Showing papers on "Telehealth published in 2007"

Continua: An Interoperable Personal Healthcare Ecosystem

Abstract: The healthcare industry must improve its delivery methods and reduce costs to address current and anticipated needs. Various technologies could help by extending treatment and care beyond traditional clinical settings into personal and home settings. However, creating such a personal telehealth ecosystem will require interoperability. Device connectivity to enterprise services is currently very proprietary. In an effort to develop interoperability guidelines for the emerging personal telehealth ecosystem, we formed the Continua Health Alliance (www.continuaalliance.org), an international alliance of more than 133 companies. The guidelines will be based on a comprehensive set of industry standards, which will serve as a blueprint for integrating a product into the ecosystem.

Improving healthcare accessibility through point-of-care technologies

Abstract: Background: The NIH is committed to improving healthcare quality in the US and has set up initiatives to address problems such as the fragmented nature of healthcare provision. A hypothesis has been developed that testing closer to the point at which care is delivered may reduce fragmentation of care and improve outcomes. Methods: The National Institute of Biomedical Imaging and Bioengineering (NIBIB), the NIH’s National Heart, Lung, and Blood Institute, and the National Science Foundation sponsored a workshop, “Improving Health Care Accessibility through Point-of-Care Technologies,” in April 2006. The workshop assessed the clinical needs and opportunities for point-of-care (POC) technologies in primary care, the home, and emergency medical services and reviewed minimally invasive and noninvasive testing, including imaging, and conventional testing based on sensor and lab-on-a-chip technologies. Emerging needs of informatics and telehealth and healthcare systems engineering were considered in the POC testing context. Additionally, implications of evidence-based decision-making were reviewed, particularly as it related to the challenges in producing reliable evidence, undertaking regulation, implementing evidence responsibly, and integrating evidence into health policy. Results: Many testing procedures were considered to be valuable in the clinical settings discussed. Technological solutions were proposed to meet these needs, as well as the practical requirements around clinical process change and regulation. From these considerations, a series of recommendations was formulated for development of POC technologies based on input from the symposium attendees. Conclusion: NIBIB has developed a funding initiative to establish a Point-of-Care Technologies Research Network that will work to bridge the technology/clinical gap and provide the partnerships necessary for the application of technologies to pressing clinical needs in POC testing.

Applying research evidence to optimize telehomecare.

Abstract: Telemedicine is the use of technology to provide healthcare over a distance. Telehomecare, a form of telemedicine based in the patient's home, is a communication and clinical information system that enables the interaction of voice, video, and health-related data using ordinary telephone lines. Most home care agencies are adopting telehomecare to assist with the care of the growing population of chronically ill adults. This article presents a summary and critique of the published empirical evidence about the effects of telehomecare on older adult patients with chronic illness. The knowledge gained will be applied in a discussion regarding telehomecare optimization and areas for future research. The referenced literature in PubMed, MEDLINE, CDSR, ACP Journal Club, DARE, CCTR, and CINAHL databases was searched for the years 1995-2005 using the keywords "telehomecare" and "telemedicine," and limited to primary research and studies in English. Approximately 40 articles were reviewed. Articles were selected if telehealth technology with peripheral medical devices was used to deliver home care for adult patients with chronic illness. Studies where the intervention consisted of only telephone calls or did not involve video or in-person nurse contact in the home were excluded. Nineteen studies described the effects of telehomecare on adult patients, chronic illness outcomes, providers, and costs of care. Patients and providers were accepting of the technology and it appears to have positive effects on chronic illness outcomes such as self-management, rehospitalizations, and length of stay. Overall, due to savings from healthcare utilization and travel, telehomecare appears to reduce healthcare costs. Generally, studies have small sample sizes with diverse types and doses of telehomecare intervention for a select few chronic illnesses; most commonly heart failure. Very few published studies have explored the cost or quality implications since the change in home care reimbursement to prospective payment. Further research is needed to clarify how telehomecare can be used to maximize its benefits among diverse adult chronic illness populations.

