role="presentation"><tbody><tr><td class="mbox-image"><div class="mbox-image-div"><span typeof="mw:File"><span><img alt="" src="//upload.wikimedia.org/wikipedia/commons/thumb/5/53/Ambox_current_red_Americas.svg/42px-Ambox_current_red_Americas.svg.png" decoding="async" width="42" height="34" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/5/53/Ambox_current_red_Americas.svg/63px-Ambox_current_red_Americas.svg.png 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/5/53/Ambox_current_red_Americas.svg/84px-Ambox_current_red_Americas.svg.png 2x" data-file-width="360" data-file-height="290" /></span></span></div></td><td class="mbox-text"><div class="mbox-text-span">This article needs to be <b>updated</b>.<span class="hide-when-compact"> Please help update this article to reflect recent events or newly available information.</span> <span class="date-container"><i>(<span class="date">June 2020</span>)</i></span></div></td></tr></tbody></table> <p><b>Remote patient monitoring</b> (<b>RPM</b>) is a technology to enable monitoring of patients outside of conventional clinical settings, such as in the home or in a remote area, which may increase access to care and decrease healthcare delivery costs. RPM involves the constant remote care of patients by their physicians, often to track physical symptoms, <a href="/wiki/Chronic_condition" title="Chronic condition">chronic conditions</a>, or post-hospitalization rehab.<sup id="cite_ref-Wicklund_2021_1-0" class="reference"><a href="#cite_note-Wicklund_2021-1"><span class="cite-bracket">&#91;</span>1<span class="cite-bracket">&#93;</span></a></sup> </p> <figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/wiki/File:CardiacSense_medical_watch.jpg" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/commons/thumb/9/99/CardiacSense_medical_watch.jpg/220px-CardiacSense_medical_watch.jpg" decoding="async" width="220" height="173" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/9/99/CardiacSense_medical_watch.jpg/330px-CardiacSense_medical_watch.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/9/99/CardiacSense_medical_watch.jpg/440px-CardiacSense_medical_watch.jpg 2x" data-file-width="3000" data-file-height="2359" /></a><figcaption>Devices like <a href="/wiki/Smartwatch" title="Smartwatch">smartwatches</a> are continually updated with new remote monitoring technologies such as heartbeat monitors.</figcaption></figure> <p>Incorporating RPM in <a href="/wiki/Chronic_disease" class="mw-redirect" title="Chronic disease">chronic-disease</a> management may significantly improve an individual's <a href="/wiki/Quality_of_life" title="Quality of life">quality of life</a>, by allowing patients to maintain independence, prevent complications, and to minimize personal costs.<sup id="cite_ref-bayliss_2-0" class="reference"><a href="#cite_note-bayliss-2"><span class="cite-bracket">&#91;</span>2<span class="cite-bracket">&#93;</span></a></sup> RPM facilitates these goals by delivering care through <a href="/wiki/Telecommunications" title="Telecommunications">telecommunications</a>. This form of patient monitoring can be particularly important when patients are managing complex <a href="/wiki/Self-care" title="Self-care">self-care</a> processes such as home <a href="/wiki/Hemodialysis" title="Hemodialysis">hemodialysis</a>.<sup id="cite_ref-3" class="reference"><a href="#cite_note-3"><span class="cite-bracket">&#91;</span>3<span class="cite-bracket">&#93;</span></a></sup> </p><p>Key features of RPM, like remote monitoring and trend analysis of physiological parameters, enable early detection of deterioration; thereby reducing emergency department visits, hospitalizations, and the duration of hospital stays.<sup id="cite_ref-center_4-0" class="reference"><a href="#cite_note-center-4"><span class="cite-bracket">&#91;</span>4<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-O&#39;Donoghue_2012_5-0" class="reference"><a href="#cite_note-O&#39;Donoghue_2012-5"><span class="cite-bracket">&#91;</span>5<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-coye_6-0" class="reference"><a href="#cite_note-coye-6"><span class="cite-bracket">&#91;</span>6<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-ict_7-0" class="reference"><a href="#cite_note-ict-7"><span class="cite-bracket">&#91;</span>7<span class="cite-bracket">&#93;</span></a></sup> While technologies are continually being developed to tackle this type of health care, physicians may utilize basic communication methods such as <a href="/wiki/Zoom_(software)" title="Zoom (software)">Zoom</a>, <a href="/wiki/Snapchat" title="Snapchat">Snapchat</a>, or even landline phones.<sup id="cite_ref-Wicklund_2021_1-1" class="reference"><a href="#cite_note-Wicklund_2021-1"><span class="cite-bracket">&#91;</span>1<span class="cite-bracket">&#93;</span></a></sup> </p><p>Pilot programs for Remote Patient Monitoring began in 1970s when <a href="/wiki/Kaiser_Permanente" title="Kaiser Permanente">Kaiser Permanente</a> created monitoring systems for rural communities in order to provide better healthcare to isolated regions.<sup id="cite_ref-8" class="reference"><a href="#cite_note-8"><span class="cite-bracket">&#91;</span>8<span class="cite-bracket">&#93;</span></a></sup> Literature related to Remote Patient Monitoring suggests that interventions based on health behavior models, care pathways, and personalized coaching lead to the best outcomes.<sup id="cite_ref-Noah_2018_9-0" class="reference"><a href="#cite_note-Noah_2018-9"><span class="cite-bracket">&#91;</span>9<span class="cite-bracket">&#93;</span></a></sup> </p><p>Research on the use of Remote Patient Monitoring technologies has helped determine that further development of telehealth ecosystems, in which physicians can give recommendations and means of care while also receiving transmitted health information, can lead to better patient outcomes and higher patient satisfaction.