Toolkits

Home Telehealth - Overview

The home telehealth technology market is vast and growing every day. This year at the American Telemedicine Association (ATA) 2011 Annual Meeting there were over 90 vendors that were classified as home telehealth vendors. When considering the various technologies that comprise the home telehealth market, the components to consider are hardware and software. Interestingly enough, the components of the technology are very similar across the market as the current concept of home telehealth is understood, but even the definition of home telehealth is expanding and changing as new technologies are emerging in the market to support it. In fact, these similarities are what can make sorting out the technologies even that more difficult. Traditionally, home telehealth has involved a base station where the patient interacts by entering data and answering questions, various medical peripherals that are used to gather patient data, and some form of software that technicians and clinicians use to configure the hardware and monitor the patient data. One might argue that the most important component of home telehealth is not the technology, rather the program that supports the technology. 

There are some manufacturers that are moving away from the traditional base station models and moving messaging and patient questioning to the point of care directly on the medical peripherals themselves. Other manufacturers are expanding the functionality of the traditional base station to include interactive audio and video, instant messaging, family collaboration components, wellness components, community connectivity, scheduling, and email for a more holistic user experience. An even newer approach is to move completely away from the base station concept and to sell software that can run on any platform interfacing interoperable medical peripherals. These vendors frequently state that they are "device agnostic," but will generally have minimum specifications for the devices they can be used on. The state of the market is currently in flux, and it is unclear what direction home telehealth technology will take in the next 12 months.

 Hardware

Home telehealth hardware can be broken down into base stations and peripherals. There are many individual technological components and features to consider when thinking about home telehealth base stations and peripherals. Understanding your patient population will help you know which technological features will be important to include or exclude from your program.

A special note for those vendors that now are “device agnostic”, meaning that they claim to work with any computing device on the market. The TTAC did not include information on the plethora of mobile computing devices that are currently on the market. Please look to a future toolkit on mobile telehealth for more information on mobile computing platforms and devices.

One alternative option to having the traditional hardware of a home telehealth base station is using interactive voice response (IVR). With IVR the interactions that the patient traditionally has over the base station, such as answering questions and receiving patient education, are done over the telephone; potentially via cellular and POTS communications. The traditional home telehealth interaction text is read to the patient by a computerized voice, and allows for patient input by pressing buttons on their telephone or in some cases by voice response. IVR eliminates the need for home telehealth base stations, but can limit the potential additional value added services of home telehealth that a patient can receive. IVR can be great for some patient populations, but may be monotonous for other patient populations. It may be less effective for learners that don’t do best with auditory inputs.

 Base stations 

Base Stations are traditionally standalone pieces of hardware that are a component of home telehealth monitoring. There are many features and/or components of a base station that make it desirable or undesirable to certain patient populations. In general, some of the features and/or components of base stations to consider are: screen type, screen color, screen size, font sizes available, button type, button size, audio options, video options, dimensions, weight, input components, output components, communication methods available, memory & processor options and power supply options.

Screen Type
There are currently two types of electronic visual displays currently available on home telehealth base stations, those that are touchscreen and those that are just for viewing. Currently, the electronic visual displays are liquid crystal displays (LCD) or organic light-emitting diodes (OLED). A LCD screen uses the light modulating properties of liquid crystals and does not emit light directly. LCD screens have low electrical power consumption needs, which allow them to be used on battery operated devices. An OLED display functions without a backlight, which allows it to be thinner and lighter than and LCD display. In low ambient light situations, an OLED can achieve a higher contrast ratio than an LCD. Having a screen that is angle adjustable may allow a user to adjust for glare and can be a favorable feature. These base units are used by many patient populations in many individualized ways and locations, so any flexibility offered may go a long way to making the unit more popular with patients.

Touchscreens allow the patient to directly touch the electronic display, removing the need for buttons and other input devices. A benefit of the touchscreen is that the icons or places for the patient to touch can be size adjusted for certain populations and are not as dependent on actual screen size. A touchscreen can be used to simplify user interactions on the hardware. Touchscreens can be a bit less durable and are subject to malfunction if abused or used inappropriately. Touchscreens can have issues with touch misalignment, where a user may touch and not be able to complete the action that they intended because their touch was not recognized. Misalignments may cause frustrations for certain populations and make touchscreen use more difficult. Touchscreens may be a technologically intimidating feature for some user populations. Touchscreens may also be more difficult for user populations that have lost feeling in their fingertips. One improvement that manufacturers might consider in the future is incorporating tactile feedback into the touchscreen user interface.

Screen Color
Some base stations offer color screens in the most traditional sense of a color screen, where color videos can be viewed and color graphics are able to be viewed. Some base stations offer color screens that are simply a green screen with white text or black text or a white screen with blue text. Make sure when you see color screen as a feature that you find out exactly what color screen means to the particular vendor.