An economic evaluation of telehealth data collection with rural populations.

Abstract: Objective: This study compared direct costs of conducting structured clinical interviews via real-time interactive videoconferencing (known as telehealth) versus standard in-person methods with American Indians in rural locations. Methods: Psychiatrists administered in person and via telehealth on two occasions the Structured Clinical Interview for DSM-III-R to 53 non-VA male, American-Indian veterans. Telehealth interviews were conducted by an integrated services digital network (ISDN) connection at 384 kbps. Direct costs were compared for the two interview modalities. Models for starting telehealth in new clinics and established clinics were created, and the models were further subdivided to examine 2003 and 2005 differences in transmission fees. Direct costs included transmission, personnel, travel, and equipment (where applicable). Results: The model of conducting interviews via telehealth in new clinics cost about $6,000 more than in-person interviews in 2003. However, reduced transmission fees and a different videoconferencing setup resulted in telehealth interviews’ costing $8,000 less than in-person interviews in 2005. The same pattern held true for the model for established clinics. Telehealth interviews cost $1,700 more than in-person interviews in 2003 but $12,000 less in 2005. Scenarios using nonphysician interviewers and current, rather than historical, transmission costs favored telehealth as a cost-effective means for clinical research. Conclusions: On the basis of current transmission costs, telehealth proved less expensive than in-person interviews. Telehealth may therefore increase the efficiency and decrease the cost of research with rural, remote, and underserved populations, facilitating the ease with which one can investigate health disparities in these otherwise neglected settings. (Psychiatric Services 58:830–835, 2007)

Home telecare for COPD/CHF patients: outcomes and perceptions.

Abstract: We evaluated the use of home telehealth for patients with chronic obstructive pulmonary disease (COPD) and/or congestive heart failure (CHF). Patients diagnosed with COPD and/or CHF who were prescribed home health-care services were randomly assigned to an experimental group where they received home health care through a combination of traditional face-to-face and telemedicine visits (n = 83), and a control group where only conventional home care was employed (n = 78). Data were collected via the Short Form 36 (SF-36), Outcome and Assessment Information Set (OASIS) and patient charts. In the experimental group, patient perceptions of the home telecare services were collected via telephone interviews. Overall, the addition of telehealth to COPD/CHF patient care was not a significant predictor of health and wellbeing, either positively or negatively. Although those receiving telehealth had worse ratings on the SF-36 general health subscale after the intervention, this measure was only significant when controlling for a number of key variables in the model. In regard to patient perceptions of home telecare, patients were satisfied with the technology and the way that care was delivered via this modality.

Smart Homecare System for Health Tele-monitoring

Abstract: An increasing aged population worldwide puts our medical capabilities to the test. Research and commercial groups are investigating novel ways to care for the aged and chronically ill both in their own homes and in care facilities. This paper describes a prototype we have developed for remote healthcare monitoring. This personalized smart homecare system uses smart phones, wireless sensors, Web servers and IP Webcams. To illustrate the functionality of the prototype we describe a series of typical tele-health monitoring scenarios.

Military and VA telemedicine systems for patients with traumatic brain injury

Abstract: Telemedicine plays a critical role within the Department of Veterans Affairs (VA) Veterans Health Administration by allowing the surveillance and care of patients who are isolated by geography, poverty, and disability. In military settings, telemedicine is being widely used to identify injury and illness and aid in the treatment, rehabilitation, and recovery of combat-wounded soldiers in theater. Rapid advances in both domains are transforming the way clinicians provide care, education, and support to patients with traumatic brain injury (TBI) and their families. This article discusses the military and VA telemedicine capabilities that are supporting the care of service members and veterans with TBI. These capabilities include new technologies that enhance the identification of TBI, management of symptoms in theater, and application of proven technologies (interactive video, Internet, and World Wide Web) to improve overall care coordination throughout military and VA systems. The impact of distance learning, teleconsultation, telerehabilitation, and home telehealth programs is also described within this context.

