The go-between is a system known as telehealth. Telehealth makes use of electronic medical devices that are placed in patients' homes and can transmit data via telephone line or Internet to a nurse who can spot a dangerous variation in vital sign readings and arrange for immediate treatment--hopefully avoiding a visit to the emergency room. The daily monitoring can also serve as an incentive for patients to follow their diet and exercise plans. The hoped-for bottom line: better health for the patient, fewer hospital visits and lower Medicaid costs for the state.
Telehealth is one of the more exciting health IT ideas to surface, and one of the few that is on the verge of a mainstream breakthrough. Although there are obstacles to widespread use--mostly in terms of upfront costs and patients' acceptance--the technology is in place and the benefits are becoming clear. While the Alabama program is one of only a handful of experimental state and local efforts, there is already an impressive track record on remote monitoring. The U.S. Department of Veterans Affairs has been practicing telehealth for nearly five years, and the results suggest that the program could lower the cost of treating long-term and chronic-care patients. VA officials report that home-care monitoring has been cutting by about one-third the patient-care costs of those who are remotely monitored.
Given those kinds of savings and the system's potential to prolong independent living for an aging population, states are keeping a close eye on the VA's system. Massachusetts, which has been holding forums on how to promote greater choices for the elderly to say at hoame as they age, has been studying a variety of home telehealth programs. The VA program, notes Massachusetts state Senator Richard Moore, may be bigger than what his state needs, "but it's certainly a good model." Moore is looking at how the VA might be a mentor for a state model and what the state can learn from the VA's successes and failures.
REMOTE CONTROLLERS
The VA telehealth program is deceptively simple. Using devices that are hooked up to a telephone or computer, a patient in the comfort of his home measures his vital signs--such indicators as weight, pulse, blood sugar, even heart and lung sounds. The devices at hand might include a digital scale for weight, a blood pressure cuff and a pulse oximeter to measure oxygen in the blood. Most participants also use a handheld messaging device that asks daily questions about how they are feeling. These answers, along with the vital-sign readings, land on a computer screen in the office of a care coordinator.If there are fluctuations in certain indicators--say, a heart patient's weight goes up five pounds overnight--or troubling answers to questions, the care coordinator contacts the patient or the patient's physician. This interchange will help determine whether a nurse should be sent to the patient's home, if an office visit to a physician is appropriate or if the patient should be sent to the hospital.
While programs in the private sector use similar devices and processes, the VA system is possibly the most ambitious. Most existing programs stick to monitoring for two or three chronic conditions, such as diabetes, congestive heart failure and asthma. The VA program, however, ranges over a much wider field. It offers remote monitoring for patients with everything from hepatitis and cancer to post- traumatic stress disorder. The largest public program in the country, the VA program serves 16,000 vets and plans to expand that enrollment to 50,000 by 2009.
So far, the VA has spent $20 million to get the program up and running and install handheld or other computer monitors in participants' homes. Much effort was expended to educate physicians about the program and train them to refer appropriate patients for enrollment. The VA also had to reach out to patients to explain the program and train them in how to use the at-home devices. Although there were initial concerns about patient acceptance of high-tech devices--given that so many of the patients are elderly--that has not turned out to be a problem. According to Adam Darkins, the chief consultant in the VA Office of Care Coordination, those needing care have been comfortable about and open to bringing the new technology into their homes. Most have become adept at using the devices.
As for costs, annual maintenance of the devices runs $500 to $1,000 per person. But the VA sees those outlays as reasonable since they have helped the system cut down on the hospitalization rate of participating patients. If remote monitoring were not available, these patients, according to Darkins, would cost the VA $25,000 per person per year in hospitalization and other health care costs.
The VA will be conducting follow-up studies to audit the program's accomplishments or failings. So far, though, the VA sees the program as well worth the initial investment.
THE HURDLES
There are, to be sure, hurdles for states to clear before they can put telehealth into practice. Chief among them is financing.
