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Publicaciones > Telehomecare:
Telemedicine for Homebound clients
Introduction
Telemedicine
Home Telemedicine
University Home Care's
Home Telemedicine Pilot
UHC'S National Beta
Test
UHC'S Home Telehomecare
Program
References
Table 1 / Table
2 / Table 3
/ Table 4
TELEHOMECARE: TELEMEDICINE FOR HOMEBOUND
CLIENTS
By Bonnie Perry Britton, M.S.N., R.N. and Vicki Whitehurst,
M.S.N., R.N.
Reprinted with permission from POPC, Vol. 12, No. 1,
pp. 16-18.
INTRODUCTION
Telemedicine is not a new or unique concept at East
Carolina University School of Medicine (ECUSOM) or Pitt
County Memorial Hospital (PCMH). Since 1992, the ECUSOM,
PCMH and Eastern Area Health Education Center (EAHEC)
have been successfully linking patients via telemedicine
technology from clinics and hospitals in our 29 county
area, to physicians at the ECUSOM/PCMH campus. ECUSOM's
telemedicine program is recognized as one of the first
and best programs in the nation (Maynard, 1998).
Just as the healthcare community came to embrace and
feel comfortable with telemedicine technology, a new
player--home telemedicine--surfaced as one of the fastest
growing areas within the telemedicine community. The
concept of home telemedicine is new not only in Eastern
North Carolina, but also in the entire United States.
From May 1997 through October 1997, University Home
Care (UHC) in collaboration with PCMH, ECUSOM and EAHEC,
conducted a home telemedicine pilot; and since January
1998, UHC has implemented the first home telemedicine
program in the state.
The purpose of this article is to describe home telemedicine
applications, discuss UHC's home telemedicine pilot
and National Beta Test, and familiarize staff with UHC's
Telehomecare Program.
TELEMEDICINE
Telemedicine is defined as the use of telecommunications
and computer technologies for the purpose of delivering
health care to patients. It is a way to diagnose, monitor,
assess, intervene and communicate with patients who
are geographically remote from the provider (Fishman,
1997). It provides for two-way transmission of data,
voice and images between the patient in the home and
the healthcare provider in the home-care agency (Sanders,
1996). Skeptics are afraid that this technology will
replace healthcare providers, but the American Telemedicine
Association reassures us that telemedicine is "for
the health and education of the patient or healthcare
provider and for the purpose of improving patient care
. . . not intended to replace the home-care visit, just
augment it." (Barrell, 1997, p. 30)
HOME TELEMEDICINE
Home telemedicine technology works over plain old
telephone service (POTS). POTS is used to transmit two-way
interactive voice, data, graphics and video between
the home and UHC. Once the patient and healthcare professional
are "connected" via video and audio, the patient
can see and hear the healthcare provider, and the healthcare
provider can see, hear and even take pictures of the
patient.
American TeleCare conducted the first home telemedicine
pilot in 1995. Twelve patients from a Minneapolis-area
managed care provider participated in this nine-month
study. The results indicated that care could be provided
via telemedicine technology and paved the way for other
home-care agencies to become pioneers in the telemedicine
market (Barrell, 1997).
Many advantages to home telemedicine are emerging.
This alternate care modality benefits patients, home-care
agencies and the entire healthcare system. The primary
patient advantages include frequent contact with healthcare
professionals, elimination of travel time, more frequent
and comprehensive health education and monitoring and
enhanced continuity of care. Economic benefits include
decreased cost of care to patients, decreased hospitalization
lengths of stay, reduced cost of home care, decreased
ER and clinic visits and reduced re-admission rates
(Kaufman and Crampton, 1996).
Even though there are many advantages to home telemedicine,
three primary barriers exist: cost of the equipment
and installation; lack of third-party reimbursement;
and resistance in the medical community (Rau, 1996).
These barriers are slowly being removed by a collaborative
effort between vendors and telemedicine supporters.