Telephone counseling to improve osteoporosis treatment adherence: an effectiveness study in community practice settings.

Abstract: Treatment nonadherence is a recognized problem, but most practice settings use education alone to address it. Psychological counseling methods generate greater behavior change but are not widely used. Telehealth nursing can be used to integrate these methods into routine clinical practice. This study was a nonrandomized trial of a telehealth program that used motivational interviewing and cognitive- behavioral techniques to improve osteoporosis medication adherence. Registered nurses delivered the intervention to 402 participants recruited from provider offices across the United States. Initial participation rates were high in this community-based sample, although attrition also was high. Six-month adherence based on pharmacy and clinical interview data was significantly higher than the general population rate. A comparison with nonparticipants approached significance, and there was a significant dose-response effect. Most reasons given for nonadherence were psychological. The results support the use of psychological techniques to improve adherence and the use of telehealth to disseminate evidence-based patient counseling.

The role of industry infrastructure in telehealth innovations: a multi-level analysis of a telestroke program

Abstract: The information-intensive nature of the healthcare industry and the potential of information technology (IT) to reduce costs and improve quality of services have increased the focus on IT-based innovations. Yet, our ability to understand and manage how IT-based innovations unfold in the context of healthcare is still limited. In this paper, we apply Van de Ven's industry infrastructure framework to investigate a telehealth innovation that provides remote medical assistance to stroke patients in a network of collaborating hospitals. The resulting multi-level analysis contributes to understanding the innovation by revealing a highly complex process of interactions between key stakeholders and healthcare industry infrastructure. Despite the innovation's strong potential, the process is mainly push-driven with minimal pull from potential adopters. Moreover, the push is created by a small group of medical innovators with limited technological and financial resources and little infrastructural support. The study contributes with contextual insights into the telehealth innovation, suggesting complementary explanations of why the healthcare industry despite considerable investments continues to lag behind other industries in adoption of IT-based innovations. The study also adapts Van de Ven's framework by applying it to a single case of innovation rather than as originally conceived to several instances of an innovation within an industry. The analysis shows how some of the components of the framework were adapted to and interpreted in the context of telehealth innovations.

Obtrusiveness of information-based assistive technologies as perceived by older adults in residential care facilities: A secondary analysis

Abstract: With the anticipated growth in the older adult population in the next few years, information designers are examining new ways for assistive technologies to support independent living and quality of life for adults as they age. Central to the role of assistive technology to support and enhance quality of life is the development of non-obtrusive technologies. Despite the importance of non-obtrusiveness to the design of assistive technologies, there remains no standard definition of obtrusiveness or measurement instrument. A conceptual framework for obtrusiveness in home telehealth technologies has recently been proposed but has not yet been tested empirically. This project performed a secondary analysis of focus group and interview data to explore the presence of the dimensions of the obtrusiveness framework in older adults' responses to information-based assistive technologies in residential care facilities. We found the existing data contained examples of each dimension (physical, usability, privacy, function, human interaction, self-concept, routine, and sustainability) and 16 of the 22 subcategories proposed by the obtrusiveness framework. These results provide general support for the framework, although further prospective validation research is needed. Potential enhancements to the framework are proposed.

Exploring the effects of telehealth on medical human resources supply: a qualitative case study in remote regions

Abstract: Background The availability of medical human resource supply is a growing concern for rural and remote communities in many countries. In the last decade, various telehealth experiences in Canada have highlighted the potential impact of this technology on professional practice. The purpose of this study was to explore physicians' and managers' perceptions regarding the potential of telehealth to support recruitment and retention of physicians in remote and rural regions.

Telehealth and the recruitment and retention of physicians in rural and remote regions: a Delphi study.

