Gary Doolittle, M.D.
Assoc. Professor, Division of Oncology, Dept of Medicine, U of Kansas Medical Center
Medical Director, Kansas Telemedicine Project.
(with Ace Allen, M.D. Director of Research, Kansas Telemedicine Project)

This feasibility study has been done in collaboration with Kendallwood Residential Care of Kansas City, MO.

Hospice care refers to specialized, relatively non-interventional care given to terminal patients. Its goals are to relieve suffering and ease the dying process for the patient and family. The concept originated in England and was introduced into the U.S. in the 1970’s, where it is largely used for end-stage comfort care of cancer patients in their homes. Typically, the attending physician continues to manage the patient’s care, as part of an interdisciplinary team that includes nurses, social workers, physical and occupational therapists, chaplains, and volunteers. Payment is through private insurance or the Hospice Medicare Benefit, which provides a fixed per diem reimbursement rate to certified programs. The Medicare benefit is a modified capitated system, where reimbursement is fixed regardless of diagnosis or cost of care, and is based on the number of days a patient is in the program. The current reimbursement is about $100/day, for up to 6 months. In many cases hospice care is provided at no cost for people who don’t qualify for Medicare or other benefits. There are currently about 2,500 hospice programs in the U.S. which care for about 1/3 of patients dying of cancer.

As noted, hospice care in the U.S. is mostly in a managed care (essentially capitated) setting. Because the Medicare reimbursement rate is fairly low, there can be considerable pressure to withhold or delay forms of treatment or on-site care that are more expensive. There is concommitant pressure to maximize efficiency. A significant portion of the expense of hospice care may be due to on-site visits from members of the multidisciplinary care team. This makes the use of telemedicine technologies especially attractive, since they obviate travel time and cost.

The Technology

We have established a pilot interactive video mediated tele-hospice project at two hospice programs in St. Joseph and Kansas City, MO. For each program a base station was installed at the hospice administrative office and at the home of a hospice nurse, to take after-hours calls. The same type of interactive video units were placed in the homes of four patients. These are "set-top boxes" (ViaTV, 8x8 Inc., Santa Clara, CA; www.8x8.com/index.html) that are placed atop a standard color television set. (see Photo) Each unit contains a wide-angle camera with a high depth of field, enabling focus from about 30cm to infinity. It also contains the CODEC (coder/decoder) which compresses and digitizes the video signal and transmits it over a regular phone line to the remote receiving unit. The set-top box connects to a television set’s video input port and to a standard telephone with a simple wiring harness. The video image is displayed full screen or smaller, at the viewer’s discretion, and 2-way full duplex audio contact is made through the telephone’s handset or speaker phone option. Images can be manipulated by pushing the appropriate dial buttons on the telephone, guided by on-screen instructions that are accessed by pushing the "#" key on the telephone. Image control features include: sizing of the remote image; picture-in-picture (PIP); higher-resolution still image capture; ability to trade off between better resolution and better motion handling using a graphical sliding toggle; and far-end camera control for pan-tilt-zoom. Apparently because the set-top box concept utilizes the pre-existing television monitor and telephone audio, it is able to keep the total cost down to about $550/unit. This has made it extremely attractive for us to try out the technology on a speculative basis, without needing to justify the cost of equipment on a return-on-investment basis.

Because the equipment operates over standard phone lines, there are no delays or added expense of establishing ISDN service to individual homes. While the set-up is fairly simple, we have found that it may be more than some people can handle. Therefore, we don’t ask patients to set up the units themselves. To simplify the installation process, we have integrated the units with inexpensive 13-inch televisions and speaker-equipped telephones; the integrated package is installed as a unit at the patient’s home. The retail cost of the integrated unit is under $1,000. Motion handling is fair, at about 10 frames/sec. With adequate lighting and when toggled to a slightly slower frame rate, the resolution is quite good and compares with much higher-priced ISDN-based units we have used transmitting at 128 Kbps.

In our study we are augmenting, rather than replacing, standard hospice nursing visits. Clients are selected on a convenience basis (i.e., they are not randomized). Once they agree to participate, the hospice nurse takes the integrated interactive video unit to their home, sets it up, and trains the patient in its use. Thereafter, the units are used as needed and wanted by the patient and the hospice care team.

The feasibility portion of this study will be completed by mid autumn, 1997. Then an implementation phase will begin, offering the service as an additional benefit to all hospice patients. We will evaluate provider and patient satisfaction, cost tracking and analysis, access to care, and impact on care.

We are especially excited about the potential for this sort of technology to enable better, less expensive access to hospice care for rural patients. In many rural areas patients may be hours away from hospice professionals, making it difficult (and sometimes impossible, in bad weather) to provide the ideal of timely multidisciplinary care.

REFERENCE

Von Gunten CF, Neely KJ, Martinez JM. Hospice and palliative care: program needs and academic issues. Oncology 10:1070-1074, 1996

CALLOUT. Equipment used in this study: Set-top box from ViaTV, 8x8 Inc. Santa Clara, CA. Operates over regular phone lines. Unit cost: $550. 408-654-0935; www.8x8.com/index.html.