Abstract
In the early years of telemedicine, the concept of disease management was not very well developed. Disease was most commonly recognized by patients who sought incident care from a physician, and after treatment they went about their lives. Of course, there were chronic ailments that would have benefited from continuous care, but the principles of seamless health were just emerging in 1990 or so. Telemedicine was appropriately focused on access to care for remote populations using advanced telecommunication technology. Continuity of care with the same medical team was considered important, of course, and your physician followed you to the hospital and through the illness and then in follow-up until recovery. This continuity by individual continuous care would come to be criticized as it entailed unhealthy work hours and questionable competence in physicians who tried to be the sole responsible party for a particular case over extended time periods. My doctor was always there, but he (or she) sure looked tired! Currently, the patient's information and its integrity maintain the string of continuity, and individual health workers play their expected role of competence as information managers. The patient is the thread of continuity, and the health workers are intermittent managers in a coherent plan. That at least is the concept!
Chronic diseases such as hypertension, renal disease, cardiac disease, asthma, other pulmonary diseases, cancer, and psychiatric disorders are routinely followed up and managed through telemedicine with strong evidence of equivalence or superiority in outcomes compared with on-site and face-to-face care. Longitudinal care is considered the norm, and through astute monitoring, problems in the natural history of diabetes or whatever can be addressed before serious consequence. The following is a brief offering of some of the seminal articles in this Journal dealing with disease management through telemedicine. There is no intent to be comprehensive because the immense contribution of telemedicine to this field cannot be presented in a limited essay. Those fine authors whose work is not included, please accept our apologies, and please continue to make this area of medicine better through your research and experience!
Although disease management was not a hot topic in the early days of this Journal, those early volumes were prescient on a topic that would soon define reform in healthcare. Telemedicine was described as an adjunct to long-term care in a 1998 article where the Internet was used for follow-up of a patient who had received a mitral valve replacement 5 years previously and still had some residual cardiac problems. 1 Subsequently, this Journal has repeatedly published articles that led the way for the management of chronic disease. Seamless, continuous, coherent management of chronic disease is becoming the expected mode of care in these conditions, and our authors have been at the front with telemedicine as a tool for such care.
In 1998, Pacht et al. 2 reported a crossover design study of telemedicine in a pulmonary clinic dealing with chronic disease problems. Telemedicine was clearly equivalent to standard face-to-face care in these patients. Researchers at the University of Illinois in Chicago in a 2000 article studied uncontrolled hypertensives, and telemedicine was applied in this early study, which demonstrated a decrease in diastolic and systolic pressures with p<0.001. Patient knowledge was assessed and found to greatly improve with the telemedicine intervention, along with lifestyle modifications and weight loss. The statistical impact of this study set a course not to be ignored in simple telephone and home monitoring of an important disease entity. The study was notable in that holistic patient care was the driver more than technology. 3
Woods et al. 4 in Georgia addressed the problem of extending coherent primary care to a rather rare disease that would predominate over their other health issues—sickle cell disease. They reported in 1998 the linkage of highly distributed sickle cell adult patients in rural Georgia with consistent primary care using telemedicine. The approach was embraced quickly by the patients, although it represented a drastic departure from their previous care for patients in a disease they had had all their lives. 4
The care of asthma requires vigilance and prompt response from families and caregivers to avoid repeated trips to the emergency department and dreadful complications. Asynchronous surveillance of a group of children in the Western Pacific demonstrated reduced emergency visits and unscheduled clinic visits over a 1-year period; patient education also benefited. 5 Because asthma is the most common chronic disease of children and care by specialists is considered more effective than care by generalists, the short supply of these specialists was addressed early through the use of telemedicine. In a 2001 study at Texas Tech, in partnership with a school nurse interface, telemedicine over 6 months monitored spirometry and general clinical condition. These researchers reported an increased number of symptom-free days per week by nearly twice, and quality of life jumped dramatically. 6
Consistent follow-up in diabetic eye disease has proven itself through telemedicine. In a U.S. Department of Defense population, using the Joslin Network over a 1-year period, nonmydriatic monitoring of diabetics proved cost-effective. 7 A full description of the Joslin protocol and its outcomes was reported for over 13,000 patients with inclusion into an electronic record by Fonda et al. 8 in 2007. Expanding the healthcare team through telemedicine to paraprofessionals has been tested in ophthalmology and certainly applies to other fields. 9
It must be obvious that just telemedicine is not the answer without a proper professional protocol validated with the technology. There are many examples of telemedicine being used in a way that did not improve results or vastly exceeded costs. It would be a good thing if there were more of these negative results! For example, in a literature review of hypertension with telemedicine, AbuDagga et al. 10 found that caregiver compliance was inferior to that of the patients! Telemedicine impact will be much better known when reviews of large series are collected. In such collections the enthusiasm of the individual reports may shrink. However, it is only by this kind of work that Cochrane authority can be gained.
Telemedicine for special needs children in their overall care has been reported from Galveston, TX, 11 as an extension of the Georgia application. Dermatology and psychiatry applications are so numerous as to exceed the scope of this piece. Long-term management in transplantation and cancer has been reported. However, we would like to conclude by pointing out the special role of telemedicine in chronic home care. Home health continues to grow as a practice tool to monitor and respond to patients' needs at home when they are so unstable that otherwise they must be cared for in an institution or hospital. Home health offers extended independence to patients with relatively serious afflictions. Sicotte et al. 12 reported the effects of telemonitoring in the home for pulmonary patients and noted an improvement in quality of life. Congestive heart failure is a condition with drastic outcomes if early intervention is not used. In an asynchronous Internet-based system, total hospital days were lowered from 133 to 44 in a cohort of 36 patients. 13 Hopp et al. 14 reported a small study by the Veterans Administration in 2006 that strongly supported the use of home health monitoring in a variety of situations. This is a very detailed description of the equipment and protocols applied. However, let us close with a study that brought together home health, informatics, and disease management for over 31,000 patients. This report by Darkins et al. 15 involved the training of 5,000 staff to participate in a program of care coordination/home telehealth. These researchers reported a 25% reduction in bed utilization, 19% reduction in admissions, and 86% high satisfaction. The program utilized the best in experience and coordination with simply stunning results. 15 This is the kind of outcome we should come to expect, but whatever the outcome, we anticipate publishing the information here in your journal in years to come.