Abstract: Introduction The availability of a medical workforce is a growing concern for rural and remote communities across Canada. In the last decade, various telehealth experiences have highlighted the potential impact of this technology on professional as well as organizational practices. But could telehealth be a strategy to attract and maintain physicians in rural and remote communities? The objective of this study was to identify a reliable list of recruitment and retention factors on which telehealth could have an impact. Methods We conducted 2 literature reviews and a Delphi study among 12 telehealth experts across Canada. Results The literature reviews identified 7 categories of recruitment and retention factors on which telehealth could have an impact: 1) individual, 2) familial, 3) contextual, 4) professional, 5) organizational, 6) educational, and 7) economic. Conclusions Experts consulted through the Delphi study reached consensus on 31 out of 34 of the proposed statements about the impact of telehealth. This consensus can now be used as a conceptual model for further studies on the topic.

Telehealth in Context: Socio-technical Barriers to Telehealth use in Labrador, Canada

Abstract: Currently telehealth is being offered as an innovative solution to austerity, staffing issues and problems accessing care in Canada's rural communities. Despite the current enthusiasm for telehealth in provincial and federal policy documents, many of these promises have not been realized. The Labrador region is a large and sparsely populated area that was vested with a federal "Smart Community" project to increase the region's technological capacity, making it one of the most connected locales in the country. While telehealth was a key component of the SmartLabrador plan, there has been limited uptake of newly available technologies for the purposes of mediating distance in health care. My work critically examines the factors surrounding this lack of uptake, and takes the work of Harold Innis as a starting point when analyzing the breakdown of time and space in Labrador. Focused around qualitative field research conducted in Labrador in 2003, I explore spatialization, structuration and work practice as they relate to telehealth use and non-use in the region. I review federal and provincial telehealth policy to provide a macro context for the study, which I then link to meso and micro levels of analysis in organization structures and situated work practice. I examine telehealth in the user context from the health care provider perspective. This reveals several constraints that have limited the usage of new technologies for health communication in Labrador. The user context must be considered in the design of telehealth programs and policy if the desired outcomes for telehealth are to be realized. The barriers to telehealth use are not simply technical, but relate to issues of privacy, culture and trust. I discuss these and other barriers with a focus on the needs of the Labrador community.

Using telehealth to increase participation in weight maintenance programs.

Abstract: HAUGEN, HEATHER A., ZUNG V. TRAN, HOLLY R. WYATT, MARY J. BARRY, AND JAMES O. HILL. Using telehealth to increase participation in weight maintenance programs. Obesity. 2007;15:3067–3077. Objective: To compare weight regain, satisfaction, and convenience among three weight maintenance programs: telehealth, traditional classes, and no program. Research Methods and Procedures: This quasi-experimental study compared weight change, satisfaction, and convenience among three program types. The telehealth participants interacted with a registered dietitian (RD) through the web and e-mail, traditional program participants attended a traditional classroom program, and no program participants received no interaction. Eighty-seven subjects (14 men and 73 women) were enrolled in the study: 31 traditional, 31 telehealth, and 25 no program participants. Eligibility included participation in a community-based weight loss program (Colorado Weigh) and minimum 7% weight loss before enrollment. Results: Subject characteristics at baseline were as follows: age, 50 9.3 (standard deviation) years; height, 1.68 0.09 m; weight, 80.5 18.4 kg, with no significant differences between groups. Over 6 months, the traditional group lost 0.5 4.3 kg, the telehealth group lost 0.6 2.5 kg, and the no program group gained 1.7 3.0 kg. Weight change among all three groups was significant (p 0.02); no program participants gained significantly more weight than the telehealth and traditional groups. There were no differences in overall satisfaction between the telehealth and traditional groups (p 0.43), but individuals in the telehealth group rated their program as more convenient compared with the traditional group (p 0.0001). Discussion: These results show the usefulness of telehealth programs in long-term weight loss maintenance. They may be a useful alternative for those who successfully lose weight in a structured behavioral program but do not choose to participate in a formal behavioral weight loss maintenance program.

Telehealth as a tool for enhancing care for patients with cardiovascular disease.

