1997 Partnerships for Networked Consumer Health Information Conference

Transcripts of Plenary Sessions and Breakout Sessions

Customizing Information 1: "Telemedicine and Telehealth Programs. Reaching Into Patients' Homes"

Tuesday, April 15
3:45-5:15 PM

Moderator: Patricia F. Brennan, R.N., Ph.D., Moehlman Bascom Professor, School of Nursing and College of Engineering, University of Wisconsin, Madison, WI

James E. Gray, M.D., M.S., Director of Newborn Services, Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA

Max E. Stachura, M.D., Director, The Telemedicine Center, Medical College of Georgia, Augusta, GA

James C. Toler, M.S.E., Principle Research Engineer, Georgia Institute of Technology, Biomedical Interactive Technology Center, Atlanta, GA

Stachura: We were informed, before we began this project in Telemedicine, of how patients would be monitored. It would be three individuals per program. We are also told by the Commission that the system has to have a mechanism that enables the patients and the nurse to deal with each other. Also, the camera in the patient's home had to be monitored by the nurse. It had to have the records of the patient's medication schedules.

Patients can access networked databases. The engineering requirements were usability, adaptability, modularity, portability, and expandability. The system design came out of this. An operating environment was a database at a central monitoring station. The patient's record was a shell of this. The communication modes supported Ethernet, ISDN ports, and wireless.

Much concern was invested in the multimedia interface and the possible patient reaction to this technology. We used a device to communicate with the patient's interface and a communication interface. We used a commercially available unit. There are four icons, and the patient can touch an icon and initiate the teleconference. You can initiate at either end. It also has a slide that will show you the parameters that guided you to make a mirrored look. There are pictures. You can use voice or you can even use the "help" function, which tells you how to use these tools. The icon with the question mark on it is the one that we don't know what will be put on. There is a keyboard or mouse available to the patient at home. The one at the hospital has a keyboard, and this is the shell.

This slide shows the configuration of the Ethernet. What we are trying to do is integrate. We are trying to move this system into doctors' homes with a desktop and some hardware that is portable. This is going to make it possible to carry a system along with you. The electronic house call with that, we hope, will be truly integrated. Let me stop at this point.

Toler: Clinical and technological issues clash. One of the things that we are currently doing is parading the technology. This is going to be real effective clinical care. We are checking that finding through testing.

What is an electronic house call? It is an electronic device used as a management tool.

You know what the parameters are. You are trying to keep on the straight and narrow. You can touch on certain icons, and you can expand on it. It is possible to participate through Jones Intercable, Inc., in Augusta, Georgia.

Why all of this? Why would I send in an introduction? We have analyzed this. Fifty percent of home health care is cognitive access, not instrumental or procedural access. One telenurse can perform several times the number of cognitive homebound visits than a nurse can in person. The patient gets benefits like access, participation, social contact, reduced isolation, and accountability. The bottom line is that this is the issue that we need to start talking about.

The real question is, what is the cost to our society for you and for me? One of my favorite examples is surveillance care for the elderly. Most of these people are placed in homes because they cannot keep up with their medication. When a home health nurse opens the door, the patient benefits. Patients in eight of the households surveyed reported that social interaction increased as a result of having the patient perspectives. Patients in seven of the households described positive reactions of other persons outside the home. The nurses felt pretty good about it. They were able to develop relations with patients in a different way, and they said that less-mobile patients are better candidates.

Just some quick numbers. There were 293 internal Medicare points with more than three inpatient admissions. This represents 13 percent of the internal medicine inpatients, and they required 59 percent of inpatient care. If you put those systems in for one-third of the patients, this could save from $1 million to $2.2 million. Also, quality of life issues are not included but are very significant in determining the overall value of home telemedicine.

The advantages to home health care are interstate licensure is not an issue; decreased health care utilization and cost; increased satisfaction with care; daily use of tele-technology prepares providers for tactical telemedicine use. The objective is to build relationships and make technology transparent. The equipment we designed does not require computer literacy for success and is technically reliable; end support is the key to patient-provider success.

Please be aware that the issues seem difficult to us now, but 25 years from now experts will say, can you believe that they held a conference about that? Thank you.

Brennan: Our next panelist is James Gray. Dr. Gray is a neonatologist and health services researcher with extensive experience using electronic information technologies to evaluate and improve the quality of newborn care. He has developed methods for performing interinstitutional comparisons of Neonatal Intensive Care Unit (NICU) outcomes and has examined important aspects of care such as newborn screening and the evaluation/management of sepsis risk in term newborns. Currently, he is investigating the use of telemedicine technologies to enhance the care provided to high-risk newborns and their families.

Gray: Max talked about cradle-to-grave care. Our project is a collaborative effort involving the department of neonatology; the Picker Institute; Lazo, Gertman, and Associates; and finally, past and present NICU families. This is funded through the National Library of Medicine telemedicine initiative.

This project is a 3-year effort to enhance the educational, emotional, and medical support provided to NICU families, both during and after their baby's hospital stay. Over the last 3 decades, we have learned how to take care of babies and send them home healthy. There are many barriers for parents to becoming very active in taking care of the babies. One relevant issue is the prolonged separation of parents and child. In addition, you may have care of siblings. For many families, it is a lack of familiarity with critical illness. Families can have multiple family members as patients. Finally, there is a couples system of postdischarge care.

In our discussions with NICU graduates, we have identified four roles for the families. They include providing enhanced opportunities for family-paced learning, emotional support, orientation to available services, and coordination of transitional and postdischarge care. We have envisioned two units to help achieve these goals: the first is called NICU Carelink, and the second is CAMC Homestation, which is a videoconferencing module, daily events module, periodic history module -- I have a problem module and a procedure instruction module. An overview of the hardware configuration is one in the home with ISDN connectivity and one in the NICU.

One finding that came out of focus groups was that parents did not want to wake up at 6:30 in the morning to call and see how the baby was doing. We realize that it is really important to keep the daily report up to date. This also tells you who is taking care of your baby on certain shifts.

NICU care is about $200,000 a day. Hopefully, we can turn this into a less costly endeavor. Thank you.

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