The ideal for which home telehealth interventions appear to strive is a care delivery system that allows for specialist consultation and ensures high continuity of care while minimizing physician time commitment. This is most frequently accomplished through heavy involvement of nurses.
Nurses tend to take primary responsibility for the administrative side of home telehealth interventions, and are almost invariably the patient’s first point of contact. In some cases, they appear to be the sole providers involved in the intervention. In a sizeable number of instances, however, they form part of a multi-disciplinary care team. The sophistication of health human resource planning in home telehealth for type 2 diabetes may be a product of the comparatively advanced state of this field. The models used in two particularly large and long-running studies are described briefly below.
In the Veterans Affairs Care Coordination Home Telehealth (VA-CCHT) programs, each participant was managed by a care coordinator. These coordinators, all of whom were registered nurses or advanced nurse practitioners, were responsible for education patients on disease management use of the home telehealth equipment. They monitored patients’ data transmissions and performed clinical assessments over the telephone if necessary. After assessing a patient, they might decide to contact a physician or specialist care provider to arrange for an appointment.
Multidisciplinary care teams were also used in the IDEATel program. Nurse case managers took primary responsibility for delivering the intervention, but patients’ primary physicians remained in charge of their patients’ care. An endocrinologist acted as intermediary by reviewing the nurse case managers’ notes and contacting the physician when it appeared necessary. Patients also had regular videoconferencing sessions with a dietitian.
Time commitments for the various providers are not often reported. However, there is reason to believe that some interventions can reduce physician-patient contact time – a development that patients would not necessarily see as positive. The amount of time required for communication with patients appears to be briefest when done through websites or text messaging. More time is required for telephone calls, and more time still for videoconferencing sessions. Typical time per patient per week is difficult to determine from the information available, but it appears to be under 30 minutes in most cases. This figure only includes time spent reviewing patient data and/or contacting patients.
It is not clear how these changes in health care delivery affect patient care. In one study, high physician workload and limitations of the home telehealth system meant that urgent patient reports were not responded to promptly, resulting in delays addressing acute symptoms and hypoglycemic events. This case demonstrates the importance of realistically assessing the health human resource needs that accompany home telehealth programs. A detailed discussion of the health human resource implications of implementing home telehealth were discussed can be found in a recent study of a pilot program that used mobile devices. As this study was retrieved in a final scan of 2011-2012 literature and was not subject to the same level of analysis as the other studies included in this review, we refer the reader to Katz et al. (2012) for more details.
Information on providers’ perceptions of home telehealth is scarce. Though there is evidence that high levels of satisfaction are achievable, there are clear indications that providers will resist using a new technology if it cumbersome to operate or not easily incorporated into existing workflow. Providers’ views on the coordinated care models described above also merit future research. Researchers in one study reported that recommendations of the intervention team were not all implemented by primary care physicians. The overall percentage of non-concordance is not given. Nor did researchers state whether this finding was unexpected.
Health care providers’ experiences with home telehealth for diabetes management were given little attention in the studies retrieved.
Uptake and Use of Technology
Summary: Uptake and use of technology outcomes were reported in 4 studies (Shea et al., 2006 and Shea, 2007; Luzio et al., 2005; Trudel et al., 2007; Watson et al., 2009). Though there is evidence that high levels of satisfaction are achievable, there are clear indications that providers will resist using a new technology if it is cumbersome to operate or not easily incorporated into existing workflow.
Study Details: In the IDEATel intervention, primary care physicians of IDEATel patients did not deliver the telehealth intervention, but maintained ongoing communication with the nurse care managers who did. While web-based messaging was available for this purpose, researchers observed that most of the physicians did not use this feature, preferring traditional options such as telephone or fax (Shea et al., 2006). Nevertheless, a survey of primary care physicians from the study’s rural sites found generally high levels of satisfaction with participation in the project (Shea, 2007).