Abstract: Telehealth refers to the use of telecommunication technology to remove time and distance barriers in the delivery of healthcare services. Telehealth can help nurses provide education and counseling, social support, disease monitoring, and disease management reminders to cardiovascular patients in their homes. As a result, patients gain more flexibility in scheduling healthcare visits, have easier and more convenient access to healthcare, may have fewer time-demanding clinic visits, receive care in a location that does not require the burden of transportation, and in an environment that is less threatening than a clinic or emergency department. Cardiovascular healthcare may be enhanced through diverse telehealth applications, including sensor technology and wearable monitoring systems, Internet-based peripheral monitoring devices, videophones, interactive voice response systems, and nanotechnology. Although telehealth enhances care, legal, human, and environmental factors need to be considered before implementing a telehealth program. Additionally, more evidence that is obtained through large multicenter controlled trials about the potential benefits and cost effectiveness of telecardiovascular health is needed.

Innovations in correctional assessment and treatment

Abstract: This article considers innovations in the assessment and treatment of incarcerated individuals. The emphasis is on immediate patient needs and inmate management concerns, rather than on rehabilitation. Assessment of this diagnostically complex population is framed in dimensional and biopsychosocial terms. Scarce resources, new scientific knowledge and technology, organizational barriers, and role transformations for psychologists will guide improvements and future research in correctional mental health care, as reflected in specific areas: dimensional assessment, suicide risk assessment, neuropsychological correlates of chronic maladaptive behavior, prescriptive authority for psychologists, and telehealth. In particular, outcome research based on a broader range of interventions will be increasingly crucial to the effectiveness of correctional psychologists' work. In the near future, the degree of impact that psychologists have will depend largely on their individual and collective initiative in promoting...

Telehealth Videoconferencing: Improving Home Parenteral Nutrition Patient Care to Rural Areas of Ontario, Canada

Abstract: Background: Telehealth videoconferencing is a medium for health care professionals to communicate and care for patients living in remote areas. The aim of this study was to provide a survey to examine management outcome of home parenteral nutrition (HPN) patients when followed by telehealth as an alternative modality of care. Methods: Twenty-six individuals who were identified to benefit from tele-health were invited to participate in a satisfaction survey. The survey was sent to patients by postal mail. The survey also documented the incidence of line sepsis and other medical HPN complications. A cost analysis was also performed according to technology, human resources, and infrastructure. Results: Eighty-one telehealth videoconference sessions have been held since the inception of telehealth in 2002. Of the current telehealth patients, 13 were eligible for the survey. The satisfaction survey response rate was 11/13 (84.6%). The average line sepsis rate for the 13 patients was 0.89/1000 catheter-days. Al...

Exploring underutilization of videophones in hospice settings.

Abstract: The aim of this study was to evaluate hospice providers' attitudes and perceptions regarding videophone technology in settings where the technology was introduced but underutilized. Specifically, the project seeks to provide an in-depth understanding of attitudes and perceptions that may lead to failure of a telehealth implementation in the hospice setting in the context of the technology acceptance model. Two hospice agencies were selected as a purposive sample. Both agencies had acquired videophones that were meant to be integrated into care delivery but ultimately were underutilized or never used. Interviews with staff were conducted over the telephone. The interview guide was constructed to capture staff perceptions and attitudes concerning videophone technology. Interviews were audiotaped and transcribed for content analysis. A total of 17 (n = 17) participants (2 hospice administrators, 1 hospice management staff, 10 nurse case managers, and 4 social workers) were interviewed. Participants found videophones to be useful in hospice care but expressed specific practical challenges, such as lack of equipment reliability, lack of human resources, and lack of clarity pertaining to caregiver eligibility criteria. While perceived usefulness of videophones was high among respondents, practical concerns can be interpreted as lack of perceived ease of use. Findings indicate that the Technology Acceptance Model (TAM) provides a good framework for an understanding of telehealth underutilization. Staff perceived that videophones were useful, but they were discouraged by their perception that the videophones were not reliable or easy to use and by their uncertainty about the cases that they were best suited for. Lessons learned are integrated into a randomized clinical trial currently under development.

