Renal Telemedicine to the Home

JG Mitchell*, APS Disney** and M Roberts**

*John Mitchell & Associates, Sydney, Australia
**The Queen Elizabeth Hospital, Adelaide, South Australia

Acknowledgement: This case report appeared in the Journal of Telemedicine and Telecare, Royal Society of Medicine, Vol 6, No.1, 2000

Introduction

At The Queen Elizabeth Hospital (TQEH) in Adelaide, South Australia, suitable patients are trained in the Home Dialysis Unit before commencing dialysis at home. However, patients often find home dialysis stressful, particularly if unexpected problems occur. We report a patient who was keen to succeed with home dialysis and became distressed when he had to be re-admitted to hospital, to dialyse. Coupled with the expected depression associated with the diagnosis of severe intractable cardiac failure, there was some doubt as to whether the patient could remain on home dialysis.

The patient was a 64 year old male with ischaemic heart disease, who dialysed at home, assisted by his wife. The patient dialysed three times per week, for 4.5 hours each time, and while he was dialysing normally received a telephone call from nurses in the Home Dialysis Unit. The patient lived in Marion Bay, a small seaside town on the east coast of Yorke Peninsula, 320 km from Adelaide.

Prior to the installation of home telemedicine equipment, the patient was frequently admitted to TQEH, for periods lasting days or weeks, related to cardiac failure and chronic chest, abdominal and kidney pain, see Table 5. Each admission involved a seven-hour, 640 km round trip, for the patient and his wife.

Case report

Videoconferencing equipment, operating on the ordinary telephone network, was installed in the patient's home on 10 March 1998. A standard PC was used, with a commercial videoconferencing package (Business Video Phone, Intel) and a modem for connection to the Internet.

The telemedicine link was used routinely during each home dialysis session and was also used on request by the patient. On one occasion during the three month study period, the patient felt particularly unwell, and rang the Home Dialysis Unit to request a videoconferencing link. The subsequent conference lasted for over an hour, during which time the nurses counselled the patient and called a renal unit registrar. The patient and his wife felt it was "as good as being in the dialysis ward" in terms of support. The patient's wife said the visual link was "very supporting for me" and both felt the visual connection invaluable. The patient's wife said:

"It gives us a lot of confidence. When there's a particular thing wrong, the staff can see it. We don't have to explain. It's very good for us to know that they can see it. It's better than a phone call. We can see their facial expressions and they can see ours."

After three months the patient was able to use the technology without his wife's assistance and they found the only barrier to the communication was that the sound was sometimes "grainy". They found the technology easy to use and reliable, and were satisfied with the level of privacy it offered. The main difficulties they identified at the start of the project were that the unit was on too high a stand and they found awkward the time lapse between the voice being transmitted and the image changing. After three months, the main difficulty was getting the light right for a good picture, at their end. They rated the mobility of the equipment very high in two questionnaires, the sound quality average on both occasions, and the image quality they rated average at the start and average-very good after three months.

The patient, his wife and the two renal dialysis nurses at the TQEH were interviewed on three occasions, using a 10 point interview schedule: at the start, after one month of operation and after three months. A summary of the patient's experience is shown in Table 2

Table 2: Summary of the patient's experience with the technology

At the start Repositioned the videoconferencing unit in the room, with back to the sun
Practiced with the computer mouse (by playing card games)
Experimented with different colours for clothes and backdrop
After one month Made the viewing screen larger
Chose the optimum colours for clothes and backdrop
Built a shelf for the PC on a trolley
Raised the monitor height
Lowered the camera to eye height
After three months Still modifying the room to optimise the lighting
Beginning to use the Internet

and a summary of the nurses' attitudes is shown in Table 3.

Table 3: Summary of the nurses' attitudes

At the start Apprehensive about the quality and reliability of the equipment
Unsure about the benefits
Concerned that the patient would over-use the equipment
Understood the value of being able to see the patient's carer set up the blood pressure machine
Saw new possibility of more complex dialysis machine being put in patient's home, due to the patient's increased confidence with home
dialysis Keen to use headphones for privacy
After three months Keen to extend telemedicine to other home dialysis patients
Recognised the value of telemedicine for peritoneal dialysis patients
Had added headphones for privacy
Identified the main applications as patient interview, clinical consultation and education

During the study period, the staff and patient developed various procedures and protocols to improve the efficiency of their working arrangements, see Table 4.

Table 4: Procedures and protocols developed

Procedures and protocols Actions
User protocols Staff and patient agreed on who would ring whom, how often, when and for what purposes
Patient consent form for recording data, taking photographs and promotional/educational activities, was devised and implemented
Technical standards Image quality was optimised, particularly colour reproduction, by adjusting the lighting and colour backdrop in the patient's home
Audio quality was optimised by correctly positioning the microphones
Work procedures Calls to the patient's home were scheduled to coincide with the patient's dialysing times
Insurance for the equipment was arranged.

Because the manufacturer's user guide was poor, a training guide was developed, and a policy and procedures manual. The videoconferencing unit was judged to be effective, given the low transmission costs (the same as an ordinary telephone call). Users had the choice between optimising clarity and optimising movement, and selected the former, as the colour of the image was more important than coping with movement. Staff and patient accepted the limitations of the image and sound quality and worked to optimise these factors, by adjusting the height of the camera and the position of the microphone.

