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HOME AND COMMUNITY TELEHEALTH FOR MINNESOTA: Background, Challenges, Potential Metro Area Eldercare Development Partnership Metropolitan Area Agency on Aging North St. Paul, MN
HOME AND COMMUNITY
TELEHEALTH FOR MINNESOTA:
Background, Challenges, Potential
Metro Area Eldercare Development Partnership
Metropolitan Area Agency on Aging
North St. Paul, MN
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TABLE OF CONTENTS
PAGE
EXECUTIVE SUMMARY 3
CHAPTER 1 - SETTING THE STAGE 9
CHAPTER 2 - TRENDS INFLUENCING HOME TELEHEALTH 28
ADOPTION
CHAPTER 3 - OPERATIONAL CHALLENGES 34
CHAPTER 4 - EFFICACY AND COST-BENEFIT 42
CHAPTER 5 - MINNESOTA RESOURCES, CHALLENGES 61
CHAPTER 6 - TELEHEALTH AMONG THE STATES 67
CHAPTER 7 - OBSERVATIONS AND RECOMMENDATIONS 75
END NOTES 80
BIBLIOGRAPHY 88
APPENDIX - ELECTRONIC HEALTH/WELLNESS PRODUCT 104
LISTINGS
PURPOSE: This report has been prepared by the Lifetime Home Project (Minneapolis, MN) for the Metro
Area Eldercare Development Partnership of the Metropolitan Area Agency on Aging (N. St. Paul, MN).
The Partnership's 2011-2013 work program contains a strategy area focused on using technology to
expand the capacity of the community long-term care system, and this report responds in part to that
strategy by:
Assessing which technologies are both care and cost beneficial, including through a review of
research literature, and
Investigating other states' public policy around the use of these technologies, comparing their
status with Minnesota's, and identifying where Minnesota could make changes that would have an
impact on technology use.
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EXECUTIVE SUMMARY
CHAPTER 1: SETTING THE STAGE
We live in an incredibly electronic world where an ever-growing number of disruptive
technologies continue to emerge and interact. They bring with them extraordinary
opportunities as well as profound changes in many areas of everyday life. The electronic
healthcare revolution is a prime example of how technology can alter practices followed
for decades and shift historic delivery capacities and boundaries.
Telemedicine is part of this revolution - the original delivery focus on remote treatment
and consultation by credentialed providers in clinical/hospital settings. Telehealth is the
term that has come to encompass telemedicine affairs along with general wellness/fitness
technologies and assistance with both post-acute and chronic care needs at home and in
the community. Original equipment connections relying on telephones have expanded to
wired and wireless options, typically using Internet linkages. Advances in radio-
frequency identification technologies have contributed to an expanding array of sensor-
based products, including those worn, surgically implanted and/or ingested biosensors.
Services provided remotely at home can be grouped into two broad categories. The first
involves equipment that monitors various body vital signs and medication adherence/
management; evolving delivery may also encompass mental health and rehabilitation
assistance. The second category involves remote activity/safety monitoring, including
emergency response and fall and/or wander management capabilities. Smart home
security and automation technologies have been marketed for decades, and some
activity/safety monitoring now similarly imbeds sensors into a home's structure and
fixtures.
As the array of remote care products for use within the home has expanded, a parallel
revolution involving wireless smart devices has taken place. Smartphones and computer
tablets are now adapted to become diagnostic tools. Peripherals devices are designed for
use with them in data gathering, and program "apps" (applications) perform a huge array
of functions. Smart device-mediated healthcare assists not just individuals, but can be
used in public health-related research, tracking and notifications. And while seniors in
the past may not have used or been comfortable with basic electronic technologies,
examples from recent surveys show general acceptance/adoption.
Electronics are relocating the "point of care" for some health and wellness services from
their historic clinical/hospital base to delivery at home, in the neighborhood and
potentially far beyond. Healthcare organizational boundaries are shifting as a result - a
major example is the home care/home healthcare industry, whose members have been the
prime historic providers of in-home medical services and support. Some functions
previously performed at home can also now be done when mobile using smart devices
and peripheral equipment. Additionally, doctors who in the past may have made home
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care/healthcare referrals are now making house calls and becoming in-home delivery care
team members. "Hospital at home" care models are also being tested.
A "quantified self" movement is expanding as electronic products routinely enable people
to self-monitor health status on a long-term basis. These products are becoming an
economic growth engine, fostered by expanding numbers of healthcare technology
incubators and evolving alliances among manufacturers, care providers and
telecommunications carriers.
CHAPTER 2: TRENDS AFFECTING HOME TELEHEALTH ADOPTION
The need for home/community telehealth is influenced by broad trends advancing in the
country. One of the most evident is efforts to respond to our healthcare and cost crises.
Home telehealth is an integral component in the design and implementation of the federal
Affordable Care Act, from priorities on avoiding rehospitalization, to testing better
methods for hospital-to-community transitions and use of home-based primary care
teams.
Another pervasive trend surrounds boomer demographics and the desire of a large
percentage of its members to age in place. By their simple numbers, boomers represent
potential demand for greatly expanded healthcare/support at home. They will continue
facing rapid exits from acute-care treatment, and many also have or will acquire age-
related chronic conditions needing long-term management. This potential increase in
demand for home-/community-based assistance will occur at the same time that care
workforce shortages are projected to increase. Geographic disparities will add to
challenges for those not living in major urban centers, particular in availability of
specialized medical services.
CHAPTER 3: MAJOR COMPONENTS AFFECTING DIRECT DELIVERY
Previously highlighted macro-trends affect home/community telehealth adoption on both
an individual and collective basis. Practitioners' abilities to incorporate telehealth into
service delivery are further affected by a number of prominent operational factors
including:
Healthcare decision-making instability, particularly surrounding the Affordable
Care Act's implementation;
Historic medical credentialing requiring that physicians and other practitioners
have licenses from all states in which they routinely deliver telehealth services;
Expansion of broadband capacity around the country and in Minnesota, its
regulation by the Federal Communications Commission and impact from some of
its recent actions;
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Data gathering/management capacities, including electronic health records
implementation;
Impacts the federal Food and Drug Administration's device regulation have on
new products coming to market and changes in existing hardware/software
systems, and most recently, on developments in the expanding mobile health
field;
Concerns about device interoperability and the role the trade association,
Continua, has played in creating a "level playing field" among manufacturers;
Financing issues - including equipment acquisition/maintenance, operations
(e.g., staff training and data management), connectivity, and the emerging
"telehealth as a service" model where companies contract to effectively become
outsourced telehealth departments;
The impact introduction of these technologies has on staffing patterns,
responsibilities, practices, and strategies for successfully promoting the
technologies' uses in an organization's culture;
Recent federal legislation aimed at increasing telehealth access for persons
insured through a range of federal services, at fostering the technology's use in
less-populated locations, and enhancing the FDA's mobile health capacity.
Findings from a 2012 national survey on home care, home healthcare and geriatric care
management agencies' telehealth usage is a proxy for the extent of adoption in those
fields. Results showed respondent familiarity with the technologies, but moderate
adoption rates for very basic equipment like personal emergency response systems and
medication dispensers (slightly over 50%). Use of various types of vital signs peripherals
was far lower (14% or less, depending on devices involved).
CHAPTER 4: EFFICACY AND COST-BENEFIT
Outcomes from a substantial number of research projects over many years have answered
the question of telemedicine's and telehealth's efficacy. However, issues regarding
whether mobile health products are sufficiently exacting in remotely performing certain
procedures are presently being researched and assessed.
The issue of the technologies' cost-benefit capabilities has also been extensively
covered over time, although interpreting results depends in part on whose costs and
whose benefits are of concern. The typical approach has been to assess direct
acquisition/operational costs and reimbursement opportunities using a business return
on investment approach. However, organizations may also factor a number of
subjective measures into the benefits side of the equations - e.g., impact on reputation,
image, "goodwill," patient/support network satisfaction. Additional broader and more
indirect qualitative measures beyond a single organization's costs-benefits should but
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typically aren't accounted for in these calculations - e.g., adverse social outcomes
technology use may reduce/eliminate, community economic benefits.
An array of abstracts or full reports for approximately 20 formal U.S. research studies
(2009 to the present) were reviewed, and findings supporting the technologies' efficacy
and/or cost-benefit summarized. Additional significant study or program result
highlights include:
The British "Whole System Demonstrator Program" involved 6,200 patients
and 240 general practices across three program sites;
A wide range of initiatives overseen by the Veterans Health Administration,
one of the earliest and most expansive telehealth adopters/users in the U.S;
A major study involving cardiac care conducted by the Center for Connected
Health, a national cutting-edge promoter of telehealth affiliated with Partners
Health Care (Boston, MA);
A residential study involving the long-term care provider, New Courtland Life
(Philadelphia, PA) and Healthsense (Mendota, MN), a manufacturer of remote
sensor activity/safety monitoring and related products;
A study by the Health Partners Research Foundation (St. Paul, MN) of blood
pressure management involving telepharmacy;
A rural telehealth initiative conducted in North Dakota, South Dakota and
Montana by St. Aleius Medical Center (Bismarck, ND) and the federally
funded Great Plains Telehealth Resource and Assistance Center (Minneapolis,
MN).
CHAPTER 5 - MINNESOTA TELEHEALTH RESOURCES, CHALLENGES
Minnesota statutes involving telemedicine (including one permitting use of remote
monitoring technology as an alternative to overnight supervision in adult foster care
settings) are highlighted. Pertinent Department of Human Services Medicaid regulations
covering telehealth services are also profiled.
The key role Minnesota home care, home healthcare and geriatric care management
agencies will perform in this evolving field is discussed, as are the findings from state
and trade association contacts that data unfortunately aren't available from them
reflecting agencies' electronic technology usage rates or operating challenges.
Three resources contributing to telehealth delivery in Minnesota are also highlighted -
broadband capacity and usage monitoring by the nonprofit, Connect Minnesota; long-
term efforts by a group of organizations to establish telemedicine networks around the
state (reflected most recently in the "Greater Minnesota Broadband Telehealth
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Initiative"), and resources available through the Great Plains Telehealth Resource and
Assistance Center (Minneapolis, MN), one of 12 regional technical services supported by
the federal Department of Health and Human Services.
CHAPTER 6: TELEHEALTH AMONG THE STATES
Telehealth is a continually changing field, including evolving affairs within each state.
Only anecdotal data on state policies and practices have been available for many years,
and a number of research and/or trade associations in response have undertaken major
data gathering/analysis projects. Many of these studies have been point-in-time reviews,
but the Center for Connected Health Policy, funded by the federal Department of Health
and Human Services, launched a website in 2013 to maintain timely data on states'
telehealth regulations and operations.
Data from the website were also used to prepare a report on states' telehealth affairs.
Summary findings include that: at least 44 states have some form of telehealth
reimbursement, at least 10 (including Minnesota) reimburse for remote patient
monitoring, all states appear to permit telepharmacy, at least nine have regulations
involving some form of special licensure, and at least 16 have laws addressing private
payer reimbursements.
Summary characteristics were profiled for states identified as permitting remote
monitoring: Alaska, Colorado, Kansas, Minnesota, New York, Pennsylvania, South
Carolina, South Dakota, Utah and Washington. Although not identified by this report,
another study's findings showed that Alabama and Wisconsin support remote monitoring,
and basic features for their programs are also highlighted. While the various reports
focus on technologies used for seniors, Medicaid Waivers support remote activity/safety
monitoring for younger persons with disabilities in states including Indiana, Ohio and
Minnesota.
The state of New York appears to use a coordinated and comprehensive approach in its
Medicaid deliver which integrates remote vital signs monitoring, patient education,
medication management and equipment management. The state has also implemented a
"Health Home" program for those with complex medical, behavioral and/or long-term
needs, using a tiered reimbursement system based on levels of connectivity and class of
telehealth devices.
Pennsylvania is another state that appears to use a coordinated management approach
including remote vital signs monitoring, activity sensor monitoring, personal emergency
response devices and medication dispensing/management. A sliding-scale "Options"
program extends client eligibility beyond Medicaid income eligibility - no cost for those
at 125% of federal poverty level, 100% for those at 300%. Area Agencies on Aging
manage reimbursements for installation and monthly fees.
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CHAPTER 7: OBSERVATIONS AND RECOMMENDATIONS
A key report objective has been to provide a working knowledge of the overall home/
community telehealth field and highlight its status in Minnesota. A number of "next
steps" within our state's affairs have emerged along the way, and include:
Promoting in-home telehealth. Home care, home healthcare and geriatric care
management occupy a central position in delivering telehealth to persons with
widely varying medical conditions and acuity. However, the extent of
adoption/use by these Minnesota's providers is unknown. A first step should be to
survey agencies to obtain benchmark data about their interests, capabilities and
barriers faced. A related step would be to survey "early adopter" long-term care
providers in the state for experiences and recommendations they would be willing
to share.
Learning from the Veterans Health Administration. VHA was one of the earliest
telemedicine/telehealth adopters in the country, resulting in an extensive, growing
body of experience. The Minneapolis VA Medical Center has been involved in
these efforts for many years, and organizations interested in promoting telehealth
in Minnesota should consult with pertinent staff there for expertise they can
provide and to identify areas where potential partnering could occur.
Home telehealth in state policy. Virtually all states have authorized using various
telehealth technologies with their Medicaid programs, but not necessarily in a
systematic, planful manner aimed at achieving the greatest cost savings balanced
against promoting personal independence. Minnesota should evaluate if its
current service delivery infrastructure is achieving optimal outcomes.
Home telehealth resource center. Telehealth has the potential to promote
independence and achieve public and private cost savings. Consumers and care
professionals need practical data on products, their capabilities and performance
to make good decisions and investments. However, information supporting
efficient Minnesota decision making isn't readily available.
A strategic response could be to organize a virtual telehealth technical assistance
center with the collaborative support of key public and private stakeholders. This
center could monitor the status of major existing and new products. It could track
legislative and regulatory actions, gather and disseminate performance-type data,
and offer how-to workshops for those products family and informal care providers
can set up and manage. It could offer periodic round-up presentations on industry
trends and offerings.
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CHAPTER 1 -
SETTING THE STAGE
We live in an incredibly electronic world where an ever-growing number of disruptive
technologies continue emerging and interacting. They bring with them extraordinary
opportunities that at the same time are profoundly changing historic, everyday conventions.
This electronic world has become a complex environment where the old often overlaps and
coexists uneasily with the new. "Mash-up,” a term from the computer field for combining
existing data or formats to yield new outputs, has become a figure of speech for the many
striking developments becoming commonplace.
New medical treatment and support approaches are being fostered, and serious cost
pressures coupled with consumer preferences further promote their adoption. In the
process, historic healthcare boundaries - who works in various fields, what’s performed
in them and where - all are shifting. The healthcare delivery paradigm is being
reconfigured, taking with it past stability and familiarity.
This report will assess developments in one facet of the electronic healthcare (r)evolution -
telehealth and related forms of support at home and in the community. It will highlight
trends influencing and shaping it, identify broad forces promoting and curtailing it, review
research literature on its efficacy and cost effectiveness, look at basic Minnesota elements
and comparative practices in other states, and consider ways to further advance the
technologies' use for the benefits they can provide.
The focus is on technologies and supports for seniors, spanning both a long age and
capability arc. At one end are boomers who have turned 65 or will do so in a few years,
and those a few years ahead of them in their late 60s through 70s. Many in this young
seniors' cohort have been exposed to and used a wide array of electronic/digital equipment
in their work and personal affairs. At the other end of the arc are persons in their mid- to
later 80s and beyond, many with modest exposure to electronic devices in general and
slight-to-moderate experience with healthcare-related uses in particular. The report will
attempt to address concerns across this span.
TERMS AND DEFINITIONS
As often happens in a highly technical and rapidly evolving field, it’s a challenge to keep
up with terms and phrases characterizing health/wellness functions now being performed
remotely. Even though somewhat academic, it may be helpful at the outset to highlight
this language for the frame of reference it provides.
Generations of prefixes have been attached to conventional treatment-, care- and health-
related words, and they highlight the shifts occurring over time in the communications
technologies involved. Tele is the original prefix which referenced how the earliest
connections were by telephones and landlines. These connections evolved over the years
to involve other types of physical lines - fiber optics and cable - and then wireless radio
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frequency broadcasting and satellites. Even though the amount of transmission via POTS
- "plain old telephone service" - has been eclipsed by the range of other connections, the
prefix is still used as an abbreviation for methods of telecommunications encompassing
all the approaches.
Telemedicine is the earliest term used to identify the field where medical personnel
and/or researchers exchange data for diagnosis, therapy, treatment, surgery, consultation,
instruction and study/analysis. (1) These exchanges may just involve data collection/
transmission or increasingly involve data collection and video. A key transmission
characteristic is that they are either done in real time or use "store-and-forward" capacity
enabling later review.
The general telemedicine discipline rapidly expanded into an extremely wide range of
specializations, many now with extensive best practices and recommended protocols.
Some involve clinical services/treatment, some involve in-home/in-community supports.
Common examples include: telepharmacy, teledermatology, telehospice, teleradiology,
telementalhealth, teleoncology, and telerehabilitation.
As various forms of broadband communications advanced, use of the technologies
expanded beyond medical personnel and practices performed in hospitals and clinics. It
now includes a wide range of medical communications, health and wellness activities
occurring at home and in the community. Telehealth and digital health have come into
widespread use as umbrella terms encompassing telemedicine and these broader
activities.
In roughly the past half-decade, the prefix e- began being used instead of tele-. It reflects
that various methods of transmission as well as equipment operations are all electronic.
More recently, the prefix m- has come into use denoting the mobile nature of connections
where data captured and/or transmission is done wirelessly with specialized equipment.
A critical, core aspect of the e-care revolution is its use of sensor technologies. Basic
sensors are extremely small electronic chips in which wireless radio antennas with a
unique frequency are imbedded - radio-frequency identification or RFID. They remain
silent until activated when a wireless message broadcast by a scanning unit (typically
hand-held) activates them to send an "on" location signal. Depending on how they're
manufactured, they operate at distances that can vary from a few feet to much wider
areas.
The essential use for basic sensors is to locate and/or identify objects and actions. The
changes brought on by their marriage with pervasive wireless transmission capabilities
are significant for the types of items that can be monitored - e.g., surgical tools, taxi
fleets, theme park visitors, buried cables and pipelines, library materials. One wide-
ranging impact is the prediction that RFID “tags” will soon replace the Universal Product
Code/UPC inventory control tool - unlike codes, RFID chips can also store data tracking
characteristics such as site of manufacturing and subsequent locations in a supply chain,
shipping history, ambient temperatures, etc.
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When basic sensors are enhanced with additional monitoring/reporting functions, they
create a further, extraordinary range of capabilities. One key example is when additional
capacities are imbedded that enable sensors to monitor/report on a wide range of
conditions in a particular environment - light, sound, heat/cold, movement, fluid flow,
vibration, pressure. As will be profiled shortly, sensor systems using these capabilities
have been developed to monitor health, activities and safety at home.
Biosensing - the term for when body-based data is obtained for diagnosis, treatment
and/or monitoring purpose – is another emerging area with profound implications.
Ranging from the outside inward, passive monitoring products and equipment are now
marketed that are:
Worn - devices imbedded in articles of clothing, wristbands or armbands, shoes,
inserts or shoelaces (e.g., for gait analysis or location monitoring), vibrating
"memory" bracelets
Direct-contact household articles - e.g., sheets and pillowcases that monitor for
temperature, moisture, cardiac functions
Skin patch applications that can monitor temperature; heart functions over an
extended period; "smart" bandages that can monitor for infection, healing rate
Surgically implanted - e.g., glucose monitors that eliminate finger-prick blood
testing; sensor-enabled heart pacemakers that monitor beat regularity and
passively transmit periodic reports as well as irregularity alerts to medical
personnel
Ingested - e.g., “digital pills” taken with other medications to monitor usage –
“Proteus” is the first ingestible sensor approved by the U.S. Food and Drug
Administration, and may represent the start of "digital medicine." (2)
The technology firm ABI Research reports that approximately 30 million wearable m-
health products were shipped in 2012, and the device market is anticipated to grow at a
compound annual rate of 40% between 2011 and 2017. (3)
HOME TEL EHEALTH
For many, advancing age brings with it health complications. Electronic monitoring
technologies that manage these needs at home go by a number of names, including
telelehomecare, home telecare, remote home health monitoring, remote monitoring and
in-home patient monitoring. They are typically provided as an extension of the services
home healthcare agencies have historically delivered, managed by personnel with
medical credentials and/or training.
Post-acute and chronic healthcare issues may be monitored as well as general health
status, with education for self-care and behavior modification also provided. This class
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of activities encompasses two broad functions. The first is monitoring and managing
acute and/or chronic health conditions, and it’s comprised of two types of activities.
Remote vital signs monitoring involves transmitting patient data by itself or in
conjunction with video.
Remote vital signs monitoring is an extremely important advance in managing chronic
conditions. Its frequent or continuous tracking can establish precise trend patterns as
well as catch subtle, sometimes infrequent changes that periodic visits to a healthcare
provider wouldn’t yield. Current vital signs monitoring products used at home are
typically designed as a suite with a small central console unit that tracks a variety of body
systems/functions, depending on a person's particular needs. The console may also have
functions built in to query, inform and/or educate. Peripheral equipment typically used
includes:
Cardiac rhythm monitors
Spirometers for pulmonary function
Glucometers (glucose monitors) for blood sugar level
Scales for general weight monitoring as well as for gain from fluid buildup due to
congestive heart failure
Blood pressure monitors
Pulse oximeters for blood oxygenation
Specialized devices - e.g., for blood coagulation or mental health medications - may also
be incorporated. As previously indicated, vital signs monitoring systems have been
designed for tracking chronic and sometimes serious medical conditions, where
assessment/follow up by healthcare professionals is needed. However, there is a broader,
expanding market where these types of peripherals are used by persons with chronic, but
not severe, conditions to either self-monitor or monitor and periodically provide data to
physicians and other healthcare providers. Consumer electronics retailers like Best Buy
as well as Walgreens, RiteAid, CVS and other major pharmacy chains are now marketing
them.
Telehealth has opened up opportunities to deliver supports that weren't previously
available at home or can be expanded in scope. For example, physical therapy and
rehabilitation are being provided using techniques from the video gaming field. It
enables individual or group work involving exercise instructions, prompts and
performance tracking once a hand's-on treatment regimen is in place. Some of these
systems are designed around the capabilities of Microsoft's "Kinect for Windows" - its 3-
D motion-capture sensor capability can be integrated into game-like interactive therapy
sessions and also potentially track movements for remote reporting. (4)
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Similarly, there is great promise in electronically assisting persons with a very wide range
of mental health needs - from medication management to direct individual and group
counseling. Seniors' mental health needs and their impact on physical health are being
increasingly recognized, and it's very likely that this services will be integrated into or
closely coordinated with delivery of home physical care services in the future.
The ability to extend the reach of mental health services is extremely important in a state
like Minnesota, where there are historic practitioner shortages as well as imbalances in
geographic distribution. A 2010 state report on telementalhealth in rural Minnesota
highlights these challenges. (5) It estimated that of the 446 psychiatrists licensed and
practicing in Minnesota, 65% practice in the metro Twin Cities area, 14% in Olmsted
County, fewer than 90 (12%) practice in rural areas and 50 rural counties have none
practicing. Those in rural locations are predominantly connected with community
mental health centers or hospitals. The number of psychologists in the state is reported as
above national averages, but they are similarly concentrated in the metro area and 13
counties have none.
The other major category of home acute and/or chronic health monitoring involves
medication adherence and management. It provides not only convenience, but responds
to a serious healthcare cost problem - according to NEHI (previously known as New
England Healthcare Institute), as many as 50% of patients in the U.S. don't take
medications prescribed for them, at a projected $290 billion cost. (6)
The issue of seniors' adherence is particularly acute. Forgetfulness - stray incidents or
due to a cognitive condition - often occurs. Patients may discontinue before a regimen is
completed when symptoms subside. They also may have difficulty with side effects
when a single medication is taken or expected/unexpected effects when multiple
medications are required. Necessary prescriptions may not be refilled for reasons
including problems or delays in ordering and/or securing and concerns about out-of-
pocket or co-payment expenses.
It's projected that, not including over-the-counter and/or herbal products, seniors take
more than one-third of all medications annually prescribed in the U.S. (7) Those who
are ambulatory fill between nine and 13 prescriptions a year (new and refills), and the
average senior takes more than five prescriptions. Electronic monitoring technologies
along with various low-tech strategies can address many of these concerns. Reminders
can be given via a range of options - text, voice, visual and/or auditory signals. Some
electronic medication devices automatically track the need for refills and may directly
alert the pharmacist - an example is the "Glow Caps" container system marketed by
AT&T. (8)
Telepharmacy is also becoming an effective adherence and care management resource, as
highlighted in a recent Minnesota Public Radio news story. (10) It reported on how
Fairview Partners, the senior care branch of the Fairview Health System, is using
webcams to connect pharmacists and relatively housebound rural seniors. The news
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story highlighted a 78-year old woman who lived for 50 years in Jordan where her
husband and she dairy farmed.
The woman at the time of the report was two years post-heart attack, has diabetes and
major stomach upset problems from taking 18 medicines daily. She is periodically linked
via telehealth webcam to a Partners' pharmacist specially certified in geriatric pharmacy.
The pharmacist periodically reviews each medication, checks for adverse drug
interactions and side effects, and adjusts doses. The Fairview Partners' operations
director reported that the system calculates per-patient savings at $1,500 in transportation
and emergency room costs avoided through use of telepharmacy.
ACTIVITY/SAFETY MONITORING
The second major class of home telehealth encompasses monitoring for well-being and
safety, and is comprised of two major components. The first is remote activity/safety
sensor monitoring or remote sensor monitoring. The original market for these systems
was long-term care settings, particularly assisted living, and vendors are now extending
them for use in both single-family and multifamily housing.
These systems employ small radio frequency sensor devices that are positioned
throughout a housing unit to track a wide range of basic activities:
Movement through the outside door(s)
Opening/closing the refrigerator or kitchen storage
Turning the stove and oven on/off
Moving around in various rooms
Getting in/out of chairs and the bed
Water flow for flushing the toilet
Humidity changes when a shower or bath is taken
The wireless sensor devices are configured to passively track activities in relation to a
person's standard activity patterns established over time. Normal conditions register as
ongoing trend data in a "dashboard" configured with the patterns. Exceptions trigger an
alert where the need for follow up is screened, or one or more designed parties are
notified to visit the site.
Companies selling/installing these products may perform the necessary remote
monitoring services, or home healthcare provider staffs may take on the responsibility.
Depending on the system and a person's situation, remote assessment may also be
performed by family, friends, neighbors or others in a person's support circle. Vendors as
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disparate as municipal governments and organizations delivering local phone,
sewer/water and/or gas utilities or home security services are also delivering services in
the field as well.
A related group of products in this category is the wide array of personal emergency
response system (PERS), fall detection and wander alert devices on the market. The
earliest PERS were pendants worn around the neck where wearers pressed an alert button
for help with a serious fall, medical crisis or other major problem. The alert was
wirelessly transmitted to a monitoring unit connected to the home's land line telephone
that sent it to a call center. Staff there talked with the user by a speakerphone in the
monitoring unit, and dispatched assistance as required.
Original PERS was limited in two ways - it had to be activated by the wearer (who might
not be capable, depending on the emergency) and the transmission range was limited to
within the home or very close to the monitoring unit. A number of tech advances have
greatly modified capabilities, though:
Internet connections and wireless communications enable sending alerts not only
from in/near a home, but also from the neighborhood and sometimes far beyond;
these connections can also enable two-way communication via a pendant,
wristwatch or belt clip worn.
Global positioning system/GPS as well as radio telemetry and similar
technologies now provide capability to determine a person's location within large
areas.
Very small devices called accelerometers track rapid shifts in body position, and
can automatically activate an alert when a fall or similar sudden change occurs.
These technologies have expanded old-style PERS capabilities to not only include
passive fall detection but help with location-finding concerns as well - not only a
caregiver wanting to find a user, but users checking on where they're located when
walking or driving. While some products still concentrate on one type of monitoring,
there's been a "function creep" with some devices now incorporating two or all three
capabilities.
These products' utility may be expanding even further in the near future. The report,
"Next Generation Response Systems: From Fear to Function," profiles how the character
of PERS devices is evolving. (10) The report highlights how these products have been
thought of as medical devices but haven't been integrated into care management. It
predicts how they could be used to monitor behavior patterns to discern potential decline
and/or the needs of specific disabling conditions. Capabilities could also extend to gait
tracking, responding to post-acute care discharge needs, monitoring seizures, better
assessing when true emergencies have taken place and in providing concierge-type
assistance.
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Sensor devices/systems for general home management have also being available in the
do-it-yourself consumer/home improvement markets for many years. These smart home
products are attached to or incorporated into the structure to provide remote home
security, automate various functions (e.g., control lights, heat, etc.) and for entertainment
purposes. A well-known example is the Insteon line of sensor products from the
Smarthome firm (11).
It had been predicted for many years that care-related devices capable of coordinating
with these other home monitoring components would eventually come to market, and that
point has now been reached with the "Iris" product line the home improvement company
Lowes carries. (12) “Sensor kits in a box” for security, automation and energy
management came out in 2012, and the company in 2013 added a caregiver kit to the
array.
Iris care components track movement and activity with visual confirmation via motion
and contact sensors. Alerts for falls or emergency situations are done via the Iris "Senior
Pendant." Pre-set monitoring patterns based on normal activities assess if/when a daily
routine isn't performed. Any follow up is done not by medical or vendor personnel, but
formal and informal caregivers.
The remote sensor systems targeted for care settings as well as the emerging consumer
market flexibly place small components in various locations throughout a living unit or
home - on doors and cabinets, on walls, under rugs and mattresses, etc. Part of the
evolving smart-home care technology market also involves sensors permanently installed
in a home's structure or installing sensor-enabled appliances and fixtures. Examples
include:
Stair landings equipped to light when stepped on or stairs equipped to register
motion when passed
Sensors positioned in floor joists to monitor gait as well as falls
Medicine cabinets equipped with monitors triggering voice response with
use/overuse
Devices extending into vital signs monitoring area, e.g., toilets that can monitor
blood sugar level
CAREGIVER AND COMMUNICATIONS RESOURCES
Although not precisely telehealth devices, various digital programs and services provide
caregivers with a range of supports and help foster communications among many parties.
Resources may help with tasks such as recordkeeping, scheduling appointments,
managing medications, hiring in-home staff, tracking care records and sharing
information among caregivers. Communications resources include phones adapted for
17
persons with reduced hearing, easy-to-use cellphone models, devices that convert speech
to text and flexible videoconferencing arrangements.
THE SMART DEVICE REVOLUTION
Home care/healthcare agencies and related organizations (e.g., hospital outpatient
departments) are expanding functions they've historically performed through use of home
telehealth monitoring equipment. At the same time, though, there's been an incredible
surge in mobile electronics products which are profoundly altering healthcare delivery
practices.
Capitalizing on availability of advanced wired and wireless communications, the
equipment foundation is based on tablet devices such as the Apple iPad, personal digital
assistants such as the BlackBerry and most frequently, smartphones such as Apple's
iPhone or Samsung's Galaxy. All these products seem to have an ever-expanding array
of features.
Basic cellphones and more advanced smartphone adoption in the U.S. is estimated at
close to 90% of the population, with 78% of adults between 50-64 years and 82% of
those between 65 and 74 having a cellphone. (13) A growing number of units on the
market also respond to a range of seniors' functional needs - streamlined features, easy-
to-understand and easy-to-finger controls, hearing aid compatibility.
Programs written for smart devices - applications or "apps" - are greatly extending health
data collection/management capabilities as well. Apps seem to be available for any and
every purpose - "...there's an app for that..." - as reflected in trends studied by the
tracking/data analytics firm, Mobilewalla. It reported that smartphone apps for the four
major operating platforms - Apple, Android, BlackBerry and Windows - surpassed one
million at the end of 2011, and that approximately 2,000 come to market daily. (14)
Within that massive market, it was estimated in early 2012 that approximately 40,000
health apps were currently available across various operating platforms. (15)
Smart device-mediated healthcare encompasses a rapidly expanding range of activities
and participants. The most basic involves care providers sending simple notifications/
prompts and alerts, whether by voice or text. A second segment involves individuals
using smart device health apps for tracking and education purposes - health and fitness
tracking has become a huge market, as has tracking family and/or caregiver health
records, histories, medications and scheduling.
An example of scope here was reported by a 2012 research study that evaluated Android-
based diabetes management apps where users self-tracked blood glucose and diabetes
medications and calculated insulin doses. (16) It identified over 80 apps where 42 were
eligible for the study - 18 were free of charge and the other 43 had an average purchase
price of slightly less than $3.00.
18
A third segment involves where health-related businesses have developed apps as a
convenience for their customers. A good example is the Walgreen app that can find
stores, refill prescriptions with a barcode scan, set personal medication reminders, look
up prescription information and make appointments at in-store clinics. (17) The
company has further expanded its electronic capacity by developing an "application
program interface" enabling outside software developers to incorporate the company's
prescription scanning/refill technology into apps the developers are creating. (18)
In a fourth smart device segment, patients use miniature peripheral medical equipment
designed to attach to a smart device for gathering various types of vital signs at home or
when mobile - monitoring blood pressure, blood sugar, respiratory function, various
cardiac functions. A fifth segment highlighted at the beginning of the chapter involves
smart devices that become biosensing data gathering/transmission tools for wearable,
imbedded and/or ingested sensor healthcare products.
