Home Telehealth: Looking Under the Hood
Telehealth is use of communication technology to deliver health services where the care recipient and care provider are separated by distance. Altering the communication channel between providers and patients can overcome geographic barriers and improve access to health services. A common use of telehealth technologies is to deliver care from a distance that would normally be provided face-to face. Thus, rather than traveling to the medical center, a Veteran can be seen by a specialist via clinical video telehealth at a clinic location closer to home, while still receiving the same care that would be provided in a face-to-face encounter. The VHA Office of Telehealth Services supports three kinds of technology-facilitated care: 1) clinical video telehealth (typically physician delivered clinic visits provided using interactive video to distant clinics); 2) store and forward (generating and uploading image data for viewing by specialists); and 3) home telehealth, employing technology-facilitated monitoring along with care management in Veterans' homes. Technologies used in home telehealth include videophones, messaging devices, interactive voice response, and devices that record and transmit vital sign data only. The remainder of this article will focus on home telehealth.
A New Model of Care
Home telehealth enables a new model of care that was not previously available or efficient for patients or providers. That is, while patients theoretically could telephone a nurse or physician each day with vital sign information, that approach is impractical when large numbers of patients need monitoring. Home telehealth technologies can be incorporated into a variety of care management programs. A number of studies have evaluated the effectiveness of home telehealth in chronic disease management, and results have been mixed. These mixed findings likely reflect variation in program design and implementation across studies. Home telehealth programs are often bundled interventions that may also include home visits, clinic visits, and other modes of communication such as email, telephone, and use of patient portals, in addition to patient data transmission. Interventions vary in terms of interaction between a patient and care manager via video/telephone, the specific content delivered via a messaging device, or whether vital sign data only are transmitted.
The type of intervention that care managers deliver in response to patient data presents an important source of variability in currently published studies. Thus, it can be difficult to ascertain the mechanism of effect in successful programs, or what is missing in ineffective programs. A systematic review of interventions used in multi-component outpatient heart failure management programs found that the number of individual interventions across studies ranged from one to seven. Although the most commonly used interventions were patient education, symptom monitoring by study staff, symptom monitoring by patients, and medication adherence strategies, these were not used in all studies.1 Although not all of the studies in the review included a telehealth component, similar variation is found in reviews of home telehealth studies. Variation also exists in workload (number of patients assigned to a care manager), type and acuity of patient needs, and the design of the workflow of reviewing and responding to patient-reported variances.
Further Research Needed
Currently published literature describing trials of home telehealth programs does not provide sufficient detail on individual program components to enable identification of the appropriate number and combination of interventions needed to improve outcomes or translate findings to practice. Researchers identify eight domains to describe chronic disease management programs: 1) risk status, demographics, and comorbidities of the sample; 2) the primary target(s) of the program (patients, informal caregivers, clinicians, and/or systems of care); 3) individual components of the intervention, e.g., patient education, medication management, post-discharge care; 4) who is involved in intervention delivery, both clinical and non-clinical staff; 5) method of communication, such as face to face, audiovisual, and/or electronic or telecommunication technology; 6) frequency of provision of the intervention delivery components, duration of the intervention, and the mix of program components for each intervention target; 7) location(s) where each intervention component is delivered, including the hospital, clinic, patient home, or community-based; and 8) outcomes, including clinical, resource, and patient-centered measures, such as adherence. 2 Consistent reporting of program components and interventions is needed to determine what works.
Finally, organizational characteristics of successful telehealth programs are consistent with implementation of other types of health services interventions. These characteristics include senior management support, formally established staff responsibilities for the program, program evaluation with feedback to staff, flexibility, creativity in developing and implementing new programs, and a business plan that supports the mission of the organization.3