In our last issue (Spring’95, pp. 26-27)) we introduced the concept of telemedicine to the home. What better, more natural place to implement modern telecommunications technology for healthcare? The most pressing need, and the most obvious place to impact healthcare costs, is in providing nursing services to the home. As we noted, there are about 1/2-billion home-health visits by nurses in the U.S. each year. Many, if not most, of these require the cognitive and observational skills of the nurse, but not their actual on-site presence. Several innovative companies are using telemedicine technology to provide home healthcare services, typically at a fraction of the price of an on-site visit.

Last issue we highlighted the approach that H.E.L.P Innovations (1-800-749-4619) has taken in Kansas. For nearly a year they have been using the hitherto unexploited capabilities of cable television systems to enable full motion, high resolution interactive audio/video transmission between selected sites served by the cable television provider. They have expanded from a pilot site in Lawrence, KS to a full-service site in Hays, KS. Their next step is to develop an electronic "house-call" system in metropolitan Kansas City. This approach is relatively inexpensive, and appears to provide adequate service at a very reasonable price (approximately one-half of what an on-site nursing visit would cost). The down sides are: (1) it requires a cooperative, technically agile cable television provider as a partner, and (2) it cannot, as currently configured, extend beyond the service area of the cable company.

Other strategies are being developed. With this issue we will examine another domestic company, American TeleCare, as well as a Japanese project. For the next issue (November’95) we’ll be doing a wrap-up, and looking at a highly innovative new approach. As always, we turn to our readers for input and leads -- so if you are aware of telemedicine-to-the-home ventures that bear reporting, please let us know!

Telemedicine to the Home: The American TeleCare Approach

For more information contact: Khalid Mahmud, M.D. Dr. Mahmud is an oncologist and CEO of American TeleCare, Inc. Address: 7680 Golden Triangle Drive, Eden Prairie, MN 55344-3732. Ph: 612-897-0000; FAX: 612-944-2247.

Dr. Khalid Mahmud, a medical oncologist trained at the U. of Minnesota, got involved in high-tech medical medical outreach years ago, with the development of mobile medical vans to provide care to the home. Two years ago he started American TeleCare, which has developed technology that permits electronic home health visits. American TeleCare focuses on product development, rather than delivery of services, and its core home health product is the "Personal Telemedicine System" (PTS) for the home. It is organized around two modules: the home unit and the nursing unit. The nursing unit is set up at a central nursing station, and is staffed by a nurse who provides electronic housecalls to multiple home units. The system works over the "plain old telephone system" (POTS). Thus, it operates over the ubiquitous analog phone lines, making it universally available. Since the first PTS was piloted in July, 1994, Dr. Mahmud reports that two full systems have been sold and installed, totaling 20 patient units.

The patient unit (see picture) consists of a videophone, telephone with speaker phone, and electronic peripheral devices including a blood pressure cuff and pulse monitor, stethoscope sending unit, and thermometer. The 2-1/2 inch screen (MCI’s VideoPhone, with a tiny camera in the monitor’s bezel) delivers color video at 7-10 frames/second. This compares to standard interactive-video mediated telemedicine applications, which typically run at a minimum of 15 frames/second at 256 lines of resolution. Nevertheless, Dr. Mahmud believes that the motion handling and resolution are adequate for the nurse to assess the patient’s mood, alertness, and some basic neurologic functions such as facial symmetry, conjugate eye movements, gross vision, stance, etc. (see picture) Queried for more details about lines of resolution, Dr. Mahmud responded, "I think that the lines of resolution and technical parameters are stressed too much. The important feature is how it is used clinically." He states that the resolution is insufficient for examining small wounds (< 1cm). However, it is adequate for examination of larger fields (see picture), and for conducting examination of patients with heart failure, chronic lung disease, asthma, cancer, infections, and diabetes, which account for the majority of patients receiving home care. The patient unit has been designed for maximal ease of use for elderly patients. Thus, it has no keyboard, and the controls are simple, well-identified call buttons (black button for routine calls, red button for emergency calls, etc.) A unique feature of the PTS is the optional "personal pendant," an emergency response system that allows emergency nursing access by the patient from anywhere in the house. Dr. Mahmud stresses that this feature has been de-emphasized in more recent versions of the PTS, because home nursing agencies prefer that patients access 911 services directly in an emergency. The patient unit sells for $4,500 and includes an electronic stethoscope sending unit.

