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Telemedicine is the use of technology to provide healthcare over a distance. Telehomecare, a form of telemedicine based in the patient's home, is a communication and clinical information system that enables the interaction of voice, video, and health-related data using ordinary telephone lines. Most home care agencies are adopting telehomecare to assist with the care of the growing population of chronically ill adults. This article presents a summary and critique of the published empirical evidence about the effects of telehomecare on older adult patients with chronic illness. The knowledge gained will be applied in a discussion regarding telehomecare optimization and areas for future research. The referenced literature in PubMed, MEDLINE, CDSR, ACP Journal Club, DARE, CCTR, and CINAHL databases was searched for the years 1995–2005 using the keywords “telehomecare” and “telemedicine,” and limited to primary research and studies in English. Approximately 40 articles were reviewed. Articles were selected if telehealth technology with peripheral medical devices was used to deliver home care for adult patients with chronic illness. Studies where the intervention consisted of only telephone calls or did not involve video or in-person nurse contact in the home were excluded. Nineteen studies described the effects of telehomecare on adult patients, chronic illness outcomes, providers, and costs of care. Patients and providers were accepting of the technology and it appears to have positive effects on chronic illness outcomes such as self-management, rehospitalizations, and length of stay. Overall, due to savings from healthcare utilization and travel, telehomecare appears to reduce healthcare costs. Generally, studies have small sample sizes with diverse types and doses of telehomecare intervention for a select few chronic illnesses; most commonly heart failure. Very few published studies have explored the cost or quality implications since the change in home care reimbursement to prospective payment. Further research is needed to clarify how telehomecare can be used to maximize its benefits among diverse adult chronic illness populations.
Telemedicine is defined as the use of technology to provide healthcare over a distance.1 Telehomecare, a form of telemedicine based in the patient's home, is a communication and clinical information system that enables the interaction of voice, video, and health-related data using ordinary telephone lines.2 As noted in other articles in this issue, typical equipment can include a telephone line; simplified, regular computer, or wireless devices; videocamera; and physiologic monitoring equipment such as a blood glucose monitor, stethoscope, blood pressure cuff, scale, or thermometer. Many terms are used, sometimes interchangeably, to describe telehomecare services. These include telemanagement, telemonitoring, telenursing, telehealth, telecare, and telehome health. For the purposes of this article, telehomecare is defined as the use of a telecommunication device with medical peripherals to provide home visits with a nurse.
The purpose of this article is to summarize and critique the published empirical evidence about the effects of telehomecare on adult patients with chronic illness. The knowledge gained is discussed in terms of how to optimize telehomecare and identify areas for future research.
Telehomecare has been tested and reported to be beneficial for providing wound and cardiopulmonary assessments, managing symptoms, and teaching for patients with diabetes mellitus (DM),2 heart failure (HF),3–6 hypertension,7 spinal cord injury,8 and chronic wounds.9,10 One small study reported using telehomecare for managing HF, wounds, and chronic obstructive pulmonary disease (COPD), and expanded its use to cancer and stroke patients.11 The earliest studies examined the feasibility of telehomecare with mixed results. Whitten et al12 studied 31 patients' perceptions of telehomecare technology that included an interactive video system. More than half of the patients (51%) felt that there was no purpose to telehomecare and only 13% thought that it could address a medical condition. Despite this, no patient found using the technology uncomfortable. Finkelstein et al13 completed a pilot study with 24 patients with HF, COPD, and chronic wounds. Telehomecare was successful with 13 patients, demonstrating that, although it was a small sample, the technology worked, and patients and caregivers could use the technology without difficulty. However, 11 patients could not use it due to severe illness, physical conditions of the home, lack of interest, or concerns about the equipment, suggesting the importance of prescreening to determine eligible patients.
Encouragingly, Jenkins and McSweeney3 reported that the majority of their 28 HF participants found the telehomecare experience comfortable and useful. They felt they could trust the monitor nurse, and the physical examination was adequate. Seventy-five percent felt that the monitor nurse would understand their needs, and 67% could see the nurse. Both patients and nurses expressed that quicker and more frequent nursing visits could be done via telehealth.
