Pros and cons of telehealth for medication management

The Royal District Nursing Service (RDNS) is continuing its trial of video conferencing technology to manage medications for older people in their homes following a decision by Intel to withdraw its Home Guide device from sale in Australia.

RDNS clinical nurse lead for telehealth projects, Carol Towers, told the Australian Centre for Health Innovation annual conference in Melbourne last week that RDNS is currently in talks with other suppliers of similar technology to provide an alternative.

RDNS has been running the trial since May 2012. In April this year, the project won the Outstanding ICT Innovation award in the Asia Pacific Eldercare Innovation Awards 2013 in Singapore.

The project is currently in a formal evaluation phase with La Trobe University, and in the meantime participants are continuing to receive the service.

The trial involves a daily video conference through the Intel device with clients in their home, in which they are prompted to take their medications. A nurse at the RDNS call centre in Melbourne observes the client as they take their meds, and checks the medications pack to ensure it is correct.

“When the nurse makes the call, she brings up the Intel Health Care Management Suite and identifies the client and presses the call button, which initiates the call to the client,” Ms Towers said.

“At the client's end, the device flashes a light and makes a sound so the client can hear the call coming in. The nurse will ask how they are feeling and do a general assessment of the client and they are prompted to take their medications.”

As part of the trial, nurses take an eHistory of the client using RDNS' Camillus client management software program. A photo of each client is taken and attached to their record on Camillus, as some of nurses have not seen the client in person.

“We needed to identify that the right person was being given advice,” Ms Towers said. “We do a lot of nursing care plans so we did a medications plan, so [the nurse] can bring up what medications they are on along with the medication authority. Then they could put notes into Camillus as well.”

Ms Towers said the objective of the trial was to look at an alternative service delivery model via remote video conferencing for medications management.

“We wanted to see if we could empower the clients to take control of their medications management,” she said. “We also wanted to demonstrate whether it was appropriate, but also to look at the technical limitations in using video conferencing for medications management.”

RDNS is also evaluating the feasibility of rolling it out throughout the organisation. This trial involved clients in three sites, each of whom would normally receive a daily visit from a district nurse.

That physical visit has been reduced to once a week, with the other six days involving a video call. Ms Towers said nurses' travelling and face to face time had been reduced from an average of 4.2 hours a week to two.

The trial received funding from the Victorian Government’s Broadband Enabled Innovation Project (BEIP) and the Department of Business and Innovation, along with Telstra and Healthe Tech, which supplied the Intel devices.

Participants were provided with the device and a broadband plan – either using ADSL2+ or a 3G/4G dongle – for free. They were also able to reduce the fees paid to RDNS for daily home visits, which normally would cost about $38 a month.

Positives and negatives

Ms Towers said RDNS had conducted surveys of clients and staff before the trial. For clients, many said they weren't sure if they could manage the technology but they were all willing to give it a go.

“One positive was that they thought it might allow them more freedom,” Ms Towers said. “By giving them a time that the nurse would call, they wouldn't have to wait around for two hours for the nurse to come. You have a call at 10 o'clock in the morning and then you're free and you can do what you want to do for the rest of the day.

“The negatives were they weren't sure if they'd like it, and a lot of them had never used computers before and were unsure of how they'd manage.”

Before the trial, some staff said they were undecided if it would be a positive experience for clients, Ms Towers said. “They also thought it would be harder to assess the situation in the home through video conferencing. They weren't sure if it would be effective for medications management.”

She said the trial also wanted to assess if by doing medications monitoring by video, nurses could then spend more time with more complex clients. “Some days it feels like you are driving by and throwing tablets out the window because you have so many clients that you have to see before 10 o'clock in the morning,” she said.

In terms of IT, “the positives were that when it worked, it worked really well,” she said.

“The clients actually learned to reboot their routers. Like most things there were times when they had to shut it down and reboot it and they found the Intel Guide was easy to use.

