A tale of two technologies: Providers rave about them

Telehomecare saves money, averts denials

Telehomecare involves a broad range of technology and services delivered in the homes of patients. American TeleCare and Rubicon, two companies with different products, and their respective clients, University Home Care and Pitt County Memorial Hospital, both in Greenville, NC, illustrate the versatility and diversity of the telehomecare market.

American TeleCare’s product allows providers to make "video visits." Nurses and patients communicate through telemedicine units placed in the provider’s office and individual’s home, respectively. The patient telemedicine unit is 10 inches high and weighs 16 pounds. It includes a video display, speakerphone, blood pressure and pulse meter, and stethoscope. Some units also have call buttons that allow patients to immediately access their home care provider at any time. Not all providers want this feature activated however, depending on their after-hours staffing arrangements and the type of central unit — portable or stationary — they have.

Create a video record

In addition to verbally interacting with and visually evaluating patients, those using the American TeleCare product can assess vital signs and take date and time-stamped photographs that can be stored for later review. The system also includes automated patient record software for use during video visits. It uses normal telephone lines and electrical outlets.

Each patient unit costs around $5,000. Most providers lease the product at a cost of around $5 per day per unit, according to Khalid Mahmud, MD, FACP, founder, chief executive officer and chairman of the Eden Prairie, MN-based company. American TeleCare provides the central station as part of any lease or purchase arrangement.

University Home Care uses its 26 American TeleCare patient units on a variety of patients, including those with pregnancy-induced hypertension (PIH), chronic diseases like congestive heart failure and chronic obstructive pulmonary disease, and asthmatic children and infants at high risk for apnea.

It combines video and in-home visits to reinforce teaching, monitor compliance, and evaluate the status of the most vulnerable among these patient groups.

The results so far are impressive. Among the first five PIH patients, for example, the combination of video and traditional home visits averted 53 hospital days and saved about $23,000, according to Bonnie Britton, MSN, RN, C, supervisor of special programs. The agency only recently implemented the service on other patient populations and does not yet have documented outcomes.

Patients also seem to like the service. University Home Care conducted a qualitative study to gauge patients’ adaptation to technology. It found that patients and their families felt a sense of pride in being more responsible for their own care than they might otherwise be. Some also said they preferred video over traditional visits because they didn’t have to worry about making themselves or their homes presentable. Others liked having the additional connection with the agency, even though it does not use the 24-hour call button.

Although it covers the same territory as a traditional in-home visit, a typical video visit takes less than half the time. They last about 12.5 minutes compared with around 30 for those in-home, according to Britton. "I’m not sure why they’re shorter. It may be that [the nurse and patient] are more focused on the task at hand, and they don’t have the paperwork and setup time of a traditional visit," she says.

University Home Care spent approximately $145,000 on its system. Its parent, Pitt County Memorial Hospital, purchased five patient telemedicine units. It acquired the remainder through several grants ranging from the Children’s Miracle Network to a state foundation to the nursing society Sigma Theta Tau. Britton plans to apply for more grants in the future and is optimistic about receiving funding.

One commercial payer has recognized the technology and reimburses University Home Care’s video visits at the same rate as a traditional visit. The agency successfully argued that there is no difference between the two except that during video visits, nurses can’t touch patients or perform interventions like dressing changes that require hands-on care.

"I don’t expect that [level of reimbursement] with everyone," Britton reports.

Still, she is very optimistic about future reimbursement prospects. Although video visits are less expensive than traditional ones, they don’t excessively emphasize the cost savings when pitching the service to payers. Doing so may open the door for them to reimburse at cost, Britton cautions.

Even if other payers won’t recognize the service, it still pays financially, according to Britton. "I’m not concerned with Medicare. When the [prospective payment system] happens, it won’t matter that it’s not reimbursed. It will be a cost savings survival tactic," she explains.

Taking the patients no one wants

Through no fault of their own, patients with wounds such as decubitus ulcers are the pariahs of the home care world. Their care can cost an agency as much as $40,000 per case. It can cripple any provider, especially Medicare-certified agencies struggling under low per-beneficiary limits.

Even under the best of circumstances, wounds are among the most intractable chronic conditions. But their treatment among primary and specialist physicians, enterostomal therapists (ET), home care providers, and payers is rarely timely and well-coordinated.

"It’s the most mismanaged condition. The wounds are neglected, not because people aren’t trying, but because they occur in debilitated elderly patients. They’re not life-threatening, and they’re chronic," says Jack Fisher, MD, director of medical research for Nashville, TN-based Rubicon. Fisher is also a practicing plastic surgeon. His frustration at seeing so many poorly managed wound cases lead him, in collaboration with Rubicon president Jean Robertson and Jeff Bauer, vice president of information systems, to develop the company’s WoundBase product.

WoundBase uses "store-forward" technology. During a normal home visit, a nurse photographs her patient’s wound using a digital camera outfitted with a floppy disk. Later, back at the office, she inserts the floppy disk into a personal computer (PC) while running WoundBase software. The software measures a variety of wound characteristics such as its width, granulation, and epithelialization down to the millimeter and stores the image in its database. The nurse can view the image on the screen and also make a hard copy using a standard laser jet or laser printer.

Still later, using the PC in his office, the patient’s physician connects to the Internet, uses his pass code to access the WoundBase system, and pulls up his patient’s wound images. He can view the image side by side with an analysis of changes in the characteristics of the wound over the course of its treatment. He too can make a hard copy of the wound image to place in the patient’s chart.

Later, the case manager from the patient’s insurance company can also access the image and make a hard copy of it if she chooses.

The digital camera creates images that are a far cry from the grainy ones typically seen on Web sites, according to Fisher. "I call them Rembrandts. I can see more things, such as fine hairs, than if I was looking at the wound in person."

The images are "crystal clear," agrees Thomas Grier, RN, director of Bibb Medical Center Home Health in Centreville, AL. Bibb Home Health now uses the WoundBase product on every wound care patient that it follows, as well as those with implanted catheters and other invasive technologies.

"It’s fantastic," Grier says of the product. In addition to documenting wounds in graphic detail, it knocks days or even weeks off the home visit-wound intervention cycle, he reports.

Under traditional wound care, "if the physician who is only a family practitioner gets a call from a nurse who says the wound’s not healing and wants to consult with an ET, he needs an image of it," he explains. "The nurse takes a Polaroid shot. No two Polaroids are the same and they’re blurry, but he sends the image to the doctor in snail mail. By the time the doctor looks at the image, you’ve lost another week. By the time he contacts the ET or plastic surgeon, you’re now two weeks removed, and the wound’s significantly worse, and the staff member out in the field is saying, Help me!’"

Rubicon charges a $500 per month software licensing and service fee. It includes software upgrades, a WoundBase work station installed in the provider’s offices and initial system training. There is no added user fee; providers can take as many images of as many patients as they want. The digital cameras Rubicon recommends for use with WoundBase cost around $800; the floppy disks for the camera are about 25 cents each.

Grier hasn’t yet had to use WoundBase images as documentation to fight denied claims, but that’s one of the main reasons he believes the system is worth using even though no payer provides funding for it.

"This is a defensive mechanism," he says. "The road to reimbursement is getting more crooked and tighter, and this is extra ammunition in your pocket." n