CONFERENCE DRAFT:
Do not quote or circulate
without permission from
the author or AcademyHealth
Technology’s Role in the Future of Long-term care
Building Bridges: Making a Difference in Long-term care Colloquium
June 24, 2006
Russell Bodoff, Center for Aging Services Technologies
Christal Stone, AcademyHealth
This paper was commissioned by The Commonwealth Fund for use at its 2006 Colloquium,
Building Bridges: Making a Difference in Long-term care, held on June 24, 2006.
Technology’s Role in the Future of Long-term care
INTRODUCTION
The United State is facing a formidable challenge in financing and delivering high
quality long-term care to an increasingly aging population. In the coming decades over
20 percent of the population will be over the age of 65, with ever growing numbers living
well beyond their 80s.1 The functional and cognitive impairments associated with
growing older will require additional assistance from a long-term care system that is
already experiencing a shortage of formal care workers as well as a network of informal
caregivers who are finding it increasingly difficult to meet the needs of loved ones. The
nation’s changing demographics, limited governmental financial support, shortages of
caregivers and facilities, and outdated practices will require resources at a level the
existing system simply does not have the capacity to manage.
This dilemma has captured the attention of a small but growing group of
academic, policy, corporate, and health care professionals. Unfortunately, the growing
budget constraints, the general lack of political will, and the abundance of special
interest lobbies have inhibited policy leaders’ ability to attain, and in many cases even
discuss, workable solutions for the long-term care system. The majority of proposals that
are put forth by the long-term care community seek to improve the current system, yet
what exists today may never be able to handle the oncoming demands. Success will
require reinventing the total process of providing aging services.
A new perspective is needed that uses imagination and innovation to break
through to a person-centered, practical, accessible approach. The objective is to create
an integrated approach to aging and long-term care that utilizes technology to address
the needs and desires of individuals as they pass through the different stages of life.
Emphasis needs to be placed on helping people age independently in the place of their
choice and aggressively pursuing prevention and wellness as a core feature of
successful aging. This perspective on growing older reflects what aging adults are
2
Technology’s Role in the Future of Long-term care
already advocating—respect, independence, and control throughout the entire life cycle.
The culture change movement promotes many of these ideals and actively works to
include the desires of care receivers and caregivers in decision-making. Other trends in
the long-term care system are beginning to address these demands through programs
that enable aging-in-place, home and community-based services, home-like institutional
environments, and consumer-directed care. Unfortunately, existing demonstrations have
not been scaled-up successfully.
This new approach to long-term care hinges on the investment, development,
and adoption of a wide range of technologies. To be clear, without a larger vision,
technology for technology’s sake will provide little benefit. Instead, technology offers
important tools to build a new paradigm for the provision of care and builds new
relationships between the older adult and the formal and informal caregiver. This
involves giving consumers the tools that empower them to take better control of their
own care and for a broken national long-term care system to start reinventing itself. As
these technologies are developed to respond to the aging challenge, they will also open
new opportunities to adapt successful approaches into the entire health care system.
No one believes that technology is a magic bullet that can solve all the agingrelated issues that are to come. However, technology offers opportunities for care to be
delivered in new ways that offer the potential to improve quality and reduce costs of
care. Two major factors impact the potential to use technologies to improve care. First,
Baby Boomers, due to their size and character, have been a disruptive demographic
through every phase of society they have entered. It should be expected that Boomers
will also compel the long-term care system to adapt to their needs and desires. This will
result in a large cohort of aging adults who will be better informed and prepared to
address aging issues. They are also the first generation that has grown up around
3
Technology’s Role in the Future of Long-term care
technology and will demand its capabilities be available to help maintain health,
independence, and general well-being.
The second impacting factor is the convergence of technologies. Computers,
televisions, phones and other information appliances are all merging into one device. As
this happens, the devices Boomers are familiar with, like cell phones and PDAs, will
become important parts of the new digital health care and long-term care delivery
system. As machine language, intelligent software, and microchip and microprocessors
continue to improve, the ability to interpret the information collected by these various
devices and customize the care experience will also progress.
Technology and its role in aging and long-term care has received growing
attention in the last year. Over three hundred stories have appeared in the media,
including coverage by three national broadcast networks. The 2005 White House
Conference on Aging provided policymakers and delegates a glimpse at the possibilities
of aging-related technologies. The Center for Aging Services Technologies (CAST), a
program of the American Association of Homes and Services for the Aging (AAHSA), is
one of only a handful of organizations addressing the potential of providing aging
services with technology. CAST’s efforts have brought together 400 organizations that
include technology companies, university research centers, and providers of aging and
health care-related services. Unfortunately, there has been minimal proactive interest
from the Administration, most members of Congress, or national foundations.
The objective of the paper that follows is to lay out the current state of the agingrelated technology field and how it can impact long-term care delivery. Advanced efforts
of other developed countries can provide valuable lessons for the United States. These
lessons in conjunction with developments from the technology industry and experiences
of early adopters has provided advances in knowledge that have begun to be captured
in early research findings. Research efforts are still in their infancy and much needs to
4
Technology’s Role in the Future of Long-term care
be explored in order to provide public and private entities with evidence on the true
potential of different aging-related technologies. Unfortunately, a number of barriers exist
that prevent technology from being used to provide new forms of long-term care. These
barriers have a number of policy implications that need to be addressed if the long-term
care system is to provide all older adults more independence, better quality care,
increased well-being, and improved efficiencies. The long-term care community has an
opportunity to build on its vast experience to redefine the system and provide leadership
for the future care of a growing population of older adults who will not be satisfied with
the status quo.
INTERNATIONAL EFFORTS
Governments of other developed countries including Japan, South Korea,
Scandinavia, and the Netherlands have been proactive in driving a technology agenda to
handle the needs of their aging populations. This has left the United States trailing in
technology investment, research, utilization rates, and government sponsored programs.