A sixth segment involves smart devices actually becoming diagnostic tools. They are
being adapted to become microscopes, perform eye examinations (e.g., retina or cataract
assessment), perform ear examinations, match test strips for diabetes urinalysis and
function as a mobile electrocardiogram.
A seventh segment of smart device-mediated healthcare extends beyond individuals into
the broader realm of public health. It focuses on issues either affecting a very large
geographic area or where a large population base needs to be assessed or monitored. The
term crowdsourced health is being used to depict these capabilities, as highlighted by the
following examples:
An epidemiologist spent many years trying to track events triggering asthma
attacks. His eventual solution was to mount a GPS sensor on an asthma inhaler to
monitor time and location where medication is taken, and send the data to a
smartphone for further transmission. This device, "Asthmapolis," was recently
used in a 500-person study in Louisville, KY to explore potential causes for the
area's higher-than-normal asthma rates. (19) The term geomedicine designates
activities that evaluate health based on location.
Epidemiology studies can involve one-time or periodic participant data
gathering. Smart devices, coupled with social media like Facebook and
Twitter, can greatly extend data-gathering capacity, frequency and the
number of participants that can be involved.
Monitoring the spread of virulent strains of influenza and other life-
threatening diseases has become a priority public health concern
worldwide. Smart devices, again coupled with social media, can rapidly
gather extensive trend data about the location, extent and severity of
outbreaks.
19
Doctors are starting to prescribe apps and the peripherals that go with them as a cost-
effective and proactive way for patients to manage chronic conditions - specialized
devices or treatment/maintenance regimens don't have to be purchased if care needs can
be integrated into products many people already own. A trend that may expand over time
is doctors prescribing and insurance companies covering costs for peripheral devices,
since apps often are free or low-cost.
Figure 1 at the end of this chapter provides examples of the various types of telehealth
products being used at home and when mobile.
SENIORS AND ELECTRONIC TECHNOLOGIES
It was argued in years past that seniors weren't capable of or interested in taking advantage
of many electronic technologies, including those supporting their care. This may have been
the case for those their 80s or older at the time. Some seniors now in this age range,
though, have had basic exposure to different types of everyday electronic technologies -
garage door openers; TV remotes; microwaves, stoves and other appliances with electronic
features; autos incorporating digital connections; digital picture frames; digital TVs.
It was also said many years ago that seniors wouldn't accept technology for their care, but
many anecdotal reports indicate remote monitoring is accepted as long as direct video
isn’t used. In many cases, seniors understand that as they become more vulnerable, these
technologies may represent the difference between living relatively independently and
having to relocate to a care setting. Anecdotal findings also indicate that seeing friends
and relatives use vital signs and sensor monitoring products may influence seniors to
view the products as a standard-of-care benchmark.
The following study results highlight the extent of seniors’ communications and
healthcare technology adoption:
The Pew "Internet and the American Life Project" reported in spring 2012
surveying (20) that:
For the first time, cellphone use among those 65/+ has exceeded 50%
(52%)
86% of Internet users age 65/+ use e-mail, with 48% doing so on a typical
day
34% of the 65/+ cohort report using Facebook, 18% on a typical day
69% of adults 65/+ report owning a cellphone (up from 57 % in 2010)
Among those ages 76/+, reported cellphone ownership is 56% (up from
47% in 2010)
20
Deloitte Center for Health Solutions reported results of a 2012 survey (21) in
which 35% of seniors and 44% of boomers indicated receptivity to using self-
monitoring technology and electronically forwarding results to their doctors.
Clarity, a hearing aid/adapted phone manufacturer, and the EAR Foundation have
partnered over the years on studies aimed at better understanding seniors' health
and lifestyles, and increasing public awareness of seniors’ hearing and other
disability issues. In 2012, the partnership supported a survey of over 800 seniors
and baby boomers exploring attitudes toward and use of technologies enabling
independent living. (22) Findings included that:
65% of seniors surveyed were open to using new technologies, with more
than half indicating willingness to have sensor technologies at home for
monitoring their health and safety.
49% of boomers were interested in new technologies that would help
monitor their parents' safety, and 50% were open to sensors being used to
monitor their parents' health and safety.
THE "POINT OF CARE" REVOLUTION
As is evident in the overview presented so far, many aspects of healthcare delivery are
profoundly changing. Methods for collecting data have gone from direct/in person to
landline phones, to computers, to cellphones and smart devices, to body sensing.
Transmission into and out of a home has gone from landlines to fiber optics and cable to
wireless via the major telecommunications carriers and satellites.
An equipment size continuum has developed in many product categories. First-
generation home vital signs units were sometimes the same size or scaled-down tabletop
versions of their hospital and/or clinic counterparts. Miniaturized versions designed for
smartphones now fit in the palm of the hand or an even smaller space. Portable and
property-imbedded alternatives are available.
There's also a residential setting/function continuum. Products and assistance are often
perceived as essentially for single-family homes, and significant use does take place there
because houses make up a very large portion of the residential stock nationally and in
Minnesota. However, both vital signs and sensor monitoring occur in individuals' owned
and rented units in multifamily properties, and kiosk-style monitoring units on the market
can collect vital signs and other health/wellness data systematically for a group of users.
All of these changes contribute to the irrevocable shift that's occurring in the point of
care. Up until the 1960s -1970s, care was predominantly provided at an institutional site
- a hospital, clinic, doctor's office - and supplemented with provider house calls. Care
began shifting in roughly the late 1970s -1980 from an institutional base to newer types
of sites, e.g., free-standing "urgicare" and "minute clinics" in retail settings such as
21
Target, CVS and Walgreens. Sites have continued shifting since then to current-day
examples such as Walmart now offering major self-service screening resources. (23)
Electronic and smart device-based mobile healthcare is further expanding this scope from
home to the neighborhood or another part of town, or other parts of the U.S. or the world.
An official for the Kaiser Permanente health organization was asked at a recent World
Health Care Congress for his perspective on home healthcare technology’s integration
into care delivery. (24) He observed that:
"With emerging clinical device technologies and mobile capabilities, the
line is blurring between home care and care anywhere, and making them
affordable for nearly everyone. I think that trend is going to continue over
the next five years to change home care in a remarkable way.”
“In three years, the ability to care for people in their own homes will be
roughly equivalent to the care [patients] got in the hospital two years ago. If
you look at that five-year swing, emerging technologies are lining up and
will enable the whole health system to take advantage of those technologies
and dramatically improve the ability to take care of people in their homes,
monitor them, provide them the assistance they need and enable more
people to go home."
THE QUANTIFIED SELF
One key byproduct from the expanding availability of electronic technologies is growth
in self-monitoring, not only for medical purposes but general wellness as well - sleep,
exercise, diet, mood, etc. This growth not only involves consumers and clients
conveying results to their care professionals, but sharing results as well as observations
about the process with like-minded individuals.
An infrastructure is now developing around the quantified self practice - the term for
the activity - with an international organization and website established for the interest
area. (25) The organization sponsors an international conference, and supporters have
established chapters throughout the U.S. and worldwide. Participants are not only those
interested in general health/wellness or who must perform extensive or complicated
personal medical tracking, but also researchers in many disciplines.
Manhattan Research, a global pharmaceutical and healthcare market research/advisory
firm, annually conducts a "Taking the Pulse" online survey of how U.S. physicians use
the Internet, mobile devices, digital media and other technologies. Its director of
physician research recently observed that, “Self-tracking is already a part of the care
paradigm and its prevalence is going to accelerate rapidly as digital connection, payment
reform, and outcome-focused delivery make advances.” (26)
The Pew “Internet and the American Life” project conducted a "Tracking for Health"
survey in 2013, the first broad review of health data tracking among all adults nationally
22
(not just Internet users). (27) 3,000/+ U.S. adults were surveyed during the late summer
of 2012, and among findings were that:
45% of those surveyed said they use a smartphone.
About 11% of all mobile phone users and 19% of smartphone users have at least
one health app on their phones. The figures rise to 22% for caregivers, 21% for
those with a chronic condition, and 21% for those who faced a major medical
crisis in the previous 12 months.
About 69% of adults monitor at least one health indicator - about 60% track
common measures like weight, diet or an exercise routine. 62% of those surveyed
have two or more chronic conditions. 33% track systems- or disease-related
indicators and 12% monitor indicators for a loved one.
21% of those who track their health use some form of technology (which could
include peripherals, a website or digital spreadsheet).
A priority for deploying home/community telehealth resources is to support persons with
major medical conditions, where boomers/seniors will rapidly become a growing target
group. These new electronic technologies may be able to either increase or at least not
reduce current levels of independent living, keep certain conditions under better control
and make patients more aware and proactive about managing health concerns. People in
younger age groups are already attracted to using mobile and/or smart device-mediated
resources for prevention and maintaining good health – they are already living digital
lifestyles. This trend can only be positive for the technology's overall diffusion.
REDEFINING “HOME” IN HOME HEALTHCARE
Certain types of care in the future will continue being provided to persons at home,
particularly for those with serious chronic conditions and/or frailty. The historic delivery
model of nurses and other medically credentialed staff providing direct-contact assistance
will continue, with some functions extended by ability to perform them using home-
based remote telehealth resources.
However, the growth of sensor- and smart device-mediated m-health capabilities is
blurring care delivery boundaries - these resources provide some forms of assistance
similar or even identical to what home care agencies may provide. With parallel or even
overlapping capabilities now existing, the "home" designation is too narrow a focus - a
phrase such as home/community healthcare, home/community telehealth or home/mobile
telehealth may be a better alternative. Another term now characterizing this evolution is
person-centered care
To further complicate affairs, home healthcare agencies going forward may not be the
only providers delivering assistance to people at home or in the community. Physicians
and other medical specialists may have historically relied on them as the conduit for
23
assisting post-acute stay patients or those with chronic conditions. However, some
physicians and hospitals are responding to a number of trends and expanding from
institutional-based services to delivering care at home as well.
In a reflection of "what goes around comes around," some physicians are returning to
making house calls, which was a practice common up through approximately the late
1950s to early 1960s. The practice since the late 1990s has seen an increase in usage due
in part to Medicare increasing the permitted billing rate. (28) These days, physicians
also may not operate individually as in the past, but as members in a wide range of new
partnership configurations aimed at delivering more coordinated care at lower costs.
Accountable care organizations/ACOs are a visible form of these new partnerships. (29)
They’re established in line with provisions of the federal "Patient Protection and
Affordable Care Act of 2010,” informally known as the Affordable Care Act (or
Obamacare). ACOs bring together groups of physicians, hospitals and other healthcare
providers to coordinate delivery of high-quality care for Medicare patients. The goal in
these alliances is to avoid duplicating services, prevent medical errors, limit
rehospitalizations and deliver proper, timely care. Alliances share any costs savings with
the Medicare program.
One significant feature in current authorizations is that ACOs are to use telehealth,
remote monitoring and other technologies to better coordinate care. (30) A disincentive,
though, is that home healthcare agencies aren’t eligible ACO partners. (31) Physicians
and other providers who in the past might have referred patients needing acute-care
follow up to home healthcare agencies now instead may directly respond to patients'
service needs.
Another evolving approach is “hospital at home” programming, a concept employed in
other countries that's emerging in the U.S. (32) Care for chronically ill persons with
acute but stable medical problems is reoriented by having physicians and other care
providers treat a patient in a familiar, comfortable setting while assessing how well the
patient functions there. Seniors are a prime target population for this programming,
particularly those with multiple chronic conditions. The ability to potentially avoid
hospital-acquired illnesses such as urinary and other types of infections is one key
benefit; another important one is minimizing disorientation and other cognitive problems
that may contribute to delirium.
An example of one general approach is to admit patients to the hospital for a few
inpatient days (sometimes following an emergency department visit) where they receive
daily doctor visits and multiple daily checks by nurses and aides. Necessary personnel,
medications, equipment and other supports are assembled during that time, and the
person is then transferred home where acute-level care continues.
The Wall Street Journal reported at the beginning of 2013 on a New Mexico hospital-at-
home program serving patients within a 25-mile radius of the facility. (33) Persons who
are sick enough to require hospitalization for conditions such as pneumonia, congestive
24
heart failure and urinary tract infections receive daily visits from a doctor and visits once
or twice a day from nurses who administer infusions and perform routine lab tests/
procedures. The hospital published a study in the journal, "Health Affairs," showing that
program costs were 19% lower for its patients when compared to similar patients, due in
part to shorter stays and fewer test.
THE HEALTHCARE TECHNOLOGY GROWTH ENGINE
Healthcare management is big business not only in the U.S. but worldwide. The
"wireless world" has become the launch platform for continuing waves of product
development - new devices and new approaches, new ways of better using existing
devices and approaches. Telehealth-related research and development has become an
economic growth engine - not only in "hard" equipment or devices but "soft" biosensing
capabilities in furnishings, clothing, personal effects, etc.
Key players in wide-ranging and sometimes very disparate fields are expanding and/or
seeking out strategic alliances to capitalize on the potential digital healthcare represents.
Telecommunications carriers have set up new divisions focused on healthcare as well as
the smart home product/service market. Device manufacturers are aligning with
telecommunication carriers to systematically integrate technologies into senior housing
and assisted living settings – an example here is a partnership between Minnesota-based
Healthsense, a vendor of sensor monitoring system, and Verizon. (34)
Another rapidly expanding area of activity involves seasoned healthcare industry
personnel teaming up with socially oriented venture capitalists to set up centers that
nurture promising product concepts and bring them to market. They’re called by a
number of names – accelerators, incubators, academies, institutes. Some target
telehealth or health-related developments, others foster new businesses in many fields
and have created a telehealth segment. They provide enrollees with many types of
assistance - legal or financial expertise, market connections, access to financing and
research facilities. The supporting businesses ultimately may take a financial stake in a
new firm or purchase the entity.
An example of an accelerator with well-known parentage is "StartUp Health," a program
of General Electric's "healthyimagination" initiative. (35) AARP as part of its
"Innovations @50+" program (started in 2011) has agreed to partner with StartUp
enrollees in its new track of research focused on products for persons ages 50+. AARP
will also offer seniors'-targeted master classes for StartUp companies to encourage
concept identification. (36)
Products coming out of this tech pipeline will continue flowing at a rate that likely will
continue growing indefinitely. Some of the resulting, expanding array will only serve to
further promote opportunities connected with home/community health telehealth and
applications there.
25
Figure 1: Types of home/community
telehealth products, features, vendors
Equipment
Typical features
Product examples
Health monitoring/management
Vital signs
monitoring
In-home – central console supports array of peripheral
devices for tracking weight, blood pressure, blood sugar,
blood oxygenation, breathing, etc. Systems also typically
provide video connection.
Mobile – miniature peripherals connect with smart devices
to perform the same as above. Apps can track, analyze,
store/forward various vital signs data.
Bosch Health Buddy
Cardiocom Commander
GE-Intel HealthGuide
GrandCare
Honeywell HomeMed
IBGStar Glucose
Monitor
Asthamapolis
iHealth Blood
Pressure/O2 monitor
Telerehabilitation
In-home – computer-based programs and/or video
interaction guides/measures exercise and movement. Many
integrate Microsoft’s “Kinect” gaming program.
5Plus Therapy
Home Therapy Team
Jintronix
MIRA Rehab
MotionCare 360
Reflexion Health
Telementalhealth
In-home and mobile – therapy typically involves computer-
based program and/or video interaction with care personnel.
Medication
adherence/
management
In-home – storage units that dispense, reorder, manage, etc.
Mobile - apps that can track med usage, refill prescriptions,
locate stores. Often are integrated into care management
apps.
GlowCaps, GlowPack
iReminder
Med Folio
Med Minder Adherence
System
MedPartner
Senticare
TabSafe
Talking Rx
e-Pill CADEX
wristwatch monitor
PillJogger
26
Activity/safety monitoring
Sensor
monitoring
system
Smart home
features
PERS/fall
detection
Wander guard
In-home system – array of small radio frequency
identification devices track activity patterns/variances,
follow up on alerts. Many temporarily attach to walls,
doors, appliances, plumbing, etc.
In-home - Products similar to the above installed in home
appliances, fixtures, structure and/or specialized fixtures.
May integrate with sensor systems monitoring security,
energy use, automated controls (e.g., heating).
In-home and mobile – person wears monitoring device in
various styles - pendant, wristwatch-style, belt clip, etc.
Some models detect if/when fall occurs. Some equipment
operates in-home/immediate vicinity; other can also be used
when mobile. Some products incorporate wander guard
function.
In-home and mobile - Various types of equipment for
monitoring a person’s location. Some designed for in-home
use. Others set a mobile electronic “geoperimeter,” send an
alert if a person moves beyond. Some products incorporate
PERS/fall detection functions. Sensors now being
imbedded in various articles of clothes - e.g., shoes.
BeClose
GrandCare
Healthsense/Sengestix e-
Neighbor
Rest Assured
VRI
WellAWARE
University of Florida
"Gator House"
Toto toilets testing blood
sugar
5Star Urgent Response
Active Care Mini Pal
AFrame Digital
Numera Libris
Philips Lifeline, GoSafe
Avtrex Navistar GPS
footware
Care Trak
Comfort Zone
Freedom by Loku
TriLoc Personal Locator
Keruve Direct Family
Locator
Lifecomm
Caregiver support
In-home and mobile – computer programs and apps for
various aspects of care management – helping to hire care
staff; tracking meds, health appointments, records, etc.
Care Linx
Care Zone
CareFamily
CareSync
CareTree Me
Diabetes Companion
Lotsa Helping Hands
27
Communications
In-home and mobile – accommodate hearing/vision
limitations in using communications tools – adapted
landline phones, easy-to-use cell/smart devices, devices that
convert text to speech, smart device apps to adapt phone for
hearing aid use.
Clarity
Clear Sounds
Doro
Great Call
Hearing Loss Simulator
Hearing Pro Test
Intel Reader
iTalk Reminder
28
CHAPTER 2
TRENDS INFLUENCING
HOME TELEHEALTH ADOPTION
The first chapter provides an overview of how technology advances create promise for
telehealthcare at home and in the community. It also highlights ways these advances are
realigning and redefining historic boundaries in healthcare delivery. Some of these
components are at a “macro” level involving legal and regulatory decision-making or
evolving professional practices. Others are at the implementation level involving very
specific financial, operations and/or organizational challenges when incorporating the
technologies into direct care delivery.
Fully delivering on potential here will involve a long-term effort to align and mesh an
extremely wide array of interlocking, “moving parts.” This second chapter will highlight
a number of prominent "macro" trends, and how they may both promote but at the same
time also hinder home/community telehealth’s expansion.
HEALTHCARE CRISIS/REFORM
We've got a very serious healthcare problem in this country. Millions go uninsured,
while costs continue to rise relentlessly. Inpatient hospital care has been identified as the
single biggest category of U.S. medical costs, accounting for nearly one in three dollars
spent. (1) Emergency department use has also become a major cost category for reasons
including inability to schedule prompt primary care appointments and physicians
referring patients for more thorough testing. Recent senior-related findings include that:
The congressional Medicare Payment Advisory Commission reported in a 2012
study that emergency department visits by nearly 60% of persons receiving
Medicare and 25% of hospital admissions potentially could have been prevented
by better home or outpatient care. (2)
A Rand Corporation study of emergency department usage and related hospital
admissions reported in 2013 that 60% of Medicare beneficiary (and 47% of
Medicaid beneficiary) inpatient admissions come through the emergency
department. (3)
Some hospitals are setting up specialized emergency departments for seniors
because their multiple chronic illnesses, vulnerability to delirium, hearing issues
and other characteristics differ greatly from departments' more conventional
trauma services. (4)
The Affordable Care Act is directed at making significant changes in many aspects of
healthcare delivery, including insurance availability and coverage, operation of the
massive Medicare and Medicaid programs and reorienting the historic fee-for-service
delivery model. ACA-related provisions are already elevating the demand/need for
29
telehealth technologies through mandates as well as a large number of demonstrations
testing out new organizational and operational approaches.
Avoiding rehospitalizations
A high-priority ACA provision is directed at reducing Medicare-related hospital
readmissions. The federal Centers for Medicare and Medicaid Services/CMS report that
nearly one in five Medicare patients discharged from a hospital - approximately 2.6
million seniors - is readmitted within 30 days at a cost of over $26 billion annually. (5)
Rehospitalization can have many causes, including insufficient directions at discharge,
the amount and quality of aftercare follow-along and too-rapid release to nursing home
rehabilitation and/or home.
In response to this situation, an ACA component added authorizations to the Social
Security Act setting penalties when Medicare-eligible persons with heart failure, heart
attack and pneumonia are readmitted. (Medicare reimbursement data rates for these
conditions from 2007 to 2009 indicated return rates of 24.8%, 19.9% and 18.3%,
respectively. (6)) Even where appropriate, a prime reason for focusing on hospitalization
and rehospitalization is that treatment costs for Medicare patients with the targeted
conditions are greater than the federal reimbursements hospitals receive.
CMS has tracked and reported 30-day readmission rates for a number of years. Affected
hospitals starting in the fall of 2012 are penalized 1% of their Medicare reimbursements,
with the penalty rising to a 2% maximum in October 2013 and 3% in October 2014. (7)
Penalizing for readmission has been controversial because it's argued that reasons vary
greatly among a group of hospitals, particularly “safety-net” institutions. Additionally, the
focus doesn't pick up costs such as repeat emergency department visits that still may
frequently occur in connection with acute healthcare use. However, rehospitalization costs
are both significant and can be measured and tracked.
In a related Minnesota example, the Allina healthcare system and other hospitals
throughout the state have been experimenting with ways to smooth discharge transitions.
(8) They've formed a statewide collaborative called RARE ("Reducing Avoidable
Readmissions Effectively") which starting in January 2011 and has reduced admissions
by approximately 2,600. Staff is assigned to serve as transition coaches to facilitate the
process and identify and resolve difficulties.
Impact from the penalty is now rippling through the hospital and post-discharge network
in the form of new, different and/or additional support measures. Home/community
telehealth will be an extremely important tool here because it can monitor patients’ status
very closely and provide timely intervention. It is very likely that researchers are
presently collecting data documenting such outcomes.
Demonstration projects
Beyond the push to avoid rehospitalizations, the Affordable Care Act's implementation
30
involves many other wide-ranging efforts a recently established “Center for Medicare and
Medicaid Innovation” is overseeing. Some involve new reimbursement approaches and
accelerated adoption of innovative practices. Others involve demonstrations that may
directly increase demand for home telehealth, including:
The “Community Care Transition Program”/CCHT is a component in the ACA’s
"Partnership for Patients." (9) It involves collaborations around the country that
through 2016 will test models for improving hospital-to-community care
transitions and avoiding rehospitalization of high-risk Medicare beneficiaries.
Among community partners are hospitals, nursing homes, home health agencies
and Area Agencies on Aging - the Twin Cities-area Metropolitan Area Agency on
Aging is a participant.
The “Independence at Home Demonstration” started in 2012 and will operate for
three years, initially involving 16 organizations and 10,000 participants. (10)
Home-based primary care teams directed by physicians and nurse practitioners
will tailor assistance, with the goals of reducing hospitalizations, improving
patient and caregiver satisfaction and lowering Medicare costs. Participating
organizations will receive incentive payments after meeting quality measures and
minimum savings requirements. Remote patient monitoring is an allowable
practice. (11)
Insurance reimbursement
In the case of Medicare, telehealth reimbursement barriers were unfortunately written
into statutes over a number of years. They originally permitted only a narrow focus on
live interaction (no "store-and-forward" technology) and on patients residing in rural
areas with health professional shortages. Changes in 2008 did expand the range of
permissible sites to skilled nursing facilities, hospital dialysis centers and community
mental health centers. (12)
For Medicaid, most states allow some form of home telehealth reimbursement in their
basic State Plan assistance or in their Home and Community-Based Waiver
programming. The technologies most commonly permitted are personal emergency
response systems/PERS and devices monitoring a range of vital signs. Remote
activity/safety sensor monitoring systems may require approval from the federal Centers
for Medicare and Medicaid Services. (Chapter 6 reviews this issue in greater detail.)
ACA consumer protection provisions unfortunately also may have created unintended
consequences for health insurers considering home telehealth coverage. (13) They must
maintain a "medical loss ratio" - the amount spent on direct patient care - at 85%,
allocating a maximum 15% of gross receipts to administrative overhead, profit and
salaries. Remote patient monitoring technologies have been categorized as an
administrative expense that must be counted against an organization's 15% ceiling.
31
Insurance companies as a result may be reluctant to approve using the technologies
unless the Act is modified to class the equipment as patient care. A similar Catch-22 also
reportedly affects Medicare-certified providers using home telehealth systems -
equipment costs must be logged on the Medicare cost report as an office, not patient,
expense. (14)
SENIOR/BOOMER HEALTHCARE NEEDS
The boomer demographic imperative has received considerable attention in the recent
past, and its compelling statistics are widely known. However, it is significant to
consider the implications its numbers have for healthcare demand and costs going
forward, relative to the incidence and prevalence of seniors' chronic conditions.
Some chronic conditions are due to living a long life - they're anticipated as part of the
aging process. Others may come from not heeding prevention recommendations in
earlier years or due to genetics, environmental or any other number of reasons. Whatever
their cause, many seniors have them, and often more than one. The federal Centers for
Disease Control and Prevention reports (15) that: more than 75% of total U.S. medical
care costs are spent on chronic diseases, that nearly one-half of American adults having at
least one condition, that approximately 45% of persons ages 65/+ have two or three
conditions and approximately 15% have four or more. (16)
Heart and circulatory problems - e.g., congestive heart failure, heart attacks, high blood
pressure, strokes - form a cluster of very prevalent seniors' disabilities. Other major ones
include pulmonary conditions (e.g., bronchitis, emphysema, asthma) and diabetes. The
Centers for Disease Control and Prevention has studied their prevalence for adults age 65
and older along with cancer and kidney disease. Results show that the incidence of
seniors with two or more of these conditions increased from 37.2% in 2000 to 45.3% in
2010 (17) - the conditions are affecting seniors at an increasing rate.
Cognitive disabilities are an additional, growing concern. The Alzheimer's Association
in March 2013 released a report estimating that one in three seniors dies displaying
aspects of the disease or another form of dementia. (18) Over 5 million people are
presently affected by the dementias, and this number is expected to reach approximately
14 million in 2050. They are now the sixth leading cause of death in the U.S, a figure
which doesn't reflect dementias' contribution to deaths recorded as due to other
conditions.
Multiple chronic conditions often cause serious healthcare complexity. Those affected
are more at risk for hospitalization, and they often need a greater number of practitioner
visits. Seniors with multiple conditions may not only require a larger number of
prescriptions resulting in higher annual drug costs, but interactions among medications
can exacerbate existing conditions and sometimes trigger new ones. The overall
character of seniors' healthcare needs, the size of the boomer tsunami and the next major
macro-level issue - aging in place - will almost certainly combine to create major,
growing demand for home/community telehealth resources going forward.
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AGING IN PLACE
Current younger seniors in their late 60s to early/mid-70s and the wave of boomers
joining them are clear in their preference to age in place during their older years.
Boomers in particular can be expected to proactively pursue this goal in ways their
parents and grandparents didn't. What it means to achieve aging in place has many
outcomes, though.
The intent in some situations is to remain in a current housing unit - i.e., "age in this
place." In other cases, the desire is to move to a different housing arrangement - perhaps
downsize - but remain in the same neighborhood and/or town. Or, it means aging in this
place for part of the year, then in another location for the balance. The term in still other
cases means aging "anywhere but assisted living or a nursing home."
The aging-in-place preference has been chronicled for many years by AARP in trend
reports periodically issued on the subject. One of the recent national random sample
surveys in this series conducted in 2010 (19) found that:
88% of those ages 65/+ strongly or somewhat agreed with the statement, "What
I'd like to do is stay in my current residence as long as possible."
92% of those ages 65/+ strongly or somewhat agreed with the statement, "What
I'd really like to do is remain in my local community for as long as possible."
The state Department of Human Services obtained pertinent Minnesota statistics on this
preference in a survey conducted in 2010. (20) The project was an outgrowth of the
Department's "Transform 2010" initiative that during the latter half of the previous
decade promoted policy and programs responding to boomer demographic trends. Better
data on boomers' concerns across a range of life issues was a priority need for Tranform
follow-along efforts, and the Department supported a survey involving 10,000 Minnesota
boomers.
Up to 3,800 participated - a very positive survey response. Two of the most pertinent
housing responses connected with aging in place were:
Expect to remain in current housing (n: 3,787)
Less than 1 year
1-4 years
5-9 years
10-19 years
20 years or more
Don't know
2.6%
12.9%
16.9%
25.5%
27.3%
14.9%
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Expect to remain in current community (n: 3,183)
Less than 1 year
1-4 years
5-9 years
10-19 years
20 years or more
Don't know
1.5%
9.1%
12.3%
21.8%
36.5%
18.9%
The recent recession negatively affected many boomers' retirement investments and home
valuations, and this situation in the near future may reinforce the remain-in-place desire
for some who lack other financial options. When coupled with ever-escalating long-term
care costs, telehealth capabilities and trends like provider house calls and hospital-at-
home assistance, it’s reasonable to expect that boomers will receive a major amount of
their healthcare in the future at home or when mobile in the community.
GEOGRAPHIC/WORKFORCE DISPARITIES
Another compelling characteristic supporting home/community telehealth's use is its
ability to reduce geographic service delivery complications. Given Minnesota's size and
development pattern, seniors in many small communities beyond the Twin Cities area
already make up a large percentage of the local population, and these figures are
projected to increase in the decades ahead. They often must travel long distances to reach
larger regional centers or county seats for hospital, clinic, specialist, etc., services. The
mirror side of this problem is its impact on home healthcare agencies' capabilities to
provide conventional in-home services.
Workforce shortages create a similar disparity - either insufficient numbers of certain
practitioners or care workers in the state, or more likely, uneven distribution. Certain
specialized care resources are understandably concentrated in large population centers,
again, requiring sometimes lengthy travel to obtain treatment or assistance. While it
won't supplant the need for direct provider contact in a medical setting or a residence,
home/community telehealth can be a capable adjunct for responding to both these
problems.
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CHAPTER 3 –
OPERATIONAL CHALLENGES
The previous chapter highlights overarching trends that individually and collectively
influence home/community telehealth adoption. Additional factors at the operations level
further affect practitioners’ and organizations’ abilities to incorporate telehealth into
service delivery. This chapter will profile many of the prominent ones.
HEALTHCARE DECISION-MAKING INSTABILITY
The environment for healthcare decision-making unfortunately has been destabilized for
a number of years by forces including:
Waiting on the outcome from the Affordable Care Act debate, then major shifts
connected with its and other reform efforts’ implementation
Potential Medicare and Medicaid redesigns which would disrupt long-standing
practices and reimbursement expectations
The still-evolving and uneven recovery from the recent recession
The ever-growing pipeline of electronic devices that hold promise but also
potential for rapid obsolescence
All these factors combine to give care organizations compelling reasons to proceed very
carefully in making home telehealth equipment investments. Many administrators as a
result have taken a very prolonged "wait and see" position - for what the economy does,
what course competitors pursue, potential impacts from reductions in public program
revenues.
The unfortunate reality is that the healthcare environment will continue encountering
disruptions like these in the foreseeable future. Proceeding cautiously may seem like a
safe course of action, but gaining exposure to and experience in working with home
telehealth technologies, even if not extensive or optimally successful, may be vital for
some organizations’ survival. There may be no good point or time for committing; the
further decisions are delayed, the further back organizations may end up on the
operations curve.
PRACTITIONER LICENSURE
States exercise a public safety responsibility in approving licenses for a range of
healthcare professionals practicing within their borders. Professionals wanting or
needing to practices in more than one state typically must obtain a license in each
location. Telehealth affords the ability to readily connect to consult, diagnose, prescribe
and even operate nationwide and around the globe. As a result, medical professionals
35
and others operating telepractices for many years have come up against barriers states'
licensing laws create.
Some states have legislated provisions facilitating interstate telehealth practice through
legislation and practitioner credentialing. The impediment licensure creates has received
considerable attention over the years, with bills periodically proposed in Congress to set
overriding national standards. Debates have been strident because such actions would
directly oppose states' historic regulatory rights.
TELECOMMUNICATIONS
REGULATION/EXPANSION
Broadband coverage/connectivity - whether nationally, throughout a state or in a
particular location - is another issue greatly affecting home/community telehealth
adoption. Policies regulating interstate and international telecommunications are the
responsibility of the Federal Communications Commission/FCC. It has been contending
with many complex issues and pressures as newer conveyance methods proliferate.
Broadband expansion efforts benefitting telehealth have been in progress over many
years, although at a too-slow pace for many advocates. The FCC has awarded
competitive grant funds for communities - rural, in particular – to develop/enhance
regional and state communications infrastructure in support of expanded capabilities. It
developed a national broadband policy plan where telehealth communications have an
integral role.