Screen Size
The size of home telehealth base station screens varies greatly among manufacturers. Screen size will generally be expressed on specification by a measurement in units such as centimeters, millimeters, or inches. The best screen size is highly debatable based on the population that the base station needs to serve and the features it needs to support. When thinking of screen size of a base station, one must understand that the larger the screen the larger the overall size of the base station as well. Some manufactures strive to have a relatively small footprint for their base station so it is not cumbersome for placement in a patient’s home. Screen size is also important depending on the functionality of the base station itself. For example, If a base station offers video interaction the screen size needs to be large enough to support this type of interaction. In general, touchscreens tend to have larger screen size.

The spatial resolution of the home telehealth base station monitor will be described in terms of the number of rows and columns of pixels, for example 480 x 234. Screen resolution will also vary by manufacturer. In general, the higher the resolution the better the images that come across the screen will be.

Font Size
Some base stations only offer one size of text. Some base stations allow for the font size to be customized by the programing. Most importantly the font should be proportionate to the size of the screen, the color of the font should make enough of a contrast for it to be easily viewed, and the actual font used should be easily viewable in multiple sizes. Larger font sizes tend to be available on larger base station screens. Instead of a patient having to read everything that is on the screen, some base stations also offer an audio output of what is seen on the screen. This can make up for the difficulties some patient populations may have with smaller font sizes. Font size can be a very individual preference that can be influence by many outside variables. It is best to see the font on the base station for yourself to make your best judgment for your patient population.

Button Type & Size
Button type and size vary widely among vendors. Button type can be classified as those that offer tactile response and those that do not. Some buttons offer a tactile as well as auditory response. A tactile response means that when a user depresses a button they will be able to feel that they have pressed it. Buttons with tactile response are better for some populations that may have difficulties feeling their fingertips and in turn have trouble pressing buttons. If a button has a tactile response but is smaller, it may be more acceptable to a user than a small button with no tactile response. Buttons may be hard to the touch or soft to the touch, as some are made of hard plastic and some are made of more pliable softer plastics. Buttons that are not raised off the main surface of the base station should at least have some sort of raised surface, which will help users with decreased vision to feel that they are on the button. Buttons that have some sort of raised surface on them or texturizing give the user some tactile feedback that they are touching the correct surface and can make buttons easier to use. Button size varies but should be big enough to be visible from as far back as about 2 feet from the base station. Buttons that are at least as big as an average fingertip and have contrasting color from the base station tend to be the easiest to use. The amount of buttons on a unit is also important. Fewer buttons tend to suggest simplicity and ease of use. Most of the buttons on base stations are blank and correspond to messages on the base station screen. There are some vendors that also have buttons with wording on them, for example “Yes” and “No” to correspond with commonly answered questions. The buttons tend to be located to the right or the left of the screen on most base stations. If a user is supposed to press a button to respond to items on a base station screen, the buttons for the responses should be close enough to the screen that a user would be able to associate a button with an onscreen response request.

Audio Options
Some base stations offer audio output and some do not. Some base stations have option for users to have everything on the screen read to them aloud. Some base stations allow a patient and a clinician to have an interactive audio conference using the base station. The base stations that support interactive functionality will have to have a built in microphone. When considering the audio options, speaker quality and easy volume control were two important issues. The base unit has to have high enough quality speakers that sounds come out clear and audible throughout the whole volume range, especially if patients are to rely on them to read the screens to them. Volume control needs to be in an easy to find location and easy enough for the patient to be able to adjust it periodically. Volume control can vary from a dial that goes from quietest to loudest to using the buttons to the sides of the screen with embedded menu control options on the screen. The volume control should also allow the patient to turn the sound off as necessary or desired.

Video Options
Some base stations will have a built in video camera and built in microphone to support live interactive video conferencing. Video is a feature on a home telehealth base station that has to be used with the appropriate patient population. Video communication requires more network resources as well, so make sure if you plan to do video visits for your patient population that they have access to the appropriate network infrastructure to support it. Please see the TTAC Desktop Videoconferencing Toolkit Standards document to learn about the various standards related to video transmissions. Some base stations support video cameras that can be moved and some are stationary, requiring the base station be moved to make video adjustments.  The base station has to have a high quality video camera and enough bandwidth to have a high enough resolution image projected to the clinician to be useful in a clinical video visit. Having a larger screen on base stations may make video interactions a bit easier. A larger screen will allow the patient to be far enough back from the screen that they can be framed in the video shot and still be able to see and hear the provider appearing to them on their screen. Some base stations do not have on onboard video camera and microphone to support live streaming video interactions, but they may still support video viewing on the base station. Make sure that if a base station supports video, you clarify if it is live interactive videoconferencing or video viewing.

Dimensions & Weight
The size of home telehealth base stations will vary from vendor to vendor. As you have already learned, there are many considerations that go into making a base station a certain size and ultimately a certain weight. If a vendor wants to have a larger touchscreen, they may compensate the base station overall size and weight by making it a flat screen or tablet like design with some sort of propping device to allow it to sit on a surface. The more features that a base station supports the larger it will tend to have to be, especially if it offers interactive features. If a base stations offers sound, it will have to have added speakers which take up room and add weight. Touchscreens tend to cause a larger screen size and therefore slightly larger units. There should be a balance in the unit size that reflects the features offered and the patient’s need. Units that are excessively heavy are less favorable. Units that have a larger footprint can be less convenient for patients. Units that are made of cheaper plastics and very light weight could also be thought of as flimsy and less reliable by some patients.

