Telemedicine promises better care, cost efficiency
Michigan, Kansas team to study use in hospice
Imagine providing hospice patients with 24-hour access to face-to-face care without bankrupting the organization with home visit costs. That’s the promise researchers in Michigan and Kansas say telemedicine brings to the hospice industry.
In March, Michigan State University (MSU) in East Lansing and the Hospice of Michigan in Southfield announced the launch of a joint project that will study the use of telemedicine on Hospice of Michigan patients.
Researchers will examine the use of the interactive video technology as part of a care program for 40 Hospice of Michigan patients during a two-year period. The goal of the study, which is funded in part by a grant from the National Telecommuni-cation and Information Administration, is to examine the use of technology to eliminate barriers, including geography and cost, to quality end-of-life care.
Technology trial
The Michigan project is part of a bistate study that will examine how the technology can improve hospice care. The University of Kansas is studying the use of telemedicine with Hospice Inc. in Wichita, Hays Home Health and Hospice Center in Hays, and Hospice Services in Phillipsburg.
"We think that telehospice will play a role in enhancing hospice care by increasing the amount of service available to patients. [It will] lift the pressure off hospice providers who are trying to provide greater access to care and relieve some of the costs associated with high-level quality care," says Pamela Whitten, PhD, assistant professor of telecommunications at MSU and lead researcher on the telehospice project in Michigan.
For no extra charge (Medicare reimburses providers who use telemedicine on a limited basis and telehospice is not reimbursed by Medicare), patients will be granted use of a 13-inch television monitor with a camera mounted on the screen. The teams will be able to control the image of the patient using the keypad of the touch-tone phone to enhance the visual interaction. For example, the team nurse will be able to zoom in and take an on-screen snapshot of a medicine bottle held up by a patient or family member.
24-hour access to care
By today’s technology standard, telehospice is relatively simple. It involves the use of standard telephone lines and interactive video technology, including speakerphone, minivideo cameras, and television monitors. Hospice patients who are participating in the study will be able to call members of the hospice or interdisciplinary team for a video consult. That allows patients and their caregivers 24-hour access to a nurse or physician.
If a caregiver is concerned about labored breathing of a loved one, for example, he or she can dial into the system, point the small camera at the patient so a nurse or physician can evaluate the patient’s condition. The clinician can then instruct the patient on the next step and evaluate whether a nurse should visit the home.
Telemedicine is nothing new to the health care industry. For example, since 1986 the Rochester, MN-based Mayo Clinic has had a satellite-based, full-motion video system to unite their clinics with sites around the world. Since then, more than 300 clinical examinations have taken place involving all specialties.
In addition to patient exams, telemedicine is commonly used to interpret electrocardiography, echocardiography, X-ray, and magnetic resonance imaging between remote sites.
Hospices have just recently voyaged into telemedicine. In May 1997, Kendallwood Hospice in Kansas City, MO, embarked on a joint telehospice project with the University of Kansas. This partnership turned out to be the genesis of the bistate telehospice project involving Michigan and Kansas.
"We wanted to see if using telemedicine in a hospice setting was feasible," says Whitten, who was a researcher on the University of Kansas-Kendallwood project.
Going on three years now, the Kendallwood experience has shown that telemedicine not only has applications to hospice, but shows promise in improving care and reducing costs, says Gary Doolittle, MD, director of the University of Kansas Medical Center’s Telemedicine Program. He is also the medical director for both Kendallwood Hospice and Hays Home Health and Hospice Center, and the principal telehospice investigator in Kansas.
Original thinking held that telehospice’s greatest potential was in serving patients in remote areas. Routine telehospice consults could be provided in addition to scheduled home visits without subjecting nurses to additional long drives to patients’ rural homes. Urgent calls could be handled in a timely manner.
"When problems or questions arise, the hospice doctor, nurse, or social worker can see and talk to the patient and family by using the telehospice equipment, assess the situation, and respond more quickly than if they had to drive to the location," Whitten says.
For Kendallwood, which serves a high number of rural patients, the use of telemedicine made sense. The technology was applied to lessen the incidence of hospice workers driving long distances for short visits, and give patients immediate access to staff when a crisis arose.
Contrary to rural areas of Kansas, Detroit is predominantly urban and suburban. Yet, Whitten says access to hospice care is still an issue in those areas. "There are neighborhoods in Detroit, for example, that are too dangerous for nurses to go into after dark," Whitten says. "There are access problems not only in rural areas, but in urban areas, as well."
And after three years of experience, Doolittle says more urban-based patients used telehospice because of the sheer number of them. "If you think about it," Doolittle says, "there are more urban patients than rural ones, because more people live in urban areas."
Most important: Patient response
For all the promise this technology holds for the hospice industry, both Whitten and Doolittle say there are still questions that need to be answered — precisely the reason the two states are conducting parallel studies.
For example, how well will telehospice be embraced by patients, their families, and professional staff that provide care? More often than not, hospice patients and their caregivers are elderly, a demographic that has been slow to adapt to rapid changes in technology.
Researchers hope to be able to measure the effect telehospice has on provider-patient interaction. For instance, what subjects are discussed using telehospice and whether it impedes or enhances open discussion with the hospice worker.
Hospices nurses, whose calling to provide care to the dying places emphasis on compassion, might see a telehospice visit as lacking the personal touch that makes hospice care unique.
"You’re talking about nurses who would do a home visit at the drop of a hat," says Doolittle.
If patients, their families, and hospice workers embrace telehospice, researchers will try to determine how the technology will improve access to hospice care. The scope of the Kendallwood project did not call for measuring, for example, utilization data before and during the use of telehospice. Researchers in both states hope to find out whether underserved groups such as rural residents and urban shut-ins can be positively affected by telehospice.
The cost of quality
Researchers will also need to determine whether telehospice can provide the same or better clinical outcomes compared to care not supplemented by telehospice. In addition, they hope to gauge the range of services that can be effectively provided using telehospice.
There is also the ugly "C" word: cost. Can telehospice help lower costs, while allowing hospice workers to provide high-quality — if not better — care? Researchers intend to track and compare the average costs of care using telehospice and traditional care using only face-to-face visits.
There have been some lessons based on the Kendallwood experience that researchers are applying to their latest study. Introducing the technology to patients, families, and hospice workers needs be as simple as possible in order to put technophobes at ease, both Whitten and Doolittle say.
Patients seem more receptive to the tech-nology if hospice workers set it up in the home to introduce them to telehospice, rather than explaining it through conversation and brochures. "Once they see how it works, and how simple it is, and how they can be in touch with a nurse 24 hours a day, they immediately see the benefit to having it," says Doolittle.
Hospice workers need continuous training to become familiar with the technology.
Unfamiliarity, Doolittle says, prevents nurses from exhibiting the confidence in the system that patients need. Hospice workers also need to make telehospice visits part of their routine, in order to breed familiarity and be confident when using it during a crisis.
"It’s not a good idea to make your first video call at 3:30 a.m. and the patient has a pain level of eight," Doolittle says.
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