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Bringing I.T. Into the Home
Health Data Management Magazine, July 2007
That's why Piehl, medical director of the pediatric diabetes program at WakeMed, is participating in tests that give diabetic teens a cell phone that doubles as a diabetes management tool.
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The phone is designed to help make sure they don't forget. It displays text reminders and various icons that appear every time the phone is opened. These signal the user to collect test data and transmit it to WakeMed.
"We have found kids using the phone are much more likely to remember to check their blood sugar," he notes. "The phone is with them all the time and reminds them that it's time to check their blood sugar."
Surveying The Landscape
Still early in the testing phase, the use of cell phones as part of a diabetes management program is part of an increasing reliance on telehealth, which is the use of information technology to manage health in the home environment.
WakeMed is using cell phones supplied by Research Triangle Park, N.C.-based Confidant International LLC and loaded with the vendor's diabetes management software. Another company, Toronto-based LifeWire, is testing the text messaging function of cell phones as the communication platform for a remote diabetes management program.
Home health agencies and hospitals are deploying home-based patient monitoring devices that patients use to collect vital signs and other health status data and transmit the data to secure Web sites via telephone lines or the Internet for clinicians to access and review.
Such devices have been around for several years, but manufacturers and software vendors continue to refine their functions and add new ones.
One new telehealth device is designed to give physicians the practice management and electronic health records functions they need when making house calls (see story, page 40).
Vendors are working on other new telehealth functionality, much of it exhibited during the American Telemedicine Association's Annual Meeting in May in Nashville, Tenn.
San Antonio-based AT&T Inc. and partner AMD Telehealth Inc. of Lowell, Mass., exhibited a three-lead electrocardiogram device that can be used with AMD's home monitoring system, which AT&T resells. The device is awaiting approval from the U.S. Food and Drug Administration.
The two vendors also are working on sending urgent clinical alerts to home health clinicians via smart phones that can access a secure Web site for more information. They also are developing software to enable patients to capture and submit health status data via smart phones.
Health Care Anywhere
Telehealth enables clinicians to monitor patients at home, where they are comfortable, and get the patients help quickly if necessary, says Bill Paschall, director of telemedicine at AT&T. "Not only has care moved beyond the four walls of the hospital, it's outside any four walls," he adds. "It's health care anywhere."
New uses also are being found for traditional telemedicine applications to enable consultation between physicians, patients and others.
For example, St. Mary's Residential Training School in Alexandria, La., is using technology from Los Angeles-based Digital Union LLC to consult in real-time with autism experts in different cities. The school, home to 186 children with autism or other developmental disabilities, has installed videoconferencing software at its site and at three specialist offices.
Using their own peripherals, such as cameras, microphones, monitoring devices, ultrasounds, stethoscopes and other devices, a trainer or clinician working with a child at the school can be coached by a remote specialist.
Walking the floor at the ATA show in May, Neal Neuberger, a consultant and secretary of the association, saw more mobile applications than ever before.
The turnout of 2,000 attendees and 160 vendors were hopeful signs for the telemedicine/telehealth industries, says Neuberger, president of Health Tech Strategies LLC of McLean, Va. "There's no shortage of entrepreneurial interest."
But he worries about the future. A range of nationally accepted standards covering data collection and exchange, and standards for use in cases that demonstrate the value of telehealth, are urgently needed, he notes.
His chief worry, however, is that the technology's biggest barriers-financing and state licensure policies-may be insurmountable.
Private insurance reimbursement for any type of telemedicine remains in the early adoption stage, Neuberger muses. Further, Congress has not been willing to adequately fund telemedicine for 15 years. Suing the Centers for Medicare and Medicaid Services to have Medicare reimburse for telemedicine services may be necessary, he contends.
ROI Is Avoiding Cost
For now, telehealth primarily is paid through grant funds or out of the pockets of provider organizations that view the technology as a cost-avoidance tool.
For the past year, Dr. Piehl at WakeMed has been testing cell phone-based diabetes management with about 10 teens. By giving them tools to better manage diabetes, he hopes to keep the teens healthy and out of the hospital.
The teens have a glucose meter that tests the blood and displays and stores results, which generally are downloaded by clinicians during an office visit.
But these kids also have a Bluetooth wireless device from Confidant International that plugs into the glucose meter and wirelessly transmits readings to the cell phone. The phone, loaded with the vendor's diabetes management software, then transmits readings via a cellular network to a secure Web server that clinicians-and parents-can access. The data can be presented in various ways, including graphs that show trends.
