“Progress was all right. Only it went on too long.” — James Thurber
According to Ian McWhinney, MD, one of the founding fathers of family medicine, “Thirty-five years ago, home visits were a major part of the family physician's work.” But he notes that home health care's significance has declined since then because of developments in communication, transportation and medical technology.1
While most of these developments have clearly advanced the quality of patient care, the decline of in-home primary care may well have hurt the doctor-patient relationship. Infrequent 15-minute (or shorter) “encounters” don't develop the bond that family physicians and their patients once enjoyed. But now, the progress that has helped distance us from our patients may be offering us a way to get closer to them — and to our family medicine roots. In this article, we'll discuss a pilot telemedicine project that we believe offers a glimpse of how family physicians can use technology, and the electronic house calls it makes possible, to deliver cost-effective care with a surprisingly personal touch.
The need for home-based care
Some see the technology-related shift in our health care delivery system as the most profound change in the modern history of medicine. Indeed, the adjustments in practice we've seen from managed care pale in comparison with the fundamental changes in health care that were accepted, seemingly without debate or question, earlier this century. Perhaps this tacit acceptance of sweeping change reflected the infectious mood of relentless scientific progress that predominated in those exciting times.
However, it's time for us to reconsider the seemingly irreversible restructuring of health care delivery resulting from this technological explosion. As McWhinney points out, shorter hospital stays, a continuing need for care following discharge, increased longevity and the trend toward receiving end-of-life care in the home all are increasing the demand for home care.1 Although the advent of managed care has certainly played its part in increasing this demand, a careful review of history reveals that the trend has been present for decades.
A large segment of the population was, in effect, disenfranchised from the new, state-of-the-art care from the beginning. This segment included those in rural areas, those whose access was limited by geographic barriers and the very poor, who did not have transportation to or could not afford the cost of care at medical meccas. These needs have been well-recognized (if not always well-addressed) by most physicians for many years.
Beyond reaching more people, physicians also can deliver better care by incorporating home visits. Implicit in the move toward medical centers was the feeling that the patient's home and family were somehow no longer central to the coping and healing processes. But as McWhinney notes, “Many of the illnesses seen in family practice cannot be fully understood unless they are seen in their personal, family and social context.”1 Students were (and are) taught to ask patients about their families and home settings, but the value of this information doesn't begin to approach that of a home visit, as anyone who performs them can attest. Even the simple symbolism of the physician at the door, bag in hand, creates a powerful bond with the patient and family and in itself may foster healing in the most spiritual sense.
Despite the value of home visits, most physicians can't hope to visit all their patients in person even once. Those who perform home visits typically reserve them for families in times of great hardship and transition, such as the death of a parent. Economically and logistically, the days of routine, in-person home visits seem gone for good. This loss of a great healing aspect of family medicine is one of the too-infrequently acknowledged tragedies of the move to office-based health care. Progress was all right — only it went on too long.
Fighting technology with technology
Ironically, the results of two new, concurrent technologic explosions — this time in computer science and telecommunications — offer hope that we might return health care to a more proper balance by incorporating sufficient home care once again. With telemedicine becoming increasingly accessible and cost-effective, our ability to regain our identities as true family healers is within sight.
Telemedicine can be defined as diagnosis, consultation, treatment, education and the transfer of medical data using interactive audiovisual and data communications. More relevant to clinicians, however, is this definition from Ira Denton, MD: “Telemedicine is not software or hardware, although it employs both. Nor is it ‘doctorware’ or ‘econoware,’ despite its value to physicians and administrators. When all is said and done, telemedicine is patientware.'”2 We should focus on this definition as we consider a return to the model of family physician as home-based healer, for it emphasizes that telemedicine should not be defined in terms of its technological components but in terms of its utility in reinforcing a neglected doctor-patient bond.