General findings from comparative studies on the use of electronic technology in health
care and long-term care settings reveal that the United States is lagging. As of 2005, the
United Stated invested $125 million to implement health information technology (HIT),
compared to the United Kingdom’s $11.5 billion.2 General Practitioners in Scandinavia,
Netherlands, and the United Kingdom are using the highest levels of electronic health
records (EHR), outpacing U.S. primary care physician adoption by as much as 73
percent.3 While these studies focused on the use of electronic technology in the general
health care arena, it can be safe to assume that their application in the long-term care
system is even further behind. HIT has been advanced the most in countries with
national governments that have taken an active interest in setting standards and rules,
and financing the significant portions of start-up costs through publicly financed health
5
Technology’s Role in the Future of Long-term care
insurance programs.4 Some countries have chosen to foster the adoption of HIT with
federal committees—several established more than a decade ago.5 The United States
established a commission to promote HIT in 2004, the Office of the National Coordinator
for Health Information Technology (ONCHIT) in the U.S. Department of Health and
Human Services. Unfortunately, Congress did not appropriate funding for FY 2004 or FY
2005 so the Department of Health and Human Services reallocated funds. In FY 2006,
Congress did appropriate $61.7 million.
Many governments leading in health technology also have been committed to
supporting programs that address the specific needs of elderly adults. These programs
have consisted of public-private partnerships, collaboration at the local level, consensus
building, standard setting, and education efforts on the availability and usefulness of
aging-related technologies. Campaigns in Finland and the United Kingdom work to get
adults online and learning how to use the internet. Australia’s Ministry on Aging has
instituted a program that provides the business sector with guidance on how to service
the older market more effectively. The South Korean government is providing $125
million dollars in grants to businesses to develop technologies to help their aging
populations. The Partnerships for Older People Projects (POPP) Project from the UK
Department of Health is using telehealth to support older adults living at home. The
European Union (EU) has instituted the ACTION Project, which provides caregivers with
online information and support to assist them with the stress and uncertainties of taking
care of an elderly adult. The EU also supports several research and development
projects examining the potential of different types of technology to increase
independence among older adults, such as the use of ‘smart home’ technology, which
provides a comprehensive array of information, communication, monitoring, and
assistive devices to support independence and safety in the residence.6
6
Technology’s Role in the Future of Long-term care
Japan may be the most aggressive in pursuing aging-related technologies to
address the most rapidly aging population in the world. The Japanese government
recognized the impending medical and long-term care challenges early and in 1989
developed a ten year strategy called the ‘Gold Plan’ . The Ministry of Finance, Health &
Welfare and Home Affairs renewed these aims in 1994 with the ‘New Gold Plan’ . Out of
these initiatives came a national long-term care insurance system in 2000. The Gold
Plan also sought to actively drive the technology agenda to address aging-related
services and long-term care needs in a cost-effective manner.
Japan’s government agencies at the local and national level cooperate to set
standards and guidelines for designing technologies that work together while educating
older adults and caregivers in the community about technological resources that are
available to assist with daily needs. Japan has invested heavily in broadband technology
and ultra-high speed fiber optic connectivity, allowing for greater speed, access, and
affordability to help eliminate the digital divide between younger and older generations.
Japan is also a world leader in the development of robotics. Robotic devices can
be used in a number of ways. For example, they may assist in therapy sessions with
dementia and Alzheimer’s patients, act as helpers and companions, or take the form of a
suit that can augment a user’s strength. Currently, the EU is working to establish
stronger partnerships with Japan in an effort to pool resources that can maximize their
achievements in addressing rapidly aging populations and fend off increasing levels of
foreign competition in the technology arena.7
NEW TECHNOLOGY OFFERS PROMISE
Though the support and use of aging-related technology may not be as prevalent
in the U.S. as it is abroad, a broad array of technologies are being developed
domestically to address challenges in a range of areas including facilitating formal and
7
Technology’s Role in the Future of Long-term care
informal caregiving, easing functional and cognitive impairments, and enabling
independent living. Some of these technologies already exist, while others are still in the
developmental stage.
One impediment to further investment and utilization of aging-related
technologies in the U.S. is the limited amount of evidence-based research that shows
technology works to improve outcome-based quality measures, enhance selfdetermination, augment system capacity, improve efficiency, and reduce costs. Initial
international and U.S.-based studies have explored methods of assessing technology,
decision-making, effectiveness, appropriateness, implementation, and financing. Several
U.S. companies and research centers have taken on the task of developing pilots and
trials of new technologies. However, most of these studies are case studies or small
trails and the often positive results are inconclusive because of the lack of
generalizability. Larger trials have taken place in Europe and Asia since government
funding is more available to support these initiatives. The insurance industry in parts of
Europe also has made significant investments, which is not seen in the U.S.
Electronic Health Records
One of the HIT initiatives that has received the most attention is the EHR, which
serves to capture, record, and share important acute and long-term care-related
information between physicians, care staff, facilities, and consumers. By enabling
access to a cohesive, comprehensive care record, providers can make better informed
decisions and individuals can be more active in managing their health. Unfortunately, the
use of EHRs has not been well developed in long-term care settings. The majority of
information known about the benefits and barriers to EHRs has been gathered from
hospitals. The Agency for Healthcare Research and Quality (AHRQ) recently released
an evidence-based report to assess available data regarding benefits and costs of HIT
8
Technology’s Role in the Future of Long-term care
systems including EHRs.8 This too failed to address needs specific to long-term care
settings. Transferable lessons from abroad and acute care settings show that, in order
for system to be practical, they must be operable between different settings. One
successful expamle is the Veteran’s Administration (VA), which is using interoperable
EHRs in their closed health system with very positive results.
