American College of Physicians: Internal Medicine — Doctors for Adults ®


High-tech solutions can improve patient monitoring

A new breed of small, inexpensive devices gives physicians new ways to stay in touch with patients

From the July 2001 ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

Products for providing home care remotely

By Ingrid Palmer

When Charles Porter was diagnosed with atrial fibrillation earlier this year, his cardiologist asked him to wear a small pager-sized monitor on his belt to track irregularities in his heartbeat. “If I feel my heart racing," explained the 54-year-old Cincinnati resident, "I just push a button on the device.”

Once Mr. Porter triggered the device, it recorded the previous 45 seconds and following 15 seconds of electrocardiogram data collected through the two electrodes stuck to his chest and side under his clothing. He then called a tracking center and transmitted the information over the phone. "They put it on graph paper and send it over to the doctor,” he explained.

While the device is essentially a high-tech version of a traditional Holter monitor, it offers some distinct advantages. Patients can keep the device for a month, not just 24 hours, as is standard with many traditional monitoring devices.

Perhaps more importantly, Mr. Porter's cardiologist was able to get results instantly. Patients don't have to schedule an appointment to bring the device to their physician, because data is transferred over the phone. While Mr. Porter acknowledged that the device was a little uncomfortable, it gave him an active role in diagnosing and monitoring his condition, which could help him get relief faster.

Mr. Porter's cardiac monitor is just one example of a new breed of devices that physicians can use to monitor patients at home or work. By transmitting data over telephone lines or the Internet, these devices are keeping physicians and their patients in close touch. They may also help keep patients out of the hospital.

New devices

Though concepts like telemedicine have long been touted as “the next big thing” in health care, with promises to improve access to patients and save physicians time and money, few have caught on. The reason? The technology can be expensive, and insurers have generally refused to reimburse physicians for their use of high-tech solutions.

With an explosion in the number of smaller, less expensive devices that can be placed in patients' homes, however, the trend toward home care technology may finally be gaining momentum.

Mr. Porter, for example, used the Event Monitor from Cincinnati-based Physicians Cardiotrace Inc. Other home-based monitoring technologies are available, from electronic stethoscopes and blood glucose monitors to systems that use handheld computers.

Alere Medical Inc., based in Reno, Nev., for example, offers an electronic scale that gives doctors daily access to information about patients' symptoms and weight. The device automatically records and sends data to a physician or other provider over the patients’ telephone lines.

The scale is one part of the AlereNet Heart Failure Program, a system that collects data from heart patients each day and transmits the information to a central database for review by cardiac nurses. Alere also produces a Web-based monitor that allows patients to answer yes-no questions about their symptoms. It then provides doctors with easy-to-read reports.

And a device known as Health Buddy allows patients to answer basic questions like "How did you sleep last night?" by entering responses on a keypad. The patient answers by pressing one of four buttons, and the device automatically transmits the information to the physician via the telephone lines.

The Health Buddy lets health professionals monitor patients remotely with a series of simple queries. Other home monitoring devices allow patients to measure their heart rate, blood pressure and weight.

(For a full list of home monitoring products, see the sidebar below.)

Early results

Alan P. Abrams, MD, a geriatrician with Harvard University Medical School and the Cambridge Health Alliance, is studying the Electronic Housecall System, which is manufactured by Cyber-Care Inc. of Boynton Beach, Fla. The FDA-approved device allows physicians to remotely monitor patients' blood pressure, temperature, blood oxygen, heart and lung sounds, blood sugar levels and weight.

Computer modules installed at the doctor’s office and patient’s home allow them to communicate and send data through modems connected only to each other. (Information is not sent via the Internet in part because of concerns that it could be intercepted.) Physicians can use the system to work with any electronic device like a digital stethoscope. At home, patients see an on-screen diagram showing them exactly where to position the device.

Though his study is still in the early stages, Dr. Abrams said his initial impression is that the technology "can be very helpful for most primary care providers who need to follow up with a significant number of patients for whom coming back and forth to an office is not practical or efficient.”

He said the patient module is extremely simple to use, even for frail, elderly patients who have no experience with technology. “It’s really not a computer,” he said. “It’s more like a flat television.” Patients simply touch the images on the screen to navigate the system, he explained.

