ection 6.7 Optimize
Optimization Strategies for Telehealth and
Home Monitoring
This tool will increase your knowledge of telehealth and home monitoring, including benefits,
challenges and implementation readiness and strategies.
Time needed: 6 hours
Suggested other tools: NA
Introduction
Home telehealth is health and education services delivered to patients in their homes. The technology
used to deliver the services includes telecommunication devices like the telephone and
telecommunication-ready health care monitors, such as blood pressure cuffs. Home telehealth
enables nurses can to be more alert to patients’ needs and address them more quickly. More
comprehensive management of their conditions helps patients stabilize more quickly and become
more competent in self-management skills.
How to Use
1. If unfamiliar with telehealth, review the glossary of terms.
2. Review current literature relating to benefits and challenges in using home telehealth.
3. Understand the current state of home telehealth technology and its relationship to electronic
health records (EHR), health information exchange (HIE), and other health information
technology (HIT).
4. Plan to adopt home telehealth for targeted patients, recognizing the needed to address
technology implementation, workflow changes, necessary documentation, and planning for
transitioning the patient to self-management.
Glossary of Terms
The following terms are defined by the American Telemedicine Association in its Home Telehealth
Clinical Guidelines, available at:
http://www.americantelemed.org/docs/default-source/standards/home-telehealth-clinicalguidelines.pdf?sfvrsn=2
Home telehealth encompasses remote care delivery or monitoring between a health care provider and
a patient outside of a clinical health facility, in their place of residence (home or assisted living). The
National Care Planning Council Guide to Long Term Care Planning also includes education services
delivered to patients in their homes as part of its definition of home telehealth. See:
http://www.longtermcarelink.net/eldercare/home_telehealth.htm.
Interactive home telehealth includes the utilization of two-way interactive audio video involving the
patient and health provider.
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Telemonitoring includes the collection of clinical data and the transmission of such data between a
patient at a distant location and a health care provider. This is done through a remote interface so that
the provider may conduct a clinical review.
Self-monitoring is the periodic and scheduled use of a device by the patient to obtain clinical data
(such as blood pressure, glucose, weight, and temperature) that is used by the patient to measure his
or her own health status.
Telemedicine is a term sometimes used synonymously with telehealth, although some reserve the
term telemedicine (and associated specialty services such as teleradiology, telemental health,
telepathology, and teledermatology) to refer only to direct patient clinical services. Telehealth is a
broader concept.
The distinctions in the diagram below between phone monitoring and telemonitoring were made by
Quality Insights of Pennsylvania in its Home Telehealth Reference 2006/2007 In addition, teletriage
is distinguished from phone monitoring and telemonitoring:
Teletriage is the unscheduled, appropriate disposition of health-related problems by skilled clinicians
via telephone or electronic information processing technologies that have been initiated by the
patient/caregiver.
Benefits of Home Telehealth
As the U.S. population ages, people are better educated, more comfortable with the use of
technology, and most want to live in their homes for as long as possible. At the same time, more
people have chronic conditions that consume ever more of the nation’s health dollar. This is
coinciding with a critical shortage of nurses and other health care personnel to care for this
population. Health care providers are forced to do more with less, as reimbursement decreases and
the focus on quality and clinical outcomes increases.
In its Home Telehealth Clinical Guidelines (2003) (available at:
http://www.americantelemed.org/practice/standards/ata-standards-guidelines/home-telehealthclinical-guidelines) the American Telemedicine Associations notes: “Advances in telecommunication
technologies used in health care over the last decade have expanded application possibilities. Home
telehealth began with home health agencies providing virtual visits by collecting one or more
personal vital signs, which were then sent to a remote monitoring station. Today, with the use of
inter-active video and store and forward, applications in the home have expanded. In addition to
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remote monitoring of vital signs, services provided by home health agencies now include such
diverse applications as hospice (palliative care), rehabilitation, case management, chronic disease
management, virtual house calls, post-surgical follow-up and more.”
Since these guidelines were published, telehealth technology has become simpler to use and many
more “smart” devices have been and continue to be introduced. For example, there are wearable
wireless devices that can combine an accelerometer, stethoscope, electrocardiogram, and other
functions to collect data from continuous monitoring. Sneakers embedded with radio frequency
identification (RFID) may read bar codes on food products to help monitor a patient’s nutrition. As
of this writing, at least one smart phone company has created a watch/smart phone that could
potentially store data to an app that could convey information directly to a remote clinical work
station when an immediate intervention is needed.