One illustrative study, commissioned by the U.S. Department of Health & Human
Services, conducted case studies in four technologically advanced post-acute and longterm care settings to evaluate the status of interoperable EHR systems. This study
highlighted some of the unique needs of long-term care settings such as the geographic
separation between doctors and hospitals, patient vulnerability to multiple threats to
patient safety, the participation of an interdisciplinary team that includes the family, and
government-mandated standard assessments particular to different care sites. It found
that one of the most valuable functions of the EHR in long-term care settings was the
transfer of care information when a patient was transitioned between settings. Other
reported benefits include improved medication management, patient safety, quality of
care, and efficiency. Nursing homes specifically could benefit from EHRs through
enhanced reimbursement, more accurate information, and more easily assessed
information that can help show trends and identify problems.9
Available research reveals that the lack of integration between mandated
assessment measures, such as the Minimum Data Set (MDS), and clinical data was a
major impediment to cross setting information sharing. Interoperability cannot be
established without agreed upon standards for electronic documentation such as those
recommended by the international standard-setting group, Health Level 7 (HL7).10 The
cost of launching and maintaining an EHR system is another major impediment to
expanding the use of EHRs. Kramer et. al. found that for long-term care sites, other than
the VA, more sophisticated HIT, such as bar codes, were not being implemented
9
Technology’s Role in the Future of Long-term care
because Medicare PAC and Medicaid reimbursement did not support their use.11 EHRs
will play an important role in how all the different technologies come together. In many
ways, EHRs are the foundation to the larger vision of a new long-term care delivery
process taking advantage of technology.
Beyond Electronic Health Records
EHRs are one initiative within a broader set of HIT that aims to enhance
connectivity and operational aspects of long-term care in order to dramatically increase
the efficiency and effectiveness of an insufficient formal care workforce. Today, care
staff in long-term care facilities have many administrative responsibilities in addition to
the provision of care. Technology can be used to strengthen organizational resources so
that care staff are free to provide more high-touch care. One provider of HIT systems
argues that a useful information management system must: eliminate redundant
paperwork, keep the data recording quick and simple, begin the recording at the
bedside, use a real-time, wireless platform that allows for updates and care plan
changes, incorporate MDS information, provide financial modeling, and be adaptable to
change.12 Software systems currently exist that assists with scheduling, care tracking,
and regulatory reporting requirements. CaraSyst from CaraVita Senior Care is a webbased application that uses PCs and hand-held computers so that nurses managing
care plans and care providers are in continual contact with each other to monitor and
track resident needs. Q Continuum System software allows all aspects of care to be
coordinated in real time across a broad range of service providers including discharge
planners, social workers, and care staff. There are many other companies that offer
similar products that can interface with PDAs, and computerized physician order entry
systems (CPOE) with clinical decision support (CDS) to assist with medication
management. The ultimate HIT system would automatically detect when a function is
10
Technology’s Role in the Future of Long-term care
performed and record that information in an EHR from which care plans are adjusted
and required quality reports are created. This would save significant time and allow
trained staff to provide higher quality care. The technologies are already available to do
a good deal of this automatic detection and data entry, but it has not been applied widely
within the long-term care setting.
Communication and Monitoring Technologies
A variety of communication technologies also can enhance caregiving efforts,
overcome geographic barriers between underserved areas and physicians, and improve
management of certain conditions. These technologies include videoconferencing and
telehealth. Several initial studies of telehealth systems have shown mixed findings. Pilot
testing of telehealth in a rural nursing home in Iowa used a mobile system that included
electronic diagnostic equipment to allow a physician to conduct a live visit from a remote
location. Despite positive reviews, barriers to the system’s effectiveness included the
installation of high-speed internet, software malfunctions, broken voice communications,
high start-up costs, and lack of reimbursement for telehealth services.13 Another pilot
test of videoconferencing in nursing homes examined both the provider and resident
perspectives. This study found that while the majority of care staff felt videoconferencing
facilitated their assessment, especially for wound care, the majority of residents did not
understand the recommended treatment plan, severely limiting their ability to make
informed decisions.14 Telehealth can also assist with the management of certain
conditions of particular concern in certain long-term care settings. A small case-control
study focusing on the prevention of pressure ulcers found that telehealth interventions
improved ulcer tracking and management.15 While these studies have been on a very
small scale, they show that there is potential for communication technologies to produce
positive results in specific areas. Further research still needs to determine the
11
Technology’s Role in the Future of Long-term care
organizational impact of these systems, their most appropriate application, and explore
whether alternative methods of evaluation such as simulations could be used in place of
small pilot tests.
Communication and monitoring technologies also exist that can enhance informal
caregiving efforts, reduce safety risks, improve quality of life, and keep aging adults
connected and engaged—helping to stave off isolation, boredom, and mental
deterioration. Communication technologies can involve simple innovations such as
telephone support lines, online instant messaging, and internet chat forums. A variety of
websites sponsored by the National Institute on Aging, National Institute of Health, and
the Alzheimer’s Association provide informal caregivers access to advice and support.
While there is evidence that only a minority of caregivers use these websites, they have
been shown to increase self-confidence in decision-making and reduce caregiver strain
to those who participate.16 Telephone support systems can provide similar benefits to
caregivers, especially for wives with low mastery of care tasks and high levels of anxiety.
17
Better systems can be developed if the views of caregivers are given greater weight
when developing communication and information technology products and services.
