A dose of telemedicine saves lives, cuts costs

Following her diagnosis of congestive heart failure in 2004, 68-year-old Carolyn Thornton was given a choice: She could wait at her suburban Boston home for twice-weekly medical readings taken by a visiting nurse and recorded in a notebook, or do it herself. Her decision to take her own daily readings and transmit them to cardiac nurses in Boston may have saved her life. When a nurse noticed a precipitous drop in Thornton’s blood pressure reading, she called the patient and urged her to seek medical attention.

Home-based vital-sign monitoring is just one way the technology known as telemedicine can save lives and improve medical care. Led by Massachusetts General Hospital (MGH), the hospitals of Partners Healthcare are forging ahead with several telemedicine initiatives that bring healthcare closer to patients.

Hundreds of patients are enrolled at home in programs that monitor vital signs, and a project that monitors patients with hypertension in their homes is due to get underway shortly. Another project that allows homebound patients to have virtual visits to doctors’ offices with specialists or consultations for second opinions serves nearly 2,000 patients per year. A fourth project allows acute-stroke patients brought by ambulance to outlying community hospitals to be quickly diagnosed by MGH’s stroke specialists.

What is startling about these telemedicine initiatives is their use of modest network technology and rock-bottom cost – just $100 per month, per patient for the heart-monitoring project, including all home and data-center hardware, communications, application development and ongoing operations for hundreds of patients.

“Simple solutions too often are overlooked,” says Doug McClure, corporate manager for technology services at Partners’ telemedicine group in Boston. “There is no breakthrough of new technology here, but a leveraging of inexpensive, reliable technology that was proven long ago.”

Telemedicine technology

Home-based monitoring begins with a small tabletop console. Plugged into it are various sensors, which may include a blood-pressure cuff, a pulse oximeter for measuring pulse and blood-oxygen saturation levels, and a scale for recording weight. The console’s liquid crystal display prompts patients through data gathering, then the patient presses a button that initiates a dial-up session to upload the data through the patient’s home telephone line.

“We’re talking about patients who often are not PC-savvy and who rarely have a broadband connection in their home,” says Dr. Joseph Kvedar, director of telemedicine at Partners Medical Group. “These devices must be user-friendly and not intimidate.” Major suppliers in the market include the TeleStation from Philips and HomMed from Honeywell.

Although the cuff, pulse oximeter and scale are connected to the console via cables, that’s changing, McClure says. “The technology is rapidly moving to wireless measurement devices that communicate with the console via either [radio frequency] or Bluetooth,” he says. Similar in concept to a wireless mouse, it’s safer for patients, especially those with limited mobility.

Data handling and analysis is straightforward, McClure says. The patient’s home device dials an ISP and uses secure HTTP to upload the data to a server inside the Partners firewall. The amount of data transmitted each day is minimal, resulting in a communications session that typically lasts less than 30 seconds. Although dedicated servers are used, this was mostly a matter of convenience. “These are not high-volume transaction-processing applications,” McClure says. “The investment in hardware was tiny.”

Session data is recorded to an Oracle or Microsoft SQL Server database containing the patient’s previous readings. McClure has members of his team working with a MySQL database, investigating the viability of eventually moving to another open source solution.

Server-side clinical algorithms developed by McClure’s staff analyze the new information in the context of each patient’s continually growing history of daily readings. Grouped into three severity levels, any condition outside the acceptable “green” boundaries set by the patient’s physician immediately are conveyed to nurses via a secure HTTP session and displayed on their workstations in yellow or red. With only exceptions reported, they are quickly noticed and can be addressed immediately.

Daily monitoring identifies sudden changes that would likely be missed during a monthly visit to the doctor or twice-weekly readings taken by a visiting nurse. Thornton discovered this firsthand when she received a call from a nurse concerned that her blood pressure had taken a precipitous drop. “I was advised to contact the doctor right away,” Thornton says. She did, and appropriate medical steps were taken. Nurses still visit, but now on an as-needed basis rather than a rigid preset schedule.

The simple operation is a result of a design philosophy that placed heavy demands on IT early, while minimizing that department’s involvement once the systems were implemented.

“We have tried to build systems that are IT labor-intensive to set up but low-maintenance in terms of operation,” says Dr. Lee Schwamm, designer and director of the TeleStroke Center at MGH. “Our standard is that these solutions must be easier than a VCR for [the] patient and the nurses to use; the last thing we want is to haul an IT person out of bed at 2 a.m. to troubleshoot a connection.”

Unlike the home-monitoring program, which ultimately will have thousands of units deployed, the TeleStroke program links subscribing community hospitals to MGH, allowing a stroke patient to receive immediate attention by MGH’s stroke specialists. The system operates as a hub-and-spoke with MGH at the center surrounded by 13 smaller Massachusetts community hospitals as far away as Martha’s Vineyard and Nantucket.

By using videoconferencing technology, stroke specialists at MGH can examine patients at the remote hospitals to help diagnose ailments and recommend a plan of care. “I can examine someone interactively with the help of a physician or a nurse on the other end, and I can make a determination of the stroke severity and the type of stroke by looking at the patient and at the brain image,” Schwamm says. “It’s almost like being in the room.”

Again, the key is simple and reliable, Schwamm says. “We use the off-the-shelf videoconferencing hardware and run the sessions over an ISDN line. It provides the bandwidth we need.” As McClure puts it, “We are much more about process innovation than technology innovation.”

