Personal Telemedicine
Evan Rosen
erosen@impactvid.com

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 video nurse.

"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 Elwin's chart.

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 technology.

"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 face-to-face.

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 number…" 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 care…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 advances.

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…American 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 healthcare.

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