Madison, Wis. – The nation’s ability to rein in future healthcare costs, which hospital executives fear could reach unsustainable levels within a decade, may depend in part on emerging technologies that are taking patient engagement to a higher level, especially in the home.
Home health monitoring and telemedicine for post-discharge care are nothing new, particularly with cardiovascular care, but it is taking on added dimension as new technology permits.
William Petasnick, CEO of Froedtert Hospital, Milwaukee, said the next generation of home health monitoring will take consumers beyond routine pacemaker monitoring and into total remote monitoring. The business value of this new direction goes beyond the desire to reduce hospitalization, and therefore cost, and extends to better resource utilization in an era of nursing and other workforce shortages, the need to better manage chronic diseases, and the desire for better patient service and outcomes.
The hospitals of today, Petasnick noted, are trying to become more highly intensive in terms of their care environments. “With less-acute patients, the more we can keep them out of an institutional setting, that’s better for care and it’s a more effective use of resources,” he said.
In this look at home health monitoring, WTN spoke to representatives of hospital, clinic, and medical device manufacturers to assess the clinical and business value attached to this evolving concept, and to identify some of the barriers to wider adoption.
An eye outside the exam room
The use of technology to convey information between patients and caregivers is moving past phones and fax machines and Internet solutions that allow patients to schedule appointments and communicate with their doctors. Several new technologies have created a surge in the field of home health monitoring, offering patients a chance to be watched and cared for without the need to visit a hospital every time they have a problem.
The idea of technology for home health monitoring has been a part of American medicine ever since 1987, when Life Alert and Life Call marketed devices under the catchphrase: “I’ve fallen and I can’t get up!” Pendants linked to an automated dialer allowed people to be connected to an operator without a phone line, giving them a connection to emergency services they otherwise wouldn’t have.
Telemedicine has expanded considerably since then, according to Jonathan Edwards, research vice president for Gartner and a lead analyst on telemedicine. Edwards said the field now includes technology such as home and mobile health monitoring, teleretinal imaging, sensors for remote diagnosis and advice to patients, teleradiology, remote cardiac monitoring, and video conferencing.
Home health monitoring, Edwards said, is a concept that uses these technological developments to assist patients who suffer from chronic or long-term medical conditions that historically require frequent visits to the hospital. Monitoring for cardiac patients is popular with several types of portable devices, but the technology is also used for cancer or diabetes patients whose vital signs suddenly can fluctuate.
“For patients with expensive conditions, it makes sense to have these devices rather than being admitted into the hospital,” Edwards said.
Joan Maro, vice president of home care and hospice and chief nurse executive at Aurora Health Care, said the technology Aurora uses for patient monitoring collects chemical levels and vital signs, with specialization to meet the requirements of many conditions. Monitors can read heart rate, blood pressure, weight, oxygen saturation, and temperature, sending signals to the Aurora offices for review and (if necessary) response by a trained nurse.
Daily monitoring, Maro said, allows clinical professionals to both keep an eye on patients in the event of emergency and also plan ahead for any new developments in their condition. Depending on the issues surrounding patient privacy, it may one day be possible for a patient’s family to access their information over a distance.
“It would be a wonderful offering for the families caring for loved ones from a distance,” Maro said. “They would be able to see that their blood pressure was in line or that they had taken their medications – even monitor them via camera.”
Home-based health in the Heartland
Wisconsin’s health providers have been busy in the field of telemedicine, particularly when it comes to developing patient communication. Some of the chief customers of GE Healthcare, one of the largest medical technology firms in the world, include Providence Health & Services‘ care manager program for monitoring the warning signs of disease; and Park Nicollet‘s efforts to monitor patients with congestive heart failure.
Brandon Savage, chief medical officer for GE Healthcare IT, said that the home health monitoring has decreased Park Nicollet’s admissions by 45 per month. “That’s people who, instead of being in the hospital, are at home with their families because they were able to reach out and just make minor changes early, rather than late, in the disease process,” he observed.
Savage said that research and development of home health monitoring continues thanks to newer technology, particularly crossovers from other industries. Sensors that keep track of prisoner activity can be modified for patients with dementia, noting changes in their behavior and informing doctors if the symptoms get worse. These sensors could be effective in individual homes, or could be expanded to cover nursing homes.
The Marshfield Clinic, which has built a reputation for providing care in areas without full medical services, also has been active in providing patients with telemedicine options that stress preventive care. The clinic has developed scales where patients are weighed daily and the weight is recorded into electronic medical records, sending notices if parameters are passed – parameters such as patient weight increasing more than three pounds in three days. From there, clinicians can decide if the change is important enough to alert a patient or schedule a future appointment.
Marshfield Clinic also is focused on setting up remote sites in areas without specialists, providing aid that is closer to home than hospitals. About 45 of these sites are set up for 100 providers, lending expertise in cardiology and pulmonary medicine. To deal with the lack of pharmacists in rural areas, they have developed remote pharmacies where local doctors are connected to pharmacists via video conferencing in an effort to rule out medication errors.
“The technology is really the second piece,” said Nina Antoniotti, director of telehealth for Marshfield Clinic. “What we’re talking about is preserving healthcare relations and the technology is used for that.”
Other clinics are developing devices to improve patient care. Beyond their monitoring system, which Maro said averages 120 patients a day, Aurora has created the MD-2 personal medication system. A coffeemaker-sized device programmed to dispense medication on a schedule of six times every 24 hours, it is linked to the computer system of healthcare providers. It immediately sends a signal if the medication is not taken and can be set up to contact three other providers if there is no response.
