Education, proper technology needed for success
(Editor’s note: This is the first of a two-part series that looks at telemedicine in home health. In this article, representatives from two agencies describe their programs and specific issues related to choosing technology and patients who are appropriate for telemedicine. In next month’s article, some of the financial aspects of telemedicine will be presented, including tips on funding programs.)
Telehealth is not a new concept to the home health patients of the Visiting Nurse Association (VNA) of Houston. Some form of telehealth has been in place for many years to help patients monitor themselves. But as technology has changed, so has the VNA Houston program. "We started our program with videophone hookups but switched to a link that did not utilize video a little more than two years ago," says Sandy McNeely, RN, MSN, telemonitoring program manager for the agency.
While the video hookup seemed attractive to many clinicians who believed they needed the eye-to-eye contact to assess their patients’ conditions, many patients were not comfortable being on screen and were timid as they talked with the nurse, she explains. "Financially, it did not create a great savings in time or dollars because we still had to have a nurse talking with the patient throughout the visit," says McNeely. While the time and expense of travel to patients’ homes was eliminated, the reluctance of patients to allow a videophone hookup in their home reduced the effectiveness of the program, she adds.
In 2001, the agency switched to the HomMed Sentry Observer, an alarm-clock-sized monitor that can be plugged into peripheral equipment that measures blood pressure, O2 saturation, weight, glucose, temperature, and heart rate.
"Although we have not needed the capability, the equipment does offer the option of a digital camera hookup to monitor daily wound care," says McNeely. Although her agency chose HomMed in Brookfield, WI, as its supplier, there are many vendors that offer telemedicine technology, she says. (See Telemedicine resources at the end of this article.) "Be sure you take a close look at your own patient population before evaluating telemedicine equipment to make sure that you choose technology that meets your needs," she suggests.
Because her agency has a large population of cardiac patients, McNeely’s telemonitoring program primarily captures information of most interest to them, such as blood pressure and weight, she points out. "We do have some diabetic patients for whom we monitor glucose levels every four hours."
McNeely’s monitors will notify the patient with an alarm when it is time to take a reading. The patient hooks up the appropriate leads or the blood pressure cuff, takes the reading, and transmits the information. The only time the patient’s telephone line is used by the monitor is during transmission, she explains. "This ensures that the patient doesn’t need a special telephone line or an extra line for the monitor," she says.
Teach disease self-management
After the data are transmitted, the reading stays on the monitor’s display for about five minutes to enable patients to record the information in a log that McNeely requires that they keep. "Our goal is to help the patients self-manage their disease, so it is important that they stay aware of their own readings and what a fluctuation in weight might mean," she explains.
Helping patients learn how to manage their conditions is a weak area in many telemedicine programs, says Ann K. Frantz, RN, BSN, director of cardiac program development for Advanced Professional Home Care in Pontiac, MI. "We’ve been doing tele-electrocardiogram monitoring since 1990," she says. "Since we started telemonitoring, the technology has advanced, and we are capable of remotely monitoring many more vital signs. But is it appropriate in all cases?" Frantz asks. "I think it is important that home health agencies take a good look at their patients and their needs and base their choice of technology on what is right for them rather than what the technology companies say is important," she states.
"Because cardiac problems represent the condition for which telemonitoring is most frequently used, it’s important to make sure you are measuring vital signs that give you a chance to identify early exacerbation of the condition," Frantz says. While weight is the most common objective measurement to identify problems, the patient already is suffering from pulmonary edema when the weight gain is noticed, she adds. "We try to ask the patient if he or she is experiencing a bloated feeling, lack of hunger, or trouble sleeping to identify problems before the weight gain, but patients don’t always recognize these symptoms," she adds.
For this reason, Frantz is monitoring patients’ pulmonary status with a device manufactured by Wantagh in Bristol, PA. "The monitor is about the size of a videotape, and the patient attaches two electrodes to take the reading," she says. The equipment measures electrical impedance changes throughout the thorax as aortic blood volume increases and decreases in response to the beating of the heart. The patient then writes the reading into his or her logbook and reports the reading when the nurse calls. "We base the number of times the nurse calls each week on the patient," Frantz adds. "We call every day during the first week the patient is on the monitor, then reduce the calls to a point at which the nurse and the patient are comfortable." Because the patients are so tuned into their readings, they will call the nurse if they notice a slight increase, she says.