<sup id="cite_ref-Riaz_2016_10-0" class="reference"><a href="#cite_note-Riaz_2016-10"><span class="cite-bracket">&#91;</span>10<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-11" class="reference"><a href="#cite_note-11"><span class="cite-bracket">&#91;</span>11<span class="cite-bracket">&#93;</span></a></sup> Researchers also note that Remote Patient Monitoring will become more important as healthcare changes from a volume focus to a value focus.<sup id="cite_ref-Riaz_2016_10-1" class="reference"><a href="#cite_note-Riaz_2016-10"><span class="cite-bracket">&#91;</span>10<span class="cite-bracket">&#93;</span></a></sup> </p><p>During the <a href="/wiki/COVID-19_pandemic" title="COVID-19 pandemic">COVID-19 pandemic</a>, Remote Patient Monitoring has been used extensively and allowed for more fields such as <a href="/wiki/Psychology" title="Psychology">psychology</a> or <a href="/wiki/Cardiology" title="Cardiology">cardiology</a> to use virtual care. By 2025, the Remote Patient Monitoring industry is expected to double, due to factors such as the COVID-19 pandemic and increased at-home care.<sup id="cite_ref-12" class="reference"><a href="#cite_note-12"><span class="cite-bracket">&#91;</span>12<span class="cite-bracket">&#93;</span></a></sup> Use of Remote Patient Monitoring has been proven to ultimately provide better patient compliance and improved physician management, while decreasing costs of care.<sup id="cite_ref-13" class="reference"><a href="#cite_note-13"><span class="cite-bracket">&#91;</span>13<span class="cite-bracket">&#93;</span></a></sup> </p> <meta property="mw:PageProp/toc" /> <div class="mw-heading mw-heading2"><h2 id="Key_features_of_RPM">Key features of RPM</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=1" title="Edit section: Key features of RPM"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <div class="mw-heading mw-heading3"><h3 id="Accessibly">Accessibly</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=2" title="Edit section: Accessibly"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Both patients and care providers can access the RPM record anytime from anywhere. Instantaneous access is helpful in making accurate health decisions and improves clinical operations.<sup id="cite_ref-14" class="reference"><a href="#cite_note-14"><span class="cite-bracket">&#91;</span>14<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Cost-effectiveness.">Cost-effectiveness.</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=3" title="Edit section: Cost-effectiveness."><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Not much evidence has been able to support whether or not telehealth is more cost effective or not. There is some research showing that it can be a less expensive way for doctors to provide care because they aren't using any of their physical resources on the patient. Sage journals published a case study researching if telehealth is cost effective for the patient in the comfort of their home. Langabeer et al. (2017), stated that this study's method was to utilize telehealth resources when people called 911 and EMS responded. Once EMS was on scene, they would pull up a virtual system putting them in direct contact with an emergency department provider at the hospital. The provider was then able to triage the patient at the scene of the call and determine the best course of treatment potentially being no transport to the hospital. This in turn is more cost efficient for the patients and the medical providers both. This showed to be helpful in-patient outcomes because the provider was able to determine the critical level of the patient therefore allowing them to determine the best course of action at an earlier time.<sup id="cite_ref-15" class="reference"><a href="#cite_note-15"><span class="cite-bracket">&#91;</span>15<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-16" class="reference"><a href="#cite_note-16"><span class="cite-bracket">&#91;</span>16<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Promptness">Promptness</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=4" title="Edit section: Promptness"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>RPM helps in faster decision-making. RPM collects, improves, and analyzes data promptly, which is time-saving. Report-making has become easy through RPM. </p> <div class="mw-heading mw-heading2"><h2 id="Technological_components">Technological components</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=5" title="Edit section: Technological components"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The diverse applications of RPM lead to numerous variations of RPM technology architecture. However, most RPM technologies follow a general architecture that consists of four components.:<sup id="cite_ref-smith_17-0" class="reference"><a href="#cite_note-smith-17"><span class="cite-bracket">&#91;</span>17<span class="cite-bracket">&#93;</span></a></sup> </p> <ul><li><a href="/wiki/Sensor" title="Sensor">Sensors</a> on a device that is enabled by wireless communications to measure physiological parameters.</li> <li><a href="/wiki/Sensor" title="Sensor">Sensors</a> can connect back to a central database by WiFi or cellular communication protocols depending on the manufacturer.</li> <li>Local data storage at patients' site that interfaces between sensors and other centralized data repository and/or healthcare providers.</li> <li>Centralized repository to store data sent from sensors, local data storage, diagnostic applications, and/or healthcare providers.</li> <li>Diagnostic application software that develops treatment recommendations and intervention alerts based on the analysis of collected data.