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Vol. 6 No. 1    Vol. 6 No. 2    vol. 6 No. 3

Telehospice: Using Telecommunication Technology for Terminally Ill Patients

Pamela Whitten,*, Gary Doolittle,# and Seth Hellmich, MA*
*Michigan State University
#University of Kansas Medical Center

Abstract

In 2000, a bi-state telehospice project was launched in Michigan and Kansas, designed to provide end-of-life services to hospice patients and their caregivers. Videophones were placed in the homes of hospice patients and hospice providers used this technology to supplement traditional care. This paper presents preliminary results from the first of this two-year project. Methods: Hospice providers (nurses and social workers) completed pre-perception surveys. Hospice patients/caregivers participated in open-ended telephone interviews. Patients choosing not to receive the service completed a decline survey to document the reasons for their decision. Finally, activity logs and patient charts yielded utilization data. Results: Hospice providers are cautiously enthusiastic about telehospice, but initially skeptical about the comparable quality with traditional visits. Patients and caregivers using telehospice, on the other hand, are uniformly positive about the service and wish to see increased utilization within their own care plans. Utilization data indicate steady use with decline forms reflecting some patients' hesitancy in receiving the service in the first place due to feeling overwhelmed.

Introduction

In spite of rapid medical advances and great changes in the health care system, one thing has remained constant: everyone eventually will die. Startling results from recent studies reveal that many people die in great pain, suffering at the hands of well-intended, but sometimes unskilled providers (Field & Cassel, 1997; The SUPPORT Investigators, 1995). In addition, although 9 of 10 Americans would prefer to die at home in the company of loved ones, in fact, more than 85% die in an a hospital or extended care facility (Valadeck, 1995). Clearly we are challenged to assure a humane and compassionate end-of-life experience for the dying.

Hospice was first introduced in the 1970s (HFA, 2001). Hospice emphasizes non-interventional care of the dying in a home setting. Family members are integral participants in the process. They provide day-to-day care, stepping into a caregiver role that is often entirely foreign. For this reason, the hospice team provides counseling services and support to family members as well as patients.

While the number of hospices has grown in the last twenty years, less than 25% of the dying in the United States access this specialized service (Von Gunten, Neely & Martinez, 1996). For rural populations, hospice expertise may not exist locally (Buehler & Lee, 1992). Some patients experience their illness in isolation, without caregiver support from family or friends (Smith, 1994). Minority populations are sometimes underserved, including cases when they are located in urban settings within blocks of large hospice organizations (Topoleski, 1997). Cost may prohibit access to hospice professionals by some patients (Cher & Lenert, 1997). Even when hospice care is readily available, some physicians fail to refer patients. Clearly, provider education is essential to assure quality end-of-life care (Cohen, 1997).

Telemedicine can transcend barriers to quality end-of-life care by providing clinical and educational services. Hospice services via telemedicine, coined telehospice (TH), can be delivered directly into a patient's home in underserved rural and urban sites, and to patients with limited caregiver support (Doolittle, Yaezel, Otto, & Clemens, 1998). In 2000, a two-year bi-state home telemedicine project was launched in Kansas and Michigan, designed to target hospice recipients and their families. This paper presents data from the first year of this project. We begin with an overview of hospice care, followed by a general discussion of telemedicine. Next, we review previous research on delivering hospice services to the home via telemedicine. We then describe the bi-state project and first-year research findings, including issues facing hospices when implementing such a service. We conclude with a discussion of the implications for hospice care.

An Overview of Hospice Care

The goal of hospice care is to improve the quality of a patient's last days by offering comfort and dignity (Hospice Foundation of America, 2001). In addition, hospice is charged with providing supportive care to family members and friends (Weitzner & McMillan, 1999). Care is provided by a team-oriented group of specially trained professionals, volunteers and family members, who address all aspects of the dying process, with special emphasis on controlling a patient's pain and physical discomfort. Hospice care also deals with the emotional, social and spiritual impacts of the disease on the patient's family members and friends, by offering a variety of bereavement and counseling services before and after a patient's death. (National Hospice and Palliative Care Organization {NHPCO} 2001). For those receiving hospice care, 80 percent will die at home, with 18% dying in an extended care facility (NHPCO, 2001).