The readings also are presented to the teens on their own phone. If readings are sporadic, clinicians can send reminder messages that show up on the screen when the phone is opened.
If results are out of established parameters, the software sends an alert to the teenager's nurse or physician. The teen also will receive a message, such as: "Do you know why you had a high reading this submission? It's important to review what caused your reading to be outside your target range of 80 to 120."
So far, testing at WakeMed has been somewhat informal and limited to a small group of teens. But preliminary results have been encouraging, Piehl says. In particular, the kids and parents have uniformly liked using the phones, he notes. "This technology provides another tool to improve diabetes management through technology already available on a daily basis," he adds. "The kids carry the cell phone and glucose meter all the time, so they have the means to comply."
WakeMed is starting to recruit up to 50 teens for a formal study that will start this fall, contingent on obtaining grant funding of about $50,000. In the original 10-patient test, Confident gave the cell phones to participants. The vendor will supply the phones and loaded software for the larger test, but the grant funds likely will pay the costs.
One incentive for participating in the smaller test was that the kids got a cell phone. That incentive will remain with the larger study, and other ways to get them to comply with their regimen will be introduced.
WakeMed will provide incentives available on the phone, such as games, music, and extra minutes or text messages, as kids achieve certain levels of testing, reporting data and controlling their blood sugar levels. The goal, Piehl says, is to get at least an 80% adherence rate.
Researchers will know the cell phone program is working if patients' hemoglobin A1C levels-a common measure of blood sugar control-go down during the test. "We're encouraged by preliminary results, but we need to see documented outcomes," he adds.
The initial test offered some lessons that are being incorporated into the larger study. "You need complete reliability of the cellular phone network," Piehl says. "If reliability is poor, there is less incentive to comply."
Consequently, software modifications will enable data readings to be transmitted over the cellular voice network as well as the data network.
Encouraging Results
Remote patient monitoring in the home is effective, says Jennie Mattia, manager of cardiovascular quality and heart failure disease management at the Fuqua Heart Center at Piedmont Hospital in Atlanta.
Three years ago, the heart center purchased 70 Remote Nurse self-monitors from WebVMC LLC, Conyers, Ga. The monitors and peripheral devices enable patients to collect vital signs and transmit them via telephone lines to a secure Web site for clinician review. Patients also answer health status questions and receive coaching messages via the touch-screen monitor.
Since 2004, the monitors and devices have been placed in 158 homes with 40 to 50 patients actively using them at any given time. The equipment stays in a home for at least three months. "We don't take the monitor unless we're comfortable the patient will do well without it," Mattia says. After the monitor is removed, the peripheral devices remain, and the patient enters data into a daily paper log.
The monitor and devices help clinicians adjust medications to levels that will assist in maintaining a stable health status. The equipment also helps patients better self-manage their conditions. "You may learn that you'll do fine if you eat one taco, but will get in trouble if you eat two," Mattia says.
Since putting the monitors and devices in patient homes, Fuqua Heart Centers has reduced hospital readmissions within 30 days by 75% for these patients.
That's important not just for patient health, but for Piedmont Hospital's finances, because "heart failure is a money loser" as Medicare does not pay for readmissions within 30 days of discharge, Mattia says.
Remote monitoring isn't a treatment option for all patients, however. Some patients have characteristics that could cause them to use the technology in an obsessive manner or not use it at all.
"Type A people who come into the doctor's office with their pills and spreadsheets aren't a candidate," Mattia explains. "They don't have to weigh themselves three times a day but will. Nor is it appropriate for the very feeble. They won't be able to effectively use the equipment without frustration."
Some other patients clearly are uncomfortable using electronic devices, and that often will be evident during a demonstration of the technology.
The Roanoke Chowan Community Health Center in Ahoskie, N.C., is using the RemoteNurse technology to monitor patients with congestive heart failure, diabetes or high blood pressure.
Funding for the program, which started last September, comes from a three-year, $360,000 grant from the North Carolina Health and Wellness Trust Fund Commission, which allocates a part of the state's share of the national tobacco settlement.
Early Going
With the program still in its early stages, the health center has not completed a return on investment analysis. The benefits, however, already are clear, says Amy Vick-Long, a telehealth nurse.
"We've done case studies and there definitely is data to prove it is working," she notes. "We've had patients telling us they feel better and the numbers show it."
Automated alerts to clinicians of adverse health status measures also help identify problems fast. "We recently had a patient whose blood pressure dropped very low," Vick-Long says.
