Telemonitoring for Chronic Heart Failure: Narrative Review of the 20-Year Journey From Concept to Standard Care in Germany
Authors: Spethmann Sebastian , Hindricks Gerhard , Koehler Kerstin , Stoerk Stefan , Angermann Christiane E , Böhm Michael , Assmus Birgit , Winkler Sebastian , Möckel Martin , Mittermaier Mirja , Lelgemann Monika , Reuter Daniel , Bosch Ralph , Albrecht Alexander , von Haehling Stephan , Helms Thomas M , Sack Stefan , Bekfani Tarek , Gröschel Jan Wolfgang , Koehler Magdalena , Melzer Christoph , Wintrich Jan , Zippel-Schultz Bettina , Ertl Georg , Vogelmeier Claus , Dagres Nikolaos , Zernikow Jasmin , Koehler Friedrich 
Published: September 2024

Background
Chronic heart failure (CHF) is a major cause of morbidity and mortality worldwide, placing a significant burden on health care systems. The concept of telemedicine for CHF was first introduced in the late 1990s, and since 2010, studies have demonstrated its potential to improve patient outcomes and reduce health care costs. Over the following decade, technological advancements and changes in health care policy led to the development of more sophisticated telemedicine solutions for CHF, including remote patient management through invasive or noninvasive telemonitoring devices, mobile apps, and virtual consultations. Years of public funding in Germany have generated evidence that remote patient management improves outcomes for patients with CHF, such as quality of life, and reduces hospital admissions. Based on these data, the Federal Joint Committee (Gemeinsamer Bundesausschuss; G-BA) decided, independently of the current European Society of Cardiology recommendations, to incorporate telemedicine as a standard digital intervention for high-risk patients with reduced left ventricular ejection fraction in Germany in 2020.

Objective
This review aims to illustrate the journey from the initial concept through pioneering studies that led to telemedicine’s integration into standard care, and to share current experiences that have positioned Germany as a leader in cardiovascular telemedicine.

Methods
We review and discuss existing literature and evidence on the development and implementation of telemonitoring for CHF in Germany over the past 20 years. Relevant studies, reports, and guidelines were identified through a comprehensive search of electronic databases, including PubMed, Google Scholar, and specialized journals focused on CHF telemonitoring.

Results
Pioneering studies, such as the TIM-HF2 (Telemedical Interventional Management in Heart Failure II) and IN-TIME (Influence of Home Monitoring on Mortality and Morbidity in Heart Failure Patients with Impaired Left Ventricular Function) trials, demonstrated the effectiveness of remote patient management applications for patients with CHF in Germany and their applicability to current practices involving both invasive and noninvasive methods. Collaborations between researchers and technology developers overcame barriers, leading to sustainable improvements in patient care. Ongoing research on artificial intelligence applications for prioritizing and interpreting individual health data will continue to transform digital health care.

Conclusions
The establishment of telemedical care for patients with HF across Europe is likely to benefit from experiences in Germany, where significant improvements have been achieved in the care of patients with HF.