After being diagnosed with heart failure two years ago, David made a slight adjustment to his morning routine.

Since then, the first thing the 75-year-old Toronto resident does upon waking every day is activate an app on his smartphone called Medly. Next, he weighs himself, takes his blood pressure and measures his heart rate, using a Bluetooth-enabled scale and cuff. Results are automatically transmitted to the app.

Following that, David answers a handful of yes/no questions asked by Medly, related to common heart-failure symptoms. Among them: Is he feeling fatigued today? Is he short of breath? Are his ankles swollen?

Thanks to a sophisticated and personalized algorithm, the app can automatically detect subtle, but concerning changes in David’s heart-failure symptoms. What’s more, it can tell him how to respond.

For example, if David’s weight suddenly rises, that could indicate fluid retention, a common and concerning symptom, signalling worsening heart failure. Medly would send him an alert advising him to take a water pill to help his kidneys shed excess fluid and salt, thereby making it easier for his heart to pump.

For very serious symptom changes, for example fainting, the app would send an alert advising him to immediately go to an emergency department or call 911.

“There is no question that if anything turns up, the app will let me know. I feel quite comfortable knowing that the Medly system is keeping an eye on me,” exclaims David, a pseudonym. He asked that his real name not be published because he doesn’t want to make his confidential health information public.

David is one of 350 heart-failure patients in the Medly program, which was launched just over three years ago at the Peter Munk Cardiac Centre at Toronto General Hospital, part of the University Health Network. By enabling early interventions in response to symptom changes, the program has resulted in dramatic improvements to patients’ health and reductions in their use of hospitals.

That’s significant because heart failure is the number one reason for hospitalization in Canada.

With Medly, heart failure-related hospitalizations have been cut in half and symptoms have improved. A biomarker for heart failure — B-Type Natriuretic Peptide — has dropped by 59 per cent. The biomarker is a protein hormone in the blood that decreases in value when heart failure stabilizes. Other measurements have shows significant improvements in quality of life and self-care.

The Medly program will soon be expanded to Toronto Western Hospital, another campus of the University Health Network. Plans are also in the works to roll it out to the Weeneebayko Area Health Authority, which provides health-care services along the eastern coasts of James Bay and Hudson Bay, including to many underserved Indigenous communities.

Given Medly’s success, its creators have pitched the Ontario government on expanding its usage provincewide.

It fits with the government’s goal of using technology to make the health system more efficient, said world-renowned cardiologist Dr. Heather Ross, division head of cardiology at the Peter Munk Cardiac Centre.

“We have to change the way we are delivering care because what we are doing now is very expensive. It is tertiary and quaternary-centre focused,” she said, explaining that the health system is too focused on treating patients once they become acutely ill and end up in hospital.

“It’s not putting the patient first,” she continued, noting that the health system needs to do more to keep patients as healthy as possible and out of hospital.

Heart failure is a condition that develops when the heart muscle is not strong enough to pump as well as it should.

Ross refers to heart failure as an “epidemic,” noting that more than one million Canadians suffer from it. One in five Canadians over age 40 has a lifetime risk of developing heart failure. Half will die within five years of diagnosis.

In the first year after diagnosis, a patient is hospitalized for an average of 26 days.

The genesis of Medly dates back almost nine years when Ross was approached by student Emily Seto, who was then working on her PhD in health informatics at the University of Toronto. Seto proposed doing her doctorate on telemonitoring technology.

Ross liked the idea because it checked a number of boxes. First, it aligned with the province’s goal of stretching every health dollar further.

Second, many patients stood to benefit. There are 350,000 patients with heart failure in Ontario and an “inordinate number” of them are not on “guideline-directed medical therapy,” meaning they are not on the right medication regimens, Ross said.

“That correlates with their risk of dying,” she warned.

Medly can help in adjusting medication doses. Drug titration for heart-failure patients can take up to 10 weeks, requiring hospital visits every two weeks. For patients in northern Ontario, that would mean frequent and expensive flights to Toronto or long drives with pricey parking fees.

But with the app, patients don’t need to travel to get their prescriptions tweaked. The eight cardiologists who are now working with Medly can adjust prescriptions with guidance of the symptom changes they see on the app.

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If there is a need for a Toronto-based cardiologist to speak with a northern Ontario patient, it is possible for the Medly program to be complemented with video visits via teleconferencing.

Medly allows cardiologists to expand their reach, use their time more efficiently and see more patients.

Ross pointed out that heart-failure patients typically have appointments with their cardiologists every six months, even when stable. But with Medly, the stable patients don’t need to make as many office visits.

“If I can avoid visits that patients don’t need to see me for, like uptitration of medication, it will increase my capacity to see other patients,” Ross said.

The app also extends the reach of registered nurse Mary O’Sullivan, clinical co-ordinator of the program. From a dashboard on her computer, she can manage all 350 patients in the program, an unusually large caseload for a single nurse.

“The algorithm is what really makes it manageable,” O’Sullivan said, explaining how Medly is programmed to meet each patient’s need.

Any alert that goes to a patient, signalling concern with a symptom change, also goes to O’Sullivan and to the patient’s cardiologist. O’Sullivan gets about 60 alerts in a morning. Most are for issues that patients can handle themselves, such as changing water-pill doses.

O’Sullivan triages the alerts, attending to the most urgent ones first. Fewer than one per cent are deemed critical. Those might involve patients who have fainted or whose pacemakers have activated because of irregular heart rhythms.

O’Sullivan usually ends up speaking over the phone to about half the patients who were alerted for reasons such as high heart rates, low blood pressure or irregular heart rhythms. She liaises with their cardiologists on response plans, which could involve medication changes, appointments at the heart function clinic or some education on heart failure.

“It’s cool. I think this is the future. There are so many patients who live remotely but still need this high-touch care,” O’Sullivan exclaimed. “It’s like having a direct line to doctors like Heather Ross. In the past, that wasn’t possible.”

Since he began using the app, David has received only one alert. The app detected that his blood pressure was low, and he received an alert on his phone, asking how he was feeling. He checked his blood pressure later in the day and it was fine.

David said the daily tracking of his weight, blood pressure, heart rate and symptoms helps him stay on top of his health.

“It creates an awareness. I have to stay trim, exercise and watch what I eat,” he said.

“I’m feeling great. I’m in better shape than I have ever been,” he added, noting that he is participating in master swimming competitions.

Work to improve Medly is ongoing. A new partnership has been formed between the Peter Munk Cardiac Centre and the University of Toronto’s Vector Institute for Artificial Intelligence to integrate big data and machine-learning algorithms into cardiac care. That will allow Medly’s algorithm to be fine-tuned.

“Patients have told us that they feel safe with Medly. It isn’t that we have put an app between us and the patient. We have created an extension of our program into the patient’s environment,” Ross said.