Since the 1990s, the FCC has pursued policies subsidizing telecommunications services
for public rural healthcare providers and nonprofits. Efforts have included subsidizing
rates to make them comparable to those in urban areas, giving rural providers a reduction
in Internet rates and providing pilot funding to subsidize constructing regional or state
healthcare broadband networks and Internet connections.
The Commission began providing a new form of assistance at the end of 2012 called the
"Healthcare Connect Fund." (1) It will aid rural recipients in building networks,
purchasing broadband services from a range of carriers, and/or upgrading transmission
speed. Non-rural providers will also be eligible at a lower priority. The FCC estimates
that this assistance will reduce rural healthcare providers’ costs by 50%. The
Commission has also launched a pilot to gauge if connectivity via the Fund can be
brought to skilled nursing facilities at a reasonable rate. (2)
In response to continuing pressure regarding the increasingly important wireless
broadcasting role in healthcare delivery, the FCC formed the "mHealth Task Force" in
mid-2012. This group has already made a large number of recommendations for ways
the Commission can accelerate m-health adoption, including the priority recommendation
that the Commission hire a permanent director for healthcare. (3)
36
In a proactive decision, the FCC in 2012 also approved a policy allowing more intensive
use in a section of the overall telecommunication bandwidth for what are called "medical
body area network"/MBAN devices. (4) This new capacity has been termed bodycasting,
and the U.S. is the first country to allocate bandwidth spectrum in this manner. The
devices making prime use of it include some outlined in the first chapter that are core to
home and community telemonitoring.
DATA ISSUES
There are at least four major concerns surrounding data generated by home/community
telehealth equipment - collection, management, consent and security. Collection and
management these days typically become issues of electronic health record/EHR
integration and compatibility with larger administrative systems’ records management
procedures and technology.
In some cases, agencies using home/community telehealth equipment may retain/manage
the data internally. In other cases, vendors from whom devices were purchased or leased
provide data analysis/management services. Cloud computing - where individuals' or
organizations' electronic data and programs are stored and handled by remote servers - is
an additional management element becoming more prevalent.
Data security extends from the collection point to parties along the way and which parties
in the ultimate stored format are authorized to view/analyze it. The Office for Civil Rights
in the federal Department of Health and Human Services is responsible for enforcing the
applicable federal law approved in 1996 - the "Health Insurance Portability and
Accountability Act"/ HIPPA. HIPPA provisions also cover aspects of confidentiality.
Agencies incorporating telehealth into delivery of home/community support services must
deal with all these trends and requirements. They have additional, emerging concerns
where extent of data knowledge relative to care provided presents potential legal liabilities.
DEVICE REGULATION
The federal Food and Drug Administration/FDA is responsible for evaluating and
sanctioning medical devices, including home telehealth equipment. Manufacturers must
adhere to its regulations in readying products for market, and the review process can take
many months. When a system of components is involved - hardware, software and
peripherals - devices must be reviewed as a whole and reapprovals must be on the same
basis. (5) To expedite the process, the Agency has begun approving telemedicine
software systems as medical device systems, which avoids the testing and approval a
whole-system review requires.
The FDA in 2010 initiated a "Medical Device Home Use Initiative" focused on safe
residential use. (6) Major components include giving manufacturers guidance on
obtaining clearance/approval for devices intended for home use, creating a labeling
repository with manufacturers’ information on file for public and professional use and
increasing the public's awareness of benefits and risks with devices used at home. At the
37
beginning of 2013, the agency also issued draft standards for regulating medical devices
intended for home use. (7)
A current debate involves mobile health wireless apps used with smart devices. At issue
is whether or not apps are "medical devices" that should come under the Agency’s review
authority. This controversy has generated considerable attention and concern within the
past couple years as the volume of apps covering health, fitness and/or medical tasks has
grown tremendously.
DEVICE INTEROPERABILITY
The history of consumer electronics has involved intense competition between/among
vendors' offerings, where device incompatibility has sometimes been the outcome. The
industry learned from experience how these expensive and disruptive battles have an
adverse impact on the buying public. The positive outcome has been that manufacturers
now are more inclined to collaborate on basic technology features and protocols, which is
what took place in the early days of telehealth expansion - major global device
manufacturers agreed to work together to create compatible, "level playing field"
technical standards.
The organization Continua (8) was established to develop and implement health/wellness
technology interoperability guidelines. Examples of approved standards include the
decision to use the Bluetooth protocol for wireless technology connections and a Good
Housekeeping-type logo for certified devices. Continua focuses efforts in three broad
market areas - chronic conditions, seniors and fitness/health/wellness. The association
currently has around 200 healthcare and manufacturing members.
FINANCING
There are a number of funding concerns connected with incorporating home/community
telehealth equipment into an agency's service delivery. They include covering costs for
acquisition, operations (including staff training and data management), repairs and
communications connections. Some federal and/or philanthropic monies have been
available over time to defray particular types of expenses (e.g., device acquisition) for
services delivered in particular locations (e.g., rural areas where healthcare needs are
underserved - a Medicare program standard).
If telehealth equipment's acquisition characteristics were similar to conventional business
operations where costs and benefits are considered over a 10- or 20-year period or longer,
decision-making could be more straightforward. As with choices involving computers
and other types of electronic equipment, committing is complicated by the concern that
technology will quickly appear on the market post-purchase with better features and
lower prices.
Some vendors address this issue by offering attractive trade-in/trade-up terms. One other
advance is the emergence of companies offering "telehealth as a service," effectively
38
becoming an organization's telehealth department. An online industry resource, "Home
Care Technology Report," in 2012 identified a sample of eight organizations around the
country following this business model. (9) Their services range from only supplying
equipment, to handling installations at patients' homes, receiving and following up on
patient monitoring data and sometimes handling care planning/coordination as well.
Markets served by these firms ranged from a metropolitan area to nationwide.
Ohio-based VRI, Inc. is an example of one of these businesses, offering a turnkey-type of
arrangement with the vital signs monitoring equipment it carries. (10) VRI purchases
equipment from various vendors, and clients lease only the devices needed. Its
equipment managers educate patients and staff about features and operations. The
company care center provides patients with monitoring reminders as necessary and
responds to alerts - a patient’s medical staff is contacted for help with minor issues, and
emergency services are immediately contacted when serious problems develop. The
company removes equipment and sterilizes it for reuse when it's no longer needed. VRI
provides oversight services for approximately 90,000 clients.
OPERATIONS,
ORGANIZATIONAL CULTURE
The different types of electronics surrounding our lives bring with them many demands.
We have to master operations and use often requires adapting practices and routines that
may have been part of our personal or professional lifestyles for many years. We're often
caught juggling between holding onto aspects of the old while we shift over and fully
commit to the new - whether or not to keep the landline phone or continue receiving print
copies of the daily newspaper.
Organizations incorporating home/community telehealth technologies into service
delivery face parallel concerns. A range of administrative procedures may have to be
revised or ultimately replaced, perhaps not successfully on the first try. Staffing patterns
or even staff numbers may have to shift considerably, along with changes in how certain
professionals must perform their jobs. Both these issues may lead to internal tensions
and impact on morale. It may be necessary to operate duplicate functions for a period,
such as continuing to keep certain written patient records while also capturing them
electronically.
Successfully incorporating telehealth technology depends not only on cost considerations
but also subjective factors like practitioner acceptance/support and the presence of
"champions" and practice leaders. Staff training becomes very important, not only at
start up but for ongoing use as well - adjustments for upgrades, switches in connections,
revised records retention and software adjustments. A definite cost to consider is the
amount of time new tasks may require within already-overextended schedules.
PROPOSED FEDERAL LEGISLATION
In response to a number of the challenges outlined in this chapter, Congress is again
39
considering telehealth-related legislative proposals. Among noteworthy bills are:
The Telehealthcare Promotion Act of 2012 (H.R.6179), which was introduced at
the very end of the 112th Congress in 2012 and reintroduced early in 2013. It was
submitted by Representative Mike Thompson (D-CA), who had experience in
working on the issue as a lawmaker in his home state. (11)
The bill would increase access to telehealthcare for persons insured through
Medicare, Medicaid, Veterans Affairs, TRICARE (active military), federal
employee health plans and the Children’s Health Insurance Program. It would
eliminate a number of impediments that for many years have restricted telehealth
expansion, including:
No covered benefits would be excluded solely due to delivery via
telecommunications;
Healthcare providers would only need licensing in their home states to
perform telehealth in other states;
Medicare restrictions on where (only rural) and how doctors-patients must
interact (directly) would be eliminated.
The bill also contains a number of new pilot programs and expansion of existing
innovative care delivery techniques.
The Fostering Independence through Technology Act (S596), authored by
Senators Amy Klobuchar (D-MN) and John Thune (R-SD), was introduced in the
U.S. Senate in March 2013. (12) Its ultimate goal is to reduce hospital
admissions and other Medicare costs by creating a pilot program enabling home
health agencies to purchase and incorporate remote patient monitoring into care
delivery. It been introduced since 2005.
The Healthcare Innovation and Marketplace Technologies Act (HR6626),
sponsored by Representative Mike Honda, was introduced at the end of the 2012
session and reintroduced in June 2013. (13) It would establish an Office of
Wireless Health in the federal Food and Drug Administration/FDA. The bill
wouldn't expand the Agency's mobile health industry regulation, but would
promote coordination among federal agencies and the industry in guiding
expansion of m-technology opportunities. It would also coordinate development
of privacy regulations, offer competitive awards, provide financing to stimulate
innovation and train employees in technology use.
HOME/COMMUNITY TELEHEALTH ADOPTION
A survey conducted in 2012 by Lori Orlov of “Aging in Place Technology Watch”
40
reflects the collective impact that challenges outlined in this and the previous chapter are
having on the extent of home-based telehealth adoption. (14) 315 supervisors of home
care, home healthcare and geriatric care management organizations (with responsibility
for approximately 34,500 workers around the country) were contacted. The inquiry
focused on technologies their workers have and use, what they recommend and data
captured/reported.
More than half the respondents indicated familiarity with telehealth technologies,
although few indicated employing systems in care delivery. Personal emergency
response system pendants/watches were the device most frequently recommended to
families - by 53% of the respondents - and medication dispensers (not remotely
monitored) were recommended by 52%. 25% said that they didn't record data from
devices but wished they did.
Specific equipment used in care delivery (n=234):
Blood pressure monitor - 14%
Weight scales - 13%
Pulse oximeter - 12%
Blood sugar glucometer - 9%
Other - 9%
Medication dispenser - 6%
Thermometer - 3%
Tehealth kiosk - 1%
0% - 20%
A prime thrust of the report was Orlov’s perception of the need to create "healthcare
information networks" - enabling easy migration of data as patients increasingly move back
and forth among medical, rehabilitation and home care settings. Orlov's comments on the
findings in her blog were that:
"In 2012, we surveyed home care, home health care and geriatric care
managers about their use of technology in their practices. The result we
found is that there is little use made of in-home technology today, at least
not telehealth and chronic disease monitoring tech, and even less use of
video communication with either the care recipient or the family." (15)
The survey didn't explore reasons for telehealth’s low adoption rate. It's almost certain
that many of the issues identified in the previous and this chapter play a role, particularly
depending on the size of an agency and whether it has free-standing operations or is part
of a larger structure such as an integrated healthcare system or major nursing home
and/or assisted living organization.
Agencies connected with the latter benefit from the economies-of-scale "rising tide" that
come from having a larger parent organization that can afford incorporating a range of
technologies to achieve operations efficiency. Far smaller agencies may not be capable
41
of making such a commitment due to upfront and ongoing costs. This would almost
certainly be the case where many clients are on Medicare and Medicaid, given the
continual rate reductions these programs have been experiencing. Presence or absence of
some form of electronic health records is also a key factor.
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CHAPTER 4 -
EFFICACY AND COST-BENEFIT
EFFICACY
The issue of efficacy in telemedicine was raised when its technologies and connections
were first introduced decades ago. However, there's widespread acceptance at this point,
as established by the proliferation of many subspecialty fields, the tremendous growth in
equipment and investment overall, and federal and state efforts to develop broadband
infrastructure.
Questions were similarly raised more recently regarding whether or not medical/health
concerns, activities and safety could be effectively tracked remotely in homes. There's
general acceptance that the technologies typically used in remote vital signs monitoring
and sensor monitoring systems are effective. If issues are raised, they may involve
questions about if specific algorithms designed into systems are optimal (which is a
vendor-specific concern).
Where efficacy issues may still arise is in the mobile telemedicine/telehealth field. For
examples, news stories have highlighted and research efforts have explored if certain
smartphone-based telemedicine approaches are effective in diagnoses requiring high
visual precision - e.g., if phone screens are adequate for reading electrocardiograms or for
teledermatology wound analysis. However, the FDA continues to approve a range of
miniature peripherals for cellphone and smartphone-based remote vital signs monitoring.
To further establish efficacy, Johns Hopkins School of Public Health announced in May
2013 that it is setting up an online mHealth evidence data base. (1) Its goal is to identify,
categorize and rate both peer-reviewed research and "grey" literature - evaluations,
project reports, white papers, blog posts, discussion boards, etc. - available worldwide.
The initiative has support from the U.S. Agency for International Development/AID.
THE COST-BENEFIT RIDDLE
Establishing costs and benefits for telehealth in general and home telehealth in particular
has faced challenges since the various technologies were introduced. Perhaps the greatest
challenge involves exactly which costs and whose benefits are considered.
The approach conventionally employed in evaluating home telehealth is very clinically
and business oriented. Healthcare professionals, researchers and practitioners typically
review it according to "hard," direct acquisition/operational costs and reimbursement
opportunities. They follow business accounting "return on investment"/ROI calculations
- a performance measure where the benefit of an investment is divided by its cost to yield
a ratio compared against ratios for other opportunities available for using the funds.
These calculations use dollar values that are concrete or can be readily factored. Among
typical categories healthcare administrators and researchers use in this approach are:
43
Equipment
Installation
Transmission linkage, operations center/s
Monitoring
Maintenance
Repairs, upgrade
Staffing
Training
Data management
Home remote monitoring cost/benefit studies are often based on ability to reduce or avoid
a certain set of outcomes – e.g., emergency department use, hospitalization and/or
nursing home admissions. Care administrators then use these measures for determining if
home telehealth monitoring service delivery is cost-effective for their organizations.
Results may be geographically specific, given that costs for equipment, staffing,
travel/transportation and other major elements vary from one part of the country to
another.
These measurements often yield readily quantifiable cost savings for many research
projects. However, there are other costs that could and should be considered as well, but
assigning dollar values may be difficult due to their qualitative character. An additional
limitation is where costs are borne by one sector or bureaucracy while benefits accrue to
another, or where costs are borne by parties at the state or local level but savings accrue
to a federal or national-level entity.
One set of qualitative measures relates to avoiding or reducing adverse outcomes, such
as:
Short- and long-term negative health impact when one or more conditions
escalates
Escalation triggering a new acute or chronic condition
Complications requiring new medications or increased medication dosage
Repeated doctor/clinic appointments and follow ups
Exposing fragile person to adverse weather or illnesses for frequent care travel
Travel time and expense - for patients, for caregivers
Lost caregiver work time
A second set of qualitative measures involves types of social benefits, such as:
44
Positive impact on local economies when patients remain in and support sparsely-
populated communities where they have been long-term residents.
The "ripple effect" where reduced burden on family members and others
providing care extends into many areas of their lives - e.g., personal and work
schedules, reduced stress levels, etc.
Positive socialization and enhanced mental health when relatively isolated
persons and remote healthcare providers systematically interact by phone,
computer and/or video. For example, the Mayo Clinic in the mid-2000s
conducted home telehealth demonstrations in southeast Minnesota serving
persons with early-stage Alzheimer's. Staff reported anecdotes of how some of
the elderly men participating paid particular attention to their appearance and
looked forward to their remote video visits with the younger women nurses caring
for them.
Goodwill from home telehealth monitoring. The business concept of "goodwill"
recognizes an asset that isn't tangible/concrete but still has a reasonable value - a
prime example is a company's/brand's reputation with investors, clients and
customers.
One type of home telehealth goodwill is patient/caregiver satisfaction, particularly
where the service represents the difference between relative independence and
relocating to a care setting. Another aspect is enhanced provider reputation for
offering services seen as innovative - when seniors know of relatives, friends and
neighbors using the technology, they consider it as a benchmark for services they
want to receive as well.
It’s no accident that social democracies such as Britain and various European countries
embrace home telehealth technologies – their healthcare insurance, regulation and
financing practices are considerably different than those in the U.S. Prevention is an
important goal in these locations, and the federal government through Affordable Care
Act provisions is in part using the influence Medicare and Medicaid to shift in this
direction. As it does so, incentives for prevention and other “softer” factors are being
incorporated into conventional healthcare cost/benefit equations that will very likely shift
how they're calculated in the future.
Laurie Orlov (“Aging in Place Technology Watch”) captured the dilemma of how the
conventional cost-benefit research mindset impedes the new paradigm’s potential (2) in
observations that:
"There are plenty of technologies out today that could help in the care
of frail and at-risk seniors, whether in a hospital, in a skilled nursing
facility, or in assisted living. Insurance companies - giants like
Humana, for example - along with hospitals, Medicare, and everybody
else are also in the yet-another-research-study mindset before
45
committing themselves to inclusion of telehealth technology in their
strategies.”
“With everyone waiting for the Godot of studies to end all studies,
medications are routinely mismanaged, patients fall out of bed, changes
in vital signs are missed, and risk reduction and prevention treatments
continue to depend on the labor of an ever-scarcer population of skilled
people who deliver most of that care face-to-face. Can it be that so
many other aspects of our lives are dramatically altered when a
technology is introduced (books, travel, communication, car safety) and
yet we continue to stumble along in a paper-and-person and nearly
technology-free health system?"
RESEARCH LIMITATIONS
A large and steady output of research has been produced for many years about the
telehealth field. Projects involving efficacy and cost-benefit may not be in the majority,
though, because they require a fairly significant infrastructure - e.g., acceptable research
design, data collection, data analysis, staffing, etc. This likely explains why a good
portion of published research focuses on:
Meta-analyses
Assessing a technology's clinical vs. home impact
Patient, caregiver and/or staff satisfaction
Efficacy among a number of technologies for a particular task -- e.g., phone
prompts by person vs. text, phone vs. computer/Internet data reporting
Reviewing performance for technical aspects of a protocol - e.g., use of anti-
coagulants
Recommendations for administrative best practices
Projects' participant attrition and reasons for it
When research studies do focus on home/community telehealth cost/benefit outcomes,
some researchers and funders may not accept positive results for a number of reasons.
One is study size, which sometimes is extremely to relatively small for a given target
population. Another is length of analysis, which may be short term - a few weeks to a
few months vs. more longitudinal attention. The protocol followed also may involve
practical reporting of an experience instead of the gold standard relying on a random
control group.
46
Some studies are sponsored by device manufacturers, where outcomes may be discounted
due to perceived bias. However, product vendors along with the federal government
may be the parties in the best financial position to undertake substantially sized
initiatives. Vendors often partner with one or more respected outside parties to conduct
a major research project in order to neutralize potential objections.
COST-BENEFIT REVIEWS
With the above perspectives in mind, the balance of this chapter will highlight a range of
home telehealth monitoring research findings. Because of differences among healthcare
systems around the world - e.g., telecommunication capabilities, protocols, technology
used, regulations, reimbursement, etc. - it was judged most appropriate to concentrate on
U.S.-based research.
Two approaches have been followed. An initial section provides narratives on projects
with noteworthy outcomes, even if efforts weren't conducted along formal research lines.
These write-ups are followed by a grid with summaries from abstracts for a large number
of pertinent published research projects.
Britain's "Whole System Demonstrator Program”
Although the focus of articles reviewed for this report is U.S. research, a major British
effort must be highlighted due to its scope. Britain's National Health Service began a
"Whole System Demonstrator Program" in 2008, testing the impact of telehealth and
telecare on use of secondary healthcare and mortality. (3) 3,230 persons with diabetes,
chronic obstructive pulmonary disease or heart failure were recruited from 179 general
practices to participate in the trial. The main outcome was avoiding hospitalizations,
which showed lower admissions, lower mortality and lower emergency department use
for the telehealth intervention group. Length of hospital stay was also shorter for the
intervention group.
Initial findings indicated that telehealth delivered a 15% reduction in emergency
department visits, 20% reduction in emergency admissions, 14% reduction in elective
admissions, 14% reduction in bed days and an 8% reduction in tariff costs. A 45%
reduction in mortality rates was also reported. The study concluded that home telehealth
is associated with lower mortality and emergency admission rates. A subsequent short-
term study of Demonstration participants found those using telehealth didn't reduce life
anxiety or depression in the process. (4)
Veterans Health Administration telehealth successes
Many people have the mindset that large bureaucracies, particularly the federal
government, are incapable of performing cutting-edge work. It would surprise them to
learn that the Veterans Health Administration in the Department of Veterans Affairs is a
47
national, even international, leader in incorporating telehealth technology into its service
delivery.
A number of factors contribute to this situation. VHA's website (5) indicates it's the
country's largest integrated healthcare system, including 152 medical centers, nearly
1,400 community-based outpatient clinics, and community living centers and other
resources. In providing care to over 8.3 million veterans annually, VHA early on
developed and began using electronic health records, the backbone for e-health in general
and telehealth in particular. The fact that the VHA is a "single-payer" managed care
system means it avoids many of the extremely fragmented civilian healthcare system’s
inefficiencies.
Medical practitioners in its system also have the advantage of being able to design policy
strategies and develop initiatives without two major barriers civilian counterparts have
faced for years - covering costs for equipment, transmissions, etc., and a 50-state medical
licensure checkerboard curtailing practice across state lines.
A likely explanation for why VHA's experiences aren't better known is because it
effectively operates in parallel with the publicly supported systems in each state. That
characteristic may complicate ability to replicate certain of its successes, but there are
many other areas where social services and healthcare personnel around the country
could benefit in learning about VHA's telehealth experiences.
VHA has focused for a number of years on responding to the retiring baby boomer
generation demographic imperative. It faces a caseload where the number of aging
veterans with multiple, chronic conditions will significantly increase in the years ahead,
and is using telehealth to gain both operating efficiencies and provide better care. As a
measure of the extent of adoption, the Veterans Administration announced at the end of
2012 that over 460,000 veterans used its telehealth services in 2011; it will work to
double that number by the end of 2013. (6)
Care Coordination/Home Telehealth Program
Given the size of its operations, VHA is very well positioned to track and report on both
technology performance and outcomes. In that capacity, it conducted within the past
decade a noteworthy and significant U.S. telehomecare cost/benefit study.
VHA in mid-2003 began operating "Care Coordination/ Home Telehealth”/CCHT to
deliver care to veterans with chronic conditions and avoid unnecessary long-term care
admissions. (7) Program participation grew from 2,000 at its start to 31,570 in 2007, and it
is now a routine non-institutional care service. The VHA has trained 5,000 staff to
implement it.
Data for 17,025 CCHT patients during the 2003-2007 study period showed a 25%
reduction in number of bed care days, 19% reduction in hospital admissions and mean
48
participant satisfaction scores of 86% after enrollment. The cost per patient per year was
$1,600, significantly lower than a hospitalization or nursing home placement.
CCHT’s performance was profiled in a study released early in 2013 by the
Commonwealth Fund, a private foundation with a mission to promote high-performance
healthcare systems. (8) It reported that reductions in bed days of care were achieved in
excess of 40 percent on pre-enrollment figures for the CCHT population, and the
reduction from 2004 to 2007 was significant across eight primary conditions. Over
70,000 receive the service in 2012.
Telementalhealth
Another facet of VHA programming involves telementalhealth offered through more than
800 community-based outpatient clinics where many veterans obtain their primary care.
This programming had over 140,000 encounters in fiscal year 2011 where providers at
150 hospitals delivered care involving 55,000 veterans at more than 500 clinics, and an
aim was to increase care to 200,000 in 2012. (9) Services delivered remotely include
individual, couples', group family and behavioral therapy, psychological testing and
medication management. Since mid-2012, co-payments have been eliminated for
veterans connected by videoconferencing from home with VA professionals.
Overall, the VA provided mental health services in 2011 to 1.3 million veterans, and it
began an initiative that year to significantly expand telehealth staffing capacity. (10)
Video services to vets at home are projected at 2,000 patients by the end of fiscal year
2012, including many that will employ a new video Internet protocol.
A recent study conducted by the director of the Administration's national
telementalhealth center and associates corroborates the effectiveness of this care delivery.
(11) The research team reviewed records for over 98,600 VA patients requiring mental
health services and new to the telementalhealth program during 2007-2010. These
patients on average had 24% fewer psychiatric hospital admissions during their first six
months in the program, compared with in-person care received in the six months
preceding entering the program. These patients also in their first six months had 27%
fewer total days of psychiatric hospitalization compared with the six months preceding
entering the program. During this same period, VA patients receiving standard care had
no change in their rate of psychiatric hospitalization or length of stay.
Home-Based Primary Care Program
As a further example of flexible programming, VHA for decades has operated a "Home-
Based Primary Care Program" using telecare resources. (12) It serves veterans for whom
periodic doctor visits are inadequate and who typically have complex conditions putting
them at risk of hospitalization or nursing home placement. Care teams make an average
of three site visits per month, and involve doctors, nurses, social workers, dietitians,
pharmacists and psychologists.
49
The program currently serves approximately 12,000 veterans annually through 116 sites -
participants have an average of 19 diagnoses and regularly take 15 medication
prescriptions. A VA study of the program in 2007 found that participant hospital days of
care dropped 69% and there was a 27% reduction in admissions.
VA InnoVAtions initiative and the VA Center for Innovation
"VAi2" is a high-priority effort begun early in 2010. (13) It's aimed at obtaining new,
innovative ideas that will advance the Agency's ability to proactively respond to current
and upcoming service delivery challenges. It prioritizes, funds, tests and implements
innovations judged most promising for improving service quality, upgrading operations
and reducing or controlling delivery costs. Telehealth strategies are a focus of its efforts.
Since its start, it has funded over 120 innovations, and its efforts in the fall of 2012 were
incorporated into a VA “Center for Innovation” which will support this outreach long
term.
An example of one funded innovation is an initiative by SweetSpot Diabetes Care. It will
remotely monitor veterans with diabetes, starting with a pilot in Dayton, OH. (14) Vets
will send blood glucose readings to the VA medical records system from home, and VA
providers will monitor the data for rising readings where potential complications may
occur. The data will also be available via cloud-based computing to facilitate vets getting
specialist care in their locales if needed.
VA use of mobile technologies
A recent example of the VA's interest in exploring the use of mobile technologies is the
"Clinic at Hand" program which began in 2012. (15) Veterans' families received 1,000
Apple iPads loaded with apps to help them provide care and connect with veterans'
doctors. Later efforts will pilot other devices and operating systems.
Partners Health Care
The Commonwealth Fund also reported on telehealth efforts promoted by Partners Health
Care, a major integrated healthcare system in the Boston, MA metropolitan area. Its
Center for Connected Health is a national cutting-edge promoter of telemedicine and
telehealth through researching, developing, testing and implementing patient-centered
healthcare solutions.
The Center’s "Connected Cardiac Care Program"/CCHP began as a demonstration
providing home telemonitoring and education for patients with heart failure, and was
expanded across the Partners' network. (16) Approximately 1,200 patients as of early
2013 had been enrolled in the CCCP, and the Center for Connected Health reported the
following findings:
51% reduction in heart failure hospital readmissions
50
44% reduction in non–heart failure hospital readmissions
Improved patient understanding of heart failure and self-management skills
High levels of clinician and patient acceptability and satisfaction
Recent case study cost savings -
$1,500/patient costs for the program, $9,655/patient saving from reduced
hospitalization = $8,155/patient net savings
Total savings: $10,316,075 for 1,265 monitored patients since 2006 (which
factor in costs for running the program, marketing, telemonitoring nurse
support, technology)
NewCourtland Life and Healthsense
The majority of home telehealth research project focus on studies involving vital signs
monitoring. A recent study evaluated use of remote sensor activity/safety monitoring
systems involved NewCourtland Life in Philadelphia, PA and Healthsense, a Mendota
Heights, MN vendor of home telehealth products. New Courtland is a "Program for All-
Inclusive Care for the Elderly"/PACE, a capitated reimbursement care model providing
seniors vulnerable to nursing home placement with individualized healthcare and social
services.
The two organizations partnered in 2008 and operated a demonstration for approximately
two years where the Healthsense “e-Neighbor” remote sensor monitoring system was
used to support seniors discharged from nursing homes who relocated to a NewCourtland
housing development. (17) Study findings reported:
33 individuals moved from nursing homes to NewCourtland Square, where e-
Neighbor systems were installed in their units. Annual costs reported for the 26
units were: $39,000 for technology and $249,600 for home care - a total cost of
$288,600 - versus $2,135,250 for nursing home residency (based on a $225/day
charge). Projected annual savings were $1,846,650.
NewCourtland also provides two- to three-person residential care homes. Sensor
monitoring systems were installed in the units of up to eight persons either
discharged from nursing homes or at high risk of admittance. Annual costs
reported for these seven units/rooms were: $10,500 technology cost and $219,500
for home care - a total of $229,500 - versus $574,875 for nursing home residency,
with a resulting projected annual savings of $345,375.
A PACE member living in the home of a daughter was prone to nighttime
wandering. The daughter sought nursing home placement, but staff installed a
system so she could continue living with her daughter. Annual costs reported
51
were: $1,500 for technology and $9,600 for home care - an $11,100 total - versus
$82,125 for nursing home residency, for projected annual savings of $71,025.
HealthPartners Research Foundation
Health Partners Research Foundation (St. Paul, MN) conducted a telemonitoring study of
cardiac patients where results were reported in 2012 at the American Heart Association's
Quality of Care and Research Scientific Sessions. (18) The study found that patients
receiving care via telemonitoring and with regular pharmacist follow-up support were
more likely to have lowered blood pressure than patients receiving traditional care.
The study involved 450 patients with uncontrolled high blood pressure who had periodic
appointments with their primary care providers. 222 received just this traditional care,
while 228 also used telemonitoring to take their pressure at home and forward results to a
secure site where pharmacists followed up with them every two to four weeks. These
participants over the course of the study received more medications than those in the
control group.
Of the 222 patients receiving traditional care, 45% saw their blood pressure lowered over
a six-month period. However, approximately 72% of the telemonitoring group lowered
their blood pressures to desirable levels during the time period, and also reported
remembering and more consistently taking their medications than those in the control
group.
St. Alexius Medical Center
St. Alexius Medical Center (Bismarck, ND) and Great Plains Telehealth Resource and
Assistance Center (Minneapolis, MN) developed a research project to determine if home
telehealth could improve access and care, and reduce costs and hospital readmissions for
patients living in rural areas in North Dakota, South Dakota and Wyoming.
The hospital instituted a "Telehealth Home Care-Coordinated Disease Management
Demonstration" for rural patients with chronic heart failure, chronic obstructive
pulmonary disease and diabetes. (19) The project ran from January 2011 thru April 2012,
and involved 38 patients with an average age of 79. All had one or more chronic
conditions, and were enrolled an average of 97 days. The only patient rehospitalized was
within 30 days of enrollment. 92% of the participants when surveyed responded that
telehealth could improve their health, 83% said it could reduce healthcare costs, 84%
responded that the equipment was easy to use, and 93% perceived that it's an easy form
of healthcare delivery.
PUBLISHED RESEARCH STUDIES
The following summaries highlight either pertinent research abstracts or full study reports
covering both a range of chronic conditions and a range of home telehealth technologies.
52
Articles were drawn from those published in the industry's two major journals -
"Telemedicine and e-Health," issued by MaryAnn Liebert Publishing (U.S.) and "Journal
of Telemedicine and Telecare," originally published by the Royal Society of Medical
Journals (U.K.), now by SAGE Publications. These were supplemented with entries from
other research journals along with noteworthy research reported in the press or by
industry sources.
The decision was also made to focus on reports published in approximately the past five
years. The field is moving so quickly that although a large number of studies were
conducted in the later 1990s and early-to-mid 2000s, equipment and strategies have
evolved considerably. Reports involving conditions not necessarily considered a
component in seniors' home healthcare - e.g., telementalhealth - have also been included
because they may become so going forward.
Research article title
(journal in which
published, cite)
Purpose, background, outcomes
Telemedicine for
Recently Discharged
Older Patients (Telemedicine and e-
Health, Volume 16 Issue
1, February 2, 2010, pg.
49-55)
Authors: Cardozo,
Steinberg
An observational study of 851 predominantly elderly,
recently discharged persons enrolled in a two-month study.
They received a nurse visit (including patient education) up
to three times per week and daily home telemedicine
monitoring of all vital signs. Readmission rate was 13% and
mortality 2%; treatment goals were met 67%, compliance
rate was 77%, average improvement in nine quality-of-care
measures was 66%. This model of care was accepted and
produced excellent short-term clinical outcomes.
Telemonitoring
Improves Home Health
Utilization Outcomes in
Rural Settings (Journal of Telemedicine
and Telecare, accepted
February 6, 2011)
Authors: Golbeck,
Hansen, Lee, Noblitt,
Christner, Pinsonneault
Study examined the hypothesis that rural telehomecare
accompanying conventional home care will result in less
hospitalization and more discharge to the community. Five
rural home health agencies participated. 1, 419 patients
comprised the test group that was telemonitored daily from
October 2006 - May 2009. A control group of 1,502 was
selected backwards from September 2006. Both groups had
home care for about 50 days. Home telemonitoring was
found to reduce the odds of hospitalization (OR=0.59,
P<0.001) and to increase the odds of community discharge
(OR=1.36, P=0.003).
