Documentación > Publicaciones > How Telehomecare affects patients

Background
Description of a Telehomecare project
Patient assessment issues
Assessment of the home enviroment
Evaluation issues
Focus group results
Survey results
Conclusions
References
Figure 1 / Figure 2

HOW TELEHOMECARE AFFECTS PATIENTS

By Kathryn H. Dansky, Kathryn H. Bowles and Liisa Palmer
Reprinted with permission from Caring, August 1999, epps. 10 - 14.

The emergence of telemedicine as an acceptable mode of healthcare delivery creates opportunities and challenges for home care providers. As part of strategic planning and deployment of a telemedicine project, agencies must ask questions such as, is this technology suitable for elderly clients? Can patients with multiple, chronic conditions benefit? Are caregivers willing to take on the responsibility of additional equipment in the home? Agencies must consider these and other issues when planning and evaluating a telemedicine project.

BACKGROUND

Telemedicine is defined as, "the use of electronic information and communications technologies to provide and support health care when distance separates the participants" (Institute of Medicine, 1996). Telemedicine is not new, but improved technologies and the current emphasis on cost containment have sparked interest in the healthcare industry. Telemedicine is generally classified into four types of applications: 1) interactive video; 2) store-and-forward teleconsultations; 3) IP (Internet Protocol) video on the Internet; and 4) cable-based video. In the first three categories, data are transferred over telephone lines-either wide bandwidth such as ISDN or T1 lines, or ordinary telephone lines. The fourth type of application, cable-based video, connects the patient to the healthcare provider through television cable.

Telemedicine in home health care is a relatively new phenomenon. The phrase "telehomecare" describes telemedicine applications that are specific to home care. Using personal computers and video equipment that transmit data over ordinary telephone lines, home health providers are now able to monitor patients and provide care at a much lower cost than technologies that use wider bandwidth telephone lines and more complex equipment.

In addition to observing and interacting with the patient, home health nurses use medical devices attached to the patient's monitoring unit to assess clinical problems and health status. For example, blood pressure measurement is accomplished with a cuff and sphygmomanometer, and an electronic stethoscope enables the nurse to listen to the patient's heart and lungs. Measurement and transmission of temperature, weight, blood glucose levels and pulse oximetry are all possible with the newest generation of models.

In addition to providing care to patients with chronic diseases, telehomecare creates opportunities for home care providers to monitor high-risk patients typically cared for in the hospital. Using video visits and medical sensors, nurses and other health professionals can interact with their patients several times a day, if needed. Telehomecare can empower disabled persons, connect socially isolated individuals to their care providers and support caregivers. Placing this technology into the patient's hands allows the patient and the caregiver to participate actively in the plan of care. The presence of the equipment and the ability to monitor health parameters, even in the absence of the healthcare provider, promotes self-care and responsibility. However, before implementing a telehomecare project, home health managers and nurses must understand how to maximize the potential of this technology.

DESCRIPTION OF A TELEHOMECARE PROJECT

The project described in this article is a partnership of Pennsylvania State University, the Visiting Nurses Association of Greater Philadelphia (VNAGP) and American TeleCare, Inc. Funded through the U.S. Department of Commerce's Telecommunications Information Infrastructure Assistance Program (TIIAP), the project began in March 1998 and will be completed in December 1999. The purpose of the project is to test the effects of telemedicine on quality of care and financial costs associated with home health services.

American TeleCare, Inc., designed and manufactured the equipment used in this project. The patient station is based on a Pentium(R)- Windows95(R) platform, with camera and speaker system. Medical sensors include a sphygmomanometer and stethoscope. The human interface consists of two large buttons (no keyboard) for patient response to audio/visual cues. The central nurse's station is also Pentium-Windows95 based. A keyboard and mouse allow the nurse to manipulate the image acquired by the patient camera and capture still images for medical use. The patient and central stations are linked together over ordinary telephone lines via a standard modem.