The nursing unit (see picture) consists of a receiver that identifies and prioritizes incoming calls, a matching 2-1/2 inch video screen, and the stethoscope receiving unit. It will have the electronics necessary to process and display the pulse and blood pressure information on a separate computer monitor. The unit is integrated with a Windows-based computerized patient record. This can also be configured to include outcomes tracking (clinical outcomes, complications, satisfaction), an electronic triage system, and a mechanism for automatic reporting to physicians. The nursing unit sells for $3,000-$8,000, depending on the level of software integration, and includes the electronic stethoscope receiving unit.

Dr. Mahmud states that the units can be rented for about $10/day, and can facilitate home care nursing for about 1/4 the cost of on-site visits. To date, Medicare/Medicaid in Minnesota are not reimbursing. However, third-party carriers and managed care systems have expressed great interest in this technology, with its evident capacity for cost savings. To date, there have been no legal challenges to the system.

Research on the system , to be published in the September ‘95 issue of Telemedicine Journal (vol. 1, issue 2), suggests that in the study population (a small contingent of home-bound patients) there was a reduction of on-site home care visits, increased compliance, reduction of hospitalizations, and an increased ability to maintain patients at home rather than in a nursing home.

Dr. Mahmud expresses considerable excitement about the potential for this technology, stating "This could considerably expand the scope of home health care, and will enhance the ability to control the rate of disease progression. This should allow health care workers to fine-tune patient care so that their problems don’t accumulate to serious levels between visits to the physician’s office. It should reduce emergency visits and hospitalizations, and will become a very powerful instrument in health care." He also emphasizes that, unlike many higher-end telemedicine systems in use today, the PTS is fully ready to be tested and used in a commercial environment, and can make a clear and immediate contribution to a health-care agency’s bottom line.

An Interview with Lisa Remington

If there is such a thing as a "central exchange" for the home health care industry, most people in the field would probably say that the Remington Report is it. The bimonthly magazine was founded in 1992 by Lisa Remington, a 15-year veteran of strategic planning and business development for the home-health industry. The Remington Report now has a circulation of 40,000. It has featured stories on nearly every aspect of home health care, including the Aug/Sept 95 issue (vol. 3, #5) devoted to emerging technology and telemedicine in home health care.

To assure that Telemedicine Today’s enthusiasm for telemedicine to the home wasn’t the result of tunnel vision and undue zealotry, we contacted Lisa Remington to solicit her views. Here’s an edited summary of what she had to tell us. The interviewer was Ace Allen, M.D.

Telemedicine Today: What role do you think telemedicine will play in the home health care of the future?

Lisa Remington: I’ll start right out by saying that telemedicine is the future of the home health industry. It is going to change the way we care for patients. Just look at the numbers, and the way health care is headed in the U.S. People want more and are willing to pay less. We’re moving toward a totally capitated health-care environment, where the pot [of health-care dollars] stays the same size regardless of the need for medical care. Since we are aging as a society, and since aging people require more health care, I think it is fair to say that the only way to make the shrinking dollars fit the increasing needs is to become a lot more efficient. Telemedicine is the only thing I see coming up that promises real improvements in efficiency.

Telemedicine Today: Can you give our readers an example of what this "new efficiency" might look like?

Lisa Remington: Sure. Let’s say you’re an HMO charged with covering 500,000 lives. Let’s say that at any given time 1% of these need daily home health care, either for chronic diseases or because short-term home health care is an alternative to expensive hospitalization. Figure that a home-health nurse can see an average of 5 patients per day using the old technology -- the automobile. The numbers work out to 5,000 patient visits divided by five, or 1,000 nurses you have to hire, just to see home-health patients. Now let’s say that half of the on-site home-health visits could be replaced by televideo visits, where each nurse could see 20 patients/day instead of five. Instead of having to hire 1,000 nurses, you’d only have to hire about 625. That’s 375 FTE’s you’re saving. Now 625 nurses are doing what it took 1,000 to do before.

Telemedicine Today: How would you figure the cost of the technology into this scenario?

Lisa Remington: The cost is going down so fast that any estimates I make won’t be very meaningful. However, the evidence I’ve seen suggests that the personnel savings will be much, much greater than the technology costs.