Clinical and Health Affairs
Managing Chronic Disease through Home Telehealth
By Stanley M. Finkelstein, Ph.D., and Edward Ratner, M.D.
Abstract
This article describes the use of telehealth to monitor chronic illness in a home setting. It discusses the state of the art in commercial telehealth systems as well as 3 research projects undertaken by the University of Minnesota’s program in health informatics that explore the potential of home telehealth to aid in care of patients with chronic conditions.
Chronic disease is increasingly recognized as a key factor contributing to high health care costs and morbidity and mortality in Minnesota and throughout the country. Exacerbations of chronic illness are the leading cause of acute care hospitalizations.1 In Minnesota, 3 of the most common chronic disease types—heart disease, cancer, and stroke—account for more than half of all deaths, and more than 170,000 Minnesotans are known to have diabetes mellitus.2
Minnesota is a national leader in chronic disease management. The state is home to the Bloomington-based Institute for Clinical Systems Improvement, which has developed and disseminated guidelines on the management of more than 50 conditions including common chronic diseases such as diabetes, heart failure, chronic obstructive pulmonary disease (COPD), headache, and depression.3 It is also home to a health plan–supported and government-funded organization, MN Community Measurement, which is nationally recognized for its innovative approach to tracking success in implementation of such guidelines.4 Minnesota is also a leader in telemedicine. For more than a decade, telemedicine systems using office-to-office videoconferencing equipment have brought specialty care to rural Minnesota hospitals and clinics.5
Now, as the price of computers, electronic physiological monitoring equipment, broadband Internet connections, and Internet videoconferencing hardware and software has fallen and these technologies have become easier to use, it has become possible to connect patients in their homes directly with their health care providers. Home telehealth, which uses a variety of technologies from the plain old telephone system (POTS) to broadband (DSL, cable), is becoming more widely used as technological, societal, educational, and financial barriers are overcome.
In this article, we describe how commercial telehealth systems can be used to monitor chronic illness in a home setting. We also discuss a series of research projects undertaken by the University of Minnesota’s program in health informatics to establish the potential of home telehealth to aid in the care of patients with chronic conditions.
Home Telehealth Systems
Four types of telehealth systems are commercially available for home use: those that use videoconferencing systems to facilitate a “face-to-face” visit; those that monitor physiological measures, continuously or intermittently recording and transmitting readings to a home health nurse; those that electronically “check” on the patient to verify that all is well or notify the patient’s doctor if something appears wrong; and those that monitor the patient for movement or lack of movement that might indicate a problem such as not getting out of bed, falling in the bathroom, or failing to open the refrigerator.
Each of these types of systems has been used for managing patients with chronic illnesses. For example, physiological monitoring of acute weight gain and changes in pulse, blood pressure, or oxygen saturation looks promising for management of chronic heart disease.6 Also, there is growing interest in using home telehealth systems to monitor people with dementia or general frailty, who might miss medications, fall, or fail to recognize or report new symptoms or exacerbations of their chronic illness.7
Home telehealth is not generally covered by third-party payers. Although some private insurers and Medicaid programs cover home telemedicine equipment and services, the cost of home telehealth often is covered by patients directly or by home health providers (including hospices) that see it as a means to improve efficiency and quality.
The Research
The use of home telehealth has grown despite the limited number of rigorous research studies typically required for regulatory or third-party payer acceptance. But despite its growing use, home telehealth is not yet a standard of care in chronic disease management. Recently, a growing number of research studies, including several randomized clinical trials, have focused on assessing the efficacy and efficiency of various home telehealth models. The following descriptions of 3 studies from the University of Minnesota suggest the possibility of a bright future for home telehealth.
Lung Transplant Home
Monitoring Program
For patients who have had a lung transplant, early identification of respiratory illness or symptoms of infection or rejection is the key to avoiding major morbidity or mortality. The Lung Transplant Home Monitoring Program (LTHMP) at the University of Minnesota was developed to assist patients and health care professionals with early detection of potential problems using home monitoring of spirometry (ie, objective measurement of pulmonary function).8,9 Approximately 280 lung transplant recipients participated in the LTHMP from 1992 through 2002.