The Telehealth Divide: Disparities in Searching Public Health Information Online

Abstract: This article explores e government inequalities to searching Medicare and Medicaid information online. Telehealth, a branch of e government, can bring public health service and insurance information to the citizen. The Centers for Medicare and Medicaid Services website, among others, has critical information for potential beneficiaries and recipients of services. Using Pew survey data and multivariate regression analysis we find people in most need of Medicare and Medicaid information online (the elderly and poor) are accessing it, and people with years of online experience are strong proponents of online searches. Despite being less likely to have broadband services, individuals in rural areas were not found to be less likely to search for information online. In conclusion, some disparities are narrowing as the elderly and poor in need of access to public health insurance are searching for it online. However, people without Internet access and experience (perhaps the oldest and poorest) remain disadvantaged with respect to accessing critical information that can link them to needed health care services.

Internet Telehealth for Pediatric Asthma Case Management: Integrating Computerized and Case Manager Features for Tailoring a Web-Based Asthma Education Program

Abstract: This article reports on the development of a personalized, Web-based asthma-education program for parents whose 4- to 12-year-old children have moderate to severe asthma. Personalization includes computer-based tailored messages and a human coach to build asthma self-management skills. Computerized features include the Asthma Manager, My Calendar/Reminder, My Goals, and a tailored home page. These are integrated with monthly asthma-education phone calls from an asthma-nurse case manager. The authors discuss the development process and issues and describe the current randomized evaluation study to test whether the year-long integrated intervention can improve adherence to a daily asthma controller medication, asthma control, and parent quality of life to reduce asthma-related healthcare utilization. Implications for health education for chronic disease management are raised.

Agreement between prospective interactive voice response self-monitoring and structured retrospective reports of drinking and contextual variables during natural resolution attempts.

Abstract: Objective: Interactive voice response (IVR) systems allow respondents to report information privately using the telephone keypad and appear to enhance reports of sensitive behaviors like problem drinking. They hold promise for telehealth applications with problem drinkers who will not seek clinical care, but IVR feasibility and data quality using such community samples have not been well studied across lengthy reporting periods in relation to established retrospective measures that are less costly and burdensome. These issues were evaluated using recently resolved, untreated problem drinkers who are targets for telehealth interventions. Method: Problem drinkers recruited from the community (24 men, 20 women) engaged in IVR self-monitoring (SM) for up to 128 days after initial resolution when the risk of relapse was high. Participants reported daily drinking, money spent on alcohol, and life-event occurrences. An expanded Timeline Followback (TLFB) interview and life-events assessment were completed after ...

Videoconferencing and telehealth technologies can provide a reliable approach to remote assessment and teaching without compromising quality.

Abstract: Cardiovascular disease remains a significant chronic healthcare problem in this country, with considerable associated economic and quality-of-life challenges. Along with these challenges, there is high demand for healthcare provider time, particularly in the areas of management of complex healthcare needs and patient education. At the same time, a critical nursing shortage exists. Telehealth technologies provide opportunities to meet the rapidly growing needs of consumers and healthcare practitioners. Many in need of services have limited access to high-end technologies. An argument has been made that the lowest level of technology needed to carry out a task should be used, if it is capable of providing the necessary services. Videoconferencing capabilities allow healthcare practitioners to engage in virtual face-to-face encounters with patients or other healthcare providers. A variety of levels of sophistication in these videoconferencing systems are available. In an effort to evaluate the effectiveness and consumer satisfaction with videoconferencing, 3 pilot studies were conducted to compare face-to-face, low-bandwidth, and high-bandwidth approaches to performing common assessments and patient education activities. In one study, a variety of experienced healthcare practitioners performed functional assessments of stroke subjects using a collection of validated scales by varying approaches (face-to-face, low-bandwidth, and high-bandwidth videoconferencing) in a randomized order. In a second study, undergraduate nursing students performed similar performance measures and taught an unfamiliar individual how to program and use an intravenous pump device, take a tympanic temperature, or to draw up insulin in a syringe. In the third study, advanced practice nursing students assessed vital signs and performed cardiopulmonary assessments on community-dwelling subjects using low-bandwidth and face-to-face approaches. Healthcare practitioners and students generally preferred high-bandwidth approaches over low-bandwidth alternatives when videoconferencing was performed; however, most participants and practitioners were satisfied with the encounters, regardless of the level of technology used.

