A recent article in American Family Physician addressed the topic of home health care.1 Another article on home health care will be published in American Family Physician in the near future.2 The first of these articles outlined the physician's role in coordinating and overseeing the wide array of home services available to patients meeting the Medicare “home bound” definition.1 This “new” system of physician guidance and approval of care provided by nurses, therapists and other ancillary providers has become the predominant home care delivery model in the United States. Under this model, physicians generally do not conduct home visits. Typically, this new system is reactive, with resources deployed temporarily when a family's need for additional support becomes apparent during an acute illness or hospitalization for an exacerbation of a chronic disease.
The second article, which I co-authored, concerns the conduct of home visits by physicians themselves—the “old” system.2 While some physicians continue to conduct home visits, the numbers have decreased dramatically because of the economic, geographic and cultural factors that have shaped our health care system since World War II. The fact that such visits strengthen the therapeutic alliance between physicians and families is seldom questioned. However, in the article, we present evidence that physician-conducted home visit programs can also provide clear medical benefits, particularly when they are proactively targeted to at-risk populations, such as the community-dwelling elderly.2 Unfortunately, current health care economics suggest this relatively time-consuming, proactive, hands-on physician home care delivery model is unlikely to supplant the current time-efficient, reactive, supervisory model.
The advent of telemedicine has provided the opportunity to develop a hybrid home care delivery system that incorporates the best aspects of the old and new home health care models. Telemedicine involves the use of distance technologies to provide patient care. No single electronic communication format defines telemedicine, although many assume it is synonymous with two-way interactive videoconferencing with integrated peripheral devices such as electronic stethoscopes. One non-videoconferencing approach was exemplified by a recent project that successfully reduced the rehospitaliztion rates of patients with congestive heart failure by using an automated paging system to send medication reminders and educational information to patients recently discharged from the hospital.3
Other technologies increasingly applied to patient care include use of the Internet and “store-and-forward” graphics transmission systems, such as e-mail. Regular telephone calls to patients at home can also be included in the broader definition of telemedicine, particularly if they are employed in an organized, proactive fashion. Which technologies are used should be determined by the clinical issue at hand as well as cost constraints, logistic feasibility, and acceptance by patient and clinician. However, interactive videoconferencing with integrated peripheral diagnostic tools does offer the closest alternative to the traditional home visit.
Since the 1950s, projects have demonstrated the usefulness of telemedicine for consultation with specialists across geographic barriers, yet home care pilot projects have only recently been conducted. Patients with chronic obstructive pulmonary disease (COPD) or congestive heart failure have most often been studied, because these diagnoses entail frequent emergency department visits and high care costs. The goals have been to reduce the rate of decline in patient function while reducing the cost of care. Nurses working in home telemedicine use predetermined yet flexible care protocols specifying the frequency of contact, parameters to be monitored and therapeutic interventions. Physicians function as health care supervisors and also help conduct a subset of telemedicine visits.
The results of these pilot studies have been promising.4,5 For example, the Home Health Department at Kaiser Permanente Medical Center, Sacramento, Calif., followed 100 patients who had COPD, cardiac disease, stroke and wounds requiring regular nursing care with home telemedicine visits by nurses while another 100 patients received usual in-person visits and occasional telephone calls. Simple, telemedicine units approved by the U.S. Food and Drug Administration were used. These units work via regular telephone lines and provide interactive videoconferencing as well as monitoring heart and breathing sounds with an integrated electronic stethoscope. Home units cost approximately $5,000, while the central monitoring station costs approximately $7,500. Study findings are summarized in the accompanying table. Care delivery cost savings of 33 to 50 percent were estimated for the telemedicine group, and patient satisfaction with telemedicine visits was reportedly high.5
|Feature||In-person visit||Video visit|
|Maximal daily caseload||5.2 patients||15 to 20 patients|
|Length of visit||45 minutes||18 minutes|
|Required travel time||Yes||None|
|Response time to patient-initiated calls||Triage by telephone 24 to 48 hours to arrange visit as needed||Triage by telephone Immediate televisit as needed|
Ideally, telemedicine should augment rather than fully replace traditional home visits. Before implementation on a wider scale, randomized trials must be conducted to determine the incremental benefit of videoconferencing and electronic peripheral devices compared with simpler, less expensive interventions such as frequent telephone follow-up calls. Additionally, solutions to the reimbursement, confidentiality, documentation and legal dilemmas raised by the use of telemedicine must be found. However, consumer-level video telephones will soon become ubiquitous, greatly expanding the feasibility of “virtual” visits. It seems likely that telemedicine will soon allow family physicians to revisit the old values of personalized, proactive physician home care with the cost and time-efficiency of the new model.