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Home is Where the Heart is....Or is it?

2000; Wiley; Volume: 6; Issue: 3 Linguagem: Inglês

10.1111/j.1527-5299.2000.80155.x

1751-7133

John E. Strobeck, Marc A. Silver,

Telemedicine and Telehealth Implementation

Heart failure is a chronic disease process that predominantly affects an elderly population with multiple comorbidities, and despite improved therapies, it inexorably advances to late stages in many people. All of this, it would seem, would make heart failure and home care and home monitoring a natural fit. If this is coupled with tremendous advances in communication technology and bandwidth, one might say that the concept of telemonitoring a patient with heart failure is a “no-brainer.” Therefore, several months ago, led by an intriguing paper on the validation of a home telemanagement system, we issued a call for papers on the topic of telemanagement. Many phone calls came in and all our inquiries to the usual suspects were met with great enthusiasm. Yet, in the end, relatively few manuscripts arrived. Presented in this issue are three intriguing and terrific manuscripts; read them and enjoy. I question, however, why more data are not available for this forum of over 20,000 readers, all of whom have an announced interest in heart failure management. My take on all this is twofold. First of all, despite the emergence of increasing numbers of home monitoring companies, their utilization remains, for now, firmly rooted within managed care. Sure, everyone uses some telemanagement schemes, but few heart failure experts I talk to are using a predominant home or telemanagement strategy for the majority of their patients. The reasons abound, including lack of sophistication of the end-users, lack of a good general product, and so on. If the truth be known, I feel the initial cost and lack of a reimbursement mechanism inhibits a broader application of these services. Thus, until we find new and more cost effective ways to diagnose and treat heart failure and provide chronic care, broad incorporation of home based telemanagement, despite demonstrated efficiency, is unlikely to occur. Finally (and I am guilty here as well), there is the issue of quality control. This refers to the fact that the home based, telemonitored program is not a robotic set of computer commands or even automated steps in an algorithm; it is, for the most part, intermediaries stepping up to the role of a heart failure expert, and frankly, some do it well while others do it not so well. Similar to heart failure care in general, there remains too much variability; therefore, one is never quite sure what the product is that they are getting from the phoned, faxed, or e-mailed reports. On a daily basis I hear myself saying to a patient who has called with an alert, such as weight gain or increased shortness of breath, “Just come in for a quick visit.” My nurses shudder, knowing that our office schedule will once again be shot, but I know that a few moments talking with and looking at the patient, feeling the skin, looking at the neck, or listening to the chest can comfortably resolve my questions and lead to proper therapies. In a self-fulfilling way perhaps, I support the notion that patients' presentations can be tricky, and that is where my experience really counts. Perhaps it is also my bias to not do anything, which helps convince the patient and family that having the diagnosis of heart failure has anything to do with homebound status. Is it also possible that at this time there are few data to put forward regarding outcomes of heart failure telemanagement? Perhaps the results are modest, or pale compared to the cost of delivering these strategies. I suppose we shall soon find out, when our next call for papers on this topic is issued. So the challenge now rests in the courts of the companies focusing on home based health care. Prove to us that this is the right thing to do. Show us your data and get involved in the discourse about the “hows,” the “whys,” and the “how much” of heart failure care. As our little epidemic continues to spiral, we need some help. If this is a part of the answer, then convince us. We are receptive and call upon you to prove that home is where the failing hearts should be!