Memory & Processor Options
As base stations have more and more functions that they support; they must also increase their processing power and internal memory. There are now basically two classes of base stations that have very different processing and memory needs. There are the base stations that are used in the traditional sense, where they are just a place for patients to input information, answer questions, and learn basic health information. There are also the base stations that offer interactive audio, video, emailing, instant messaging, and a myriad of other expanded functions. The base stations with more features are the ones that require advanced processors and increased internal memory to run smoothly. Not all base stations need advanced processors and large internal memories to be extremely functional. Be careful not to let claims of fast processors and large internal memory stores be a deciding factor when considering a base station, unless you are comparing base stations with similar functionality and feature sets.

You will find the memory and processor options described in terms of hard drive size, amount of Random Access Memory (RAM) and a processor type. Hard drive size is really just a function of the amount of longer term storage capacity anticipated for the unit. The amount of RAM necessary depends on the platform that the base station is running and the types of interactions that are occurring, somewhere between 128 to 256 megabytes (MB) of RAM should be sufficient for those base stations operating on Windows platforms. Base stations that are running on Linux operating systems will require less RAM because of the operating systems efficiencies.

 Input and Output Components

Base station input and output components tend to cause patients the most anxiety, especially if they are the ones that are required to plug the right cords into the corresponding plugs to make the unit functional. Anything done to ease this anxiety will go a long way to making a unit more user friendly and ultimately used more. Some vendors have color coded corresponding cords and ports that the cords plug into. Some vendors label each cord and each port, where the names will match up when something is plugged in correctly. Some have a combination of labeling and color coordination. In general, the more assembly that can be done ahead of time for patients, the better. However, having patients plug in or assemble home telehealth base stations is appropriate for many patient populations, especially with our increasingly technically savvy population with regard to consumer electronics. Likewise, it is absolutely inappropriate for some patient populations to have to do anything except use the base station.

Input and output options available on the base stations will vary based on the peripherals that are used with the base station, the way data is communicated to and from the base station, and the type of data that is communicated to and from the base station. Wireless forms of base station communication for data exchange and peripheral communication will be described in the communication options section of this document. Some common wired input and output ports are: RS 232 serial data ports, Video Graphics Array (VGA), Universal Serial Bus (USB), RJ45 ports that support Ethernet cables, and RJ11 ports for plain old telephone line cables. Some vendors support proprietary ports that require proprietary cables for various peripherals. With a movement towards standards based manufacturing, vendors should attempt to steer clear of using proprietary connectors and strive to have common connections to increase interoperability. See the TTAC Home Telehealth Toolkit Standards document for more information on the Continua Health Alliance and ZigBee Alliance and their work in standardization in the home telehealth market.

Communication Options
Home telehealth base stations are set up to communicate data by various methods depending on the vendor, the type of data that needs to be transmitted to and from the base station, and the speed at which the data needs to be transmitted to and from the base station. When considering a base station it is important to understand the connectivity options that are available to your patient population before making any decisions to which method of communication you can safely use. Most areas in mainland United States are equipped to handle broadband communication, however very rural areas may not have the infrastructure to support this type of communication and may be limited to plain old telephone service (POTS) communication. In rural areas where there may be infrastructure for POTS, the lines may not present in the patient’s homes and may need to be installed. Some rural areas may not have the infrastructure to support POTS communication, but may be able to support cellular communications.  There are some areas that are so remote that they are only able to support satellite data communications. When convenience and mobility are characteristics required of a user population, cellular communications might be the best option.  

The different methods of communication that a home telehealth base station might use to communicate data are: Plain Old Telephone Service (POTS), Direct Service Line (DSL), Cellular or sometimes seen as Code Divisions Multiple Access (CDMA), Broadband, Satellite, Bluetooth, Infrared (IrDA), WiFi otherwise known as the IEEE Standard 802.11, Mobile Broadband Wireless Access (MBWA) or IEEE Standard 802.20, and Worldwide Interoperability for Microwave Access (WiMax) or IEEE Standard 802.16 a form of wireless Broadband. Some of the base stations have forms of wireless communication built in and some require an additional piece of hardware for wireless communication. See the TTAC Home Telehealth Toolkit Standards document for more information on the various technological and telecommunications standards that apply to the home telehealth market. See the toolkit section on input and output components to read about various types of ports and cables that a base station might use to access these various types of communication options.

