Telemedicine may be the answer to the inpatient education dilemma

Videophone sessions replace traditional nurse visits

Although the elderly cardiac patient wasn’t officially part of a Tele-home study, he proved to be the perfect patient to give Kaiser Permanente nurses in Sacramento, CA, experience with their telemedicine techniques. He spent at least five to 10 days in the hospital each month. In addition to hospital stays, the patient frequently made unscheduled physician visits or went to the emergency department.

During the four months the patient received daily telemedicine visits, he was never admitted to the hospital and made no trips to the emergency department, or had unscheduled office visits. Working with a nurse on a daily basis, the patient and his caregiver were able to learn how to live with chronic heart problems.

Kaiser’s Tele-home Health study — one of many telemedicine efforts underway that may have a long-term impact on patient education — is comparing standard home health care against a telemedicine model. The Kaiser program supplements some of the in-person visits with videophone visits, providing patients with more frequent access to health care professionals. Two hundred Kaiser patients in the Sacramento Valley are participating in the one-year study that began in the summer of 1996. The study focuses on patients who need a lot of teaching because of chronic conditions such as diabetes, chronic obstructive pulmonary disease, and severe congestive heart failure.

Patients in the control group receive traditional home health nursing visits while treatment group participants use a home telemedicine unit for some of their check-in visits. The unit, the size of a small microwave oven, is equipped with blood pressure- and pulse monitors and a stethoscope, and operates over standard telephone lines. The only difference between the two groups is the use of telemedicine.

"We don’t do anything terribly different on telemedicine visits then we would on the in-home visits. The visits have all the same components such as assessment, teaching symptom control, and planning," says Linda Wheeler, MSN, PHN, nursing team leader at Kaiser Sacramento Home Health.

Although results still are not available, the Kaiser study and other innovative approaches could show that telemedicine is the answer to the inpatient education dilemma. Often, there is no time during a hospital stay to teach a patient all the skills needed to manage a chronic disease at home. When there is time, the patient is usually too sick to learn. Videophone visits could provide the opportunity to reinforce teaching and cover information that wasn’t taught. Nurses could teach the patient when he or she is ready to learn.

"Often, when patients are released from the hospital they need a lot of education. They are on new medication, new therapies, or they have a new disease process they need to learn to manage at home," says Jill Deuser, RN, MBA, project manager for Tele-home Health at Interactive Technologies Initiative, Kaiser Permanente in Oakland, CA.

Many educational opportunities

Providing a continuum of care by educating patients in their homes using videophones is one way telemedicine is being used as a teaching tool. The Eastern Montana Telemedicine Network is pioneering another approach, using two-way interactive videoconferencing technology to connect people in rural areas to the community outreach classes offered in Billings.

"As part of the Deaconess-Billings Clinic Health System, we have a health conference center with an auditorium that seats 200, but people in outlying areas can participate interactively at all our telemedicine sites," says Thelma McClosky Armstrong, director of the network. Participants use videoconferencing equipment installed in a conference room at each site. The system is voice activated so whoever is speaking — whether the educator or an audience member asking a question — appears on a monitor in each location.

Teleconferencing requires a hefty financial investment. The cost for equipment runs about $50,000 to $70,000 per teleconference site, McClosky Armstrong says. A video "bridge" to connect conferencing sites costs another $100,000. And monthly telecommunications bills can cost up to $10,000, depending on site distances. In total, Deaconess Billings spent $1million on hardware for 11 teleconferencing sites, McClosky Armstrong says.

With the aid of the telemedicine equipment purchased through grants, Montana health professionals conducted depression education sessions followed by screenings. The lecture and education piece were transmitted to all sites from Billings, while clinicians at each remote site did the screenings. Because Montana has the third highest suicide rate in the country and there are no psychiatrists in half the state, such outreach efforts are vital, says McClosky Armstrong.

Other education programs have included a neurology series with classes on headaches, sleep disorders, and Alzheimer’s. There also is a women and heart disease series and nutrition seminars. (For tips on effective teleconference teaching, see story, p. 27.)

Telemedicine sites connect people in remote areas with support groups and provide professional speakers to educate group members about their diseases. For example, a diabetes support group in Glendive requests a topic from the diabetes nurse educator in Billings about once every three months, says McClosky Armstrong.

Because Montana is sparsely populated, a community may have only one or two people with a certain disease, but they still can participate in a support group via the telemedicine site. "Two people don’t make a support group, but if there are 10 sites with two people in each site, you have a very active support group. Telemedicine provides a good way to connect people who have the same disease process and gives them the opportunity to hear medical educators and specialists," says McClosky Armstrong.

In 1996, the Eastern Montana Telemedicine Network conducted 1,300 conferences with 13,000 participants. "We probably saved close to a million dollars in travel costs for our rural sites for all educational activities. Many of the trips would be overnight stays," says McClosky Armstrong.

Telemedicine uncomplicated

While the cost of the equipment might prohibit many patient education managers from duplicating the educational projects at Kaiser Sacramento Home Health and in Eastern Montana, telemedicine need not be so complicated. "Many people are making telemedicine more than it really is. In its simplest terms, it is the transporting of information from one location to another. Nothing more complex," says Jay Sanders, MD, president and CEO of The Global Telemedicine Group in McLean, VA. That means telephone help lines staffed by nurses as well as a Web site on the Internet can constitute telemedicine.

An economical way to extend patient education beyond the hospital stay is with a Web site, says Paul C. Tang, MD, associate professor of medicine at Northwestern University Medical School and medical director of information systems at Northwestern Memorial Hospital in Chicago. For example, a postpartum Web site might include a page with answers to all the most frequently asked questions about breast feeding.

Kaiser is considering integrating the Tele-home Health system with its Web site, so nurses interacting with patients using telemedicine could steer patients to educational materials on the Web site. The patient could download the material and have it in hand while the nurse reviewed it.

Sanders says one of the greatest strengths of telemedicine is it gives control back to the patient. "Telemedicine, in whatever forum you want to discuss, is access to an information database the patient can constantly re-look at or hear. At the other end of the pendulum, it is immediate access to a health care provider. It provides the capability for the patient to be more a part of their own health care maintenance and become more educated," he explains.

Wheeler has noticed that the Kaiser Tele-home Health project has put some accountability at the patient and caregiver level. "People are so used to the dependent role we have given them in their own health care, and as long as we keep doing in-home visits, they maintain that position," Wheeler says. Because the patient or his or her caregiver must participate in a telemedicine exam, they begin to understand how weight or blood pressure affects their health. "It draws them into the whole care cycle," she says.