In late 2012, the Institute of Medicine (IOM) conducted a workshop and published a summary on
The Role of Telehealth in an Evolving Health Care Environment (available at:
http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-CareEnvironment.aspx). It identified a number of benefits and challenges.
Benefits of Telehealth:
 Improved management of hypertension, congestive heart failure, and diabetes.
 Improved physiologic measures.
 High rates of satisfaction.
 Better adherence to medication.
 Support “management by exception” so that home health services can be concentrated on
individuals shown to need the most help on any given day, thus increasing the number of
patients that can be managed by one nurse. (See: “Strategies for Incorporating Telehealthbased Care Coordination and Management Solutions into Programs to Integrate Care for
Dual Eligibles” (2012), Center for Technology and Aging available at:
http://www.techandaging.org/Dual_Eligibles_Issue_Brief.pdf.)
 Reductions in hospitalizations, readmissions, lengths of stay and costs. (For research on
substantial hospitalization-related cost savings from home telehealth, see: Chen, H. et al.
(2011) Telehealth and Hospitalizations for Medicare Home Healthcare Patients, American
Journal of Managed Care, available at: http://www.ajmc.com/publications/issue/2011/20116-vol17-n6/AJMC_11jun_ChenKalish_e224to30. For specific findings from the Home Care
Association of New York State, see: http://www.hca-nys.org/TelehealthBriefingDoc.pdf.)
Telehealth Challenges:
 Patient preferences and acceptance of devices and intrusion in their lives.
 Attrition in use of these technologies after home health services end. To address this issue,
studies suggest putting telemonitoring devices in the home for the first half of a patient’s
home health period, using this time to contact the person frequently, reiterate directions, and
coach. Then remove the devices in the second half of the period, resume in-person visits but
monitor for and reinforce the self-care routines. See the Guide to Long Term Care Planning
from the National Care Planning Council available at
http://www.longtermcarelink.net/eldercare/home_telehealth.htm).
 Using off-the-shelf devices, such as mobile phones, gaming systems, social media, etc. to
connect to providers. Issues include whether the devices are compliant with health care
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interoperability standards, such as Health Level Seven [HL7] Data Communications
Protocol.
 Management of data flowing in from all the devices, and presenting the information to
providers in a meaningful and actionable way.
 Policy changes are needed in everything from clinician licensure/certification, especially
across state lines (see the American Telemedicine Association Telehealth Nursing Fact Sheet,
available at: http://www.americantelemed.org/docs/default-documentlibrary/fact_sheet_final.pdf) to reimbursement by Medicare, Medicaid, and commercial
payers.
 Broadband connectivity remains a challenge in rural and underserved areas. (See the Federal
Communications Commission Eighth Broadband Progress Report, June 2011, available at:
http://www.fcc.gov/reports/eighth-broadband-progress-report).
Home Telehealth Technology and Terminology
Home health technology has significantly improved in its usability. Full-scale work stations and
peripherals may now have only one on/off button, with color-coded icons and easy-to-follow verbal
and/or printed directions to help patients obtain and transmit information. Many require only a “plain
old telephone system” (POTS) to use. For example,
A patient with congestive heart failure can step onto an automated scale connected to the
household POTS and have weight submitted directly to the home health agency. Telenurses
wear an alerting device and receive the name and phone number of the home care patient
who has gained one-to-two pounds within a 24-hour period, so the patient can be contacted
immediately by phone. With connectivity to the patient’s electronic health record (EHR), the
nurse is able to order a diuretic for the patient—immediately if necessary.
As you approach the marketplace for telehealth services, the following are some key terms to
understand (in addition to those discussed in Section 1.3 Interoperability for EHR and HIE):
Asynchronous means that transmission of information occurs in one direction at a time.
Asynchronous transmission is used in the telehealth encounter type called Store and Forward (S&F).
Bandwidth is a measure of the information carrying capacity of a communications channel that is a
practical limitation with respect to size of images that can be communicated, cost, and capability of
telehealth services.
Broadband refers to communications (e.g., broadcast television, microwave, and satellite) capable of
simultaneously transmitting several messages.
CODEC is an acronym for coder-decoder and is the capability of converting analog video and audio
signals into digital video and audio code—essential for transmission of data and its storage (such as
in an EHR).
Data compression refers to the ability to reduce the volume of data to smaller packets that can
facilitate data transmission. Technical standards exist for various types of data compression.
Document camera is one that can display written or typed information, photographs, graphics, and—
in some cases—x-rays.