Already, Roanoke Chowan is getting ready to add new technologies to the remote monitoring program. These include a fluid monitor plugged into RemoteNurse that will enable diagnosis of fluid build-up two weeks before symptoms appear, Vick-Long says.
By summer, the health center expects some patients to be using cell phones or mobile computers to collect and transmit data.
The center also is working with vendor WebVMC on workflow enhancements to the secure Web site that clinicians use to access results and send messages to patients. "There are different ways of arranging patient data," Vick-Long explains. "We want all information on each patient summarized on a single page, rather than clicking multiple tabs."
Roanoke Chowan, which serves four counties with a combined population of about 40,000, further expects to participate in a pilot project to incorporate mental health protocols in the RemoteNurse monitor so primary and behavioral care can be better integrated.
Sidebar
A Doctor Is in the House
Some doctors do still make house calls. C. Gresham Bayne, M.D., has "done nothing but house calls" for more than two decades. He's tried dozens of information systems to support his work, "and none of them could do everything we needed a system to do," he recalls.
This year, Bayne and the seven other physicians and physician assistants at San Diego-based Call Doctor Medical Group found the solution. But they had to team with software developers to design and build their own mobile practice management/electronic medical records system. The system enables documentation of care and charges in the home as well as the accessing of previous patient data.
Bayne, president of the group practice, also is founder and medical director of Janus Health, a start-up vendor that went to market in May with its Janus OS information system.
Health care is experiencing a "house call revolution," Bayne contends. It started to percolate in 1998 when Medicare dramatically increased payment rates for house calls. The growing elderly population also is fueling demand. Further, wireless technology has matured significantly in the past year, "allowing us to build an integrated system to support physicians in the field," he adds.
Janus Health is targeting the growing number of physicians who serve 7 million home-bound elderly patients. But its software will be "very easy" to adjust for home health care agencies and others who provide care services in the home, Bayne says.
Janus OS runs on laptop computers and Tablet PCs using the Microsoft Windows or Mobile operating systems. Access cards from Verizon Communications and other telecommunications firms are used to access a cellular network to download data to the computing devices and transmit information to the remotely hosted information system.
Download speeds are fast, but uploading speeds-which can automatically be done as a physician drives back to the office or to the next home-are slower, at 115 kilobits per second.
When a house call is scheduled using the information system's practice management functions, the patient's last clinical encounter, treatment plan, and recent laboratory work and medications automatically are uploaded from the EMR to the physician's computer. The physician documents care during the home visit, clicks "send," and billing and clinical data are transmitted to the practice management and EMR modules as the physician drives to the next destination.
Using a computer at the point of care in the home has not caused Bayne to change his practice patterns. "House calls are very unstructured because we don't have control of the home environment." He prefers a Tablet PC because its handwriting recognition software converts jotted notes to electronic text.
Call Doctor Medical Group is a participant in a Medicare pay-for-performance demonstration program. Encounter templates include fields that must be filled with P4P-mandated data before the patient chart can be closed. As of mid-May, the practice was Janus Health's first and only signed customer. The vendor charges no up-front fees for the information system; it charges a $12.75 use fee per house call.
From the group practice, the vendor is gaining some real-world lessons on what other functions are needed. For instance, "portable printers for physicians are not ready for prime time yet," says John Pyshny, vice president of sales.
The information system was built with robust global positioning satellite software, including verbal driving directions that turned out to be more of a luxury than a necessity. "We thought GPS mapping would be important," Bayne says. "But 99% of the time, you're going back to homes you already know. You just need a map that pops up with the appointment." Consequently, GPS became an optional feature.
Vendors Must Step Up
What really is needed, Bayne says, is for medical device manufacturers to outfit their products with Bluetooth wireless connectivity to transmit data to the laptop or Tablet PC. Devices that plug into a computer to transmit data aren't the answer, he adds. "In the house, you don't want wires dragging over open wounds and bed pans."
Consequently, physicians must manually enter data, such as blood pressure and pulse oximeter readings, into the information system.
But when entering data, doctors might have to put down their instruments on potentially unsterile surfaces. Or, a patient could spill water on an instrument or accidentally knock it on the floor. All of this has happened during home visits, Bayne says. And it's all avoidable if the instruments can transmit data to the information system.
"You walk in the house with a black bag with $10,000 worth of diagnostic equipment, none of which will work with the computer," he laments. "The device manufacturers have not figured out that Bluetooth is an important feature. We can do almost anything with these devices that any other doctors can do. What we can't do is get these devices to talk locally."
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