Family members are integral participants in the process. They provide day-to-day care, stepping into an intense caregiver role that often is entirely foreign (Brown & Stetz 1999). Members of the hospice staff make regular visits to the home for patient assessment and psychosocial support.

The process of hospice care begins with the development of a care plan. The care plan is tailored to meet individual needs of the client and family members. The plan may include nursing care, personal care, social services, counseling, even homemaker services (Buckingham, 1996). The frequency of home visits is determined based on the patient's individual needs. Upon initial admission to hospice, visits may be relatively infrequent, perhaps weekly. As the disease progresses, the number and duration of home visits may be increased.

Although this is currently considered the model for excellent end-of-life care, it should be remembered that the hospice team develops a plan of care, overseeing the custodial efforts of the caregiver. While hospice personnel are on-call 24 hours a day, seven days a week, they are available primarily for home nursing and to guide caregivers in their custodial role. Hospices do not, as a rule, provide around-the-clock nursing care.

In 1999, hospices in the U.S. cared for over 700,000 dying patients, an increase from 540,000 the year before (NHPCO, 2001). While these numbers are encouraging, the large majority -- more than 70% -- of people in the U.S. die without the comprehensive, holistic approach that hospice care offers.

The reasons patients and families fail to access the hospice systems are many and varied (Dahlin, 1999). While most Americans wish to die at home, this can only become a reality when a strong network of family and friends is willing to step into roles as primary caregivers, assuming the day-to-day care of the hospice recipient. Many hospices will not admit a patient unless a family member or friend is available to serve in the integral role of caregiver (Dahlin, 1999).

Where hospice care is available, physicians sometimes fail to refer patients due to lack of awareness. Some providers, both physicians and nurses, see death as a failure, something to be avoided at all costs. Referring to hospice would be open acknowledgement of this obvious "failure." Some physicians are uncomfortable with "giving up" or fear that patients will lose hope if referred for hospice care. Furthermore, our present system of Medicare reimbursement requires physicians to certify a patient's condition as terminal, one associated with a prognosis of six months or less. This is sometimes a difficult call, particularly for a patient suffering from a terminal illness other than cancer. Estimating terminal prognosis is a major barrier to hospice care (NHPCO, 1998). Although acceptance of the concept of hospice is growing, access to hospice services can still pose a challenge. Even though over 3,100 hospices operate in the U.S., hospice care is particularly difficult to access in rural areas (Buckingham, 1996). Several barriers limit access to rural hospice resources. Personnel with specialized hospice expertise may not exist locally (Buehler & Lee, 1992). Large geographic coverage areas, coupled with low population densities found in the rural sector, make delivery of hospice care more challenging. Finally, for some, cost may prohibit access to hospice professionals (Cher & Lenert, 1997).

For many with private insurance, hospice benefits are pitifully inadequate, covering only a minimum number of nursing visits and ancillary services. In such cases, patients often hold out as long as possible, choosing to avail themselves of hospice services only at the very end, rather than "squander" the benefit before it is "truly needed." The scenario is worse for patients with no insurance coverage. Most would rather go without rather than run the risk of accruing debt for surviving family members. Because of these obstacles, many rural residents are forced to use inpatient or long-term care facilities for hospice services instead of having the choice of dying at home.

Another challenge is to deliver hospice services cost efficiently. In the U.S., Medicare is the largest payer, covering more than two-thirds of hospice recipients. Under the Medicare plan for hospice benefits, patients agree to a non-curative treatment approach for their terminal illness. In order for hospices to receive Medicare payment, comprehensive care addressing the "whole patient" must be provided, which may include physician services, home nursing visits, home health aide and homemaker visits, social work and counseling services, bereavement counseling, medical equipment, drugs related to the hospice diagnosis, physical and speech therapy, and dietary counseling. More recently, as part of the effort to balance the federal budget, the Medicare reimbursement rate was decreased for rural patients. In theory, lower wages for hospice personnel in rural areas should translate into lower overhead expenses. In reality, many urban-based hospices care for rural clients, incurring additional expenses related to travel for home visits. By decreasing the reimbursement for rural patients, an undue financial burden was placed on those urban hospices serving rural areas. Today, some medical communities employ telemedicine in order to allay these barriers to quality service and care for all types of health services.