St. Vincent's Home A remote monitoring program was implemented to study
53
Telehealth for
Congestive Heart
Failure Patients (Telemedicine and e-
Health, Volume 15 Issue
2, March 17, 2009, pg.
148-153)
Authors: Whitten,
Bergman, Meese,
Bridwell, Jule
whether patients (n=50) had enhanced clinical outcomes and
perception of this form of care. Results showed significant
physical, behavioral and emotional improvements in:
shortness of breath, managing oral medications, engaging in
moderate activities, amount of energy, leg/ankle swelling,
need to sit/lie during the day, fatigue, need for
hospitalization, treatment side effects, anxiety. Interviews
showed patients found the service easy to use and that this
form of care was as good as in person.
(NOTE: St. Vincent's (Indianapolis, IN) conducted a
subsequent study involving patients with congestive heart
failure and/or COPD; many also had additional chronic
conditions. Approximately 300 individuals were enrolled in
the program immediately following hospital discharge from
10 participating hospitals in the St. Vincent network. The
study also had extra equipment capacity as well as nursing
time, so the pilot was expanded to include persons with other
complex conditions.
Initial results show a study group 75% reduction in 30-day
readmission rate compared with those in the control group
and an 85% reduction compared to the national average. A
significant example involved a patient who prior to the
project had 13 heart failure admissions in one year at a
$156,000 cost for the system. She had no admissions during
11 months of project participation.)
Impact of Blood
Pressure
Telemonitoring on
Hypertension
Outcomes: A
Literature Review (Telemedicine and e-
Health, Volume 16 Issue
7, September 3, 2010)
Authors: AbuDagga,
Resnick, Alwan
Five major databases from 1995-2005 were searched for
evidence of blood pressure monitoring on blood pressure
control for subjects with hypertension as a primary diagnosis.
15 articles met review criteria. Blood pressure telemonitor-
ing resulted in reduction of blood pressure in all but two
studies. Across studies, systolic pressure declined by 3.9 to
13.0mm Hg and diastolic declined by 2.0 to 8.0mm Hg - this
magnitude of effect is comparable to those in efficacy trials
of some antihypertensive medications. Some of studies also
included secondary outcomes, e.g., healthcare utilization and
costs. Compliance among participants was favorable.
Home-Based
Preventative Care in
High-Risk Dialysis
Patients: A Pilot Study
(Telemedicine and e-
Pilot study to determine if home-based preventive care using
telehealth technology improves healthcare outcomes, quality
of life and is cost effective due to proactively managing
underlying chronic conditions. 44 dialysis patients
participated - 19 in a remote technology group (mean age
54
Health, Volume 17, Issue
4, May 25, 2011)
Authors: Perman,
Wada, Minatodonai,
Halliday, Miyamoto,
Lindo, Jordan
57), 25 in a usual care group (mean age 62).
Hospitalizations, hospital days, emergency room visits, usual
care costs and customary charges were significantly less for
those in the remote technology vs. usual care group. Quality
of life remained the same for the usual care group from outset
to study midpoint, decreased slightly for the technology
group. Results suggest telehealth technology can play an
important role in improving health outcomes and cost of care
for end-stage renal patients.
Managing Heart
Failure Patients After
Formal Homecare
(Telemedicine and e-
Health, Volume 15 Issue
10, December 22, 2009)
Authors: Dansky,
Vasey
Study to determine if using telehealth equipment after
discharge from formal home healthcare improves clinical
outcomes, self-management. Patients recruited from ten
home health agencies nationwide; monitored them to 180
days after discharge. All used the Health Buddy (Bosch)
telehealth system during formal health services. Patients
were randomly assigned to telehealth and control group upon
discharge; those in the former continued with the technology,
those in the latter had no further intervention.
Patients in telehealth group showed greater improvement in
respiratory status and activities of daily living. None were
hospitalized (vs. 28% in the control group) or used the
emergency room (vs.26.1% controls with at least one visit)
during the study. Telehealth patients more likely reported
tracking their weight and increasing their diuretic dose
following ankle swelling, sudden weight gain, shortness of
breath. Results suggest patients with heart failure may benefit
from continuing to use telehealth equipment after post-home
health services.
Perception, Satisfaction
and Utilization of the
VALUE Home
Telehealth Service (Journal of Telemedicine
and Telecare, accepted
February 7, 2011)
Authors: Finkelstein,
Speedie, Zhou, Potthoff,
Ratner (NOTE: not a
cost-benefit study, but
included because the
authors are with the
Randomized, controlled trial evaluating perception,
satisfaction and use of home telehealth services from home
care agencies. Control subjects continued receiving usual
care, intervention subjects supplemented usual care with a
web portal providing videoconferencing and electronic
messaging, access to health-related services and general Web
access. No significant perception differences at inception regarding
technology between the two groups. At 60 days, the
intervention group was significantly more positive towards
technology, perceived it met expectations, and would
recommend it to others. Intervention group made fewer
emergency department visits, more eye doctor visits, fewer
55
University of Minnesota)
visits in all categories of home care services, and less
transportation service use. Results suggest frail elderly can
adopt home telehealth technologies which may enable them
to maintain independent living.
Use of the Internet to
Remotely Monitor
Heart Failure
(Telemedicine and e-
Health, Volume 16 Issue
1, February 2, 2010)
Authors: Biljana, Kaan,
Araki, Ignaszewski, Lear
Investigation of if using a web site for monitoring patients
with heart failure could be as effective as use of in-home
telemonitoring equipment. 20 participants were recruited
from those newly referred to a heart function clinic; 17
completed the study. Weight and symptoms were entered on
the web site, with a nurse tracking change in participant
health status for six months. Self-care, quality of life, six-
minute walk test and N-terminal prohormone brain natriuretic
peptide were assessed.
Significant change was observed in maintenance subscale of
Self-Care of Heart Failure Index. There was a trend toward
improvement on confidence subscale of Self-Care of Heart
Failure Index, Minnesota Living With Heart Failure
Questionnaire, walking test and NT-proBPN. Participants
and nurses demonstrated favorable web site uptake. Results
showed favorable Web site acceptance/use and associated
with improved self-care skills. Further investigation with
larger population warranted.
Feasibility and Impact
of Telemonitor-Based
Depression Care
Management for
Geriatric Homecare
Patients (Telemedicine
and e-Health, Volume 17
Issue 8, September 22,
2011)
Authors: Sheeran,
Rabinowitz, Lotterman,
Reilly, Brown,
Donehower, Ellsworth,
Armour, Bruce
Objective was to test feasibility, acceptability and
preliminary clinical outcomes from using homecare
monitoring technology to deliver depression care
management. Three stand-alone nonprofit agencies (New
York, Vermont, Miami) participated. 48 English- and
Spanish-speaking elderly homebound homecare service
clients were recruited, participated for a minimum of three
weeks.
Evidence-based depression care management was adapted for
incorporation into telemonitoring platform. In-home
interviews gathered data on diagnosis, severity, patient
satisfaction. Telehealth nurses and patients reported high
levels of protocol acceptance. 17 patients had major
depression criteria at baseline and were in the mild range at
follow up. Preliminary outcomes suggest this method
improves depression severity, although findings require
testing in a randomized clinical trial.
Evaluating the
Evidence Base for the
MEDLINE, EMBASE and CINHAL databases were
searched for randomized controlled trials involving home
56
Use of Home Telehealth
Remote Monitoring in
Elderly with Heart
Failure (Telemedicine
and e-Health, Volume 15
Issue 8, October 15,
2009, pgs. 783-796)
Authors: Dang,
Dimmick, Kelkar
remote monitoring of patients with congestive heart failure
(excluding monitoring solely involving telephones and
studies not presenting outcomes related to healthcare
utilization).
Nine studies met the selection criteria, with greatly varying
interventions. Six of the nine suggested a 27%-40%
reduction in overall admissions. Two demonstrated a 40%-
46% reduction in admissions; two other studies showed
similar but not statistically significant trends. Three of the
nine studies suggested significant reduction in mortality -
30%-67% - and three showed significant healthcare cost
reduction. Two studies suggested a 53%-62% reduction in
bed days of care. Two showed significant reduction in
number of emergency room visits. Four showed significant
overall outcome improvement using telemonitoring. These
data suggest telemonitoring is a promising strategy, with
more data needed targeted to population, technology,
monitoring frequency/ duration, and optimal combination of
case management and monitoring for consistent, improved
outcomes.
Effectiveness of Home
Telehealth in
Comorbid Diabetes and
Hypertension: A
Randomized,
Controlled Trial
(Telemedicine and e-
Health, Volume 17 Issue
4, May 25, 2011, pgs.
254-261)
Authors: Wakefield,
Holman, Ray, Scherubel,
Adams, Hillis, Rosenthal
Objective was to evaluate efficacy in using nurse-managed
home telehealth on critical need to control hypertension in
veterans with diabetes. A randomized, controlled clinical
trial compared two remote monitoring intensity levels and
usual care.
Intervention subjects had decreased hemoglobin A1c during
first six months vs. control group, but groups were
comparable six months after intervention withdrawal. High-
intensity subjects had a significant decrease in systolic blood
pressure compared to other groups at both six and twelve
months. Adherence improved for all groups, with no
significant difference among them. Finding was that home
telehealth provides a practical, innovative strategy for
increased early detection of major clinical symptoms
requiring intervention.
Diabetes Management
via Mobile Phones: A
Systematic Review
(Telemedicine and e-
Health, Volume 18 Issue
3, April 5, 2012, pgs.
175-184)
Purpose was to analyze peer-reviewed research articles
addressing mobile phones' common uses/functions in
monitoring/managing diabetes, their potential clinical role,
and current state of research on the subject. Articles from
2000-2010 were identified; twenty-one were analyzed for the
review. The majority approached phone use from patients'
perspectives. Over 50% of the studies involved patients with
57
Authors: Holtz,
Lauckner
Type 1 diabetes. 71% of the studies used a study-specific
phone app with supplementary features and texting.
Outcomes varied considerably, with positive trends in
improved self-efficacy/self-management and hemoglobin
A1c. Review results indicated mobile phones may help
persons with diabetes manage their conditions; however,
many lacked sufficient samples or intervention lengths to
determine if results were clinically significant. Suggested
future research: integration into a healthcare practice,
provider perceptions, cost.
Integrated Telehealth
and Care Management
Program for Medicare
Beneficiaries with
Chronic Disease
Linked to Savings
(Health Affairs, Volume
30 Issue 9, 2011, pgs.
1689-1697)
Authors: Baker,
Johnson, Macaulay,
Birnbaum
Study examined the impact of the Health Buddy (Bosch) care
coordination approach for chronically ill Medicare
beneficiaries. Patients in two clinics in the northwest U.S.
were in the intervention group, compared with a matched
control group, as a part of a Centers for Medicare and
Medicaid study, "Care Management for High Cost
Beneficiaries."
The evaluation found significant savings - 7.7%-
13%/person/quarter ($312-$542) among patients using the
home telehealth system during a two-year study period.
Findings suggest carefully designed/managed care
management programs incorporating telehealth can help
reduce healthcare expenditure, warranting further assessment
by Medicare. Results also indicated that the intervention
may have contributed to significant mortality differences
between the two groups, which future research should
explore.
Healthcare via
Cellphones
(Telemedicine and e-
Health, Volume 15 Issue
3, April 21, 2009, pgs.
231-240)
Authors: Krisha, Boren,
Balas
(NOTE: study doesn't
focus on cost-benefit
review or precisely on
home telehealth, but it
has a significant number
of participants, some of
Study reviewed 25 research projects on voice and
text messaging efficacy in care management and outcomes.
20 randomized controlled studies and five controlled studies
were identified. 19 assessed outcomes of care and six
processes of care. Selected studies encompassed over 38,000
participants (10,374 adults and 27,686 children) in 12 clinical
areas and 13 countries.
Message frequency ranged from five per day to weekly.
Significant improvements noted were in medication
compliance, asthma symptoms, HbA1C (hemoglobin/
diabetes related), stress levels, smoking cessation rates, and
self-efficacy. Process improvements included fewer failed
appointments, faster diagnosis and treatment and improved
teaching and training. The study concluded that cell phone
58
whom could have
received home-based
contacts)
voice and short message service enhancing standard care
with reminders, disease monitoring and management, and
education can help improve health outcomes, care processes.
Reliability and Validity
of Gait Analysis by
Android-Based
Smartphone (Telemedicine and e-
Health, Volume 18, Issue
4, May 2012, pgs. 292-
296)
Authors: Nishiguchi,
Yamada, Nagai, Mori,
Kajiwara, Sonada,
Yoshimura, Yoshitomi,
Ito, Okamoto, Ito, Muto,
Ishihara, Aoyama
Smarthphones have built-in accelerometers - devices used to
measure rapid position changes - which now are being
installed in personal emergency response systems (PERS).
The researchers developed a phone gait analysis application
and evaluated the reliability and validity of using
smartphones in assessing gait patterns. Results highly
correlated with those obtained from a control tri-axial
accelerometer.
Use of Remote
Monitoring to Improve
Outcomes in Patients
with Heart Failure: A
Pilot Trial (International
Journal of Telemedicine
and Applications,
published online May
19, 2010)
Authors: Kulshreshtha,
Kvedar, Goyal, Halpern,
Watson
Pilot trial of whether or not remote monitoring could be
successfully implemented for ambulatory patients recently
hospitalized for heart failure. 150 patients from
Massachusetts General Hospital were randomized to an
intervention group (n=82) and a control group (n=68). Vital
signs over six months were transmitted to a nurse
coordinating care with a physician.
Participants had a lower all-cause readmission rate compared
to the control group, although not statistically significant.
Heart failure-related readmission rates were similarly
reduced. The trial demonstrates remote monitoring can be
successfully implemented for ambulatory patients with heart
failure, and may reduce readmissions.
Home Telehealth
Improves Clinical
Outcomes at Lower
Cost for Home
Healthcare
(Telemedicine and e-
Health, Volume 12 Issue
2, 2006, pgs. 128-136)
Authors: Finkelstein,
Speedie, Potthoff
Study involved a randomized controlled trial for persons
receiving skilled nursing care at home, and three groups were
established. Monitoring group M received skilled home
nursing visits, videoconference virtual visits and vital signs
monitoring. Video intervention group V received skilled
home nursing visits and videoconference virtual visits.
Control group C received skilled home nursing visits.
Results at six months included: 42% of C, 21% of V and 15%
of M were admitted to nursing homes or hospitals.
Participants in the M and V groups had better activity of
59
(NOTE: earlier than the
time period for studies
reviewed, but included
because authors are with
the University of
Minnesota.)
daily living ratings at the study's conclusion than the C
group. Morbidity showed no differences between groups
with the exception of higher scores at study completion for
activities of daily living. Average total costs were estimated
at: $48.27 for actual in-person home visits, $22.11 for virtual
video visits only, and $33.11 for virtual monitoring visits.
The results demonstrated that virtual visits can improve
patient outcomes at less costs than traditional in-home visits.
Home Telemental
Health Implementation
and Outcomes Using
Electronic Messaging
(Journal of Telemedicine
and Telecare, accepted
July 2011)
Authors: Godleski,
Cervone, Vogel, Rooney
Study was done in conjunction with home electronic
messaging program begun in 2007 by the VA Connecticut
Healthcare System. 76 patients used a home messaging
device for at least six months where they received daily
questions covering disease management protocols, alerts,
education via a landline phone. A nurse practitioner
evaluated the data daily and did follow up. Diagnoses of
those participating included: schizophrenia, post-traumatic
stress disorder, depression, substance abuse.
In the six months prior to enrollment, 42 patients were
hospitalized for 46 admissions and 47 had a total of 80
emergency room visits. During the study period, six were
hospitalized for nine admissions and 16 had a total of 32
emergency room visits. Participants indicated when
surveyed a high level of satisfaction with the program.
Proactive Integrated
Care Improves Quality
of Life in Patients with
COPD (European
Respiratory Journal,
Volume 33 Issue 5,
1031-1038, May 1,
2009)
Authors: Koff, Jones,
Cashman, Voelkel,
Vandivier
Self-management strategies, which can improve health
outcomes in chronic obstructive pulmonary disease, typically
focus on improvement and not early detection/treatment. A
randomized (U.S.) clinical trial evaluated whether integrating
self-management with proactive remote monitoring could
increase health-related outcomes, addressing complications
from unreported exacerbations and delayed treatment. 40
Stage 3 or 4 chronic obstructive pulmonary disease (COPD)
patients were randomized to receive proactive integrated or
usual care for three months.
Primary outcome was change in quality of life and secondary
was change in healthcare costs. The intervention group
improved their quality of life (10.3 units on the St. George's
Respiratory Questionnaire) vs. 6 units for the control group.
Intervention healthcare costs declined by $1,401, control
group costs had a $1,709 increase, and nine exacerbations
(seven unreported) were found in intervention participants.
Proactive integrated care has the potential to improve COPD
60
outcomes through self-management and early detection.
Home Telehealth in
High-Risk Dialysis
Patients: A Three-Year
Study (Telemedicine
and e-Health, Volume 19
Issue 7, 520-522, July
2013)
Authors: D. Minatodari,
S. Berman
Larger-sample continuation of a previous pilot project
demonstrating improved health outcomes and cost savings
with home telehealth and nurse oversight of persons
undergoing chronic dialysis for end-stage renal disease. 99
patients in study - 43 in remote technology group, 56 in usual
care group.
All outcomes measures were significantly lower for the
technology vs. usual care group: hospitalizations (1.8 vs.
3.0), ER visits, number of days hospitalized (11.6 vs. 25).
Cost analyses were similarly significant for the technology
vs. usual care group - hospitalizations and ER use ($66,000
vs. $157,000) Conclusion is that current results support
previous findings that home telehealth can contribute to
improved health outcomes and care costs for this population.
61
CHAPTER 5 -
MINNESOTA RESOURCES, CHALLENGES
STATE LAWS
General statutes
No definition for telemedicine or teleheath was found when state statutes were scanned.
No statutory requirements were found in a number of other potential policy areas such as:
requirements connected with informed consent, regulations requiring private
payers/insurers to permit services, limitations on the location where services can be
delivered or special licensing requirements for interstate practitioners.
M.S. 147.032 (1) addresses interstate practice of telemedicine. It allows
physicians in other states who want to deliver services by telehealth to do so if
they have an unrestricted license in good standing in their home states, don't open
an office or meet patients or receive calls from them within Minnesota and
annually register with the state Board of Medical Practice.
Physicians aren't required to register if their services: respond to an emergency,
are provided less than once per month or serve fewer than 10 patients annually, or
when the services involves consulting with a Minnesota physician who has
ultimate diagnosis/care authority.
M.S. 151.37 (2) sets requirements for prescribing legend medications (which by
federal law must be dispensed by prescription). It identifies the set of
medications affected, and stipulates that a prescription must be based on a
documented patient evaluation which must include an examination able to
adequately establish a diagnosis and identify underlying conditions and potential
treatment to avoid. These requirements apply when a referring provider performs
an in-person examination where a consulting practitioner provides services and
issues a prescription/order via telemedicine (Subd. 2(e)(5)).
Medicaid-related statutes
Three statutes were located that permit use of/reimbursement for telehealth through the
state's Medicaid program:
M.S. 256B.0625 Covered Services - Subd. 3b Telemedicine consultations.
(3) Consultations via two-way, interactive video and store-and-forward
technology are covered, and the physician must provide a written opinion
for the patient's record. A maximum of three consultations are permitted
per person per calendar week, and payment is at the full allowable rate.
62
M.S. 256B.0625 Covered Services - Subd. 46. Mental health telemedicine.
(4) Mental health services otherwise covered in a direct, face-to-face
encounter may be provided by interactive video and at the full covered
reimbursement rate, when appropriate for a person's condition and needs.
Equipment used must comply with Medicare standards in effect at the time.
M.S. 256B.0653 - Home Health Agency Services. Subd. 4. Skilled nurse visit
services. (5) Visits are permitted when prior authorization is approved and at
a limit of two per patient per day. Delivery must be by live interactive
audiovisual, augmented by store-and-forward technology. Visits are
permitted when a patient's condition can be measured and assessed without a
hand's-on encounter.
Special conditions for residential programs
M.S. 245A.11, Sect. 7a. Alternate supervision technology; adult foster
care license. (6) The Department of Human Services can allow an adult
foster care provider to use remote monitoring technology to replace staff
providing on-site nighttime supervision. The monitoring technology must
alert the license holder if an incident occurs jeopardizing the health, safety
or rights of a foster care recipient. The section sets out a range of
procedures the license holder must develop, document and retain on file.
MEDICAID REGULATIONS
The "Minnesota Health Care Provider Manual" covers the following telehealth
issues:
Physician and Professional Services. (7) Referring parties can be physicians
and physician assistants, nurse practitioners and clinical nurse specialists,
certified nurse midwife, podiatrist or mental health professionals.
Consulting parties must be either a physician or oral surgeon. Physicians'
consults performed via two-way interactive video or store-and-forward
technology can be reimbursed.
Prior authorization is required for telehealth performed by providers not
located in Minnesota or adjacent counties in other states. Reimbursement is
also permitted for two-way interactive video in an emergency department,
including if a physician isn't present at the referring site but nursing staff is
handling care. Payment is limited to three consultation sessions per week,
or for only one reading/interpretation of diagnostic tests.
Home Care. (8) Delivery can be reimbursed to a site other than where the
practitioner is located when the service is within the professional scope of
63
practice of a healthcare professional. It must receive prior authorization,
and is currently only approved for skilled nursing visits.
Elderly Waiver and Alternate Care. (9) Telehomecare delivery is permitted
in both programs.
Home and Community-Based Services. (10) There are four disability
Waivers - Community Alternatives for Disabled Individuals, Community
Alternatives for Care, Brain Injury and Mental Retardation/Developmental
Disabilities. Remote monitoring technology acquisition is permitted under
Environmental Accessibility Adaptations and ongoing monitoring costs are
permitted under Specialized Supplies and Equipment and 24-Hour
Emergency Assistance.
(As a point of clarification, reimbursement for remote monitoring equipment
with a health/ medical focus - such as vital signs monitoring - is to come
through basic state Medical Assistance programming. Activity/safety
monitoring reimbursement - such as emergency response or sensor
monitoring - is to come through the Waivers (and potentially Alternate
Care).
PRIVATE HEALTH INSURANCE REIMBURSEMENT
It is not known to what extent insurers and managed care organizations in Minnesota
cover home telehealth, and if so, which devices are permitted and arrangements
required. Managed care organizations would be the most likely group to permit them,
given their broadly standardized member policies and emphasis on prevention. Unless
no use/reimbursement is permitted, fee-for-service payers' policies may be difficult to
assess due to their many group contracts.
STATUS OF TELEHEALTH IN
HOME CARE/ HOME HEALTH
Perhaps the most basic piece of information needed about the status of in-home telehealth
in Minnesota is its adoption rate and surrounding circumstances. Have home care, home
healthcare and geriatric care management organizations incorporated telehealth into their
service delivery? If so, issues to explore include:
Number involved and length of time
Device/s used
Vendor/s
Connection adequacy
Electronic health records, integration experiences
How capital expenses have been met
Adequacy of public, private reimbursements
64
Delivery costs trends
Outcomes achieved
Level of receptivity
Training scope and extent
As points of reference, the Minnesota Department of Health’s Web-based provider
directory (11) and staff indicate that over 1,800 agencies deliver licensed home care
services throughout the state. The Minnesota Home Care Association (12) represents
approximately 250 of the state's home care agencies, and a number of geriatric care
management organizations operate within the state.
Representatives for all three of the above groups were contacted to inquire about
availability of data profiling use of telehealth resources in home/community care
delivery. These contacts/organizations knew of no data sources covering trends, and it's
very timely to consider conducting surveys through them for this purpose. An alternate
approach could be to review billing records connected with the state's general Medicaid
and Medicaid Waiver programs. Current categories for claims and reporting in the latter,
though, are in groupings covering a number of services/devices that are too broad to yield
desired data.
OTHER MINNESOTA RESOURCES
Broadband coverage
Connect Minnesota is a nonprofit that monitors availability of broadband capacity and
usage characteristics in partnership with the state Department of Commerce. It reported
early in 2013 that the state has a 78% access rate, as compared to 72% in 2011. (13) It
also reported that 51% (approximately 2.1 million) of the state's adults use the Internet on
cellphones, laptop or tablet computers; the previous year's survey been 39%. (14)
A Connect Minnesota priority is to maintain updated maps showing coverage
characteristics throughout the state, such as density of households served/unserved,
delivery speeds, presence of multiple providers in an area, growth/expansion. Maps are
available for counties, congressional districts and statewide. They show that the seven
Twin Cities metropolitan area counties are technically covered, other than small areas in
southeast Dakota County and northeast Washington County.
The organization performs periodic residential and business usage surveys, and one in
2011 showed the following breakdowns for Minnesota adults using the Internet at home
or outside to access e-health assistance: (15)
65
Users' locations
e-Health access usage rate
Statewide (1.9 million)
Cellphone statewide (346,000)
55%
27%
Urban/suburban (1.5 million)
Cellphone urban/suburban (277,000)
57%
28%
Rural (424,000)
Cellphone rural (69,000)
50%
23%
Age 65/+ (176,000) 56%
Disabled residents (262,000) 66%
Beyond connectivity are equally important issues requiring attention, including choice,
reliability and affordability. The Dayton Administration in 2011 established a
"Governor's Task Force on Broadband" with the primary goal of identifying and
recommending actions to correcting broadband access and adoption disparities within the
state. (16) Its 2012 report recommended options including tax credits to stimulate
installation in unserved and underserved areas, coordination among rural public
installation efforts (e.g., hospitals, schools, libraries, public safety facilities) and
coordinating broadband deployment and highway construction projects.
The Blandin Foundation has also been instrumental for many years in encouraging
telehealth adoption. It initiated a "Minnesota Intelligent Rural Communities Initiative” in
2011 with federal financial assistance. (17) The effort’s goals are to provide training,
education, technical assistance and pursue efforts to remove broadband adoption barriers
in the 80 Greater Minnesota counties. The foundation has sponsoring conferences, and
served as a facilitator - its website (18) provides information on use, access and trends in
the state, particularly rural.
Telehealth networking efforts
There are a growing number of states around the country where telemedicine and
telehealth delivery are priority components in developing a broadband infrastructure
"backbone." The infrastructure in some cases enhances an already strong healthcare
delivery system, it's aimed in other cases at making up for deficiencies. Minnesota has
no statewide network, but a group of organizations with existing telemedicine systems
applied in 2007 for grant funding the FCC had available to construct statewide or
regional broadband telehealth networks.
This effort is called the "Greater Minnesota Broadband Telehealth Initiative” (19, 20),
and has been a partnership among:
Minnesota Telehealth Network (which evolved from University of Minnesota
rural connections via federal grants)
Medi-sota Network (southwestern Minnesota)
66
North Regional Health Alliance (Minnesota and North Dakota)
SISU Medical System (northeast Minnesota)
Minnesota Association of Community Mental Health Facilities/MACMH
(linking mental health centers in the state)
The effort envisions creating connections to link the various partners' existing systems to
deliver telehealth and facilitate health information exchange, improve access for patient
care, and reduced barriers and increase coordination in serving rural areas. There are
broadband hubs and "points of presence" in Duluth, Brainerd, Willmar, Grand Forks,
Minneapolis, and at 80 of the partnering providers' participating sites.
Great Plains Telehealth Resource and Assistance Center
The federal Department of Health and Human Services approximately a decade ago
provided funding to establish twelve regional programs around the country encouraging
development of telehealth infrastructure and capacity, particularly in rural areas.
Minnesota is served by the Great Plains Telehealth Assistance and Resource
Center/GPTRAC, which began operating in 2006 and is located at the University of
Minnesota. (21)
GPTRAC serves six Midwest states - North and South Dakota, Nebraska, Minnesota,
Iowa and Wisconsin. It provides technical supports for a range of organizations at all
stages of program development/operation. It assists in identifying grant and other
sources of capital funding, fosters collaborations, tracks regional resource growth and
provides various types of educational opportunities for industry professionals.
Great Plains staff was contacted about the status of Minnesota home/community
telehealth activities, particularly whether many home care, home healthcare and/or
geriatric care management organizations have sought technical assistance for developing
programming. Staff indicated that this provider segment unfortunately isn't very large
and few have been involved in GPTRAC offerings, although the Center is available and
willing to provide assistance.
67
CHAPTER 6 -
TELEHEALTH AMONG THE STATES
It's often useful in our federal system to assess if other states have best practices in
various issue area that Minnesota could adopt or pursue. Reviewing telehealth in this
manner is complicated by the nature of the field, where individually complex
disciplines - medicine and long-term care, telecommunications, technology diffusion,
federal/state/ local policy - all intersect and create unique conditions in each state. A
second complication is how developments in all these areas are taking place at ever-
increasing speed. A third is the fact that the other states are all continually developing
their own practices.
Obtaining up-to-date data as a result has been extremely difficult as has maintaining
currency. The lack of timely information on states' affairs in the past few years led the
federal government, key research and trade associations to undertake major data
gathering and analyses projects. Among them have been:
The "CAST Analysis of State Payments for Aging Services Technologies" (1)
was issued in 2011 by the Center for Aging Services and Technologies and
reviewed states' Medicaid reimbursements. CAST is a coalition of about 400
organizations that support developing, evaluating and promoting a range of
technologies enhancing the aging experience. It's affiliated with the long-term
care trade association, Leading Age.
The "50-State Medicaid Statute Survey" (2), which was issued in 2011 by the
Center for Telehealth and e-Health Law/CTEL, another key national resource
in the field.
Both these reviews obtained very useful data, but they were one-time surveys. Another
important national resource in the field - the Center for Connected Health Policy/CCHP
- fortunately launched a website at the start of 2013 where it has committed to respond
to this shortcoming. (3)
CCHP is funded by the federal Department of Health and Human Services to serve as
the "National Telehealth Policy Resource Center." Among key tools, the website has
an interactive map where each state's existing telehealth policies are extensively
profiled and an interactive tracker profiling states' pending laws and rules.
Immediately preceding the website launch, the National Center also released a report -
"State Telehealth Laws and Reimbursement Policies - A Comprehensive Scan of the 50
States and the District of Columbia" - containing the data used to set up the website's
interactive state trackers. (4) The report reviews both state laws and regulations in
general, and then those specifically affecting a state's Medicaid program administration.
68
CCHP SUMMARY FINDINGS
Evaluators aggregated data across all the states in 12 review categories to produce the
following profile:
Center for Connected Health Policy
Telehealth Findings Among the States
Telehealth feature
#
states
Additional notes
Definition for the
practice
50 Vary from a narrow definition for telemedicine while
using telehealth to encompass it along with other
services (whether in statute or states' Medicaid
regulations)
Some form of
telehealth
reimbursement
44 Six additional states have Medicaid managed care
plans that weren't reviewed, so this total may be larger
Only reimburse
for live video
44 Ranges from permitted with no distinction among
services to limiting to one type of service
Reimburse for
store-and-forward
7 This method is expressly prohibited in some states'
definition of telehealth
Reimburse for
remote patient
monitoring
7
3
Permitted by states' Medicaid programs - AK, CO, KS,
MN, NY, UT, WA
Permitted by states' Departments of Aging Services -
PA, SC, SD
Other states reimburse for home health, but no
definition could be located to determine if remote
monitoring was included
Reimburse for
video, store-and-
forward, remote
monitoring
3 --
Reimburse for
transmission
and/or facility fee
17 Some may follow the Medicare policy of only doing so
for an originating site
Location
limitations
- It wasn't established how many states may follow the
Medicare policy of only reimbursing for persons
located in rural/underserved areas or where significant
distance may be involved. It also wasn't established
how many may limit what is a permissible
originating/distant site, where the home may be
excluded.
69
Consent 30
10
6
4
No mention in state law or Medicaid policy
Required in state law, but not in Medicaid policy
Required in Medicaid policy, but not in state law
Required in both Medicaid policy and state law
Telepharmacy 50 Appears permitted throughout the states, with differing
standards on how the required provider/patient
relationship is established
Licensure 9 Some form of special licensure
Laws for an unidentified number of states don’t
specifically address licensing but make allowances for
contiguous states or allow temporary licensure under
certain conditions
Private payers 16 Laws exist affecting their reimbursement, although not
necessarily mandating
CCHP REMOTE MONITORING FINDINGS
One of the specific categories CCHT tracked was policies in the 10 states (including
Minnesota) where remote monitoring is permitted and reimbursed through Medicaid
programming. The following were the findings:
Center for Connected Health Policy findings
for states permitting
Medicaid-related remote monitoring
State
Remote monitoring - policy or
comments about status
Information source/s
AK AK Medicaid reimburses for services delivered through
self-monitoring
To be eligible for self-monitoring or testing, service must
be via telemedicine application based in recipient's home,
where the provider is only indirectly involved in
provision.
