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Assessing Quality of Telehealth: Home Heart Failure Care Comparing PatientDriven Technology Models R


Assessing Quality of Telehealth: Home Heart Failure Care Comparing PatientDriven Technology Models R – PowerPoint PPT presentation

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Title: Assessing Quality of Telehealth: Home Heart Failure Care Comparing PatientDriven Technology Models R

Assessing Quality of TelehealthHome Heart
Failure Care Comparing Patient-Driven Technology
ModelsR01 HS015459
  • Lee R. Goldberg, MD, MPH
  • Associate Professor of Medicine
  • Heart Failure/Transplant Program
  • University of Pennsylvania
  • September 27, 2007

What is Quality?
  • Perspective who is interested?
  • Patient
  • Provider
  • Payer
  • Health Care Institutions
  • Society
  • Cost (only reduction in costs or effectiveness?
    Total vs. Hospital?)
  • Quality of Life
  • Improved adherence to Evidence Based Medicine
  • Safety - improved or not worsened?
  • System performance Does the technology perform
    as designed or intended?
  • Improved survival

Competing Interests
Heart Failure A Good Target for Disease
  • Common chronic disease
  • High costs direct and indirect
  • Decreased quality of life
  • High mortality
  • Extensive research to guide therapy
  • Appropriate therapies extend life and improve
  • Therapies are challenging to use and implement
    in this high risk population
  • Technology available to monitor

Factors for Successful Implementation of a
Telemedicine System for Heart Failure
  • Prompt consistent response to received patient
    data to provide rapid feedback
  • Clinical algorithms that include action plans
    that avert negative consequences in response to
    an alert situation
  • Patient trust of the system and its clinicians
  • Reliable, easy to use technology
  • Notification to clinicians of missed data

Barriers to Successful Implementation of
Telemedicine Interventions
  • Reimbursement for supervision of telemedicine and
    disease management systems
  • Trained clinicians to manage the data and the
  • Mechanisms to consistently and reliably review
    patient data and alerts
  • Development of appropriate algorithms to respond
    to patient data in a manner that improves patient
  • Medical-legal liability for data collected
  • Professional licensure across state lines
  • Lack of evidence for types and frequency of
    patient data collected and impact
  • Clinicians fear of being replaced by technology
  • Physician acceptance

Lingering Questions
  • Type of technology - Intensity
  • Is simple better? scale versus implantable
  • Is there too much data? can we hurt people by
    responding too quickly?
  • Dose of technology
  • Daily monitoring necessary?
  • Duration of intervention
  • How long to continue?
  • Withdrawal effect or do patients learn?

Our Study
  • A study comparing 3 different care models of
    outpatient heart failure care
  • Usual care
  • Electronic monitoring (scale, BP cuff, questions,
    /- glucometer) with nurse case management
  • Electronic monitoring with self-management
    interactive voice response system

Our Primary Hypotheses
  • Both electronic disease management strategies
    will be superior to usual care in reducing
  • The patient self-management electronic disease
    management arm will not be inferior to nurse case
    management disease management arm

Our Secondary Hypotheses
  • Quality of life will be improved for the
    patients in the electronic disease management
    arms as compared to usual care
  • Quality of life will not be different between
    the two electronic disease management arms
  • Adherence to heart failure guideline care will be
    improved in the electronic disease management
  • Self Management will reduce the cost of HF care
    more than Case Management by eliminating the cost
    of nursing case management.

Our Secondary Hypotheses
  • Assessment of Self Management patients vital
    signs and symptoms by the expert clinical
    decision support system, coupled with tailored
    self-care algorithms, will improve patients self
    efficacy in the management of their disease more
    so than in patients in the Case Management group.
  • Self Management and Case Management patients will
    have greater satisfaction with care than Standard
    care patients.
  • Physicians satisfaction will be higher with Self
    Management and Case management approaches to
    patient management than Standard care.

Measured Outcomes
  • Hospitalizations for HF, cardiovascular and all
  • Hospital length of stay (LOS)
  • ER visits for HF, cardiovascular and all causes.
  • Survival, mortality and fatal and nonfatal
    myocardial infarctions
  • Self-efficacy in management of heart failure as
    well as HRQoL and its dimensions assessed by the
    Kansas City Cardiomyopathy Questionnaire
  • Acute care visits to physicians.
  • Satisfaction with care

Our SitesGeographically and Population Diversity
  • University of Pennsylvania, Philadelphia, PA
    Coordinating Center
  • Urban and suburban practices in and around
    Philadelphia metropolitan region
  • Charleston Area Medical Center, West Virginia
  • St. Vincents Health Care, Billings, Montana
  • Indian Health Service Montana
  • University of Louisville Data Coordinating

Inclusion Criteria
  • Documented HF (systolic, with lt45 LVEF, or
    diastolic dysfunction with normal LVEF) via
    echocardiogram, MUGA or coronary angiography
    within the last 18 months.
  • Male or Female gt/ to 18 yrs of age
  • Working telephone
  • Cognitive ability to use equipment
  • Ability to stand unsupported for 20 seconds
  • NYHA classification of II IV (verified by CRC
    at enrollment.)
  • HF managed by a primary care physician, internist
    and/or cardiologist.