When it comes to treating a stroke, every minute counts, and the lack of stroke specialists at these small hospitals was the impetus for creating the TeleStroke program. One form of stroke treatment is to administer Tissue Plasminogen Activator (tPA), a clot-busting drug that can greatly reduce the disability resulting from a stroke. But tPA must be administered within three hours of symptom onset.

Conquering challenges

The overall Partners network is very large, with more than 40,000 users dispersed across six major Boston-area hospitals, clinics, joint ventures and research labs, and an affiliation with Harvard Medical School. Even though each telemedicine system is implemented as a silo, isolated from the overall network, the overall Partners infrastructure presented several technical challenges.

McClure’s development team divided these challenges into three categories – patient, communications and data. None proved difficult to solve.

Education calmed patients’ fears and eased apprehension among nurses. “If a patient puts on the blood-pressure cuff incorrectly or stands on a scale while holding her dog, we get bad readings,” McClure says. These two readings are used to calculate fluid-retention levels, the critical factor for patients with congestive heart failure such as Thornton. The goal is so-called “wear and forget” wireless sensors, but the technology isn’t quite there.

“Both nurses and patients were reluctant at first,” says Kathy Duckett, a registered nurse and director of clinical programs at affiliate Partners Home Care, whose clinicians administer the program. “Instead of a visiting nurse taking a reading just twice a week, the patient now does it every day. They become more involved in the process and know they are being monitored more closely.”

Kvedar agrees that acceptance often requires a nudge, more so within the medical community than among patients. Telemedicine is viewed by many in healthcare as “counterintuitive,” turning the long-accepted model of the “patient going to where the healthcare is” upside down. Nurses who believed that distance medicine would drive a wedge between patient and care giver now acknowledge that patients in fact feel more connected. “Patients know their data is being looked at every day.”

Communications – simply getting the data out of patients’ homes – was the next hurdle. Because most older patients do not have a broadband Internet connection, solutions were designed for the lowest common denominator, a dial-up line in every home.

But as today’s Internet-savvy population becomes tomorrow’s telemedicine patients, the widespread presence of broadband in homes will allow downloading of interactive, rich educational content.

Perhaps the biggest challenge was the development of algorithms to analyze incoming patient data and understand its meaning in the context of the patient’s history of previous readings. Many months were spent developing and testing these algorithms.

In deploying the TeleStroke videoconferencing solution at other hospitals, Schwamm found that hospitals with larger IT infrastructures that have not implemented videoconferencing must spend more time and manpower to configure firewalls and allay security concerns.

“Larger institutions are the hub in this model, not the outlying spoke, so issues of scalability compound for the hub hospital as more smaller hospitals sign up and become additional spokes in the wheel.”

Conversely, hospitals with a modest IT infrastructure will find implementation straightforward. “All it takes is a small server, an ISDN line and a videoconferencing unit.”

The beauty of home-based telemonitoring and the associated server-side applications is its low cost. A yearlong project following 500 patients costs $600,000, pocket change by medical-industry standards.

Calculating a return is not what these projects are about. The rate of hospitalizations for patients 65 and older with congestive heart failure skyrocketed from about 60 per 10,000 in 1970 to nearly 230 per 10,000 in 2000, according to the National Heart, Lung and Blood Institute.

“Successful implementation of telemedicine translates to fewer hospitalizations, less stress on the healthcare-delivery system, better utilization of healthcare professionals and improved quality of life for patients,” Duckett says.

Currently, half of all patients with congestive heart failure die within five years of being diagnosed, Duckett says. Telemedicine is changing that. “Daily monitoring allows us to react quickly, administer treatment or adjust medication, and cut down on hospitalizations and doctor visits. We are saving lives and reducing healthcare costs at the same time.”

Now stabilized and sensitized to the diet and environmental factors that affect her health, Thornton no longer needs her telemonitoring console and is free to travel. “Telemonitoring made me feel like a trailblazer,” she says. “I was lucky to be invited into this program; today I feel much stronger.”

Upcoming initiatives

With development on the home health monitoring and TeleStroke projects largely complete, Partners is tackling new initiatives.

Nearing its launch is the Partners Healthcare hypertension-monitoring project, an outgrowth of its heart-monitoring effort. In its initial phase, it will keep track of several hundred patients with chronic high blood pressure. Because they are not homebound, and the only sensor required is one to measure blood pressure, mobility is a bigger factor.

“These patients are not homebound, so use of their cell phones as a data aggregation and transmission device is an obvious use factor,” McClure says.

The metric for success will be the degree to which Partners can help people manage their blood pressure more effectively, with an ultimate goal of avoiding downstream effects, such as stroke, heart attack and congestive heart failure. Hypertension is not an acute condition, but it is one that is significantly more pervasive throughout the general population.

Also on the docket are a patient-management system and a fully electronic patient medical record. These are under development as Web services based on protocols promulgated by Health Level Seven (HL7), an ANSI-accredited Standards Developing Organization (SDO) that operates in the healthcare arena – much as the IEEE sets network standards. While other SDOs define protocols for such healthcare domains as pharmacy, medical devices, imaging or insurance-claims processing, HL7’s domain is clinical and administrative data.

The Partners road map calls for a fully electronic patient record that will incorporate hospital test results, radiological images and telemonitoring data. Once implemented, Web-based visits to doctors’ offices, whether in Boston or elsewhere, can become more efficient, eliminating the administrative expense and delay associated with retrieving a paper-based patient medical history.

“The electronic medical record is our Holy Grail,” McClure says.

Shore is a technology journalist in Southborough, Mass., who provides product-strategy consultation and editorial-development services to technology companies. He can be reached at www.joelshore.com.