All subjects performed full spirometry at home and recorded vital signs and respiratory symptoms using an electronic spirometer/diary instrument initially designed for this program. Subjects performed 3 forced vital capacity maneuvers at the same time each day using the spirometer. Subjects were able to obtain reliable and valid spirometry measurements at home that were comparable to those obtained in the clinic; home monitoring of FEV1 was highly correlated with FEV1 values measured in the hospital’s pulmonary function laboratory. Respiratory symptoms recorded included frequency of coughing, quantity and color of sputum, frequency of wheezing, and dyspnea at rest. Vital signs included blood pressure, weight, pulse, and temperature.
All data were date and time stamped when they were entered into the spirometer/diary and stored in the instrument until they were downloaded to the study data center. Subjects downloaded the stored data by telephone once a week. Transmitted data were reviewed weekly by a research triage nurse who notified the transplant center staff of subjects who needed follow-up treatment.
Study results included high levels of patient satisfaction, with home monitoring adherence during the first year at almost 80% and a subsequent drop-off in the following years; detection of potential problems (eg, chronic rejection or bronchiolitis obliterans syndrome) earlier than would be possible by regularly scheduled or unscheduled clinic visits; and an increase in outpatient versus a decrease in inpatient visits, with a lower cost of care resulting from this shift in resource utilization. The cost of care for the group that had the best rate of adherence was 60 percent less than that of the group with the worst adherence.10 As a result of the study, the Home Spirometry Program at the University of Minnesota Medical Center, Fairview, was established to continue regular monitoring of lung transplant patients.
TeleHomeCare
TeleHomeCare was a randomized, controlled trial designed to assess the benefits of using low-cost, standards-based telecommunications and monitoring technologies for homebound patients needing skilled home health care.11,12 The project was a collaboration of the University of Minnesota and four clinical partners representing both urban (Fairview Health System in Minneapolis) and rural (Tri-County Hospital in Wadena, Lakewood Health System in Staples, and Cuyuna Regional Medical System in Crosby) Minnesota. It focused on patients with congestive heart failure, COPD, or chronic wounds. Subjects at each study site were randomly assigned to 1 of 3 study groups, stratified by their underlying medical condition.
Control group subjects received standard home health visits from nurses. Subjects in the second group received standard visits from home health nurses plus 2 supplemental virtual visits per week. Subjects in the third group also received home-based physiologic monitoring devices specific to their underlying health problem. Virtual visits consisted of 2-way audio and video interactions between a home health nurse at the central site and the subject at home. The sites used commercially available equipment that required the patient to have only a television monitor and touch-tone access to voice-grade telephone lines. A set-top box, a device that enables a television set to become a user interface to the Internet, with a built-in camera was placed at the home health care sites. A similar set-top box with a movable eyeball camera that has variable focus was used in the patients’ homes. The camera allowed subjects to zoom in on areas of interest when transmitting images for evaluation. An electronic message board was used for communication between the subjects and their home health nurses.
Physiological monitoring devices included home spirometers, pulse oximeters, and blood pressure cuffs. Daily measurements and information about symptoms were recorded in an electronic diary. Specific monitoring devices and questions about symptoms were selected for each subject, depending on their underlying disease. Diary reports were automatically e-mailed to the designated home health care nurse each week. Summary reports and a warning message were immediately e-mailed to the home health care nurse when data were outside subject-dependent thresholds.
Fifty-three patients completed the study with 19, 14, and 20 in the control, video/Internet, and video/Internet/monitoring groups, respectively. Subjects were, on average, 74.3 years old. Positive perceptions of TeleHomeCare increased significantly for both groups that received virtual visits but not for the control group. Perception of the TeleHomeCare program was measured using the Telemedicine Perception Questionnaire, a validated instrument developed for this program and now in use worldwide to track user perception of telehealth programs.13 All home health care patients were satisfied with their care, but satisfaction ratings significantly increased among those who received virtual visits. The general trend showed that satisfaction increased as the level of the TeleHomeCare intervention increased, from no intervention for the control group to video and video-plus-monitoring for the intervention groups. Home health care nurses conducting the virtual visits encountered few technical problems and found the virtual visits to be useful. Fewer patients in the intervention group required transfer to a higher level of care (hospital, nursing home) than did control subjects during and within 6 months of participating in TeleHomeCare. Subjects in the video groups required the fewest transfers to higher levels of care (17%). Those in the control group required the greatest number of transfers (42%). Costs per visit were greatest for actual home care visits ($48) and least for video-only virtual visits ($22), with costs for the video-plus-monitoring group in between.
