Hardware Cost is aBy M.L. Baker | Posted 05-11-2005
Bathroom Scales Aim to Save Lives (and Money)
When a patient's heart begins to fail, blood loses its forward thrust. Fluid builds up in the lungs, abdomen and lower limbs, causing dry cough and sudden weight gain.
Catching and addressing these signs quickly can avert a crisistrips to the emergency room, hospitalization and worse.
Hoping to catch the process in its earliest stagesto avoid both the health risks and the costs critical care incursome clinicians are prescribing blood cuffs and weight scales that can transmit readings from a patient's home to a health care facility.
Whole suites of medical devices exist that can zip data straight from a patient's bathroom scale to a clinician's screen.
"The devices are wireless and transmit to a phone hub. The patient stands on the scale, the scale [data] goes to the hub, then into the phone line, and then the nurses will look at the data," explains Gerrye Stegall, a clinical specialist with American Healthways Inc., a disease management company, which covers more than a million patients for a range of diseases.
If the data trigger an alarm, nurses call patients to figure out if they need to change medication, visit an outpatient clinic or modify behavior in other ways.
The goal is not just to keep patients healthier but also to cut health costs by cutting down the need for expensive hospitalizations and services.
So-called remote monitoring devices are being used to treat children with asthma, adults with mental health disorders and older patients with everything from heart diseases to diabetes.
Some 50,000 patients with severe chronic diseases such as diabetes, congestive heart failure, hypertension and breathing difficulties had remote monitoring devices in their homes in 2003, according to Sachin Thukral, a health care analyst with Frost and Sullivan. He singles out home monitoring systems as one of the two most successful areas in telemedicine. (The other area is teleradiology.)
Some systems allow for real-time audio and video consultation with a physician.
Eclipsys Technologies Corp. is developing "a highly mobile robot equipped with extremely high-performance two-way video and audio, remote control mobility and communication system, and a medical-grade wireless connectivity," according to Thukral.
The Health Buddy device made by Health Hero has ports that can connect to anything with USB, like cameras and identification devices, as well as medical equipment.
Motiva, from Philips Medical Systems, communicates with patients through their televisions.
Most programs send patient data to a Web page that collates information from several patients, flagging those whose blood pressure, pulse rate or other vital signs pose a cause for concern. Clinicians regularly review and respond to these data.
American Healthways' Stegall uses remote monitoring for patients with heart failure.
More than 90 percent of patients approached about the devices agree to take them, she said, and added that with the devices, patients "feel more supported than threatened."
Devices can do more than simply take a reading; some can ask patients questions about how they're feeling.
And some, like the Health Buddy device manufactured by Health Hero, use this information to coach patients into better behavior.
The device is in 5,000 homes, being used to help manage diseases including childhood asthma and heart failure.
Next Page: Friendly gadgets, serious impact.
Friendly Gadgets, Serious Impact
It's an attractive four-button device with a color screen that looks more like a child's video toy than a medical device. But it has FDA clearance to receive and transmit data from a variety of glucose meters, electronic weight scales, blood pressure meters and a device that measures lung function.
Patients using Health Buddy answer daily questions about their activity and well-being and receive advice about how to improve their health.
Remote monitoring has been around for a long time, according to Health Hero CEO Steve Brown, but new devices can be programmed to interact with the patient.
"Collecting data is just not enough. You really need to coach patients, and then give the right data so clinicians can manage by exception," Brown said.
In other words, clinicians decide precisely which patients to contact and when, based on their vital signs.
Brown thinks remote monitoring and coaching devices will revolutionize how patients interact with the health care system in much the same way that iPod has changed people's experience with the music industry.
"We are changing patients' experience with the health care system; we've changed it from being episodic to something that's chronic."
It can change the way clinicians practice medicine, said Jon Ehrman, associate program director of preventive cardiology at the Henry Ford Heart and Vascular Institute.
He is assessing the Health Buddy device for managing heart failure, comparing it with a traditional disease management program in which nurses call patients periodically to check on how they are doing.
Clinicians like the device, he said, and "have adapted their work day to incorporate the surveillance and response to the information on the HB [Health Buddy]."
Ehrman says preliminary results from his study on heart-failure patients are promising.
Patients show improvements in "functional status, quality of life indicators and a variety of clinical values."
It works for the bottom line as well: Their care costs nearly $140 less per month than for patients without the device.
Patients only take the device if they want to, and spend a few minutes a day interacting with it.
"Most are happy to use a device like this and gain some peace of mind that someone is watching over them," Ehrman said.