The device is somewhat more complicated on the provider’s end. “The learning curve is steeper for the physician,” Dr. Abrams said. But he added that because “so much time is spent in the doctor’s office teaching” patients about their illnesses, these devices can significantly improve education and save time. Dr. Abrams also said that he believes that as long as the technologies are used to supplement, rather than replace, home or office visits, they can be very helpful to both internists and their patients.

Help for the chronically ill

Proponents of monitoring technology predict that patients with chronic conditions requiring constant monitoring, such as diabetes, heart disease and asthma, stand to benefit the most.

“People with chronic illnesses who can understand how to use the module, who aren’t afraid of technology and who would benefit from more rigorous monitoring” are good candidates, explained Dr. Abrams. “Someone with diabetes, congestive heart failure and lung disease, for example, can use this kind of technology to reduce the costs of ER visits and hospitalization.”

Several pilot studies have analyzed the effectiveness of home-based monitoring. Patients report feeling more connected, better educated and more in control of their disease management.

A study led by Paul A. Heidenreich, ACP-ASIM Member, of the Veteran Affairs Medical Center in Palo Alto, Calif., found that during a one-year period, medical claims fell from $8,500 to $7,500 on average for the 68 patients who used computers to record and transmit their daily weight, vital signs and symptoms. By comparison, claims for the control group doubled during the same period, from an average of $9,200 to $18,800. (American Heart Journal 1999;138:633-40.)

According to a study in the June 5, 2001, Annals of Internal Medicine (134:1024-32), patients whose blood pressure was monitored by a home telemedicine service that sent weekly status reports to their physicians saw a drop in blood pressure of 2.8 mm Hg arterial and 4.9 mm Hg systolic.

And last year, the U.S. Army conducted a study involving 28 patients with type 2 diabetes. Patients received weekly “virtual house calls” in which a nurse spoke to them through video and audio connections about nutrition, exercise and medication. Patients were also able to transmit test results through the system to nurses, who e-mailed results to physicians.

The three-month study, published in the August 2000 issue of Military Medicine (165:579-84), showed that patients who participated in weekly video conferences lowered their blood sugar levels by 16% and their weight by 4%.

Slow acceptance

Despite promising results, these technologies have been slow to catch on. While some internists welcome the influx of home care technologies, others remain skeptical, citing concerns about privacy, impersonal care and reimbursement issues.

Some physicians, for example, worry that patients will make a mistake using the technology and transmit bad information. Others fear that if nurses end up doing most of the day-to-day monitoring, they will be cut out of the loop and lose touch with patients.

Michael A. Burgin, ACP-ASIM Member, an internist in Columbus, Ohio, added that “confidentiality and privacy issues are always a concern” when trusting sensitive patient information over the Internet. This is one reason many companies have turned to phone-based systems, where devices communicate to computers via a modem.

But reimbursement is probably the single largest concern keeping physicians from embracing these types of monitoring technologies. When Mr. Porter wore his Event Monitor, an insurance company paid the manufacturer roughly $400 a month in rental fees. It also paid Mr. Porter's cardiologist to read and interpret the results that were sent to him.

Not all physician reimbursement is so simple when using monitoring devices. The Electronic Housecall System that Dr. Abrams is studying, for example, offers physicians a full range of diagnostic testing, but it costs between $300 and $400 a month. Officials from Cyber-Care Inc., the company that sells the system, said that most fee-for-service insurers do not pay physicians for their use of its technology.

Because the Health Buddy device starts at around $75,000 plus monthly fees, company officials say that most of its clients are disease management companies. Most physicians interested in the technology work with a disease management network, which provides the service and sends reports to the patients' doctors.

Slowly, however, some insurers are sensing these devices' savings potential and are beginning to look at reimbursing doctors in the ambulatory setting. Cyber-Care officials, for example, said they are working to convince payers to reimburse physicians who use its system. And Medicare has begun limited coverage of some devices, including the Event Monitor used by Mr. Porter.

Other vendors said that several insurers are implementing policies that reimburse doctors for their use of high-tech tools. For now, however, most seem to be considering reimbursement for such technologies on a case-by-case basis.

Ingrid Palmer is a freelance writer in Marlton, N.J.


Products for providing home care remotely

Below are several companies’ home health care devices that can make chronic disease management easier for internists and their patients.