Alabama's Medicaid agency was able to get its program off the ground through a fortuitous circumstance. The University of South Alabama had developed the technology and software to run a telehealth program, and after a trial run in one county, brought it to the state's attention. With the university's initial investment already in place, the state Medicaid program was able to use a portion of its Medicaid funds to pay for the pilot program.
But that does not solve all fiscal issues, especially if the program hopes to expand. As Kathy Hall, deputy commissioner at Alabama's Medicaid agency, notes, financing is a risk for any program where the savings are not immediate but many years down the road. "Sometimes it's hard to measure the value of these interventions," she says.
And it's a point Massachusetts' Senator Moore makes as well. In his state, legislative backers of a telehealth system have had trouble convincing other lawmakers to sign on to the program, he says, because the initial investment may not be able to pay for itself in the first budget year.
There are also questions of standards and regulation. Moore notes that his state would be able to set regulations and push local doctors and patients to use the new technology. However, for health technology in general--and telehealth is no exception--to move forward, the federal government needs to step in and set standards so that communication between various systems is possible.
This is an issue the VA did not have to worry about. It was able to set up its own system with its own standard and insist its physicians, hospitals and other providers use it. "This isn't the case with Medicaid," says Donna Folkemer, group director for the National Conference of State Legislatures' Forum for State Health Policy. "Medicaid is paying for care, but it's not picking doctors and health plans. The state is never going to have as much control as the VA has."
Hall alludes to that point, too. Although doctors are offered incentives to encourage their patients to enroll in the Alabama program, some physicians haven't been willing to learn how to use the program and that has limited participation.
There's another limit to participation that Medicaid programs face: a very different patient base. Where elderly, ill VA patients have been fairly compliant about taking their vital signs and sending them in at prescribed times, that's not necessarily the case with younger, less routine-bound Medicaid patients. Hall tells the story of one participant in Alabama's program: a high school student whose diabetes readings were in constant flux, causing the care nurse in charge of monitoring the readings great concern. As she and a nearby community nurse looked for reasons why the student's blood-sugar levels were spiking, they came to realize that the student was not being monitored well at home. Her mother was not helping her take the readings or insisting that her daughter report her vital signs at prescribed times, making it difficult for the care nurse to intervene with therapies. The nurses arranged for the school to get involved. The student now goes to see the school nurse as soon as she arrives. The nurse helps her record her vital signs and send them to the care nurse at the university office, who can then call back with interventions to keep blood sugars at a more stable level. The result: The student's diabetes has stabilized and so has her overall health.
And that's the great hope that telehealth holds for the Medicaid program. "We have to come up with some new ways of dealing with things," Folkemer says. "We have to do something with how we deliver services where people live their lives."
SMALL CELL
The VA may be the largest telehealth program in the public sector, but there are other versions and variations. The San Mateo Medical Center in California is running a program for asthma patients. The program tracks 60 people between the ages of 5 and 18. Each participant is given a cell phone, which is provided through a donation from Cingular, and at 2 p.m. each day, the patient (or a family member) uses a special application in the phone to enter vital signs and statistics. These data go to the patient's case manager and are categorized as red, yellow or green, depending on the potential for danger to the patient. If the readings are in the red danger zone, for instance, the patient is immediately contacted to see what the problem is and how it can be resolved before it lands the patient in the hospital. Since November 2005, no patient in this asthma care group has been hospitalized, and that is saving the public medical center a good deal of money. Dave Hook, medical center spokesman, says people seem to like the program because it is "like having a doctor at your fingertips." --H.K.THE TELEHEALTHY HOME
Researchers at universities and technology companies have been toiling away at a "smart" house that would be embedded with devices that can, in effect, turn a house into a telehealth home. Working through a network known as CAST--the Center for Aging Services Technologies-- researchers are developing devices to monitor or provide care, such as:- a medicine cabinet that tells the patient what medicine to take;
- a bed that can keep an eye on sleeping habits and take a person's weight;
- a computer game such as Solitaire that a doctor can look in on to measure dexterity and cognitive function;
- a robot that can act as an in-home aide by leading patients to certain rooms, reminding them to take their medicine, eat or use the bathroom.
