Telemonitoring in general practice

Reviewed: 14.07.25

Chronic conditions account for 60-70 per cent of all deaths worldwide and are the leading cause of inequality in health outcomes across social groups.

As the prevalence of chronic illness continues to increase with our aging population, remote home telehealth monitoring is emerging as a possible means of delivering care in a more cost effective and patient-centred way, while overcoming problems of inaccessibility (Waitemata DHB, n.d.).

A Waitemata DHB review (n.d.) of a remote home monitoring trial that ran from 2010-2012 demonstrated:

• patients feel looked after and safe
• patients become more knowledgeable about their condition and are better able to self-manage
• patients can access care more easily, and in a more timely way
• families are more included in care
• clinical staff involved are not only able to share roles more widely, but also feel the service adds value to patient care.

There is debate and ongoing research needed to demonstrate the impact of telemonitoring on hard outcomes like morbidity and mortality. Wherever a programme needs significant resources, a focused and deliberate pro-equity approach is needed to avoid increasing inequity of access to the poor and marginalised. Internationally, home monitoring devices have proven effective at reducing ED visits, hospital admissions and mortality, while improving experiences of care and confidence in self-management of chronic disease (Martin-Lesende et al., 2017).

A meta-analysis of 15 systematic reviews of telemonitoring among heart failure patients showed that home telemonitoring interventions reduce the relative risk of all-cause mortality (0.60 to 0.85) and heart failure-related hospitalizations (0.64 to 0.86) compared with usual care (Kitsiou et al., 2015).

In 2021 Pinnacle completed its own telemonitoring pilot, aimed at exploring the use of remote monitoring. Overall both patients and clinicians found the service to be valuable, while the findings suggest telemonitoring has the most impact for patients with severe illness.

At-home telemonitoring readings alerted clinicians to changes in a patient’s condition earlier, with one GP noting that the biggest impact was seen when earlier intervention prevented hospitalisation or a more severe case of hospitalisation.

This resource

The aim of this document is to share our key learnings and help you implement a telemonitoring service in your practice if you choose to do so.

• How telehealth monitoring may work for your practice, including specific requirements and processes.
• A break down of options for telemonitoring implementation.
• A list of potential partners that can help with implementation if you choose to proceed.

We hope you find it useful.