AK Dept of Health and
Social Services, AK
Medical Assistance
Provider Billing
Manuals, Section 1:
Physician, Advance
Nurse Practitioner,
Physician Assistant:
Services, Policies and
Procedures
AK Admin. Code, Title
7, 110.625(a)
70
CO CO Medical Assistance program will reimburse at a flat
fee set by state board when the patient:
Is receiving home health provider services for
congestive heart failure, chronic obstructive
pulmonary disease, asthma or diabetes
Requires doctor or podiatrist-ordered monitoring
at least 5x/week
Has been hospitalized two/more times in past 12
months due to conditions related to the disease
Misses no more than 5 sessions in a 30-day
period
Home has space for equipment and full
transmission capability.
Additional restrictions apply as per state statutes.
Additionally, Medicaid home health reimburses only if
the patient has no other insurance
Reimbursement: CO
Revised Statutes 25.5-5-
32. Requirements: 10
CO Code of Regulation
2505-10.
KS KS Medicaid reimburses for home telehealth using real-
time, interactive audiovisual equipment for monitoring
significant change in health status, timely assessment of
chronic conditions or providing other skilled nursing
services. Must be performed by an RN or LPN.
Agencies may bill skilled nursing services on the same
day as telehealth services.
Eligible reimbursements:
Prescribed by physician
Medically necessary
Beneficiary consent signed
A skilled nursing service
Not exceeding 2/wk. for non-Home- and
Community-Based Service patients
Dept. of Health and
Environment, Kansas
Medical Assistance
Program, Provider
Manual, Home Health
Agency
MN Telehomecare is reimbursed in Elderly Waiver (EW) and
Alternative Care (AC) programs. Reimbursement is only
for skilled nurse visits.
Telehomecare is defined as use of telecommunications
technology by a home healthcare professional to deliver
home healthcare services within the professional’s scope
of practice to a recipient located at a site other than the
site where the practitioner is located.
MN Dept. of Human
Services, Provider
Manual, Elderly Waiver
(EW) and Alternative
Care (AC) Program
MN Dept. of Human
Services, Provider
Manual, Home Care
Services
http://www.dhs.state.
mn.us/main/idcplg?Idc
Service=GET_DYNA
MIC_CONVERSION
&RevisionSelectionM
71
ethod=LatestReleased
&dDocName=id_0089
9
NY NY is In the process of updating its Medicaid telehealth
reimbursement policies. Managed care reimbursement
is optional. Review of 18 managed care plans found
telehealth coverage for at least six providers:
NY Dept. of Health,
Medicaid Health Homes
http://www.health.ny.go
v/health_care/medicaid/
program/medicaid_healt
h_homes/
PA The Dept. of Aging, Office of Long-Term Aging offers
TeleCare services under the Aging and Waiver program -
technology with services permitting those with chronic
conditions to remain independent using in-home
technology for measuring/monitoring health status,
sensor and activity monitoring, medications
dispensing/monitoring.
PA Dept. of Aging,
Office of Long Term
Aging, APD #09-01-05
SC Bureau of Long-Term Care Services offers
telemonitoring to maintain/promote health status of
Medicaid Waiver participants via monitoring of body
weight, blood pressure, oxygen saturation, blood glucose
levels, basic heart rate information.
SC Health and Human
Services, Bureau of
Long Term Care
Services
http://www1.scdhhs.gov/
openpublic/insidedhhs/b
ureaus/BureauofLongTer
mCareServices/telemonit
oring.asp
SD Dept. of Health and Human Services/Adult Services and
Aging reimburses for home-based system providing daily
monitoring of clinical data such as heart rate, blood
pressure, oxygen saturation, temperature, weight, and
that can act as a medication reminder. Staff determines if
telehealth can be accessed through Medicare or other
resources and isn't available through any other funding
source.
Standards are set out for what health status a patient must
have to be eligible, what types of patients are
appropriate, specific procedures that must be followed in
the monitoring practices.
SD Dept. of Social
Services, Dept. of Adult
Services & Aging,
Telehealth Technology
http://dss.sd.gov/elderlys
ervices/services/telehealt
h.asp
UT Reimbursement is available through UT Medicaid
Telehealth Skilled Nurse Pilot Project for Patients in
Rural Areas.
Patient eligibility related to condition (limited to
diabetes), geographic location, frequency of service need,
set out, along with home health agency delivery
UT Admin. Code R414-
42-2.
72
requirements.
WA WA Medicaid permits remote monitoring for patients
diagnosed with unstable condition and at risk for
hospitalization or a more costly level of care. Limited to
one interaction/day, based on licensed practitioner's care
plan.
Eligible and ineligible services set out.
WA Administrative
Code Sec. 182-551-
2125.
WA State Health Care
Authority, Medicaid
Provider Guide, Home
Health Services (Acute
Care Services)
ADDITIONAL STATES USING REMOTE
MONITORING RESOURCES
The CCHP report did not identify that Alabama or Wisconsin permitted in-home
monitoring, yet one of the other reports cited earlier - the Center for Telehealth and e-
Health Law's "50-State Medicaid Statute Survey" - indicated that these states permit it as
well. The CTEL report findings for these states were:
State Medicaid telehealth
reimbursement standards
(general)
Medicaid home care telehealth and/or
remote monitoring reimbursement
standards
Alabama Reimburses for services provided
by psychiatrists and providers
specializing in dermatology if the
recipient of the services does not
have access to a provider of that
service within 50 miles of their
residence.
Reimburses for in-home monitoring
systems to physicians enrolled in the
Patient 1st program (Alabama’s primary
care case management program). The
monitoring program enables a patient to
record certain vital signs and/or test
results at home and transmit data to a
central repository so primary medical
provider can monitor patient’s
condition.
Wisconsin Reimburses for a wide range of
health services provided via
telemedicine as long as the
provider is licensed in-state.
Covered services include mental
health /substance abuse
treatment, care provided by
physician assistants, nurse
midwives, nurse practitioners,
and rural health clinic services.
Wisconsin’s Family Care Waiver
program covers some telehealth services
provided in the home.
73
REMOTE MONITORING FOR
PERSONS WITH DISABILTIES
Much of the remote monitoring research and tracking focuses on using technologies in
assisting seniors. However, various forms of telehealth assist younger persons with a
range of disabilities and are a component of a state's overall telehealth practices.
Researchers focusing on seniors’ affairs may unfortunately miss these data.
That appears to be the case for the CCHT survey profile for Minnesota, which didn't
include a description of how use of remote monitoring technology is permitted as an
alternative for overnight supervision in adult foster care homes, as highlighted at the
beginning of this chapter. At least two other states - Indiana and Ohio - have been
federally approved to reimburse for use of remote activity/sensor monitoring in Medicaid
Waiver programming for persons with a developmental disability. (5, 6)
HOME TECHNOLOGIES OTHER THAN
REMOTE MONITORING
The CCHT report captured data on states' remote monitoring practices, but didn't break
out the type of technologies involved. However, the Center for Aging Services
Technologies' 2011 review focused on state Medicaid reimbursements rates for a range of
technologies and in the process identified what types are permitted. It found that 44
states (including Minnesota) allowed reimbursements for various forms of personal
emergency response systems/PERS and 16 (including Minnesota) reimbursed for various
forms medication management (e.g., reminders, automatic dispensing, etc.)
STATE FEATURES OF NOTE
Although drawn from a number of sources, the preceding information provides a basic
profile of the extent states have laws and regulations in place to promote telehealth
services. Virtually all have some form of telehealth authorization. When it comes to its
standing relative to other states in other areas, the CCHP and CAST reports highlight
that Minnesota is in the relatively small group of states with Medicaid regulations
reimbursing for remote monitoring and among the 16 reimbursing for various forms of
electronic medication management.
Additional information on some of the states authorizing remote monitoring was located
in the report, "Home Telehealth in California: Benefits and Opportunities - White Paper,"
issued by AgeTech California. (6) This project gathered data to compare California’s
features with those of other states'.
New York has taken what may be one of the more coordinated and comprehensive
approaches integrating telehealth into care delivery. Its legislature enacted a Medicaid
"Home Telehealth" program as an 18-month pilot starting in 2007. (7) The program
included remote vital signs monitoring, patient education, medication management,
equipment maintenance, and was adopted in 2009 as a part of the state's general Medicaid
74
program. Eligible providers are home health agencies and community-based long-term
home health programs or programs affiliated with a nursing home or hospital.
New York began implementing a "Health Home" program for those with complex
medical, behavioral and/or long-term needs via the medical home care management
model, with a care manager coordinating services among multiple providers. A tiered
reimbursement system is used that provides different rates for levels of connectivity and
class of telehealth devices involved.
Pennsylvania is another state that appears to have incorporated home telehealth
technology into a coordinated delivery approach. (8) It began its "TeleCare Program" as
a Medicaid Waiver demonstration in 2007, and received federal approval to include it in
the state's Waiver program in 2008. Services include remote vital signs monitoring,
activity sensor monitoring, personal emergency response devices and medication
dispensing/ management.
Eligible providers (depending on technology) include Medicare-certified home health
agencies, personal care/homemaker providers, pharmacies, hospitals. Participation
extends beyond Medicaid-eligible clients via the sliding-scale "Options" program - no
cost for those at 125% federal poverty level, 100% for those at 300% level. In what may
also be an unusual arrangement, Area Agencies on Aging manage reimbursement for
installation and monthly fees.
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CHAPTER 7 -
OBSERVATIONS AND
RECOMMENDATIONS
This report has been prepared to give readers a working knowledge about many facets of
the expanding home/community telehealth field. A particular objective has been to look
across affairs and at the status in Minnesota to determine what efforts need to be initiated
to advance adoption here in the state.
As shown throughout the report, this field has a great number of “moving parts.” Some
with a critical impact on expanding and enhancing capabilities also have impediments
that will take a considerable effort over many years to resolve. Just a couple examples
include concerns as central as modifying Medicare’s various limitations on the
technology’s application, and not only continuing to expand broadband resources in
Minnesota, but making sure they’re both reliable and affordable.
The following issues appear to be key next steps to pursue in supporting home/
community telehealth adoption in the state.
PROMOTING TELEHEALTH IN
HOME AND GERIATRIC CARE
The smart device and biosensing revolutions are reframing aspects of the point of care -
assistance that in the past couldn't be envisioned as flexible or mobile is now becoming
both. Persons with medical support needs, potentially even fairly significant ones and
even when fairly elderly, will increasingly be able to get out and about while still
receiving care.
Home care and home healthcare agencies' service delivery will still remain extremely
important, and they likely will remain the predominant providers of this form of care
even as reform efforts evolve. As highlighted in Chapter 5, though, the status of home
telehealth within the industry in Minnesota - extent and character of existing use or
interest in/capability for developing capacity - is unknown.
A very first task should be to survey the state's home and geriatric care providers to
obtain benchmark data about receptivity to incorporating telehealth into care delivery and
key barriers curtailing it. Results would identify priority issues requiring attention in
order to expand capacity. Another possible step would be to survey assisted living
"early adopters" about experiences with incorporating technologies into their care
settings. The goal would be to identify their decision-making processes, key outcomes,
major challenges faced and how they have been addressing them.
76
LEARNING FROM THE VETERANS
HEALTH ADMINISTRATION
As profiled in Chapter 4, the Veterans Health Administration has extensive experience
resulting in considerable success with many large-scale telehealth initiatives. The
Minneapolis VA Health Care System for many years has participated in the "Care
Coordination and Home Telehealth" program which the chapter profiled, and some of its
staff has been actively involved in national VHA telehealth system developments.
Organizations interested in promoting home/community telehealth within Minnesota
should do outreach with Health Care System staff to learn more about its local and
national efforts and partnering opportunities that may be present.
HOME TELEHEALTH IN STATE POLICY
Chapter 6 highlights how home telehealth services are being used in other parts of the
country. Virtually all states have authorized using some types of technologies, but the
process in many cases may have been on an incremental basis – e.g., responding to
provider authorization requests as they work with certain devices. There are examples of
some states, though, where decisions about where, when and how to deploy home
telehealth technologies have been handled more holistically.
Such an approach requires a systems-type focus on how the technologies should be
integrated into different aspects of care delivery to most fully realize cost savings and
other available benefits. It requires committing resources for an oversight infrastructure -
planning, analysis, networking, training, etc. - and acknowledging that the commitment is
a long-term one. As the array of devices and their capabilities continue growing, they’re
no longer disparate novelties but practical tools that can and should be deployed in a
comprehensive and coordinated manner.
Each state may have to reach an adoption “tipping point” before it considers following
this approach. It may come in conjunction with significant budget reductions, cost-
cutting efforts, or as the scope and character of Medicaid changes within federal
entitlement reform efforts. Alternately, it may come from officials who have the
foresight to understand and act upon irrevocable changes underway in healthcare
delivery. Minnesota should explore as soon as possible how it could become an “early
leader” by laying groundwork to pursue such a proactive strategy.
SUPPORTING TELEHEALTH AS A SERVICE,
PROMOTING REWARDS AND INCENTIVES
Device/system affordability is a very major hurdle organizations face when considering
incorporating technologies into care delivery. Part of the problem is the absolute cost,
and a second critical factor is potential rapid obsolescence due to rapid technology
advances. The historic lack of reimbursement rewards and incentives is a third deterrent,
such as when providers using the technologies achieve operating efficiencies and/or
77
prevention savings, but financial benefits accrue to public programs and/or public/private
insurers. Many organizations may be choosing not to make any commitment because of
these realities.
Chapter 3 highlights how some vendors are responding to the obsolescence concern by
offering attractive trade-in/trade-up terms. Another promising option is where vendors
lease products and provide services effectively as a care provider's outsourced telehealth
department. Depending on leasing rates, this "telehealth as a service" approach may be
an extremely practical way to respond to adoption deterrents. The number of firms
working in this market segment nationwide as well as in Minnesota is unknown.
As recommended earlier, key home care service providers should be surveyed to learn to
what extent financing concerns are slowing device/system adoption in the state. If so,
interested stakeholders - e.g., the Department of Human Services, health insurers,
provider trade associations - should collaborate to explore if "telehealth as a service"
vendors can be encouraged to operate and/or expand in Minnesota. If advancing the
extent of home telehealth usage is judged as a clear public policy benefit - whether
overall or for the state Medicaid program in particular - some form of public/private
venture or public incentives could also be explored.
A related issue involves the historic return-on-investment method for calculating costs
and benefits, and promoting research and demonstrations to expand this metric. When
looked at even for a single provider, there are non-ROI benefits that may justify
incorporating the technologies into care delivery. Two highlighted in Chapter 4 are
patient and family satisfaction levels and providers acquiring a reputation for delivering
benchmark-level care. Both these factors provide attractive marketing opportunities.
Additional benefits from multiple social accounting standpoints have received little
systematic recognition to date largely because of the difficulty in measuring them. For
example, many of the technologies prevent or limit conditions from escalating,
medication costs from increasing, and/or treatment scope from expanding. While these
are critical outcomes, qualitative results here don't meet the hard data measures
"evidence-based practice" seeks.
One response could be for state stakeholders interested in advancing telehealth use to
sponsor projects where before-and-after data at least could be available to research. For
example, forward-thinking employers could be approached to partner in monitoring
caregiver employees' time away from work, travel costs, etc., prior to technology use and
then at intervals once in use.
Similarly, subsidized senior housing providers have residents who cycle back and forth
among their apartments, hospitals, nursing homes and rehab facilities. A study could
document housing providers' cash flows (including vacancy payments) before and after
incorporating telehealth into residents' in-home support. Small-town pharmacies and
other local businesses could be additional parties in such an assessment - documenting
78
the financial impact as residents reduce or eliminate services when absent from their
homes vs. outcomes when maintained with telehealth.
HOME TELEHEALTH ASSISTANCE CENTER
The telehealth device marketplace is confusing for the typical caregiver, even for the
typical provider. Developments take place so frequently and across so many market
segments that it’s difficult monitoring availability, features and comparative costs.
Quality/reliability data on certain products – particularly those of well-known companies
- are available from research and user reports/ratings. However, data on other products –
particularly the flood of smart device apps - either don't exist or are only available in
anecdotal reports posted on websites or blogs.
Users need help in making wise decisions. Providing such help long term is extremely
important for advancing the technology’s adoption and realizing benefits it can yield. A
proactive strategy to do so would be to organize a virtual technical assistance center.
Such a resource could target serving individuals and caregivers of various income levels,
or operations could be expanded to additionally assist staff of public, private and
nonprofit agencies.
Among functions a virtual center could perform would be to:
Monitor promising products in the development/regulatory pipeline, those coming
to market, changes made to existing product lines, key legislative and regulatory
actions, in-state broadband expansion issues.
Determine what performance-type data are available for various products, and if
necessary, supplement gaps by performing basic, selective testing/screening.
Given the profusion of devices and products in some categories, simplified
buyer/user recommendations could be prepared.
Develop and offer “how-to” workshops for technologies that relatively skilled do-
it-yourselfers could install and operate.
Offer periodic/annual “roundup” presentations for consumers and practitioners
highlighting broad industry trends, projections, new products, etc.
Monitor best practices other states have developed.
Home/community telehealth technologies will occupy a growing role in healthcare
delivery in the future, and it’s in many organizations’ interests to collectively establish
and back such a resource. Organizations involved in oversight or service delivery for the
Medicaid population – the state Department of Human Services, counties, the various
health plans – could benefit by having timely information federal regulators seek, and in
setting rates and approving provider device requests. Outreach could assist not only
those with low incomes/assets, but those at a more moderate level who might otherwise
79
excessively spend down resources and need to enroll in public programs. Feasibility
should be assessed by approaching likely stakeholders to gauge interest and willingness
to collaborate on funding, probably on a subscription basis. This service would directly
benefit backers by keeping them apprised of major affairs in the field, greatly minimizing
expenses otherwise required if done individually. California is one state with many
telehealth resources supports that could be looked to as an example.
80
END NOTES
CHAPTER 1
1) A 2007 Indian study found 104 peer-reviewed definitions for telemedicine. (Sood, Sanjay J., Solomon
Negash, Victor W.A. Mbarika, Mengistu Kifle, and Nupar Prakash, "Differences in public and private
sector adoption of telemedicine: Indian case study for sectoral adoption," Studies in Health Technology and
Informatics, 2007, 130:257-68).
2) Catherine Paddock, "FDA approves ingestible sensor that tracks health from the inside," Medical News
Today, August 3, 2012, http://www.medicalnewstoday.com/ articles/ 248557.php
3) Greg Slabodkin, "Wearable mHealth device shipments to hit 30 million by year's end," Fierce Mobile
Healthcare, December 11, 2012, http://www.fiercemobilehealthcare.com/ story/wearable-mhealth-device-
shipments-hit-30-million-years-end/2012-12-11
4) Jonah Comstock, "Slideshow: 7 startups using Microsoft Kinect for online physical therapy,"
MobiHealth News, May 16, 2013, http://mobihealthnews.com/22351/ slideshow-7-startups-using-
microsoft-kinect-for-online-physical-therapy/
5) "Rural Health Advisory Committee's report on telemental health in rural Minnesota, Minnesota
Department of Health, Office of Rural Health and Primary Care, July 2010, pg. 24, http://www.health.
state.mn.us/divs/orhpc/pubs/rhac/tmh.pdf
6) "Thinking outside the pillbox: Medication adherence and care teams: A call for demonstration projects,"
NEHI, 2010, pg. 2, http://www.nehi.net/publications/48/medication_adherence_and_care_teams_a_
call_for_demonstration_projects
7) "How many pills do your elderly patients take each day?" HealthCare Professionals Network Live,
October 4, 2010, http://www.hcplive.com/conferences/ aafp_2010/How-Many-Pills-Do-Your-Elderly-
Patients-Take-Each-Day
8) GlowCaps/Pack: http://www.vitality.net/glowcaps.html
9) Elizabeth Stawicki, "Webcam connects pharmacists to immobile Minn. seniors," Minnesota Public
Radio, January 31, 2013, http://minnesota.publicradio.org/display/ web/2013/01/31/health/webcam-
connects-pharmacists-to-immobile-seniors
10) Laurie Orlov, "Next generation response systems: From fear to function," Aging in Place Technology
Watch, 2013, http://www.linkageconnect.com/files/1/Articles/NextGeneration ResponseSystems
Final02202013.pdf
11) Smarthome: http://www.smarthome.com
12) Lowe's IRIS home monitoring system: http://www.lowes.com/cd_Iris_239939199
13) Linda Barrett, "Health and caregiving among the 50+: Ownership, use and interest in mobile
technology," AARP Research and Strategic Analysis, January 2011, http://www.aarp.org/
technology/innovations/info-01-2011/health-caregiving-mobile-technology.html
14) Brian Natt, "Smartphone apps set to surpass the 1 million mark next week," TNW (The Next Web),
December 2, 2011, http://thenextweb.com/mobile/2011/12/02/ smartphone-apps-set-to-surpass-the-1-
million-mark-next-week/
81
15) "Hopkins researchers aim to uncover which mobile health applications work," Baltimore Sun, March
14, 2012, http://articles.baltimoresun.com/2012-03-14/health/bs-hs-mobile-health-apps-20120314_
1_health-apps-app-works-mobile-health
16) Andrew P. Demidowich, Kevin Lu, Ronald Tamler, and Zachary Bloomgarden, "An evaluation of
diabetes self-management applications for Android smartphones," Journal of Telemedicine and Telecare,
June 2012, http://www.ncbi.nlm.nih.gov/pubmed/22604278
17) Walgreens convenience app: http://www.walgreens.com/topic/apps/learn_about_ mobile_apps.jsp
18) Neil Versel, "Walgreens introduces API for mobile prescription refills," MobiHealth News, February 5,
2013, http://mobihealthnews.com/20171/walgreens-introduces-api-for-mobile-prescription-refills/
19) "Asthmapolis raises $5 million from social capital," MobiHealth News, April 4, 2013,
http://mobihealthnews.com/21428/asthmapolis-raises-5-million-from-social-capital/
20) Kathy Zickuhr and Mary Madden, "Older adults and Internet use," Pew Internet and the American Life
Project, June 6, 2012, http://pewinternet.org/Reports/2012/Older-adults-and-internet-use.aspx
21) "Deloitte 2012 survey of U.S. health care consumers: INFO Brief: Information technology, social
media and online resources," Deloitte Health Center, 2012, pg. 15, http://www.deloitte.com/view/en_US/
us/Industries/US-federal-government/ center-for-health-solutions/research/5044a32d8481b310V
gnVCM3000003456f70aRCD.htm
22) "Clarity final report: Aging in place in America," prepared by Prince Marketing Research (Power
Point), August 20, 2007, http://www.slideshare.net/clarityproducts/clarity-2007-aginig-in-place-in-
america-2836029www.clarityproducts.com/research
23) Julie Appleby, "Walmart health screening stations touted as part of self-service revolution," Kaiser
Health News, February 19, 2013, http://www.kaiserhealthnews.org/ Stories/2013/February/19/self-
health-care-kiosks-walmart.aspx
24) Liz Seegert, "Kaiser Permanente CIO predicts "dramatic" shift in care delivery with direct home
health impact," Home Health News, May 1, 2013, http://www.homehealthnews.org/ 2013/05/ kaiser-
permanente-cio-predicts-dramatic-shift-in-care-delivery-with-direct-home-health-impact/
25) Quantified Self: http://quantifiedself.com
26) "Taking the pulse U.S. 2013 study," Manhattan Research, April 2013, http://
manhattanresearch.com/News-and-Events/Press-Releases/physicians-embrace-patient-self-tracking
27) Brian Dolan, "Pew: Most US adults track health data but few use digital tools," MobiHealth News,
January 28, 2013, http://mobihealthnews.com/20040/pew-most-us-adults-track-health-data-but-few-use-
digital-tools/
28) Jaimie Lazare, "Hospital at home: Patient care model of the future?" Aging Well, Vol.6, No. 2, pg. 20,
http://www.todaysgeriatricmedicine.com/archive /0313p20.shtml
29) "Accountable care organizations (ACOs)," CMS.gov, http://www.cms.gov/Medicare/Medicare-Fee
for-Service-Payments/ACO/index.html?redirect=/aco/
30) "Telemedicine in the Patient Protection and Affordable Care Act (2010), American Telemedicine
Association, 2010, http://www.americantelemed.org/docs/ default-source/ policy/telehealth-provisions-
within-the-patient-protection-and-affordable-care-act.pdf
82
31) "Accountable Care Organizations," CMS.gov, http://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/ACO/index.html?redirect=/aco/
32) Jaimie Lazare, "Hospital at home: Patient care model of the future?" Aging Well, Vol.6, No. 2,
http://www.todaysgeriatricmedicine.com/archive /0313p20.shtml
33) Laura Landro, "Hospitals try house calls to cut costs, admissions," Wall Street Journal, February 6,
2013, http://online.wsj.com/article/ SB10001424127887324610504578278 102547802848.html
34) Kathryn Grayson, "Healthsense inks deal with Verizon," Minnesota Business Journal, May 3, 2011,
http://www.bizjournals.com/twincities/blog/ in_private/2011/05/healthsense-inks-deal-with-verizon.html
35) "GE and StartUp Health partner to accelerate consumer health innovation," Business Wire, January 8,
2013, http://www.businesswire.com/news/home/20130108006845/en/GE-StartUp-Health-Partner-
Accelerate-Consumer-Health
36) Jonah Comstock, "StartUp Health, AARP partner to advise startups on seniors," MobiHealth News,
April 17, 2013, http://mobihealthnews.com/21688/startup-health-aarp-partner-to-advise-startups-on-
seniors/
CHAPTER 2
1) “Chronic disease and health promotion,” Centers for Disease Control and Prevention, 2011,
http://www.cdc.gov/chronicdisease/overview/index.htm
2) Sara Sadownik and Nancy Ray, "Population-based measures of ambulatory care quality: Potentially
preventable admissions and emergency department visits," MEDPAC: Advising the Congress on Medicare
Issues, 2012, http://www.medpac.gov/transcripts/1012_ presentation_ppv.pdf
3) Kristy Gonzalez Morganti, Sebastian Bauhoff, Janice C. Blanchrd, Mahshid Abir, Neema Iyer,
Alexandria C. Smity, Joseph V. Vesely, Edward N. Okele, Arthur L. Kellerman, "The evolving role of
emergency departments in the United States," Rand Corporation, 2013, p. 33,
http://www.rand.org/content/dam/rand/ pubs/research_reports/RR200/RR280/RAND _RR280.pdf
4) "Newest hospital trend - ERs for elderly," Aging on NBC NEWS.com, March 14, 2011, http://www.
nbcnews.com/id/42n075980/ns/health-aging/t/newest-hospital-trend-ers-elderly/#.UgpTp6zhfbo
5) David C. Goodman, MD, MS; Eliott S. Fisher, MD, MPH; Chiang-Hua Chang, PhD., "The
revolving door: A report on U.S. hospital readmissions - After hospitalizations: A Dartmouth Atlas report
on readmissions among Medicare beneficiaries," Robert Wood Johnson Foundation, February 2013, pg. 3,
http://www.rwjf.org/content/dam/farm/reports/ reports/ 2013/rwjf404178
6) Kumar Dharmarajan, MD, MBA; Angela F. Hsieh, PhD; Zhenqiu Lin, PhD; Hector Bueno, MD, PhD;
Joseph S. Ross, MD, MHS; Leora I. Horwitz, MD, MHS; Jose Augusto Barreto-Filho, MD, PhD; Nancy
Kim, MD PhD; Susannah M. Bernheim, MD, MHS; Lisa G. Suter, MD; Elizabeth E. Drye, MD, SM;
Harlan M. Krumholz, MD, SM., "Diagnoses and timing of 30-day readmissions after hospitalization for
heart failure, acute myocardial infarction, or pneumonia," Journal of the American Medical Association,
January 20/30 2013, http://jama.jamanetwork.com/article.aspx?articleid=1558276#qundefined
7) "What the Affordable Care Act says about readmissions," Hospital and Health Networks, http://www.
hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2011/0311HHN_
Inbox_correction&domain=HHNMAG
8) Mary Lerner, "Minnesota hospitals are testing ways to reduce return trips," Minneapolis Tribune,
October 12, 2012, http://www.startribune.com/lifestyle/health/173818361.html
83
9) "Community-Based Care Transition Program," CMS.gov (Center for Medicare and Medicaid Services),
http://innovation.cms.gov/initiatives/CCTP/index.html
10) "Independence at Home Demonstration," CMS.gov, http://innovation.cms.gov/initiatives/
independence-at-home/
11) "Telemedicine in the Patient Protection and Affordable Care Act (2010)," American Telemedicine
Association, 2010, http://www.americantelemed.org/docs/default-source/ policy/telehealth-provisions-
within-the-patient-protection-and-affordable-care-act.pdf.
12) "Telehealth service sites expand," AAPC, 2009, http://news.aapc.com/index.php/2008/ 11/telehealth-
service-sites-expanded/
13) "American Telemedicine Association annual meeting wrap-up: Trends and predictions," Tim Rowan's
Home Care Technology Report, May 2, 2012, http://homecaretechreport.com/ article.asp?id=1528
14) Ibid.
15) "At a glance: What are chronic diseases?" Centers for Disease Control and Prevention, http://www.
cdc.gov/chronicdisease/resources/publications/aag/chronic.htm
16) Brian Ward, PhD and Jeannine S. Schiller, MPH., "Prevalence of multiple chronic conditions among
U.S. adults: Estimates from the National Health Interview Survey, 2010," Centers for Disease Control and
Prevention, http://www.cdc.gov/pcd/issues/2013/12 _0203.htm
17) Virginia M. Freid, Amy B. Bernstein, and Mary Ann Bush, "Multiple chronic conditions among adults
aged 45 and over: Trends over the past 10 years," Centers for Disease Control and Prevention, NCHS Data
Brief Number 100, July 2012, http://www.cdc.gov/nchs/data/ databriefs/db100.pdf
18) Jon Hamilton, "Alzheimer's 'epidemic' now a deadlier threat to elderly," National Public Radio, March
19, 2013, http://www.npr.org/blogs/health/2013/ 03/19/174651566/ alzheimers-epidemic-now-a-deadlier-
threat-to-elderly
19) Teresa A. Keenan, "Home and community preferences of the 45+ population," AARP Research, 2010,
http://assets.aarp.org/rgcenter/general/home-community-services-10.pdf
20) "Transform 2010 data report - Baby Boomer survey," Minnesota Department of Human Services,
November 2010, http://www.dhs.state.mn.us/main/groups/ aging/documents /pub/dhs16_156199.pdf
CHAPTER 3
1) "Healthcare Connect Fund fact sheet," Federal Communications Commission, February 25, 2013,
http://www.fcc.gov/document/healthcare-connect-fund-fact-sheet
2) "Proposed bill would expand telehealth services, bolster federal payouts," Healthcare IT News, January
3, 2013, http://www.healthcareitnews.com/news/proposed-bill-would-expand-telehealth
3) Brian Dolan, "FCC to hire healthcare director, step up health efforts," MobiHealth News, Sept. 25, 2012,
http://mobihealthnews.com/18527/fcc-to-hire-healthcare-director-step-up-health-efforts/
4) Dr. Mohit Kausal and Blair Levin, "Broadcasting live from you: Better health care," MobiHealth News,
June 7, 2012, http://mobihealthnews.com/17576/broadcasting-live-from-you-better-health-care/
84
5) "Modernizing rural health care: Coverage, quality and innovation," UnitedHealth Center for Health
Reform and Modernization, July 2011, pg. 51, http://www.unitedhealthgroup. com/hrm/UNH
_WorkingPaper6.pdf
6) "Medical devices - home use devices initiative," U.S. Food and Drug Administration, http://www.
fda.gov/MedicalDevices/ProductsandMedical Procedures/HomeHealthandConsumer/HomeUseDevices/
ucm208268.htm
7) "Draft guidance for industry and FDA staff - Design considerations for devices intended for home use,"
Food and Drug Administration, December 12, 2012, http://www.fda.gov/medicaldevices/deviceregulation
andguidance/guidancedocuments/ucm331675.htm
8) Continua: http://www.continuaalliance.or
9) "New breed of telehealth vendor removes price as excuse for waiting," Tim Rowan's Home Care
Technology Report, May 9, 2012, http://homecaretechreport.com/article. asp?id=1531
10) VRI: http://monitoringcare.com
11) "H.R.6179 - To promote and expand the application of telehealth under Medicare and other Federal
health care programs, and for other purposes," Congress.gov, http://beta. congress.gov/bill/112th/house-
bill/6719
12) "S.596 - Fostering Independence Through Technology Act of 2013," Congress.gov, http://beta.
congress.gov/bill/113th/senate-bill/596
13) "Rep. Honda reintroduces mobile health innovation legislation," iHealth Beat, June 14, 2013,
http://www.ihealthbeat.org/articles/2013/6/14/rep-honda-reintroduces-mobile-health-innovation-bill.aspx
14) Orlov, Laurie, "The future of home care technology," Aging in Place Technology Watch, July 2012,
http://www.ageinplacetech.com/files/aip/Future%20of%20Home%20 Care%20Technology%20Final-07-
31-2012.pdf
15) Orlov, Laurie, "December 2012 year-end wrap and 2013 trends to watch - Laurie Orlov's blog," Aging
in Place Technology Watch, http://www.ageinplacetech.com/blog/december-2012-year-end-wrap-and-
2013-trends-watch
CHAPTER 4
1) Greg Slabodkin, "Shades of grey: Beyond peer-reviewed literature for mHealth evidence," Fierce
Mobile Healthcare, May 21, 2013, http://www.fiercemobilehealthcare. com/story/shades-grey-beyond-
peer-reviewed-literature-mhealth-evidence/2013-05-21
2) Orlov, Laurie, "There goes telehealth, taking it on the chin again," Aging in Place Technology Watch,
April 17, 2012, http://www.ageinplacetech.com/blog/there-goes-telehealth-taking-it-chin-again
3) Adam Steventon, Martin Bardsley, John Billings, Jennifer Dixon, Helen Doll, Shashi Hirani, Martin
Cartwright, Lorna Rixon, Martin Knapp, Catherine Henderson, Anne Rogers, Ray Fitzpatrick, Jane Hendy,
Stanton Newman, "Effect of telehealth on use of secondary care and mortality: findings from the Whole
System Demonstrator cluster randomised trial," British Medical Journal, published June 21, 2012,
http://www.bmj.com/content/344/ bmj.e3874
4) Alyssa Gerace, "Study: Telehealth doesn’t improve life quality for those with chronic conditions,"
Home Health Care News, February 28, 2013, http://homehealthcarenews. com/2013/02/study-telehealth-
doesnt-improve-life-quality-for-those-with-chronic-conditions/
85
5) "Veterans Health Administration - About VA," U.S. Department of Veterans Affairs, http://www.va.
gov/health/aboutVHA.asp
6) David J. Barton, "VA to expand telehealth services to reach 825,000 veterans, Adam Darkins
comments," ExecutiveGov, November 5, 2012, http://www.executivegov.com/ 2012/11va-to-expand-
telehealth-services-to-reach-825000-veterans-adam-darkins-comments/
7) Adam Darkins, Patricia Ryan, Rita Kobb, Linda Foster, Ellen Edmonson, Bonnie Wakefield, Anne E.