Vendors are reducing the cost of equipment, and supporters
are collecting data to validate that home telemedicine
is a cost-effective alternative care delivery system.
Some supporters are training medical students, resident
physicians and attending physicians regarding telemedicine
and their future roles in this technology. Kansas Blue
Cross is currently the only third-party payor reimbursing
for home telemedicine visits (Dakins, 1997); all other
reimbursement is being negotiated on a case-by-case
basis.
Because home telemedicine is in its infancy, there
are no standards for patient selection or indications
for care. The most frequently cited clinical and operational
indications are listed in Table 1 (Baines, 1996 and
Dakins, 1997). Care that can be provided is listed in
Table 2.
UNIVERSITY HOME
CARE'S HOME TELEMEDICINE PILOT
From May to October 1997, UHC, in collaboration with
the ECUSOM, PCMH and EAHEC, conducted a home telemedicine
pilot. The primary objectives were small-scale testing
of the technology, determination of provider and consumer
acceptance and early identification of implementation
difficulties.
Each agency provided support and played a key role
in the pilot. PCMH provided the capital for the equipment;
ECUSOM Communication Department provided invaluable
and extensive technological and communication support;
EAHEC provided administration support and collected
consumer and patient satisfaction; and UHC implemented
the pilot, collected demographic and economic data and
supported daily operating expenses, including staff
and leadership costs. The targeted population was elderly,
chronic patients with diagnoses of Congestive Heart
Failure, Diabetes Mellitus, Hypertension and patients
receiving multiple visits per day.
Because there are no models available for implementing
home telemedicine, all key players experimented with
appropriate ways to implement and not to implement home
telemedicine. The pilot survived a myriad of problems
with the phone service and the POTS system, the effects
of rain on phone service and multiple software malfunctions.
Even with these difficulties, the pilot was successful
in demonstrating the need for home telemedicine technology
and patient-consumer satisfaction with the technology.
In addition, with each case, cost savings to the patient
and the agency were demonstrated.
UHC'S NATIONAL
BETA TEST
Following our successful pilot, UHC enjoyed the opportunity
to be an American TeleCare Beta Test Site in November
and December 1997. The experience was a wonderful learning
opportunity for both American TeleCare and UHC. Six
sites within rural Eastern North Carolina were chosen,
including two elementary schools, an ECU OB/GYN clinic,
an affiliate home-care agency, a patient home and two
Registered Staff Nurses' homes.
In collaboration with the Pediatric Asthma Program,
the system was placed in two elementary schools to evaluate
the ability to assess school-age asthma children utilizing
telehomecare technology, with particular emphasis on
auscultation of lung sounds and video snapshot clarity
to visualize peak flow meters and inhalers.
In collaboration with the ECUSOM and PCMH Clinical
Nurse Specialists, the equipment was placed in an OB/GYN
clinic at the ECUSOM to evaluate the ability to interpret
fetal heart strips, assess epriorbital edema, obtain
blood pressure readings and hear fetal heart tones.
Finally, the system was placed in various rural settings
in Eastern North Carolina to assess usability. Valuable
feedback was provided to the vendor, and the test concluded
that telemedicine equipment is not only beneficial for
elderly, chronic patients, but has the potential to
be used in the pediatric and OB/GYN patient populations.
During the pilot, UHC completed a grant application
seeking funds to expand our telemedicine services to
patients. When the grant was not awarded, the support
was sought from the Clinical Information and Support
Office and PCMH. PCMH approved an expansion of the program
in December 1997, and UHC officially started a telehomecare
program in January 1998.
UHC'S HOME TELEHOMECARE
PROGRAM
Since January 1998, UHC has started a telehomecare
program with six home units. One unit, dedicated to
the pediatric patient population, was funded by the
Children's Miracle Network. The goals of the program
are to improve patient access to care, increase the
number of visits, prevent health status deterioration
that results in rehospitalization and emergency room
visits, increase availability of the multi-disciplinary
team, and train healthcare professionals in telemedicine
technology. Inclusion and exclusion guidelines are found
in Table 3 and Table 4. The focus is on patients who
require frequent re-admissions, emergency room and clinical
visits.