Fiber optic cables transmit data, voice, Internet access, and video with speeds in excess of 100 Mbps
(for comparison, see POTS and Trunk or Digital Subscriber Lines); the service is very expensive and
are usually used either by the telephone company itself to support other services, or local campus
connectivity.
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Integrated Services Digital Network (ISDN) is a common dial-up transmission path for interactive
video (ITV). Per minute charges accumulate at a contracted rate and are billed to the site placing the
call.
Interactive video/television is analogous with video conferencing technologies that allow for twoway, synchronous, interactive video and audio signals for delivering telehealth. It is often
abbreviated ITV, IATV, or VTC (video teleconferencing).
Plain old telephone system (POTS) is a telephone service providing voice and data transmission at
speeds of 33 to 64 kilobits per second (Kbps).
Synchronous means transmission of information can occur in both directions at the same time,
supporting interactive video connections. Synchronous transmission is used in the telehealth
encounter or consult type called Real Time.
Trunk or Digital Subscriber Lines from the telephone company offer high-speed data, voice, or
compressed video access in two directions. T1/DS1 has a transmission rate of 1.544 megabits per
second (Mbps) and T3/DS3 has much faster (and costlier) service speeds of 45 Mbps.
Telematics refers to the use of information processing based on a computer (e.g., EHR) in
telecommunications, and the use of telecommunications to permit computers to transfer programs
and data to one another.
Universal Service Administration Company (USAC) administers the Universal Service Fund, which
provides affordable health, education and other telecommunication services to rural facilities and
others.
Videoconferencing is the two-way transmission of digitized video images between multiple
locations.
WiFi is the name of wireless networking technology that uses radio waves to provide wireless highspeed Internet and network connections.
Implementing Home Telehealth
Just as with EHR and HIE, in planning to adopt home telehealth technology, it is important to apply a
process that includes: a readiness assessment of both the home health agency and each patient to
whom home telehealth services are offered; optimal selection of equipment; proper implementation;
attention to workflow changes; assurance of necessary documentation; and planning for transitioning
the patient to self-management.
Readiness of Home Health Agency for Home Telehealth
An organizational evaluation should be done to determine whether the agency is ready to provide
home telehealth services. The assessment might include:
 Availability of telehealth nurses. These are generally registered nurses who may have
undertaken a certification program (which may be a state requirement), but at a minimum
demonstrate:
o Ability to be approachable via the phone (e.g., courteous, clear and understandable
language, non-judgmental, not minimizing patient complaints)
o Good listening skills (e.g., discovering details in patient conversation, interrupting
patient only if necessary)
o Effective interviewing techniques (e.g., asking open-ended questions, active listening,
motivating)
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o Ability to detect emotional cues via the phone (e.g., crying, dyspnea, silence)
o Critical thinking and problem-solving skills, collaboration with patient/caregiver in
care planning
o Appropriate and medically acceptable interventions, including consideration of
extraneous factors/barriers to implementation of care plan
o Ability to evaluate a care plan and its implementation, including obtaining
understanding, re-education as needed, revision of plan as needed.
 Availability of supporting documentation technology, such as EHR to document telehealth
encounters in a timely, accurate, and complete manner and receive and use data feeds.
 Availability of supporting HIE technology, such as using the Direct protocol for email and/or
participating in an HIE organization (HIO).
 Call system that appropriately handles patient/caregiver calls (see Workflow Changes
below).
 Policy and procedure development and compliance practices. The organization should have a
culture of using written procedures to guide work; and to ensure compliance with policies for
clinical interventions, reimbursement, service productivity, and quality of service.
Readiness of Patient for Home Telehealth
For each patient, there should be a physical and cognitive assessment of capabilities for using home
telehealth services. For example:
 Does the patient have the cognitive skills to remember or perform certain tasks without inperson coaching? Are there any language or health literacy barriers that would preclude
success?
 Does the patient have physical limitations, such as hearing and vision, needed to
communicate with a telehealth nurse? Does the patient have sufficient mobility to use
telehealth devices? Is a caregiver always present to perform these services if necessary?
 Is the home environment conducive to implementing telehealth? Distances between the
telehealth work station, telephone, and usual patient location should be considered. A layout
of the physical area and the patient’s normal path can help assess what furniture might need
to be moved and where cables can be safely placed. If furniture moving is necessary, will
there be support for this if furniture is heavy?