In his study, about 90 percent of patients respond to the device daily, more than 70 percent felt that it improved communication with their doctor, and more than four-fifths said they would use the device after the study if offered.
In some cases, an in-home monitoring device could let people with mental health diseases live independently, said Dawn Velligan, co-director of the division of schizophrenia and related disorders at the University of Texas Health Science Center.
She tested an electronic pillbox made by InforMedix that reminds patients when to take pills and records when, and if, patients take their medicines as instructed.
So far, Velligan, who receives consulting fees from InforMedix, has data from 10 patients.
"Adherence prior to study was around 50 percent, and with it it's 94 percent," she said, a statistically significant improvement.
The pillbox also asks patients whether they have completed basic daily tasks like brushing their teeth or getting dressed.
Remote monitoring devices are often part of disease management programs.
Not all of these programs place expensive monitoring devices in the home; instead, some rely on telephone interactions between patients and nurses at call centers to encourage patients to take care of themselves and to help them distinguish danger signals from acceptable fluctuations.
American Healthways, for example, uses remote monitoring devices for some programs, but not for others.
Stegall said she likes the concept of systems that ask patients questions, and that her vendor for monitoring devices, Philips Medical Systems, offers them, but says she wants to see more data before putting them in patients' homes.
For example, she says she wants to be sure that what a patient will tell a device is as reliable as what a patient will tell a nurse.
She expresses a similar attitude toward electronic pillboxes, which currently require clinicians to replenish medicine every month or so: "I don't think all the kinks are worked out yet."
Thukral says the technology still needs to overcome several barriers.
Legal issues can be uncertain.
For example, if the clinician and patient aren't in the same state, it's unclear which states' rules apply.
Privacy and security concerns are in worse shape, he said: "There are not many safeguards that currently exist to take care of the security and privacy of patient data transmitted between two sites.
"No authentication systems exist today to check if the data has been transferred to the right person as planned." (The companies interviewed for this article said that their data are encrypted and that clinicians use authentication procedures.)
Next Page: Hardware cost is a major barrier.
Hardware Cost is a
By most accounts, the biggest barrier is the cost of the technology and disputes about who should pay for it.
Many health care payers, including CMS (Centers for Medicaid and Medicare), are set up to reimburse physicians for procedures, not the monthly fees charged by disease management companies.
Ehrman's study and many others pay for the services through grant money, but that will stop once his study concludes.
Many health care payers are wary.
In a controversial report on the subject last year, the Congressional Budget Office concluded that while disease management programs might improve patients' health, there was no clear evidence that the programs saved money.
However, as Medicare costs skyrocket, CMS is exploring ways to keep down expensive hospital and nursing home care.
The bulk of Medicare costs come from chronic diseases, according to CMS.
Forty-three percent of Medicare spending goes for the 14 percent of Medicare beneficiaries with congestive heart failure; 32 percent goes for the 18 percent of beneficiaries with diabetes.
"Helping people before they get to a crisis is really the hottest field in Medicare right now," said Health Hero's Brown.
But CMS doesn't want to pay for new services unless they prove their worth.
Late last year, CMS began a groundbreaking experiment.
It is set to cover some 180,000 chronically ill patients in 10 regions chosen for their high enrollment of patients with chronic diseases.
In each region, some patients will be enrolled in a so-called chronic care improvement programs, which monitor patients and encourage them to follow health guidelines and get necessary preventive care; they may or may not use remote monitoring devices.
Companies that manage these patients will not be paid unless they can demonstrate at least a 5 percent cost savings over a randomly matched control population in the same region.
The savings are expected to come mainly from fewer hospitalizations and emergency room visits.
The most effective companies will have first crack at disease management contracts for millions of Medicare patients.
Key to the effective use of the remote monitoring devices is knowing exactly when patients benefit from having the costly devices at home.
Stegall said American Healthways, which has received contracts in two of the 10 CMS pilot regions, has evaluated patients with stable condition after equipment was removed from their homes.
"People have retained for more than six months the habit of weighing themselves and keeping their blood pressure under control," she said.
Ehrman of the Henry Ford Heart and Vascular Institute said his study is currently addressing the question of how long patients should have remote monitoring devices at their home.
"These patients will always have heart failure and always have the chance of hospitalization. What we don't know yet is how we can identify people who have learned well enough, either from the HB or via other means, that we can trust them to recognize when they are starting to get into trouble and act upon it."
Stegall said that the average length of time patients keep the devices varies, but that she tries to wean patients off the devices in six to nine months.
The ultimate goal, after all, is to help patients take care of themselves.
"It helps patients manage their own information. It's not a watchdog."
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