UHC is collecting demographic, financial and operational
data to demonstrate effectiveness of this technology.
Two grants have been obtained to further study home
telemedicine. One will expand care, and the other will
facilitate qualitative study to examine patient and
caregiver adaptation to home telemedicine.
REFERENCES
Baines, B. "Tele-Home Care in a Managed Care
Setting," The Remington Report. November/December
1996, pp. 27-29.
Barrell, J. "Telemedicine: You Can't Do That
at Home," Infusion. November 1997, pp. 19-35. Telehomecare
Conference, Chicago, August 22, 1996.
Dakins, D. "In Defining Telemedicine's Impact,
the Medium is Not the Message," Telemedicine and
Telehealth Networks. August 1997, pp. 12-14.
Fishman, D.J. "Telemedicine: Bringing the Specialist
to the Patient," Nursing Management. 1997:28(7),
pp. 30-32.
Kaufman, S. and K. Crampton. "Cost Savings Using
Home Telemedicine," Telehomecare Conference, Chicago,
August 22, 1996.
Maynard, L. "Today's TV Doctors," Carolina
Country. February 1998, pp. 18-19.
Rau, K. "Home Telemedicine: A Rural Perspective,"
Telehomecare Conference, Chicago, August 22, 1996.
Sanders, J. "Telemedicine for Home Care: Where
Are We, Where Do We Need to Be," Keynote Address,
Telehomecare Conference, Chicago, August 22, 1996.
TABLE 1
INDICATIONS FOR HOME TELEMEDICINE
CLINICAL INDICATIONS-PATIENT SYMPTOMS
Shortness of breath, chest pain, hypertension, edema,
confusion and non-compliance with medication, therapy
or scheduling regimen.
Patient Disease
Chronic: diabetes, COPD, CHF, hypertension, asthma,
stroke, cancer, pain, AIDS, terminal illnesses, immuno-compromised
Acute: surgical, anxious patient, frequent monitoring
needs or early hospital discharge
Other: multiple home visits per week, high users of
the emergency department and hospital, nursing home
placements
OPERATIONAL INDICATIONS
- Patients requiring two or more nursing visits per
week
- Patients who do not require hands-on care with
each visit
- Patients with poor compliance to instructions or
medication
- Patients with an unreliable caregiver situation
- Patients seen in the emergency room within the
past two months
- Patients hospitalized within the past six months
TABLE 2
CARE THAT CAN BE PROVIDED VIA TELEHOMECARE
- View patients
- ssess conditions
- Observe medication administration--oral or injections
- Monitor VS
- Check weight
- Assess mental status, functional status and overall
health status
- Point-of-care clinical data: EKG, BP, pulse oximetry,
peak flow spirometry, blood glucose, digital/analog
stethoscope for heart, lung and bowel auscultation
TABLE 3
PATIENT INCLUSION GUIDELINES
- Chronic disease in a state of decline to include,
but not limited to Congestive Heart Failure, Chronic
Lung Disease, Diabetes, Cancer and Psychiatric Disorders
- Does not require hands-on care with each visit
- Emergency Room visits in the past two months
- Hospitalization in the past six months
- Requires frequent clinic visits
- Poor compliance with instructions or medications
- Willing to carry out mutually agreed upon responsibilities
TABLE 4
PATIENT EXCLUSION GUIDELINES
- Insufficient electrical or telephone service to
operate the system
- Daily visits
- Unable to learn the telehomecare system, unless
full-time capable
- caregiver present
- Uncooperative and/or combative
- Unstable to the degree that inpatient management
is needed
- Refuses to sign consent for treatment
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