House Calls
Remote monitors can be lifesavers for chronic disease patients
An extra pound doesn't seem like much. But for George Grande, that little quiver on the bathroom scale could signal that his heart is drowning. Grande, 82, has heart failure, and what used to be a strong, muscular pump now lets blood and fluid pool in his lungs, adding an extra pound or two. More fluid and he'll end up unable to breathe, fighting for his life.
That's the last thing he wants. "I've been to the hospital so many times," says Grande, who lives in the small town of Boxford, Mass., about 20 miles from Boston. His voice sounds tired as he recites the litany: "Three open-heart surgeries, an aorta problem, a leaky heart valve." To keep him safe at home, any weight change needs to be spotted quickly.
It is. About three months ago, Grande's nurse gave him a little device called a monitoring station, which let him input his vital signs. "Every morning it reminds me to check myself," says Grande. "I plug in a blood pressure cuff and a scale, and it sends that stuff over the phone, right to my nurse. A few weeks ago, it picked up a weight gain, and they called me right away and told me to adjust the dose of my medication. That's very reassuring, to know someone is always watching out for me."
Daily care. More healthcare professionals are watching out for patients with chronic conditions like Grande using this kind of remote monitoring. Heathcare agencies spent about $55 million in 2003 on telehealth and expect to spend $260 million in 2010. The key is the daily check of vital signs, a drill that can catch problems much faster than a monthly clinic visit. The technology is easy to use for senior citizens and for kids and adaptable to a wide range of illnesses. Study after study has shown that it helps keep people healthy and out of the hospital and allows scarce medical resources to be stretched over a wider area for a longer period. "It's been great for our patients and great for our agency," says Rhonda Chetney, director of clinical operations for Sentara Home Care Services in Chesapeake, Va. "These are very brittle patients who go in and out of the hospital a lot. With these units in the home, that stops."
Partners HealthCare, Grande's health plan, has placed American TeleCare Monitoring Stations in hundreds of homes and cut hospital readmissions for its heart failure patients by 33 percent. In Brooklyn, N.Y., Coney Island Hospital gave similar devices to 69 asthmatic kids who had been hospitalized at least once a month during the previous winter, and during the next winter all but one avoided the hospital completely. Across the country, the Department of Veterans Affairs has been testing these appliances in the homes of patients with diabetes and lung diseases as well as heart failure; it has found a 35 percent reduction in readmissions and a 60 percent drop in emergency visits. "Plus we get 90 percent patient satisfaction ratings," says physician Adam Darkins, the VA's chief consultant for care coordination. "That's why we'll have these devices in 12,500 homes by the end of this year."
The monitors are hooked up to patients' telephone lines. Using buttons or a touch-screen, the devices engage people in a dialogue about their condition by asking how they feel and if they took their medications. "It will ask a question like 'Are you short of breath?' " says Lisa Canterbury, a nurse and director of a branch of Deaconess Home Care in the small town of Magee, Miss. Her agency uses a four-button device called a Health Buddy. "Then it will follow up with 'Is this unusual shortness of breath?' because a lot of our patients are short of breath anyway."
Better behavior. Some of the monitors also have plug-in gizmos that measure pulse, blood pressure, and weight automatically. The patients' answers and the medical data are zapped to the home care agency, where clinicians can immediately review them. Anything that seems out of whack triggers an alert and a phone call. "It keeps me on my toes," says Charles Thomas, 82, a pulmonary disease patient in Downingtown, Pa. "The other day I missed a question, and my nurse was on the phone, asking why."
The daily back-and-forth helps change patient behavior, and that is crucial. Nothing is as effective as a motivated patient. A nurse or doctor can remind a patient to do something during a weekly or monthly visit, but patients often forget the advice in a few days. "Once you put these units in the home, patients actually start taking better care of themselves," says Chetney. "They get on a scale and see 2 extra pounds and can relate that to yesterday's hot dogs at the Fourth of July picnic and go, 'Whoa!' "
Chetney, whose service uses a touch-screen device called the Vitel Net's Turtle, likes the ability to customize the virtual chat. If she has a question she wants to ask a specific person--say, whether the patient's spouse is around or away--she can easily do that herself.
On the clinical side, telehealth lets agencies spread expertise further than ever before. At Partners, for instance, the agency has several patients with open wounds, from operations or recurring diabetic ulcers. But the agency has only four wound-care nurse specialists. It could take several weeks for the four nurses to visit all the patients, during which time the wound could get infected. Yet a staff nurse can get there in a few days, take photos of the wound with a digital camera, and send them to a wound specialist, who can provide specific instructions on care. "A telehealth visit costs me one third of what it costs to send a nurse out," says Chetney. "When insurance, like Medicare, only gives you a lump sum for home care, you can rip through that really fast with daily visits." Deaconess, in Mississippi, charges patients $9 per day for telehealth monitoring, while a nurse visit costs at least $100 per day.
The VA's Darkins cautions that the technology, though alluring, is not appropriate for every illness. Alzheimer's patients, for instance, may not have the cognitive ability to use the monitors. Yet for people with mild cognitive impairment or stroke, the devices might work quite well, reminding them to take their medications.
Another concern is that the monitors won't be effective without trained nurses and doctors behind them. Agencies can't simply buy the technology and expect miracles, Darkins says. Telehealth works because it provides continuous care, and if the staff doesn't know how to use the machines correctly, there will be gaps in care. But when the monitors are employed with training and commitment, that is exactly what telehealth will prevent: having patients fall through the gaps.
This story appears in the August 1, 2005 print edition of U.S. News & World Report.