Many articles have reviewed the technological components and history of telemedicine systems in detail.3 Suffice it to say that a wide range of systems is available; some are simple, such as special telephones with built-in computers that transmit still images and real-time audio; some are complex, transmitting images via satellite and linking users for computer-based, real-time video conferences over statewide networks. The Internet has value for some telemedicine applications, but its usefulness is limited, at least for now (see “If you think web browsing is slow ... ”). We have used systems of wide-ranging complexity, but this article will focus on our most broadly applicable experience, which involved a high-end system.
If you think web browsing is slow ...
The Internet is likely to play an increasing role in telemedicine. But for now, its use is limited primarily by the Internet's inability to handle the data transmission speeds needed for real-time applications. Internet-based videoconferencing is available, but for most people using regular phone lines, the connection is slow, the picture is very jerky and the medium is unreliable (the connection often freezes, the resolution may be poor, Internet traffic may limit the ability to log on at all, etc.).
Internet telemedicine also brings with it well-known concerns about the security of information transfer. Who may be tapping in to information being transmitted? Can a patient be sure there's really a health care professional at the other end of the line?
Finally, many Americans — particularly those who might best be served by electronic house calls — still lack Internet access. And many people who are online don't use hardware advanced enough to allow useful videoconferencing.
But look for more telemedicine on the Internet in the future. It's already being used for some “store-and-forward” patient interactions, such as E-mail. In the near future, store-and-forward consultations (e.g., sending digitized X-rays to a radiologist) also are likely to become more common. And as the bandwidths commonly used for Internet access increase, real-time telemedicine will become a more realistic possibility.
The Electronic Housecall Project
“Where we're going, we don't need roads.” — Christopher Lloyd (a.k.a., “Doc Brown”) in the movie Back to the Future
At our facility, we were fortunate to be involved in a telemedicine research program, the Electronic Housecall Project. It had two primary goals:
To explore the feasibility of a home telemedicine project,
To determine the effect of frequent electronic home visits on the utilization patterns and cost of care for chronically ill patients with multiple medical problems. Such patients' illnesses are complex and chronic, so treatment endpoints are often ambiguous.
The second goal was based on a financial analysis at our facility revealing that 13 percent of internal medicine patients consumed 59 percent of inpatient medical costs during fiscal year 1994. These 293 patients with complex, chronic conditions accounted for 1,299 (also 59 percent) of our 2,215 internal medicine admissions. Had we prevented only one admission for each of these patients, we would have saved $1.4 million. So we selected the project's participants from these frequent users of high-cost inpatient care, as well as from those who often used expensive outpatient services.
During the project, which ran from February through November 1996, 13 chronically ill patients received 116 electronic visits. The patients' homes were wired for health care delivery using traditional cable TV lines and were equipped with a custom-developed “home station” of computer hardware (see “The tools for an electronic house call”). With this hardware, standard one-way TV cable can be used for two-way communication, making health care possible.
A video camera and microphone were installed in each patient's home to collect audiovisual data. Various medical instruments, such as stethoscopes, sphygmomanometers, otoscopes, thermometers, pulse oximeters and other peripherals were attached to the system, which transmitted data from the instruments along with the audiovisual signals.
On the caregivers' end, the videoconferencing equipment was housed in a dedicated office in the hospital near our clinic. A nurse coordinator conducted the patient conferences; the patients' attending physicians also attended some conferences. Conferences were scheduled at times mutually acceptable for the patient, nurse and physician.
Because this project was conducted under a funded research protocol, there were no equipment costs to the institution or the patients. If the hardware had been purchased “off the shelf,” each unit would have cost about $16,000. But this figure reflects the cost of telemedicine research prototypes, not finished products designed to be marketed to consumers, which would undoubtedly be less expensive.
The tools for an electronic house call
The diagram below illustrates the hardware installed in the homes of the 13 patients in the Electronic Housecall Project. It includes a touch-screen video monitor, a video camera, speakers, a modem, a minitower CPU and a vital signs monitor.
While the hardware is interesting, it was our experience with patients that made us believers in the benefits of telemedicine house calls. The two case summaries that follow illustrate the promise of home telemedicine in terms of cost savings and improved patient satisfaction.
