It's 9:30 AM Monday and Linda McRae is preparing to
see her first patient at the Kaiser Permanente home health care center in
suburban Sacramento. But Linda's patient is 23 miles away. Rather than drive
there, Linda walks into the center's video room, because it's time to become a
"Good morning. This is Linda McRae. Are you ready for
a visit?" Linda asks her patient over a regular phone line. The patient,
69-year-old Elwin Geyer, is ready. So, Linda and the patient count
"one-two-three" together and then they both push the video button. Within three
seconds, the image of an emaciated patient suffering from chronic lung disease
pops up on Linda's video nurse unit. The unit is an MCI Videophone customized
by American TeleCare.
Elwin's wife, Jean, appears on screen with him. She
lets Linda know that Elwin had an emergency on Saturday evening during which a
nursing supervisor made a special video visit. "I see that," says Linda,
glancing at Elwin's chart. "There was shortness of breath. How's he doing now?"
Elwin is apparently doing much better.
Linda conducts the same line of questioning she would
if this were a face-to-face visit. "How is your appetite? How about the
bowels?" After getting answers from Elwin and his wife, it's time to monitor
the patient's breathing. So, Linda must call on a separate phone line and
listen to breathing sounds through headphones. Jean has learned to move the
stethoscope around her husband's body. The stethoscope is connected to the
American TeleCare video unit. "OK. Take a deep breath for position one. Ok.
Position two now. Three. Four. Five. Go to the back." The video screen shows
the bony figure of Elwin rise up, turn and descend with difficulty. "Six.
Seven. Eight. Nine. Ten. OK. Can you put it over his heart and let me listen?"
Linda looks at her watch. "OK. Fine. Are you coughing up anything?" The answer
is no. "Do you feel congested in your chest, because it still sounds like
you've got some congestion there." Jean explains that there is much less
congestion than on Saturday when Elwin had a panic attack. Linda notes this on
The video visit is part of a hectic schedule of home
visits, most of which Linda will do face-to-face today. The Kaiser tele-home
health program is now going into full-swing after a 17-month trial that wrapped
up last October. Now home health care nurses like Linda will begin including
video visits as a regular part of their schedules. Linda has spent 35 years as
a registered nurse, thirteen of those years in home health. Now she can add
video nurse to her list of credits. And despite common notions that only
younger professionals warm up quickly to new technology, Linda insists that she
liked video nursing from the moment she saw a demonstration of the
"I like it. Almost all the patients I've had have
liked it," says Linda. "It gives them a sense of confidence that help is only a
phone call away and they can see the nurse." One benefit for patients is the
immediacy of video. When Elwin experienced emergency breathing problems late on
Saturday, an in-person nursing visit would have been nearly impossible because
the home care staff is off-duty after 5 PM. However, a video visit requires no
driving time and therefore a supervisor was able to look in on Elwin before
leaving for the day.
Kaiser is currently quantifying the benefits of its
trial tele-home health care project. Early results suggest significant time
savings. For example, the Sacramento home health care staff estimates that
face-to-face nursing visits require 45 minutes on average while tele-home
health visits take just 18 minutes on average. Unlike a video visit, a
face-to-face visit requires driving time and other time. "There's more
interaction and greeting," according to Linda. "You have to wash your hands,
take your equipment out of your bag and wash your hands again." Preliminary
results of the trial indicate that nurses can conduct about 15 visits per shift
via video while they can make no more than six visits per shift
The Kaiser tele-home health care project in Sacramento
is the brainchild of Linda Wheeler, a home health team leader, and Barbara
Johnston, a hospice nurse. The two women got the idea while they were taking
courses for Master's degrees in nursing. They took one course together via
distance learning technology. The professor was in Oakland and the students
were at four other sites. When an assignment came to develop a business plan,
Wheeler and Johnston decided that they could make a case for using video
technology in the home health field. "It went from a business plan for a school
project to a proposal for funding to a year-and-a-half long funded research
project," explains Wheeler.
The study included 100 treatment patients and 100
control group patients. In phase one, Kaiser home health managers assigned one
tele-home health nurse to conduct all of the video visits. In phase two, all
staff nurses conducted video visits.
The next step for Wheeler and Johnston is to sell
tele-home health to Kaiser regional administrators. "We sometimes have to push
on the doors a bit, but it's happening. And I think the organization is open to
the concept," Wheeler says. Kaiser's Northern California Region includes 2.7
million health plan members, 3800 physicians, and 26,000 staff. There are 13
million patient/provider encounters in the Kaiser region per year. Currently,
the Sacramento home health agency is using 20 patient units and 2 nursing
systems from American TeleCare. These are first-generation systems that Kaiser
plans to replace. The staff plans to evaluate American TeleCare's new
technology along with lower-cost mainstream consumer video phones available
from C-Phone Corporation and 8x8. All 30 nurses at the home health agency have
some experience as video nurses.
As Kaiser integrates video nursing as standard
practice at the Sacramento facility, supervisors are considering two different
approaches. One approach is to designate certain nurses to handle all video
visits. This strategy makes the program easier to manage, according to Wheeler.
