Telemedicine Resurrects the House Call
Home health product market is booming
By Kathy Kincade
Driven by an aging baby boomer population, limited Medicare and Medicaid funds, and the desire of many elderly and chronically ill patients to remain at home rather than be hospitalized, the demand for home healthcare services is on the rise. Expenditures for home-health services are expected to double within the next five years, and some analysts estimate that the nation's $400 billion annual hospitalization tab could be reduced by $50 billion by providing more medical care in the home.
Current home-care methods are somewhat limited, however, and not always as efficient and cost-effective as many healthcare providers and managed-care organizations would like them to be. In most cases, a visiting nurse travels to several homes a day, assessing wound healing, monitoring chronic illnesses, and evaluating overall patient health. If necessary, the nurse will contact a physician to consult about a patient; most of the time, however, such discussions take place after the nurse has left the patient's home. This can lead to significant lag time between the home visit and the physician's followup. In addition, depending on the distances the nurses must travel and the seriousness of each patient's condition, some are only able to see about four or five patients per day.
Thus, under mounting pressure to provide better, more cost-effective healthcare to an expanding patient population, many HMOs and home-health agencies are investing in telemedicine and integrated information systems to help manage costs and meet demands. Their goal is to be able to remotely monitor chronically ill or recovering patients on a regular basis to ensure earlier intervention when needed, facilitate communication, and improve outcomes. If this happens, some analysts believe that 20 percent of all home healthcare visits in the U.S. (136 million annually) will be delivered via telemedicine by 2001.
Low-Cost and Portable
Similar to conventional home healthcare, home "telecare" can reduce healthcare costs by giving patients a more-comfortable and less-expensive option to nursing home, emergency room, and hospital visits. But home-telecare services have the added advantage of improving access to care and often the quality of care itself, especially in rural regions where the elderly population can be disproportionately large but hospitals and physicians are few and literally far between.
Home-based telemedicine generally falls into one of two categories: systems that the patient uses or systems that the visiting nurse uses. In both instances, the home-based system is linked via standard phone lines to a hospital or provider network. Current home-telecare technologies range from data-only heart-monitoring devices that deliver simple analog signals, to full-motion interactive videoconferencing systems that enable patients to have an electronic encounter with their doctors, right in their own living rooms. These systems can also accommodate various electronic peripherals to enable remote monitoring of vital signs and remote assessment of ears, eyes, and skin.
Since not all patient encounters require a physician to interact with the patient or observe their movements in real-time, many providers opt to use the "store-and-forward" method. Store-and-forward works much like e-mail except that static images, computerized test results, and even sounds from an electronic stethoscope can be saved in a file (often an electronic patient record) and then forwarded to the appropriate physician for review at a later time. Not only is this approach often more convenient (especially for the physician), but the line charges are much lower than for live video.
The Internet is also emerging as a tool for home-based telemedicine. Several companies have developed software packages that enable patients to become more proactive in their care, for example keeping customized diet diaries that can be monitored online by remote healthcare providers or querying physicians directly via e-mail.
More sophisticated Web-based products are also beginning to appear; for example, IBM is marketing a system called TeleCaster that enables real-time patient monitoring over the Internet. According to the company, TeleCaster enables healthcare providers and family members to view real-time color-video "snapshots" of patients by accessing a proprietary, secure Internet web site. The system can also capture and transmit the patient's heart rate and blood oxygen level; future enhancements should include blood pressure and temperature monitoring.
Commercial Products Abound
IBM is not alone in its efforts to capitalize on this potentially lucrative market. In fact, the commercial pioneers in home telecare (small vendors like American TeleCare and HELP Innovations that have spent much of this decade developing and testing low-cost telemedicine technology for use in the home) are suddenly being challenged not only by other telemedicine vendors but by the likes of AT&T, Hewlett-Packard (HP), NEC, and Sprint.
Even so, American TeleCare is still the market leader, with sales of more than 200 systems in the US alone. Kaiser Permanente's California-based Home Health Department purchased 22 of American Telecare's Personal Telemedicine Systems last year for a 200-patient home-health study designed to evaluate patient access, quality of care, efficiency of service, and patient and provider satisfaction. The PTS systems, which feature a two-way videophone, blood pressure and pulse-monitoring devices, and electronic stethoscopes, were used in conjunction with phone calls and home visits for half of the patients in the study, while the other half received only traditional home visits. Among other things, Kaiser found that ambulance calls declined dramatically among those patients with the PTS systems, as did patient anxiety levels.
Home-based telemedicine products are also being developed for chronic-disease management. Lazo, Gertman & Associates (Boston, MA) is conducting several clinical trials designed to demonstrate that its CAMC (Continuously Available Medical Care) distributed-network software package can reduce hospitalizations and improve long-term outcomes for chronically ill patients. The Veterans' Administration hospital in Boston, MA is studying CAMC's ability to monitor and manage insulin-using diabetics in their homes, while Newton Wellesley Hospital (Boston, MA) is using the system to better manage patients suffering from cardiac, respiratory, diabetic, and other chronic conditions that can lead to as many as 100 home-health visits per year.
Perhaps the most interesting twist in home-telecare devices intended for patient use is the ViaTV Phone introduced last year by 8x8 (Santa Clara, CA). This interactive video system uses the patient's own television set and a touch-tone phone to deliver low-resolution, real-time images over standard phone lines to a physician's desktop PC. ViaTV also has advanced image modes that enable a physician to send fairly high-resolution still images to a colleague for review. According to the company, the system is already finding applications in the alternate-site care market, particularly by hospitals and other long-term care facilities that also cater to homebound patients.
Laptops and Backpacks
Portable telemedicine technologies are also being developed specifically for use by visiting nurses and other home-health providers. For example, Telemedicine Corporation of America (Chantilly, VA) has developed a multimedia point-of-care laptop system called DistantCare that is small enough to fit in a backpack but powerful enough to offer interactive video, store-and-forward, and electronic patient record management and scheduling. The system can also be integrated with other record-management and billing systems, enabling patient data to be added to existing files much more quickly and reducing billing cycle times.
The technology is already attracting some big names in the healthcare field. Columbia/HCA, which provides health services to 55,000 homes per day, is evaluating a laptop system designed to enhance the clinical decision-making process in remote settings. The device, which was developed by a consortium of computer and communications vendors, currently costs about $15,000 and features interactive video, store-and-forward, JPEG compression, and voice-recognition capabilities.
Columbia is initially testing the system for monitoring wound care. Historically, Columbia's visiting nurses have taken Polaroid photographs of wounds and forwarded them to the physicians for review. From those snapshots, the physicians must assess how the wounds are progressing and decide whether changes in medication or treatment are needed. Using the laptop telemedicine system, however, the visiting nurse can dial up the physician while still in the patient's home, transmit the images in real-time, and facilitate a live consultation between the patient and physician. Images can also be captured and stored in an electronic medical record that can then be integrated into the hospital's existing network. Columbia's hope is that telemedicine can reduce the cost of inappropriate therapy and shorten the time between data collection and decision making.
"We want to show that this technology can improve quality and outcomes, reduce patient discomfort, and bring physicians to patients," said Ann Schmidt, senior vice president of strategic product development for Columbia Homecare Group (Dallas, TX).
About the author…
Kathy Kincade is a freelance writer specializing in telemedicine, medical lasers, medical diagnostics, and regulatory issues. She be can be reached at 18622 Crest Ave., Castro Valley, CA 94546. Phone/Fax: 510-278-8434; e-mail: 74351.2262@compuserve.com.