</li></ul> <p>Depending on the disease and the parameters that are monitored, different combinations of sensors, storage, and applications may be deployed.<sup id="cite_ref-O&#39;Donoghue_2012_5-1" class="reference"><a href="#cite_note-O&#39;Donoghue_2012-5"><span class="cite-bracket">&#91;</span>5<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-smith_17-1" class="reference"><a href="#cite_note-smith-17"><span class="cite-bracket">&#91;</span>17<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Applications">Applications</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=6" title="Edit section: Applications"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Physiological data such as <a href="/wiki/Blood_pressure" title="Blood pressure">blood pressure</a> and subjective patient data are collected by sensors on peripheral devices. Examples of peripheral devices are: <a href="/wiki/Blood_pressure_cuff" class="mw-redirect" title="Blood pressure cuff">blood pressure cuff</a>, <a href="/wiki/Pulse_oximeter" class="mw-redirect" title="Pulse oximeter">pulse oximeter</a>, and <a href="/wiki/Glucometer" class="mw-redirect" title="Glucometer">glucometer</a>. The data are transmitted to healthcare providers or third parties via wireless telecommunication devices. The data are evaluated for potential problems by a healthcare professional or via a clinical decision support algorithm, and patient, caregivers, and health providers are immediately alerted if a problem is detected.<sup id="cite_ref-center_4-1" class="reference"><a href="#cite_note-center-4"><span class="cite-bracket">&#91;</span>4<span class="cite-bracket">&#93;</span></a></sup> As a result, timely intervention ensures positive patient outcomes. The newer applications also provide education, test and medication reminder alerts, and a means of communication between the patient and the provider.<sup id="cite_ref-center_4-2" class="reference"><a href="#cite_note-center-4"><span class="cite-bracket">&#91;</span>4<span class="cite-bracket">&#93;</span></a></sup> The following section illustrates examples of RPM applications, but RPM is not limited to those disease states </p> <div class="mw-heading mw-heading3"><h3 id="Cancer">Cancer</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=7" title="Edit section: Cancer"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Use of RPM among patients with cancer has been proven to improve outcomes overall, with studies showing improvements in re-hospitalization rates and decreased healthcare resource usage.<sup id="cite_ref-Pritchett_2021_18-0" class="reference"><a href="#cite_note-Pritchett_2021-18"><span class="cite-bracket">&#91;</span>18<span class="cite-bracket">&#93;</span></a></sup> These remote monitoring technologies help to lower severity of pain as well as improving <a href="/wiki/Depression_(mood)" title="Depression (mood)">depression</a>.<sup id="cite_ref-19" class="reference"><a href="#cite_note-19"><span class="cite-bracket">&#91;</span>19<span class="cite-bracket">&#93;</span></a></sup> </p><p>The RPM has improved the life expectancy of Cancer Patients up to 20%. Remote patient monitoring devices help in early interventions, prescriptions, chemotherapy modifications, etc. RPM has helped in reducing Cancer emergency room visits or prolonged chemotherapy treatments. It is estimated that the hospitalization rate of patients with RPM is 2.8% and without RPM is 13%<sup id="cite_ref-20" class="reference"><a href="#cite_note-20"><span class="cite-bracket">&#91;</span>20<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="COVID-19">COVID-19</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=8" title="Edit section: COVID-19"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/wiki/File:COVID-19_Nurse.jpg" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/commons/thumb/4/4c/COVID-19_Nurse.jpg/220px-COVID-19_Nurse.jpg" decoding="async" width="220" height="124" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/4/4c/COVID-19_Nurse.jpg/330px-COVID-19_Nurse.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/4/4c/COVID-19_Nurse.jpg/440px-COVID-19_Nurse.jpg 2x" data-file-width="1920" data-file-height="1080" /></a><figcaption>The use of remote patient monitoring reduces face-to-face interactions between physician and patient.</figcaption></figure> <p>RPM can provide continuity of care for symptomatic <a href="/wiki/COVID-19" title="COVID-19">COVID-19</a> patients post-discharge from hospital and those with mild to moderate oxygen desaturation levels that do not require hospitalization, and patients with long-COVID symptoms. Due to the nature of the pandemic, RPM is a necessary means of providing care to at-risk patients such as elderly or <a href="/wiki/Immunocompromised" class="mw-redirect" title="Immunocompromised">immunocompromised</a> people. </p><p>Studies show that the use of RPM during the pandemic has helped to reduce hospitalizations<sup id="cite_ref-21" class="reference"><a href="#cite_note-21"><span class="cite-bracket">&#91;</span>21<span class="cite-bracket">&#93;</span></a></sup>&#160;and decrease the use of acute care resources.<sup id="cite_ref-Pritchett_2021_18-1" class="reference"><a href="#cite_note-Pritchett_2021-18"><span class="cite-bracket">&#91;</span>18<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-22" class="reference"><a href="#cite_note-22"><span class="cite-bracket">&#91;</span>22<span class="cite-bracket">&#93;</span></a></sup> </p><p>The FDA has given emergency authorized use of RPM technologies for the purpose of decreasing the spread of COVID-19 and to prevent overload for healthcare resources and personnel.