Telemedicine

Communities are seeking new solutions to address the important health care issues of rising costs, improved access to services, and acceptable levels of quality and continuity of care. New approaches including telemedicine and telehealth are emerging to address some of these issues. Perhaps the most innovative technology introduced in the health care arena, telehealth has a potentially bright future. Advances in the last decade have expanded the concept of telehealth to include any technology employing telecommunication technologies to deliver health services. This may include videoconferencing on personal computers, larger room-based systems or even regular analog phone lines. It may also include applications of Internet telephony, including data, voice and/or audio transmitted through the Internet (Whitten & Gregg, 2001).

Telecommunication technologies have been used for medical diagnosis, care and education since the invention of the telephone. Telehealth techniques, as defined previously, have been developing for the past four decades. Wittson and colleagues (1961) were the first to employ telehealth for medical purposes in 1959 when they set up telepsychiatry consultations via microwave technology between the Nebraska Psychiatric Institute in Omaha and the state mental hospital 112 miles away (Jones & Colenda, 1997; Wittson, Affleck, & Johnson, 1961). In the same year, Montreal, Quebec, was the site for pioneer teleradiology work being done by Jutra (1959).

In the 1970s, there was a flurry of telehealth activity as several major projects developed in North America and Australia, including the Space Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project of the National Aeronautics and Space Administration (NASA) in southern Arizona; a project at Logan Airport in Boston, Massachusetts, and programs in northern Canada (Dunn, Conrath, Acton, Higgins, Math, & Bain, 1980). Grigsby and Kaehny (1993) reviewed telehealth activities undertaken prior to 1993. They found that with the exception of the 20-year-old telehealth program at Memorial University Hospital of Newfoundland, none of the programs begun before 1986 had survived. Although data are limited, early reviews and evaluations of these programs suggest the equipment was reasonably effective at transmitting the information needed for most clinical uses and that users were for the most part satisfied (Conrath, Puckingham, Dunn, & Swanson, 1975; Dongier, Tempier, Lalinec-Michaud, & Meunier, 1986; Fuchs 1974; Murphy & Bird 1974). However, when external sources of funding were withdrawn, the programs simply folded. Perednia and Allen (1995) suggested the failure of these programs was caused primarily by the inability to justify them on a cost-benefit basis. Other researchers questioned the role of other potential issues such as limited physician acceptance (Michaeis, 1989).

The decades of the 1960s, 1970s, and 1980s witnessed a series of telehealth pilot and demonstration projects. In the early 1990s, new and fairly inexpensive digital technologies became commonly available, enabling video, audio and other imaging information to be digitized and compressed. This facilitated transmission of information over landlines with relatively narrow bandwidths, instead of through more expensive satellites, or relatively unavailable private cable or fiber optic lines. In 1992 there were only nine interactive-mediated telehealth programs in the U.S., performing a total of 1,715 consultations. By 1996, there were 69 programs, performing a total of 20,000 consultations (Grigsby & Allen 1997).

Preliminary studies indicate telehealth is a viable alternative for provision of health care (Perednia & Allen 1995). Indeed, research findings related to medical feasibility and satisfaction testify to the potential of this alternative. Allen and colleagues reported that the telehealth interaction was found to be a reasonable substitute for an on-site patient-physician encounter, in terms of patient-physician satisfaction and ability to transmit information and diagnoses.

Technological enhancements in recent years have expanded the telehealth paradigm. Telehealth providers have a wide range of choices for equipment and delivery structures for provision of care. Telehealth is employed in a wide range of settings, including specialty care from urban to rural hospitals, schools, jails, mental health centers, and patients' homes (Whitten, Doolittle, Hellmich, & Cook, 2000). Prior research has documented the feasibility and efficacy of delivering traditional home health services via telemedicine. For example, the Department of Public Health and Environmental Science in Japan conducted a study using videophones for home health services for patients afflicted with ailments ranging from muscular dystrophy to arthritis (Takano, Nakamura, & Akao, 1995). Results demonstrated a statistically significant improvement in nearly every parameter of communication, independence and social cognition over the study period. In addition, health care workers reported general satisfaction with the usefulness of the technology in assessing clients' conditions and family relations.

