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Telemedicine Offers New Way to Manage Asthma

Jennifer C. Murphy

Surprisingly, compliance isn’t always a problem for patients who have asthma. This is what Debora Chan has found during her first two months working with children who have the disease. Her patients are not only complying with their regimen, but they are also enjoying being monitored. Yet, half of these patients will visit Chan only through a series of fiber-optic cables, a modem, and a computer monitor. Despite the distance, Chan said, "I am forming tighter bonds with them because we’re having more contact with them."

Based at Tripler Army Medical Center in Oahu, Hawaii, the Telemedicine In-Home Monitoring Evaluation Pilot project is supported by a grant from the U.S. Army Medical Research Acquisition Activity fund. The pilot study involves 10 pediatric patients 6–17 years old with persistent mild to severe asthma, randomized to two groups. Five children receive traditional in-person patient counseling about managing their disease, while the other five receive the same information through another means, the Internet.

Communicating by e-mail. Exclusion criteria for the project did not include whether the patient had a personal computer or access to one. All children who were Army-dependents, had asthma, and were interested were eligible to participate, including those with a learning or physical disability.

The children assigned to the Internet group speak with Chan, the asthma case manager, through a videotaped recording, which they send to her as an e-mail attachment. Patients then receive feedback electronically. In addition to Chan, a nurse case manager, a pediatric pulmonologist, and a pediatric intensive care specialist supervise the project.

All participants visit the center initially and then at specific time intervals to meet with Chan. Those in the Internet group receive additional training on using the video recorder and computer, if needed. They also receive, on loan from the Army, a home computer and video camera for the duration of the study.

This pilot study, in addition to looking at compliance issues, also aims to examine the impact of patient education on the use of peak flow meters in conjunction with a metered-dose inhaler (MDI) and spacer for asthma management. The participants must record their peak-flow readings every day and videotape themselves using a peak flow meter twice a week. Participants then transmit the videotape and the peak-flow-meter readings to Chan.

The project, said Chan, takes advantage of a technology called "store and forward," which is an alternative to video communication delivered in real time over the Internet. With store and forward, the patients store their video and the diary entries and then forward the files twice a week to Chan, who views the material at her convenience. The primary goal of the asthma program is to show that the Internet-based interactions between patients and their health care providers achieve a level of compliance equal to or better than that achieved by in-person visits.

Assessing the data. Because the pilot study involves only a few participants, Chan and the primary investigator for the project, Lieutenant Colonel Charles W. Callahan, realize the limitations of the pending results. "We’re not looking for statistical significance," Chan said. The group’s primary goal is to determine if the entire project is feasible, not just for them, but also for the participants. Chan hopes to determine if today’s computer technology can be successful at supporting larger projects similar to the pilot project.

The six-month pilot study has been up and running for about three months, with each of the 10 current participants having begun the project at various times. Chan hopes to plan future studies involving telemedicine with a greater number of participants and for a longer duration.

Seeing a need. Interest in the current project originated with a 1997 study by Chan and colleagues that suggested a need for better management of asthma in children using MDIs with spacers. There is evidence in the literature indicating that fewer hospital admissions and emergency room visits occur when a multidisciplinary team aggressively manages asthma than when a multidisciplinary team is not involved.

According to Chan, a common problem among children is the incorrect use of MDIs. That was, in fact, the primary impetus behind the telemedicine project. By properly educating the children and their parents on how to use an MDI and spacer, the health care team may avert subsequent worsening of the pathology, future hospitalizations, and unnecessary increases in drug dosage.

Additionally, the state of Hawaii has a relatively high prevalence of asthma. According to a 1998 article in Morbidity and Mortality Weekly Report from the Centers for Disease Control and Prevention, the prevalence of asthma in Hawaii is 6.0%, affecting 73,100 people. Chan and colleagues estimate the number to be even greater now, at 103,000, with almost 26% of affected people younger than 18 years. After release of the 1997 National Heart, Blood, and Lung Institute guidelines on the diagnosis and management of asthma, Chan and her colleagues developed the telemedicine program and the home-management plans used for educating the patients.

Working with new technologies. One issue that is inevitably raised when sensitive data are transmitted electronically is privacy. Chan said all available safety and security precautions were taken when the study was designed. It was developed by using guidelines specific for the electronic transmission of medical data. All patients are assigned a unique, anonymous identifier, and all information is encrypted. Furthermore, patient-specific data is password protected and kept in an office that is securely locked. Once the project is finished, all electronic data will be erased.

If the participants need help with any part of the program, they can access the project’s home page. All pertinent technological questions—for example, how to work the cameras—and other relevant information can be found on the project’s Web site. The user-friendly site includes a virtual tour of what is expected of both the child and the parent throughout the study. It also contains a daily asthma diary, specific instructions, activities, requirements, and a specific timeline relevant to each patient.

Thus far, Chan said, most of the participants have had few problems using the technology, even the 30% who were initially considered computer-illiterate.

Telepharmacy presents pharmacists with some potential gray areas, however. Currently, Chan said, pharmacists are not reimbursed for any service they provide to people if it is done over the Internet. On May 1, the Department of Health and Human Services issued a memorandum explaining reimbursement for telehealth services provided to Medicare beneficiaries starting October 1. A project like Chan’s would not be covered because it uses store-and-forward technology; only real-time services performed by a health provider are eligible for reimbursement, according to the legislation that authorized the telehealth payments. Also, pharmacists are not recognized in the Social Security Act as health care providers who may bill Medicare for patient care services, such as those administered as telehealth.

All participants in the Tripler telepharmacy project are dependents of Army personnel. Chan said she and her colleagues expect the results to be applicable to people outside of the military health system, those with other diseases, such as diabetes mellitus and cardiac conditions, and even to people incarcerated in correctional facilities.

Although Chan said the project is going well and is showing success with people who have not had prior computer experience, crossing the digital divide in larger populations may be more difficult. All participants in this project were loaned a personal computer by the Tripler Army Medical Center. Funding on that scale to non-Army dependents or patients is not realistic, Chan said, and poses a viable limitation to applications of telepharmacy projects. She hopes the potential benefits of telepharmacy, such as freeing up valuable physician, nurse, or pharmacist time to attend to more complicated and time-consuming health issues, are not overshadowed by the potential drawbacks.