Lancaster, "Care coordination/home telehealth: The systematic implementation of health informatics, home
telehealth, and disease management to support the care of veteran patients with chronic conditions,"
Telemedicine and e-Health, January 2, 2009, http://online.liebertpub.com/doi/abs/10.1089/tmj.2008.0021
8) "Case studies in telehealth adoption - Scaling telehealth programs: Lessons from early adopters," The
Commonwealth Fund, pg. 4, January 2013, http://www.commonwealthfund.org/~/media/Files/
Publications/Case%20Study/2013/Jan/1654_Broderick_telehealth_adoption_synthesis.pdf
9) "VA discontinues copays for in-home telehealth services," Association of American Medical Colleges,
September 28, 2012, https://www.aamc.org/advocacy/washhigh/highlights2012/305424/092812
vadiscontinuescopaysforin-hometelehealthservices.html
10) "VA to increase mental health care access through 200,000 telemental health consultations in 2012,"
U.S. Department of Veterans Affairs, Office of Public and Intergovernmental Affairs, June 20, 2012,
http://www.va.gov/opa/pressrel/pressrelease. cfm?id=2335
11) Mitchell Zoler, "VA's telemental health efficacy surpasses face-to-face encounters," Clinical
Psychiatry News, May 7, 2012, http://www.clinicalpsychiatrynews.com/news/more-top-news/single-
view/va-s-telemental-health-efficacy-surpasses-face-to-face-encounters/9120a6468f89121e11f8
549b152cc526.html
12) "VA home-based primary care program: A primer and lessons for Medicare," American Action Forum,
November 1, 2011, http://americanactionforum.org/sites/default/files/VA%20HBPC%20Primer
%20FINAL.pdf
13) Jonah Czerwinski, "Hotbed of innovation: The exciting new initiative at Veterans Affairs," Excellence
in Government, September 11, 2012, http://www.govexec.com/excellence/promising-practices/2012/09/
hotbed-innovation-exciting-new-initiative-veterans-affairs/58002/
14) Bernie Monegain, "VA to help veterans with diabetes with remote monitoring," Healthcare IT News,
November 8, 2012, http://www.healthcareitnews.com/news/va-help-veterans-diabetes-remote-monitoring
15) Pamela Lewis, "VA launches iPad pilot program," American Medical News, May 29, 2012,
http://www.amednews.com/article/20120529/business/305299997/8/
16) "Case studies in telehealth adoption - Scaling telehealth programs: Lessons from early adopters," The
Commonwealth Fund, pg. 6, January 2013, http://www.commonwealthfund. org/~/media/Files/
Publications/Case%20Study/2013/Jan/1654_Broderick_telehealth_adoption_synthesis.pdf
17) Lauire M. Orlov, "Benefits of technology in Philadelphia PACE program: A case study," Aging in
Place Technology Watch, nd, http://www.healthsense.com/phocadownload/whitepapers/home/
pace_program_white_paper.pdf
18) Bernie Monegain, "Research shows telemonitoring helps control blood pressure," Fierce HealthIT,
May 12, 2012, http://www.healthcareitnews.com/news/research-shows-telemonitoring-helps-control-blood-
pressure
86
19) "Honeywell HomMed telehealth products and services utilized with high success in telemedicine
efficacy study for rural patient population," Honeywell HomeMed, nd, http://www.google.com/url?
sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CDgQFjAA&url=http%3A%2F%2Fwww.hommed.co
m%2Fwp-content%2Fuploads%2F2013%2F02%2FCP302.02-Honeywell-St.-Alexius-Medical-Center-
Case-Study.pdf&ei=6NMTUpzCNuLbyQGM5IDYAw&usg=AFQjCNGhNfDegTbTHSy0iK16forqg7
KqNA&sig2=QC733SH7UL8mWQsttc5-cw&bvm=bv.50952593,d.aWc
CHAPTER 5
1) MS147.032: https://www.revisor.mn.gov/statutes/?id=147.032
2) M.S. 151.37: https://www.revisor.mn.gov/statutes/?id=151.37
3) M.S. 256B.0625: https://www.revisor.mn.gov/statutes/?id=256B.0625
4) ibid
5) M.S. 256B.0653: https://www.revisor.mn.gov/statutes/?id=256B.0653
6) M.S. 245A.11: https://www.revisor.mn.gov/statutes/?id=245A.11
7) Minnesota Health Care Provider Manual - Physician and Professional Services: http://www.dhs.
state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=Latest
Released&dDocName=id_008926#P468_31347
8) Minnesota Health Care Provider Manual - Home Care Services: http://www.dhs.state.mn.us/main/
idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDoc
Name=id_008994#
9) Minnesota Health Care Provider Manual - Elderly Waiver and Alternative Care: http://www.dhs.state.
mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestRele
ased&dDocName=id_056766#
10) Minnesota Health Care Provider Manual - Home and Community Based Services Waiver Services:
http://www.dhs.state.mn.us/main/idcplg?IdcService =GET_ DYNAMIC_CONVERSION&Revision
SelectionMethod=LatestReleased&dDocName=id_008995#
11) Minnesota Department of Health home care provider directory: http://www.health.state.mn.us/
divs/fpc/directory/showprovideroutput.cfm
12) Minnesota Home Care Association website: www.mhca.org
13) Michael Olson, "Broadband at home: Nearly 8 in 10 Minnesota households connected," Minnesota
Public Radio, March 13, 2013, http://blogs.mprnews.org/ground-level/2013/03/ broadband-at-home-nearly-
8-in-10-minn-households-connected/
14) "Exploring broadband's impact on Minnesota healthcare," Minnesota Connect, June 2012,
http://www.connectmn.org/sites/default/files/connected-nation/Minnesota/files/ mn_ehealth_finalv2.pdf
15) "The growth of mobile Internet," Connect Minnesota, March 2013, http://www.connectmn.org/
sites/default/files/connected-nation/Minnesota/files/mn_ mobile_ broadband_final.pdf
16) "Annual report and broadband plan 2012," Governor's Task Force on Broadband, December 10, 2012,
http://mn.gov/commerce/images/2012_Broadband _Annual_Report.pdf
87
17) “CK Blandin Foundation, Minnesota Intelligent Rural Communities,” Broadband USA Connecting
America’s Communities, http://www2.ntia.doc.gov/grantees/CKBlandin
18) Blandin on Broadband website: http://blandinonbroadband.org/2013/07/02/blandin-broadband-enews-
july-2013/
19) Maureen Ideker, John Linnell, Jeff Plunkett, "Building a dedicated network for rural health care (Power
Point)," Greater Minnesota Telehealth/e-Health Broadband Initiative (GMTBI), nd, http://www.health.
state.mn.us/divs/orhpc/conf/2011/presentations/5e.pdf
20) Jeff Plunkett, Maureen Ideker, "Greater Minnesota Telehealth/e-Health Broadband Initiative -
Minnesota's FCC rural health care pilot projects," 2012 Minnesota Broadband Conference - Building our
connected future: Minnesota's better with broadband," 2012, http://www.slideshare.net/atreacy/greater-
minnesota-telehealthehealth-broadband-initiative-gmtbi
21) GPTRAC: http://www.gptrac.org
CHAPTER 6
1) Scott Peifer, “CAST analysis of state payments for aging services technologies," Center for Aging
Services and Technologies (CAST), 2011, http://www.leadingage.org/uploadedFiles/Content/About/
CAST/CAST_State_Payment_%20Analysis.pdf
2) "50-State Medicaid statute survey," Center for Telehealth and e-Law, February 2011, http://ctel.org/
expertise/reimbursement/medicaid-reimbursement/
3) Center for Connected Health Policy: http://www.telehealthpolicy.us
4) "State telehealth laws and reimbursement policies - A comprehensive scan of the 50 states and the
District of Columbia," Center for Connected Health Policy, 2013, http://telehealthpolicy.us/
sites/telehealthpolicy.us/files/uploader/State%20Telehealth% 20Report%20July%202013%20Final.pdf
5) "Part 10: Service definitions and requirements sections 10.0 - 10.30" (DDRS Waiver Manual - Section
10.9: Electronic Monitoring)," Indiana Division of Disability and Rehabilitation Services, 2012,
http://www.in.gov/fssa/files/DDRS_Waiver_ Manual_ Fall_2012.pdf
6) John L. Martin and Mark Davis, "Fostering Technology - Implications of Remote Monitoring in Ohio's
Waiver Program (Power Point)." Ohio Department of Developmental Disabilities, June 7, 2012.
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CC8QFjAA&url=http%
3A%2F%2Fwww.nasddds.org%2FMeetings%2F2012MidYearConference%2F2012MYCPresentations%2
FMARTIN-6.7.2012.pptx&ei=k9ITUoamAumoy AHRnoCgCg&usg=AFQjCNGhdT1EN134e-
fE0kuQvbnCAv-HTQ&sig2=1VjZmzpVahgIhTu 2AL781A&bvm=bv.50952593,d.aWc
6) "Home Telehealth in California: Benefits and Opportunities - White Paper," AgeTech California, April
2012, http://www.leadingage.org/uploadedFiles/Content/About/CAST/Policy/AgeTech_CA_Home_
Telehealth_Whitepaper.pdf
7) ibid, pg. 7
8) ibid, pg. 6
88
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"Veterans Health Administration - About VA." U.S. Department of Veterans Affairs (website).
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telehealth." Honeywell Home Med, nd. http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=
web&cd =1&ved=0CE8QFjAA&url =http%3A%2F%2Fwww.hommed.com%2Fwpcontent%2Fuploads%
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synthesis.pdf
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conditions." National Medicare Readmission Summit, June 1-2, 2009 (Power Point).
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aged 45 and over: Trends over the past 10 years." Centers for Disease Control and Prevention (NCHS
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Goodman, MD, MS, David C; Eliott S. Fisher, MD, MPH; and Chiang-Hua Chang, PhD.
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104
APPENDIX
ELECTRONIC HEALTH/WELLNESS
PRODUCT LISTINGS Three broad types of electronic health/wellness products are marketed for use at home and when mobile:
Individual equipment and coordinated systems
Smart devices (smartphones, tablets, etc., sometimes specially adapted) and peripheral equipment developed
to use with them
Smart device applications (apps)
Products respond to an extremely wide range of needs, and have been grouped into the following categories::
1. Activity/safety sensor monitoring - tracking movement, daily routines
2. Caregiving - services, supports
3. Communications - modified/adapted equipment
4. Emergency/fall monitoring - often linked with wander monitoring
5. Hearing/vision - supports
6. Medication adherence/management
7. Physical functioning - rehabilitation, sleep monitoring, etc.
8. Robotics - monitoring and care-providing devices
9. Vital signs monitoring - e.g., heart, lungs; blood oxygen, sugar, pressure levels; certain medication levels
10. Wander monitoring - often linked with emergency/fall monitoring
The following listings profile a sample of currently available products and their capabilities. A grid for each of the above categories
provides information on: product and manufacturer names, a short summary of features and Web addresses where more information
can be obtained. Summaries of features and capabilities have been taken from manufacturers' information. Each category listing is
grouped by: in-home equipment/systems, smart devices/peripherals, and/or apps. Inclusion in a listing implies no endorsement.
105
1) ACTIVITY/SAFETY SENSOR MONITORING -
EQUIPMENT
Product/vendor
Characteristics, features
Web address
Ambio Remote
Health Monitoring
System
(Ambio Health)
Activity/safety monitors (motion, door/window) for purchase a
la carte. Customer decides when alerts should be issued, can
receive by telephone, text or e-mail. System also sells vital
signs monitoring peripherals that automatically record/store
readings on company's computer server, where users can view
results, print, etc. Family members can log in to check user's
status. Care center sends reminder messages for readings
and/or if missed.
http://ambiohealth.com
Artemis
(Independa, Inc.)
Multi-function monitoring support system. "Artemis"
component uses a range of sensors to monitor user and home
environment, also monitor a range of vital signs. "Angela"
component provides social engagement/caregiver
interaction/entertainment via specially adapted LG televisions
and Samsung Galaxy tablets.
http://www.independa.com
BeClose Senior
Safety System
(WH Interactive
LLC)
Family/caregiver-operated system uses sensor devices placed
throughout a home to monitor an array of conditions. Units
gather data on typical activity patterns, forwards to Web
charts tracking daily routine. Alerts sent when typical patterns
change significantly. .
http://beclose.com
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Close By Network
(Close by Network)
Families choose what to monitor in home, using sensor devices
tracking an array of conditions. Monitoring data sent to care
center's computer server, which alerts designated members of
user's Care Network when normal conditions change, there's
no movement/activity or the user activates a help button. Care
Network can be notified by e-mail or text.
http://www.closeby.com
eNeighbor/
S.E.N.S.System
(Healthsense,
Sengistix, LLC)
Sengistix uses the eNeighbor monitoring system Healthsense
markets for senior living/care settings in its "Secure
Environmental Network of Support"/S.E.N.S.system for
homes. Sensors monitoring a range of conditions are placed
throughout a residence. Activity/safety data tracked by care
center, including auto fall detection, wandering. Alerts sent to
notify caregivers when major changes occur in standard
activity patterns.
http://www.sengistix.com.
Family Link
(iKare Corporation)
Remote monitoring/communication system tracks motion in
room where located. Also a one-touch interface for seniors
and family/caregivers to connect - e-mail messages, photo
sharing, video chat.
http://www.familylink.net
GrandCare
(GrandCare
Systems LLC)
Multi-function monitoring/support system. Activity/safety
component uses sensor devices to track not only a range of
user conditions, but home temperatures, lighting controls,
phone caller screening. Caregivers receive alerts if/when
activity patterns/in-house conditions change. Other system
components involve caregiver/user communications, location
monitoring, vital signs data gathering, medication
management, socialization/ entertainment. Caregivers access
various features via online "Care Menu" - add messages, view
trend data, set up rules for receiving alerts.
http://www.grandcare.com
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Iris
(Lowes)
Set of "sensor kits in a box" provide a range of "smart home"
functions controllable by mobile devices. Kits for
safety/security (with video add-on capability - streaming,
recording), remote controls/scheduling for appliances, etc.,
energy management, door remote locking/unlocking. Newer
care kit uses a range of sensor monitors to alert when help is
needed or daily routines change.
http://www.lowes.com/cd_Iris_239939199_
Lively
(Lively)
Multi-function monitoring/support system. Artfully designed
monitoring units track activity/safety - e.g., pill container use,
eating, if/when person is farther than 400 feet from base unit.
Sends periodic reminders/alerts Social network component
also available.
http://www.mylively.com/
Nonnatech
(Nonnatech)
Family caregiver-directed system monitors user from computer
or phone using wireless streaming video. Automatically
notifies caregivers on mobile phone or computer via text or e-
mail of user's status. Can purchase a base unit and different
types of sensors individually. Can create rules for turning
devices on/off, grouping devices, connecting with other family
members.
http://www.nonnatech.com/Home_Page.htm
Sonaba Wellbeing
Monitor
(poms)
poms - peace of mind. Multi-function monitoring system,
activity/safety component tracks daily routines and uses
device to monitor for emergencies; follows up as required.
Other components include automatic medication reminder,
social communication features, digital photo frame, remote
setup, daily caregiver updates.
http://sonamba.com
WellAware System uses array of sensors to monitor activity patterns, sleep http://www.wellawaresystems.com
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Systems
(WellAware
Systems)
quality. Alerts sent to care center when standard patterns
change; caregivers receive reports highlighting trends/changes.
(Note - purchased by Healthsense in July 2013.)
1) ACTIVITY/SAFETY SENSOR MONITORING -
SMART DEVICE APPS
Product/vendor
Characteristics, features
Web address
Presence
(People Power)
Converts old Apple devices into security cameras for use with
wi-fi - one device is set up as the camera, one as the monitor.
Can be programmed for video clips.
https://itunes.apple.com/us/app/presence-
by-people-power/id618598211?mt=8
Monitoring Home
(APPFlyer)
Converts iPhone into a monitoring camera that can face detect
before uploading to Facebook or DropBox for remote review.
Can program camera intervals from five seconds to 24 hours.
Camera screen can be set on auto-hide so use isn't visible.
https://itunes.apple.com/us/app/monitoring-
home/id510325018?mt=8
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2) CAREGIVING - SERVICES
Product/vendor
Characteristics, features
Web address
Care Family
(Care Family)
Provides caregivers nationwide with expertise on a wide range
of issues - companions, personal care, medical support.
Assists in finding, hiring and managing the right caregiver.
Handles payment, taxes, insurance, etc.
https://www.carefamily.com
CareLinx
(CareLinx, Inc.)
Assists in locating reputable caregivers - family completes
survey, CareLinx staff assists with referrals. For annual
membership fee, family receives background checks, pre-
screened caregivers/profiles (e.g., education, work
experience, availability, reviews). Caregiver and family set
payment rate. Company handles liability insurance, taxes,
screening, paperwork; charges 15% per invoice for services.
http://www.carelinx.com
CareTree.Me
(CareTreeMe)
Software to facilitate homecare. Family creates account and
enters profile of care recipient - e.g., personal information,
medications, important documents. Other key parties have
access, receive e-updates, etc., with security filtering for
what's provided. Once care staff hired, they document
arrival/departure, receive messages/tasks; system calculates
billable hours.
http://www.caretree.me
DementiaGuide
(Dementia
Website and smart device app capture data on person's
condition so caregivers can track progress, become
http://www.Dementia Guide.com
110
Guide, Inc.)
collectively informed and better plan for care. Provides
background on the condition, strategies to manage day-to-day
circumstances, understanding for better communicating about
symptoms and how they change, disease management
techniques. Site identifies important information to share
with medical personnel, other care providers and family
members.
eCaring
(eCaring LLC)
Software for recording, monitoring, managing health at home
- icon-based care tracker. System includes Care Tracker, Care
Journal, Care Alerts, Care Portrait with key data for all users,
Care Payroll Module for care personnel time documentation.
http://ecaring.com
Lotsa Helping
Hands
(Lotsa Helping
Hands, Inc.)
Assists in bringing together volunteers through online
communities that organize/provide support for caregivers.
Provides a location for persons interested in/willing to
volunteer services.
http://www.lotsahelpinghands.com
Making Care
Easier
(Making Care
Easier)
Care management platform in Internet, also versions for
Apple and Android devices. Provides location for family,
friends, caregivers to coordinate care, maintain relations.
Family "dashboard" becomes central location for information
about care needs, tasks, actions, care and emergency plans.
Site provides how-to suggestions, advice. Online community
of caregivers/ experts for providing assistance in
development. Also has information on useful
products/services.
http://www.makingcareeasier.com/families
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2) CAREGIVING - SMART DEVICE APPS (See VITAL SIGNS MONITORING - SMART DEVICE
APPS section for related listings)
Alzheimer's Apps
1.0
(AppsforAll, LLC)
Peer-reviewed apps providing assistance for patients and
their caregivers. Ratings and reviews. For Apple devices.
http://itunes.apple.com/us/app/alzheimers-
apps/id351904904?mt=8
ALZTrack
(Handhold
Adaptive, LLC)
Journal tool to aid Alzheimer's caregivers in tracking
interventions, behaviors, symptoms, therapy, medications.
For Apple devices.
https://itunes.apple.com/us/app/alztrack/id449453
732?mt=8
Balance
(National
Alzheimer Center)
Covers multiple functions for dementia caregivers -
scheduling, medication management, physician diary,
resources about the condition, caregiving tips, connections
with other family members. For Apple devices.
itunes.apple.com/us/app/balance-for-alzheimers-
caregivers/id609839752?mt=8
Care First
SymptomChecker
(Care First Blue
Cross Blue Shield.)
Developed by healthcare provider serving Maryland, parts of
Virginia and Washington, D.C. Designed for when users are
traveling or doctor's office closed. Assists in making a
decisions about level of care (if any) needed, provides relief
for minor illnesses/injuries. Based on protocols used by
physicians/nurses in 10,000 practices and 400 nurse call lines
in the U.S. and Canada. For Apple devices.
http://itunes.apple.com/us/app/carefirst-
symptomchecker/id411717364?mt=8
Care Partners
Mobile
(Philips Home
Keep track of what's needed to care for elderly parents.
Creates a shared to-do list and reminder calendar for invited
network of caregivers - allows those participating to make
http://www.lifelinesys.com/content/resources/car
epartners-mobile
112
Monitoring) sure necessary tasks are addressed. For Apple devices.
CareCoach
(Verilogue, Inc.)
Uses supportive care team of friends, family, advisors to assist
patients in having productive healthcare appointments.
Patient can seek team advice/input on questions to ask
doctors, record outcomes from doctor visits and share with
family or caregivers on secure website, CareCoach.com. For
Apple devices.
http://www.carecoach.com/home
https://play.google.com/store/apps/details?id=co
m.verilogue.MHPRecorder&hl=en
Caregiver Apps
1.0
(AppsforAll, LLC)
Evaluates, provides background on caregiver apps on the
market. Provides a forum for peer-recommended review.
For Apple devices.
http://itunes.apple.com/us/app/caregiver-
apps/id351907820?mt=8
Caregiver's Touch
(H2Mobile, LLC)
Helps manage, access critical information. Can gather:
medication history, medical/ hospital history, financial/legal,
emergency information, insurance, military, religious, assets,
etc. In both Apple device and Web versions.
http://itunes.apple.com/us/app/caregivers-touch/
id362291852?mt=8
CareSync
(Continuum Labs,
Inc.)
For family health records - collect, organize, store, share
healthcare information. Use Visit Manager to organize for
appointments. Track medications, conditions, allergies,
manage contacts. For Apple devices.
https://itunes.apple.com/us/app/caresync/
id635439202?mt=8
CareZone
(CareZone)
Provides constant access to contacts, helpers. Tracks
medication types/dosages/use, records/files, tracks to-dos,
can create journal record. Identifies key/emergency contacts,
calendar for scheduling, shared notes/instructions. Can notify
up to 100 contacts. For Apple devices.
https://itunes.apple.com/us/app/care-zone-family-
organize/id552197945?mt=8
HealthSpek PHR
(Healthspek)
Personal health record - myProfile (health reference
information), Medications (reminders, automated refill alerts,
https://itunes.apple.com/us/app/healthspek-phr-
personal-health/id576488481?mt=8
113
order online), Chart Now (healthcare practitioner can access
data), myDashboard. Primarily for Apple iPad.
iCam
(SKJM
LLC)
For use when care recipient has computer, webcam - allows
monitoring multiple live feeds over wi-fi or cellular. Record,
play back events, can set up for motion detection. For Apple
devices.
https://itunes.apple.com/us/app/icam-webcam-
video-streaming/id296273730?mt=8
iTriage
(iTriage, LLC)
Stores personal health data (including insurance information),
medical conditions, medication data. Site provides lookups
on doctors, facilities, medical symptoms/conditions,
medications, procedures. In Apple and Android device
versions.
https://play.google.com/store/apps/details?id=co
m.healthagen.iTriage&hl=en
myFamily
(LyfeChannel)
Helps families manage health and prevention information
personalized for each family member. Can customize
prevention information, save relevant tips and tools, create
personal health alerts/reminders, track medical checkup/
vaccination/prescription information. For Apple devices.
http://lyfechannel.com/healthfinder_app/
114
3) COMMUNICATIONS - EQUIPMENT
Product/vendor
Characteristics, features
Web address
Amplified Phone
with Big Button,
Braille
(Clarity Products)
Jumbo keys with Braille characters, electronic voice repeats
numbers after dialing. 35-37 dB amplifier. Hearing aid-
compatible, bright ring flasher, loud ringer (up to 85 dB) with
adjustable ring tones. Digital processor minimizes background
noise. 10-number memory speed- dial keys announced either
in pre-recorded or user's voice. Three-number, one-touch
programmable emergency keys.
http://clarityproducts.com
AmpliVoice 50
Talking Caller ID
Amplified
Telephone
(Sonic Alert)
Land line style; can set up to meet needs of persons with vision
and/or hearing impairments. Can log 64 incoming calls, 30-
number ID of incoming calls. Audible number read-back for
calls placed, three auto-dial keys. Amplifies up to 40dB,
hearing aid compatible, large keypad and numbers.
Visual/sound ringer (up to 50dB).
http://www.sonicalert.com/products-
amplified-phones-AmpliVOICE50.html
Big Button Photo
Dialer
(Innovative
Technology
Electronics Corp.)
Unit can direct dial up to 24 numbers by pressing large
photos/picture keys (2"x3") instead of phone keypad. Keys
can be modified for Braille. Unit can adapt to any speed dial
phone, including cordless. Good for seniors, persons with
disabilities, children.
http://www.sharperimage.com
CareLine Home Corded or cordless handset phones, both with larger buttons. http://www.vtechphones.com/careline/carelin
115
Safety Telephone
Systems
(VTech)
Corded version has speed-dial photo buttons for frequently
called numbers. Call voice announce, digital answering
system, volume boost, emergency button pendant that calls
two numbers, two programmable buttons, 50-number
programmable phone book, audio boost.
e-home-safety-telephone-system
ClearSounds
Freedom Deluxe
Phone
(ClearSounds)
Cordless phone unit with extra handset (includes vibrating
function). 125 dB amplification in handset, full-range tone
control. System can expand to up to five handsets. 95 dB
adjustable base ringer, 85 dB adjustable handset ringer. Eight
one-touch photo memory buttons, one emergency button.
Talking phonebook, caller ID. Hearing aid-compatible, digital
answering machine.
http://www.maxiaids.com/store/prodList.asp
Doro Secure 740
(Doro)
Company with cellphones designed for seniors. Model 740
has simple menus, touch screen, sliding keypad for text
messaging. Large text, clearly labeled menu. Five-megapixel
camera takes pictures and doubles as magnifying glass.
http://www.dorousa.com
Ensemble
(Clarity)
Amplified phone that incorporates 7" screen Android pad.
Caller's speech routed through captioning company (Clear
Captions), appears on screen as well as is amplified in phone
headset. Adjustable font, sound level. Clarity customer
service can remotely adjust phone features for users.
http://clarityproducts.com
Galaxy Note II
(Samsung)
Large touch screen (5"+) can be used with stylus. Easy Mode
feature - simplifies home screen in providing access only to
key functions.
https://www.samsung.com/global/microsite/
galaxynote/note2/spec.html?type=find
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Independa
(Independa, Inc.)
Multi-purpose care suite. "Angela" interface connects with
special LG ProCentric Healthcare TVs or Samsung's Galaxy
Tab2 tablets. Caregiver Web program can enter text displays
over normal TV broadcast. Single-touch access to video chat,
simple e-mail, daily schedule, prompts, alerts, med reminders
caregivers can enter via Smart Calendar. TV has custom-
designed camera, microphone, point-and-click Magic Remote,
large screen fonts, higher contrast/ brighter colors for seniors'
vision. Is also the portal for vital signs and home sensor
monitoring via "Artemis" system component.
http://www.independa.com
Invisible Clock II
Personal Timer
(Time Now Inc.)
Belt-mounted unit with both beeping and vibrating alarm. Can
set up to 12 daily alerts. Countdown timer can be set for a
single or repeating alert. Also contains Stopwatch function.
www.invisibleclock.com/
iTalk Reminder
(Neutrano)
Reminder alarm clock using voice recognition technology.
User speaks and clock sets up to 10 reminder messages, syncs
with alarm function. Can be used for many scheduling needs,
such as medication reminders.
http://italkreminder.com/
Jitterbugs
(Great Call)
Button-style (Jitterbug) and touch screen-style (Jitterbug Plus -
adapted Android-based Kyocera Milano model). Has
keyboard, yes/no navigation buttons; Plus has camera. Long-
life battery. Can load with Great Call apps - "Meds Coach,"
"Urgent Care" (emergency response), live nurse contact.
http://www.greatcall.com
Kind Reminder
(Kind Reminder)
Pendant records messages in a familiar voice to play on
demand. Operated by pressing single large button. Can reduce
person's anxiety and caregiver's need to repeat messages.
www.kindreminder.com/
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Large Display
Talking Caller ID
(Emerson)
Desktop unit like a small computer screen. Has three-line
display for text/messages, caller ID.
http://www.harriscomm.com/index.php/large-
display-talking-caller-id.html#.UeH7Gqzhfbo
LivelyGram
(Lively)
Uses paper, ink and the mail to communicate. Circle of
family/friends share photos, messages, status updates. Service
compiles content, forwards to user approximately semi-
monthly.
http://www.mylively.com
Motiva
(Philips Healthcare)
Turns home TV into patient's personal healthcare
channel/virtual coach. Delivers educational videos on demand,
provide timely reminders (medications, etc.). Provides
feedback on vital signs measurements, health-related surveys
for patient understanding/compliance. Connection with
family/friends enables support network to connect on daily
health needs.
http://www.healthcare.philips.com/us_en/prod
ucts/telehealth/products/motiva.wpd
Pal
(Clarity Products)
Cellphone modified for seniors' use. Easy-to-read screen,
amplified sound/adjustable tone control, programmed
emergency help button, sends/receives text messages.
http://clarityproducts.com
Pantech Flex
(AT&T)
Cellphone with Easy Experience mode for simple, clean home
screen for seniors - large fonts, clear icons, quick access to
phone, camera, messages, menu, Web and contacts, app
shortcuts. Also has voice commands and dialing. Android
operating system.
http://www.att.com/shop/wireless/devices/pan
tech/flex-gray.html#fbid=CxNGjx2kY5B
Presto and HP
Printing Mailbox
(Hewlett Packard)
Presto Service receives e-mail, digital photo and other digital
content, converts into printouts without the need for computer
or Web connection. HP Printing Mailbox receives/prints
Presto Service messages. Shares a standard phone line, uses
http://www.presto.com/
118
standard print cartridges and paper. Only content from those
on the Presto Friends list forwarded. Good for persons with
vision impairments or who can't readily use a telephone.
Reader
(Intel)
Unit that scans to convert text to speech. Can store
information like an MP3 device.
http://www.careinnovations.com/products/
intel-reader-text-to-speech-technology
Sonic Alert
Amplified Corded
Telephone for
Visual/Hearing
Impaired
(Sonic Alert Inc.)
Model BDP400 announces numbers, menu options when
pressed. Vocalizes names, numbers, menu, commands,
date/time. Volume control up to 40 dB.
http://www.sonicalert.com/products-
amplified-
phones-bdp400.html
VibraLITE3
(Global Assistive
Devices, Inc.)
Vibrating reminder alarm wristwatch unit (also has chimes).
Auto reload timer for reminders.
http://www.globalassistive.com
VideoCare
(HomeCare
California)
Touch screen with two-way video, doesn’t require keyboard,
mouse or any computer skills. Can be connected with wireless
vital signs monitoring peripherals. Approved network
members send user photos or videos from smart devices. Also
serves as secure Internet portal for sharing pictures, data.
Management handled remotely by caregivers/family via cloud-
based computer server.
www.homecare-california.com
Wireless Carrier
for Vision
Impairment
(Odin Mobile)
First mobile phone carrier to target persons with vision
impairments. Access-friendly hand unit, user guides are text-
to-speech friendly. Customer service can remotely connect
with unit to provide assistance.
http://odinmobile.com
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4) EMERGENCY/FALL MONITORING - EQUIPMENT
Product/vendor
Characteristics, features
Web address
5Star Urgent
Response
(Great Call)
Personal profile put on record, pressing button contacts care
center for help. Device tracks person using GPS, displays on
online locator map. Optional UrgentCare app can access
nurses 24/7 (doctor, if necessary); has symptom checker,
medical dictionary. 5Star function integrates into Great Call's
Jitterbug line of mobile phones.
http://www.greatcall.com
Active Care
MiniPAL
(Active Care, Inc.)