In another study, Kaiser Permanente Medical Center examined Tele-home Health care in order to assess satisfaction and quality of care (Johnston, Wheeler, Deuser, & Sousa, 2000). Preliminary findings indicated that patients liked using the home video system, found it simple to use, and stated it was very reassuring. Moreover, staff satisfaction with the system was very high.

A Kansas-based home health pilot study documented the feasibility of using telehealth technologies to bring services into the homes of patients in Kansas (Whitten, Collins, & Mair, 1998). The focus of the project was to demonstrate the feasibility of installing equipment in patients' homes and to track patient and providers' perceptions of the technology. A total of 54 subjects received some type of telehealth-based home health care during the course of the study. The pilot study concluded that telehealth equipment could be installed and used to see patients in their homes. On the whole, patients perceived the system to be a valuable resource; few patients ever felt the system was obtrusive or unhelpful. The majority felt the technology lived up to their expectations and had great potential.

Hence, research indicates that employing telehealth technologies for delivery of health services into the home is effective and satisfactory. Hospice care may be delivered directly into a patient's home via telehealth for clients in underserved rural locations and for those with limited caregiver support (Doolittle. et al., 1998). Telehospice has the potential to address barriers to quality end-of-life care by providing clinical and educational services directly to patients and caregivers in their homes.

A preliminary telehospice pilot study examined the feasibility of placing low-end videoconferencing units into homes of hospice patients located in Kansas City, Missouri. Over the testing period, the researchers found general satisfaction with the TH system, with nurses and social workers acclimating to the video calls (Doolittle et al., 1998). Further study sought to determine whether hospice personnel felt it feasible to provide hospice services to underserved populations in their homes via telehealth, and whether caregivers felt the quality of TH care would be comparable to traditional care. At the time of the study, a total of 40 telehealth visits had been conducted. Data from this study strongly suggested the hospice personnel perceived that telehealth might improve access and conceivably decrease costs (Whitten, Cook, & Doolittle, 1998).

This pilot study also unearthed potential advantages of transcending geographic distance in rural settings and enhancing provider safety in urban surroundings. TH allowed nurses to visit and treat patients without leaving their home/offices (Doolittle et al., 1998). Doolittle (2000) performed a cost-measurement study tallying expenses of a traditional hospice service versus costs incurred while launching and maintaining a TH service over two different study periods. For traditional hospice services the cost per visit was $126 and $141 for the first and second study periods, compared to just $29 for TH visits.

Developing interpersonal relationships is an essential part of hospice. This project examines the utility of technology as a communication tool in a highly interpersonal environment for hospice care, the patient's home.

The Michigan/Kansas Telehospice Project

Two large hospices in Michigan and Kansas are engaged in a bi-state TH project designed to use telemedicine technology to enhance end-of-life care. Both hospices have a statewide presence, with clients located in urban and rural settings. The projectis currently investigating issues of cost, access implications, and delivery of TH service in both rural and urban settings. The two-year study, currently in its second year, is funded by a grant from the National Telecommunication and Information Administration, Technologies Opportunities Program (TOP), of the U.S. Department of Commerce. In each rural and urban office, nurses, social workers, spiritual care counselors and physicians have access to videophone technology, which operates on regular analog phone lines. With this technology, hospice workers are able to connect with and assess patients through videophones located in their homes The hospice nurse offers TH at the time of the introductory meeting. If the patient accepts the service, the hospice worker will immediately install and test the equipment for the patients and caregivers. Hospice workers routinely call patients at least once a week to perform the requisite hospice task; however, the TH patient is also empowered to employ the technology in order to reach hospice workers at the local or state offices. Data from the first year of this project are presented in this paper.

Methods

This project was designed to examine a wide array of issues from provider and patient perspectives, specifically: costs, access, delivery, and satisfaction. First-year experiences offer interesting insights into three areas, specifically: provider pre-perceptions, patient and caregiver perceptions and satisfaction, and utilization data from providers and patients. To examine these issues properly, each research question employs different research methods.

