From telemedicine to e-health, case management opportunities abound

Here’s advice from professionals leading the charge

It’s an old, familiar problem. Case managers are trying to provide adequate and appropriate services with fewer resources. The good news is that thanks to the Internet and other communication channels, there are some new solutions to that ever-present challenge.

Michael L. Jones, PhD, founding director of the Virginia C. Crawford Research Institute at Shepherd Center in Atlanta, knows firsthand. "We found that we were having to discharge patients earlier and earlier, and we weren’t able to send our staff out for home assessments as we did in the past or provide as much follow-up support as we’d like," he says. Shepherd Center is a 100-bed hospital specializing in spinal cord- and brain-injured patients. "In 1996, we started exploring the use of telemedicine to help us fill the gaps in service caused by early discharge and to help prevent secondary complications such as pressure ulcers and urinary tract infections." (See stories, pp. 164 and 166, for further discussion of the Shepherd Center’s telemedicine experience.)

In addition to telemedicine, which typically links patients and providers through a system of telephone lines, video cameras, and monitors, many health care organizations are looking at Internet solutions to provide low-cost yet effective services such as helping patients with chronic diseases better manage their health.

Stan Bernard, MD, MBA, president of Bernard Associates, a health care Internet consulting firm in Neshanic Station, NJ, has coined the term "care space" to describe this growing Internet segment. He divides the "care space" into the following two segments:

  1. Care management. "These are Internet-based approaches to comprehensive care services to patients. This is not the same as content space’ or health care sites whose primary purpose is to provide information in generic form that may or may not be provider-validated," Bernard notes. "Care management sites involve on-line interactions between a patient and their own health care professionals with the primary objective of better health outcomes."
  2. Care tools. "These applications monitor, measure, or record health status," he explains. "Some of these sites offer home testing options which allow patients to . . . upload tests such as pinprick glucose or cholesterol tests directly to the Web. The site’s health care professionals then tell you the meaning of your results and may make suggestions for lifestyle changes."

Whether organizations are using Internet applications or other telemedicine technology to provide patient education and monitoring services, professionals familiar with those applications agree on the potential benefits for patients and providers. They include:

  • Better access for patients. "Patients are tired of sitting in waiting rooms reading old magazines," says Joan Bristow, RN, MA, vice president of risk management for The Doctors’ Company, a health care professional liability insurer in Napa, CA. "Telemedicine options give patients greater access to their providers."
  • Convenience. "Most of our patients are discharged from Shepherd Center in a wheelchair," Jones says. "They are going to have transportation and access hassles every time they try to get back to the clinic for a visit. With the use of telerehabilitation technology, we have been able to save patients a clinic visit and still monitor their progress and provide necessary education and support."
  • Cost reductions. "Shepherd serves patients in several states. To move some of our patients across the state for a follow-up clinic visit involves a $3,000 to $4,000 ambulance trip," Jones says. "The telerehabilitation program eliminates the need for that ambulance trip, and we can still make sure the patient receives necessary follow-up visits."
  • Delivery of the appropriate intervention at the appropriate time. "The care space [Internet] creates the ability to provide the most appropriate care — the right provider at the right time at the appropriate site," says Bernard. "The patient doesn’t always need to come into the hospital. Many times the patient can be treated in the home or the physician’s office. Monitoring and communicating with the patient via the Internet allows the health care professional at the care management site to help direct the patient to the most appropriate care."

Perhaps the largest remaining barrier to the continued growth of the "care space" and other remote patient intervention efforts is physicians, say Bernard and Jones. "Patients want to interact with their physicians on-line, but their physicians aren’t compliant," notes Bernard. "One recent survey found that 77% of patients prefer to get on-line health information from their own physicians, but only 10% of physicians have a Web page or give their e-mail addresses to patients."

Liability concerns

Physicians continue to shy away from the Internet for legitimate reasons, Bernard adds, such as patient confidentiality concerns, fear of additional uncompensated work time, and professional liability concerns.

Bristow points out that physicians are right to remain cautious about communicating with patients via the Internet and other remote communications systems. "In moving from physical, face-to-face house calls to telephone calls to e-mail replacing telephone calls, we are dealing with the potential for new medical malpractice issues," she notes. (See story, p. 167, for information on liability risks associated with e-health and telemedicine programs.)

Although providers and case managers may remain reluctant, Bernard predicts that consumer demand will force them to communicate with patients on-line. "In addition to [their] other potential, Internet applications are much less expensive than telemedicine models," he says. Health care organizations should consider preparing now, if they haven’t already, to create their own "care space" or risk being frozen out of the rapidly proliferating e-health market, he adds.

Bernard says case managers and their organizations should consider using these strategies for expanding their current products and services via the Internet:

  • Design Internet clinical delivery models and processes.
  • Promote member/patient recruitment and retention using highly personalized communications and information.
  • Counter physician resistance to Internet use by engaging physicians to help develop Web-based clinical applications.
  • Use physician "e-reminders" to modify physician behavior in areas such as improved Health Plan Employer Data and Information Set performance measures.
  • Use patient e-reminders to improve treatment compliance.

"People inside and outside of health care tend to hold one of three views about whether or not the Internet can deliver patient care," notes Bernard. "One view is that the entire discussion on health care and the Internet is way overblown, and the Internet will never be able to deliver on all of its promises."

By contrast, a second view holds that the Internet will dramatically change health care delivery in the United States, he says. "Finally, there is a third view that falls somewhere in between the first two. This view basically is that the Internet will change the way health care is delivered, but as a complement to existing health care delivery services."

Bernard holds the third view. "Consumers are driving the growth of the e-health space in their search for better health care. I think the Internet can enhance care management capabilities as a complementary tool that helps empower patient/ provider relationships."

While many health care professionals argue that the Internet and other telemedicine applications are "dehumanizing," Bernard argues the opposite. "Patients now get about seven minutes with their physician. They are frustrated with the current system. The Web can offer patients that additional information and care they’re searching for from their providers. Providers that offer Web services are telling patients, I’m caring for you 24/7. I wasn’t able to do that before the Internet.’ In that way, the Web can actually increase interactions and improve patient satisfaction within the patient/provider relationship."

In addition, Bernard says that when health care organizations develop their own Web sites, they control the information their patients receive via the Internet. Other sites on the Internet can dissociate the patient from the provider. "The patient goes on-line and gathers information without telling the physician and then acts on that information, which may not be medically appropriate. This is a real source of potential conflict and is happening every day," he notes.

(For more on the use of the Internet in health care, see Case Management Advisor, May 2000, pp. 73-81, and June 2000, pp. 93-98.)