Challenges for Home Telehealth

I spent much of the day working on a series of questions for a grant proposal. One of the questions was, “what are the challenges that you found, and how did you manage to work around them?” I wrote:

We strive to make the technology as transparent as possible for both patients and providers. As far as patient trust is concerned, we feel that patients need to be prepared for the project. In most cases we have found it works well for us to make a preliminary visit to the patient’s home, not just to do an evaluation, but also to explain how the program works, and to introduce ourselves. When we arrive for the actual installation, the patients know us, and are comfortable with us being in their home. It is not unusual for us to contact the patient via the phone during the course of the project, and with virtually all of them we ended up on a first-name basis, and they recognized our voices on the telephone.

In one case a patient asked us to remove the equipment and they terminated their participation. This was an Alzheimer patient living independently with no family support. In two or three other cases were were able to determine from the patient that they wouldn’t be a successful candidate for the project; either they asked us to remove them from consideration, or we made a recommendation that the person not be included.

In several cases, after visiting an especially frail patient for an evaluation, we were skeptical that the unit would work for a patient; these patients became our dramatic success stories.

It is not unusual that a patient will ask us to explain the project to a family member so that the family member can advise them if it is OK. Especially with dementia or Alzheimer patients, it is very helpful to have family involved.

For patients with memory problems, we found that if they hadn’t turned the unit on in preparation for a scheduled class, we could call them on the phone, and ask them if they intend to participate. Almost always they said they had forgotten, and if we would give them a few minutes, they would join in.

In cases with existing Internet connections, we need to be sure that the unit can be called from outside the person’s home, and it usually requires that we have one-time access to their home internet router to make adjustments.

In some cases, an existing internet connection goes to a computer in the den, (i.e away from the DocBox, attached to the TV in a living room). One solutions to this problem include stringing wire from the den to the living room TV. In several cases we ended up installing a separate dedicated internet connection. This isolates our unit from their existing home network, which makes troubleshooting easier.  We don’t do internal home wiring.  Although we have attempted using wireless connections, we haven’t had success. This may be something to try again however, as the wireless technology has improved.

Sometimes people joke about “Big Brother”, i.e. the ability to view the patient without their knowledge. We try to make the following points:

• Our camera has an orange light on it, which when lit, means that the camera is active. If the light is not on, then there is no way any image is being transmitted
• There is a limited set of people involved in the project, including our tech support personnel, and the medical personnel running the project. The patient will see some of these people on their TV as part of the project (especially us… as well as whoever is facilitating that day’s session) but the number of people viewing are limited. They are not broadcasting on the internet or YouTube.
• We do make the point that even though the viewership is very limited, the connections are “quasi-public”… that they can be seen by several other people and so patients should be comfortably dressed and ready to be “seen” by their peers and other project participants once the session starts. (This has never been a major problem.)
• We will typically record some parts of sessions mid-way throughout a project. We will obtain their written permission and explain how we would use these recordings Typically we make these recordings available after an individual request by other medical personnel.