RQ1: What were the providers' pre-perceptions of Telehospice?

Subjects for this research question encompass all Hospice of Michigan employees (N=28) who: a) worked in rural and urban offices located in Detroit, Alpena, Gaylord, and Wayne Suburban (all located in Michigan), and b) were to participate in the TH project (i.e., nurses, physicians, social workers, and spiritual care providers). On the Kansas side, subjects for this study were all Hospice Incorporated employees (N=19) working in offices located in Wichita, Coffeyville, and Pittsburg working on the TH project. An eleven-item, five-point Likert survey was administered to all subjects in each location. Surveys were administered four weeks after project orientation in each office to ensure that providers would have a basic understanding of TH while also possessing limited actual experience. Descriptive statistics were employed to analyze the data from the provider surveys.

RQ2: What are the patient/caregiver perceptions of Telehospice?

Subjects for this research question include Michigan (n=51) and Kansas (n=5) TH patients and their caregivers, from locations in both the rural and urban communities. Patients were interviewed unless they were too ill to participate, in which case their primary caregiver was interviewed, a common practice in hospice research. A thirteen-item, open-ended interview questionnaire was employed to glean perceptions and assess levels of satisfaction from patients and caregivers. The questionnaire explored satisfaction with the TH service, as well as perceptions of the technology, service, and potential uses. The interviews were performed over a traditional telephone. Analyses of the interviews involved thematic coding of answers and comments. General, overarching themes were pulled from all responses of the patients and caregivers in order to facilitate categorization of concerns, perceptions, and satisfaction relative to the TH service, technology, and its potential in future applications.

RQ3: What is the actual utilization of the TH service for patients and providers?

Subjects for this research question encompass all Michigan and Kansas providers, patients and caregivers, specifically all participants in the TH project. To assess potential and actual utilization of TH, the researchers employed two data collection techniques that included a decline survey and nurses' notes. Decline surveys were administered to all potential TH patients who chose not to participate in the project. The eight-item decline form examined issues involving technological fear, reasons for declining the service, and the emotional status of the patient during the survey. Additionally, nurses' notes recorded during routine and non-routine TH visits were utilized. These notes document the participants in TH visits, disciplines present, outcomes/dispositions of the visits, and number of telemedicine calls occurring during a given time period.

Results

RQ1: What are the provider pre-perceptions of TH?

Data from hospice provider preconception surveys (N=47); (Michigan N=28, Kansas N=19) revealed favorable perceptions of the TH equipment, specifically with comfort and the relative ease of use. However, hospice nurses expressed more ambivalence toward TH services being as efficacious as traditional hospice services. It should be noted that the respondents reported their average number of TH visits at the time of survey completion between one and five, with the majority resulting from nurses as opposed to social workers or spiritual care workers. Table 1 outlines the survey questions, means and their standard deviation.

Survey Question Mean Standard Deviation
The TH equipment is easy to use 3.73 .7270
TH is a good way to deliver hospice care 3.11 .8685
The hospice patient is easy to hear
when utilizing TH		 3.36 .9423
The hospice patient is easy to see when
utilizing TH		 3.14 .8333
I enjoy the TH visits 3.14 .9900
TH increased my access to the hospice patients 3.26 1.0931
provide via TH is comparable to the care
I provide in-person		 2.21 .9249
I would rather visit with the patient
in-person as opposed to TH		 4.33 .8083
I feel comfortable using the TH equipment 3.55 .9989
TH will improve the quality
of hospice care given to patients		 3.57 .6954
My office has clear procedures for
enrolling TH patients		 3.93 .8279

Table 1 Preconceptions of Providers about Telehospice. (The Likert scale ranges from 1 (strongly disagree) to 5 (strongly agree)).

RQ2: What are the patient/caregiver perceptions and satisfactions of TH?