The job of the home telehealth base station is to send and receive information. They communicate with secure servers to transmit the data that has been collected about the patient. In order for this information to be transmitted it has to be broken down into smaller parts. Information travels across and among networks as data broken down into multiple packets. A packet is a chunk of data that is a certain number of bytes. A byte of data is an 8 digit sequence of bits, or binary digits, zeros and ones to be exact. The Continua Health Alliance & Zigbee Standards will dictate the exact byte size of packets and how that data will be sent and received. A packet of data contains information that allows it to travel around and between networks by following protocols that get it to where it needs to go. When the packets arrive at their destination, they can be reassembled as data to look like the original information that was sent.

Base stations that connect to send data over a POTS connection will use a modem to communicate with a server via the copper wires in telephone lines. The modem can be internal or external to the base station.  A modem, or modulator-demodulator, is used to encode and decode the information that is to be transmitted. Data goes through a process where it is compressed, packetized, and converted from a digital to analog signal and is then sent to the RJ11 jack for transmission. Data goes through the reverse process when it is received.  Modems must adhere to communication standards and protocols to be able to transmit information.  Home telehealth base stations are programed to call up and report information at specific times; they are not continuously transmitting data. Likewise they receive “calls” with information and programming at specific times of day. A patient cannot be on the phone making voice calls at the same time the base station is sending or receiving information.  This is a very economical option for base station communication because most households have a phone line, and there are no additional charges for transmitting data in this fashion. However, there are areas of the country where a great deal of households do not have phone lines, especially with more low cost wireless cellular options becoming available.

Some bases stations may use DSL to send and receive data. DSL is a form of broadband communication that uses telephone lines to transmit data. There are some very real physical limitations to the use of DSL in a patient’s home, and DSL is not available in all areas. With DSL a patient can be on the phone at the same time that the base station is sending and receiving data. DSL uses the copper wires of a regular telephone line but utilizes an extended bandwidth, or range of frequencies, that are above those needed to make voice calls. DSL customers can receive data faster than they can send data. Base stations that connect via DSL can receive larger amounts of data, like streaming educational videos for example, and have the capacity for live interactive audio and video. DSL comes at an additional charge to the consumer, and may be cost prohibitive to some patients. A DSL modem can be internal or external to a base station.

Broadband connectivity refers to a telecommunications signal of greater bandwidth than the usual signals intention. The extra bandwidth can be utilized for high speed internet traffic; the broader the band the greater the capacity for speed. A wired broadband connection is available to the public over telephone lines as DSL and over cable. Wireless broadband connections are also available to consumers. Mobile broadband uses Wireless broadband technologies to connect devices to the internet using cellular towers. Wireless broadband uses the radio frequency spectrum. WiFi, WiMax, and cellular (possibly referred to as CDMA referring to the communication protocol) can all give wireless mobile broadband connectivity. Each form of wireless will connect to the internet in slightly different ways. Wireless broadband is standards based communication. The standards are there to promote and certify compatibility and interoperability. Home telehealth base stations will have either an internal or external access point to be able to send and receive wireless data. With regards to home telehealth base stations, broadband connectivity simply increases the possibilities for functionality of the base station. Base stations that have broadband still move data in packets, but the speeds for sending and receiving are fast enough to enable interactive audio and video and other capabilities reliably. Wireless broadband connectivity adds to the portability of a home telehealth base station.

A telehealth base station may connect to the internet using satellite connectivity. The use of satellite is limited because of cost, availability and latency issues for most consumers. However, there are some areas that have no other means of connectivity and could use satellite connectivity to connect to the internet to transmit and receive data. Satellites are able to send and receive messages through space using waves of the electromagnetic spectrum and using satellite receivers to convert the waves into binary packets. Those vendors that offer satellite communication generally require additional hardware to accompany the base station and may only offer this form of communication as a custom feature.

There are lots of different ways that home telehealth base stations can connect with peripheral devices to transmit and receive data. Wired solutions are: component cables, ethernet cables, and USB. Wireless solutions are: wireless USB, WiFi, Infrared, and Bluetooth. All have in common the fact that in home telehealth all of the communication should be standards based. The messages and how the messages are communicated are all standards based.  There are standards and specifications designed by the Continua Health Alliance and ZigBee Alliance that promote interoperability of devices and standards based communications. Please refer to the TTAC Home Telehealth Toolkit Standards document for more information on these standards.  In the case of wired communications the data travels between the device and the base station and back again. With wireless communications, the data travels utilizing radio frequencies in the case of WiFi, wireless USB, and Bluetooth and by using infrared light waves in the case of Infrared communications.

Power Supply
The power supply method and amount of power necessary for home telehealth base stations will vary from vendor to vendor. The amount of power necessary to power the base station will depend on how the base station sends and receives data and other factors. For example, a base station that communicates with POTS may need to be plugged in and a base station using USB to connect to a home computer may draw power over the USB connection making additional power unnecessary. It is important to consider your patient population when considering power supply. If a unit runs on batteries, it may be cost prohibitive for a patient to purchase replacement batteries. Also, not all homes have a steady power supply. Some units have built in surge protectors, which are important to protect base stations in areas where power surges are a common. All the specifics about patient’s homes and power supply should be known in advance of placing technology in their homes.

