The Home Telehealth Primer

By Audrey Kinsella MA, MS, July, 2008
Author's note: This article first appeared on a long-term care informational Web site in 2005, written by the author on request to familiarize the ever-broadening range of players in the home telehealth field about the scope of home telehealth and its potential to extend on conventional care services. Asked recently by the TIE staff to update the article yet keep it introductory still for our new audience in mid-2008, this article is an introduction to what has truly become a rapidly burgeoning healthcare frontier in the 21st century, and it is targeted for those just learning about this exciting service field. Much has changed since I developed the Home Telehealth segment of the TIE in 1995, and much has been written about even newer technology that we should be expecting in our own and our parents' increasingly smart living rooms. I am very glad that looking back on describing developments in the field gave me the opportunity to showcase some of the best writing I've seen in the field about the promise of home telehealth provided by stellar thinkers Dr. Richard Satava and Dr. Ron Pion both of whom are quoted at length in the article.

Introduction: What is Home Telehealth and Why Is It Needed?

The Institute of Medicine defines telemedicine as the "use of electronic information and telecommunications technologies to provide and support health care when distance separates the participants." Home telehealth is an expansion of the basic definition of telemedicine to include the use of telecommunications to provide care services to a patient in his or her place of residency.

But, why is home telehealth needed? To answer that question, it's helpful to examine a typical day in the life of a home telehealth patient. Meet Mary Smith, a composite case drawn from many examples. Mary is a 63-year-old resident of Gatesville, Kansas, has lived with diabetes for 15 years and has had many complications during that time. Travel to hospitals and specialists has been difficult and the visits expensive. On her last discharge from hospital to home, her doctor approved home telehealth services and monitoring.

It's 6:30 AM in Mary's rural farmhouse where she has lived most of her life. Mary is awakened by her alarm going off reminding her to measure her blood glucose and blood pressure and to send those readings through her telephone to her telenurse, Susan Brown, who works 200 miles away in Wichita. Susan will receive the information and contact Mary if there is a change of health status or if help appears to be needed.

Mary sends her first report at 8:00 AM but she doesn't do it with a regular phone call. She does it by using two telemonitoring devices--a blood pressure cuff with a telecommunications plug-in and a similar device to monitor blood glucose--that are attached to a telehealth, computer workstation. The telehealth work station is connected to Mary's phone line and is linked through the line to Susan's computer in Wichita.

After Mary's computer sends its data, Susan receives the information on her own computer and can instantly interpret the state of Mary's health. In addition, an inexpensive camera perched on top of Mary's telemonitor can take snapshots of Mary as she measures her insulin, inserts her syringe, and rotates injection sites, and will send the pictures along to her nurse so that Susan can actually see Mary and how she is doing. If she needs to, the nurse can give her patient a phone call and coach her along. Using her telemonitoring machine and a telephone, Mary can be connected with a nurse, ask a question, or be reminded of a routine on a 24/7/365 basis.

Mary, who lives alone, also suffers from hypertension and has had some bouts of depression related to living with multiple chronic diseases. Until now, her children had felt that sending her to live in a nursing home was a good choice, but, with telehealth, Mary can monitor herself regularly and learn lifelong self management routines. Currently, nursing home placement is not necessary; she can get the assistance she needs at home. And the challenge of monitoring and managing her own health on a daily basis has given Mary focus and helped her with her depression. In addition, with the regular counseling she receives from her nurse and careful management of exercise routines, she has already reduced her number of medications and has not made any emergency room visits in a long while.

Cost savings typically realized by the use of home telehealth, as in this case, are seen in the short term (in reductions of on-site personnel) and in the long term (as a result of reduced numbers of costly hospitalizations and visits to emergency rooms).

After more than a decade, some acceptance has taken hold of the idea of home telehealth service use. Home telehealth is health and education services delivered to patients in their homes in part by telecommunication devices like the telephone and telecommunication-ready healthcare monitors like a blood pressure cuff. More remote (rather than in-person) contact with patients is possible using telehealth as an adjunct to conventional care. With telehealth and the increased opportunities for communications that it affords, health professionals can assess patients' status and change and reiterate parts of their care plan routines, as frequently as is needed.