Patient/caregiver interviews (N=51) resemble provider perceptions in terms of positive perceptions regarding equipment efficacy. Like providers, patients/caregivers perceive the equipment to be safe and effective. However, data from the patient/caregiver interviews revealed stronger enthusiasm regarding TH care than indicated in provider surveys. For example, 33 % of patients revealed that TH increased their access to their provider, especially during the night hours or in case of an emergency. Further, caregivers reported an increased level of comfort associated with the equipment, due to the video component of the service as well as ease of use in case of emergencies. One caregiver stated:

"The TH phone and equipment is nice because I can call my nurse during the night and during emergencies, especially since I can see and hear them over the phone."

In addition, both caregivers and patients felt TH improved traditional hospice care. According to one patient:

"I like to view the nurses over the phone; it helps during my check-ups because I can tell and show her any problems I'm having, and my caregiver can also use the equipment to talk with the nurse in case a new question comes up."

In general, caregivers and patients were satisfied with the services, especially with regard to the ability of the equipment to facilitate instant "face-to-face communication." Patients and caregivers also expressed similarities between traditional hospice and telehospice services. Many caregivers felt telehospice was an extension of traditional hospice services, thus affording patients another facet to their home care. Further, many patients expressed the desire to utilize telehospice equipment for more daily hospice procedures. Caregivers in particular expressed a need to use the equipment more, specifically for non-traditional check-ups, emergency situations, and supplanting weekly in-person visits. Interestingly, providers were conservative in their desire to expand utilization of TH, whereas patients expressed a greater desire to increase use of the service.

RQ3: What is the potential and actual utilization of the TH service for patients and providers?

Enrollment for TH has shown a general increase and consistency over the past year. Figure 1 demonstrates TH patients serviced each month for rural versus urban patients in Michigan and Kansas. A total of 118 Michigan patients and 44 Kansas patients were enrolled in the project.

Figure 1.TH Patients Serviced Each Month for Rural versus Urban Patients in Michigan and Kansas.

In addition, TH has been used in several innovative, interesting ways that do not necessarily represent the traditional and more common uses of the service. The following are excerpts taken from archival data, and represent examples of TH services rendered to the patients and caregivers in Michigan.

"A telehospice patient with a Foley catheter was extremely restless. The caregiver called the office to get help. At some point, the nurse found out that there was no urine output and asked to see the Foley via the telehospice equipment. The caregiver pulled the covers aside to show the catheter and the nurse found it was kinked. The nurse instructed the caregiver to straighten the tubing and urine started to flow immediately, creating immediate relief for the patient."

"A patient from the Alpena team had a carotid bleed. His wife was extremely anxious about his condition because she knew he would die from a massive bleed - which he did. We talked to her daily, sometimes several times a day. When she would become anxious, we could assess the situation via telehospice and reassure her that all was fine, or give her direction. There were times when she was so anxious that we would have her on telehospice while we were sending a nurse out to the home. Ultimately, this allowed her to keep her husband at home, something she had promised him. She could have not kept that promise otherwise -- unless we had a nurse practically camped out in the home -- and we did not have the resources to do that. We gave her such heavy support that she was very pleased with the care. I don't think she would have been that satisfied without telehospice."

Another important facet of the research involves the reason(s) for the declination of TH service. The decline surveys from Michigan (N=244) and Kansas (N=58) provide important data regarding why some patients did not participate in the project. First and foremost, in both Michigan and Kansas just under 50% of decline forms were completed by nurses because the patient did not qualify to participate in the project due to exclusionary criteria, including variables such as blindness, absence of a phone line, the patient was actively dying or in a long-term facility, or the hospice nurse felt the component could not augment hospice care. Amongst the 50+% of patients who completed the decline survey of their own volition, 41% were not interested in participating in the study, 27% felt they did not need the service, 19% attributed the refusal to equipment factors (e.g., too many machines already in the home, did not want to learn a new device), and the remaining patients ascribed the refusal to several other deterrents such as not wanting to participate in a study, privacy issues, and a deficiency in learning "new technology."

Discussion

There is tremendous potential for TH as evidenced by interview data collected from providers and patients. This augmentation to traditional hospice care could reduce expenses incurred by hospice organizations to pay providers to travel great distances to care for patients, particularly those in the rural sector. Furthermore, TH calls may also alleviate time constraints placed on providers due to these considerable distances to patients' homes.