“One interesting thing was that the device is such an unusual looking thing, that it would act as a prompt for the clients to take their medications. When it called, that was the time for their medications.

“One of the challenges was that the server was based in the US, so if they (in the US) rebooted, it was usually at a time when it was our client contact time. It would be nine o'clock in the morning and we'd lose contact with our clients during a call. We discovered that quite early and were able to resolve the situation.”

She said the ADSL connection was affected by demand, especially at nine o'clock in the morning when schools came online and there was more competition for bandwidth.

Case studies

Ms Towers described the experience of two clients, both elderly women living alone. One, a 94-year-old with anxiety, osteoporosis, hypertension and memory loss, had been referred to RDNS mainly for medication management.

The client's family was happy for her to be on the trial, and took to calling the Intel device “the pill TV”, she said. This client now receives morning and evening calls as she is starting to forget to take her evening medications.

“The other lady was an 86-year-old who was living alone in Melbourne's outer suburbs. That is an area that is a high-risk fire danger category, and it is now a no-go zone. If it's a code-red day, the district nurses aren't allowed to travel to those areas, so we have to look at other ways of managing their care.

“She has a diagnosis of dementia and hyperthyroidism. She commenced on the 27th of December, and we had some extreme fire danger days in January and February. As a result of the video conferencing, there was no interruption to her care.”

Other anecdotal evidence for the worth of the trial include an instance involving an elderly brother and sister. The sister took the call from the nurse but when asked to fetch her brother, she told the nurse that he was on the floor and she couldn't help him up.

Ms Towers said the nurse at the call centre was then able to call an ambulance and continue talking to the sister until it arrived. Similarly, an elderly man complained of pain in one arm during a call, and again an ambulance was ordered.

One client in particular stood out, she said. This was a younger man with diabetes and mental health issues who disliked being visited daily by a nurse. Ms Towers said he far preferred to use video conferencing and his mental health had improved.

“He is much more animated when he talks to the nurses on the video call, and his case worker says it has changed his life.”

Lower cost options

RDNS is looking to further expand its use of telehealth, using different technologies that can allow conference calls. Ms Towers said she sees particular value in telehealth for providing expert advice to nurses in the field, and RDNS is currently developing an integrated telehealth project for a stomal therapy clinical nurse consultant and for wound care nurses as well.

While La Trobe University is still finalising its formal evaluation, the big question remains whether telehealth is a sustainable business for RDNS. Anecdotal evidence provided to Pulse+IT shows that the Intel devices and others like them can be very expensive – some costing up to $5000 – so there can be a large upfront investment required on the part of organisations looking at the technology.

However, Ms Towers said cost savings could be achieved through reduced travelling times and redirection of nursing care for more complex cases. She said the service would be sustainable if 250 or more clients were assisted in this way.

One of the keynote speakers at the conference was UK-based telecare expert Kevin Doughty, director of the UK's Centre for Usable Home Technology (CUHTec). Dr Doughty said RDNS and other groups looking at introducing similar telehealth services should refer to the UK experience, where these sorts of programs have been trialled over the last decade.

He urged the organisation to look beyond devices such as Intel's to far cheaper options.

“Buying boxes is not the solution; it is system redesign and minimal technology,” Dr Doughty said. “The question is whether you want to go down the same road as the UK did, making all of the same mistakes.”

He said one answer lay in the development of relatively cheap smart TVs with set-top boxes that could do the job of the Intel device for a fraction of the cost.

For example, the Centre for Usable Home Technology has investigated a set-top box technology developed by Red Embedded, which requires only a domestic broadband link to provide video calls via the television.

“The infrastructure required is the broadband,” Dr Doughty said. “That is the biggest investment and ultimately what will give the biggest return on investment.”

This article has been slightly edited from the original to emphasise that RDNS is continuing with the trial despite Intel's planned withdrawal from the market.

Posted in Aged Care

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