Selection of Equipment
To select the right equipment, consider the following features (in addition to those relating to terms
defined above and to those described in Section 2.10 Requirements Analysis and Prioritization for
EHR and HIE):
 Vendor-related considerations
o Minimum number of units to acquire
o Monitoring service offered
o Equipment obsolescence
o Cloud-based storage
 Product-related considerations
o HL7 compliant
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o Size/weight for portability
o Backup battery and/or operational batteries
o Video quality, if applicable
o Sound quality, if applicable
o Clinical peripherals
 FDA approved
 Vendor flexibility
o Security controls meet HIPAA requirements
 Agency-side ease of implementation
o Integration with EHR
o Connectivity to HIE services used
o Special equipment (e.g., cameras, connectivity) setup
o Digital picture download
 Ease of implementation in a home
o “Plug and play” devices that fit standard telephones and computers
o Need for routers, (internal/external) modems, and other peripheral devices
o Number of peripheral devices (e.g., automated scale and other clinical monitoring
devices as well as computer-related peripherals such mouse, smart phone) that can
function at one time (i.e., how many serial ports)
o Digital picture upload
 Agency-side ease of use
o Ability to transmit, retrieve, and store data
o Ability to generate clinical, productivity, and usage (e.g., telephone charges) reports
o Call routing capability
o Programmability for unique patient needs
o Education content
 Ease of use in a home
o Easy-to-understand icons
o Accommodation for limited English proficiency, low health literacy, vision/hearing
issues
o Equipment reliability
o Sanitation and safety factors
Implementation
In addition to the normal installation process, system configuration, testing, training, and go-live (see
Section 4 tools), consideration should be given to how a telehealth nurse will install the necessary
devices in the client’s home. There should be no need for special technology training. But “tele-
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proofing” should be performed (once an assessment is done to support that the client and home are
suitable for home telehealth) to ensure safety, including:
 Appropriate placement of devices so that cabling distances are minimized
 Duct-taping cables to the floor
 Using colored tape on rearranged furniture
 Training the patient/caregiver
 Leaving easy-to-read instructions
 Clearly marking/programming device with home health agency phone number
 Ability to swap clinical peripheral devices as needed
 Check on telecommunication costs, especially for those who need to transmit data and
communicate with the agency frequently
Workflow Changes
In addition to a nurse spending a much greater percentage of time on the phone instead of in the field,
the following workflow changes should be considered:
 The equipment should support the ability for data flowing into the agency to be routed
automatically to the right computing devices, patient records, and even fields within an EHR.
Nurses should not have to spend time filing electronic data.
 Incoming call routing, wait-time management, voicemail messaging, triage, and disposition
should be evaluated. For example, there are significant differences when using an automated
telephone menu vs. a live receptionist.
 Telephone considerations and placement of nurses in the agency should consider the nature
of the clients and conversations. Nurses may have to speak very loudly to their clients, which
is not conducive in an environment without sound-proofing in the cubicles. Spending
considerable time on the phone requires comfortable headsets and the need for a certain
amount of exercise. Will Bluetooth headsets for smart phones be a suitable answer, or will
this be more disruptive to others and potentially a privacy issue?
 Nurse assignment to clients should consider that home telehealth monitoring is a 24x7
operation. Shift nurses may be required and must have access to client data. If the agency is
not 24x7 accessible, there must be a clear path for incoming calls/alerts to ultimately be
responded to by a nurse. Consideration needs to be given to whether a recorded message
directs the caller to another resource, or there is an answering service. There must be specific
policies for after-hours response time. There must be remote access to data being received, if
not also to the client’s full EHR. There may need to be additional resources to direct
clients/caregivers to other providers and/or community resources.
 Workflow relating to when it is appropriate for a nurse to conduct an in-person visit and how
access is provided to data and resources during the visit vs. at the agency.
 Documentation may also vary with use of a desktop device with telephone connection and
field-ready devices. This includes not only access to data but the ability to fully document on
a timely basis. In an office with many calls, policy should support the ability to complete
documentation prior to taking another call. It may be necessary to use a white board for quick
note taking that can easily be erased for the next call.
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Transitioning the Patient To and From Telehealth Services
As noted earlier, home health services are available only for a specified period of time. Not only
must you consider how to introduce a client to telehealth, but how to wean the client from the home
health agency monitoring. Clients should be assessed on their ability and willingness to accept
telehealth services, as well as the potential for the services to be fully self-managed. Care planning
should be carefully thought through so the patient/caregiver knows how to problem solve and whom
to contact for what type of service.
Copyright © 2014 Stratis Health.
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Updated 01-01-14