The use of telehealth for diabetes management: a qualitative study of telehealth provider perceptions

Abstract: Background Monitoring and Messaging Devices (MMDs) are telehealth systems used by patients in their homes, and are designed to promote patient self-management, patient education, and clinical monitoring and follow-up activities. Although these systems have been widely promoted by health care systems, including the Veterans Health Administration, very little information is available on factors that facilitate use of the MMD system, or on barriers to use.

Participatory and persuasive telehealth.

Abstract: Technological advances in telehealth systems are primarily focused on sensing and monitoring. However, these systems are limited in that they only rely on sensors and medical devices to obtain vital signs. New research and development are urgently needed to offer more effective and meaningful interactions between patients, medical professionals and other individuals around the patients. Social networking with Web 2.0 technologies and methods can meet these demands, and help to develop a more complete view of the patient. Also many people, including the elderly, may be resistant to change, which can reduce the efficacy of telehealth systems. Persuasive technology and mechanisms are urgently needed to counter this resistance and promote healthy lifestyles. In this paper, we propose the participatory and persuasive telehealth system as a solution for these two limitations. By integrating connected health solutions with social networking and adding persuasive influence, we increase the chances for effective interventions and behavior alterations.

Initiatives to Promote Effective Self-Care Skills in Children and Adolescents with Diabetes Mellitus

Abstract: Intensive management of type 1 diabetes mellitus (T1DM) is increasingly becoming the ‘ideal’ standard of care for pediatric patients at diabetes centers across the world. This ‘ideal’ standard is based on two landmark studies that documented that keeping blood glucose levels as close to normal as possible and achieving this as early as possible in the disease course helps to prevent or delay the devastating long-term complications of T1DM. Simultaneously, initiatives supplemental to the medical care of young patients with diabetes that are attempting to improve the self-care behavior and glycemic control of young patients with diabetes have been implemented. There is consensus among recent meta-analyses and critical reviews of these interventions that their overall impact on glycemic control is modest to moderate at best. Because of the need for healthcare cost containment and allocation of resources, we have attempted to identify the components of these different initiatives that have the potential to be practical, cost saving, and integrated into the routine clinical care of diabetes. Interventions based on coping-skills training, motivational interviewing, behavioral family systems therapy, and multisystemic therapy models require the expertise of a highly trained mental healthcare professional. Moreover, none of these interventions has yet been implemented or evaluated within the ongoing context of routine ambulatory diabetes care. Finally, each of these interventions requires additional time commitments from young patients with diabetes and their families. The Care Ambassador intervention and programs based on the Family Teamwork intervention do not require highly trained, expensive staff for delivery and have been successfully integrated into routine pediatric diabetes-care settings. Moreover, the Care Ambassador model has also been shown to reduce expensive adverse outcomes across a broad spectrum of youth with diabetes. Finally, telehealth interventions for youth with diabetes may hold great potential as a lower-cost intervention to supplement routine diabetes care and to optimize glycemic control for pediatric patients; however, we await the rigorous evaluation of the application of telehealth interventions across a range of outpatient pediatric diabetes-care settings. Pediatric diabetes care requires an environment of supportive, collaborative communication grounded in realistic expectations for youths. Thus, ongoing evaluations of outcomes of these various interventions are needed within multiple healthcare settings.