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 Peripherals

Home telehealth peripherals are the devices utilized to collect biometric data that will be transmitted. Most home telehealth peripherals will connect to a home telehealth base station and transmit their data to the base station, which will in turn transmit the data to a server where it can be monitored. Some peripherals can transmit data directly to a server and do not require a home telehealth base station to be used. Some peripherals can be connected directly to any computer or mobile computing device, which will then allow their data to be transmitted.

Traditionally home telehealth peripherals were centered around collecting vital signs data, i.e. heart rate, oxygen saturation levels, blood pressure, temperature and weight. As the home telehealth market expands and changes the consumer will see an increase in the number of home telehealth peripherals that are available for use and will see the information that is being collected change as well. There will even be some peripherals that will be sold that will not collect any data at all; rather they will be peripherals that add value to the holistic and comprehensive home telehealth experience.

There are standards that have been developed that dictate exactly how certified standards based devices should interact with one another and transmit data. The Institution of Electronics and Electrical Engineers (IEEE) has developed the personal health data 11073 family of standards. These standards establish norms for communication between the devices and compute engines that enable interoperability. There are plenty of devices on the market that are proprietary, but as a consumer there are benefits to purchasing standards based equipment. When you purchase standards based equipment you can be sure that it will be interoperable with other standards based equipment. More and more manufacturers are beginning to offer certified standards based equipment.

When selecting a vendor you will find that they tend to pair peripheral sets with disease states. Peripherals can also be purchased individually or in an á la carte fashion. Peripherals are generally available with wired or wireless connections to a base station. The data that is collected is broken down into data packets and transmitted the same way information is transmitted and received from base stations. In general a wired peripheral will connect to a base station using an ethernet cable, a serial RS 232 cable, a USB cable, a VGA cable, and occasionally by a proprietary cable. A wireless peripheral will connect with a base station via WiFi, Bluetooth, a cellular adaptor, wireless USB, an infrared signal, and occasionally a proprietary wireless dongle. Each peripheral has different clinical uses and patient considerations. Some issues with wired peripherals: they add to the overall footprint of the base station, they must be kept in the same location as the base station, the cords can be fall hazards, and they are less able to be used at the point of need. On a positive note, wired peripherals will always have a reliable connection to the base station to transmit data. Some issues with wireless peripherals: they may have data transmission problems, they may have difficulty transmitting data at a distance, and they are not physically connected to anything so they can tend to get lost easier. Some positives about wireless peripherals: they can be used at the point of need and standards based peripherals should be automatically recognized and transmit data on their own. Home telehealth peripherals are either battery operated or require power cords and adaptors to be plugged in. Some run on rechargeable batteries, where the unit can be plugged in to charge and later be unplugged for use and mobility. There are some units that have one limited battery that cannot be recharged or changed, but are so power efficient and cost effective that by the time they have been through a product lifecycle they can easily be replaced.

Scales
Home telehealth scales have digital readouts of the patient’s weight on an LCD screen. Some have the need to be zeroed before patient use and some do not. Some will only measure the weight once, while others might take multiple readings and do an average. Some scales will require the user to wait on the scale and then display the weight after a certain number of seconds. Some of the newer generation home telehealth scales are being modified to include handles for the user to hold on to. Most home telehealth scales can weigh a patient up to 500 pounds. Some scales have several pads on the bottom to balance the scale out, while some are mounted on a base. Some can be used on carpet and some require a hard surface. Some of the scales offer a lighted background on the LCD readout. Some scales include an audible read out of the weight, which can be very useful for those patients with decreased eyesight. Some vendors offer scales that can be used sitting down, which can be useful for those with decreased mobility.

Blood Pressure Monitors
Electronic blood pressure monitors are currently available to consumers as a household item. The electronic blood pressure monitors used in home telehealth are very similar to those sold to consumers. Home telehealth blood pressure monitors are available either incorporated into a home telehealth base station or as separate standalone units. Home telehealth blood pressure monitors transmit the data that they collect. Patients using a home telehealth blood pressure monitor eliminate the need for logbooks, improve data accuracy and eliminate falsified readings. Home Telehealth blood pressure monitors utilize adjustable and fixed size blood pressure cuffs. As with any blood pressure measurement, using the correct sized cuff gives the most accurate reading. In 2011 a bariatric sized cuff was released, and should be used for larger arms to get the most accurate readings. A very nice feature of the home telehealth electronic blood pressure monitoring cuffs is the angled design; the angle makes it much easier for the patient to put the cuff on themselves. Some units require the patient’s arm to be at heart level for the most accurate reading, others have no special requirements for the patient’s arm. Standard systolic and diastolic blood pressure measurements can be obtained, as well as heart rate and mean arterial pressure in some cases. Heart rate and mean arterial pressure are obtained by specialized algorithms utilized the by equipment as the blood pressure readings are being obtained.  In the future, it would be useful for manufacturers to design units that will recite results out loud for patients with decreased eyesight.