Health Buddy (—Manufactured by Mountain View, Calif.—based Health Hero Network Inc., Health Buddy is a small in-home messaging device that connects to patients’ existing home telephone line. The appliance allows patients to view answer simple questions from their physician about their health, such as “How are you feeling today?” or “How did you sleep last night?” The patient answers by pressing one of four buttons and the device automatically dials a toll-free number, sends the day’s responses and collects new information from the healthcare provider.

“The device has large buttons and bright screens,” said Shawn Hopwood, director of marketing for Health Hero. “If you know how to read and push a button, you can use this product.” There are no fancy networks to navigate. “All the patient has to do is answer the questions,” he said. The system is just as easy for the professionals at the medical center receiving the data, Mr. Hopwood added. “The responses show up on the nurse’s computer screen and if anything was answered negatively, it will be flagged for follow-up.”

Health Hero currently provides 10 different sets of questions targeting different chronic diseases that can be used with the Health Buddy. Heart patients, diabetics, asthmatics and people with depression are most likely to benefit from the system. Most of Health Hero’s current customers are disease management companies who send reports to the patients’ doctors after analyzing the information. The cost for implementation begins at $75,000 plus monthly fees. Most interested internists sign up with a disease management network, which then provides the service, Mr. Hopwood said.

MD.2 Personal Medication System—Available to patients who need reminders to take their medication, the MD.2 machine tells patients when it’s time to take their regimen of drugs. When the computerized voice rings out, “Time to take your medicine,” patients simply push a button on the foot-tall machine and it dispenses the correct dosage. If the patient does not respond to the prompt after 90 minutes, the device dials caregivers to alert them. Interactive Medicine Development sells the MD.2, which was designed by two physicians, for about $800 apiece.

Acculink Modem System (—The Acculink Modem System by Roche Diagnostics in Indianapolis, Ind., works with the company’s Accu-Chek Complete blood glucose meter. The system allows a diabetic patient to prick her finger, put a drop of blood on a test strip and place it in the meter, which transmits the results directly from her telephone to her doctor’s computer or fax machine.

Medtronic Inc. (—Medtronic Inc.’s patient management system allows patients to transmit over the Internet a variety of cardiac information gathered from the company’s pacemaker monitors or implanted heart monitors. Internists can purchase this system for about $8,000 plus monthly fees, according to Medtronic’s chief executive William George.

American Medical Development (—This vendor sells a wide range of home monitoring equipement, including ECG recorder/transmitters, three types of remote stethoscopes and a scale that automatically transmits a user’s weight measurement over a standard phone line to a receiving station, where readings are displayed both graphically and numerically. They also offer devices for remote monitoring of blood pressure and vital signs.

American TeleCare, Inc. (—The company’s AVIVA home telemedicine system connects stations in patients’ homes with a central station in a healthcare provider’s office or clinic. The system features live, two-way audio/video and medical peripherals including a telephonic stethoscope, blood pressure meter, glucose meter, scale and pulse oximeter. The company has more than 125 programs operating in the U.S. and Canada.

HomMed, LLC (—This Brookfield, Wisc.-based company offers monitoring systems that transmit data from a patient to a physician using wireless digital pager technology or a standard telephone line.

The patient unit, the HomMed Sentry, alerts users when it is time to collect vital sign data, then walks them through steps use the attached devices that check heart rate, blood pressure, oxygen saturation, weight and temperature. An optional spirometer or glucose monitor can also connect to the unit.

The clinician unit, the HomMed Observer, flags any abnormal readings while tracking patient data for up to six months and charting trends. The system alerts practitioners of late or missed measurements and stores and tracks information on patients’ medications.

TeleHealth Systems, Inc. (—This interactive voice response system “makes automatic house calls to patients at specific times,” explained G.H. Roesener, president of the Greenwood, Ind.-based company. “Once the patient picks up the phone, he hears recorded questions that his doctor has selected based on his condition. The patient responds to the questions using the telephone keypad.” The system then automatically stores data from his responses and prints it out at the physician’s office or hospital for review.

The system does not require patients to place special equipment in their homes. It includes a page-a-nurse option that about 50% of Telehealth’s customers use, Mr. Roesener said, though this option requires a full-time nurse to monitor the incoming calls.

Internists can gain access to the technology in one of two ways: sign up for the complete system, which includes hardware, software, installation and training, at an initial cost of $44,000, or subscribe to the company’s eVisit Center (877-490-6161) and pay a base rate of $5 per patient call. This alternative allows doctors to “use the service without having to invest in it,” Mr. Roesener said.


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