Monitoring and Sensors
Monitoring and sensor devices can help preserve an older adult’s independence
and safety by connecting the caregiving network through status updates and
notifications of possible problems. Sensors can measure basic bodily functions,
performance on activities of daily living (ADLs), and health status. Current beta testing is
being conducted on the Home Assurance Monitoring System Project. This is an in-home
monitoring system that uses non-video, non-audio security sensors to collect and
translate information to caregivers about active, quiet, sleep, home, away, and kitchen
activity. The ‘Magic’ Medicine Cabinet is an online device that monitors blood pressure
12
Technology’s Role in the Future of Long-term care
and weight measurements, and provides trend reports to physicians or caregivers by
email. The MDKeeper is a similar device but it is worn on the wrist and uses biosensors
to check and record vital bodily functions. There are many other companies that have
had emergency monitoring systems in the market place for years. Unfortunately, the use
and effectiveness of these devices has not been evaluated with high quality studies.
Assistive Technology
Other aging-related technologies focus on assisting older adults dealing with a
variety of physical and cognitive impairments that can threaten independence. According
to the Assistive Technology Act of 1998, assistive technologies are, “any item, piece of
equipment, or product system that is used to increase, maintain, or improve the
functional capabilities of individuals with disabilities.”18 Another array of tools can help
manage chronic diseases to prevent deterioration, emergency room visits, and
institutionalization. Both low-tech and high-tech devices can reduce the need for
assistance when facing physical handicaps that can result in limited mobility, balance,
and strength. One aim has been to develop devices that prevent falls, which can have
devastating effects for an aging adult’s health and freedom. Low-tech devices in this
arena include hand railings, ramps, and walkers. More high-tech devices can monitor
gait to signal when fall risk is high or work to improve balance. Researchers at Harvard
Medical School and Boston University are investigating how vibrating soles in shoes can
improve balance and prevent falls. NOCwatch is testing FallSaver, an unobtrusive
transmitter that identifies who is at risk of falling and reliably alerts the wearer and
caregivers when an individual is about to get up unassisted. Intel and its university
partners are developing technology that monitors gait to identify diseases such as
Parkinson’s disease up to a decade earlier—enabling early treatment. The University of
13
Technology’s Role in the Future of Long-term care
Virginia is also developing a passive gait monitoring system that is under going trials to
help reduce falls among seniors.
A variety of other assistive devices focus on preserving and enhancing cognitive
abilities. Software programs are being developed to detect early signs of dementia and
Alzheimer’s allowing for earlier intervention. The University of Michigan is field testing
the Auotminder system to support those with memory impairment by providing them with
flexible, adaptive reminders of their daily activities based on rich modeling and reasoned
alerts. Oregon Health and Science University is developing technologies to monitor
cognitive ability and change through measuring key strokes and response time while an
older adult plays card games on a computer. For aging adults with more severe forms of
cognitive decline, wander management systems can preserve a higher degree of
freedom and ensure security by controlling door access, tracking movement and
employing various deterrent techniques like automatic sprinklers.
Electronic medication and health management devices can assist aging adults
control complex health conditions like diabetes and congestive heart failure helping to
prevent severe complications and deterioration. Diabetes management efforts focus on
the continuous monitoring of blood glucose levels to guarantee timely intervention and
improved treatment compliance. Some companies are even exploring how health
monitoring devices can be built into cellular phones and other consumer devices.
Medication management and compliance is another important step in preventing
unnecessary decline. This can be accomplished with wireless technology that can
automatically remind an aging adult about medication and monitor compliance. The
MD.2 from Interactive Medical Developments organizes, reminds, dispenses and
monitors an individual’s medication and adherence. SIMpill monitors medication
compliance and produces real-time alerts using wireless technology and text messaging
14
Technology’s Role in the Future of Long-term care
capabilities. The PillAid automatically notifies users with visual and audio medication
reminders using a small microchip to read a smart card.
Overall, the goals of assistive technology developments are to facilitate the
health and well-being of aging adults and to allow them as much control and
independence as possible throughout the natural aging process. Several early studies
have examined the benefits and tradeoffs with the use of assistive technologies. Work
by Emily Agree, Ph.D. and colleagues compared pain, fatique, time intensity, and
reported unmet need across settings that used assistive technologies and those that
used personal care services. They found that assistive technologies were reported to be
more tiring, time consuming, or painful, but fewer assistive technology users reported a
desire for personal care services signaling less unmet needs.19 A follow-up study found
that assistive technology use was associated with fewer informal care hours but not
formal care hours.20 A third study also found a strong relationship between reduced
hours of help and the use of assistance technology.21 These studies also showed that
those who were unmarried, better educated, and had better cognitive ability were more
likely to use assistive technologies, while those who were Medicaid recipients, poor, or
cognitively or psychologically impaired were least likely to use any assistive technology
devices. While limited evidence exists regarding clinical effectiveness, the current
literature does not indicate whether assistive technology interventions are cost effective.
Again, ongoing research needs to evaluate the effectiveness, costs, and social benefits
of assistive technologies. There also needs to be further exploration as to why different
groups are utilizing existing devices at different rates and how best to address this
growing disparity.
15
Technology’s Role in the Future of Long-term care
Smart Technology
Several major investments have been made in initiatives that attempt to create
synergy between a broad range of state of the art technologies in order to provide aging
adults an environment that suits their desires and meets their social and care needs.
Smart home technology integrates information and communication technology to enable
independent living. A ‘smart home’ can utilize a network of non-invasive sensors
throughout the home to monitor older people’s activities; assist with memory decline;
provide emergency assistance, fall prevention, and detection; identify early changes in
health status; administer medication; and assist with other functional and cognitive
impairments. The availability of ‘smart home’ technology is very limited but is bound to
increase as professional homebuilder associations design more homes with aging-inplace technology already established.22 As an example, Elite Care Technology’s
Creating Autonomy-Risk Equilibrium (CARE) System is an integrated system that is
being used at Oatfield Estates, an assisted living facility in Milwaukie, Oregon, to foster
independence, manage safety risks, improve quality control, and monitor health status.
