Bridging the gap: in-home monitoring device reduces cost of treating underserved populations in rural Alabama – What works: telehealth/telemed
Hypertension is more prevalent among Southerners than other Americans, according to the January 2000 issue of Stroke: Journal of the American Heart Association. Rural residents are at an even greater risk. In the Third National Health and Nutritional Examination Survey conducted from 1988 to 1994, 70.4 percent of black men living in nonmetropolitan areas in the South had high blood pressure, compared to 54.3 percent of black men living in Southern metropolitan areas.
According to a Baylor College of Medicine study, black men between the ages of 35 and 44 are twice as likely to die from high blood pressure than Caucasian males. The story is even grimmer for black women, who are 15 times more likely to die from high blood pressure than Caucasian women.
While the contributing factors to this geographic variation are many, one thing is sure: The rural South is ripe for the benefits of telemedicine.
The Office of Emerging Health Technologies (OEHT) at the University of South Alabama College of Medicine in Mobile began in 1998 as the Southwest Alabama Rural Telehealth Network. The program was charged with looking for new communication-oriented telehealth tools that could provide better care to people without health insurance in rural Alabama. We especially wanted to address the most chronic health issues in rural Alabama: congestive heart failure, hypertension, obesity and diabetes.
Unfortunately, we found that many exciting advances in telemedicine such as videoconferencing could not be used with some of our populations. This was due to the lack of T1 lines to rural health clinics for Internet access and the lower education and income levels of the populations these clinics serve. As a result, we broadened our mission to look for new technologies that could improve patient/doctor communication or patient outcomes that were not reliant on the Internet (or even the patient’s understanding of it) to achieve our objectives.
One of the technologies that fit the bill was Cybernet Medical’s MedStar system. The MedStar interface device and accompanying collection server were introduced in mid-2001 for improving in-home patient chronic disease management. The battery-powered and portable MedStar device collects outpatient physiological data from multiple off-the-shelf instruments such as blood pressure cuffs and weight scales. It then uses a proprietary dialing protocol to securely transmit the digitized data over a standard phone line to a server located at a clinic or a disease management company’s facility. The MedStar device is small and light-10 square inches and weighing less than a pound–and operates on standard AA batteries.
Before we learned of the MedStar system, we had built a demonstration prototype to illustrate an in-home monitoring device we felt would suit the needs of a rural population. We were convinced that home-based devices using anything other than a standard telephone line were too large and difficult to use–and too costly. When we discovered the MedStar device, we were surprised at how closely it matched our prototype in concept and functionality, so our choice for an in-home monitoring solution was easy.
In April 2002, we began a pilot program to monitor hypertensive black patients served by the Grace Busse Clinic in Pine Apple, a town of 300 in a South Central Alabama county of 14,000 residents. The clinic serves six counties neighboring Pine Apple and treats about 30 patients per day for a variety of simple ailments and more chronic diseases like diabetes. Sister Roseanne Cook, C.S.J., M.D., director of Grace Busse Health Center and one of only three doctors serving the area, selected the initial 19 participants. All of the participants had been hospitalized within the last year for hypertension-related problems.
“We had a simple goal for the program,” Cook says. “We wanted to help these patients understand the value of diet and exercise in controlling blood pressure through daily monitoring. We knew that if they were monitored on a daily basis, they would see results. Our long-term objective was to reduce the number of times these patients unnecessarily visited the hospital emergency room. Basically, we wanted them to understand that following the doctor’s advice would make them feel better.”
Through funding provided in part by a grant from the Health Resources and Services Administration’s Office for the Advancement of Telehealth, program participants were given MedStar units and the peripheral devices-automated blood pressure cuffs or electronic scales-that they needed. Training the participants was as simple as showing them how to connect a peripheral device to the MedStar unit, turn on the MedStar unit, activate the peripheral to perform a measurement, connect the MedStar unit to a phone line, and push a button to transmit the reading, along with the participant’s ID code, from the MedStar unit to our server.
We encountered minimal problems in implementing the program. From a technical standpoint, the equipment performed as designed but needed to be tweaked for differences in telecommunications services, since patients did not use the same service provider–area coverage is provided by national carriers and a small, rural telephone company–and had varying service features. For example, in one case, call waiting affected the ability of the MedStar unit to transmit data. However, this was easily corrected through a special interface already installed in the MedStar unit. In another case, the patient needed to plug the MedStar unit into the telephone itself rather than the phone jack, probably to compensate for the type of phone line.
According to Susan Malone, OEHT clinical coordinator, another issue that needed to be addressed was the healthcare workers’ concern that the use of this technology would disconnect them from their patients. Yet, “Once everyone understood how the program worked and the benefits we could achieve, there was more enthusiastic support,” she says. “We now have a dedicated field representative who works with the patients and their healthcare providers to encourage a partnership by answering questions and showing how technology can actually enhance personal care.”
Of the 19 participants in the Pine Apple study, all but one completed the 90-day trial. None visited the emergency room or was admitted to the hospital during that time, so the clinic did not have to absorb the cost for treating these uninsured patients. Because hospitals, especially those in rural areas, bear a huge portion of the costs for servicing a chronically underfunded population, they have a vested interest in keeping such in-home monitoring programs intact.
Since it requires less than $500 to outfit each patient with a MedStar unit and peripherals, and we estimate that it costs about $1 per day for the management of each patient, the annual program cost is about $850 per patient. With emergency room visits running $600 to $800 per visit–and if hospitalization results, it becomes $3,500 to $8,000 per patient–the program nearly pays for itself through the avoidance of a single emergency room visit.
“One of our program participants used to visit the hospital emergency room at least monthly,” Cook says. “Whenever he felt dizzy or had a headache, he headed to the hospital for a blood pressure check. Now, he can take a reading at home, send the data to us and be reassured that his blood pressure is in check.”
Although the Pine Apple pilot program was scheduled to end in August 2002, we continued to monitor 16 of the patients at their request. (The other two patients did not continue after the program convinced them that their physicians’ advice was correct and they could monitor themselves without our help.) What’s more, in October, we conducted a one-week trial in Evergreen, AL, with 21 participants that added pulse oximetry to the connected peripheral suite; OEHT intends to expand this program in the spring. Another 22 patients suffering from congestive heart failure were enrolled in a Geneva, AL, project that resulted from our presentation to the Alabama Department of Public Health.
The Office of Emerging Health Technologies is committed to improving the healthcare provided to Alabama’s rural residents. We are convinced that home healthcare monitoring is one of the methods we can use to quickly make a difference in improved patient outcomes.
Carl W. Taylor
Office of Emerging Health Technologies
University of South Alabama College
Cybernet Medical Corp.
Ann Arbor, MI
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