This increased contact is much needed today apart from the comfort value that it provides. Now, at the beginning of the 21st century, changes in the financing of conventional home care have significantly affected doing home care "business as usual." A greater thrust toward demonstrating improved patient health outcomes and accountability of monies spent has become the order of the day as a result of home care's chief payer--the Center for Medicare and Medicaid Services (CMS)--instituting the Prospective Payment System (PPS) for Home Care, in October 2000. For more information, see the notes at the end of the article.

The impending nursing shortage nationwide will affect the delivery of usual home care services as well. Add to the mix an increasing number of patients discharged earlier to home care, owing to hospital-based PPS and its bent toward reduced lengths of stay, (LOS), and telehealth contact that is used as a supplement to the conventional two-to-three-times-per week in-person home nursing visit is becoming very much welcomed indeed.

But using telehealth is not a last resort option by any means. Challenged by fewer (affordable) visits, fewer nursing staff, and increasing and often costly legions of elderly home care patients, nurses and patients alike can benefit from focused and frequent telehealth contact. According to Gary L. Glissman, BS, RN, CCM, who is a long-time nurse and home care agency manager, the opportunities for providing home telehealth solutions are virtually unlimited:

Is there value in telehealth? Yes, and it's two-fold at least. Among these:

1. Nurses can be more alert to patients' current needs and address these needs in a more timely manner than ever before;
2. Patients who receive telehealth interventions can receive more comprehensive management, leading to more rapid stabilization and, ideally, learn how to become more competent in self management skills (learning self management being the most cost effective home health service interaction of all).

Does Home Telehealth Technology Work in Today's Ordinary Home?

The latest high technology telehealth devices are often described in a tone of astonishment in the popular press. These articles describe radiofrequency identification devices (RFIDs) embedded in sneakers, devices that can monitor and reorder supplies, and smart gadgets that become a timely, all-around personal assistant. Unfortunately, much of this "tele-ready" equipment is still in the lab and not in the average home where people, particularly the elderly, need regular health services and personal health monitoring.

There's good news about how these needs are being addressed, if slowly, though. In the last 10 years telecare-ready devices have become better designed to meet today's health needs and have become extremely affordable--enabling their use by ordinary people/patients who need health services at home. Telecommunications-ready blood pressure cuffs, glucose meters, and other peripherals average only several hundred dollars or less. Similarly, the full-scale telehealth workstation, which can accommodate most needed monitoring devices in healthcare (pulse oxymeter, weight scale, glucose meters, and so on) are available for as little as several thousand dollars (compared to more than $20,000 per station less than 20 years ago).

Thankfully, increased simplification of home telehealth products and systems have also become the hallmark of good design. Typically, today's full-scale workstation and peripherals will have only one operating button, such as an on/off switch. Color-coded buttons and easy-to-follow verbal or printed directions for helping patients to obtain and transmit information are commonplace. For example, for congestive heart failure (CHF) patients, who are among the largest and costliest group in home care today, a significant part of their daily "televisit" simply involves stepping on an automated weight scale that is connected to the household telephone line and transmits the number directly and accurately to the patients' nurse at the home care agency. Telenurses at the home health agency wear an alerting device and receive indications of the name and phone number of home care patients who have gained one-to-two pounds within a 24-hour period (a significant number for a CHF patient), and ought to be contacted immediately by phone.

How does this automated transmission translate into more effective telehealth? According to Mary Bondmass, Ph.D., RN, a nurse who worked for years with a CHF home telehealth program in Chicago, every one of these telephone contacts with patients is a learning or teaching opportunity (Kinsella, 2003). Nurses get the chance to reiterate or re-phrase information that they have provided to patients in person, or to offer new information. The telenurse's interactions can be entirely informal, as indicated in this example where the nurse asks patients who show a weight increase a series of questions:

Nuse: "What did you have for dinner last night?"

