AHRQ highlights benefits, challenges of telehealth

Grantees in low-income, rural areas provide data

By developing secure and private electronic health records for most Americans, and making health information available electronically when and where it is needed, health information technology (IT) can improve the quality of care, even as it makes health care more cost-effective, asserts the Agency for Health Care Research and Quality in a new report. (To download a free copy of the report, go to: healthit.ahrq.gov.) As part of its IT initiative, the organization has recently homed in on the role telehealth can play in the overall effort to accomplish this overarching goal.

Telehealth can improve patient safety and quality of care, but implementation is not easy, the report asserts. For example:

  • One project demonstrated that remote pharmacy services provided to rural hospitals during irregular hours (nights, weekends, and holidays) can more effectively detect and prevent dangerous medication errors than traditional methods; this can be attributed to pharmacists manually reviewing (night and weekend) orders first thing in the morning before turning to day-shift activities.
  • Another project demonstrated that remote pediatric care can easily treat common childhood illnesses from schools and child care centers, helping working parents who cannot leave their jobs.

However, when it came to implementation, the report cited challenges with using the equipment:

  • One project indicated that vendor-supplied home monitoring devices failed to work on a regular basis. As a result of this failure, approximately one-third of the patients who were enrolled in the study became frustrated with the devices and stopped using them.
  • Two projects reported that the video cameras they were using to transmit video and still images did not provide adequate resolution to yield clear images of small pills (medications) and patient wound areas.

The report focuses on grants in the health IT portfolio that are implementing telehealth — which AHRQ defines as "the use of electronic information and telecommunications technologies to support clinical health care, health-related education, public health, and health administration from a distance." These grants were awarded in 10 states — Arkansas, California, Minnesota, Montana, New Mexico, New York, Oklahoma, Pennsylvania, Tennessee, and Texas — and serve primarily low-income rural areas with high rates of chronic illness.

Improving access

The actual intent of the report, says Teresa Zayas-Caban, PhD, AHRQ's senior manager, health IT, was to look at implementation challenges, "but we have anecdotal evidence that the biggest benefit was improved access to care. Many of the grantees work with community-based organizations in rural areas, and for them it is hard, for example, to get in touch with specialists."

Several participating providers also claimed that integrating telehealth with their electronic health record (EHR) systems offered many "critical benefits," and helps facilitate the provision of team-based care. "That means being able to share data in real-time with the provider at the other end, and also longitudinally, particularly with specialists and nurse case managers focusing on patients with chronic illnesses," Caban explains. "The real-time data that come from the EHR can be observations — blood pressure, glucose readings, and so forth — things that can be monitored through telehealth."

For example, she says, one project in wound care for diabetics modified the intervention to include monitoring of glucose readings, because some patients with diabetes also are at risk for other conditions and were being mentored in risk-reduction activities such as losing weight and controlling blood pressure.

"In the same project, allied health providers and home health care workers were linking with wound care specialists that were not in that area, as well as with primary care providers who were tracking their patients," adds Caban. Follow-up research, she says, shows improved outcomes. 1,2

Pilot tests recommended

To eliminate, or at least minimize, some of the equipment use problems noted in the report, Caban says that serious consideration should be given to "vigorously" pilot testing all equipment being considered.

"Many of these problems came up during the intervention," she notes. "So, for example, the users could have piloted different types of cameras to compare the transmission quality using high-speed Internet and dial-up, but they did not take the time to do that. Some grantees had settled on a specific camera, and then later realized they needed more bandwidth to get better images."

Small pilot tests, with a mockup of the kind of information you are trying to view, would be most helpful, she continues. "In one example, the grantee wanted the home health worker to show the meds the patient was on, but the camera did not have the resolution necessary to be able to look at [the labels] in detail," she shares. "If you already know how you want to use the intervention, take four or five products you might be working with and run several tasks you want to accomplish."

There can be unique considerations involved, Caban notes. "In the wound care project, for example, a lot of the patients were elderly; they needed equipment that was easy to use, where they only needed to push one button," she says. "However, they also wanted to minimize the intrusiveness of being monitored, and they were concerned that even if the camera was off it could still see them, for instance, in the bath." A solution was found, however. "They got a camera with a little lid that could be put up or down so the patients would be assured no one could see them," says Caban.

Which brings up another critical point, she continues. "We can't emphasize enough how important it is not only to really pilot test, but to also take into consideration the needs of your users — which, in this case, includes patients as well as providers," she concludes.

[For more information, contact:

AHRQ National Resource Center for Health Information Technology. Phone: (866) 356-3467. E-mail: NRC-HealthIT@ahrq.hhs.gov.]

References

  1. Arora S, Geppert CM, Kalishman S, Dion D, Pullara F, Bjeletich B, Simpson G, Alverson DC, Moore LB, Kuhl D, Scaletti JV. Academic health center management of chronic diseases through knowledge networks: Project ECHO. Acad Med 2007 Feb;82(2):154-60.
  2. Arora S, Thornton K, Jenkusky SM, Parish B, Scaletti JV. Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Public Health Rep 2007;122 Suppl 2:74-7.