2. Monitoring Health Status and Delivering Health Education Via Home Telemedicine ‘There’s No Place Like Home…’ Donna C. Vogel MSN,CCM ATA 6-06-01 Home Telemedicine Team: Joseph Erdos MD, Ph.D; Helen Noel Ph.D., APN; Donna Vogel MSN, CCM; Forrest Levin MS; Kathleen O’Neill APRN; Leo Calderone MS; David Cornwall MBA

3. Why Telemonitoring? VHA – world’s largest HMO –Serves > 3.6 million patients –Over 178,000 patients receive home services daily Changing resources –Patients need more health self-management options –Dx best managed by telemedicine - CHF, COPD, DM, CAPD http://www.ntia.doc.gov/reports/telemed/execsum.htm http://www.ntia.doc.gov/reports/telemed/execsum.htm Increased emphasis on health prevention, frequent monitoring, education & documentation Pts have increasing difficulty traveling –Transporting patients to clinics is time consuming, costly & fails to prevent unpredictable events at home Focus on ambulatory, primary & home care –Moving to a model of care that extends beyond the walls of the hospital and clinics

4. Goals Improve access to care Monitor patients’ physiologic status & pain –BP, T, pulse oximetry, blood glucose, ECG, weight, breath & heart sounds; camera for visualization; questionnaire Improve patient education Expand home-based care Unique Internet based technology –Simple & easy to use –Active server technology Integrate telemedicine data with HIS –VISTA - Veterans Health Information System and Technology Architecture

5. Home Unit Monitors Health Status & Delivers Web-Based Education Connects to a wide variety of sensors Touch screen has large buttons and user help Flexible, convenient, and easy to use

6. Architecture SQL Server 7.0 Windows 2000 Text and image data Archived. Data is linked to Intranet and sent to VistA HOMEHOME Toll Free access MS RAS Connection Ethernet 56k DSL VISTA Intranet Patient or Care Provider takes measurements VSB HospitalInternet Firewall Encryption PKI VA Connecticut Hospital Server Hospital Server VA Connecticut Hospital Server Hospital Server

7. Expected Outcomes…. Improved level of independence Improved knowledge & management of disease –Patient empowered to manage their health through education –Efficient daily monitoring with feedback available to patients Improved continuity of care & quality of life Improved compliance with plan of care & advance directives Improved patient/provider satisfaction Decreased healthcare costs –Move data not people –Decrease # of ER/Unscheduled visits –Avoid hospitalization Timely diagnostics for rapid intervention

8. Monitoring Physiologic Data Web-based data-reporting –All data sent from home is available on a secure web site Clinicians see data organized by patient, date, compliance status and physiologic measurement type. Trend charts show monitored vital sign results Data Integrated with VISTA Specific vital signs (including pain) on CPRS cover sheet Indicates data obtained via home telemedicine Trend charts show monitored vital sign results

9. Clinician’s Report Clinician selects ‘Clinician’s Report’ to view their patient’s data Secure Web Site

10. Web Page Displays Patient Data

11. Vital sign data from the telemedicine unit CPRS COVER SHEET IN VISTA

12. Health Education Features Disease-specific web modules –Modules can be accessed from home –Content available in text, streaming video, and audio –Web-based questionnaire to assess learning –Trend charts show modules accessed Progress note automatically sent to VISTA –Results of patient education is documented Appointments also sent from VISTA to home unit

13. Web-based Education Selecting the Web button will connect the patient to their personalized web site. The site will give access to educational modules, their medical records, VA appointments and more.

14. Patients select an education module to view Web-Based Disease Modules

15. After reading content, patient can respond to questionnaire Web-Based Questionnaire

16. Patient responses are recorded and sent to VISTA as a Progress Note. Learning Assessment

17. Patient Education Progress Note Progress Note ‘SUBJECT’ shows which education module was passed or failed

18. Education Features… more Medication reminders –Audible tone reminds patients to take a specific medication –Self-monitoring tools record when medications were taken, forgotten or purposefully omitted –Visual compliance feedback to providers and patients using easy-to-read, real-time charting

19. Audible Reminder Feature

20. Education Features…more Hospital to Home messaging –Clinicians can send email messages to patients providing valuable education and feedback to encourage self-care. Video conferencing ability –User initiates call to clinician for face-to-face meeting and provide/reinforce education.

21. Email Messaging & Video Conferencing The ‘Video Phone’ creates a a video conference session with the provider at the appointed time. The ‘Advice’ button opens an email list showing messages from clinician.

22. Disease Management Clinician Alerts –Digital alert system for timely intervention through: Digital pagers email Web –Alerted when: a patient’s vital signs exceed pre-set limits patient has failed an educational module a medication noncompliance event is detected

23. Clinician Alerts This page shows the clinician a list of their patients that have triggered an alert. The alerts can be linked to an out-of-limit condition for a particular vital sign, or an unsatisfactory score on the patient education questionnaire as seen here.

24. Clinician Response By selecting the small ‘+’ by the patient’s name, the clinician can enter any pertinent comments. The alert is cleared after a comment is entered.

25. Technology and Security Microsoft software for client and servers (NT/2000, SQL7, IIS, Exchange) Full NT security model followed –Username/Password Authentication –Firewall protection for dial-up lines Patient Confidentiality addressed –Computer Access Agreement –Consent forms for data and images Lessons Learned Educating patients/caregivers & staff is critical –Not every patient will be suitable Training support staff is essential Skilled IT support for database integration Close vendor relationship is key

26. VCR Pricing Trend ($) Cost(1,000 units) As the use of home telehealth technology increases, costs will decline. COST

27. “There’s No Place Like Home” For more information contact Donna Vogel at: donna.vogel@med.va.govdonna.vogel@med.va.gov