<sup id="cite_ref-Pritchett_2021_18-2" class="reference"><a href="#cite_note-Pritchett_2021-18"><span class="cite-bracket">&#91;</span>18<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-23" class="reference"><a href="#cite_note-23"><span class="cite-bracket">&#91;</span>23<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-24" class="reference"><a href="#cite_note-24"><span class="cite-bracket">&#91;</span>24<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Chronic_Obstructive_Pulmonary_Disease_(COPD)"><span id="Chronic_Obstructive_Pulmonary_Disease_.28COPD.29"></span>Chronic Obstructive Pulmonary Disease (COPD)</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=9" title="Edit section: Chronic Obstructive Pulmonary Disease (COPD)"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>For patients with <a href="/wiki/Chronic_obstructive_pulmonary_disease" title="Chronic obstructive pulmonary disease">chronic obstructive pulmonary disease</a>, RPM may contribute to increased patient knowledge, earlier interventions, and shared decision making. However, the evidence is varying and issues of cost, and the shift of responsibilities to patients have also been raised.<sup id="cite_ref-25" class="reference"><a href="#cite_note-25"><span class="cite-bracket">&#91;</span>25<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-26" class="reference"><a href="#cite_note-26"><span class="cite-bracket">&#91;</span>26<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-27" class="reference"><a href="#cite_note-27"><span class="cite-bracket">&#91;</span>27<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Dementia_and_falls">Dementia and falls</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=10" title="Edit section: Dementia and falls"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <figure class="mw-default-size" typeof="mw:File/Thumb"><a href="/wiki/File:Telehealth_-_Response_Watch.jpg" class="mw-file-description"><img src="//upload.wikimedia.org/wikipedia/en/thumb/b/b5/Telehealth_-_Response_Watch.jpg/220px-Telehealth_-_Response_Watch.jpg" decoding="async" width="220" height="361" class="mw-file-element" srcset="//upload.wikimedia.org/wikipedia/en/thumb/b/b5/Telehealth_-_Response_Watch.jpg/330px-Telehealth_-_Response_Watch.jpg 1.5x, //upload.wikimedia.org/wikipedia/en/thumb/b/b5/Telehealth_-_Response_Watch.jpg/440px-Telehealth_-_Response_Watch.jpg 2x" data-file-width="530" data-file-height="869" /></a><figcaption>Telehealth response watch</figcaption></figure> <p>For patients with <a href="/wiki/Dementia" title="Dementia">dementia</a> that are at risk for falls, RPM technology promotes safety and prevents harm through continuous surveillance.<sup id="cite_ref-center_4-3" class="reference"><a href="#cite_note-center-4"><span class="cite-bracket">&#91;</span>4<span class="cite-bracket">&#93;</span></a></sup> RPM sensors can be affixed to the individual or their assistive mobility devices such as canes and walkers.<sup id="cite_ref-center_4-4" class="reference"><a href="#cite_note-center-4"><span class="cite-bracket">&#91;</span>4<span class="cite-bracket">&#93;</span></a></sup> The sensors monitor an individual's location, gait, linear acceleration and angular velocity, and utilize a mathematical algorithm to predict the likelihood for falls, detect movement changes, and alert caregivers if the individual has fallen.<sup id="cite_ref-center_4-5" class="reference"><a href="#cite_note-center-4"><span class="cite-bracket">&#91;</span>4<span class="cite-bracket">&#93;</span></a></sup> Furthermore, tracking capabilities via <a href="/wiki/Wi-Fi" title="Wi-Fi">Wi-Fi</a>, <a href="/wiki/Global_positioning_system" class="mw-redirect" title="Global positioning system">global positioning system</a> (GPS) or radio frequency enables caregivers to locate wandering elders.<sup id="cite_ref-center_4-6" class="reference"><a href="#cite_note-center-4"><span class="cite-bracket">&#91;</span>4<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Diabetes">Diabetes</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=11" title="Edit section: Diabetes"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p><a href="/wiki/Diabetes" title="Diabetes">Diabetes</a> management requires control of multiple parameters: <a href="/wiki/Blood_pressure" title="Blood pressure">blood pressure</a>, weight, and blood glucose. The <a href="/wiki/Continuous_glucose_monitor" title="Continuous glucose monitor">real-time delivery of blood glucose and blood pressure readings</a> enables immediate alerts for patient and healthcare providers to intervene when needed. There is evidence to show that daily diabetes management involving RPM is just as effective as usual clinic visit every 3 months.<sup id="cite_ref-28" class="reference"><a href="#cite_note-28"><span class="cite-bracket">&#91;</span>28<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Congestive_heart_failure">Congestive heart failure</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=12" title="Edit section: Congestive heart failure"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>A systematic review of the literature on home monitoring for <a href="/wiki/Heart_failure" title="Heart failure">heart failure</a> patients indicates that RPM improves <a href="/wiki/Quality_of_life" title="Quality of life">quality of life</a>, improves patient-provider relationships, shortens duration of stay in hospitals, decreases mortality rate, and reduces costs to the healthcare system.<sup id="cite_ref-29" class="reference"><a href="#cite_note-29"><span class="cite-bracket">&#91;</span>29<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-30" class="reference"><a href="#cite_note-30"><span class="cite-bracket">&#91;</span>30<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Infertility">Infertility</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=13" title="Edit section: Infertility"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>A recent study of a remote patient monitoring solution for infertility demonstrated that for appropriately screened patients who had been seeking In-Vitro Fertilization (IVF) treatment, a six-month remote monitoring program had the same pregnancy rate as a cycle of IVF.