The sample consists of diabetic patients who are discharged from the hospital and referred to VNAGP. Patients are randomly assigned either to the intervention group or to a control group. Patients in the intervention group receive video visits in addition to skilled nursing visits, while patients in the control group receive skilled nursing visits only. A standardized diabetes clinical pathway is used for patients in both groups.

Nine staff nurses from the VNAGP were selected specifically for the project based on clinical expertise with diabetic patients. Before beginning the project, the team held a three-day training session at the VNAGP. Staff reactions throughout the project were generally positive.

PATIENT ASSESSMENT ISSUES

Before installing any equipment in a patient's residence, patients must be assessed to determine whether this technology is appropriate and acceptable. In this project, nurses must determine if patients are able to participate. Problems that preclude admission to the project include cognitive impairments, severe hearing impairments and severe mental health problems.

After the nurse determines that the patient is physically and mentally able to participate, she or he must than assess the patient's attitude toward using computers and this new technology. Research indicates that individual characteristics such as older age tend to correlate with unfavorable attitudes toward computer use (Laguna and Babcock, 1997); but age is negatively correlated with computer experience (Dyck and Smyther, 1994) suggesting that, as older persons gain more experience with computers, they will feel less anxious about using technology.

In this project, patients were not reluctant to try the technology. In the rare cases of refusal, if the patient continued to be resistant after gentle persuasion, the nurse did not pressure him/her and reassured the patient that regular visits would continue. The most frequent reason that patients declined the equipment was that they were overwhelmed with their illness and did not want any additional demands placed upon them.

ASSESSMENT OF THE HOME ENVIRONMENT

The nurses must also assess the home environments of potential telehomecare recipients. Figure 1 indicates the criteria used when assessing readiness for telehomecare. Obviously, patients must have electricity and a telephone. The easiest installations are in homes with a telephone plug-in jack versus the phone line being wired directly into the wall (hard wired). This problem exists in some older homes, but is rare. On the occasions when it does happen, the nurses call on a VNA security officer who has experience in converting hard-wired telephone lines to a jack. He makes a home visit and converts the line.

The next consideration for an appropriate home environment is lighting and space. Often the nurses must supply a desk lamp to light the face of the patient for better video reception. Without front lighting, the patient appears as a dark silhouette. Placement of the video equipment is also important. The nurse should avoid having a window behind the patient. The best conditions are natural light from a window shining onto the face of the person on video. Also, the patient must have room to sit comfortably in front of the monitor. All cords must be out of the way of foot traffic. The nurses use duct tape to secure any loose telephone lines or extension cords.
In many homes, space is a problem.

Although the video monitor is smaller than a personal computer, in small homes, or those with a lot of clutter, it is sometimes difficult to find a tabletop on which to place the machine. In some instances, the agency provides a fold-up table to hold the machine. (The need for table lamps and fold-up tables are additional expenses incurred when running a telehomecare program. In addition, the agency had to purchase power strips, extension cords, carrying bins, luggage carriers, duct tape, telephone cord extensions and connectors.)

Protection from vandalism and theft is another consideration. Staff in this project has successfully placed telehomecare equipment into homes in high-crime areas without incident. There is no formal policy about the issue, other than trusting the nurse's judgment. The project team has not denied any patient a machine for this reason, and there have been no instances of vandalism or theft; however, two instances of tampering with the equipment have occurred.

In one case, a patient's grandchild loaded a computer game onto the machine and cause some minor malfunction. The nurse discovered the game, deleted it, and the unit worked fine. In another instance, one curious user unscrewed the case on one unit to see what was inside. The unit had to be sent back to the manufacturer to be reassembled.

To deter theft, staff replaced the attractive, black computer cases provided by the manufacturer with thirty-gallon rubber containers sold at hardware stores. The nurses arrive at the home with a luggage carrier, toting what looks like a load of laundry. In addition, staff does not advertise the fact that the base unit in the patient's home is actually a personal computer.

