The era of patient-centered health care is being ushered in quietly with wearable technology and telemonitoring of home medical devices. Many advances in health care technology are aimed at older adults, not only because of the vast market potential but also because older adults prefer convenient home monitoring of their chronic conditions to the long waits associated with traditional access to health care in the medical office. In addition, some technologies in the home can assist older adults to "age in place," supported by smart appliances and memory support. For older adults and their families to use health technologies, devices must be easy to use, meet a medical need without being cost-prohibitive, and preserve their privacy and security (Wang, 2018).

Wearable technology is a classification of mobile technology integrated into clothing or accessories to collect data or deliver a service while being worn. For example, smartwatches combine the functions of a watch with a fitness tracker and heart rate monitor. Other more elegant solutions are under development at universities around the globe, including contact lenses that deliver eye medications (Deng et al., 2018), contact lenses that monitor glucose levels (Garvey, 2009), and smartwatches paired with smartphones that measure glucose levels continuously and trigger alerts when abnormal levels are detected (Medgadget, 2018).

TELEMONITORING DEVICES

Telemonitoring has wide applications for older adults, for whom falls are common and problematic events. Existing alert technologies use an emergency button worn around the neck of a person at risk for falls that is pressed whenever a person needs help or has fallen. Where these products are lacking is the ability to alert family members or health care providers before a fall occurs. With new systems, video cameras and sensors are used to detect when a person is at a higher risk of falling (Phillips et al., 2017) based on a slowing gait and shorter stride length as compared to baseline. Other monitoring devices look for changes in the activity levels of older adults and send alerts to family members about these changes (Medgadget, 2019). And some provide an automatic light at night when a person is detected getting out of bed; if the older adult goes to the bathroom at night more frequently than baseline, this could indicate an illness, which, if left untreated, puts the older adult at risk for a fall.

With diminished sensory function (sense of smell and visual acuity) experienced by older adults, food safety can become a problem. Sensors are being developed to detect the ripeness of food and send the data to an app that reports its estimated shelf life (Fraunhofer-Gesellschaft, 2019). These sensors can also be an important adjunctive monitoring device for older adults with mild cognitive impairment and their family members.

Older adults on warfarin no longer require monthly visits to check their home prothrombin time using international normalized ratio (INR) levels. Rather, devices send INR levels to cloud-based storage that can be accessed by health care providers. While home testing for INR levels has been covered by Medicare since 2008 (Centers for Medicare & Medicaid Services, 2008), it is becoming more convenient, reducing the burden of testing for older adults and their health care providers.

There are now devices that allow home monitoring of electrocardiograms (ECG). The AppleWatch Series 4 provides a single-lead ECG that can be shared with health care providers. In addition, QT Medical has developed a hospital-grade 12-lead ECG device that can detect rhythm disturbances, ischemia, and myocardial infarction at home (http://www.qtmedical.com). With the device held in one hand, the leads are fitted into flexible soft strips to fit over the precordium, single soft leads on the right and left shoulders, and the left hip. The device sends an ECG strip to the user's smartphone that communicates with the health care provider via a cloud platform. A less intrusive ECG monitor has been developed by a research team from Rochester Institute of Technology (Conn, Schwarz, & Borkholder, 2019). The team devised a toilet seat with sensors embedded in the seat to measure blood pressure, stroke volume, peripheral oxygenation, heart rate, heart rate variability, and cardiac electrical waveform analysis. The toilet seat measures body weight when lifting feet off the floor. So far, blood pressure, stroke volume, and peripheral oxygenation have been validated with hospital-based monitoring of those parameters.

Development of technologies to conduct "home visits" for the diagnosis and treatment of illnesses is becoming a common feature used by insurance plans to decrease the cost of care. For example, a Blue Cross Blue Shield plan offers a platform for videoconferencing with a health care provider to decide if an office visit or hospitalization is needed. The startup company, Tyto, recently received FDA approval for the use of its device by individuals and their health care providers to conduct a health history and physical exam (https://www.tytocare.com). The device has attachments to examine the ears, mouth, heart, lungs, and abdomen. The data are transferred in real time to a provider using a smartphone, offering a way to have an office visit in the home.

Taking telemonitoring a huge step further, Medically Home (http://www.medicallyhome.com) has developed a business plan to place medical equipment with telemonitoring in the homes of patients who need hospitalization. Eligibility for the services includes individuals with heart failure, pneumonia and other respiratory infections, urinary tract infections, cellulitis, and a few other diagnoses. There is scant research on the safety and effectiveness of home-based hospital care; therefore, nurse researchers should follow these technology developments and plan for effectiveness studies.

IMPLICATIONS FOR NURSING EDUCATION

The advances in wearable technology and home-based monitoring require nurse educators to teach students across all levels to anticipate the use of such devices or to suggest relevant and helpful technologies to keep older adults in their homes longer. For example, in a clinical rotation on orthopedics, a nursing student might suggest the use of a fall detection device for an older adult who had sustained a fall with injuries. A family nurse practitioner student who recognizes that an older adult is having trouble remembering to take medications might suggest using a smart medication organizer with an alert system. A student in a PhD program might develop new technology and test the effectiveness of the device in promoting safety in the home. At a minimum, nursing programs should include these emerging technologies in their informatics courses at all levels or weave the information into the curriculum at points such as in a community health course in an undergraduate program or in a module on syndromes in the older adult population. The students we teach today will likely become the leaders with mobile technology and telehealth.

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