As positive reports of patient and provider acceptance of telehomecare began to surface, so did the adoption of the prospective payment system, changing reimbursement from fee for service to prospective payment for an episode of care. Because of this change, home care agencies are financially at risk and therefore are seeking new ways of providing cost-effective quality care. Simultaneously, the home health industry is coping with challenges, including a nursing shortage, increased concern over quality of care, decreasing reimbursements, and an aging population with complex chronic illnesses. These challenges require new and creative ways to deliver efficient, high-quality care. Telehomecare is believed to be an effective and innovative way to deliver services under these demanding conditions, and the home care industry is increasingly integrating this technology.14 A retrospective chart review revealed that as many as 45% of home care visits may be suitable for telehomecare of some form.15 Given these facts, it is important to analyze and report the effects of telehomecare so that it can be optimized.
PubMed, MEDLINE, CDSR, ACP Journal Club, DARE, CCTR, and CINAHL databases were searched for the years 1995–2005 using the keywords “telehomecare” and “telemedicine,” and limited to primary research in English. Telehomecare is a new technology so a 10-year search was determined to be adequate. The subject of home healthcare was searched and combined with subject searches for Telemedicine, Telenursing, and Telehealth. The reference lists of articles were also examined for frequently cited studies. Dissertations and theses were not searched. Articles were selected if telehealth technology with peripheral medical devices was used to deliver home care for adult patients with chronic illness. Studies where the intervention consisted of only telephone calls or did not involve video or in-person nurse contact were excluded. Articles were entered into a table of evidence, summarized, and critiqued based on purpose, sample size, study design, and outcomes.
The 19 studies included in this analysis (Table 1) were organized into 4 themes: (1) effects on adult patients, (2) chronic illness outcomes, (3) providers, and (4) costs.
Many assume that older adults will be unwilling to use technology or will lack the dexterity, or visual and auditory acuity to operate the equipment. Seven studies, reported in 10 articles, challenge these assumptions.3,10,11,19–21 Jenkins and McSweeney3 and Johnson-Mekota et al10 reported that more of their patients were satisfied with the telehealth consultation than with the in-person consultation. However, patients felt they better understood their condition when they saw the nurse in person. Diabetic telehomecare patients felt that the technology empowered them21 and that the equipment's presence reminded them to prepare for nursing visits.20
Dimmick et al11 reported an increased sense of security, ease of use, reduced pain and anxiety for 14 patients with a variety of chronic illnesses. A larger study with 90 HF patients reported that patients felt significantly more confident managing their HF when using a telehealth device with or without nurse visits compared with receiving telephone calls alone.26 More recently, Chumbler et al17 reported that of 111 older adult telehealth users, 98% said it was easy to use, 85% felt more secure, and 92% felt it was helpful in managing their chronic illness (diabetes, hypertension, heart disease, and respiratory disease).
In conclusion, most studies report that patients were receptive to and satisfied with telehomecare, dispelling the myth that elderly patients are not willing to try computers.19,24 Study participants were comfortable with the use of the technology,19 and some even reported greater empowerment21 or increased confidence in managing chronic illness.26
Many studies have evaluated the effects of telehomecare on chronic illness outcomes. Research has shown decreased rehospitalization rates in patients with HF,4,6,7,28 diabetes,2,21 and spinal cord injury8; better diabetic management16; and the ability to assess chronic wound progression using telecommunications technology.9 However, variations in sample characteristics, such as age, equipment type used, intervention length, and study design, make generalizations difficult. For example, Chumbler et al18 reported interesting results when comparing weekly intense telehealth intervention to daily less intense monitoring for 297 diabetic veterans. In this non-randomized sample, the daily monitored group had 52% less all-cause hospitalizations, 53% less diabetes-related hospitalizations, and 8 fewer bed days of care over 12 months than the weekly monitored group. These findings stress the need for rigorous evaluation of the types and intensities of telehomecare monitoring to determine the optimal fit for particular types of patients.
Two studies found significantly reduced hospitalization rates when using either telehealth or telephone follow-up compared with usual care, but they failed to show significant value of telehealth over the less expensive telephone follow-up.5,8 The results suggest that positive results may be achieved without the expensive equipment used in telehomecare and that for some chronic illnesses and age groups, the telephone may be sufficient technology. However, more research is needed because these studies had younger patients in their sample, small sample sizes (n = 37 and 47) with 3-group designs.
Gardner et al9 demonstrated the value of telehomecare for remote management of wounds by comparing the accuracy of chronic wound assessments on 11 patients using interactive video technology and in person. Agreement was noted over 75% of the time for 8 of the 9 wound characteristics used. The authors believe that this level of agreement indicates that chronic wound assessment was not diminished by the use of the communications technology, despite small sample size and only 1 nurse was used. Additionally, the nurse at the distant site was not trained in wound assessment and felt that she learned a great deal, indicating this technology's potential to transfer nursing knowledge.
