Unintended Consequences: How Telehealth Can Fail to Manage Chronic Diseases

Kavita Radhakrishnan, RN, PhD, and assistant professor at the University of Texas at Austin School of Nursing

Kavita Radhakrishnan, RN, PhD

In my last blog, I illustrated the potential benefits of telehealth in managing chronic diseases in the community. In this blog, however, we will see how telehealth can fail to achieve its intended objectives.

1.   Financial benefits?

A home health agency (HHA) expects a steady return on investment (ROI) on the telehealth units in the long term through reduction in nurse utilization costs, but that is often not the case. Many telehealth devices are yet unable to distinguish between genuine vital sign fluctuations and false alarms. Home health nurses have reported increased nurse visits and phone calls owing to the need to check on patients after every alarm triggered by telehealth, especially for patients with complex chronic diseases such as heart failure. Increased nurse workloads without meaningful follow-up interventions can increase nurse frustration with telehealth equipment and, consequently, reduce use of expensive telehealth devices for patients.

Telehealth devices are expensive, averaging around $5,000 per unit. In addition, frequent updates of outdated telehealth devices due to changing telecommunication means used by patients (cell phones or VOIP) further increases the telehealth maintenance expenses for a home health agency (HHA).

Reduction in hospitalization?                                                                                                

Patient co-morbidities such as atrial fibrillation or circulatory issues play a significant role in clouding the accuracy of telehealth measurements. For some patients with complex chronic diseases, there is no prior indication provided by telehealth before hospitalization. For example, weight changes may be too late to signify deterioration in heart failure; more sensitive measures such as cardiac impedance are needed to capture early deterioration.

In addition, unclear communication protocols between health-care providers may result in confusion over ownership of telehealth data and the resultant responsibility towards initiating follow-up interventions. Delayed interventions may increase the odds of patient hospitalizations. The telehealth system is still primitive in its ability to present data in a meaningful manner. Physicians and home health nurses who make decisions on care regimen changes are overwhelmed by the deluge of telehealth data. “Data fatigue” may further reduce the efficiency of telehealth for managing chronic diseases.

2.   Sense of security or intrusive?

Some patients perceive the numerous phone calls or visits in response to every telehealth alarm as obtrusive and intrusive to their privacy. Home health patients increasingly use cell phones over landline telephones. To cope with patients’ changing telecommunication means, telehealth devices are placed at locations that are aesthetically unattractive or are dangerous due to increased patient fall risk. Visual perception of fluctuating telehealth vital signs worries patients with anxiety disorders, which may adversely impact their health status or ability to self-care.

3.   Promotion of self-care or dependency?

Current home health reimbursement policies require that telehealth devices be removed from patients’ homes at the time of discharge. However, home health patients with complex diseases at times get too dependent on telehealth. They feel vulnerable without the constant assurance of someone checking on their vital signs every day. Patients may stop notifying their physicians of adverse symptoms assuming the telehealth nurses would do so on their behalf. Such patients may need to be weaned off telehealth to foster more independence in their self-monitoring before discharge from HHAs.

These are just some of the issues that expose the need for extensive research on systemic usability and decision support solutions to make telehealth a workable and efficient technology to manage chronic diseases in the community.

—Kavita Radhakrishnan, RN, PhD, MSEE, assistant professor

6 thoughts on “Unintended Consequences: How Telehealth Can Fail to Manage Chronic Diseases

  1. I totally disagree with your comments on the validity of remote patient monitoring and how it would be detrimental to patients. Your comments are unsubstantiated and quite frankly lacking in good solid evidence and understanding of what the current ability of remote patient monitors can and can’t do in the home health setting. The cost of monitors is nowhere near 5000.00 dollars anymore and more like 40.00/month. The 30 day re-hospitalization rates of successfully monitored CHF and post MI patients is in the single digits for most home health agencies, and the increase in PRN visits due to false negatives and positives is almost non-existent when monitored and triaged correctly. I respect your opinion as a professional and I invite you to look deeper into the technology that is backed by hundreds of scientific articles and objective studies proving otherwise. I do agree that in some cases the technology is not beneficial at this time but in the case of home health patients there is plenty of room for the systems and much benefit for both patient and home health agency.

    • Thank you for your response, Mr.Garcia. I welcome this opportunity to engage in a dialog about this topic.

      Recent high-quality randomized controlled trials are some examples of good solid evidence that have failed to establish conclusively that home telehealth reduces 30-day hospitalization rate especially for patients with heart failure (HF) (Pekmezaris, 2012; Wade, 2011; Takahashi, 2012; Gellis, 2012). Having said that, I do agree that telehealth can play a part to reduce hospitalization rates for certain home health patients, especially patients with less severity (Pekmezaris, 2012) (See my earlier blog http://blogs.utexas.edu/nursing/2013/03/18/can-telehealth-improve-chronic-disease-outcomes-in-the-community/).