As any home care nurse knows, the home environment provides surprises and challenges. Infestation with roaches and other pests required the project team to develop a procedure for disinfecting the machines when they return from such an environment. The nurse places the machine in the rubber bin while in the patient's home. Once back at the home care agency, the nurse sprays a fog insecticide inside the container and seals the lid for 24 hours. The unit is then thoroughly wiped down with antibacterial soap and rinsed with a damp cloth. As part of the installation procedure, the nurses educate the patients about the value and care of the equipment, especially emphasizing not to drink liquids or eat foods near the machine.

EVALUATION ISSUES

Strategic planning includes the development of clearly stated goals and objectives. Evaluation of the project requires collecting relevant data, both during the project and after its completion, to determine if goals and objectives have been met.
The project team collects data from a number of sources. Focus groups are used to evaluate nurses' responses and to give them opportunities to discuss patients' responses. Focus groups are group interviews on topics supplied by the researcher, who typically takes the role of moderator. The hallmark of focus groups is the "explicit use of group-based action to produce data and insights that would be less possible without the interaction found in the group" (Morgan, 1988). Notes from the focus groups are coded and analyzed using qualitative analysis.

FOCUS GROUP RESULTS

The project team identified many technical problems in the focus group sessions. The nurses expressed frustration with the number and complexity of technical problems with the telehomecare equipment. They reported that patients often experienced similar frustrations, particularly with connection problems. The nurses were able to allay the patients' anxieties in most cases; however, a few patients asked to have the equipment removed from the home.

Project staff learned that patients with a Personal Emergency Response System may experience technical problems. An additional switch that enables the emergency system to seize the line is required. Without this device, when the patient activated the response system during a video visit, the unit would not be able to access the line. One patient had this possible conflict, and the project staff worked in conjunction with the manufacturer to produce the appropriate device.

Analysis of the focus groups also helped the project team identify important patient-care issues. The nurses' comments are very personal and offer new insights into the nurse-patient relationship. For example, nurses mentioned that this technology adds a new communication dimension, creates a new "bond" and increases patient rapport. This relationship is viewed as a partnership. "Excitement" was mentioned frequently by both nurses and patients.

This special relationship fosters patient empowerment. One nurse remarked, "The patients start out saying they can't do this and the next thing you know, they're slapping your hand out of the way!" The nurses feel that the use of the technology reminds patients to prepare for nurse visits by making sure their records (logs of blood sugar notations) are up to date. According to the nurses, patients in the project report that they now bring their logs to physician office visits.

SURVEY RESULTS

Data were collected directly from patients to evaluate changes in health status and satisfaction with home health care.

Changes in patients' health status were analyzed using the SF-36, which was administered over the telephone at time of admission and discharge from the study. This survey, which is useful in measuring general health status as well as differentiating health benefits produced by varying treatments, satisfies the minimum psychometric standards required for group comparisons (Ware, et al, 1995).

Scales were constructed to represent the following dimensions: Emotional Functioning, Physical Functioning, Pain and General Health. Reliability statistics, designed to model internal consistency based on the inter-item correlations, were calculated. All scales are above acceptable levels, ranging from .82 (General Health) to .90 (Emotional Functioning). Preliminary analysis of these data indicates that both groups show improvement for each scale; however, the video group shows a greater improvement in General Health. (Note: these preliminary analyses are based on small sample sizes.)

All patients are interviewed over the telephone to evaluate patient satisfaction with home health care. A shortened version of the instrument developed by Dansky, Brannon and Wangsness (1994) is used for this purpose. Preliminary analysis indicates that patients are very satisfied with their care. Patients receiving the video equipment generally appear to be satisfied with the intervention. Open-ended questions posed to each video patient have generated the following responses:

"The machine seems to remind me to take care of my diabetes better."
"Using the stuff (the blood-pressure cuff, the stethoscope) makes me feel like I understand better what the doctor is doing when I go for my check-up."
"Learning to use a real computer made me proud of myself."
"I figured out on my own that I was getting sicker by checking my blood pressure with the machine."
"The nurse could tell by using the machine that my wife needed to go to the hospital right away."
"I really liked having this machine and I think it helped me get better faster."
Negative feedback can be classified in two areas: issues related to the home and technical issues. These included issues such as concerns about the amount of electricity that the equipment used, the amount of space the equipment took up and complaints about the "jerkiness" of the picture.