However, there are other arguments favoring video nursing as a standard
practice for every home care nurse. One of those arguments is continuity of
care and the benefits of ensuring that the same nurse visits a patient
in-person and via video.
It's pushing 10 AM now back in the video room of
Kaiser's Sacramento home health facility, and Linda McRae is wrapping up her
visit with Elwin Geyer. "Do you want me to ask the doctor about anything?"
Elwin's wife says he would like medication for the panic attacks. "I will ask
the doctor," says Linda. Minutes later, Linda is leaving a voice mail for Dr.
John Takakuwa at a Kaiser clinic in nearby Rancho Cordova. "Hi. This is Linda
McRae from home care. I'm calling about Elwin Geyer, medical record
" She brings the doctor up to date on Elwin's condition and passes
along the request for additional medication. "It would help if the doctor had
video and I could say maybe you should look in on this patient," Linda insists.
Kaiser home health managers say they plan to equip physicians with video
technology in a later deployment phase.
Home health care administrators and others who are
looking to telemedicine as a cure-all to busted budgets and patient care
problems can get the scoop from Linda McRae and others on the front lines about
the advantages and limitations of the technology. Linda says that her video
visit with Elwin worked fine because he thinks and speaks clearly. "For someone
who is confused and unable to answer questions, it may not be as satisfactory,"
insists the 35-year nursing veteran. "Also, some patients require hands-on
for instance, wound care. Or, if you're doing a lot of instruction,
like teaching a new diabetic."
While Linda appreciates the immediacy of video and the
time savings the technology offers, she believes overuse of telemedicine would
be a mistake both for patient care and nurse morale. "I like video, but I
wouldn't want to do just this
to sit in front of a machine all day without
personal contact. No. You can't do everything this way."
Part of the challenge for telemedicine system vendors
is to recreate the face-to-face experience through video. The closer vendors
come to achieving this objective, the more effective a video visit becomes and
the more tolerant nurses become of the technology. Linda uses a
first-generation system from American TeleCare. This system offers a 2 1/2-inch
screen, which is too small to get a reasonable look at the patient. Also, Linda
had to switch from the speakerphone to the handset because Elwin had problems
hearing her. The new generation of American TeleCare technology called Aviva
helps address these problems. New models provide a 5-inch screen, offer a boost
in audio quality, and a better frame rate. While 5 inches beats 2 1/2, bigger
would be even better. One new PC-based model displays the patient's "telechart"
alongside the video. This is useful in that the nurse no longer must look away
from the screen to check a chart.
Linda conducts her video visits using regular phone
lines. POTS (Plain Old Telephone Service) is both a blessing and a curse. It is
a blessing in that POTS is nearly universally available in the United States,
though this is far from true in many other parts of the world. POTS is a curse
in that the video quality is still limited, despite significant recent
On the flip side, there is a strong argument that goes
something like this: POTS is good enough for tele-home care because bed-bound
patients rarely move much and therefore the low bandwidth of POTS is acceptable
for this application. Dr. Khalid Mahmud, Chairman and CEO of American TeleCare,
makes the case well. "The need for full motion video is created by people who
sell bandwidth. It's not a need for many clinical people." Nevertheless, the
goal should be to create a video experience that best mimics a face-to-face
encounter. Since broad bandwidth to the home is by no means readily available
and affordable, a trade-off is necessary. It is important, however, to realize
that today's video quality over POTS is a compromise solution rather than a
desired result. Even better quality is still desirable for tele-home health
care. Perhaps video compression experts can achieve this over POTS.
Next-generation cellular video may also be an option. Also, DSL (Digital
Subscriber Line) technologies and some types of cable modems may also bring
higher-quality video to the home. ISDN (Integrated Services Digital Network)
provides a middle-bandwidth solution, but provisioning problems and lack of
availability in some areas have rendered ISDN an awkward solution in the United
States. ISDN to the home is more prevalent in parts of Europe and Asia, and
would therefore be a more appropriate transport option in those areas.
An interesting note on product design
TeleCare originally designed its systems with a patient call button. This
button would let the patient connect immediately with a video nurse. However,
the company has had to remove this feature from its systems because home care
organizations are far from prepared to staff video visit rooms 24-hours a day.
This may evolve, however, as patients demand greater service and home care
administrators grow more confident in telemedicine.
The most significant aspect of tele-home health is the
reduced isolation the technology can provide. Often, patients suffering from
chronic diseases enter the hospital because they crave emotional support and
company that they may lack at home. Video visits from nurses, nutritionists,
social workers, and physicians can provide that support far more cost
effectively than hospital admissions can. Also, video support groups will
evolve in which patients will be able to see and speak with other patients with
similar conditions. This will help take the pressure off health care workers in
providing emotional support.
Virtual health communities are beginning to evolve.
Linda McRae is among a handful of pioneers who are exploring the benefits and
drawbacks of an unstoppable trend in health and technology. Trial and error,
evaluation and analysis, supply and demand will assist providers in setting
standards for care as tele-home health fills a void in the delivery of
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