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Disease Management Via Telehealth: Technology Tools for the Year 2005 by Loretta Schlachta-Fairchild, RN, PhD(c), CHE

Telemedicine has been historically perceived in primarily the medical domain. Teleconsultation - medical consultation from physician to physician using telemedicine technology - has been the primary activity to date when telemedicine is considered. In contrast, however, telemedicine's core definition means tele - 'distance' and mederi - 'healing'. Within the root definition of 'distance healing' is the yet to be unleashed capability of telemedicine technology. Distance healing can be achieved in many venues: patient to nurse, from medical nutrition therapist to patient, from wound therapist to physician, and so on.All health professionals such as social workers, nurses, psychologists, respiratory therapists, etc. can also practice within the purview of distance healing. An expanded perspective of telemedicine is beyond physician teleconsultation as the prevailing use of the technology. What has been accomplished thus far in the evolution of telemedicine may be just the tip of the iceberg in terms of potential for the impact on costs, patient care and the health care delivery system in the U.S. and in other countries. All health providers can and should leverage this technology in their practice to benefit patient care.

Telehealth Invites Future Possibilities

A broader concept of telemedicine is telehealth. Telehealth includes the use of interactive video for healthcare practice, the use of the Internet, both for providers' and patients' access to clinical information, and expanded use of peripheral monitoring devices. Peripheral monitoring devices and biosensors are becoming very small, portable and fairly low cost so they can be deployed not only in clinics and inpatient settings, but in patient's homes. With technological advances, more and more care already is and can be shifted to the true "point of care" - the home. In the home, the decisions and practices of patients that ultimately affect their health care trajectory are first made. Thus, the greatest opportunity for impacting patient's health and utilization costs occurs in the home setting. In previous experience with placing peripheral monitoring devices in patients' homes, findings suggest that patients will use peripheral monitoring devices. Once they do, and become familiar with them, they then begin to achieve empowerment and self care. Experience suggests that patients begin to actively manage their own disease, when mentored and in partnership with providers. In providing self-care, patients then do not as frequently seek out the acute, more expensive forms of care.

Home based telemedicine technology, encompassing interactive video with healthcare providers and use of peripheral medical devices in the home, will be a fundamental delivery model for health care in the future. Technologies are rapidly evolving whereby a computer in the home is no longer required. Interactive video devices over a patients' own TV set and using the existing phone line in the home are today a technical reality. They are a user friendly and low cost solution to provide home telemedicine-based care to patients. Patient access to electronic information via the Internet is becoming very popular in terms of consumer demand. The impact of both of these phenomena is yet to be evaluated. But there's no doubt that consumers (in healthcare, called patients) have an appetite for convenient, accessible health care and clinical information.

A strategic tool for nursing's future in the light of all the talk about technology and boxes and wires and video and cameras is the caring and therapeutic relationship that nursing brings to health care delivery. It's not been lost on anyone that what telemedicine technology is about is access to care. But like anything else in life, fundamentally, beyond all the technology, therapeutic success is based on relationships. Once therapies are in place, it is therapeutic relationships that appear to make a difference in patient outcomes. Perhaps it's not so much the technology that makes a difference, but that patients respond to consistent access, care, monitoring and attention. The whole phenomena of home-telemedicine delivered care and its effect is yet to be thoroughly explored. Preliminary findings in programs across the country find overall good patient acceptance, embracement and results of care via telehealth technology.

Telehealth: Where and How to Use It

Some arenas specific to telenursing use of telemedicine technology to consider and exploit for the future are listed below. Other opportunities, both in nursing and in healthcare in general, are limited only by the current paradigm of the existing model of healthcare delivery.

1. Preventive medicine, community health, home health, acute and primary care. Especially in geographically remote, or underserved areas, telehealth technology can provide mentorship, information, consultation, education and treatment resources. A model that has been utilized is telemedicine technology for Nurse Practitioner (NP) to MD consultations in NP run clinics.

2. School health and the ability to link various schools, conduct counseling, education, and to see children when they're sick at school is also an opportunity. School nurses often cover multiple institutions, which provides a logical opportunity for use of telemedicine technology.

3. Discharge follow up. When patients have multiple comorbidities and medications, post acute management in homes, nursing homes, and/or subacute facilities is an opportunity.

4. Psych/community mental health is an arena that is ripe for the use of telehealth technology. Interactive voice and video has been demonstrated to have efficacy in telepsychiatry, and can be used by allied professionals and psychiatric clinical nurse specialists as well.

5. Disease Management is another arena of application. Disease management is a form of practice that treats high risk, high cost patients that have diagnosed conditions for which there are broad variations in treatment. The approach attempts to standardize the care and treatment of such patients to achieve an impact upon healthcare outcomes and healthcare utilization costs. Disease management is more than case-managing patients. It's intervention. It is also an iterative process: evidence based health care delivered to the patient in conjunction with analysis and adjustment of the care by process improvement. The basis of disease management is the use of clinical practice guidelines. Home-based, telemedicine technology can be used as a tool for the delivery of disease management care.

Disease Management: Where Did It Come From?