CONCLUSIONS

Patient responses to this technology generally are positive. As they became immersed in the operations, many patients experienced anxiety and frustration with using the equipment, but these reactions did not deter them from participating in the project. Experience indicates that elderly patients should not be stereotyped as being "computer-phobic"; with practice and encouragement, very frail and elderly individuals can use this equipment effectively.

The project team found that simple instructions, reviewed by the nurse, and information left in the patient's home, are important for clarification and reinforcement. The VNA nurses designed a manual to use on home visits. This manual supplemented the instructions from the vendor and included simple diagrams as well as steps for troubleshooting. Recommendations for enhancing patients' responses to telehomecare are listed in Figure 2.

As the use of telehomecare increases, there is much to learn about its impact on end-users, patients and home health agencies. Further research is needed on the content of the video visits and an analysis of patterns of use to determine the types of patients and nurses who respond well to telehomecare. As additional medical peripheral devices are added, an analysis of their impact on patient care is needed as well. Evaluating the impact of this technology on patients is a critical step for determining the most appropriate and efficient use of telehomecare technology.
About the Authors: Kathryn H. Dansky, R.N., Ph.D., is Associate Professor of Health Policy and Administration at Pennsylvania State University. She has more than twenty years of healthcare experience and currently studies management issues in healthcare organizations.

Kathryn H. Bowles, R.N., Ph.D., is Research Assistant Professor at the University of Pennsylvania School of Nursing and Director of Nursing Research at the Visiting Nursing Association of Greater Philadelphia.

Liisa Palmer is a doctoral candidate in Health Policy and Administration at Pennsylvania State University.

REFERENCES

Dansky, K., K. Bowles and T. Britt. "Nurses responses to telemedicine in home health care." Health Information Management, vol. 13, no. 4 (Winter 1999): 27-38.
Dansky, K., D. Brannon and S. Wangsness. "The influence of human resource management practices on patient satisfaction in home health care." Home Health Care Services Quarterly 15 (1994): 43-56.
Dyck, J. and J. Smither. "Age differences in computer anxiety: The role of computer experience, gender and education." Journal of Educational Computing Research 10, no. 3 (1994): 239-248.
Institute of Medicine. Telemedicine: A Guide to Assessing Telecommunication in Health Care. Washington, D.C.: National Academy of Sciences, 1996.
Laguna, K. and R. Babcock. "Computer anxiety in young and old adults: Implications for human-computer interactions in older populations." Computers in Human Behavior 13, no. 3 (1997): 317-326.
Morgan, D.L. "Focus Groups as Qualitative Research." Newbury Park, 1988.
Ware, J., M. Kosinski, M. Bayliss, C. McHorney, W. Rogers and Raczek. "Comparison of methods for scoring and statistical analysis of SF-36 health profiles and summary measures: Summary of results from the Medical Outcomes Study." Medical Care 33, supp. (1995): AS264-AS279.

FIGURE 1

FIGURE 2

RECOMMENDATIONS FOR ENHANCING PATIENT'S
RESPONSES TO TELEHOMECARE

• Set realistic goals and objectives; include nurses in the planning process.
• Assess patient attitudes toward computers before beginning the project, periodically during implementation and at the completion.
• Assess the home environment for adequacy of electricity, lighting, space and safety.
• Review benefits and risks with patient, obtain written consent and provide a copy of consent form for patient/family.
• Provide training and opportunities for patients to gain experience and confidence with the equipment before beginning video visits.
• Leave instructions, with diagrams, in home. Instructions should be printed in a large font, with language appropriate to minimal (fifth grade) reading levels.
• Provide technical support, either online or in person, during working hours, with back-up plan for on-call and weekend nurses.
• Provide feedback to patients regarding improvements in health status, clinical measures, etc.
  

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