Basic Electrocardiogram (ECG or EKG)
Home telehealth ECG units transmit data, are generally 1 lead or 3 leads, and are approved for use by patients. An ECG may be in the form of a belt has a sensor that is placed around the chest. Another form of ECG has two egg shaped metal balls that a patient has to put their hands on to obtain a reading. There are some garments with biometrical sensors that can obtain an ECG. There are some units that require the patient to place leads on their chest, in the way that a more traditional ECG is obtained. There are versions of ECG that have pads with imbedded sensors that the patient will place on their body. As long as a connection with the body’s electrical current can be established, an ECG can be obtained. The accuracy of ECG readings obtained by patients should always be suspect, but may lead to early detection of problems with certain patient populations. ECG data should be used in conjunction with additional vital signs and assessment of the patient’s signs and symptoms.

Digital Thermometer
Digital thermometers that transmit data can be used for home telehealth. There are models on the market that are the traditional digital thermometer design used for oral readings and there are models available that can take measurements in a patient’s ear. Generally probe covers are also required to accompany this device and must be provided to the patient.

Blood Glucose Monitor
Home telehealth blood glucose monitors are very similar to home use blood glucometers except that they transmit data. They require the extra supplies consisting of testing strips and lancets to be used by patients. Patients using a home telehealth blood glucometer eliminate the need for logbooks, improve data accuracy and eliminate falsified readings. Home telehealth blood glucometers give whole blood glucose readings.

Pulse Oximetry
Home telehealth pulse oximetry is used to obtain a patient’s oxygen saturation and very often subsequently measures the patient’s heart rate. Pulse oximeters can be freestanding or integrated into a home telehealth base station. There are wired and wireless solutions available. The sensors can be permanent and reusable or disposable. Each piece of equipment will have its own algorithm for obtaining oxygen saturation and heart rate.

Peak Flow Meter
Peak expiratory flow, also called peak expiratory flow rate, is a person's maximum speed of expiration achieved during the maximally forced expiration initiated at full inspiration. A person’s peak expiratory flow is measured with a peak flow meter, a small hand-held device. Peak flow meters that are used in home telehealth have the ability to transmit data. Peak flow meters can be very patient education intensive in order to obtain usable, fairly accurate results. Some models of home telehealth peak flow meter may have an additional disposable apparatus that comes with the unit which becomes an additional supply that must be given to the patient for use.

ZOE™ Fluid Status Monitor
ZOE provides a clinician with noninvasive assessment of a patient's fluid status. ZOE fluid status monitors measure thoracic base impedance or “Zo”, gauging the resistance of small frequency electric current as it travels from the top to the bottom of the thorax. The less resistance the current meets, the more fluid that exists in the chest. To use the ZOE monitor, the patient places two ZOE electrodes on their chest and attaches them to the ZOE interface wires. When fluid levels in the body increase, Zo levels decrease as early as two weeks prior to weight gain on scales. Remote fluid monitoring provides clinicians with a quick and noninvasive method of determining whether patients are experiencing fluid congestion or dehydration.

Vibration Response Imaging (VRI)
VRI is a new technology in the home telehealth market. VRI technology provides a radiation-free dynamic lung image by visualizing vibrational energy transmitted during a single respiratory cycle. Changes in the patient’s condition will be reflected by a corresponding change in the vibration response. Various acoustical measurements are obtained and transmitted as a quantitative indicator of a patient’s condition. At the time of this assessment, in home VRI is not currently FDA approved for use with patients.

Personal Emergency Response Systems (PERS):
PERS are automated dialing systems which can transmit one or more coded messages to a remote monitoring station when activated by the user or by a sensor. PERS is an in-home emergency service. It enables aged and disabled individuals to stay in their residences with less caregiver intervention and reduces hospitalization by facilitating early emergency treatment and transport. User activation is by means of a small, battery-powered transmitter. The transmitter can communicate with specific services aimed at protecting the wearer. Some base units are speaker phones and permit the monitoring station to stay in contact with the user until local help arrives. Person Emergency Response Systems are becoming part of the expanding definition of the home telehealth model that allows for holistic care and aging in place as value added services to the tradition vital signs collection model of home telehealth monitoring.

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 Software

Home telehealth software serves as a means to monitor the data that is collected by home telehealth hardware and to facilitate communication between patients and clinicians. Generally, each home telehealth vendor has their own proprietary software that accompanies their hardware; the software is simply another feature of a home telehealth package. Some home telehealth vendors offer their software for free to accompany their hardware, some offer their software for free with additional upgrades for purchase, and some vendors require the software package to be purchased along with the hardware.

As part of the new and expanding definition of home telehealth there are more and more versions of software available to consumers. Traditionally home telehealth software was meant to be for clinician use. There are some home telehealth vendors that have home telehealth software that is for patient use, either by an HL7 interface to a personal health record or as a permission based role in their web based software. Some home telehealth vendors use home telehealth software as an interface to Interactive Voice Response (IVR) systems as well. As vendors become more hardware agnostic, home telehealth software will be substituted for what used to be the concept of the home telehealth base station and be used as a conduit to collect home telehealth peripheral data from various home telehealth peripherals, before packing it and sending it on to clinicians.  