PAL = Personal Assistance Link. Operates with GPS and
advanced triangulation Alert unit worn on pendant or belt.
One-button connection to care center for emergency/fall help
and fixing person's location.
http://activecare.reyinteractive.com/pal
Alert1 Medical
Alert System
(ADT Companion
Service)
Pendant- or belt-style alert unit (extra for spouse), base station
(plugs into phone jack and outlet). 24/7 care center emergency
monitoring service. 24-hour battery backup. Care center
notified of low battery.
http://www.alert-1.com
AmberSelect
(Visonic)
Monitors for inactivity, falls, environment (smoke, water,
intruders, carbon monoxide). Initiates emergency call and
picks up incoming calls when wearing remote transmitter.
Two-way speakerphone, up to 16 customizable reminders.
Local and remote programming via computer or telephone
line, 24-hour backup battery.
http://www.visonic.com/Products/Wireless-
Emergency-Response-Systems/AmberSelect
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Attentiv
(Cardiocom)
Multi-function care system. Attentiv component provides
emergency response and 24/7 health monitoring. Connects
with Linkview component for vital signs, NetResponse
component for daily check ins/education, TeleResponse
component providing comparable services for users who only
have telephone.
.
http://www.cardiocom.com
Automatic Fall
Detection
(VRI)
Pendant-style alert device worn by user, base unit connects to
electric outlet. Detects falls when no sudden movement occurs
within 10 seconds. Alert sent to care center; care staff talks
with patient and contacts caregiver, neighbor, emergency
personnel as required. 600-foot range. Compatible with VRI
Cellular Medical Alarm.
http://monitoringcare.com
Care Innovations
Link
(GE-Intel Care
Innovation)
Base unit plugs into phone land line and power outlet. Alert
device worn on pendant, wrist strap, belt clip. Alerts sent to
care center, follow up as required with personal contacts,
emergency responders.
http://linkmedicalalert.com
Depend One
(Depend One LLC)
Two-way voice pendant, optional belt or wrist adapter
available, base unit plugs into electrical outlet. 600-foot range.
30-hour battery backup; automatically recharges when power
restored. Optional house key lockbox for emergency
responders.
https://www.dependone.com/
eCare+Voice
(Spectraforce
Technologies)
Phone with GPS and cellular technologies - used for
emergency assistance in home and outdoors. SOS button
connects 24/7 to Secureus care center via two-way voice
communication. Person's location shown on Internet map.
Cord-free charging available. User receives low battery alert.
http://ecaregps.com
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Freedom Alert2
System
(EmoryDay LLC)
Pendant- or belt-style alert unit, base station. Device connects
with existing phone, mounts on wall or worn as pendant. No
monitoring center - one of four contacts notified. (or 911 when
none available). 600-foot range, long-life battery.
https://www.freedomalert-911.com/
GoSafe
(Philips Heatlhcare)
Uses a suite of locating technologies - GPS, wi-fi locating,
audio beacon, cell tower triangulation, in-home
communication for poor cell reception. Two-way cellular
voice communication, fall detection capabilities. Can go a
week between charges.
http://philipslifelinegosafe.com/new
Guardian Alert911
(EmoryDay LLC)
Pendant or belt clip alert device, base station plugs into phone
jack. Two-way voice communication to 911.
https://www.guardianalert-911.com/?x=bab
Life Alert
Product Suite
(Life Alert)
Life Alert Medical Alarm - pendant- and wristwatch-style alert
units for medical problems and/or intruders.
Emergency Phone Help - small cellphone alert unit with GPS
for contacting the help center from anywhere in the U.S.
Phone never needs charging, battery lasts 10 years.
User Cell/Smartphone Emergency Protection - user's current
cellphone can be set up for speed dial to help center. App
provided for smartphone to reach center.
Fire, CO2 Protection - Company can also provide special
detectors that contact help center if they sense fire and/or CO2;
center talks with user or contacts emergency services if no
response.
http://www.lifealert.com/
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Life Alert 50+ Full Protection - package provides all of the
above services.
Life Station
Medical Alert
System
(Medical Alert)
Pendant or wristwatch-style units for emergency response.
User files a personal action plan with care center. Pressing
unit button contacts center; center follows plan for making
contacts when user unresponsive. Caregivers receive
automatic alerts. 400-foot range. Automatic weekly testing.
Base unit has speakerphone feature.
http://www.lifestation.com
Lifecomm
(Verizon Telematics)
One of the earliest mobile emergency response devices with a
wide range of features. Originally developed/marketed by
Hughes Telematics, recently purchased by Verizon, will
relaunch later in 2013 (features to be determined).
http://lifecomm.com
LifeGuardian
Medical Alarm
System
(LifeGuardian
Technologies, LLC)
GPS-enabled cellphone and fall detector device. One-button
press to contact care center. Four programmed speed-dial
numbers, volume adjust. Phone book takes up to 20 entries.
Emergency data kept on file; center notifies contacts chosen to
receive alerts. For emergencies when traveling, center uses
proprietary GPS-based directory to send assistance to person's
location. Pre-approved family/caregivers contact center to
locate family member. Also provides non-emergency
concierge-type service.
http://www.lifeguardianmedicalalarms.com/
Lifeline Medical
Alert
(Philips Healthcare)
Pendant- or wristwatch-style alert device. Standard
CareParnter Communicator base unit works with land line
phones, 15-hour backup battery. Also a cordless Phone
Communicator base unit with easy-to-press buttons, high-
contrast screen. Standard model provides basic access to care
center help; AutoAlert also incorporates fall detection
http://philips.lifelinesystem.com/
content/home
123
technology. Can link with Philips Medication Dispenser.
LifeLink Prodigy
Medical Alarm
System
(Matrix Interactive
LLC)
Pendant-style alert unit (wristwatch-style coming in 2013),
two-way communication through base unit - goes through call
list when activated, pressing panic button three times calls 911.
300-foot range.
http://www.lifelinkmedicalalert.com
LifeStation
(LifeStation Inc.)
Pendant- and bracelet-style alert unit (extra available for
additional resident). Base unit plugs into electric outlet and
phone jack. Care center staff responds to alert requests. 400-
foot range. Automatic weekly testing, battery backup.
Optional house key lockbox for emergency responders, extra
wall-mount buttons for bathroom, hallway.
http://www.lifestation.com
Lifestream
MobileHelp
(Honeywell
HomeMed)
Emergency response system using cellular and GPS locational
technologies. Alerts received by care center that follows up
with user, emergency personnel as required. Can integrate with
Honeywell Lifestream Solutions System.
http://www.hommed.com/lifestream-
products/mobilehelp/
Lifetrac Mobile
(Secura Trac)
GPS locator phone worn on pendant, belt, in pocket. Alerts go
to contacts chosen, 911. When SecuraFence electronic
boundary ("geoperimeter") set, alerts sent when person
crosses. Phone stores contacts/phone numbers, has three
programmable speed-dial numbers. Personalized website
provides satellite map when tracking, historical data.
http://www.lifetrak.com
Link to Life
Detection Suite
(Fall Detection
Systems)
Fall Detection System - pendant-style alert unit, base unit.
Care center receives alerts; center contacts user, designated
caregiver or emergency services for follow up. Options
include intrusion detection, inactivity monitoring, lockbox for
http://www.falldetectionsystems.
com/index.html
124
house key for emergency personnel.
Personal Emergency Response System - pendant-style alert
unit, base unit controls in Braille. Base can receive alerts from
up to 16 alert units, contacts care center for follow up
Cellular Medical Alert - system uses cellular network - no
phone land line needed for console unit (which mounts on wall
or desktop). Wireless button alert device, two-way voice
system with care center. 24 wireless zones, four wireless keys.
85 dB sounder with voice siren. Voice-prompt programming,
family message center records/plays back voice messages.
http://www.personalemergencyresponse.com/
http://www.cellularmedicalalertsystems.com/
Medical Alert
System, Digi Alert
(VRI)
Medical Alert model for phone with land line service, Digi
Alert model designed for use with digital phone service or
VOIP (voice over Internet protocol). Pendant alert device -
when activated, care center contacts to check on assistance
needed. Care center alerted when battery low. Compatible
with VRI Automatic Fall Detection device. 600- to 800-foot
range.
http://monitoringcare.com
Medical Home
Alert System,
MobileAlert
(Medical Alert
Systems by Connect
America)
In-home and mobile models for emergency response. In-home
has base unit with two-way voice and speakerphone capability,
backup battery, delayed silent alarm feature, Braille characters
on important buttons. MobileAlert model uses GPS
technology. For both, call center contacted when button
pushed, sends assistance needed - family, emergency services,
etc.
http://www.medicalalert.com/
MediPendant
(MediPendant)
Pendant-, belt clip-, wristwatch-style alert device for
contacting care center staff. 600-foot range. Staff have
http://www.medipendant.com/
125
emergency medical technician certification. 30-hour backup.
MobileCare
Monitor
(AFrame Digital,
Inc.)
Wristwatch-style unit for emergency alert to care center, auto
fall detection (also monitors gait), notes when device isn't
being worn. Data can be combined with vital signs data
obtained via wireless peripheral devices. Care center alerts
sent to designated caregivers via smart devices, can be viewed
on Web site. Can integrate with electronic door locks.
Medications logging/reminders.
http://www.aframedigital.com/
MobileHelp
(MobileHelp)
Wristwatch- or pendant-style unit. Three system models, use
wireless cellular, GPS, so user can summon help anywhere.
Classic model is for in-home use. Solo model is for home use
when phone line isn't available. Duo model is for when phone
line available and for when mobile (with GPS). Honeywell
HomeMed product - device integrates with other products in
the company's Lifestream Management Suite.
http://mobilehelpnow.com
Numera Libris
(Numera, Inc.)
System integrates mobile emergency response, two-way voice,
automatic fall detection, GPS location tracking. Libris also
connects with Numera Net computer platform to accept vital
signs data from a range of vendors' wireless health devices,
can then forward to family, professionals, etc.
http://numera.com
Nurse Alert
(Nurse Alert, Inc.)
24-hour emergency nursing service, accessed via app for
Apple, Android, Blackberry smart devices. Provides 24/7
Nurse Triage Call Center service wherever user is located.
http://www.nurse-alert.com
QMedic
(QMedic)
Wristwatch-style unit for emergency monitoring - base unit
connects to phone line. Call center available 24/7 at button
press. Alert sent to Apple or Android smart devices for
http://www.qmedichealth.com
126
abnormal health activity. 800- to 1,000-foot range. No device
battery charging - one-year battery life, company monitors.
Alert given when not worn.
Ready Response
Medical Alert
System
(Walgreens)
Pendant- or wristwatch-style alert unit, base with two-way
voice capacity. 24-hour battery backup, 24/7 care center.
Additional alert unit provided for bathroom. Auto reset after
activation.
http://www.walgreensreadyresponse.
com/index.php
Rescue Alert Med
Alert
(Rescue Alert)
Pendant- and wristwatch-style alert unit, two base unit models
- standard for phone line, advanced for cable- and Internet-
based phone service. Periodic testing. Both have two-way
voice, 600-foot range. Standard base has 60-hour backup
battery, advanced unit has 90-hour.
http://www.rescuealert.com
ResponseLINK
Medical Alert
System
(Response Link)
Pendant- or bracelet-style alert unit, base has emergency and
general help buttons for contacting care center, speed dial for
programmed phone numbers. 24-hour backup battery, care
center notified of low charge. Adjustable volume control,
programmable reminders.
http://www.responselink.com/
Senior Safety
(American Senior
Safety Agency)
Pendant- and wristwatch-style alert unit, two systems. Basic
alert system has two-way voice in the base, 24-hour backup
battery, auto notification for low batteries 300- to 400-foot
range. Advanced system has 600-foot range, 60-hour backup
battery, compatible with all home phone service, family check-
in capability through speakers, can answer telephone with
"help" button, care staff trained as emergency technicians.
http://www.seniorsafety.com/)
SenseAFall
(24eight)
Device worn like a pager, automatically senses for falls,
connects to care center for follow up. Uses cellular
http://www.24eight.com/products.html
127
triangulation and GPS to locate user, creates computer map.
Usable in home and outdoors. Battery lasts five-seven days
between charges, gives low battery alert.
Sonitor
Technologies
(Sonitor
Technologies, Inc.)
Device uses ultrasound - technology now used for hospital
patient tracking. Wristwatch-style unit sends positional signal
via wi-fi every 15 seconds care center. Center monitors
measurements and only sends relevant data if help needed.
Alarms triggered by fall, irregular movement patterns, lack of
movement, resident sending alert.
http://www.sonitor.com
SureResponse
(Verizon)
Pendant-, wristwatch- and/or belt clip-style mobile system
using GPS for location. Backup telephone cable also provided
for when within range of the home docking station (to
conserve battery). Pressing alert button connects with care
center, staff contacts family, other caregivers. SureResponse
Online Internet portal used to manage user profile/alerts and
set up authorized caregivers.
https://wbillpay.verizonwireless.com/vzw/nos
/safeguards/SafeguardProduct Details.
action?productName=sureresponse&
intcmp=INT-MVZ-VNT-SURERESPONSE
Telecare/PERS
Solution
(Tunstall Healthcare)
Device for emergency/fall alert, Vi base unit receives
signal/sends to VoiceCare response line, staff determines
appropriate follow up.
http://americas.tunstall.com/pages/Telecare-
PERS
128
5) HEARING - EQUIPMENT
Product/vendor
Characteristics, features
Web address
Lifetone HL
Bedside Fire
Alarm
(Lifetone
Technology, Inc.)
Plug-in designed to provide specialized fire alert for persons with
hearing impairments. Works in conjunction with standard (T3)
fire alarms - continually monitoring, when heard, HL unit sends
three signals - flashing text on device screen, 90dB alarm at a
special frequency and vibrating bed shaker. Battery backup.
Easy-to-read display, can also be used as a daily alarm clock. .
http://lifetonesafety.com
5) HEARING - SMART DEVICE APPS
BioAid
(University of
Essex, UK)
Uses phone's audio feed from built-in microphone, amplifies and
plays through headphones. Amplifies soft sound, de-amplifies
loud ones. Also permits users to save profiles for amplification
needed in different settings (e.g., TV, restaurant). For Apple
devices.
https://itunes.apple.com/us/app/bioaid/id577
764716?mt=8
Hearing Aid
(TiAu Engineering
UG)
Low-medium-high frequency sound equalizer, noise canceling
capabilities. Works with devices following Bluetooth wireless
standards and plugged-in headphones. For Apple devices.
https://itunes.apple.com/us/app/hearing-aid-
free/id465924798?mt=8
HearingAmp
(Medicom Corp.)
User can amplify/filter sounds in environment - uses phone's
microphone to tune sounds. Preset frequency profiles provided;
https://itunes.apple.com/us/app/hearingamp/
id536166856?mt=8
129
users can modify these or create new ones. For Apple devices.
Hearing Loss
Simulator
(Starkey
Laboratories)
User chooses prerecorded, common sounds to simulate specific
hearing losses; option available to record user's or another's voice
for playback through the different losses. Also includes graphics
on loudness/frequency of the common sounds, speech and
individual speech sounds. Compatible with Apple iPad.
https://itunes.apple.com/us/app/hearing-
loss-simulator/id398352094?mt=8
Hearing Test #1
(Aveos)
Tests ear sensitivity for 20 frequencies between 100 Hz and 17
KHz, compares the results. For Apple devices.
https://itunes.apple.com/us/app/hearing-test-
1/id350730542?mt=8
Hearing-Check
(RNID)
User listens to sounds, enters numbers with keypad, receives test
results at conclusion. Designed for checking age/noise hearing
loss. For Apple devices.
https://itunes.apple.com/us/app/hearing-
check/id485312957?mt=8
HearAmp
(PINTA-offbeat)
Provides capabilities of an assistive listening device - amplifies
sounds coming into phone's microphone using compression
amplification techniques. For Apple devices.
https://itunes.apple.com/us/app/hearamp/id4
86202363?mt=8
5) VISION - EQUIPMENT
Product/vendor
Characteristics, features
Web address
Extreme Reader
XR1
(Second Vision,
Scans text onto computer for magnification, variety of screen sizes
available. Can listen to DAISY-formatted books, play music CDs.
http://www.secondvisiononline.com/
extremereader.html
130
LLC)
Eye-Pal
(ABiSee, Inc.)
Lightweight, portable USB scanner/reader - converts print to
speech, text files or refreshable Braille. Works with both Mac and
PC computers.
http://www.abisee.com/
Intel Reader
(GE-Intel Care
Innovations)
Takes picture to convert text to speech - complete point-shoot-
listen device. Needs no additional equipment, networking, or
special software.
http://www.careinnovations.com/
products/intel-reader-
text-to-speech-technology
KNFB Reader
(K–NFB Reading
Technology, Inc.)
Mobile software - smart device user takes photo of print to be read.
Software employs character recognition for converting text to
speech for reading contents out loud. Also displays print on
device's screen and highlights words as spoken. For Nokia devices.
http://www.knfbreader.com
myVisionTrack
(Vital Arts and
Science)
Enables patients with retinal disease (diabetic retinopathy, macular
degeneration) to perform regular home self-screenings. Software
compares current to past results, physician automatically notified of
significant changes. Results also forwarded to patient's electronic
health record. Currently only cleared for prescription use -
manufacturer distributes preloaded on Apple iPhones.
Downloadable version of software to come.
http://myvisiontrack.com/myvisiontrack/
NetraG
(EyeNetra)
From MIT Media Lab research. Enables user to self-exam, get a
prescription, identify providers. Creating Internet site for patients,
doctors to connect worldwide via mobile app (Test2Connect).
http://eyenetra.com/
Optelec Clear
Reader+Basic (OptelecUS Inc.)
High-resolution camera takes picture of text, reads in high-quality
speech.
http://www.optelec.com/en_US/home
131
Optelec
ClearView
(OptelecUS Inc.)
Vendor carries a series of flat-screen devices that magnify materials
to various powers. High-contrast and photo viewing mode in some
models.
http://www.optelec.com/en_US/home
Optelec Compact
(OptelecUS Inc.)
Lightweight, video, hand-held, pad-style version of above
magnifying products for when mobile.
http://www.optelec.com/en_US/home
VictorReader
Stream
(Humanware)
Hand-held media player. Download documents and MP3s on
stream for reading/navigating. Has text-to-speech function for
reading in text format such as Bookshare. Integrated microphone
also available for recording notes.
http://www.humanware.com/microsite/str
eam/index.html
ZoomText 10
Magnifier
(aisquared)
Enlarges, enhances computer screen contents. ZoomText software
available that combines enlarging technology with reading tools so
user can see/hear program actions, record on mobile device, focus
in on specific text zones. ZoomText Keyboard also sold with large,
easy-to-read keys and a number of keys controlling ZoomText
functions.
http://www.aisquared.com
5) VISION - SMART DEVICE APPS
Product/vendor
Characteristics, features
Web address
Vision Aid
(Action!)
Supports mobile users with reading difficulties or low vision via
main smartphone functions - call, write e-mails or text messages,
checking phonebook. Functions to come include: calculator,
calendar, optical character recognition, magnifying glass, text
editor. For Apple devices.
https://itunes.apple.com/us/app/vision-
aid/id632709230?mt=8
132
VisionAssist
(Slinkyware - IP
Holdings, Ltd.)
Converts smart device into hand-held electronic magnifier.
Designed for persons with low vision from macular degeneration,
glaucoma, diabetic retinopathy, cataracts, color blindness. Can
connect with Apple devices, big-screen TV or computer monitor
for enlarged viewing.
https://itunes.apple.com/us/app/
visionassist/id502356279?mt=8
VisionSim
(Braille Institute)
Developed so persons with normal vision can experience nine
degenerative eye conditions - age-related macular degeneration,
cataracts, chronic open-angle glaucoma, corneal edema, diabetic
retinopathy, homonymous hemianopia, macular degeneration,
retinal detachment, retinitis pigmentosa. Severity can be
manipulated, still images can be saved/shared. Also provides
background on the conditions. For Apple devices.
https://itunes.apple.com/us/app/visionsim-
by-braille-institute/id525114829?mt=8
133
6) MEDICATION ADHERENCE/MANAGEMENT - EQUIPMENT
Product, vendor
Characteristics, features
Web address
AdhereTech
(Adhere Tech, Inc.)
Cellular connection in unit vs. cap or bottom attachment.
Wireless pill bottle continuously measures exact number of
pills in bottle (check for accidental overdose), use monitored
by care center, uses text message or automated phone call to
give reminders. Company can offer computer program
interface to other vendors for customization.
http://www.adheretech.com
Dispense-a-Pill
(HealthOneMed)
Dispensing/storage/monitoring. Unit can store up to 90-day
supply of eight medications. Built-in alarm, low pill supply
warning. Phone call alerts for missed dosage. Battery backup.
http://www.healthonemed.com/
category_s/46.htm
EMMA
(InRange System)
"Electronic Medication Management." Modeled after skilled
nursing medication dispensing process. Dosing instructions
sent from facility's server to EMMA unit at home. Audio/
video alert at dose time, patient activates. Doses can be
adjusted remotely, new medications sent by mail. Produces
reports for caregivers.
http://www.inrangesystems.com/#1
Beep 'n Tell
(ePill, LLC)
Bottle with multiple reminder alarms, chip for recording
prescription information. Times chosen between doses,
replacing cap resets alarm. Personal message (e.g., from
caregiver) can be entered and played back as needed.
http://www.epill.com
134
ePill CADEX Alarm
and Medical
ID Databank
(ePill, LLC)
Wristwatch-style reminder. Can program up to 12 beeping
sound reminders, including text message on display with
medication name/strength, other instructions. Databank
stores important health information - name, phone number,
diagnoses, allergic reactions, emergency contacts, list of
medications, blood type, doctor/insurance information.
http://epill.com
GlowCap, GlowPack
(AT&T Vitality)
Wi-fi-enabled medication containers - GlowCap is a
medication bottle; GlowPack for blister packs, inhalers,
injection solutions, ointments, etc. Dosing schedule entered
with care center, glow or sound emitted when should be taken.
Message sent to care center when opened for adherence
tracking. Flashing light, ring tone or call to user's phone
provided for missed dose. Pressing special button on unit
connects with pharmacist for reorders. Physician reporting
also provided.
http://www.vitality.net
Med eMonitor
System
( InforMedix)
Unit for storing/monitoring medications and providing
information on protocol to follow. Five electronically
monitored compartments - when lid lifted, action time/date
stamped to create journal. When unit placed in cradle, data
uploaded to monitoring center.
http://www.informedix.com
MedFolio Pillbox
(MedFolio)
Storage/dispensing unit, designed by pharmacist. Stores and
identifies medications, can be transported. Audio, visual, text
reminders, remote adherence tracking via company computer
site.
http://www.medfoliopillbox.com
MEDGlider
MedPort System
(ePill, LLC)
Container for organizing a week of medications. Provides up
to four daily reminders by voice, sound or light, large display.
Reminder unit slides on container top.
http://www.epill.com
135
Med-ic eCAP
Monitor
(Mediary Corp.)
Bottle cap records when bottle opened. Unit also available
with optional beeping/flashing reminder feature and optional
room temperature monitor.
http://informationmediary.com/ecap/
Medication
Dispensing Service
(Philips Healthcare)
Storage/dispensing/monitoring unit. Support center programs
dispensing schedule, caregiver or patient fills multi-day, multi-
dose cups. Caregiver alerts when dose missed, at refill time.
Connects to user's phone line.
http://www.managemypills.com/content/
MedMinder
(MedMinder Inc.)
Storage/dispensing/monitoring unit. Can store for taking up to
four times a day over seven-day period (or if one daily dose,
stores for 28 days). Container cups hold 10-12 pills, trays can
be prefilled by pharmacist or caregiver. "Maya" unit
unlocked, "Jon" unit locked (overdose guard). Cellular
modem connects with care center - usable even without phone
or Internet connection. Range of reminders - light, then
musical tone, then phone call. Can notify multiple caregivers
on adherence, provide with adherence reports, or can log into
online system for records.
http://www.medminder.com
MeDose
(ePill, LLC)
Wristwatch-style unit uses vibration or sound to provide up to
six daily reminders, can count down/count up, auto reset
interval timer, auto calendar.
http://www.epill.com/medos.html
MedPartner
Medication
Reminder
(Honeywell
HomeMeds)
Plugs into outlet, has battery backup. Provides voice
instructions and visual cues to alert user when to take
medications, number of pills, correct bottle.
http:///www.hommed.com
136
MedReady
(MedReady, Inc.)
Carousel-style storage/dispensing/monitoring unit. Models
have different types of alerts - one sends daily compliance via
the Internet, flashing light for those with hearing impairments.
Models connect with care center via phone line, cellular.
http://www.medreadyinc.net
MedSignals
(LIFETECHniques)
Storage/dispensing/monitoring unit, sits in cradle connected to
phone and electric outlet. Differs from most - stores each
medication in separate compartment vs. each day's dose/s.
Electronic voice advises number of pills to take from container
with lighted indicator. Provides alerts when medications
should be taken, records time when lid opened, uploads to
company's server, charts tracking patient and caregivers
available.
http://www.medsignals.com
MedSmart
(AMAC)
Storage/dispensing/monitoring. Locked unit provides up to
six daily reminders. Monitoring by phone, e-mail, text. Care
center reporting to caregivers, other parties. Compliance
Dashboard chart shows adherence over time.
http://www.amac.com/medsmart.cfm
Ontime Rx
(AmeliaPlex, Inc.)
Text screen device that alerts when medication dose
scheduled, displays drug name/dosage/prescribed directions,
reminders for refills and other health tasks.
http://www.ontimerx.com
PillStation
(Senticare)
Storage/dispensing/monitoring unit. Photo shot as medication
taken to confirm, document correctness. Customized
reminders via pill bin lights. Glow on unit indicates if taken
as required. 24/7 button for contacting call center. Works
with wired/wireless connections.
http://www.senticare.com
Proteus
(Proteus Biomedical)
First microchipped (sand grain size) pill approved by FDA.
Taken with other medications to show adherence. Stomach
http://proteusdigitalhealth.com
137
acid creates current to operate - data broadcast to adhesive-
backed skin patch that sends to smart device or via Web to
doctor. Ingestion day/time as well as heart rate, temperature
and body position recorded.
Rx Timer Cap
(Rx Timer Cap, Inc.)
Pill bottle with digital timer on cap shows how long since the
medication was taken last.
http://www.rxtimercap.com/
SimpleMed
(Vaica USA)
Unit that organizes, reminds, dispenses, tracks. Connects to
phone line, notification by text, e-mail or talking with call
center staff. Simple MedII combines the unit and personal
emergency response function.
http://www.vaica-usa.com
TabSafe
(Tab Safe Medical
Services, Inc.)
Medication storage/dispensing/monitoring unit. Cartridges
prefilled by pharmacist with medications, can be stacked as
many as four high and locked inside dispenser cabinet.
Medications dispensed in varying combinations at set times of
day. Physician and pharmacist can make changes remotely
through phone line. Remote caregiver/family notified by
phone line if doses missed.
http://www.tabsafe.com
Talking Rx
(Talking Rx, Inc.)
Device with maximum 60-second voice recording capacity
attaches to standard pill bottle. Records medication name and
other helpful information, instructions by caregiver or
pharmacist that can be accessed at any time by pressing
special button. New message recorded each time prescription
refilled. 85dB playback for persons with hearing impairments.
http://www.talkingrx.com/
uBox
(Abiogenix)
Storage/dispensing unit - can remain unlocked or locked until
time for dose. Spinning carousel connects to smart device
app with schedules, calendar, ability to notify family/caregiver
http://my-ubox.com
138
network if dose/s missed.
WatchMinder 2
(Watchminder)
Wristwatch-style unit alerts user to take medications, check an
appliance or perform a certain procedure (e.g., change wound
dressing). Memory has series of health-related reminders that
can be incorporated - e.g., time to do exercises.
http://watchminder.com/
6) MEDICATION ADHERENCE/MANAGEMENT - SMART DEVICE APPS
Product, vendor
Characteristics, features
Web address
Care4Today Mobile
Health Manager
(Jannsen Research and
Development, LLC)
Secure website and app that enables user to store vital
information and receive medication reminders, refill
prescriptions, set up provider appointments, store important
medical contact information. For Apple devices.
https://itunes.apple.com/us/app/care4today-
mhm/id594525004?mt=8
Medication Tracker
(Vikas Kumar)
Track up to four medications at one time. Stores unlimited
family history. Statistics screen with daily-to-yearly averages,
totals.
https://itunes.apple.com/us/app/medication-
tracker/id305661888?mt=8
MediSafe
Virtual Pillbox
(MediSafe Project)
System for promoting adherence. Reminders received on
smart device via app, user enters response when medication
taken. Gradated prompts if not - soft/loud alarm, care network
member/s notified. For Apple and Android devices. Also
available via automated phone system for those without a
smart device - patient records use by touch tone, caregivers
receive phone alerts for missed doses. Part of compliance
"MediSafe Project."
https://itunes.apple.com/us/app/medisafe-
family-edition-
medication/id573916946?mt=8
https://play.google.com/store/apps/
details?id=com.medisafe.android.client&hl=
en
139
Personal Caregiver
(Personal
Caregiver, Inc.)
Assists in tracking medications/reminders for up to three
people. Refill reminders based on usage, alerts for missed
doses. Database with 17,000+ medications. Premium version
includes FDA recall alerts, more detailed medication
information.
http://www.personalcaregiver.com/
Pilljogger,
MedWheel
(Pilljogger)
Device and app for med tracking, reminders. MedWheel is
carrying case designed for back of smartphone - coordinates
with Pilljogger app to show compliance. For Apple devices.
http://www.pilljogger.com
Prescription
Manager
(RexXoft LLC)
Maintains prescription information to help with management.
Can enter doctor/pharmacy contacts. Calculates refill needs.
https://itunes.apple.com/us/app/
prescriptionmanager/id413750919?mt=8
Prescription Pill
Identifier
(Mobile-Pills)
Database with over 10,000 drugs. Identifies through color,
shape, imprints; provides brief background.
https://itunes.apple.com/us/app/prescription-
pill-identifier/id625676662?mt=8
140
7) PHYSICAL FUNCTIONING - EQUIPMENT
Product/vendor
Characteristics, features
Web address
Accusom Deliver
(NovaSom)
FDA-cleared home testing kit for obstructive sleep apnea,
specialists at company website access/analyze data. Sleep
specialists can order home test through company, which ships
device to patient; staff helps patient through process involves
measuring overnight 12 physical/neurologic factors.
http://www.novasom.com/hst-order.htm
Jintronix
Rehabilitation
System
(Jintronix, Inc.)
Uses Microsoft Kinect to give patients immediate follow up,
measures range of motion and other functions, monitors rehab
progress, prescribes new/customized activities.
http://jimtronix.com
Lark Pro
(Lark)
Provides sleep coaching - learn sleep type, seven-day sleep
assessment, sleep profile developed over time. Provides sleep
actigraphy tracking (used by sleep clinics to track activity and
how much time slept), sleep data summary. Has silent
vibration alarm clock with audio backup. (Original product of
the National Sleep Foundation.)
http://lark.com
LifeGait
(MiniSun)
Palm-sized device performs gait analysis in many settings.
Detects over 40 types of physical activity/postures, records
amount/intensity/type of body motion, provides 17 gait
measures, analyzes behavior, plays back video clips of daily
activities, provides ECG reading, estimates energy
http://www.minisun.com/ideea_overview.asp
141
expenditure.
MIRA
(MIRA Rehab, Ltd.)
Uses Microsoft Kinect to make home physical therapy
exercises into medical video games. Provides therapist with
performance data (e.g., range of motion, level of objective
reached), limb/body angle measurements that otherwise would
require direct contact for measurement. Can help therapist
with rehab scheduling, working with multiple clients.
http://www.mirarehab.com
Nova Som HST
( Nova Som)
Home Sleep Test product for obstructive sleep apnea, uses
chest, finger and breath sensors. Sends gathered data via
smartphone for same-day diagnosis. Company mails system
directly to user on doctor's order.
http://novasom.com
Rehab Measurement
Tool
(Reflexion Health,
Inc.)
Uses Microsoft's Kinect to track patient's therapy adherence.
Online instructional videos and resource materials available.
Software instructs patient on exercises through animations and
measures if done correctly. Therapists can prescribe
preloaded exercises or design individually.
http://reflexionhealth.com
SleepTrak
(iMPak Health)
Uses credit card-sized near-field communication (NFC) device
worn on arm cuff. (NFC allows electronic devices to establish
radio communication by touching or coming close together.)
Transmits data to user's computer for self-tracking, can pair
with NFC-enabled smart devices.
http://impakhealth.wordpress.
com/about/
Smart Bed System
(BAM Laboratories)
Multi-function self-inflatable monitoring pad device placed
under mattress. Measures wakefulness, in/out of bed, body
position, along with various vital signs measures. Data
transmitted to company's cloud platform for analysis. Can be
http://bamlabs.com/products/
142
viewed on PC or mobile devices, or integrated into electronic
health records.