Patient education essential
Along with teaching the patient how to use the monitor, the nurse gives extensive education on what can cause pulmonary edema, Frantz says. Patients who experience an increase in thoracic impedance are asked about their diet on the previous day to determine what might have caused the fluid retention.
"Our patients are quick to realize that the extra pickles they ate at the birthday cookout for their family member might be the reason for the increase." The benefit to catching the fluid retention before it causes weight gain is that simple treatments such as a serving of asparagus, a natural diuretic, or an extra dose of a diuretic such as furosemide, she points out.
Because her monitoring program relies upon the patient to take readings and report them to the nurse over the phone, education is important, Frantz says. "We want the patients to be active participants in their care so we make sure that we teach them at the beginning of care and throughout the monitoring in conversations and visits with the nurse," she says.
The key benefit to using telemonitoring, especially for cardiac patients, is that you can reduce the number of hospitalizations and better care for the patient, McNeely points out. "It was important for us to show our physicians how our program could provide trend data that give an accurate picture of their patients’ health and how early intervention will keep their patients from experiencing an acute episode that requires hospitalization or a visit to the emergency room," she adds.
While not all patients are appropriate for telemonitoring, the ones who are put on a telemonitoring program will appreciate the service, says McNeely. (See how to set guidelines for choosing patients.) "The ability to monitor themselves and understand what the data mean gives the patient and family members confidence in their ability to self-manage the disease."
For more on telemedicine in home health:
• Sandy McNeely, RN, MSN, Telemonitoring Project Manager, Visiting Nurse Association Houston, 2905 Sackett Road, Houston, TX 77098. Telephone: (713) 630-5579. E-mail: [email protected].
• Ann K. Frantz, BSN, RN, Director of Cardiac Program Development, Advanced Professional Home Care, 1787 W. Big Beaver Road, Troy, MI 48084. Telephone: (248) 649-5250. E-mail: [email protected].]
Telemedicine resources
• American Telemedicine Association, 910 17th St., N.W., Suite 314, Washington, DC 20006. Telephone: (202) 223-3333. Fax: (202) 223-2787. Web site: www.americantelemed.org. The organization’s web site contains a library of guidelines and resource material related to telemedicine as well as links to related sites.
• Wantagh, 2014 Ford Road, Unit G, Bristol, PA 19007. Telephone: (215) 826-9998. Fax: (215) 826-8102. Web site: www.wantagh-inc.com. Company produces monitor that can be used by home care patients to measure cardiac impedance.
The following companies offer telemedicine products and services to the home health industry:
• AMD Telemedicine, 67 Middle St., Lowell, MA 01852. Telephone: (800) 742-1674 or (978) 937-9021. Fax: (978) 937-5249. Web site: www.amdtelemedicine.com.
• American TeleCare, 7640 Golden Triangle Drive, Eden Prairie, MN 55344. Telephone: (800) 323-6667 or (952) 897-0000. Fax: (952) 944-2247. Web site: www.americantelecare.com.
• HealthCare Vision, 2601 Scott Ave., Suite 600, Fort Worth, TX 76103. Telephone: (888) 836-7428 or (817) 531-8992. Fax: (817) 531-2360. Web site: www.healthcare-vision.com.
• Health Hero Network, 2570 W. El Camino Real, Suite 111, Mountain View, CA 94040. Telephone: (650) 559-1000. Fax: (650) 559-1050. Web site: www.healthhero.com.
• HomMed, 19275 W. Capitol Drive, Suite 200, Brookfield, WI. Telephone: (888) 353-5440 or (262) 783-5440. Web site: hommed.com.
This is the first of a two-part series that looks at telemedicine in home health. In this article, representatives from two agencies describe their programs and specific issues related to choosing technology and patients who are appropriate for telemedicine.
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