Luzio et al. (2005) found that physicians’ acceptance of the study’s telehealth system was compromised by a technical shortcoming that necessitated double data entry. Similarly, the electronic medical record (EMR) in Watson et al. (2009) was not well integrated into the telehealth system in question. Providers stated that this made it difficult to incorporate use of the EMR into their workflow. In Trudel at al. (2007), on the other hand, the fax-back system that providers used to access patient data (see study for details) was reported to be “simple and efficacious”. It did not result in significant changes to provider workflow.
Effects on Practice and Patient Care
Summary: The effects of telehealth on practice and patient care were reported in 3 studies. IDEATel data was presented in Shea et al. (2006). The 2 studies described in Cho et al. (2006, 2009), though distinct, were based in the same hospital and employed very similar interventions. Findings indicate that caution in the initial stages of home telehealth implementations may be warranted.
Study Details: In the IDEATel intervention (Shea et al., 2006), recommendations for medication changes from the intervention team were forwarded to the patients’ primary care practitioners for application. The researchers reported that not all recommendations were actually implemented by the primary care physicians. The overall percentage of concordance is not given. The reasons for non-concordance were not reported, nor did researchers state whether this finding was unexpected.
In Cho et al. (2009), the intervention had some negative effects on patient care. Authors report that the telehealth intervention was not optimized for flexible, real-time patient-provider communication. Urgent patient reports of acute symptoms and hypoglycemic events were not responded to promptly. This lack of prompt feedback was attributed to the doctors’ workload as well as to limitations of the telehealth system. It was recommended that critical alert software and automatic response algorithms be developed in order to facilitate faster provider responses. Increased levels of dissatisfaction with care were seen among the intervention patients in this study.
Cho et al. (2006) looked at the effect of the telehealth intervention on the frequency with which clinicians prescribed drug modifications. The authors found no significant differences between the intervention and control groups in the number of medication changes per patient.
Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 additional article that addressed effects on practice and patient care (Katz et al., 2012). Katz et al. (2012) examined results from a mobile health pilot program to assess the effects of health human planning on implementation success. As this study was not subject to the same level of analysis as the other studies included in this review, we will not attempt further analysis. See Katz et al. (2012) for more details.
Cost and Time Savings
Summary: Only 1 study reported on provider cost and time savings. While this level of evidence is insufficient to support conclusions, time savings do appear to be possible.
Study Details: Cho et al. (2006) found that physician-patient contact time was ‘relatively reduced’ with the telehealth intervention when compared with in-person appointments.
Recent Developments: A scan of material from 2011-2012, a time period not covered by our initial searches, found 1 additional article that addressed effects on practice and patient care (Cho et al., 2011). In this study, a home telehealth intervention using a disease management algorithm that pre-screened and categorized blood glucose readings led to significant reductions in physician time. Patient glycemic control was not compromised. As this study was not subject to the same level of analysis as the other studies included in this review, we will not attempt further analysis. See Cho et al. (2011) for more details.
|And on the qualitative side . . .The qualitative articles retrieved indicated that, in general, home telehealth did add to health providers’ workloads. Often these workers were nurses. Hopp et al. (2007) reported that this additional work included ”time to set up the machines, monitor the information . . . on a daily basis, follow-up of alerts through contacting patients, and [making] periodic reports on patients” (p.4.). A common concern among nurses interviewed in Hopp et al. (2007) was that these activities were not within their skill set and took away from their normal patient obligations. Recruitment of a dedicated person to deal with technical set-up issues was suggested by the authors.
Starren et al. (2005) examined the experience of registered nurses as telehealth installers for the IDEATel project. Nurses were responsible for the installation of the home telehealth units and for training patients how to use the device as well as using the blood pressure cuff and glucose meter. For the study, 5 nurses completed 288 installations. The average time of each installation visit was 167 minutes per home, and average travel time was 105 minutes. The installation session was considered critical to the success of the program because this was the only face-to-face interaction between the patient and the nurse.