Interestingly, nurse and provider surveys reflected more potential barriers when compared to the patient/caregiver surveys. Adoption at the nursing level is essential to the livelihood and sustainability of TH. "Champions" in each hospice office are essential because of the hospice organizational structure, the sensitive nature of the work, and most importantly, providers are the only source of diffusion and utilization of the hospice equipment. Not only are providers responsible for determining which patients use the service, they are also accountable for initiating and conducting TH visits. Furthermore, when launching TH service, nurses consistently agree the telemedicine calls should be used for after-hours acute problems (e.g., pain assessments, symptom management, medication checks, etc.) to determine if an in-person visit should be made, showing some reluctance when considering use of the units during normal working hours. When nurses discuss potential uses of TH, particularly anxious patients/ caregivers often come to mind -- they feel such clients would benefit from frequent video visits for emotional support.

TH may impact the interrelationship between providers and patients because it is a relatively new channel for communication. Although data on this particular issue are still being collected, it is interesting to note that traditional hospice visits on average are considerably longer than the average TH call, with the latter typically being less than fifteen minutes.

Clearly, the service delivery modalities, traditional in-person versus TH, are different. Anecdotally, some nurses report a 'strictly business' approach to a telemedicine visit, as opposed to a longer, less formal home visit. While this observation requires further study, we anticipate the time differential between traditional and TH visits may lessen as hospice providers and patients become more accustomed to this form of health care delivery.

Family caregivers and friends report general satisfaction with TH, perhaps more so than the patients. Some quickly embrace the TH service and it is not hard to imagine why. Well-meaning family members have often been abruptly thrust into a role as caregiver, charged with the care of a dying loved one that may encompass anything from morphine administration to changing bedpans. We hope to address these acceptance questions through further study.

This TH project will make an important contribution toward improving care of the dying by advancing the level of knowledge in four significant ways. First, it will provide important lessons about the ubiquity, reliability, and timeliness of telecommunication technologies to deliver critical medical services directly into patients' homes. Second, it will tell us whether telemedicine can positively affect the home health field that is currently in disarray due to inability to reach many patients in need of services cost-effectively. Third, it will demonstrate whether telemedicine can overcome barriers to access in urban and rural areas. Finally, it will provide data enabling future providers throughout the country to easily incorporate TH services into their service mix.

TH will not replace the need for traditional hospice visits. However, TH allows patients and caregivers to communicate quickly with members of the hospice care team. The ultimate goal of TH is to bolster the hospice philosophy of care, while allowing patients to remain in the familiar surroundings and comforts of their home.

The first year of the project yielded several preliminary results which speak to the utility and potential for TH. However, the project seeks to expand in its second year to include data collection techniques such as: videotaping TH interactions to assess common verbal and non-verbal themes, conducting post-perception surveys of hospice providers to understand how attitudes about telehospice have changed, and continuing to interview patient and caregivers, while assessing decline forms and nurses' notes. In addition, cost studies are in progress. The second year of the project should provide fruitful data to further our understanding of the role of telehsopice.

Acknowledgments

The Bi-state Telehospice project is funded through a grant from the National Telecommunication and Information Administration, Technology Opportunities Program, U.S. Department of Commerce.

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About the Authors

Pamela Whitten is Assistant Professor of Telecommunication at Michigan State University. She was formerly Assistant Professor in the Department of Family Medicine at the University of Kansas Medical Center. Her work has appeared in Journal of Telemedicine and Telecare, Telemedicine Journal, The American Journal of Hospice & Palliative Care, Journal of Continuing Education in the Health Professions, Science Communication, and Geriatrician:Journal of the American Society on Aging.
Address: 409 Communication Arts Building, Michigan State University, East Lansing, MI 48824-1212.

Gary Doolittle, MD, is Medical Director. Center for TeleMedicine & TeleHealth. University of Kansas Medical Center.
Address:University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160-7171.

Seth Hellmich is a graduate student and research assistant in the Department of Telecommunication at Michigan State University.
Address: 402 Communication Arts Building, Michigan State University, East Lansing, MI 48824-1212.

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