Video hookups link babies and their families

Telemedicine may have cost, quality impact

When new mothers depart Beth Israel Deaconess Medical Center in Boston, leaving behind their premature infants, technology is easing some of the trauma of separation.

The medical center is testing - to good results thus far - use of telemedicine to connect families at home with infants in the neonatal intensive care unit. Using video conferencing equipment, families are able to see the baby, talk to him or her, and even receive instruction from the clinical staff about the child's care, both during the hospital stay and afterwards. When the child goes home, the system can be reversed, with NICU clinicians in the medical center looking in on the baby and the family.

The idea developed a couple of years ago during a conversation between James Gray, MD, director of newborn care in the NICU, and Charles Safran, MD, an internist who now is director of the project, called Baby CareLink.

"After a little conversation, we realized that we have an interesting group of patients to apply these [telemedicine] technologies to," recalls Gray. "In the past, telemedicine technology was talked of in terms of chronic illnesses. That's not the way we perceive our patients, but we do have patients who stay in the hospital for extended periods of time." The average is two to three months.

Funding for the project was obtained from the National Library of Medicine, and an evaluation study is being conducted to determine if the use of telemedicine will improve care, reduce lengths of stay, and decrease the costs of caring for newborns who weigh three pounds or less and remain hospitalized for at least two months.

The key components of CareLink include a home-based multimedia computer, complete with modem, high-speed phone lines, and a videoconferencing unit. Families selected for the study are provided with the equipment, which includes a home computer. Gray points out that computer literacy is not a requirement for the study - either as test subjects or control subjects - and thus far learning the technology has not been a hindrance to families.

And the beauty of the project is that it allows parents to do a lot of what new parents like to do most - just watch their baby. "Parents can get up in the middle of the night, turn on their computers, and see how their babies are doing," says Safran.

For security reasons, the process requires assent at both ends of the phone lines. For instance, parents can fire up their computers at any time and call the NICU. Someone on staff must position the video camera - contained in a moveable cart - at the baby.

Security was a key concern in developing the system, Gray notes. To clear that hurdle, the medical center partnered with Security Dynamics Inc. of Bedford, MA. Security Dynamics produces the SecurID token which guards against unauthorized access. To log on the system, both parents and hospital staff must enter a personal identification number combined with a one-time password, generated by the SecurID token. The password, contained in a card about the size of an ATM card, changes every 60 seconds. This two-factor authentication provides protection against unauthorized access and substantially greater security than traditional passwords.

On-line support included

Besides the live video, Baby CareLink also provides on-line support services for the new parents. This includes resources from the medical center, local government, and communities. Parents can browse an on-line library containing book reviews on topics related to their NICU infants and surf the World Wide Web for other sites.

In addition, Gray notes that a Web page is created for each infant featuring information about the baby's course in the NICU as well as a gallery of photographs so that extended family and friends can share in the baby's birth and development. The Web features are a potentially valuable addition to the education of the parents, he notes.

Also, the Web sites become a virtual classroom for the new parents by providing a means for parents and staff to communicate questions or concerns. Gray notes that the computer also includes a Web-based discharge planning module where staff can "prescribe"discharge learning materials that are specific to parents of individual babies. Using their home-based computer, parents can prepare for the baby's arrival home by reviewing the computer material and using checkmarks to select options the computer poses. These checkmarks, in turn, will generate a computer note to the NICU staff about any areas of care the parents may be having difficulty understanding.

The computer sessions offer tips on general techniques, such as how to take a baby's temperature and positioning the baby for sleep, and the staff can add materials specific to certain infants, such as how to mix a particular formula, Gray says.

The "warm and fuzzy" aspects of Baby Carelink are obvious, but the key question is how will it impact the quality and cost of highly expensive neonatal care? That will be answered next year when the results of the randomized trials are analyzed, Gray says. The study involves about 150 patients, half of whom will be part of Baby CareLink and half receiving traditional care.

Gray says possible benefits being investigated include telemedicine's ability to educate parents. "It possibly can play a role in the transformation of families who have no previous child care experience, and who need to, during their baby's NICU hospitalization, become comfortable and confident in their abilities before we send the babies home," he says.

Another possible key benefit could come after the baby is discharged. "We can, through video conferencing, export expertise from the NICU into the home," Gray says. "It's really kind of a virtual Visiting Nurses Association, but it allows the people with the most skills in the care of these kids [NICU staff] into the families' homes. And these are people who have a pre-existing relationship with the family, and that's an important combination."

As usual, much of the future of telemedicine in the NICU will be based on the impact it has on lengths of stay, and that's a major question the study seeks to answer, Gray says. "The way we might affect that is by changing the readiness of babies to go home. But when you release a baby there are three questions involved - is the baby ready, is the family ready, and is the community ready? This system may be a way of improving the latter two."