CLAUDE MANN doesn't know
how to use a computer keyboard or surf the Web. But the 84-year-old
diabetic, a hospital chaplain, is a true believer when it comes
to the power of home telehealth.
Faithfully, every day, the Harlem resident uses computerized
devices to check his blood sugar and blood pressure. He then pushes
a button to send the results via the Internet to his doctors at
Columbia Presbyterian Medical Center, New York City.
Although he is monitored from afar much more than in person,
Mann has never felt so involved in the care for his disease. "This
is a great thing that happened, to have this computer here now,"
he says. "I'm kind of my own doctor, me and the computer.
'Claude, your sugar's up. Claude, your pressure's up.' 'OK then,
Doc,'" he chuckles.
Mann is one of the fortunate minority with access to technological
innovations that shift nonemergency care back to the home. It's
the 21st-century, virtual version of the old-fashioned house call.
The trend has the potential to be a perfect prescription for what
will soon ail most Americans.
Chronic conditions such as diabetes, heart disease and asthma
affect almost half of all Americans and have become the leading
causes of illness, disability and death, noted a recent Institute
of Medicine report on health care quality. As the population ages,
these numbers are expected to shift so that the majority of Americans
will suffer from a chronic condition. An estimated 80 percent
of health care spending--as much as a whopping 17 percent of the
gross domestic product--will be devoted to the chronically ill
by 2010.
Pilot studies have found that home telehealth technology helps
patients better manage their illnesses, reducing emergency department
trips, unnecessary doctor's office appointments and costly visits
by home nurses. Keeping long-term-care patients out of the hospital
saves countless health care dollars.
Yet obstacles exist, the greatest being insurers' reluctance
to reimburse for care that's not delivered face to face. Other
barriers besides costs also are cited--physicians' resistance
to new technology, computer system incompatibilities, questions
about accuracy, widespread broadband access and privacy issues.
"With the growth in chronic disease, [the use of devices]
is going to become increasingly prevalent," says John Glaser,
vice president and chief information officer for Partners Healthcare
System Inc. in Boston. "But there are costs such that provider
organizations are not necessarily going to want to pursue this
vigorously."
Diabetic Monitoring
Mann and his wife, Adelaide, are patients in the largest nonmilitary
telemedicine effort ever undertaken by the federal government--a
$28 million, four-year demonstration project called IDEATel (Informatics
for Diabetes Education and Telemedicine). Launched in 2000 and
funded by the Centers for Medicare and Medicaid Services (CMS),
the project was designed to evaluate the use of advanced telecommunications
technology to manage the care of Medicare beneficiaries with diabetes.
Home telemedicine units--complete with glucose meter, blood
pressure cuff, camera to take pictures of skin and feet, videoconferencing
and Web access to specially tailored educational materials--were
placed in the homes of 750 diabetes patients across New York state
in isolated rural areas as well as in impoverished areas of Manhattan.
A like number in the control group have continued with their usual
care.
Mann, a retired nurse's aide at Harlem Hospital, looked dubiously
at first on the custom-made, $5,000-plus unit by American TeleCare
Inc. of Eden Prairie, Minn. "I said to myself, 'What am I
going to do with a computer?' I said, 'Lord, where am I going
to put it?'"
But the unit that first simply took up space has helped improve
his health and kept him out of the doctor's office. Mann figures
he's been able to regulate his blood sugar levels and manage his
health better because of the computer, heading off potential health
problems. "If it wasn't for this computer, I'd have to lean
on my doctor, wait on an appointment," he says. "I'd
recommend it to anyone who has diabetes."
While IDEATel is just for diabetics, the impact is much broader.
IDEATel leaders are looking at the project's effectiveness in
terms of both outcomes and costs. Justin Starren, M.D., who's
closely involved in the project as assistant professor of medical
informatics at Columbia Presbyterian, says that what the question
boils down to is, Should Medicare be paying for this? The answer
should have a far-reaching effect on other home telehealth projects.
IDEATel leaders won't say whether the units have improved diabetic
care and saved money until the study is completed in 2004. But
initial results are encouraging. "Patients love it; they
very much like being connected to their doctors," Starren
says. "And the physicians like the increased information."
Little Success Stories
The response is similarly positive among the congestive heart
failure patients in Minnesota who use a different remote monitoring
system provided by Minneapolis-based HealthPartners.
The device they use is a scale called the DayLink monitor:
It states their weight aloud, asks questions about their condition
and sends the results by phone into the Web site of its manufacturer,
Alere Medical Inc.