After three months, the staff indicated that they would like to see telemedicine extended to about half of their 15 home dialysis patients, mainly those in the country. They also saw value in some metropolitan patients having access to the technique. They saw potential for telemedicine to be used with peritoneal dialysis patients.

Discussion

Telemedicine to the home currently takes two main forms: videoconferencing or remote telemetry (e.g. monitoring of blood pressure and heart rate) via telephone lines. The major uses of telemedicine to the home are to replace house calls for elderly patients living at home. In these cases, telemedicine is predominantly for monitoring patients' well being and for providing advice, counselling and encouragement. Extensions of these types of uses include mental health or palliative care patients. (1,2,3)

In our study the patient and his carer identified a range of benefits of the telemedicine link. Most important, it saved a trip to Adelaide on one occasion when the patient experienced chest pains and severe cramp while on dialysis. Monitoring from Adelaide, via the telemedicine link, saw this crisis pass. The staff were surprised that they were able to use the telemedicine link so much for clinical matters such as monitoring the haemodialysis and blood pressure and checking on the appearance of the fistula. Other benefits included a sense of increased support; an ability to solve problems more easily and quickly; and a sense that help was more easily at hand than simply using a telephone.

There were significant cost savings for both the patient, in not having to travel to Adelaide for regular admissions, and to the health system, in avoiding in-patient services. In the 14 months preceding the trials, the patient was admitted to hospital 10 times. The cost of admissions to TQEH in the 3 months preceding the installation of the home telemedicine link was AUS $9,343, see Table 5. The costs of each admission varied, depending on the treatment required. The patient and his spouse also incurred additional expenses, including loss of income for the spouse, travel and accommodation costs.

Table 5: Patient's admission record prior to the home telemedicine link

Date admitted to the QEH Length of stay (days) Cost to the hospital (AUS$)
30 November 1997 5 1,524
22 December 1997 2 553
29 December 1997 2 365
12 January 1998 1 238
26 January 1998 3 708
5 February 1998 19 5,955
Total 32 9,343

After the equipment was installed in the patient's home, there were no further admissions.

The major costs of home telemedicine were the equipment, at about AUS$2,550 per site. An additional telephone line, if it had been required, would have cost approximately $250 to install. The call charges were the same as telephone costs, that would have been incurred anyway. Some extra time was required by staff to install and test the equipment.

The nursing staff generally felt that the regular videoconferencing link to the patient's home was a direct replacement for the regular telephone call that they made to the patient. The extra time the nursing staff spent on videoconferencing calls - for example, during a few serious incidents - resulted in a decision that the patient did not need to come to the hospital for treatment. If the patient had been admitted, the effect on the Renal Unit nurses' time would have been greater than the time spent videoconferencing.

Table 6: Summary of costs and benefits

Tangible costs For the patient Some additional phone calls to the hospital
For the hospital AUS$2,550 for the PC; AUS$250 for computer trolley
Staff training time: say, 2 staff x 2 hours each at AUS$25 per hour: AUS $100
Intangible costs For the patient none identified
For the hospital staff stress in coping with another innovation
Tangible benefits For the patient psychological support and reassurance available
visual link available quickly and cheaply
a 640 km round trip to hospital saved
For the hospital potential saving of approx. AUS$9,000 from no admissions (i.e. the cost of a similar admission rate in the three months prior to the trials)*
routine patient management (e.g. monitoring blood pressure, counselling, provision of advice)
management of a serious situation (e.g. chest pains and severe cramp)
consultations by a range of staff (e.g. nephrologist, palliative care doctor, social worker)
Intangible benefits For the patient rise in confidence and self-esteem, and pleasure in living
support for the patient's spouse
For the hospital encouragement for the staff

* The cost savings are based on the estimated saved trips to hospital, using the three months prior to the telemedicine trial as an indicator of the possible level of admissions and costs.

The trial provided proof of the value of a visual link. For instance, when the patient had problems with measuring his blood pressure, a video call to the Home Dialysis Unit enabled the nursing staff to see that he was using the equipment incorrectly, hence solving the problem. The success of the trial led to installation of equipment in the home of a second patient, who lived on the River Murray, near Waikerie, 177 km north east of Adelaide. The software and hardware were also loaded onto the home computer of the senior nephrologist who manages the dialysis patients.

In summary, the use of telemedicine to the home of a dialysis patient 320 km from Adelaide was very successful in enabling the patient to stop the frequent hospital admissions that had been occurring. The patient and his carer felt that the videoconferencing link to the hospital provided them with significant and improved service. The equipment operated over an ordinary telephone line and provided video images that were good enough for counselling, guidance and reassurance. The equipment could be used by staff to observe patients and their carers carrying out procedures such as haemodialysis and measuring blood pressure. In emergencies, as happened on one occasion, the telemedicine link could be used for clinical observation of the patient.

References

1. Fisk, M.J. Telecare at home: factors influencing technology choices and user acceptance. Journal of Telemedicine and Telecare, 4:2, 1998, pp.80-83

2. Kinsella, A. Home telecare in the United States, Journal of Telemedicine and Telecare, 4:4, 1998, pp.195-199

3. Wootton, R., Loane, M., Mair, F., Moutray, M., Harrisson, S., Sivananthan, S., Allen, A., Doolittle, G, and McLernan, A. The potential for telemedicine in home nursing, Journal of Telemedicine and Telecare, 4:4, 1998, pp.214-218