This system also reduces costs by increasing staff efficiency by monitoring encounters,
documenting services, monitoring staff and resident locations, and improving response
to assistance calls. ‘Smart house’ technology opens doors, controls environment, and
ensures safe use of systems. Elite Care has demonstrated what is already possible
when aging service providers allow their imaginations to drive new methods of care.
RESEARCH AGENDA
It is clear much research is needed, yet to advance the field with limited
resources, efforts can be maximized by exploring a specific set of research questions
that develops and tests new technology and measures its impact. Development and
testing research requires collaboration between the technology industry, research
16
Technology’s Role in the Future of Long-term care
institutions, providers, caregivers, and elders. The limitations, capabilities and desires of
older adults must be an integral part of the design process. To incorporate older adults’
needs, more has to be known about how these individuals experience technology and
the most effective ways to provide proper instruction. This analysis should also be
sensitive to differing needs within an increasingly diverse population of older people.
Exploring the effects of gender, class, education, and race can clarify how technology
can be most appropriately developed and implemented for a broad range of consumers.
Another significant goal for the research community is to increase the number and size
of pilot projects so products can be taken out of the laboratory and into real world
situations. Promising areas that should receive continued development and application
include monitoring and sensor devices, communication tools, medication dispensing
systems, and telehealth solutions.
The other major goal of a research agenda must be to evaluate the impact
technology can have on the challenges facing the long-term care system. It has been
postulated that technology may have the ability to improve quality and well-being,
increase function and independence, and aid in early detection, management, and
treatment of chronic and cognitive diseases. To determine where technology is most
effective, a set of carefully considered outcome-based measurements should be
performed. It is also necessary to explore whether aging-related technology can reduce
long-term care and health care costs overall if consumers, providers, and government
financers are to make significant investments in aging-related technologies.
BARRIERS
Despite technology’s potential to help meet the unfulfilled needs of the long-term
care system, implementation has been slow. Many new technologies are viewed by the
long-term care community as far off realities. Since so many of these technologies are
17
Technology’s Role in the Future of Long-term care
designed to allow additional amounts of treatment in the home, many providers are
concerned about what this will mean to their future business models. Traditional longterm care providers will face new levels of competition as retailers like Best Buy, WalMart and Target and service companies like the telephone, cable, and electric utility
companies look to new revenue streams from the information pipes they have running
into consumer’s homes. Yet, if the challenges facing the long-term care system are to be
managed, innovative tools must be found that can support new approaches that promote
autonomy, choice, and control. These new approaches to long-term care, while in their
infancy, are beginning to gain momentum but many barriers exist that hinder the
availability, affordability, and utilization of the essential tools provided by technology.
These challenges must be overcome if a sustainable long-term care system is to be
realized. Issues regarding technology that need to be addressed include privacy and
security, age bias, business investment and development, liability, regulations,
reimbursement, and lack of evidence-based, evaluative research. All of these issues
present unique hurdles that must be addressed if technology is to facilitate a solution to
providing long-term care services to a growing population of older adults.
Privacy and Security
The preservation of privacy and security in an era of advanced information
technology is an important ethical debate that is occurring in many sectors of the health
care industry and society at large. A great deal of the privacy discussion has been driven
by media attention to break-ins to financial institutions, which creates a high level of fear
about how information is used. Many strategies for monitoring and disease management
require the collection of mass amounts of data. Concerns arise regarding who has
access and control of this data. Balancing the roles of caregivers, family, and the elderly
is key. Just as in consumer-directed models, as much control as possible should be
18
Technology’s Role in the Future of Long-term care
given to the individual receiving the services. The privacy issue easily can be handled by
giving older adults total control and choice over who has access to their information.
Privacy can be guaranteed if information security is assured. Therefore it is security that
is the real issue. Technology companies and providers must be in a position to assure
the consumer that their information sharing directions are followed without being
compromised. Security tools are being developed by the companies who are producing
and running these systems. HIPPA privacy rules and safeguards used in other
information technology reliant sectors, such as the banking industry, are being
incorporated so that various security layers are built into the technology. The long-term
care community should hold companies to a high standard regarding privacy and
security to ensure these safeguards are included and enhanced in every product.
Ageist Attitudes
Certain ageist attitudes also hinder the development and implementation of
technology for the elderly. Marketing departments of many companies remain primarily
interested in the youth market even though the Boomer market represents the largest
single body of wealth in the country. The pervasive belief that older individuals are
unwilling and/or incapable of using new technologies also has a significant impact on
how technology is developed, marketed, and used. Yet, surveys reveal that how younger
people view older people and how older people view themselves is quite different.23 24
For example, focus group research conducted by the Center for Aging Services
Technologies (CAST) found that many near-retirees (50-65 year olds) who were caring
for their parents were open and excited about the various technological solutions that
could make caregiving tasks easier.25 They also had an expectation that technology
would be available for their use in the future so that their children didn’t have to face the
same caregiving challenges.
19
Technology’s Role in the Future of Long-term care
The familiarity many baby boomers already have with technologies like
computers and cellular phones may also indicate that attitudes about the acceptability of
technology for the elderly will evolve. Increased acceptability by older adults must be
coupled with sensitivity to the natural aging process so that new technologies are
developed with the needs of the aging as a priority. Examples of these needs include
larger buttons, appropriate instructions, and readable displays for older eyes.
Technologies must be simple to use, set up, and control. Yet, in the technology industry,
younger engineers develop products that are geared and marketed toward younger
generations. Older adults and their particular needs are often overlooked during the
research and development phase. As in these examples, negative perceptions and lack
of understanding of older people prevent many companies from developing for and
investing in the aging market place.