SleepMapper
(Philips Respironics)
Continuous positive airway pressure (CPAP) product transmits
data to healthcare providers who check in with patients at
home, adjust equipment and modify therapy. Philips now
making data available to patients to help with compliance. For
Apple and Android products.
http://www.sleepmapper.com/
7) PHYSICAL FUNCTIONING - WEB SITES, SMART DEVICE APPS
Product/vendor
Characteristics, features
Web address
Prime Wellness
(Prime Wellness)
Online program creates exercise regimen helping older adults
to avoid falls. Taught by physical therapist.
http://primewellness.com
RehabMinder
Therapy Assistant
(Rehab Minder Pty
Ltd)
Hand and upper limb exercise database that can be animated.
Can create an existing hand therapy program on the device or
create with therapist; who can review on device as
rehabilitation progresses. Injury profile prepared for specific
body part and exercises matched to it; can create multiple
profiles. Glossary of terms, helpful resource materials
available.
https://itunes.apple.com/us/app/rehab-
minder-therapy-assistant/id647025352?mt=8
Theravid
(Theravid, Inc.)
Injury rehabilitation website. Online portal provides access to
physical and occupational therapists, orthopedic surgeons,
primary care doctors, chiropractors and trainers - professionals
develop individualized program, send workout reminders.
http://www.theravid.com
143
Secure messaging system.
144
8) ROBOTICS - EQUIPMENT
Product/vendor
Characteristics, features
Web address
Ava
(iRobot - US)
Robot independently navigates, many brands of computer
tablet devices can be used for head. Voice-based interaction
- speech recognition, text to speech. Adjustable-height
torso. User connects via touch, voice, gesture, following
person. Software designers can program it on tablet devices.
http://www.irobot.com/en/us/cool_stuff/Researc
h/
Human-Robot_Interaction.aspx
Bestic
(Robotdalen)
Eating robot for those who can't pick up/use utensils.
Product now available in Europe/Sweden and 2012 clinical
trials in U.S.
http://www.robotdalen.se/en/Projects/Bestic---
a-feeding-robot/
Carebot
(Gecko Systems -
US)
Family care and personal assistance robot. Answers
questions, helps with daily living activities, provides
reminders. Video enables virtual visits between user and
circle of support. Provides emergency notifications.
Technology transfer to wheelchairs -CyberMobility.
http://www.geckosystems.com
Double Robotics
(Double Robotics -
US)
"Wheels for the iPad." Puts an Apple iPad on adjustable
shaft and wheels to enable flexible movement for
teleconferencing, telecommunications. Weighs 15 pounds.
Control can be coordinated for multiple Double units in any
locations. Shaft can adjust Pad in approximately four- to
five-foot range.
http://www.doublerobotics.com/
145
GiraffPlus
(Orebro University,
Sweden)
Robot developed by team of European researchers with
Swedish lead. Monitors vital signs, sleep patterns, basic
activities interacts with care user. In final clinical trials.
http://www.giraffplus.eu
Hector
(CompanionAble
Consortium)
Robot developed by team involving University of Reading
(UK) and European partners. Responds to voice activation,
keeps daily routines, provides reminders, detects falls, assists
remote control center. Final clinical trials in 2012.
http://www.companionable.net
Helios
(Hello Labs - US)
Portable telepresence robot and app using Apple and
Android smartphones. Only need Web browser, connection.
Turn on app, put phone in device, remote user takes control
of device. Remote input sent with their video feed as screen
markers, Helios sensors interpret as commands. Software
developers can also develop targeted programming.
http://launch.hellolabs.co
Kompai
(Robosoft
Technologies Pvt.
Ltd. - France)
Social companion robot developed for "MobiServ,"
European sensor-based research consortium care project.
Talks, understands speech, navigate independently.
Provides reminders, keeps track of tasks, plays music,
monitors sleep, falls, water intake. Video enables virtual
visits with remote parties - family/friends, doctors, other
medical personnel. In final clinical trials.
http://www.robosoft.com
http://www.mobiserv.eu
vGo
(vGo - US)
Robot do various types of examinations, enable telepresence
exchange between user and remote parties via wi-fi. (e.g.,
now being used to connect sick children with teachers,
classmates). Remote control center computer adjusts tilt and
camera zoom. Four feet tall, weighs 18 lbs.
http://www.vgocom.com
146
9) VITAL SIGNS MONITORING - EQUIPMENT
Product/vendor
Features
Web address
Ambio Remote
Health Monitoring
System
(Ambio Health)
Multi-function system tracking vital signs and activity/safety.
System sells vital signs monitoring peripherals that
automatically record/store readings on company's computer
server where users can view results, print, etc. Family
members can log in to check person's status. Care center
sends reminder messages for readings and/or if missed.
http://ambiohealth.com
BAM TLC Smart
Bed System
(BAM Laboratories)
BAM - Body and Motion; TLC - Touch-free Life Care. Pad
device placed under bed mattress pad, tracks heart
conditions/data - e.g., rate, breathing, motion/ movements/
position change, presence in bed. Company's computer
server evaluates data, packages into reports, resource
materials. Gives immediate motion and bed exit alerts to
minimize falls. Care personnel receive timely data via
computer or mobile smart device.
http://www.bamlabs.com
Cardiocom Suite
(Cardiocom)
Multi-function care system. LinkView component has touch
screen base, interactive video, measures vital signs.
"Attentiv" component has personal emergency response and
around-the-clock health monitoring. NetResponse Web
system for daily health checks, education, receives vital signs
data from any Internet-enabled smart device or computer.
TeleResponse is system for daily health checks, education
and vital signs data entry for those who only have telephone.
http:www.cardiocom.com
147
CardioNet MCOT (CardioNet)
Company provides mobile cardiac telemetry - patient's sensor
sends passive wireless message on abnormal heart beats.
MCOT model can receive video support, interface can
enables communicating in multiple languages. Up to 30 days
of continuous monitoring and data storage, provides video
support.
https://www.cardionet.com/index.htm
Care Innovations
Guide
(Intel-GE Care
Innovations )
In-home care management touch screen device/application,
connects with desktop computers, notebooks, tablets.
Supports videoconferencing, a range of vital signs monitoring
equipment, patient-specific educational content. Care
personnel notified if data or user's answers to daily queries
indicate serious changes.
http://www.careinnovations.com/
products/guide-disease-
management#/homeapp_t
Gensis Touch,
Genesis DM
(Honeywell Home
Med)
Touch screen model gathers vital signs information, transmits
to Honeywell's Lifestream Management Suite for care staff
assessment/follow up as required. Also can provide
education and videos. Genesis DM console model provides
disease-specific assistance through guided screenings, related
educational materials.
http://homemed.com
GrandCare
(GrandCare
Systems)
Multi-function system. Seniors relay vital signs data, track
medication schedule and movements around home on Web-
based touch screen. System uses 28-compartment automatic
medication dispensing/storage unit that can provide reminders
with instructions, prompts if not taken (records when
opened/closed). System also has personal emergency
response component, social connections - music, photos,
messages, Skype video.
http://www.grandcare.com
148
Health Buddy
System
(Bosch Healthcare)
Healthcare provider daily sets up T400 model console unit to
receive monitoring session - gathers vital signs (using a range
of vendors' wireless equipment or entered by user), reviews
symptoms, completes standard assessment surveys, receives
behavior reinforcement education materials. Completed
session forwarded to healthcare provider for review/follow
up; new session developed/sent for the next day.
http://www.bosch-telehealth.com/en/us/
products/health_buddy/health_buddy.html
Health e-Care
System,
Healthy e-Chair
(Commwell
Medical)
Audiovisual patient monitoring system that tracks vital signs.
Oversees patient’s food and medication intake, provides
immediate online help for emergencies. Manages patient
electronic health record. Company also carries patented
"Healthy e-Chair" - contains sensors for monitoring a range
of vital signs. Controlled remotely by care center.
http://www.commwellmedical.com/
index.php?option=com_content&view=
frontpage&Itemid=1
Healthyanywhere
(Biosign
Technologies)
Health-at-Home system has touch screen base unit and
peripheral devices that gather data on various vital signs.
Also provides access to educational/nutritional content,
information exchange between patients and providers.
http://www.biosign.com/healthanywhere.aspx
Ideal Life
(Ideal Life)
Range of vital signs monitoring devices that communicate
through base unit (Pod) - Gluco-Manager (blood sugar), BP
(blood pressure)-Manager, Body-Manager (scale), Step-
Manager (pedometer), Body-Manager Plus (chair scale),
Breath-Manager (respiratory peak flow meter). Partnership
in 2013 with ADT to integrate into its "Pulse" system for
home security monitoring option.
http://www.ideallifeonline.com
Independa Suite
(Independa, Inc.)
Multi-function monitoring support system. "Artemis"
component monitors range of vital signs. "Angela"
http://www.independa.com
149
component provides social engagement/caregiver interaction
via specially adapted LG televisions and Samsung Galaxy
tablet. (Messages appear over regular programming.)
Caregiver/user can video chat, exchange reminder notes, give
medication prompts, simple e-mail/Web browsing.
Lifeview
(American Telecare)
Physician-led clinical team uses remote monitoring
equipment to assess and provide frequent in-home patient
video interaction.
http://lifeviewtransforms.com
mymedic
(Tunstall Healthcare)
Desktop console unit where user receives daily prompt to take
vital signs (using a range of peripheral devices transmitting
by wireless, infrared, cable), data transmitted to care center
for analysis/follow up with user and doctor. Large color
display, soft-touch buttons.
http://americas.tunstall.com/pages/
Telehealth-Products
Numera Libris,
Numera Home Hub
(Numera, Inc.)
Multi-function system - integrates telehealth vital signs data
with emergency response service, locational tracking, auto
fall detection. Numera Libris telehealth component designed
to connect/obtain data from peripheral devices manufactured
by many vendors. Home Hub works with phone lines,
cellular mobile or broadband connections.
http://numera.com
PhysioGlove
(Commwell)
Glove-shaped unit fits over patient's/caregiver's hand and
takes electrocardiogram remotely, sends via smart device to
healthcare providers. Glove also can track a range of
additional vital signs.
http://www.commwell.com
SimplyHome
(SimplyHome)
Suite of products to promote independent living - console and
peripherals for monitoring blood pressure, oxygenation,
glucose, weight; medication dispenser, emergency response
http://simply-home.com
150
monitor, electronic controls for managing environment,
hand's-free headset.
Telehealth Advisor
(McKesson)
System includes Bosch Health Buddy console unit and two-
way communication of vital signs, educational and
compliance information between home and care provider.
http://www.mckesson.com/telehealth/
TeleStation
(Philip)
Core console unit for company's remote patient monitoring
system. Transmits vital signs (measured wirelessly or entered
manually), provides two-way communication between user
and care provider. Unit prompts user to answer customized
health survey questions.
http://www.healthcare.philips.com/
us_en/products/telehealth/
products/telestation.wpd
VitalPoint Home
Monitor
(CJPS Medical
Systems)
"H20 connectivity" - from user's Home 2 healthcare Office.
Desktop display unit for monitoring multiple vital signs.
Large touch screen, voice schedule reminder, messages from
healthcare providers, illustrations for taking vital signs
measurements and reporting symptoms. Operates via phone
line, Internet connection or cellular. Monitor can track more
than one user.
http://www.cjps.com/medicalsystems/
vitalpointhome/literature.php
Viterion V200 (Bayer-Panasonic)
Desktop console for taking a range of vital signs
measurements, data sent via Viterion TeleHealthcare Network
to company's server where healthcare personnel can access.
(Note: company sold in mid-2013; system status to be
determined.)
http://www.viterion.com/index.cfm
151
9) VITAL SIGNS MONITORING - SMART DEVICES, PERIPHERALS
Product/vendor
Features
Web address
Asthmapolis
(Propeller Health)
GPS-enabled inhaler and app, can track air, etc., conditions
that may affect/trigger an asthma attack.
http://www.asthmapolis.com
BGM Blood
Glucose Meter
(Telecare)
Cellular blood glucose meter - takes readings, sends to
company's computer server, two-way communication for user
and healthcare professional, can enter into electronic health
records. Don't need a cable or another smart device to use.
http://telecare.com
Blood Pressure
Dock
(IHealth Labs)
User's blood pressure monitor inserted into device to
measure/track pressure numbers, heart rate, pulse wave.
Results forwarded via Apple device to iHealth mobile app.
Dock doubles as smart device charging station.
http://www.ihealthlabs.com
Blood Pressure
Monitor (Withings)
Tracks, stores data, can e-mail to doctor. For Apple devices.
http://www.withings.com
ECG Check
(Cardiac Designs)
First FDA-cleared, over-the-counter heart electrocardiogram.
Wraps around smartphone, sends readings to phone, then to
company server or care provider. Readings displayed on
screen, stored/transmitted, checked by company. Provides
stoplight-color status. Can rapidly check for rhythm problems.
http://www.cardiacdesigns.com
152
e-Thermometer
(Kinsa Health)
Thermometer unit plugs into Apple device, operates using
phone's battery. http://www.kinsahealth.com
Genesis Meter
(Genesis Health
Technologies)
For testing blood sugar - blood drop placed on test strips
inserted into unit, readings display on unit and sent to user's
"myGHR" online account in company's computer server. Can
store up to 450 readings.
http://www.genesishealthtechnologies.
com/GenesisMeter.aspx
igBS Star
(AgaMatrix,
Sanofi)
Blood glucose meter that can be used independently or also
connects by app with Apple devices for displaying/
communicating data. Test strip inserted into device, blood
drop applied, reading display/stored.
http://www.ibgstar.us
iPhone ECG
(AliveCor)
First FDA-approved mobile heart electrocardiogram monitor -
currently by prescription for tracking (not diagnosis); over-the-
counter version coming in 2013.
http://www.alivecor.com
iSPO2
(Masimo)
Meter that plugs into smart device, measures blood perfusion
(how well capillaries transport), oxygen level, pulse.
http://www.masimo.com
Life Vest
(Zoll)
Wearable monitors for sudden cardiac arrest - shock delivered
if one occurs. Can use following a heart attack, before/after
bypass surgery or stent placement. Also suitable for patients
with certain heart conditions (e.g., cardiomyopathy or
congestive heart failure). Can also be used as temporary
safeguard while physician evaluates patient's long-term
risk/treatment plans.
http://lifevest.zoll.com
Meter Sync Cable
(Glooko)
Cable compatible with 20 standard blood pressure cuffs.
Records, tracks pressure reading, carbohydrate intake, insulin
http://www.glooko.com
153
dose. Can send results to doctor.
My GlucoHealth
(Entra Health
Systems)
Test strip inserted into device, results in three seconds. Data
sent to company computer server for analyzing/forwarding to
healthcare professionals. Reminders given on food intake,
medication adherence.
http://myglucohealth.net
New-Generation
Cane
(Fujitsu)
Device uses Bluetooth wireless standards, GPS, wi-fi, cellular
radio in handle. Tracks temperature, blood pressure, heart
rate readings.
http:// www.fujitsu.com
OneTouch
VerioSync System
(Life Scan)
Glucose monitoring device - data sent to app, sends to smart
device, alerts user if irregular patterns detected. 14-day
summary displayed, stores up to 2,500/one year of
events/results. Notes can be inserted to accompany readings.
For Apple devices.
http://www.onetouch.com/?utm_campaign=
Tier%201%20-%20Verio%20Sync&utm_
source=google&utm_medium=cpc&
utm_content=General%20EXACT&utm_term=
onetouch%20verio%20sync%20system
Scanflo
(Scanadu)
For analyzing urine. User buys disposable cartridge, software
tests for a number of conditions (e.g., pregnancy related,
kidney failure, urinary tract infection).
http://www.scanadu.com/scanflo
SCOUT
(Scanadu)
Device held to temple, provides range of vital signs in five
seconds- heart rate, breathing rate, blood pressure, heart
electrocardiogram, body temperature, blood oxygen level.
Data uploaded to computer application.
http://www.scanadu.com/scout
Smart Body
Analyzer
(Withings)
Tracks weight/body composition, heart rate, measures indoor
air quality, can provide weight goal coaching.
http://www.withings.com/en/bodyanalyzer
154
SmartSlipper,
SmartInsoles
(24Eight)
Shoe inserts that monitor foot pressure, gait, for fall detection. http://www.24eight.com/products.html
SureSense Rx
(Orpyx Medical
Technologies)
Shoe insole collects foot pressure data for persons with
diabetic neuropathy (excessive heel pressure, ulcers,
amputation risk). Transmits to wristwatch-style monitor or
smart device.
http://orpyx.com/pages/surrosense-rx
Tinke
(Zansorium)
Device plugs into Apple device ear jack for taking blood
oxygen reading. Finger placed on device, analyzes blood
vessels via light and infrared, sends to an app displaying
readings. Measures heart/respiratory rate, blood oxygen
level. Operates with phone's battery.
http://www.zensorium.com
uCheck
(Biosense
Technologies)
Urinalysis by cellphone for kidney, also possibly bladder and
liver problems. Takes photo of strip, compares to color grid,
reports results. For Apple products, Android version coming.
http://www.uchek.in
Wireless Blood
Pressure Monitor
(iHealth Labs)
User can track blood pressure numbers, heart rate, pulse wave;
share results with family or doctor, chart results, track daily
activity/diet.
http://ww.ihealthlabs.com
Wireless Body
Analysis
Scale
(iHealth Labs)
Measures, track nine body composition characteristics on
iHealth mobile app. Can be used on or offline. Logs daily
calorie intake. Unit can track data for up to 20 users.
http://www.ihealthlabs.com/wireless-body-
analysis-scale-feature_27.htm
Wireless Pulse
Oxymeter
Unit checks blood oxygen level and pulse rate. Can review
results on unit, organize records.
http://www.ihealthlabs.com/health-and-fitness-
products-wireless-wireless-pulse-oximeter_80.htm
155
(IHealth Labs)
Wrist Blood
Pressure Mointor
(iHealth Labs)
Unit wirelessly tracks readings, physical activity, daily diet.
Can share results with doctor, family, chart results
http://www.ihealthlabs.com
Wrist Ox2
Model 3150
(Nonin)
Fingertip device gathers blood oxygen data, sends to
wristwatch-style tracking unit. Transmits recorded readings to
user's computer or smart device. Unit can store 270 hours of
readings at one-second resolution for later analysis by
physician. Can be used with company software for walk, sleep
tests.
http://www.nonin.com
9) VITAL SIGNS MONITORING - SMART DEVICE APPS
Product/vendor
Features
Web address
AsthamSense
(iSonea Inc.)
Assesses symptoms, medication use, breathing data. Sets
reminders for taking medications and measurements. Tracks
data over time, can share with healthcare providers, stores
family emergency contacts/phone numbers. Review up to one
month of metering, symptoms and medication adherence. For
Apple and Android devices.
http://soundasthma.com/asthma-management-
application/
https://play.google.com/store/apps/details?id=c
om.ezasia.isonea&hl=en
Asthma Buddy
(Evolution 7)
By National Asthma Council of Australia. Provides
information on what to do in an emergency, how to
develop/follow a medication action plan. Stores emergency
https://itunes.apple.com/us/app/asthma-
buddy/id549409802?mt=8
156
contact information, has links for helpful resources on the
National Council's website. For Apple devices.
Asthma Journal
(iHealth Ventures
LLC)
Helps track/monitor triggers, medication effectiveness, patterns
over time. Charts, graphs profile data in various formats. User
can add notes, other materials. For Apple devices.
https://itunes.apple.com/us/app/asthma-journal-
iasthma/id320698258?mt=8
Asthma Journal
Free, Journal Pro
(Ringful LLC)
Daily journal with entries in questionnaire format, use to create
personal health profile. Also provides latest news on research,
prevention, treatment. For Apple devices.
https://itunes.apple.com/us/app/asthma-journal-
free/id330093663?mt=8
https://itunes.apple.com/us/app/asthma-journal-
pro/id321929833?mt=8
Asthma MD
(Mobile Breeze)
Keeps a journal, graphs trends to share with doctor, tracks
triggers. Interested users can submit data to participate in
asthma research project. For Apple devices.
https://itunes.apple.com/us/app/asthmamd/id34
9343083?mt=8
Asthma Puff
Counter
(WarSoft)
For albuterol and steroid use monitoring over time. Graphs
show usage, severity, etc. For Apple devices.
https://itunes.apple.com/us/app/asthma-puff-
counter/id601942071?mt=8
Asthma-Charter,
Charter MMC
(e-Agent)
Records inhaler peak flow and medication dosage. For Apple
devices.
https://itunes.apple.com/us/app/asthma-
charter/id288858034?mt=8
https://itunes.apple.com/us/app/asthma-charter-
mmc/id340813408?mt=8
AsthmaCheck
(mutterelbe
medical UG)
Developed by pulmonary specialists. Records medication peak
flow, provides review statistics to transmit by e-mail, provides
medication/refill reminders. Periodically runs five-point
symptom checker (following Global Initiative for
https://itunes.apple.com/us/app/asthmacheck/
id381131894?mt=8
157
Asthma/GIMA protocols). For Apple devices.
Blood Pressure
Tracker
(1026
Development)
Tracks daily blood pressure, pulse and blood sugar, charts
averages. For Apple devices.
https://itunes.apple.com/us/app/blood-pressure-
tracker/id310333731?mt=8
Blood Sugar
Tracker (HealthyCloud
LLC)
Logs blood sugar levels, sets target range, graphs levels for
comparison over time. Can forward data to healthcare
providers. For Apple devices.
https://itunes.apple.com/us/app/blood-sugar-
tracker-by-healthycloud.
com/id398293939?mt=8
Blood Sugar
Tracking
(Jeremy Furr)
Sets reminders for checking and stores blood sugar readings,
provides notifications, stores reports with past entries. For
Apple devices.
https://itunes.apple.com/us/app/blood-sugar-
tracking/id593298256?mt=8
CardioSmart
Med Reminder
(American College
of Cardiology)
Takes/tags photos of medications used, has database of
drugs/doses/side effects, interactions. Provides refill
reminders, tracks medication history, places call to pharmacy
for refill. For Apple devices.
https://itunes.apple.com/us/app/cardiosmart-
med-reminder/id540439111?mt=8
Caretalk
(Higher Way
Co., Ltd.)
Measures body temperature by infrared sensor, can keep
automatic diary. For Apple devices.
https://itunes.apple.com/us/app/caretalk/
id561859724?mt=8
COPD Tracker
(Everyday
Health, Inc.)
Tracks daily symptoms - shortness of breath, chest tightness,
cough, mucus, fatigue/trouble sleeping, weather. Can e-mail
data to doctor. Also has 30 useful articles, access to online
community for posting help requests
(www.EverydayHealth.com).
https://itunes.apple.com/us/app/copd-tracker-
from-everyday/ id450578479?mt=8
158
Coumadin
(Clinical Cliffs)
Calculates coumadin loading and maintenance doses for two
different anti-coagulation therapies. App originally designed
for healthcare professionals, but adapted as become more active
in treatment. For Apple devices.
https://itunes.apple.com/us/app/coumadin/id303
861701?mt=8
Diabetes
Companion
(dLife)
Tracks/manages blood glucose level - records carbohydrates,
insulin, blood glucose data over time, logs meals and meter
readings, provides daily to monthly reports, can e-mail data.
Provides access to dLifeTV show - 400 videos on living with
diabetes, 4,000 expert questions and answers, recommendations
for 9,000 good recipes and 25,000 specific foods. For Apple
devices.
https://itunes.apple.com/us/app/diabetes-
companion/id360403719?mt=8
Diabetes Personal
Calculator
(iTenuto Soft)
Developed for persons with Type 1 diabetes injecting pre-meal
fast or rapid-action insulin. Assists in selecting foods,
modifying servings/weights, calculating insulin dose rates
based on glucose readings. For Apple devices.
https://itunes.apple.com/us/app/diabetes-
personal-calculator/ id365215622?mt=8
Diabetic Dosage -
An Insulin
Calculator
(Kalianne
Neumann)
Provides suggestions for fast-acting insulin dosage using
correction number recommended by user's physician, current
blood glucose level, total of carbohydrate units eaten. Dosage
units determined by type of insulin delivery device used. For
Apple devices.
https://itunes.apple.com/us/app/diabetic-dosage-
insulin-calculator/ id421962268?mt=8
Emergency
Helper (coravy Ltd.)
Preset message for sending emergency e-mail to contacts and
maps location if device user is unable. For Apple devices.
https://itunes.apple.com/us/app/emergency-
helper/id411876311?mt=8
Emergency Info
4Family Lite
(BHI Technol-
Family version of Emergency Info. Can upload family member
photos; record birthdates, blood types, medication information,
emergency contacts. One-touch emergency phone call,
https://itunes.apple.com/us/app/emergency-
info-4family-lite/id352726412?mt=8
159
ogies, Inc.)
provides quick access to all members' medical information.
For Apple devices.
Emergency Lock
Screen
(PSchaschl)
Operates like a medical alert bracelet if smart device is locked
and user impaired - important information inserted into
customizable picture accessible on the lock screen. For Apple
devices.
https://itunes.apple.com/us/app/emergency-
lock-screen/id509849333?mt=8
Heart Attack
Check Test
(Jommi Online)
Quick test of symptoms for potential heart attack - based on
World Health Organization physician survey format. For
Apple devices.
https://itunes.apple.com/us/app/heart-attack-
test-check-for/id406383475?mt=8
HeartWise Blood
Pressure Tracker (SwEng L.L.C.)
Quickly records/tracks blood pressure, resting heart rate,
weight. Can review trend data, statistics on daily changes, set
reminders for taking medications and measurements. Data can
be sent as a report, spreadsheet, plain text. For Apple devices.
https://itunes.apple.com/us/app/heartwise-
blood-pressure-tracker/id311716888?mt=8
HeartWorks60
(Pointer Software
Systems, Ltd.)
Tracks heart rate data obtained from chest strap monitors
designed to Bluetooth Smart and ANT+ wireless standards.
Can record for many hours, saves data in enlargeable graph.
Can keep records for multiple sessions. For Apple devices.
https://itunes.apple.com/us/app/heartworks60/id
460962986?mt=8
Medication
Manager and
History Tracker
(eMedical
Companion, Inc.)
Tracks medication intake history, adds new medications.
Stores medication bottle pictures, provides refill reminders; can
add dosages, schedule, starting/ending date. E-mails records
for up to six family members to healthcare professionals.
Password protected. For Apple devices.
https://itunes.apple.com/us/app/medication-
manager-history/ id382200355?mt=8
Medication
Tracker
(Men in Shades)
Tracks up to four medications - frequency, time of day,
starting/ending dates. Stores family history. Statistics screen
can provide daily to yearly totals, averages. For Apple devices.
https://itunes.apple.com/us/app/medication-
tracker/id305661888?mt=8
160
OnTrack
Diabetes
(GExperts, Inc.)
Tracks blood glucose, food eaten, medication, blood pressure,
pulse, exercise and weight. Variety of reports and graphs
generated. For Android devices.
https://play.google.com/store/apps/details?id=c
om.gexperts.ontrack&hl=en
Pain Care
(Ringful LLC)
Users can track pain levels, location, duration, mood and more;
can share data with a physician or other parties. For Apple and
Android devices.
https://itunes.apple.com/us/app/pain-
care/id347787779?mt=8
Spot a Stroke
F.A.S.T
(American Stroke
Association)
Borrows from app developed by the Australia National Stroke
Association. F - check face for ability to smile/droop on one
side; A - ask to raise arm/see if drops, S - speech slurring, T -
importance of time in contacting 911. Also has information on
dealing with/preventing a stroke, nearby hospital locations, 911
hotline connection. For Apple and Android devices.
https://itunes.apple.com/us/app/spot-a-stroke-
f.a.s.t./id594995265?mt=8
161
10) WANDER MONITORING - EQUIPMENT
Product/vendor
Characteristics, features
Web address
CA100
(Pioneer Medical
Systems)
Low-cost wander management. Small, portable - no hard wiring,
can move to any room. One controller can monitor multiple doors,
more than one vulnerable person can be monitored. Ankle cuff
monitoring device.
http://www.pioneeremergency.com/
Caretrax (Caretrax)
System works with telemetry, has two tiers of monitoring. Home
option triggers alarm when a wireless "geofence" boundary is
passed, searches in one-mile vicinity. Responder option (police,
fire) uses transmitter bracelet assigned unique frequency for
tracking when local officials participate in Project Lifesaver and are
contacted about wander incident. (System's original target
population was persons with autism.)
http://www.caretrak.com
Comfort Zone
(Alzheimer's Assn.)
GPS/cellular locational monitoring where family chooses options
price tiered by distance. Monitoring center provides assistance
24/7. Subscription also includes Medic Alert - access to stored
emergency health records - and Safe Return- medallion with
emergency number and contacts for vulnerable person. Wandering
or medical emergencies reported to 24-hour emergency response
center Community "Safe Return" network (local Association, law
enforcement personnel) is activated. When individual located,
personnel call medallion's emergency contacts.
Association also offers lower-priced service combining Medic Alert
http://www.alz.org/comfortzone
http://www.alz.org/care/dementia-
162
with the Safe Return program. medic-alert-safe-return.asp#works
Door and Window
Wireless Wander
Alarm
(Seniors Super
Store)
Door sensor unit mounts on bedroom or other key interior, and/or
exterior door. When door opened, send signal to caregiver's remote
monitoring unit (chime or vibration).
http://www.seniorssuperstores.com/
Freedom
(Lok8u)
Uses proprietary radio frequency identification technology and
global positioning. Vulnerable person wears a watch transmitter
with emergency button. When alert triggered, caregivers go to
secure customer computer portal for mapping readouts.
http://www.lok8u.com
Keruve Direct
Family Locator
(Vision Localization
System)
Designed for persons with first-stage Alzheimer’s. Person wears
GPS watch with safety lock. Caregiver has portable, small-screen
tracking unit that displays map with person's tracked location.
http://www.keruve.com/?gclid=
CMKVmKbD87cCFUaZ4AodAksAzQ
Lifecomm mPers
(Hughes Telematics,
Inc.)
Wristwatch-style tracking unit using GPS provides two-way
communication, auto fall detection. (Purchased by Verizon in 2013;
market return/features to be determined.)
http://www.lifecom.com
Navistar GPS
Footwear System
(Aetrex Worldwide,
Inc.)
Uses satellite and cellular technology embedded into shoes.
Subscriber sets desired wireless boundary geozone, is alerted when
person moves beyond. Antenna, battery installed in shoe right heel,
recharges in about 2 hours. Subscriber sets up account online (also
checks battery strength there), can track position - every 30 minutes
(basic plan), every 10 minutes (premium plan). Alert notice sent by
e-mail or smart device text message.
http://www.navistargpsshoe.com/
gps-shoe-how-it-work
163
Personal Locator
Service,
Smart Shoes
(GTX Corp.)
Company partnering with Google Maps for creating displays of
locations identified by GPS for GTX-enabled products. One
example is "Smart Shoes" with imbedded sensors that track user
location.
http://www.gpsshoe.com/
smart_shoe_google_premier_api.cfm
Smart Door
Monitor
(Smart Caregiver
Corp.)
Anti-wandering products - door monitoring system (wristband
sensor triggers alarm), weight-sensing floor mats, motion-sensing
monitors.
http://www.careelectronics.com/
Traxxit360
(Traxxit
Technologies)
Company operates in multiple markets - e.g., uses for locating
children, pets, assets, etc. Units monitor geographic location and
altitude. Users register devices, set boundaries, provide cellphone
number/s for receiving alert e-mails or texts via "My Traxxit"
software.
http://www.traxxit.com
TriLock Personal
Locator
(iLoc Technologies)
Uses cellular and global positioning technology for wander
management where multiple geofence zones can be set. Also
provides fall detection/alert. Has bi-directional voice capability,
SOS check-in button. Can be set up on website or smart device.
http://www.iloctech.com/triloc
WanderCARE100
(Care Electronics,
Inc.)
Subscribers set range for monitoring. Vulnerable person wears
WanderCare transmitter (with unique electronic code) on wrist,
ankle, belt or in special fanny pack. If person moves out of pre-set
zone and doesn't return within 15 minutes, alarm sounds for
caregiver. Person can be tracked up to one mile. WanderCARE can
also connect to a voice dialer that can notify up to four
persons/pagers.
http://www.careelectronics.com/
Wherifone GPS
Locator Cellphone
Cellphone equipped with GPS enables tracking person on outline
map or location can also be obtained by text message. Three easy-
http://www.mightygps.com/
wherify.htm
164
for Seniors
(Whereify)
dial numbers can be programmed, 20-number phone book. Model
also manufactured for children.
10) WANDER MONITORING - SMART DEVICE APPS
Product/vendor
Characteristics, features
Web address
TellMyGeo
(Iconosys)
Vulnerable person's smartphone can be set to send regular GPS
alerts to caregiver's phone. Simple buttons for emergency use.
Medical history can also be stored for use by emergency responders.
For Android devices.
http://tellmygeo.com
GeoFence
(MobSafety.net)
GPS tracker that gives real-time information on location of
vulnerable person carrying smartphone who has left a designated
geofence area. For Android devices.
https://play.google.com/store/apps/detail
s?id=com.gpit.android.lifestyle.mobsafe
ty.geofence&hl=en