Several other studies demonstrated positive chronic illness outcomes beyond preventing rehospitalization. A randomized telehomecare study with patients with diabetes significantly increased self-management,16 improved general health,21 significantly increased the number of people discharged to home (n = 174) than those receiving usual home care. The LaFramboise team26 achieved improvement over time in quality of life, functional status, and depression with no between-group differences. Chumbler et al17 used a 3-group case control design with 12-month follow-up to achieve improved function with instrumental activities of daily living, activities of daily living, and cognition in the telehomecare group compared with matched controls. However, this study had several limitations such as a nonrandom sample and large amounts of missing data.
In summary, most published studies show that telehomecare can positively affect outcomes, including rehospitalization rates, self-management, adherence, general health, and length of hospital stay for patients with chronic illnesses such as HF, diabetes, hypertension, or wounds. Two small studies5,8 that included younger patients raise questions regarding whether the use of extensive telemonitoring equipment provides better outcomes than simple telephone use. Few studies have examined the effect of telehomecare on function or quality of life. Most studies used relatively small sample sizes (n = 11–90),4,5,7–9,26,28 with the exception of 4 studies that used samples of 174, 216, 226, and 297.2,6,17,18 Findings from these larger studies suggest that telehomecare used with elders with chronic illnesses such as HF and DM, will lead to improved clinical outcomes. However, only 2 of these larger trials were randomized with a control group.2,6
Researchers also have studied the effects of telehomecare on nurses. Nurses reported that using telehomecare technology added dimensions to caring by creating new types of bonds with patients, and that patients who received telehomecare were more focused and more comfortable managing their diseases.20 Nurses also reported it was useful for monitoring vital signs, saved time and money, increased productivity,11 and gave them to ability to provide better care to patients.10 However, nurses noted that the complexity of technology can be frustrating and anxiety provoking.20
The above 3 studies agree that nurses feel that they can provide quality care using telehomecare. Dansky et al20 implied that nurses would find the technology even more useful if it was streamlined and simplified. As is the case with most research regarding telehomecare, small groups of providers used in these studies (n = 9–12) and the variety of equipment make it difficult to generalize results to all nurses and providers. Also, all studies are limited to exploring the impact on nurses with none addressing impact on physicians or other members of the healthcare team.
Finally, logic suggests that telehomecare could save money by limiting nurse travel and time and overall healthcare utilization. To examine this assumption, several studies have included costs and healthcare utilization as outcome measures.
In a quasi-experimental study, Johnston et al25 studied the use of remote video technology with 212 chronically ill patients. They found no differences in the quality indicators of medication compliance, knowledge of disease, or self-care ability; patient satisfaction; or service use. Although the average direct cost for home health services, including equipment and communication expenses, was higher in the intervention group than in the control group, the total mean costs of care, excluding equipment costs, were lower in the intervention group. The cost savings were attributed to fewer hospitalizations while the quality of care remained stable. Benatar et al6 and Dansky et al2 both significantly decreased hospitalization charges for their randomized telehomecare patients versus controls.
Using these data, Dansky et al22 estimated the financial costs and savings associated with providing telehomecare services. They suggest that, although the initial cost of the equipment and training imposes additional expenses, over time telehomecare contributes substantial savings through reductions in rehospitalizations and travel costs without compromising quality, and the financial benefit increases exponentially as the duration and number of patient care episode increases. Pringle-Sprecht et al27 agree, stating that increased equipment use will offset the initial cost and depreciation, and make telehealth more effective in terms of saved time and reduced transportation costs for the nurse and the patient.
All 4 studies reviewed indicate that telehomecare has the potential to be cost effective. Three larger studies2,6,25 showed that although initially care delivery costs were increased due to the cost of equipment, overall costs of care were decreased due to decreased hospital charges and travel costs. In most studies, small sample sizes and lack of robust economic analyses preclude generalization of financial results. Further, most of the studies that evaluated costs were conducted before the change to a prospective payment system. Patients in these studies received telehomecare in addition to in-person visits. This additional care may have influenced the achievement of positive outcomes and is important to note. The extra care also equates to extra cost. New evaluations of the cost and quality effectiveness of this technology are needed under the new reimbursement structure.
This small body of telehomecare evidence reveals potential benefits for patients, providers, and the healthcare system. The research suggests that home care using communication and monitoring technology is feasible and acceptable to patients, caregivers, and providers. The addition of telehomecare technology seems to improve outcomes among patients with chronic illness, most often HF, diabetes, and chronic wounds. Finally, over the long term, cost for management of chronic illness seems to decrease with the use of telehomecare.
