by Kimberly Shea, PhD, RN
The University of Arizona College of Nursing
This column was made possible by an educational grant from
Chamberlain College of Nursing
Shea, K. (October, 2011). Guest Editorial: Home Health Telemonitoring: Don’t forget the goal of self-care. Issues, Impacts and Insights Column. Online Journal of Nursing Informatics (OJNI),15 (3). Available at http://ojni.org/issues/?p=861
I’m delighted to feature the guest commentary of Kimberly Shea, whose expertise in home care and informatics has led her to ask important questions about our use of telemonitoring to facilitate home care. I’m sure you will enjoy her thoughtful and provocative discussion.
Judith Effken, OJNI Senior Editor
I am an informatics advocate and whole-heartedly believe in technology for enhancing patient care. There is no way that our healthcare system could ever consider providing adequate care for all the Americans with disease or injury without the use of technology in the community. However, I continually reflect on an unresolved discussion that I had with a colleague. My stand was that patients must learn how to assess and take care of themselves. I believed that telemonitoring technology should be time limited and used as a teaching tool to transfer care responsibility to patients and their families/friends. My colleague believed that we should further develop a system that can provide on-going telemonitoring for people living with chronic conditions because a single nurse can monitor hundreds of patients remotely. We did agree that the current method of monitoring a patient remotely is in an infantile state and that readmissions are costly. To clarify, we were discussing remote telemonitoring that is commonly used in home health care for vital signs such as blood pressure, weight, temperature, oxygenation and blood sugar. I strongly believe that as we design and implement technology for home health care, we need to consider the possibility that long term telemonitoring may be detrimental to motivating patients to care for themselves. I believe that the responsibility for long term monitoring of vital signs and symptoms should rest with a patient/family/friend professional and not a remote monitoring nurse.
My background as a home health nurse predisposes me to believe in the value of self-care. Home health care involves making a visit to a home in response to a provider’s order for assessment and follow-up care after a health related event has temporarily compromised the patient. Patients are usually post surgical or experiencing an exacerbation of a chronic condition. During the visit the nurse evaluates the patient’s condition, monitors current status, provides healthcare services and teaches self-care activities. If possible, family members or friends are included in the instruction so that there is someone nearby that is knowledgeable and can assist the patient. Acknowledging that home health nurse visits are time-limited requires that all involved must listen intently, ask questions and demonstrate understanding. Frequently a hard copy or website is provided as a supplement to the self-care instructions; but the onus of providing care is on the patient, family and/or friends. The number of visits a patient receives is derived from a complex algorithm consisting of insurance type, service provided and self-care capability. Home health visits focus on teaching patients: how to perform care, what are important signs and symptoms to monitor, and when to seek professional help. The goal is to transition the patient to an independent state by monitoring patients while their health risk is high and providing tools for self-care that come from a professional, evidence-based resource.
During my years of home health care, I traveled thousands of miles, covering a county that stretches over 9000 square miles. I could have been much more efficient with the use of remote monitoring. So I returned to graduate nursing school and obtained a PhD that combined home health and telemonitoring to examine relationships between patient, nurse and home helpers. Home telemonitoring technology with feedback that motivates self-care is now the focus of my research. I have a better understanding of the value of limiting professional intervention and immediately transferring responsibility for understanding their health to the patient and family. My dissertation research further confirmed my beliefs. I observed patients with long term telemonitoring rely on the remote nurse to call if anything was wrong. The patients did not look at their vital sign values before they sent them to the nurse and even less effort was given to attempts at interpretation. Additionally, a frequent reason that patients gave for liking the technology was that the service included a direct phone line to the telemonitoring nurse. Without the telemonitoring service, direct contact with a health professional would involve being put on telephone hold, waiting hours for a return phone call or reentry into the healthcare system via clinic, urgent or emergency care or rehospitalization.
It is imperative that the cost of repeated readmissions be avoided; but, as community-based informaticians, we should focus our efforts on providing tools that enable patients to be independent with the best quality of life possible. If a patient requires on-going vital sign monitoring for long periods of time then they are living in an environment that could be considered a home-based telemetry unit. Do we really want to create this level of care? Despite many years of research, methods of achieving self-care are not defined because there are so many differences between individual patients’ resources, abilities and motivations. These differences will always be present. Home health nurses are experts at providing care that is tailored to individuals in their homes. Self-care should be a partnership among professionals, patient and family. Telemonitoring should be used as a tool to teach patients the importance of evaluating and acting on their vital signs and symptoms daily. Additionally, telemonitoring should serve as a source of content for communication such as reinforcing the interpretation of numbers that comprise the vital signs, not as a place holder to provide access to a nurse. Self-care requires effective communication that flows in both directions and prompt access to professional advice. The need for effective communication should be the impetus for community-based informaticians to develop technology that will support improved content of communication and not just be another type of communication. We are at a crucial point where the home is the new healthcare place of the future, and we need to keep our focus on the goal of integrating technology. I strongly believe that the goal of telehealth is to support the individual to live independently and understand how to provide their own day-to-day care in such a way that their quality of life is optimized.
Proofed by Barbara Smith