Patient: "Hmm, Chinese take-out, again?"

Nurse: "Tell me what you've been eating this week, it sounds like a lot of salt."

This would then lead into the "teaching opportunity" about salt and fluid retention that the patients would have heard at least once before.

The nurse might say: "Look at your ankles," which may be swollen with retained fluids; or, if she noted a shortness of breath, which can indicate fluid in the lungs, she would point that out. Patients would then get an immediate, practical lesson in cause, effect, and correctable actions for managing and preventing fluid retention.

No, the nurse did not have to calibrate or program the scale to do telehealth. She did have the opportunity to get information that the scale automatically transferred to her pager and computer and to use the telephone to reinforce details for her CHF patients about their newly learned daily routines. She also could order a diuretic for the patient in a more timely fashion than might be the case with less frequent patient-nurse contact.

When viewed this way, home telehealth practice and its provision for augmenting and extending usual in-person services may seem much more attractive than its reputation for "automating" (rather than providing in-person "caring" ) services bears out.

Does Home Telehealth Work For Every Patient?

Increasingly, experimenters have begun to conclude that, from a business perspective, telehealth works best with those patients who need the most frequent contact. For example, those patients living with diabetes who routinely overeat foods high in carbohydrates, or forget to measure their blood sugars regularly every day need more interaction, instruction, and coaching to stay relatively well.

Linda C. Pearce, RN, CDE, a certified diabetes educator and nurse, notes the vital importance of ongoing education delivered conventionally or via telehealth--whatever it takes to get people, living with diabetes, on the road to self management. A person newly diagnosed with diabetes must learn around 150 different tasks in order to reach disease self management (Pearce, 2004).

Rather than brand some difficult and costly patients "noncompliant," it needs to recognized that sometimes they may be patients who simply don't remember what to do or eat, and as a result are frequently hospitalized and cost more. The educational need for telehealth is clear in cases like these. As Pearce notes about usual education for newly diagnosed persons living with diabetes much needed competency in self management, "Cannot be achieved during a brief hospital stay, most particularly during a brief educational session just prior to discharge while family or friends are waiting to take the patient home."

Stephen Clements, MD, an endocrinologist who works with home telehealth and diabetes programs similarly suggests the benefit and value of increased contact for these patients: "I believe the best way to have an impact on the patient is by giving constant personal feedback to the patient on how well he or she is doing."

Home telehealth services that provide continuing education and informal and frequent reminders and coaching may affect or "work" for other long-term chronic care populations who need to learn lifetime changes, those followed more than 60 days after the typical home episode.

Ensuring That Home Telehealth Works Better

The need for patient assessment for appropriateness of home telehealth can't be overstated if telehealth is expected to work for that patient. That is why all patients who are targeted to receive home telehealth (even the likeliest candidates who have chronic diseases and are willing to change behaviors with telehealth help) must be assessed more closely than they would be for usual home care services. Patients can't simply agree to use telehealth to meet the challenges of changing their life-long routines. They must be assessed thoroughly for physical and cognitive capabilities for addressing these challenges correctly and effectively. Home care agency nurses need to assess patients' cognitive skills indicating their abilities to remember or perform certain tasks without onsite coaching by the nurse; and the patients' physical capabilities, such as their degrees or limitations of hearing and seeing must be assessed as well if telehealth contact is to be successful.

A sample Patient Assessment as Appropriate for for Assignment to Home Telehealth form is provided in PDF format.

Getting the home "right" is an important consideration as well in deciding whether home telehealth will work well. Just as the home care patient has to be assessed as an appropriate user of telehealth (demonstrating, for instance, that he can tell time, that he can turn on and use the system, and so on), so the home has to be assessed by nurses as appropriate for telehealth (or made to be appropriate and safe). Nurses doing the assessments will be looking at measuring distances between telehealth workstation, telephone, and usual patient location (easy chair in living room, chair at kitchen table, and so on), and usual routine footpaths in the room or rooms typically used by the patient.