We can apply this knowledge to increase patient involvement and self-determination, which are especially important in the context of the recent Institute of Medicine's promotion of patient-centered, patient-directed care.29 Positive results have been achieved with diabetic patients who improved in their self-management when using telehomecare as opposed to traditional home care support.2,16 The evidence indicates that patients are accepting of the technology and are willing to use it to self-monitor. Increased convenience and privacy are selling points.11 However, patients do not want to lose in-person contact completely,3,10 so a combination of telehomecare and in-person visits seems best.
Few evidence exists to guide providers regarding what is the best combination of telehomecare and in-person contacts. We do know that telehomecare helps us to be more efficient while achieving equal or better clinical and cost outcomes. For example, the average in-person home health visit in one study was 45 minutes compared with 18 minutes for a telehomecare visit.25 The authors noted that with traditional home care, the nurse can see 5 or 6 patients in 1 day; telehomecare may allow 15 to 20 video visits per day. Dansky et al22 suggested a cost-effective pattern of telehomecare use, but no studies have tested various patterns of telehomecare versus in-person visits to find the most effective one. Based on the projection of Dansky's team22 and information from Wooten et al,15 a starting point to increase efficiency might be to use telehomecare to achieve a 45% reduction in-person visits.
The evidence strongly suggests that telemonitoring reduces rehospitalization for patients with HF and diabetes. This guides us to target those most at risk for rehospitalization. Telehomecare also works best for conditions that require close monitoring and quick intervention such as HF. This principle may also apply for patients with asthma, COPD, pain management, or unstable conditions such as cancer, but few studies have explored using telehomecare for these conditions. Also, very little is known about how patients of various age groups react to telehomecare. Two small studies suggested that telephone follow-up may be enough in younger cohorts, again indicating the need to experiment with various levels of technology and patterns of care with varying subjects other than older adults.
Outcomes of completed telehomecare research tell us that the reduction of rehospitalization and increased patient involvement in self-monitoring are the most common outcomes. However, little impact in improvements in quality of life and function has been made and we need to design telehomecare interventions to improve these outcomes. Involvement of other disciplines may be one strategy. In general, nurses react favorably to the use of telehomecare, but there are no reports of how it affects medical, social work, or physical therapy practice. Nurses need to educate our colleagues from other disciplines as to the benefits of telehomecare and help them to use it as a tool for patient care.
Although most of the studies achieved positive outcomes and the technology appears safe and well accepted, there is much more to learn. This review included 19 completed studies. The researchers used different designs and equipment among mainly small samples of patients and providers. Five studies used randomized samples and only 2 studies were randomized clinical trials with sample sizes of 174 and 216. Most were pilot studies with samples sizes from 11 to 90 patients and used pretest-posttest design or matched controls. Therefore, more rigorous studies of telehomecare technology among larger, diverse populations are needed. Investigators should carefully describe the features of the technology and the patterns of care so that accurate comparisons can be made.
Telehomecare is a new intervention so the body of evidence is sparse. There is much more to learn to optimize the use of telehomecare. Table 2 contains suggestions for future research. For example, although positive outcomes have been achieved, little is known about the mechanism behind those outcomes. It is not known how changes in therapy are made based on data provided by telehomecare technology. More studies are needed that use methods described by Dansky et al.23 They videotaped telehomecare interactions to analyze nursing activities. Such studies can inform us about how information and knowledge are transferred during a telehomecare visit.
This review suggests that the age of the patient and type of disease may be significant factors. This analysis was limited to studies with older adults, but telehealth has been used in children and younger adults with similar results. However, there have been no studies that compare patients of different age groups or diseases to determine the best technology or patterns of care for particular cohorts. Further, no studies have examined the value of telehealth technology for patients who do not qualify for home care but need close monitoring. Also, the length of the intervention across all of the studies was short term with a follow-up of less than 6 months. Studies are needed that examine the longer term benefits of telehealth. Finally, in most of the published studies, telehomecare was provided in addition to usual care. Therefore, studies are needed that truly examine the cost effectiveness of telehomecare when used in conjunction with in-person versus traditional visits alone. By expanding the research on telehomecare, we can apply more evidence toward optimizing the use of this promising technology.
Kathryn H. Bowles, Associate Professor, School of Nursing, University of Pennsylvania, Philadelphia, Pa.
Amy C. Baugh, Acute Care Nurse Practitioner, Cardiac Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.