If they've suddenly gained several pounds or are short of breath
(classic warning symptoms for heart-attack victims), an alert
pops up on the computer screens of Alere's heart monitor nurses
in Reno, Nev. The patient gets a quick call from the nurse, who
then notifies the cardiologist.
It's relatively simple technology. The only requirement of
the patient is to step on a scale once a day and answer a few
spoken questions. "Nothing we're doing is rocket science,"
acknowledges Jan Wuorenma, R.N., HealthPartners' senior project
director for chronic care. But it provides a way to monitor the
condition of vulnerable patients who, mostly elderly and living
alone, don't want to "bother" their doctor or family.
Results also have confirmed what other projects are finding:
Simply knowing that someone is watching the numbers can motivate
patients to collect measurements regularly. Heart patient David
Archer, for example, a 66-year-old retired data processor, admits
he often didn't go to the trouble of reporting symptom changes
in the past. He credits having the AlereNet system in his home
in Cottage Grove, Minn., with keeping him alive these past two
years.
"This program is really like Big Brother looking at you
every day, but in a good way," Archer says. "I just
believe in it. And it gives me incentives. The doctor put me on
the program; I figured I ought to do my part. It's a form of motivation."
Greg Walton, past chairman of the Health Information and Management
Systems Society, notes that clinical trials of home health monitoring
devices and home health agency experiences are revealing "lots
of little success stories."
"It's an emerging market, but it will mature," adds
Walton, senior vice president and CIO of Carilion Health System
in Roanoke, Va.
Projects have been launched from rural Maine to California,
by university medical centers, disease management firms and Veterans
Affairs hospitals, as organizations try out a variety of home
care devices being produced largely by startup firms in a fragmented,
developing market.
A sampling of the projects:
- Asthmatic patients at Children's Hospital Oakland (Calif.)
used the interactive Health Buddy appliance made by Health Hero
Network of Mountain View, Calif., to input daily data about airflow
and other aspects of their condition and send it via telephone
line to a secure Web site. Asthma clinic director Kelley Meade,
M.D., says the nearly $400,000 clinical trial was a huge success,
as children took their medication more often, managed their health
better and became more active because of the devices.
- The University of Tennessee Medical Center's Telemedicine
Network is electronically monitoring both diabetics and heart-failure
patients in their homes. Network manager Sam Burgiss says the
results have been quite successful: "They show very much
an improved state of the patient, and they also show an improved
cost situation."
- Georgetown University Medical Center keeps tabs on diabetes
patients via a Web-based system it developed for receiving data
from participants who use glucometers at home to upload their
blood sugar measurements. It also is testing a monitoring device
for heart-failure patients.
- University of California San Diego endocrinologist Tim Bailey,
M.D., is using a software system made by Carlsbad, Calif.-based
iMetrikus called MediCompass to download and track patient-measured
glucose levels. He's confident it's helping him improve their
care.
- Military hospitals have taken a leading role in the use of
remote monitoring, unhindered by questions about reimbursement,
licensing and available funding that impede non-governmental
providers.
- The University of Pennsylvania reports high patient satisfaction
and compliance levels among 400 congestive heart-failure patients
using the Alere electronic scales in an ongoing three-year demonstration
project funded by CMS. "These devices have unbelievable
potential to impact the care and quality of life of these patients,"
says Lee Goldberg, M.D., assistant professor of medicine in the
heart failure and cardiac transplant program.
Cautious Health Plans
Many of the home monitoring devices are relatively inexpensive,
and experts say they will become more efficient and even less
costly with time and competition. But providers and health plans
are proceeding with caution, their concerns rooted in much more
than the purchase price.
Just a handful of health insurers have started incorporating
home telehealth technology into patient care. Most are holding
back, awaiting strong evidence that the devices can improve quality
of care and cost-effectiveness over a sustained period of time.
PacifiCare Health Systems Inc., for one, employs two remote-monitoring
devices in its cardiovascular disease management programs. The
Santa Ana, Calif.-based insurer uses the Alere scale in seven
states where it provides coverage. It collects data from an ambulatory
ischemia monitor worn by high-risk patients and made by QMed Inc.
of Laurence Harbor, N.J.
While satisfied with its foray into remote monitoring, PacifiCare
has no plans to expand its involvement. Health management director
Kathy Cartelli is hesitant to rely on patients' use of complex,
developing technology. "I have a hard time picturing people
using all of those things," she says. "We need to avoid
getting too involved with bells and whistles."