Private Sector
Between the negative perceptions of older people and the lack of interest in the
aging market, many U.S. companies are simply not addressing the needs of a growing
segment of the population. For example, there has been little discussion of the potential
of technology to serve an aging population within major industry groups like the
Business Roundtable. Not only does this delay the advancement of aging technology, it
also negatively affects the productivity of the workforce that will increasingly have to
provide additional care to family members. The reality of limited public funding will
require the private sector to compensate for gaps left by the government. This includes
bringing innovations to market through private investment and support. Leading
corporations like Intel, Honeywell, General Electric, and Philips have already begun to
turn their attention toward aging technology. The long-term care community can look for
20
Technology’s Role in the Future of Long-term care
new partnerships within this industry to help it better understand the needs of an aging
population.
Government Leadership
The government, both local and national, can serve an important function by
providing the necessary leadership in finding innovative solutions to the upcoming aging
and long-term care challenges. If government can harness and leverage its role as the
largest health care payer and provider to drive the adoption of technology, widespread
private sector participation will soon ensue. In addition, the government can begin
reassessing how research funding is allocated so that promising technologies can be
tested and evaluated. The government can become a vocal advocate by encouraging
federal and state agencies to research the benefits of technology in providing long-term
care, urging corporate executives to take an active role in addressing the growing needs
of an aging society, and raise awareness of the issues in the broader community. It is
also important that the government take the lead on a collaborative effort to set
standards and guidelines for the use and interoperability of aging-related and healthrelated technology. The Department of Health & Human Services has actively promoted
the use of HIT and EHRs, though many of these efforts neglect the specific needs of the
long-term care system and broader applications of technology. Unfortunately, other
federal agencies have neglected to prioritize the impending challenges to the long-term
care system. For instance, the Department of Commerce has done little to educate
business on aging-related technology opportunities in the global marketplace or about
the danger of losing future market share to companies in other countries that have
already made major advances in addressing the needs of their aging populations.
Incentive, reward, and support for technology adoption is another important tactic
21
Technology’s Role in the Future of Long-term care
available to the government. Lack of support from the U.S. government could hinder
progress and weaken the technology industry’s competitive position.
Liability
Investment by technology companies is also hindered by their hesitancy to enter
the health care sector given the perceived high liability risk. Liability is a significant issue
that stands out in the United States, perhaps contributing to the advances other
countries are making who do not have the same restrictions. Tort reform is a contentious
political debate that involves many business sectors besides just health care. It doesn’t
matter whether there is actual high liability risk in the health care sector. If it is a
perceived issue that is preventing companies from getting involved in long-term care
related technology, it has real consequences. Many companies, universities and
practitioners are also wary of initiating pilot projects or testing new technologies due to
the fear of liability. They simply aren’t willing to risk the consequences. More liability
concerns are also falling on informal caregivers since they are increasingly being held
responsible for new levels of care. One approach in the United States sidesteps tort
reform by having Congress waive liability concerns during the trail phase as was done
with homeland security technology.
Regulations
The state and federal oversight system can also produce a significant barrier to
advancing the utilization of technology within the formal long-term care and health care
system. Many providers have questions and fears relating to potential noncompliance
when introducing new processes. Many of the current federal regulations are compatible
with efforts to engage the consumer with their care and improve their quality of life. Still,
parts of the current regulatory structure are locked into a system that is based upon
antiquated models of care. These polices prevent the necessary growth and innovation
22
Technology’s Role in the Future of Long-term care
that can take the long-term care system in a crucial, new direction. Regulations that
hinder the adoption of new methods for providing care can include the use of telehealth
over state lines, approval of new assistive and monitoring devices, and standards that
dictate the frequency of required visits without regard to alternative forms of contact.
These regulations can even hinder the adoption of superior connectivity such as when
states continue to require long-term care facilities to have wired access before they can
install wireless service. Even FDA regulations on the approval and certification of
medical devices can hinder the implementation of technology. For example,
incorporating health-related technology into widely utilized devices such as cellular
phones can greatly increase the adherence and efficacy of important health practices by
allowing for automatic monitoring, tracking, and reporting of glucose levels of a diabetic
individual. But FDA regulations consider the phone a medical devise that would require
recertification every time one receives a software update—a common practice with
cellular phone technologies.
Not all regulations impede the advancement of technology nor are they
unreasonable, especially in a time when past approaches still abound. It must be
acknowledged that changing either state or federal regulations is overwhelming and
risky, but it is a task that is necessary if the long-term care system is to move beyond the
definition of it was to become a system defined by what it might be. The challenge for
the long-term care community is to achieve updated regulations for an unrealized
structure without loosing the hard-fought safety and quality assurances that apply to the
current system. Advocates, providers, and consumers in conjunction with government
and industry leaders must be integral contributors to common sense reforms. This
ensures that the values of a new long-term care approach will guide changes that
preserve the spirit of existing regulations but adapt them to accommodate future
directions.
23
Technology’s Role in the Future of Long-term care
Reimbursement and Financing
Reimbursement within the current system is a significant challenge that hinders
the growth and accessibility of technology. Currently, many important technologies are
not reliably covered by Medicaid and Medicare, severely limiting the extent to which
long-term care practitioners and consumers can access new approaches to care.
Certain assistive and communication technologies are reimbursed in very restrictive
ways. Medicare covers some assistive technology as home health care. Many
restrictions are placed on the permissible functions of a device, the allowable charge,
and definitions of medical necessity. Telemedicine is another area where Medicare
provides limited reimbursement, but only if eligible beneficiaries receive qualified
services in an eligible facility. Home health agencies are allowed to adopt telehealth
technologies that promote efficiencies or quality of care, but Medicare will not reimburse
for telehealth or count it as a ‘visit’ under the home health benefit. Medicaid considers
telemedicine to be an optional service that a handful of states have chosen to cover in
different ways.