<sup id="cite_ref-31" class="reference"><a href="#cite_note-31"><span class="cite-bracket">&#91;</span>31<span class="cite-bracket">&#93;</span></a></sup> The remote patient monitoring product and service used had a cost-per-patient of $800, compared to the average cost of a cycle of IVF of $15,000, suggesting a 95% reduction in the cost of care for the same outcome. </p> <div class="mw-heading mw-heading3"><h3 id="Surgery">Surgery</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=14" title="Edit section: Surgery"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>When compared to standard of care with no devices, a 2021 study showed that post-surgical remote patient monitoring detected 30% more medication errors, 10-14% reduction in patient paint, and a 5% reduction in hospital re-admissions.<sup id="cite_ref-:0_32-0" class="reference"><a href="#cite_note-:0-32"><span class="cite-bracket">&#91;</span>32<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-:1_33-0" class="reference"><a href="#cite_note-:1-33"><span class="cite-bracket">&#91;</span>33<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-34" class="reference"><a href="#cite_note-34"><span class="cite-bracket">&#91;</span>34<span class="cite-bracket">&#93;</span></a></sup> The randomized study, conducted by <a href="/wiki/Philip_James_Devereaux" title="Philip James Devereaux">PJ Devereaux</a> and Micheal McGillion, split 905 patients between a standard of care group and a RPM group, which used at-home clinical grade vital sign devices to transfer their vital signs to a Clinician Portal where they were monitored remotely and could communicate through text, chat, or video calls.<sup id="cite_ref-:0_32-1" class="reference"><a href="#cite_note-:0-32"><span class="cite-bracket">&#91;</span>32<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-:1_33-1" class="reference"><a href="#cite_note-:1-33"><span class="cite-bracket">&#91;</span>33<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-35" class="reference"><a href="#cite_note-35"><span class="cite-bracket">&#91;</span>35<span class="cite-bracket">&#93;</span></a></sup> The scientists (<a href="/wiki/Philip_James_Devereaux" title="Philip James Devereaux">Devereaux</a> and McGillion) are now conducting two follow-up studies (PVC-RAM 2<sup id="cite_ref-36" class="reference"><a href="#cite_note-36"><span class="cite-bracket">&#91;</span>36<span class="cite-bracket">&#93;</span></a></sup> and PVC-RAM 3<sup id="cite_ref-37" class="reference"><a href="#cite_note-37"><span class="cite-bracket">&#91;</span>37<span class="cite-bracket">&#93;</span></a></sup>) to investigate secondary findings of PVC RAM1. </p> <div class="mw-heading mw-heading3"><h3 id="Telemedicine_in_prison_systems">Telemedicine in prison systems</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=15" title="Edit section: Telemedicine in prison systems"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>A forerunner to RPM, Florida first experimented with "primitive" telemedicine use in its <a href="/wiki/Florida_Department_of_Corrections" title="Florida Department of Corrections">prisons</a> during the latter 1980s.<sup id="cite_ref-38" class="reference"><a href="#cite_note-38"><span class="cite-bracket">&#91;</span>38<span class="cite-bracket">&#93;</span></a></sup> Working with Doctors Oscar W. Boultinghouse and Michael J. Davis, from the early 1990s to 2007, Glenn G. Hammack led the <a href="/wiki/University_of_Texas_Medical_Branch" title="University of Texas Medical Branch">University of Texas Medical Branch</a>'s development of a pioneering telehealth program in <a href="/wiki/Texas_Department_of_Criminal_Justice" title="Texas Department of Criminal Justice">Texas state prisons</a>.<sup id="cite_ref-39" class="reference"><a href="#cite_note-39"><span class="cite-bracket">&#91;</span>39<span class="cite-bracket">&#93;</span></a></sup> Many of the studies conducted on telehealth have focused on the effectiveness in rural or remote communities so an article published by plos one looked at a study done focusing on the effectiveness of telehealth in the prison system. This review looked at 29 different studies that all utilized telehealth in the prison slightly different. The parameters and interventions delivered varied causing the outcomes to vary. The overall systemic review provided mixed evidence on the impact and outcomes of telehealth usage in prisons. Considering the fact, the world population is growing this means so is the prison population which also means the spectrum of health issues is also broadening. This being the main reason for these studies to have been conducted. This leads to the conclusion that more testing and studies must be completed too fully determine the effectiveness in patient outcomes. There was definitely evidence in the studies showing a positive effect from telehealth in the prison system and it did in some cases prove to be effective with positive impacts. It also showed in some cases to be just as effective as normal conventional care. The study stated that the idea to consider is what is being treated and what the context of the situation being addressed is. If the situation is critical, then other measures or responses may be necessary.