21st century tools: Telehomecare cuts staff costs, gathers quality information
Combination of virtual and real visits provides good care
In George Orwell’s 1984, Big Brother was able to look into people’s homes and know what they were doing and how they were feeling. While telehomecare is not as intrusive as the technology Orwell imagined, it does give home health personnel an opportunity to check on patients more frequently without requiring extra staff and travel time.
The Veterans Affairs (VA) Connecticut Healthcare System in West Haven, CT, has used telehomecare since an initial pilot project in 1997. Patients with chronic conditions that typically require frequent home health visits or trips to VA clinics were included in the study, says Donna Vogel, MSN, director of continuing care and case management for the system. "Congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease patients were included because we believed that ongoing monitoring would result in timely intervention that would reduce the number of visits needed and the number of admissions to the hospital," she explains.
The VA pilot study did show a 21% decrease in emergency department, clinic, and home health visits for the group receiving telehome visits during a six-month period. This translated to a $200 per-patient savings over the per-patient cost of the control group, she says.
The VA telehomecare system uses Internet-based technology to create a link between the patient and the case manager. A monitor that uses touch-screen technology is placed in the patient’s home. Along with the monitor, different attachments are available to measure temperature, blood pressure, and weight. "We can tailor each patient’s system with the attachments that capture the vital signs we need," says Vogel. "A pulse oximeter, EKG, stethoscope, and fingerstick glucometer are all available," she adds.
"The patient has a schedule of how often to take vital signs," says Vogel. Because the information travels from the patient’s home to a database that can be accessed through a secure web site, a nurse does not have to be sitting at a terminal for the information, she says. If the patient’s readings are outside parameters that have been preset by the physician, the nurse receives a message as soon as he or she logs on to the system. "These alerts enable the case manager to immediately check the patient’s information and provide timely intervention," explains Vogel.
In addition to gathering vital sign information, the system also can be used to provide educational information as well as reminders about physician visits and times to take medications, Vogel says. At this time, the messaging capability is one-way from the provider to the patient, she says.
Simple systems also work
The TeleHomeCare Project, coordinated by the University of Minnesota in Minneapolis, has four hospital home health agency participants and has had almost 60 patients use the service, says Stanley Finkelstein, PhD, project coordinator.
"We wanted a system that is relatively inexpensive and offers easy access for most patients," he says. For those reasons, the project chose a system that employs a small box that uses the patient’s television set as a video monitor and connects to the patient’s telephone line. The system’s camera is attached to the box by a 6-foot cable, he explains. The camera can stay in one place as the patient talks to the nurse or it can be moved to show the nurse a swollen ankle or a wound, he explains.
Patients have set appointment times to "meet" with the nurse who can be seen on the television. During the visit, patients report vital signs they have taken with equipment provided by the home health agency, Finkelstein says. The nurses discuss any topic that is normally discussed in a face-to-face visit, he says.
During the testing phase of the project, the virtual visits did not replace actual home visits, he says. "We did not want to take a chance that care would be compromised while we tested the system, and we also wanted to compare the two types of visits." Virtual visits were a little shorter than actual visits but the number of topics and quality of information gathered were the same in both types of visits, he adds.
Obviously, the virtual visits were more cost-effective because the nurse did not have to travel to the patient’s home, Finkelstein adds.
"When we first started telehome visits, nurses were hesitant," Vogel admits. They quickly realized how they could manage the care of a large group of patients more easily, she adds.
Training is necessary to make sure nurses know how to access the information via the web site, she points out. The greatest advantage of the web site-based system is that nurses can check on patients from any location using any computer, she says.
The most important part of training nurses in the Minnesota telehomecare project is to teach them not to move much, Finkelstein says. "Because we are using telephone lines to transmit images, movements are distorted and can be distracting." For this reason, nurses are taught not to talk with their hands and to limit body or head movements. He videotapes some of the virtual visits to use in training nurses so they can see how they look to patients.
Another key to success is to educate patients as well. Not only do they need to understand how to use the equipment, but they also need to know that a telehomecare system is not to be used for emergencies, Vogel points out.
Both Finkelstein and Vogel see great advantages to using telehomecare. Not only do these systems gather information but they can also be used for further patient education.
"The more information patients have, the more closely they will follow their schedule for medications and other treatments," Vogel says.
[For more information about telehomecare projects, contact:
- Donna Vogel, MSN, Director of Continuing Care and Case Management, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT 06516. Telephone: (203) 932-5711, ext. 4387. Fax: (203) 937-3868. E-mail: [email protected].
- Stanley Finkelstein, PhD, Coordinator, TeleHomeCare Project, University of Minnesota, Mayo Mail Code 609, 420 Delaware St. S.E., Minneapolis, MN 55455. Telephone: (612) 625-6406. Fax: (612) 625-2199. E-mail: [email protected].]
Telemedicine Resources
• Telemedicine Information Exchange is a web site that contains information on vendors, funding, news, conferences, and articles related to tele-medicine. There is a section devoted to home health. The Telemedicine Information Exchange is maintained by the Telemedicine Research Center, 2121 S.W. Broadway, Suite 130, Portland, OR 97201. Telephone: (503) 221-1620. Fax (503) 223-7581. Web site: http://tie.telemed.org/.
• The American Telemedicine Association web site contains news updates related to issues such a Medicare reimbursement, as well as publications, clinical guidelines, and other support material. American Telemedicine Association, 910 17th St., N.W., Suite 314, Washington, DC 20006. Telephone: (202) 223-3333. Fax: (202) 223.2787. Web site: www.atmeda.org. E-mail: [email protected]
• The Technology Opportunities Program of the National Telecommunications and Information Administration offers grants to fund research projects utilizing telecommunications or the Internet. The web site has a description of various projects that have been funded as well as information on the grant application process. Technology Opportunities Program, Office of Telecommunications and Information Applications, National Telecommunications and Information Administration, U.S. Department of Commerce, 1401 Constitution Ave., N.W., Room 4092, Washington, DC 20230. Telephone: (202) 482-2048. Fax: (202) 501-5136. Web site: www.ntia.doc.gov/otiahome/top/index.html. E-mail: [email protected]
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