Reimbursement restrictions and low reimbursement rates on telehealth and
assistive technology highlight how current policies may hinder the accessibility and
advancement of many devices that may be beneficial to caregivers and older adults with
special needs. The lack of a reliable financing mechanism also hinders investments from
technology companies if they believe there is no market for their products. Payers need
to rethink the entire approach to how providers are reimbursed when they do not see
people face-to-face as frequently but maintain high quality care and positive outcomes.
There are indications that the upcoming cohort of older adults are willing to help
finance technologies that can improve quality of life, independence, and safety as both
informal caregivers and consumers. A study by CAST found that Baby Boomers who are
24
Technology’s Role in the Future of Long-term care
starting to care for their elderly parents would pay out-of-pocket for technology that
would be helpful. A study by Forrester Research showed similar findings.26 This cohort is
also willing to take more responsibility and control of their own care given their
experiences with their parents.27 Still, indications that there is an untapped private
market has not been convincing enough to drive the industry to make major investments
or induce payers to institute cost sharing arrangements.
Currently, public investments in untested long-term care approaches are
extremely limited. The current long-term care system is under tremendous financial
strain that is predicted to grow dramatically. But without a way to finance newly
developed services, practitioners will not have incentives to adopt new approaches that
could help reduce costs and increase service capacity, nor will aging individuals have
the means to access them. The CMS directed Quality Improvement Organization
program and state-based Medicaid waivers may be two potential avenues that would
enable technology to get the foothold it needs to become fully integrated into the servicedelivery system. By allowing individuals the freedom to make choices that enable them
to receive the care of their liking, using assistive technology may provide a preferable
approach than hiring a personal aid. Approaches that match new financing mechanisms
to the tools of technology embodies the integrated approach that will move the long-term
care system into the future.
POLICY AGENDA
It is necessary to develop a policy agenda that addresses barriers to
technologies that can provide increased independence, quality, and efficiency in longterm care. Strategies to upgrade broadband capabilities and make it universally
available should be a key element of increasing the usefulness and capabilities of
technology. Industry and government will need to work together to produce a set of
25
Technology’s Role in the Future of Long-term care
standards that generates a higher degree of interoperability so that system integration
can take place between different products and different care settings. Other policy
issues include identifying and modifying regulations that impede efforts to implement a
person-centered integrated approach that uses technology to address the needs and
desires of aging individuals. Providers should also be educated on how new care
approaches align with current rules. Financing mechanisms should be developed that
allow appropriate access to proven technologies through the Medicare and Medicaid
programs. Through this process, issues of access can also be addressed to ensure that
the diverse population of aging adults have equal opportunities to the benefits facilitated
by new and existing technologies.
Government leadership and investment can drive the technology agenda by
developing collaborative partnerships with a wide range of stakeholders to address the
needs of an aging society. CAST has advocated that Congress establish a National
Commission that would bring together high level representatives from aging services,
physicians, nursing, hospitals, technology companies, insurance interest, home builders,
finance and banking, university research centers, consumers, policymakers and other
key groups to lay out a rode map for reinventing our care systems. The Commission
would be charged by Congress to bring back a coordinated roadmap within two years.
The Commission would also recommend the proper home in the Federal government to
coordinate such activities among the different agencies. Currently, there is no agency
with that charge. The federal government is also in a position to help build an evidencebase through grants, trails, and demonstration projects. This requires a review of the
present government research strategies. Currently, grant requests generally fall between
the scopes of National Institutes of Health (NIH) and National Science Foundation
(NSF). NIH turns down many aging services technology grant requests as they are not
26
Technology’s Role in the Future of Long-term care
totally medical based and involve too much engineering. NSF turns down the grant
requests because physicians and nurses are involved.
CONCLUSION
The long-term care community, often described as a slow moving, unexciting
field, has the opportunity to drive major changes in our nation’s health care system.
While many leaders acknowledge the fact that, in many ways, the entire health care
system is broken, the age wave gives the long-term care community an opportunity to
reorganize, develop new partners, and lead a dramatic transformation in long-term care
and the broader arena of health care. The field is comprised of many dedicated
professionals who perform miracles everyday in the delivery of care to older adults.
However, it is also a field with tremendous history and a reputation for not being able to
adapt well to change. To be successful in the future, long-term care providers will need
to develop new partnerships and new relationships with technology companies,
information service companies, retailers, acute care facilities, and universities to reinvent
a transformation of care from the institutional environment to a home-based
environment.
Long-term care providers will have to rethink their audience as well. Is the market
only the older adult or is the first contact with potential clients at much earlier ages when
prevention and wellness services can be offered to one age group and different services
to their parents at the same time? Lobbying efforts by the long-term care field have
traditionally focused on funding (Medicaid issues) and quality. Battles over dollars have
gone on for years and will continue to go on if new approaches are not taken.
Congressional staff are worn down by these battles and may be hesitant to help look at
new approaches to care for a field they perceive as always in need of dollars.
27
Technology’s Role in the Future of Long-term care
Small providers like Elite Care have demonstrated that we do not face
technology issues as much as imagination issues. Current technologies already open up
exciting opportunities to reinvent care. Future developments will move at the pace of the
leaders who implement these technologies and work toward rebuilding their models of
care. Yet, new technologies always bring concerns. Privacy and security are important,
but most people in the field feel these can be addressed. Equality of care is important.
Consumers who are able are willing to pay for new technologies may benefit over those
who do not have the income to purchase the technology tools if reimbursement does not
change. The danger will be a society divided even further into the haves and have nots.