<sup id="cite_ref-40" class="reference"><a href="#cite_note-40"><span class="cite-bracket">&#91;</span>40<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Veterans_Health_Administration">Veterans Health Administration</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=16" title="Edit section: Veterans Health Administration"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The Veterans Health Administration (VHA), United States' largest integrated healthcare system, is an early adopter which became highly involved in the implementation and evaluation of RPM technologies. It has expanded use of RPM beyond common chronic disease applications, to post-traumatic stress disorder, cancer and palliative care. VHA's findings indicate improvements in a wide range of metrics, including decrease in emergency department visits, hospitalizations, and nursing home admissions.<sup id="cite_ref-coye_6-1" class="reference"><a href="#cite_note-coye-6"><span class="cite-bracket">&#91;</span>6<span class="cite-bracket">&#93;</span></a></sup> Findings from the VHA Care Coordination/Home Telehealth program show that RPM deployment resulted in significant savings to the organization.<sup id="cite_ref-41" class="reference"><a href="#cite_note-41"><span class="cite-bracket">&#91;</span>41<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Whole_System_Demonstrator_Trial_in_UK">Whole System Demonstrator Trial in UK</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=17" title="Edit section: Whole System Demonstrator Trial in UK"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>The UK's Department of Health's Whole System Demonstrator (WSD)<sup id="cite_ref-42" class="reference"><a href="#cite_note-42"><span class="cite-bracket">&#91;</span>42<span class="cite-bracket">&#93;</span></a></sup> launched in May 2008. It is the largest randomised control trial of <a href="/wiki/Telehealth" title="Telehealth">telehealth</a> and telecare in the world, involving 6191 patients and 238 GP practices across three sites, <a href="/wiki/London_Borough_of_Newham" title="London Borough of Newham">Newham</a>, <a href="/wiki/Kent" title="Kent">Kent</a> and <a href="/wiki/Cornwall" title="Cornwall">Cornwall</a>. The trials were evaluated by: <a href="/wiki/City_University_London" class="mw-redirect" title="City University London">City University London</a>, <a href="/wiki/University_of_Oxford" title="University of Oxford">University of Oxford</a>, <a href="/wiki/University_of_Manchester" title="University of Manchester">University of Manchester</a>, <a href="/wiki/Nuffield_Trust" title="Nuffield Trust">Nuffield Trust</a>, <a href="/wiki/Imperial_College_London" title="Imperial College London">Imperial College London</a> and <a href="/wiki/London_School_of_Economics" title="London School of Economics">London School of Economics</a>. </p> <ul><li>45% reduction in mortality rates</li> <li>20% reduction in emergency admissions</li> <li>15% reduction in A&amp;E visits</li> <li>14% reduction in elective admissions</li> <li>14% reduction in bed days</li> <li>8% reduction in tariff costs</li></ul> <p>In the UK, the Government's Care Services minister, Paul Burstow, has stated that <a href="/wiki/Telehealth" title="Telehealth">telehealth</a> and telecare would be extended over the next five years (2012-2017) to reach three million people.<sup id="cite_ref-43" class="reference"><a href="#cite_note-43"><span class="cite-bracket">&#91;</span>43<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Limitations">Limitations</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=18" title="Edit section: Limitations"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>RPM is highly dependent on the individual's motivation to manage their health. Without the patient's willingness to be an active participant in their care, RPM implementation will likely fail. The shift of accountability associated with RPM brings up liability issues.<sup id="cite_ref-smith_17-2" class="reference"><a href="#cite_note-smith-17"><span class="cite-bracket">&#91;</span>17<span class="cite-bracket">&#93;</span></a></sup> There are no clear guidelines in respect to whether clinicians have to intervene every time they receive an alert regardless of the urgency. The continuous flow of patient data requires a dedicated team of <a href="/wiki/Health_care_providers" class="mw-redirect" title="Health care providers">health care providers</a> to handle the information, which may, in fact, increase the workload. Although technology is introduced with the intent to increase efficiency, it can become a barrier to some healthcare providers that are not technological. There are common obstacles that health informatics technologies encounter that applies to RPM. Depending on the <a href="/wiki/Comorbidities" class="mw-redirect" title="Comorbidities">comorbidities</a> monitored, RPM involves a diverse selection of devices in its implementation. Standardization is required for data exchange and interoperability among multiple components. Furthermore, RPM deployment is highly dependent on an extensive <a href="/wiki/Wireless_telecommunications" class="mw-redirect" title="Wireless telecommunications">wireless telecommunications</a> infrastructure, which may not be available or feasible in rural areas. Since RPM involves transmission of sensitive patient data across telecommunication networks, <a href="/wiki/Information_security" title="Information security">information security</a> is a concern.<sup id="cite_ref-smith_17-3" class="reference"><a href="#cite_note-smith-17"><span class="cite-bracket">&#91;</span>17<span class="cite-bracket">&#93;</span></a></sup> Debate surrounds the potential <a href="/wiki/Cybersecurity_standards" class="mw-redirect" title="Cybersecurity standards">cybersecurity</a> issues of RPM, including the likelihood of hacks which could pull personal medical data.<sup id="cite_ref-Ondiege_2017_44-0" class="reference"><a href="#cite_note-Ondiege_2017-44"><span class="cite-bracket">&#91;</span>44<span class="cite-bracket">&#93;</span></a></sup> Additionally, most remote monitoring devices are limited to single-user applications, and could be expanded in the future for better inclusion of multi-user technologies.