Disease management has evolved as a potential solution to the increasingly expensive acute-based healthcare delivery system. When fee-for-service reimbursement was common, providers and healthcare institutions received payment for actively treating patients and filling hospital beds. The next step was early managed care, where excess capacity (empty beds) in hospitals was present, so institutions and providers could charge less for doing all that care, yet still achieve revenues based on the volume of care delivery. The current healthcare arena has evolved to capitation as a reimbursement model. In capitation, a set amount of revenues occurs for an agreed upon population of patients. The incentives for reimbursement have changed, and thus healthcare delivery is looking for economies in the way that care is 'managed' or delivered. As a result, techniques such as critical paths and case management help achieve economies in getting patients rapidly in and out of expensive hospital settings. The Department of Defense, being the largest managed care organization in the world, receives a certain amount of dollars each year from Congress to take care of their beneficiaries. The DOD is essentially a capitated environment; a managed care "company". The DOD, too, can take advantage of the economies and patient outcomes achieved via the use of disease management as a healthcare delivery approach.

Within the civilian sector, disease management is used as a tool to achieve cost savings and improve patient outcomes. Disease management's premise is that of a fundamental change from the acute perspective of healthcare delivery to a proactive, preventive perspective. In general, economies have already been squeezed out of the acute health care system by group purchasing, generic medication use, critical pathways and other efficiency efforts. The success of disease management is in a fundamental change in perspective: to prevent patients from ever coming into the acute health care system. Once patients are in the Emergency Room, an outpatient setting, or even starting down a perfectly designed and executed critical path, it's too late. Only by beginning intervention post diagnosis and before acute events occur, can fundamental healthcare changes and their resultant savings be realized.

Healthcare Tradition Meets Economic Reality

The disease management approach, with or without using home telemedicine technology, is a fundamental shift which often meets resistance. Because it's not the way facilities and providers, particularly physicians, are structured or trained to practice and deliver health care, it appears threatening. So why would anyone subscribe to disease management? Chronic illness consumes an increasingly large percent of the health care dollar. Pareto's law of economics applies to healthcare delivery: 20% of the patients cause 80% of the economic activity. Pareto's law is evident in health care delivery where a small group of chronically ill patients consumes a large percentage of the cost of care. Surprisingly, Pareto's law holds as well in military health care. In a review of data from a major military medical center, it was found that a small percent, 12% of the patients consumed 54% of the health care dollars. So that incidence does occur within the military health care system, where one would think the population would be younger and healthier. And as the DOD moves toward Medicare subvention, care of even more elderly and chronic patients will challenge the healthcare delivery system financially and operationally. In the civilian sector disease management has produced a 10% to 40% reduction in health care utilization costs, depending on the population and the disease group. Within the DOD, evidence of positive results from disease management is beginning to occur. The Office of the Lead Agent, Tricare Region 9 recently completed a disease management pilot for pediatric asthma. They achieved a decrease in health care utilization cost and improvement in quality of life with a group of high risk, pediatric asthma patients using a home telemedicine based, disease management approach (See PACMEDTEK Proceedings, LTC Alton Powell, presentation).

Disease Management via Home Telemedicine: How Does it Work?

Disease management really does work but it is a fundamental change in the delivery of care to patients. Disease management fits in the continuum of care after diagnosis. Ideally, after risk analysis, patients who are identified as the most severe and high risk, are optimum candidates for disease management. Since disease management occurs at the beginning of the continuum of care, all of the costs associated with the rest of the (acute) continuum of care are avoided. That is the goal of successful disease management. Thus is the opportunity of a home telemedicine-based approach to disease management. Care can be delivered by all the disciplines: physicians, nurses, nutritionists and psychiatric specialists and others, to patients in their home, the true point of care. The disease management process operationally relies on a nurse team leader who works in partnership with and as an extension of the patient's treating physician. The nurse, in conjunction with other multidisciplinary team members, is guided by physician-approved therapeutic protocols and uses a telemedicine delivery platform to deliver and coordinate care to patients. The disease manager nurse uses a computer and over the Internet can access protocols via an information system that can initiate and deliver patient outcomes and store them into a database for analysis. The analysis yields the effect of the protocols, the effect of disease management, and ultimately predicts changes in patient status. Physicians and the healthcare delivery system should view disease management as being a physician force multiplier, i.e. taking the medically prescribed plan of care for a patient, using established protocols and ensuring that the medical regimen is delivered and adhered to. As those who have been in healthcare for some time realize, just because a patient has medicine and an instruction sheet in their hand when they leave a clinic or hospital, doesn't mean that they will properly use it, understand it, or benefit by it.

Conclusion and Future Predictions

Telehealth and home telemedicine-delivered care will fundamentally change the way healthcare delivery occurs. It will also radically affect the business of health care delivery. The challenge is to leverage the opportunity of home telemedicine technology to shift from provider focused to patient-centric focused health care delivery. A further challenge is to exploit the technology to achieve fundamental change, not just automate or facilitate current healthcare delivery processes. As a population and healthcare system, we are in the infancy stages of this approach. There are many questions to be answered. There are many challenges, technical, professional and interpersonal. But from all preliminary indications, patients embrace this approach, both clinically and economically. Those patients who currently feel that the health care delivery system is reducing their health care benefit may achieve a whole new level of access and satisfaction with a home telehealth-based disease management approach. A mutual benefit for payers and purchasers is that the approach is cost effective, individualized, and customer friendly.

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Source: Proceedings, Pacific Medical Technology Symposium, PACMEDTek: Transcending Time, Distance and Structural Barriers . Aug 17-21, 1998 Honolulu, HI. Los Alamitos, CA: IEEE Computer Society.

The opinions and positions included in this article are those of the author and do not reflect the official policy or position of the Department of Defense or ITeleHealth, Inc.

Ms. Schlachta-Fairchild is a Telehealth Consultant and the former Clinical Director, Strategic Monitored Services, Inc. Ms. Schlachta-Fairchild can be reached at lschlachta@itelehealthinc.com.