If the long-term care field in conjunction with technology partners can demonstrate
quality improvements and costs savings, the public and private payers will have to
consider appropriate reimbursement. If technology isolates older adults, then all these
initiatives have failed. Instead, the opportunity exists to allow technology to open up new
forms of communication for people as they age. Better communication with family,
friends, caregivers, and health care providers should all improve with new tools coming
to market. The opportunity for new hobbies and educational opportunities should help
make retirement a much more rewarding part of the life experience. The challenge is
apparent and the solutions are becoming available. Future generations will judge how as
a society, as policy makers, and as service providers, we respond to this moment in
global history.
28
Technology’s Role in the Future of Long-term care
1
Projections of the Population by Age, Sex, Race and Hispanic Origin for the United
States: 1999-2100 (Middle Series). U.S. Census Bureau, 2003.
2
Anderson GF, et al. Health Care Spending and Use of Information Technology in
OECD Countries. Health Affairs, 2006. 25(3):819-831.
3
Taylor H, Leitman R (eds.). European Physicians Especially in Sweden, Netherlands
and Denmark, Lead U.S. in Use of Electronic Medical Records. HarrisInteractive Health
Care News, 2002. 2(16).
4
Anderson GF, et al. Health Care Spending and Use of Information Technology in
OECD Countries. Health Affairs, 2006. 25(3):819-831.
5
Taylor H, Leitman R (eds.). European Physicians Especially in Sweden, Netherlands
and Denmark, Lead U.S. in Use of Electronic Medical Records. HarrisInteractive Health
Care News, 2002. 2(16).
6
Magnusson L, Hanson E, Nolan M. The Impact of Information and Communication
Technology on Family Carers of Older People and Professionals in Sweden. Aging &
Society, 2005. 25:693-713.
7
Kitazume T. EU-Japan Ties Have Big Potential to Move on to a New Dimension. The
Japan Times, April 29, 2006.
8
Shekelle PG, Morton SC, Keeler EB. Costs and Benefits of Health Information
Technology. Evidence Report/Technology Assessment No. 132. (Prepared by the
Southern California Evidence-Based Practice Center under Contract No. 290-02-0003.)
AHRQ Publication No. 06-E006. Rockville, MD: Agency for Healthcare Research and
Quality. April 2006.
9
Triplett, L. Electronic Supportive Documentation: Welcome to the Future. Nursing
Homes Long Term Care Management, 2002. 51(12):40-42.
10
Wagner, L. New Technologies Enhance Patient Safety. Provider, March 2004:20-37.
11
Kramer A, et al. Case Studies of Electronic Health Records in Post-Acute and Longterm care. U.S. DHHS, Office of the Assistant Secretary for Planning and Evaluation,
2004. Accessible at http://aspe.hhs.gov/dalong-term carep/reports/ehrpalong-term
care.htm.
12
Sheridan J, et al. Virtual Administrator. Nursing Homes Long Term Care Management,
2004. 53(1):27-30.
13
Daly JM, et al. Nursing Home Telehealth System: Keeping Residents Connected.
Journal of Gerontological Nursing, 2005. 31(8):46-51.
14
Laflamme MR, et al. A Pilot Study of Usefulness of Clinician—Patient
Videoconferencing for Making Routine Medical Decisions in the Nursing Home. Journal
of the American Geriatrics Society, 2005. 53:1380-1385.
15
Phillips VL. Using Telehealth Interventions to Prevent Pressure Ulcers in Newly
Injured Spinal Cord Injury Patients Post-Discharge. International Journal of Technology
Assessment in Health Care, 1999. 15:749-766.
16
Magnusson L, Hanson E, Nolan M. The Impact of Information and Communication
Technology on Family Carers of Older People and Professionals in Sweden. Aging &
Society, 2005. 25:693-713.
17
Feeney Mahoney D, Tarlow BJ, Jones RN. Effects of an Automated Telephone
Support System on Caregiver Burden and Anxiety: Findings from the REACH for TLC
Intervention Study. The Gerontologist, 2003. 43:556-567.
18
Vickery K. Assistive Technology Improves Lives of People with Disabilities. Provider,
May 2005: 16-26.
19
Agree EM, Freedman VA. A Comparison of Assistive Technology and Personal Care
in Alleviating Disability and Unmet Need. The Gerontologist, 2003. 43(3):335-344.
29
Technology’s Role in the Future of Long-term care
20
Agree EM, et al. Reconsidering Substitution in Long-term care: When Does Assistive
Technology Take the Place of Personal Care? The Journals of Gerontology Series B:
Psychological Sciences and Social Sciences, 2005. 60:S272-S280.
21
Hoenig H, Taylor DH, Sloan FA. Does Assistive Technology Substitute for Personal
Assistance among the Disabled Elderly? American Journal of Public Health, 2003.
93(2):330-337.
22
Cheek P, Nikpour L, Nowlin ND. Aging Well with Smart Technology. Nursing
Administration Quarterly, October-December 2005. 29(4):329-338.
23
Cutler SJ. Ageism and Technology. Generations, Fall 2005. 29(3):67-72.
24
Pew R and Van Hemel S, eds. Technology for Adaptive Aging. National Academies
Press: Washington, D.C.
25
Center for Aging Services Technologies. “Baby Boomer” Interest in the Use of
Technology for the Delivery of Aging Services and Healthcare: A Summary of Focus
Group Research. American Association of Homes and Services for the Aging, 2005.
26
Boehm EW, et al. Healthcare Unbound’s Early Self-Pay Market: What Vendors Can
Learn From Digital-Ready Consumers. Forrester Research, July 1 2005.
27
Center for Aging Services Technologies. “Baby Boomer” Interest in the Use of
Technology for the Delivery of Aging Services and Healthcare: A Summary of Focus
Group Research. American Association of Homes and Services for the Aging, 2005.
30