Exclusion Criteria
  • Life expectancy less than 6 months or Hospice
  • Outpatient inotropic therapy (Milrinone,
  • End stage renal creatinine gt/ 3.0
  • Patient non-competent or unwilling to provide
    voluntary consent
  • Weight gt 350 lbs
  • Detailed current disease management program

  • Shipped to patients home
  • Connected to phone line
  • Equipment identical for the two technology arms

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ImplementationDesigning the Intervention
  • Designing the IVR for the electronic only
    disease management arm
  • Sensitivity versus specificity
  • Consensus on the clinical content
  • Review by experienced heart failure clinicians
  • Patient focused
  • Easy to use
  • Easy to understand
  • Short and to the point
  • Safe
  • Many concerns and delays during the design phase

ImplementationSafety Pilot of the IVR
  • Given challenges with the IVR safety pilot using
    simulated patients was performed
  • Members of IRB
  • Family members of study staff
  • AHRQ staff
  • Multiple technical and clinical issues
    idenitified and corrected
  • Delayed enrollment but improved safety and
    understanding of a new patient management system

ImplementationVendor Issues
  • Technology up-time
  • Many technical issues with IVR
  • Many technical issues with servers, phone lines,
  • Troubleshooting with subjects and providers
  • Support for installation
  • Support for problems
  • Equipment issues
  • Defective
  • Batteries
  • Availability of vendor on off hours

General Vendor Considerations
  • Privacy HIPAA issues
  • Service guarantee
  • System monitoring continuous?
  • Approved equipment (FDA/FCC)
  • Support hours
  • Interface issues
  • Fax
  • Web
  • E-mail
  • Pager (text messaging)
  • Integration
  • ?EMR interface

Telehealth Implementation Issues
Farberow B, Hatton V, Leenknecht C, Goldberg LR,
Hornung CA, Reyes B. Caveat Emptor The Need for
Evidence, Regulation and Certification of Home
Telehealth Systems for the Management of Chronic
Conditions, AJMQ in press.
Telehealth Implementation Issues
Farberow B, Hatton V, Leenknecht C, Goldberg LR,
Hornung CA, Reyes B. Caveat Emptor The Need for
Evidence, Regulation and Certification of Home
Telehealth Systems for the Management of Chronic
Conditions, AJMQ in press.
ImplementationOvercoming Provider Resistance
  • Providers (practices) concerns
  • Too much time to review data/alerts
  • Coverage during day and on nights/weekends/holiday
    s critical labs
  • Medical-legal concerns about responsibility for
    data where and how to document
  • Educate to respond (not just file)
  • Educate to respond appropriately
  • Comfort with adjusting medications over the phone
  • Use of extra visits/ER when appropriate only
  • Learning curve observed with most clinicians

  • Phone line (land line)
  • Not cellular only
  • Not Voice over internet (VOIP)
  • In the home? (or access daily nearby?)
  • Ability to install equipment
  • Ability to hear and see well enough to use the
  • Ability to stand on the scale

  • 134 subjects randomized
  • About 33 have completed 12 month follow-up
  • About 50 have completed 9 month intervention

  • Several technology related challenges
  • Server down
  • Communication down
  • IVR errors
  • Provider issues
  • too many alerts in IVR arm
  • Educate around adjusting parameters to make
    alerts meaningful

  • Seem to prefer the nurse case management arm
  • Interacting with a person
  • Nurses identify other issues that may increase
    cost but improve either quality of care or
    patient satisfaction
  • Battery replacement
  • Accuracy of scale questioned
  • Technical due to carpeting and scale placement?

Early Results
  • Many anecdotes from call center, providers and
  • Identified serious medication errors
  • Intervened to avoid ER or hospitalization
  • Identified several educational opportunities
  • Missed data transmission is an important
    parameter to be followed
  • Nurse Case Managers seem to promote patient
    self-care and encourage patient-clinician
  • IHS group many more hospitalizations and ER
    visits in all arms

  • Several barriers to implementation of telehealth
  • Provider
  • Vendor
  • Subject
  • Despite this our early results look promising
    with both technology arms performing well
  • Desperate need for vendor regulation,
    standardization and/or certification
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