      However, like you pointed out in your response that telehealth is not beneficial in some cases, the above blog pointed out conditions when telehealth may not be effective, especially for frail elderly patients or patients with complex combination of chronic diseases and co-morbidities. For home health patients, it is still unclear what aspects of a telehealth intervention contribute to good patient outcomes (Desai, 2012). Maybe a good disease management program and care coordination protocol that utilizes telehealth as one of their tools is the answer to good patient outcomes. However, it would be misleading to promote telehealth to home health agencies as the sole or key factor contributing to reduced hospitalizations for all patients with chronic diseases.

      Homecare nurses have reported frustration with increased workload related to managing telehealth alerts (Wade 2011; Johnston, 2010; Radhakrishnan, 2012). In my retrospective study and another study, less than 3% of telehealth alerts were associated with key medical events such as hospitalization, ER visit or medication titration rates (Radhakrishnan et al, 2013; Biddiss et al, 2009). While management of telehealth alerts can be outsourced to telehealth service provider companies such as yours, home health agencies are still liable to clinically intervene based on information from the telehealth alerts.

      Home health agencies that were early adopters of telehealth technology and had purchased early models of telehealth equipment may find cost of upgrades prohibitively expensive. Also while the $40.00/month rental fees may be a reasonable cost model, it may not take into account other add-on fees such as on-site staff, coordination among healthcare providers who clinically intervene based on telehealth data or interface of telehealth data with home health EHR etc. Here is more recent evidence on telemonitoring in eight rural home health agencies where — although the telemonitoring group received fewer nursing visits per episode than the control group — cost analysis data; including labor, travel, and equipment costs, failed to support the hypothesis that decreased utilization of skilled nursing visits alone could offset the costs of the telemonitoring technology (Hansen, 2011).

      I agree that telehealth can be a valuable adjunct to good home health disease management when monitored and triaged correctly. While telehealth technology could potentially benefit home health agencies, there is still plenty of room to improve this technology. My blog was an attempt to illustrate those aspects of telehealth technology that need to be improved upon, to make it more effective in the home healthcare setting and deliver better quality care to home health patients.

      References:
      Biddiss E, Brownsell S, Hawley M. (2009). Predicting need for intervention in individuals with congestive heart failure using a home-based telecare system. Journal of Telemedicine and Telecare, 15(5):226.
      Desai, A.S. (2012). Home monitoring heart failure care does not improve patient outcomes: looking beyond telephone-based disease management. Circulation, 125(6):828-36.

      Gellis, Z.D., Kenaley, B., McGinty, J., Bardelli, E., Davitt, J., Have, T.T. (2012). Outcomes of a Telehealth Intervention for Homebound Older Adults With Heart or Chronic Respiratory Failure: A Randomized Controlled Trial. The Gerontologist, 52(4):541–552.

      Hansen, D., Golbeck, A.L., Lee, k., Noblitt, V., Pinsonneault, J., Christner, J. (2011). Cost Factors in Implementing Telemonitoring Programs in Rural Home Health Agencies. Home Healthcare Nurse, 29(6):375-82.

      Johnston, G., Weatherburn, G. (2010). Automated weight monitoring in chronic heart failure: The excluded majority. Journal of Telemedicine and Telecare, 16(4):190-192.
      Pekmezaris, R., Mitzner, I., Pecinka, K.R., Nouryan, C.N., Lesser, M.L., Siegel, M., et al. (2012). The impact of remote patient monitoring (telehealth) upon Medicare beneficiaries with heart failure. Telemedicine Journal and EHealth, 18(2):101-108.
      Radhakrishnan, K., Jacelon, C., Roche, J. (2012). Perceptions on the use of telehealth for Heart failure by homecare nurses and patients: A mixed method study. Home Health Care Management & Practice, 24(4):175-181.
      Radhakrishnan K, Bowles KH, Hanlon A, et al. (2013). A retrospective study on patient characteristics and telehealth alerts indicative of key medical events for heart failure (HF) patients at a home health agency. Telemedicine Journal of EHealth. [Epublication ahead of print Jun 28, 2013]

      Takahashi, P.Y., Hanson, G.J., Pecina, J.L., Stroebel,R.J., Chaudhry, R., Shah,N.D., et al. (2010). A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study. BMC Health Services Res, 10:255.

      Wade, M., Desai, A., Spettell, C., Snyder, A., McGowan-Stackewicz, V., Kummer, P., et al. (2011). Telemonitoring with case management for seniors with heart failure. American Journal of Managed Care, 17(3):e71-9.

  2. Great job Dr. Rahhakrishnan! I really appreciate your perspective on the unintended consequences of technology in home health settings! Totally agree with you- to my opinion, at the current state, the technology is not there yet in terms of usability, lack of appropriate home health relevant contents etc. Also, I loved your interesting point on increasing dependence… indeed, all those REQUIRE further investigation!

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