Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project.

The biggest need in home- and community-based care relates to chronic disease. The 100 million Americans with chronic disease account for about 75 percent of health care expenditures. Traditionally, chronic disease has been managed through an episodic office-based model rather than a care management model, which uses frequent patient contact and regular physiologic measurement. More than a decade ago, the VA developed a care management program that offered personalized education, monitoring, and feedback at home from a remote disease management support team. Use of technologies for chronic disease care management has been associated with reductions in hospitalizations, readmissions, lengths of stay, and costs; improvement in some physiologic measures; high rates of satisfaction; and better adherence to medication. Studies of home monitoring programs have shown specific improvements in the management of hypertension, congestive heart failure, and diabetes. However, more and higher-quality studies are needed. In the future there will likely be more laptop-based and tablet-based devices used in the home. In addition, there will likely be even smaller devices used for physiological monitoring. For example, companies are developing wearable wireless devices that can combine an accelerometer, stethoscope, electrocardiogram, and other functions to collect data from continuous monitoring. There may also be watches or rings that can measure blood pressure and heart rate.

Patient preference and acceptability is one challenge in home-based telehealth. Many studies show attrition with the use of these technologies after the pilot ends. More information is needed regarding what kinds of devices people want to use and how much intrusion they are willing to accept in their lives. We also need to determine how to best involve patients and their families in care. Another challenge is to determine how to use off-the-shelf devices (e.g., mobile phones, gaming systems) in care. Furthermore, how can we manage the data flowing in from all these devices and transform it into information that is actionable by a clinician? Many physicians do not have disease management teams, so how does the small rural doctor’s office use the data in a meaningful way? Finally, policy changes are needed to enable the use of these technologies.

OFFICE-BASED TELEMEDICINE

Telemedicine has also been used for decades in clinical settings. In 1906, the inventor of the electrocardiogram published a paper on the telecardiogram. Since the 1920s, the radio has been used to give medical advice to clinics on ships. Alaska has been a model for the development and use of telemedicine for decades. For example, community health aides in small



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