Bill McIvor, executive vice president of Greensboro, N.C.-based
Accordant Health Services, says self-testing "just doesn't
make economic sense right now." "Companies like American
TeleCare and Alere and Health Hero are all pioneers that are doing
some exciting things," he says. "But the universe of
possible users of this technology is quite small right now. It's
just like producing the first VCRs, the first digital cameras.
You need economies of scale."
The skepticism has resulted in a somewhat limited market for
remote monitoring. Companies such as iMetrikus and LifeMasters
Supported SelfCare Inc. have compiled extensive networks of monitoring
and patient testing data, but so far they've drawn more interest
from pharmaceutical manufacturers looking to evaluate medications
than from disease management programs, providers and health plans.
"We're hoping this will become a standard of care,"
says Ronald Lau, vice president of engineering for San Francisco-based
LifeMasters. But, he adds, the health care industry wants better
proof that it works.
Randy Moore, M.D., the CEO of American TeleCare, hopes the
business model will take off as more managed care companies come
on board. "What frustrates me is ... our industry pays for
sickness care and not for keeping people well," Moore says.
"We don't want to reward people indirectly for having people
in the hospital; we want to make sure the economic incentives
reward them for keeping patients healthier."
Molly Coye, M.D., founder and CEO of the nonprofit Health Technology
Center in Menlo Park, Calif., says it's an unfortunate irony that
without third-party reimbursement, the devices cause doctors and
hospitals to lose business, not because patients are dissatisfied
but because they're healthier.
"It's a terrible contradiction for many health leaders
and physicians because they know that some of these devices have
already been shown to have a positive impact on patient outcomes,"
she says. "But there's no way to pay for them."
Other Barriers
Among other hurdles ahead for Web-enabled home monitoring,
experts single out the tremendous cultural change that will be
required before physicians can incorporate such systems into their
practices on a broad scale.
Access to real-time data on patients carries great opportunities
to improve care and reduce unnecessary hospital visits and costs,
and physician-patient relationships stand to benefit from daily
monitoring. But time-crunched doctors may feel like air traffic
controllers without a new system, or more nurses, to manage all
the data streaming in.
"It definitely can be time-saving," says Meade, the
Oakland pediatrician. "But it means setting up time in your
day to be able to receive the information and interpret it. We
need to figure out how to fit it into our already busy days."
Physician acceptance will be closely tied to financial incentives,
according to Ronald Pion, M.D., a California physician and outspoken
health technology advocate. "Unfortunately, there is little
reason at present for fee-for-service physicians to encourage
expanded home care services," says Pion, former CEO of Medical
Telecommunications Associates and now managing director of Lido
Capital, a health consulting firm in Irvine. "Those physicians
are compensated for seeing patients in their offices or institutional
settings, and expecting a paradigm shift to occur without economic
incentive is unrealistic."
The medical community's version of the digital divide--limited
access to telemedicine technology--also looms.
Health care communications systems need to be faster and cheaper,
and more homes must have high-speed Internet access before remote
monitoring can fully work, says Kazi Ahmed, CEO and president
of NuMedics Inc., adding that government grants and financing
needed to speed the process have been lacking. "Building
the technology is the easy part," he says.
A computer scientist, Ahmed founded NuMedics in Beaverton,
Ore., after developing software to better care for his own diabetes.
More than 60 hospitals and clinics now use NuMedics software,
including a diabetes monitoring program at the University of Washington
Medical Center in Seattle.
Coye thinks Web-enabled devices are in need of a strengthened
information technology infrastructure in health care so that data
can be shared widely and easily among different systems and doctors.
Other possible stumbling blocks for the devices include concerns
about confidentiality, security, licensing and fraud linked to
the electronic transfer of patient data, although HIPAA has forced
organizations to address several of them. There also are questions
about the reliability of such data. Patients are notorious for
poor self-reporting, according to Joseph Kvedar, M.D., director
of telemedicine at Partners Healthcare and an associate professor
at Harvard Medical School, Boston.
All those pitfalls are being watched closely by CMS in the
diabetes demonstration project in New York state and by sponsors
of the various other trials going on across the country. "I
don't see caution as being unwarranted," says Starren, of
the government-funded IDEATel project. "If I were paying
for it, I would take a cautious attitude as well. Because any
mistake you make [regarding reimbursement] is easily a multibillion-dollar
mistake."
Even with all the unresolved issues, home monitoring is the
fastest growing area of telemedicine. Kvedar says the devices
have an even brighter future once concerns are resolved. "It's
an extremely important and rapidly expanding area of telemedicine,
and it's critical for health care to get this right," he
says. From patients to doctors to health systems, "everyone
should win."
Dave Carpenter is a freelance writer based in Chicago.