Home telehealth software in the traditional sense, is offered to the user on a secure web based server. Only those who log in have access the encrypted data that is being collected and the various features of the software. The server can be hosted by the vendor, by a hosting company the vendor contracts with, or locally on a server purchased by your organization. There are pros and cons to each method of hosting, and will most likely be determined by organizational policy for data management. If you do go with a hosted server, either with the vendor or through a hosting service they contract with, make sure to enquire about the security and data backup practices that they use. It is important to have your CIO and/or IT staff as well as compliance staff, basically those who know your organizations philosophy on handling secure patient data, involved in the decision making around how the data will be hosted.

With the home telehealth software being hosted on a secure web based server it should be viewable on multiple operating systems and multiple platforms. It is important to inquire whether the software is supported on Windows, Apple, Linux, etc. devices and in what versions. It is important to ask about which handheld devices are supported for viewing the software and if there are any specific apps available that allow for ease of use when working in the software and viewing the data on handheld devices.

Even though the data being collected from the peripherals may be standards based, the way home telehealth software packages data and deals with it after it is collected remains proprietary and vendor specific. If you have a home telehealth program where you need to have equipment from multiple vendors and you wish to use a specific home telehealth software, you may need to work with all of the vendors involved for a custom programing solution. You may end up in a situation where you have to have different software for each type of equipment that you have in your program. Some electronic health records on the market may offer a means to view and possibly work with the data being collected by the various equipment being used in your program via an HL7 or custom programing interface.

The user interface of the software can make or break the user’s experience of the software. The user needs a concise way to view data that is not overwhelming when considering the potential amount of data they can be dealing with. One way of limiting a user’s interaction with the multiple features in the software is to make it “role-based.” In a role-based software design users have distinct roles and will interact with specific software features in distinct ways. The user interaction is based on the principle that there are some features that not every user needs to interact with. Some vendors will refer to this as different levels of security for different user groups. Within a role certain features may be available and others may be hidden. In a role-based software, it makes sense to have a clinician role as well as an administrative role at minimum. For example, the administrative role may not have access to patient data or have the ability to have live interactions with patients, but may be able to add patients to the systems and keep the equipment inventory. Some home telehealth software vendors will offer a basic level of access for the patient, where they can log in and only see their data.

Another way of limiting the user’s interaction with a vast amount of data is to offer multiple ways the data can viewed. In some of the software, when a clinician enters the portal they are only initially presented with vital signs data that require immediate action based on the parameters that they have set ahead of time. This is sometimes called viewing the data by exception, where only the exceptions to the rules or parameters that have been established are viewed and addressed and the remaining data that falls within parameters is assumed to be within normal limits. Some of the software allows the users to segregate the data that they are viewing by patients, groups of patients, or by disease state.

Another way of limiting the user’s interaction with large amounts of data is to have it viewed in a dashboard fashion. You may hear vendors refer to their software as offering a dashboard view of the data. In software development, a dashboard is a user interface that is meant to look like a cars dashboard and designed to be easily read. Vendors will take what is potentially a large amount of vital signs data in a database format and do things to the data to make it easy to read or glance at and gain information from. For example, they may color code the vital signs according to where they fit in the predetermined ratings classifications with the colors green, yellow and red. The simple green, yellow and red color classifications might indicate to a clinician where the vitals are within the established parameters. Some vendors will use a series of flags, checkmarks and various other symbols to indicate specific things in their dashboard view. Some vendors will also color code patient profiles to let the clinician have an overall idea of the type of patient they are dealing with. Color coding patients by disease state can be difficult when you are dealing with patients that have multiple comorbidities. In general, all vendors structure the data so that a user can find out more information about a specific patient in a matter of 1 to 3 additional clicks. Software that requires multiple clicks and multiple screens to get further into the data may be cumbersome to clinicians that need to be able to do every process in the fastest most efficient way possible.

In home telehealth software, as vital signs data is being monitored there will be data that falls outside of the established parameters. This data is very commonly referred to as an “alert.” The parameters which alerts are based upon can be predetermined within the software, customized by the program administrator for all clinicians, customized for each clinician that views data in the software, customized for groups of patients based on disease state, or customized for each patient that is being monitored. In general, when there is an alert in the software it requires some sort of action on the clinician’s part. Alerts are handled differently by each software. One software may require the user to click on the alert and be given a dialogue box to free text in their actions related to the alert. Another software may require the user to click on the alerted data and be presented with a dialogue box that has standardized checkbox answers for actions taken related to the alert. At the very least home telehealth software should offer a way for clinicians to document their actions related to alerts, or when vital signs are outside of the established parameters.

Clinical documentation will be built into the software around alerts, alert parameters, messaging, patient education, and possibly live interactions. Home telehealth software clinical documentation will generally be checkbox charting by exception, long form, or structured SOAP notes depending on the situation, the clinician, and the specific vendor.