Frank Byrne, president of St. Mary’s Hospital in Madison, called home-based health monitoring “a short connecting flight from what we offer now,” including emergency calls and alerts. He said physiologic monitoring (for things that do not cause illness) is a future option that could be implemented through Home Health United, a home health agency that St. Mary’s co-owns with other hospitals.
“It’s a very short connecting flight, given the way technology is progressing, to add more detailed information beyond, `I’ve fallen, and I can’t get up,’” he said.
Roadblocks to communication
One barrier to the use of telemedicine is the lack of electronic knowledge transfer, which Byrne said can be done through telemedicine channels. He recalls attending a telecommunications demonstration 15 years ago where someone showed how an otosocope, an instrument used to examine the inner ear, could be used in combination with a computer to produce images for caregivers to examine in a care setting.
“There is not a lot of that happening at this point, and I’m not sure how quickly that is going tot happen,” Byrne said.
Advancements in telemedicine still are a long way from becoming standard for every patient about to collect Social Security. Despite the ideas dating back to Life Alert, the technology of home health monitoring still falls into what Edwards called an immature field. “We’re going toward the precipice and taking a long time to move through the cycle,” he said.
The biggest obstacle, Edwards said, is not the devices themselves but transmittal of data from those devices, and the lack of an infrastructure to monitor and detect the data. Without an appropriate recording system, the information collected cannot be compared to normal health criteria and therefore is of limited use to doctors and other providers.
Developing these records systems can be a problem, since telemedicine is held back by the oldest issue in the medical field: money. Maro said that at this time reimbursement for in-home monitoring is limited, chiefly due to a lack of documentation to prove that home health monitoring is cost-effective and leads to improved outcomes.
Funds are limited for telemedicine, Edwards said, because insurance and payer companies have been slow to lend support for the technology. These limitations mean that, in many circumstances, patients have to cover their own costs, leading to circumstances where third-party vendors have to bypass primary care and therefore are not integrated with the physicians’ medical records.
“The group is paid by activity, so they don’t have any incentive to keep the patient at home,” Edwards said of healthcare’s profit mentality.
Telemedicine’s success, Edwards added, will depend on the success of pilot projects and grant funding, which help develop interest and documentation in the field. One of the more encouraging investments has been made by the U.S. Veterans Health Administration, which has thousands of patients suffering from conditions such as diabetes and cardiac failure. The field also is driven by organizations such as the Continua Health Alliance, which unite device and healthcare industry leaders committed to improving technology for home health devices.
Device development will also play a role, as the three areas of telemedicine identified by Edwards – messaging systems to prompt and alert patients, devices to record vital signs, and tools for video conferencing – continue the trend of merging into one device. Unified devices like these would allow healthcare providers to consolidate operations, a move that also could lead to wider adoption by insurance companies.
Of course, the most important factor for home health monitoring will be for developers to remember who they are designing the technology for. “For anybody, the issue is creating a healthcare environment and creating it where services are needed,” said Antoniotti (Marshfield Clinic). “It’s what’s efficient for providers and giving [patients] a good experience.”
Telemedicine is expected to expand with the specter of “Baby Boomers” approaching retirement, a trend that will dramatically increase the elderly population. “The elderly patients are more likely to have chronic conditions, which are typically more expensive to manage,” Edwards said. “Therefore, an elderly population will need more home health monitoring.”
Not everyone believes the aging population will be the primary driver of future healthcare costs. Donna Friedsam, associate director for health policy with the University of Wisconsin-Madison Population Health Institute, cited recent U.S. Congressional Budget Office and Office of Management and Budget analyses that suggest the aging population is not the only culprit.
In challenging the conventional wisdom, the Congressional Budget Office has issued a series of reports on the growth in healthcare costs. In one analysis, it notes that the aging of the population is frequently cited as the major factor contributing to the large projected increase in federal spending on Medicare and Medicaid, but asserts that aging accounts for only a modest fraction of projected growth.
According to the CBO, the main factor is the extent to which the increase in healthcare spending exceeds the growth of the economy. The CBO also indicates that gains from higher spending are not clear, but there is substantial evidence that more expensive care does not always mean higher-quality care. “Consequently, embedded in the country’s fiscal challenge are opportunities to reduce costs without impairing health outcomes overall,” the CBO stated.
The Office of Management and Budget goes a step further, saying the long-term fiscal challenge is “almost entirely unrelated” to demographics and Social Security, but it is mostly confined to inefficiencies in the private and public healthcare system – inefficiencies that concepts like home health monitoring would address.
OMB said more than half of the projected increase in the cost of Medicare and Medicaid is not attributable to demographics, but rather to the growth in per-person healthcare costs. If the per-person cost of healthcare rose at the same rate as GDP at each age level – for example, if GDP rose 30 percent in 10 years, then it would cost 30 percent more to treat a person at age 65 – the increase in the cost of Medicare and Medicaid over the next 40 years would be less than the increase in the cost of these programs over the last 40 years. While not a trivial expense, the OMB argues that the nation managed to absorb this cost in the past without serious damage to the economy.
Friedsam also believes the cost problem is attributable primarily to malfunctioning of the healthcare system, not to demographics. “The emphasis should be on need to reign in internal inefficiencies of the healthcare system to handle the aging of the population,” she said.
Petasnick (Froedtert Hospital) said the cost issue is too complicated to attribute it to any one factor, but he would not dismiss the contribution of an aging population. “It’s a whole combination [of things],” he said. “Clearly, demand is increasing. As the population ages, we see more chronic disease and the cost of chronic disease management is an acute issue in this country.”
Efficiencies come into play in terms of the move toward healthcare process improvement, Petasnick added. “The challenge we have in healthcare is to reduce variation,” he said. “A lot of institutions, ours included, are involved in process improvement methodologies – Six Sigma and lean methods – to improve efficiencies and do more in terms of standardization of practice.”