In assessing and then preparing the home for telehealth, it is crucial that no hazards be introduced as a result of setting up a telehealth system, and any changes that are introduced to a patient's usual setting or routine path made safe. This safeguarding activity may call for nurses duct-taping wires to the floor, using brightly colored tape on rearranged furniture, and otherwise taking all steps to avoid affecting patients' safety by introducing home telehealth. Call it "tele-proofing" a room to ensure safety.

It needs to be recognized, in addition, that if features of a patient's room present insurmountable obstacles (i.e., the room is very crowded with keepsakes, many wires are needed, and the patient's eyesight is poor), then some patients like these may not be deemed appropriate for assignment to telehealth and only conventional care should be provided.

Understanding Home Telehealth Equipment

Understanding telehealth equipment doesn't require anyone to become a mechanical or software engineer. In fact, it's important to know that at present, many devices used in telehealth really are familiar healthcare tools such as a stethoscope, pulse oxymeter, or blood glucose meter that now have telecommunications capabilities. That means that with the special adaptations that they have, patient information and physiological measurements (like blood glucose or blood pressure levels) can be sent by patients from their homes to nurses at their offices using ordinary telephone jacks and telephone lines. No rewiring of the house is required and no exceptional telecommunication costs are typically incurred by patients--particularly those living with multiple chronic diseases--who need to communicate with their nurses frequently.

It's good to know that telehealth can assist in more frequent "visits" with patients. In fact, over the last decade an enormous amount of resources have been dedicated to establishing whether and how home telehealth devices can replicate the in-person skilled nursing visits and avoid the in-person costs. Any popular engineering or technology journal article on telehealth and detail will be provided on how closely the new tools capture off-site what used to be acquired and noted by hand by nurses.

However, there are new needs that are becoming better appreciated. These focus on the burgeoning numbers of elderly patients at home and many of them living longer with one or more chronic disease who cannot possibly be cared for adequately using the conventional model of a handful of skilled nursing visits per week for a few months. In today's circumstances, the need for telehealth to educate and help patients learn to self manage cannot just be a hoped for consequence of home care admissions that uses telehealth.

Government paid homecare visits typically last on average about 41.5 days but are paid-for under prospective payment for up to 60 days worth of care. We have to actually help patients to become better prepared for self monitoring and self managing when the home care admission ends and there isn't a nurse at the other end of the monitoring equipment.

One forward looking approach that has been taken by home care agencies to addressing this need has been to put telemonitoring machines in the home for the first half of the patients' admission periods and use this time to contact them frequently, reiterate directions, and coach. Usual services are provided during the second 30 days of the admission period with special attention given during in-person visits to ensuring that the self care routines are followed regularly and correctly.

These kinds of trials make sense. After all, for some people living with multiple chronic diseases this practice is part of what will need to be lifetime, daily self-care routines.

Telehealth's Role in the Changing World of Medicare-funded Home Health Care

Elderly patients living with chronic diseases have become the focus of numerous CMS-sponsored demonstration projects that span not just home care but all of healthcare delivery in the U.S. One of these, the Medicare Coordinated Care Demonstration Project, is testing whether "coordinated care services" provided for Medicare beneficiaries living with complex chronic illnesses can help keep patients healthier and lower overall costs as a result of diverse types of healthcare contact. In this case, for thousands of Medicare beneficiaries living at home, we're not looking at usual home care service delivery as in the Medicare model. Instead, we're looking at services received in various places, from multiple healthcare sources, by people who happen to live at home.

Think of this and other Medicare-sponsored demonstration projects as looking at elderly chronic disease populations in a laboratory setting--what medications do they buy, how many healthcare encounters do they have and with whom, and so on. Telehealth will be used some of the time, for monitoring. However, a focus on long-term education through telehealth ought to be a central one. This focus has always been the keystone of telehealthcare delivery--namely, the increased opportunities for education provided by informed sources who are located at a distance.

