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Long-distance care 'Telenursing' project here brings treatment to patients in their homes via video Tuesday, August 10, 1999 By Christopher Snowbeck, Post-Gazette Staff Writer
It's not everyday that John W. Wherry III drops his drawers before a video camera so that pictures of his posterior can be zoomed from his home in Beaver County to a computer monitor in Anne Grzybek's office.
It only happens two or three times a week.
Grzybek is a nurse with Landmark Home Health Care of Hampton, which is caring for Wherry, 56. He's being treated for a pressure wound he developed on his backside during a nearly year-long hospitalization following a heart attack.
The video monitoring system -- dubbed "telenursing" -- provides nurses with a new way to monitor the wound as it heals. Though he receives daily home visits from a nurse who changes the dressing, the telenursing system can take pictures and forward the images to Wherry's doctor and insurance company.
Wherry jokes a bit with Grzybek about the technology.
"I keep telling Anne I want some 8 by 10 glossies so I can set up a stand at the mall and sell copies," Wherry said during a recent televised visit.
But they both think telenursing is part of home care's future, in which televised visits supplement in-person visits from nurses. For patients who don't need hands-on care, in fact, the televised sessions could replace in-person visits.
That worries some nurses who work in home care companies and wonder what telenursing means for their job security. The technology also could raise patient concerns about the privacy of their medical information as it gets beamed across phone lines and stored on computers.
But proponents say telenursing has been well received in other parts of the country, and they believe it will help reduce costs while improving home care.
"If you're using it to its maximum capacity, the effect it would have on your nursing productivity would make it worthwhile," said Janet Kavallo, administrator of In Home Health Services, a New Jersey home care company that has used telenursing technology for two years. "You may be able to reduce the size of your work staff, which nobody wants to hear.
"A nurse can only make sometimes six or eight visits per day," Kavallo said. "With this, you can make 10 or 15 visits per day."
Landmark's program is the first in the region. It is working with a Maryland company called VueCare to place telenursing machines in 300 homes around Pittsburgh by the end of the year. Seventeen patients are enrolled, said George E. Harris IV, VueCare's chief executive.
Most home care visits are paid for through the Medicare, while telenursing visits are not. ,So the Landmark pilot project is being funded with $150,000 from Highmark Blue Cross Blue Shield, which wants to study how the system affects costs.
VueCare's Harris said Highmark has contributed a start-up grant of about $150,000. Merck-Medco Managed Care, USX Corp. and Gateway Health Plan -- an HMO for Medical Assistance recipients -- are also partners in the program, although the exact nature of their involvement hasn't been fully spelled out.
VueCare is working with more than 15 doctors in the Pittsburgh area so that they have access to the technology, as well.
"They can use the technology to refer their patients into our program," Harris said. "More important, they can use the technology to access their patients and patient data."
As Medicare and other health plans move to "capitated" reimbursement systems, in which health-care providers receive a set sum of money per patient, home-care companies will be forced to work within set budgets for groups of patients. Telenursing could be the most efficient way to provide the care.
Landmark's program is one of the roughly 80 telenursing projects around the country.
Patients participating in the Pittsburgh program receive a TV monitor and camera in their home at no cost. The primary camera unit costs about $600 and the monitor another $200. A secondary camera is installed in just the right spot in a patient's home to zoom in on, say, a wound -- costs less than $100.
Nurses arrange for a telenursing visit in advance and then phone a patient moments before the scheduled appointment. With the advance warning, patients know that the next time their phone rings, they should "answer" by using a remote control that turns on the telenursing system. When the patients feel ready for prime time, they can press a big green button on the remote to turn on the cameras.
Patients see a nurse on their TV screen, while a nurse in Hampton sees the patient on her computer. Nurses can check blood pressure and temperature and listen to a patient's heart through the system.
Landmark has only been working with the technology for a few weeks, but one thing about the images transmitted through the telenursing unit is clear: The picture isn't.
"It looks like a badly filmed foreign movie," said Wherry, the patient from Hanover Township in Beaver County.
There's a delayed motion to the image that produces a blurry, shifting picture whenever someone on either end of the system moves.
But the snapshot nurses can take with the system is clear enough to closely examine stitches on a wound -- or, for example, the "M" on an M&M candy.
Wherry suffered a heart attack in May 1998. He spent the next three months recovering at Allegheny General Hospital before going to a rehabilitation hospital for another seven months.
"I developed a bunch of infections, and my kidneys failed," Wherry said. "They had to put me on dialysis. Fortunately, we fought off the infections and my kidneys started working again -- they called me the miracle man."
It was during the many months of hospitalization that Wherry developed the bed sore. He expects it will be healed by the end of the month, at which point his nursing visits -- both in-person and on-camera -- will end. Wherry has used telenursing for about six weeks.
"There's no technology yet to change my dressing over the television," Wherry said. "But if I didn't need to get that done, they could still monitor me. ... If I would have any kind of emergency, I could call them or they could call me."
Kathryn Dansky, a nursing researcher at Penn State University who works on a telenursing project in Philadelphia, said the technology lets nurses teach patients self-management skills without having to drive to the patients' homes.
A nurse might be dealing with an elderly diabetic patient, for example, who has bad eyesight. The nurse may have already taught the patient how to give himself insulin, but with the television system the nurse can watch the patient draw up the insulin, show the dosage over the camera and then make the injection. With the technology, a nurse can supervise and train patients or their caregivers on how to change dressings on wounds using the proper sterile techniques.
Barbara Johnston, a researcher with Kaiser Permanente's telenursing project in California, said the technology also has promising applications for hospice patients. Johnston said that a 1997 study of 200 patients with the Kaiser Permanente HMO showed that patients receiving a combination of telenursing and traditional home care visits fared as well as patients who received only traditional visits.
Johnston said telenursing gives nurses more flexibility and certainty in scheduling appointments because they don't have to worry about the time spent in a car driving from one home to another.
"We were surprised to find out that patients like using this," Johnston said. "We thought they would find this cold-hearted and not as nurturing. ... But people actually are very open to it."
Patients say they like the technology so long as it supplements the care they receive. If it were to replace actual visits, patients might feel differently.
"There's no doubt that you would rather have someone in person," Wherry said. "But this would be better than no contact."
Before telenursing is widely practiced, proponents will have to clear a few hurdles.
The first is opposition from nurses who already work in the home care companies. Johnston, for example, said this was a problem for Kaiser Permanente.
"You have to be careful that you're not taking what would be a nursing task and allocating that to someone with lesser skills," said Dansky, the Penn State researcher.
Another potential problem -- that exists with telemedicine as well as electronic medical records and other potential advances -- is that patients might become concerned about the growing use of computer systems that store medical information.
"You can send a picture, text, a report to whomever you need to," said Dr. John Benitez, an emergency medicine physician at the University of Pittsburgh Medical Center who has studied telemedicine. "From a consumer's standpoint, there's going to be a worry -- who's going to be getting a picture or text of me?
"I think it's a perceived problem, but I don't know how real it is."
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