<sup id="cite_ref-Ondiege_2017_44-1" class="reference"><a href="#cite_note-Ondiege_2017-44"><span class="cite-bracket">&#91;</span>44<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Reimbursement">Reimbursement</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=19" title="Edit section: Reimbursement"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <div class="mw-heading mw-heading3"><h3 id="United_States">United States</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=20" title="Edit section: United States"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Since 2020, <a href="/wiki/Medicare_(United_States)" title="Medicare (United States)">Medicare</a> fully covers doctors and other medical staff receiving payment for RPM patient setup and training. This is then followed by a fixed monthly amount for operating health monitoring devices and logging patient readings. <a href="/wiki/Medicaid" title="Medicaid">Medicaid</a> also covers these procedures in 34 states.<sup id="cite_ref-45" class="reference"><a href="#cite_note-45"><span class="cite-bracket">&#91;</span>45<span class="cite-bracket">&#93;</span></a></sup> </p><p><a href="/wiki/Cigna" title="Cigna">Cigna</a>, <a href="/wiki/Humana" title="Humana">Humana</a> and <a href="/wiki/UnitedHealth_Group" title="UnitedHealth Group">UnitedHealth Care</a> are among the large private U.S. private health insurance companies that offer members to track certain health data, such as blood pressure, glucose values and other metrics, and send them to their virtual primary care providers who can review the data during patient visits. Some of these plans include coverage of the use of medical devices for remote patient monitoring.<sup id="cite_ref-46" class="reference"><a href="#cite_note-46"><span class="cite-bracket">&#91;</span>46<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading3"><h3 id="Germany">Germany</h3><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=21" title="Edit section: Germany"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Digital health applications (known as DiGA in German: "Digitale Gesundheitsanwendungen") have been eligible for nationwide insurance coverage since the end of 2019 through a fast-track application process.<sup id="cite_ref-47" class="reference"><a href="#cite_note-47"><span class="cite-bracket">&#91;</span>47<span class="cite-bracket">&#93;</span></a></sup> <a href="/wiki/Medical_device" title="Medical device">Medical devices</a> that are used for remote patient monitoring through apps, have to be considered Category I (low risk) or IIa (low-medium risk) to be eligible.<sup id="cite_ref-48" class="reference"><a href="#cite_note-48"><span class="cite-bracket">&#91;</span>48<span class="cite-bracket">&#93;</span></a></sup> Telehealth and coaching, even when combined with remote patient monitoring through wearables, is not directly covered by the DiGA directive, but needs to be reimbursed separately under different provisions.<sup id="cite_ref-49" class="reference"><a href="#cite_note-49"><span class="cite-bracket">&#91;</span>49<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="Controversy">Controversy</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=22" title="Edit section: Controversy"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <p>Published by the <a href="/wiki/New_England_Journal_of_Medicine" class="mw-redirect" title="New England Journal of Medicine">New England Journal of Medicine</a>, a randomized controlled trial involving congestive heart failure patients concluded that the use of telemonitoring failed to provide a benefit over usual care.<sup id="cite_ref-chan_50-0" class="reference"><a href="#cite_note-chan-50"><span class="cite-bracket">&#91;</span>50<span class="cite-bracket">&#93;</span></a></sup> The telemonitoring patient group was instructed to call a designated number daily, and answer a series of questions about their symptoms using a keypad.<sup id="cite_ref-chan_50-1" class="reference"><a href="#cite_note-chan-50"><span class="cite-bracket">&#91;</span>50<span class="cite-bracket">&#93;</span></a></sup> Clearly, the process described by Chaudhry et al. (2010) differs from the RPM methodology illustrated in the overview, which involves actual collection and transmission of physiological data through point-of-care devices. With articles<sup id="cite_ref-51" class="reference"><a href="#cite_note-51"><span class="cite-bracket">&#91;</span>51<span class="cite-bracket">&#93;</span></a></sup><sup id="cite_ref-52" class="reference"><a href="#cite_note-52"><span class="cite-bracket">&#91;</span>52<span class="cite-bracket">&#93;</span></a></sup> from <a href="/wiki/Forbes" title="Forbes">Forbes</a> associating RPM with the negative findings by Chaudhry et al. (2010), it may be difficult to clear the misconception that telemonitoring is synonymous with remote patient monitoring. Researchers at the Semnan University of Medical Science have determined that while Remote Patient Monitoring is a more feasible type of care for elderly people at home, especially during a difficult period like the ongoing COVID-19 pandemic, it is difficult for physicians to maintain control over their care while not under their supervision.<sup id="cite_ref-53" class="reference"><a href="#cite_note-53"><span class="cite-bracket">&#91;</span>53<span class="cite-bracket">&#93;</span></a></sup> The lack of standardization of RPM nomenclature and definition makes it difficult to differentiate between different forms of patient monitoring involving technology. Different forms of RPM have varying effectiveness, with researchers supporting more resources going towards developing technologies which counter the pitfalls of these methods.