Telehealth Screen for Depression in a Chronic Illness Care Management Program

Abstract: Chronic illness accounts for the majority of healthcare expenditures in the United States. Innovative telemedicine programs have been developed to help lessen the chronic illness burden, yet few have been developed to address comorbidity. Programs accommodating comorbidity are needed because most older adults suffer from two or more chronic illnesses. One of the most common and serious comorbidities in chronic illness is major depression, which has been shown to exacerbate morbidity, mortality, and cost. This study presents data on a telephone-based interactive voice recording (IVR) home monitoring program that was expanded to include quarterly screens for depression using the Patient Health Questionnaire (PHQ). Patients in an ongoing telehealth heart failure program were administered the PHQ-2 and PHQ-9 in November 2005 (Round 1) and February 2006 (Round 2). Patients were informed about the screen beforehand and an emergency protocol was established. At both screens, more than 90% of the patients completed the screen. Approximately 30% of the patients endorsed one of the PHQ-2 items in both rounds. Patients endorsing either of the PHQ-2 items then completed the full PHQ-9. Nurse care-managers contacted those scoring above the threshold of 10 on the PHQ-9 indicating possible depression. One patient expressed suicidality and was appropriately assessed for safety. There was no indication that patients were less likely to complete the screen in Round 2, although their average depression scores were slightly lower when compared with Round 1. A regular telephonic IVR screen for depression can be integrated into a standard illness management protocol. Following a preestablished emergency plan for the assessment of suicidality was successful. This serves as a model for using technology to manage comorbid depression and chronic illness.

The Relationship of a Diabetes Telehealth Eye Care Program to Standard Eye Care and Change in Diabetes Health Outcomes

Abstract: Several studies suggest that telehealth eye care programs that combine retinal imaging, education, and some care management can improve patient adherence to annual, comprehensive eye examinations and follow-up treatments. Little is known, however, about whether such programs relate to other, more distal outcomes that affect diabetic eye disease, such as blood glucose control. This paper assesses the relationship of participation in a diabetes telehealth eye care program with standard, face-to-face eye care as well as improvements in other diabetes-related health outcomes. We conducted a retrospective study using data from electronic medical records of Joslin Diabetes Center (n=13,752). The data span 2 years: baseline and follow-up. Subjects' eye care groups were no eye care, eye care outside of the clinic, standard eye care at the clinic, or participation in the Joslin Vision Network telehealth eye care program. We analyzed the relationship of participation in the telehealth eye care program at baseline to follow-up eye care groups and changes in hemoglobin A1c, low density lipoprotein levels, and systolic blood pressure. The results show that participation in the telehealth eye care program was significantly correlated with whether subjects later obtained standard eye care, improvement in hemoglobin A1c, and improvement in low density lipoprotein. Thus, telehealth eye care programs that incorporate evaluation, education, and care planning are related to use of recommended eye care and improvements in certain diabetes-related health outcomes. Such programs can address the many aspects of care necessary to reduce risk of vision loss due to diabetic retinopathy and other diabetes-related complications. Future research might test hypotheses suggested by sociological and psychological theories regarding causation between participation in a telehealth eye care program and other diabetes care.

The Cost-Utility of a Care coordination/home Telehealth Programme for Veterans With Diabetes

Abstract: We examined the cost-effectiveness of a care coordination/home telehealth (CCHT) programme for veterans with diabetes. We conducted a retrospective, pre-post study which compared data for a cohort of veterans (n=370) before and after the introduction of the CCHT programme for two periods of 12 months. To assess the cost-effectiveness, we converted the patients' health-related quality of life data into Quality Adjusted Life Year (QALY) utility scores and used costs to construct incremental cost-effectiveness ratios (ICERs). The overall mean ICER for the programme at one-year was $60,941, a value within the commonly-cited range of cost-effectiveness of $50,000-100,000. The programme was cost-effective for one-third of the participants. Characteristics that contributed to cost-effectiveness were marital status, location and clinically relevant co-morbidities. By targeting the intervention differently in future work, it may become cost-effective for a greater proportion of patients.