In the future, to deliver this education to the homes of many thousands of people living with chronic diseases and to others needing health information, we will be relying on the Internet. And we won't be inventing any new delivery communication systems but using the Internet through already accessible telephone/videophone devices and televisions in the ordinary living room. (A brand new development reported only as of July 2005 indicates research by major telecommunications and utilities companies and computer vendors to begin to use household electrical jacks to access the Internet, making the technology even more accessible for all of us.

Ron Pion, MD, a physician who has been actively involved in healthcare communications for decades, writes on today's changing circumstances in home healthcare and its expanded yet still uncharted horizons. He likens this time of the dawn of Internet use in healthcare to Columbus's voyage to America and those uncharted days:

"Short term return on investment was not among the key priorities of the funders of Columbus's voyage to new and uncharted lands more than 500 years ago. A longer view was in order, one that involved perceived future riches for the nation and access to a multitude of new and unfamiliar resources.

Today, our New World is the Internet. It is one still as new and uncharted as the West seemed to all sailors and armchair travelers in Columbus's day. And there may be other similarities between that world and ours. Today's voyages involve understanding the Internet landscape's rich resources which we don't really know much about yet or whether they will work..

The promise of the Internet in health care is absolutely stunning and hard to grasp as yet, particularly for home health care applications. This potential great benefit rests in connecting the relatively isolated (from in-patient-related staff and procedures) home health care population to critical information and communications with professional and informed assisters.

Is there really value in the Internet in home care today, in this highest touch of healthcare delivery settings? The answer is yes, and it lies in three words: connectivity, connectivity, and (still more) connectivity (Kinsella, 2003).

Connecting patients more often to their caregivers in home care, and over the longer term, to the needed resources for helping them to self manage is clearly expected to yield documented and significant improvements.

Home Telehealth and Smart Technologies

Apart from needy and elderly patients living with multiple chronic diseases, a research focus in home telehealth is on wellness and health maintenance--at all ages. One visionary health researcher (and a surgeon), Richard Satava, M.D., describes doable home telehealth that is as easy to use as common household items like toothbrushes. In his analogy, these , "smart" or information-gathering toothbrushes operate just like the toothbrushes we already know and use, but they are now newly wired and offer interactive feedback--in this case for oral health--for promising cures and other helpful medical information. Of course his example of toothbrushes can be extended to all sorts of common household items that can be worn or used to give feedback on a person's health. Dr. Satava explains:

Wireless systems are predicated upon a set of non-invasive, wearable monitors which can accurately measure certain critical factors, such as vital signs or blood chemicals. For fitness and for heart disease individuals, these measurements will be blood pressure, pulse rate, and electrocardiogram (EKG) that can measure the performance of the heart as a measure of total body fitness or as a warning for heart failure and irregular heart beats. Other sensors, such as blood sugar and sweat, can determine the fatigue level of a fit person, or the dangers in persons living with diabetes or other metabolic diseases. As a stand-alone system, these monitors can notify the person about their excellent health, or alert them when an impending crisis is about to occur. In the latter situation, urgent action can be taken to avoid a serious medical emergency, thus preventing the person from a complication of their disease that would require hospitalization.

The same information as above could be arranged to be fed into a telemedicine network wirelessly and make the information available to a nurse or physician. Whether on a real-time basis, as in patients who are at home immediately after a surgical procedure, or on a reporting schedule (like, once a day or once a week), the transmission to the healthcare provider can have the doctor's or nurse's expertise available to those persons who are high risk, without needing the person to be in the hospital. From a very practical perspective, this information can be made available to a caregiver, usually a daughter or son, when the parent lives alone-?this provides both reassurance to the family as well as an early warning if something goes wrong.

The promise is that, in the immediate future, more and more of these sensors will become available, and they will be even smaller and less intrusive to a point of being literally invisible. A good example is the smart t-shirt, which automatically begins monitoring vital signs when you put the shirt on. Other devices are being created which are like common accessories, such as watches, ear rings, or lockets. The result is that our population will have the reassurance that their health is being monitored and they will be alerted if there are problems. In addition, many sensors will be embedded throughout the house, especially in the bedroom, bathroom and kitchen, to monitor many functions, such as sleep patterns, body chemistries, or nutritional intake. All of the collected information will go into a central personal computer that provides the information back to the person ? safe from the outside prying eyes. If--and only if--the person wants someone else to have the information, will it be sent to family members, nurses or doctors.