<sup id="cite_ref-Noah_2018_9-1" class="reference"><a href="#cite_note-Noah_2018-9"><span class="cite-bracket">&#91;</span>9<span class="cite-bracket">&#93;</span></a></sup> </p> <div class="mw-heading mw-heading2"><h2 id="See_also">See also</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=23" title="Edit section: See also"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <ul><li><a href="/wiki/Biotelemetry" title="Biotelemetry">Biotelemetry</a></li> <li><a href="/wiki/Telehealth" title="Telehealth">Telehealth</a></li> <li><a href="/wiki/EHealth" title="EHealth">eHealth</a></li> <li><a href="/wiki/MHealth" title="MHealth">mHealth</a></li></ul> <div class="mw-heading mw-heading2"><h2 id="References">References</h2><span class="mw-editsection"><span class="mw-editsection-bracket">[</span><a href="/w/index.php?title=Remote_patient_monitoring&amp;action=edit&amp;section=24" title="Edit section: References"><span>edit</span></a><span class="mw-editsection-bracket">]</span></span></div> <style data-mw-deduplicate="TemplateStyles:r1239543626">.mw-parser-output .reflist{margin-bottom:0.5em;list-style-type:decimal}@media screen{.mw-parser-output .reflist{font-size:90%}}.mw-parser-output .reflist .references{font-size:100%;margin-bottom:0;list-style-type:inherit}.mw-parser-output .reflist-columns-2{column-width:30em}.mw-parser-output .reflist-columns-3{column-width:25em}.mw-parser-output .reflist-columns{margin-top:0.3em}.mw-parser-output .reflist-columns ol{margin-top:0}.mw-parser-output .reflist-columns li{page-break-inside:avoid;break-inside:avoid-column}.mw-parser-output .reflist-upper-alpha{list-style-type:upper-alpha}.mw-parser-output .reflist-upper-roman{list-style-type:upper-roman}.mw-parser-output .reflist-lower-alpha{list-style-type:lower-alpha}.mw-parser-output .reflist-lower-greek{list-style-type:lower-greek}.mw-parser-output .reflist-lower-roman{list-style-type:lower-roman}</style><div class="reflist"> <div class="mw-references-wrap mw-references-columns"><ol class="references"> <li id="cite_note-Wicklund_2021-1"><span class="mw-cite-backlink">^ <a href="#cite_ref-Wicklund_2021_1-0"><sup><i><b>a</b></i></sup></a> <a href="#cite_ref-Wicklund_2021_1-1"><sup><i><b>b</b></i></sup></a></span> <span class="reference-text"><style data-mw-deduplicate="TemplateStyles:r1238218222">.mw-parser-output cite.citation{font-style:inherit;word-wrap:break-word}.mw-parser-output .citation q{quotes:"\"""\"""'""'"}.mw-parser-output .citation:target{background-color:rgba(0,127,255,0.133)}.mw-parser-output .id-lock-free.id-lock-free a{background:url("//upload.wikimedia.org/wikipedia/commons/6/65/Lock-green.svg")right 0.1em center/9px no-repeat}.mw-parser-output .id-lock-limited.id-lock-limited a,.mw-parser-output .id-lock-registration.id-lock-registration a{background:url("//upload.wikimedia.org/wikipedia/commons/d/d6/Lock-gray-alt-2.svg")right 0.1em center/9px no-repeat}.mw-parser-output .id-lock-subscription.id-lock-subscription a{background:url("//upload.wikimedia.org/wikipedia/commons/a/aa/Lock-red-alt-2.svg")right 0.1em center/9px no-repeat}.mw-parser-output .cs1-ws-icon a{background:url("//upload.wikimedia.org/wikipedia/commons/4/4c/Wikisource-logo.svg")right 0.1em center/12px no-repeat}body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-free a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-limited a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-registration a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .id-lock-subscription a,body:not(.skin-timeless):not(.skin-minerva) .mw-parser-output .cs1-ws-icon a{background-size:contain;padding:0 1em 0 0}.mw-parser-output .cs1-code{color:inherit;background:inherit;border:none;padding:inherit}.mw-parser-output .cs1-hidden-error{display:none;color:var(--color-error,#d33)}.mw-parser-output .cs1-visible-error{color:var(--color-error,#d33)}.mw-parser-output .cs1-maint{display:none;color:#085;margin-left:0.3em}.mw-parser-output .cs1-kern-left{padding-left:0.2em}.mw-parser-output .cs1-kern-right{padding-right:0.2em}.mw-parser-output .citation .mw-selflink{font-weight:inherit}@media screen{.mw-parser-output .cs1-format{font-size:95%}html.skin-theme-clientpref-night .mw-parser-output .cs1-maint{color:#18911f}}@media screen and (prefers-color-scheme:dark){html.skin-theme-clientpref-os .mw-parser-output .cs1-maint{color:#18911f}}</style><cite id="CITEREFWicklund2021" class="citation web cs1">Wicklund E, ed. 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class="mw-cite-backlink"><b><a href="#cite_ref-53">^</a></b></span> <span class="reference-text"><link rel="mw-deduplicated-inline-style" href="mw-data:TemplateStyles:r1238218222"><cite id="CITEREFBahariniyaAsarMadadizadeh2021" class="citation journal cs1">Bahariniya S, Asar ME, Madadizadeh F (2021-03-31). <a rel="nofollow" class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8150075">"COVID-19: Pros and cons of different caring techniques of elderly patients"</a>. <i>Journal of Education and Health Promotion</i>. <b>10</b>: 87. <a href="/wiki/Doi_(identifier)" class="mw-redirect" title="Doi (identifier)">doi</a>:<span class="id-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="https://doi.org/10.4103%2Fjehp.jehp_1536_20">10.4103/jehp.jehp_1536_20</a></span>. <a href="/wiki/PMC_(identifier)" class="mw-redirect" title="PMC (identifier)">PMC</a>&#160;<span class="id-lock-free" title="Freely accessible"><a rel="nofollow" class="external text" href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8150075">8150075</a></span>. <a href="/wiki/PMID_(identifier)" class="mw-redirect" title="PMID (identifier)">PMID</a>&#160;<a rel="nofollow" class="external text" href="https://pubmed.ncbi.nlm.nih.gov/34084834">34084834</a>.</cite><span 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