Patient 1: Mrs. K, a 72-year-old widow who lives alone, has orthostatic syncope, emphysema, hypertension and severe degenerative joint disease. She had begun visiting the clinic more frequently for no clear medical reason. She has a history of falls due to decreased mobility from osteoarthritis, but traditional home-nursing interventions, including “fall-proofing” her house, didn't reduce the frequency of her clinic visits. Often, these visits seemed to be more to provide social interaction than to resolve any organic issues. Given multiple staffing cutbacks in the military health care system, outpatient visits are at a premium. So we began to seek other ways we could address her need for social contact and reassurance.
Before enrolling in the study, Mrs. K was visiting our clinic weekly. After her enrollment, we saw a dramatic change in her utilization and, more importantly, in her social outlook. The project's nurse maintained weekly contact with Mrs. K via the telemedicine hookup and filtered Mrs. K's concerns, identifying those that needed a physician's attention. Mrs. K greatly enjoyed the “companionship” of the system, reporting that she really looked forward to her weekly conferences.
The hookup also enabled us to confirm that Mrs. K's ability to perform activities of daily living was more than adequate. During the weekly conferences, we could see her immaculately kept house and her lush collection of healthy houseplants.
As a result of the project, Mrs. K's outpatient visits decreased from weekly to quarterly, saving an estimated $4,408 during the study period.
Patient 2: Mrs. C was 63 years old and had a complex medical history, including atrial fibrillation, severe chronic obstructive pulmonary disease and breast cancer. She was enrolled in the study primarily to facilitate palliative home care in her final months.
The project's nurse prevented one hospital admission for Mrs. C during this period by using the telemedicine hookup to identify early respiratory decompensation. Assuming an average length of stay of 6.3 days based on her admission history and diagnoses, this saved an estimated $22,850.
Just as important, we provided expanded psychosocial support for Mrs. C's husband, who incidentally was diagnosed with lymphosarcoma during his wife's decline. Like Mrs. K, he voiced his overwhelmingly positive impression of this approach to patient care. In fact, Mr. C enrolled in the project when his wife died.
These are only two of the project's outpatient and inpatient success stories. Cost savings for the five patients whose hookups worked consistently totaled $75,580, which alone might warrant expanded use of similar systems.
These cost savings are projections of expenses that we prevented by avoiding hospital admissions or outpatient visits. As we've noted, we had no equipment expenses with this project, so our savings don't include the cost of the technology. But data from nonresearch telemedicine networks also indicate a strong potential for savings. As part of their managed care systems, Health Partners in Minnesota and Kaiser Permanente in northern California are using telemedicine to reach rural, postoperative and “frequent flyer” patients. Based on results from about 200 patients, they project business savings of around 30 percent from using telemedicine to provide home care to these patients — including installation and purchase costs.4
However, as health care professionals, we were most impressed with and gratified by the renewed emphasis on managing illness in the context of home and family that the system allowed. Unlikely as it may seem, high-technology telemedicine appeared to enable “higher touch” care in many cases.
This pioneering project gave us a fascinating peek into the not-too-distant future of health care, making clear that the era of the electronic house call is already under way. Technologic advances are letting us come full circle, eventually back to the delivery of most outpatient health care in the home — back to the future. And this time, where we're going, we don't need roads.
Problems to overcome
“Caution: Cape does not enable user to fly.” — Warning label on a children's Batman costume
Telemedicine, like any new patient care tool, won't be a panacea. One concern is the tendency to overemphasize the technological aspects of telemedicine and, indeed, to equate it with its technology. Recently one of the founding fathers of telemedicine, Jay H. Sanders, MD, president of the American Telemedicine Association, has recommended changing the emphasis of research from cutting-edge, sophisticated systems to off-the-shelf formats ready for widespread use.5 This should prevent telemedicine's implementation from being continuously pushed into the future — always just ahead of its users.
Several other problems must be addressed before implementation will be widespread. First, telemedicine equipment is not as reliable as health care professionals and patients will demand. In our project, for example, we experienced many transmission glitches over the cable TV lines, and only five of the 13 patients had relatively trouble-free hookups and transmission for the project's duration. For telemedicine to be implemented beyond a research setting, transmission must be foolproof.