These technologies are here today, and are beginning to be networked together over the Internet, to empower each person to know more about their daily health and therefore live a healthier life style (Satava, 2002).

There it is: new and high technology in our usual medicine cabinet, bathroom mirror, and toothbrush. A telehealth measuring equipment world that is gravitating toward the ordinary household fixture (the telephone, television set, sensors in the stove and in our floorboards) should be the expected "new" ways for all of us to keep on track and stay well at home. Part and parcel with this development of available and discrete teletools for usual routines is an embracement of the idea of remote monitoring on an as-needed, when-needed basis.

How Close to Achieving It Are We Today?

Many developments in the lab or on the design boards (such as wearable and noninvasive glucose or heart rate monitors) allow for independence. These devices help us live with diabetes or heart disease and still travel and live a life instead of having to remain immobile receiving regular health services at home. These new devices enable people living with chronic diseases not to stay close to home at all, if desired.

Fine, but in the business world of home health that has adapted its policies and planning to conform to Medicare regulation (followed by CMS as well as most other health insurers as a standard), home care patients are required to be homebound with few exceptions during their 60-day or more admission period. More telehealth devices will enable home care patients to receive usual services off site, such as at an adult day care center. And healthcare plans are following suit by making accommodations to allow payments for these home health services away from home. So, as needs change and technologies become available, we may not be thinking that home care has to be delivered very close to home at all.

In short, just as the U.S. proposed legislation, Money Follows the Person Act of 2003, and later (still proposed, Act of 2005) is requiring federal healthcare monies to follow the patient (away from nursing homes, when possible, and to community-based care settings), so home telehealth is following suit. In the future, we should expect home technology to follow people to where they are and to be delivering paid-for services to them where and when needed.

Notes

Details about PPS for Home Care are available on the CMS Web site. Information with case examples on early use of telehealth under PPS for Home Care is provided by the author, in PPS and Home Care Services: Telehealth's Needed Role (at least as of Oct. 2000), online at the Telemedicine Information Exchange.

Appendix 1: Medicare's Current Reimbursement Policy for Telehealth

201.13 Telehealth.--An HHA (home health agency) may adopt telehealth technologies that it believes promote efficiencies or improve quality of care. Telehomecare encounters do not meet the definition of a visit set forth in regulations at 42 CFR 409.48(c) and the telehealth services may not be counted as Medicare covered home health visits or used as qualifying services for home health eligibility. An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to its clients, a doctor may take their availability into account when he or she prepares a plan of treatment (i.e., may write requirements for telehealth services into the POT). Medicare eligibility and payment would be determined based on the patient's characteristics and the need for and receipt of the Medicare covered services ordered by the physician. If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished.

(Source: Centers for Medicare & Medicaid Services (CMS). Medicare Home Health Agency Manual [HM-11]. Washington, DC: GPO: Section 201.13

References

Clement S. Look Homeward. The Home Telehealth Community of Care, 2001. (Link last checked on June, 2008).

Glissman G. Home Telehealthcare: Process, Policy and Procedures (ed[s]. Kinsella A). Kensington, MD: Information for Tomorrow, 2003.

Hoffman C, Rice D, Sung H. Persons with chronic conditions: their prevalence and costs. Journal of the American Medical Association, November 13, 1996, 14276(18): 1473.

Home Healthcare: Wired and Ready for Telehealth, the Nurses' and Nursing Students' Edition. Information For Tomorrow, 2003.

Pearce L. Look Homeward. The Home Telehealth Community of Care, 2004. (Link last checked on June, 2008).

Satava R. Coming Home. The Home Telehealth Community of Care, 2002. (Link last checked on June, 2008).