Another term you will hear associated with home telehealth software is messaging. When vendors are referring to messaging they are talking about the communications that clinicians are having with patients via the home telehealth hardware that is in their home. The “messages” are generated using the home telehealth software as the vehicle for delivery. Messages can be a part of a library that comes with the software or can be customized by the user. Messages that come as part of a library are generally categorized by disease state. Messages can be educational messages to the patient, customized communications to a patient, as well as questions related to a patient’s symptomology and disease state.  The messaging library may also consist of videos that can be streamed to patients. Some home telehealth software will offer a video library with premade patient education or disease state related content and some will have the option for users to upload their own videos. You may hear from vendors that their messaging has branching logic or offers flexible patient interactions. Branching logic allows the questions to change or be delivered according to how the previous question was answered, so there is built in logic to how the questions are delivered. Branching logic is important because it can be used to get more information from patients. Home telehealth software will offer options to when messages are delivered to patients. Some software will only allow messages to be delivered once per day, some twice per day, and some will allow for special messaging at any time in addition to the regularly scheduled messaging. For the home telehealth software that is customizable, clinicians will usually be able to schedule what messaging they want delivered to the patient and when. When messaging is delivered it will most likely be a line of questioning as opposed to one question at a time. It is important to remember that messaging can become burdensome to patients and reduce compliance when it is irrelevant or repeating. Vendors will build in a way to cycle messages that may be customizable as well. Some vendors will say they have clinical pathways or care plans for certain disease states. Generally a care plan or clinical pathway is symptomology questions paired with patient education all delivered to the telehealth hardware with a specific systematic approach. The delivery of messaging to the home telehealth hardware will happen based on upon the scheduling of the messages that need to be delivered. The software will establish communication with the hardware and the messages will be downloaded as data packets.

Some home telehealth hardware can support live interaction with patients. These live interactions can take place via messaging, live audio, and/or live video. Home telehealth software can act as the control portal for these live interactions. A number of home telehealth software allows the user to send near real time custom messages to patients in response to patient data. Some vendors have a form of instant messaging the will allow clinicians to interact with patients via messaging in real time. Some vendors allow live audio and/or video interaction with patients. All of these interactions can be initiated within menus in the home telehealth software. Some of the home telehealth software will require the clinician to conduct the live video with the patient using the same home telehealth hardware that the patient is using to establish the two way call. Other software will use a webcam along with the home telehealth software to control the interaction. With clinicians getting more used to desktop videoconferencing applications, it will make these types of interactions less intimidating and more clinically useful as time goes on. All of these live patient interactions require the patient to have enough bandwidth on their side of the equation to support meaningful interactions.

Some home telehealth software has functionality to support maintaining the equipment through the software itself. It may allow users to keep an equipment inventory; some may even offer a real time inventory. It will allow users to assign patients to equipment, and reassign the equipment as it is moved from patient to patient. It may also give users the option to do system upgrades to the associated home telehealth hardware remotely.

Some vendors allow access to clinicians and/or home telehealth programs, but also have portals for patients and even their families to access data as well. Some vendors that say they have access for patients and families mean that their software can be interfaced with commercially available personal health records.

Most users of home telehealth have the need to do reporting on the data associated with their program. To meet that need, home telehealth software generally has some reporting capabilities built into the software. Some vendors offer additional accompanying software with expanded reporting capabilities for purchase. Some vendors allow users to do customized reporting with built in reporting wizards that allow them to parse out the data that they are seeking. All of these built in reporting capabilities may not meet your programmatic reporting needs, and you may still need to work the vendor to see if they offer additional custom reporting. Custom reporting can be high cost and is not even available from all home telehealth vendors.

Most telehealth vendors will state that they have the ability to interface with electronic medical records. Some will even state that they can do bidirectional interfacing. For the most part home telehealth software will package the home telehealth data and then use HL7 messaging to get the information into the electronic health record, this is called unidirectional interfacing. Bidirectional interfacing is when data can move from the home telehealth software to the electronic health record as well as from the electronic health record to the home telehealth software. For the most part the only type of data that can also move from the electronic health record to the home telehealth software is patient demographics data. Most major electronic health records are well versed in accepting and disseminating data in HL7 format and make it relatively easy to work with home telehealth vendors to give and receive data. Once a home telehealth vendor has worked with an electronic health record to share data it can generally share data with that electronic health record interdependent of where either are located. If your organization has a custom installation of a well-known electronic medical record there may need to be some custom interfacing done. If your organization has electronic medical record that the home telehealth vendor you are working with has never worked with, there will also likely need to be custom interfacing done. Custom interfacing may range from just a bit of programing to get HL7 messages exchanging to labor intensive custom programing to exchange proprietary data sets. When custom interfacing is required, check with both your electronic medical record company and the home telehealth vendor to see if the companies are able and/or willing to participate. Before you make a decision to go with a home telehealth vendor that requires custom interfacing, use caution and obtain a clear timeline and set of expectations from all parties involved.

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