Second, we would have much preferred to have videoconferencing equipment in attending physicians' offices, which would have let them participate more directly. We used the approach we did only because of the study's funding limitations. Sophisticated real-time, two-way videoconferencing such as we used remains expensive, although costs are declining yearly. We are still a long way from having these systems available in every physician's office, let alone every household. While satellite TV systems and personal computer technology will eventually make this capability ubiquitous, another group of disenfranchised patients — this time the “high-tech disenfranchised” — may for a time join the other health care system “outsiders” we noted earlier.
Third, the utilization patterns of some patients in the study didn't change. While the reasons for this finding are unclear, home telemedicine obviously won't solve every case of overutilization.
Another problem is that of “selective scope.” Current technology allows only a peephole view of the home, which, of course, can't compare with an in-person home visit. But, as we've said, the likelihood that a physician can visit all his or her patients in person is vanishingly small, so telemedicine represents a reasonable compromise.
Telemedicine also brings with it many medicolegal issues related to malpractice, licensure boundaries, documentation and the security of information transfer. (See “Practicing in one state while sitting in another?”)
Another barrier to the implementation of telemedicine is that the reimbursement rules need to be clarified. Currently, reimbursement varies from state to state and payer to payer. HCFA has approved telemedicine reimbursement nationwide, provided that the area being served is considered to be a “provider shortage area” (i.e., underserved). Most private plans don't reimburse for telemedicine, but we expect this to change in the near future, particularly as studies of cost-effectiveness proliferate.
Finally, and most critically in the current climate, more detailed and definitive outcomes research on telemedicine is desperately needed to justify its move from a subject for pilot projects, such as Electronic Housecall, to an integral element of patient care. While we believe cost issues alone shouldn't determine telemedicine's future, concern about cost is a reality of our present system that can't be ignored.
Practicing in one state while sitting in another?
Telemedicine presents a number of legal issues that physicians haven't had to consider before, including the following:1
Whose laws govern? Federal tort law generally holds that the laws of the state in which a negligent act is committed will determine the nature and basis for a claim. Thus, if a physician in Georgia has a telemedicine consultation with a patient in Texas, the Texas “rules of patient engagement” govern the interaction. (Interestingly, this scenario may lead to the demise of interstate variations in legal standards, as lawyers and physicians will probably find it more practical to create and adhere to universal standards. This is true also for the variability of rural and urban “community standards of care.”)
Licensure. Licensure is a related, unresolved issue. If a physician has only a Georgia license, is he or she allowed to consult with a patient in another state? As use of telemedicine expands, we may also see pressure for a national medical license.
Shared liability. Another interesting issue is the potential sharing of liability in medical malpractice cases. In a 1989 medical case (not involving telemedicine per se), a computer consultant was found to have committed professional malpractice by making the “wrong” systems decision. Certainly telemedicine involves many layers of expertise, and who will be legally responsible for the outcomes must be clearly defined.
Documentation. To date, it's unclear which facility in a telemedicine interaction should have control of the corresponding medical record and in what format (e.g., video, audio, paper, etc.) the record should be kept. No universal standard exists.
Security. Any widespread use of telemedicine over the Internet or other networks will necessitate the use of multiple codes to allow variable levels of access to information, as well as great efforts to secure the systems against hackers. Nightmare scenarios include accidentally transmitting medical information to the wrong address (or to someone masquerading as a physician) and allowing hackers to break into medical information that they then broadcast over the Internet. A more likely but equally troublesome possibility is that medical information could become more readily available to nonclinical staff.
Tune in tomorrow
These problems must be resolved before telemedicine will be used generally, but workable solutions to most of them are just around the corner. We hope family physicians will be among the first to embrace this valuable tool, which has the potential to restore the proper balance of institutional and home health care delivery, a balance that has been lacking for the past half century. The era of the electronic house call is here, and family physicians must become leaders in the development, use and promotion of the “patientware” systems of the future.