Virtual Assisted Living Umbrella for the Elderly
Virtual Assisted Living Umbrella for the Elderly (VALUE) is a randomized controlled trial that began in 2003 and will be completed in 2007.14 The objective of the trial is to study whether elderly patients using telemedicine technologies can remain independent at home for a longer period of time than patients in a control group. The intervention group receives as many as 9 months of enhanced services consisting of virtual visits from a home health nurse using Internet-based videoconferencing technology, a Web portal for ordering supportive assisted living services, and physiological monitoring. The portal provides an easy way (involving a few mouse clicks) for subjects to obtain services such as having meals delivered to their homes, scheduling transportation, and getting help with home chores; make doctor and nurse appointments; and order prescription refills. The control group is monitored and assisted by family members or health providers in person or using the telephone. VALUE is a collaboration of the University of Minnesota, Volunteers of America Minnesota Affiliate in Minneapolis (urban setting), and Tri-County Hospital in Wadena (rural setting).
A total of 100 subjects (50 at the urban site and 50 at the rural site) are participating in the study. Eligible subjects are at least 60 years old, living independently in the community, managing one or more chronic disease, able to physically manipulate the system controls, able to read and understand instructions, and have a telephone. The VALUE workstation installed in intervention subjects’ homes uses a PC platform with a broadband (DSL or cable) connection, secure IP videoconferencing software, and a Web camera.
The primary measure of VALUE is the ability of the intervention to delay or avoid the need for subjects to leave their residence for an assisted-living program or nursing facility. Secondary measures include patient satisfaction, use of community and health services, and reliability and ease of use of the technology in the homes of frail, elderly patients.
Perceived benefits of the program are convenience, time savings, and the opportunity for more frequent contact with a nurse. General concerns voiced by potential participants focused on computer and Internet training and use, problems with vision and manual dexterity, and cost. Appropriate training eased patients’ technical anxiety about using the system, and good design ensured that even patients with limited dexterity were able to use it.
Participants were able to use the system with little difficulty once they completed the training, but getting past their computer fears was a significant barrier to recruiting participants. Cost was not an issue for research study participants, but it will likely be an obstacle to widespread use of home telehealth until realistic payment strategies are implemented.
Intervention subjects have been satisfied with the VALUE workstation and the quality of the virtual visits, and have found the portal design (layout, colors, size, navigation, and content) acceptable, as confirmed during discussions with their nurses during virtual visits and by the frequency with which they log on to and navigate around the portal site.
Discussion
These and other studies are demonstrating that home telehealth is an effective, efficient, and practical tool for treating patients with chronic illness.15,16 A significant number of home health agencies have found that home telehealth can enhance or be a substitute for the work home health nurses do at a cost comparable to or lower than that of a home visit. With travel costs rising and the price of technology falling, interest in this way of delivering care will grow. Further research, such as that being done at the University of Minnesota, will help define how best to apply home telehealth to the management of a range of chronic conditions.
Major challenges to the adoption of home telehealth programs are the need to ensure continued user satisfaction and provider acceptance, maintain clinical quality, and establish satisfactory reimbursement policies. These 3 studies have demonstrated that such challenges can be satisfactorily addressed by appropriate use and customization of the technology. Recent policy changes on the part of payers, including reimbursement by the Centers for Medicare and Medicaid Services for some forms of home monitoring (eg, home spirometry) and coverage of telehome care services for Medicaid beneficiaries in some states, are another positive sign that this technology may be adopted in the future for home care.17
In its varied forms, home telehealth has been shown to be a valuable tool in monitoring and managing chronic illness. Its use will likely increase in coming years. Physicians should understand how home telehealth operated by home care agencies and other organizations can help ensure patient adherence to care plans recommended by evidence-based guidelines. Telehealth technologies can help physicians extend their ability to manage patients with chronic illnesses. But policy and reimbursement barriers must be overcome if this to become a reality. MM
Stanley Finkelstein is a professor in the department of laboratory medicine and pathology and Edward Ratner is a professor in the departments of health informatics and internal medicine at the University of Minnesota Medical School.
The LTHMP was funded in part by NIH Grant #RO1–NR02128. The TeleHome Care and VALUE programs were funded in part by grants #27-60-98031 and #27-60-03010, respectively, from the U.S. Department of Commerce Technology Opportunities Program and matching funds from clinical and industry partners. Additional funding was provided by a Geriatric Academic Career Award (K01 HP00037-01).
References
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