- Email: [email protected]
Audio-Visual Communication and Its Use in Palliative Care
Vol. 23 No. 2 February 2002
Journal of Pain and Symptom Management
171
Palliative Care Rounds
Audio-Visual Communication and Its Use in Palliative Care Nessa Coyle, RN, MS, Natalia Khojainova, MD, John M. Francavilla, MS, and Gilbert R. Gonzales, MD Pain and Palliative Care Service (N.C., N.K., G.R.G.) and Department of Neurology (J.M.F.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
Abstract The technology of telemedicine has been used for over 20 years, involving different areas of medicine, providing medical care for the geographically isolated patients, and uniting geographically isolated clinicians. Today audio-visual technology may be useful in palliative care for the patients lacking access to medical services due to the medical condition rather than geographic isolation. We report results of a three-month trial of using audio-visual communications as a complementary tool in care for a complex palliative care patient. Benefits of this system to the patient included 1) a daily limited physical examination, 2) screening for a need for a clinical visit or admission, 3) lip reading by the deaf patient, 4) satisfaction by the patient and the caregivers with this form of communication as a complement to telephone communication. A brief overview of the historical prospective on telemedicine and a listing of applied telemedicine programs are provided. J Pain Symptom Manage 2002;23:171– 175. © U.S. Cancer Pain Relief Committee, 2002. Key Words Audio-visual communication, telemedicine, TeleEye, palliative care
Introduction Complex palliative care patients are often home-bound, and cared for by family members guided by community nurses and with the back-up of a palliative care team. Face-to-face contact with physicians is infrequent and may occur through clinic visits, if the patient is able to travel, or through occasional home visits. With advances of medicine, previously lethal diseases like cancer and AIDS have become chronic conditions. There is a growing num-
Address reprint requests to: Gilbert R. Gonzales, MD, Pain and Palliative Care Service, Memorial SloanKettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA. Accepted for publication: May 8, 2001. © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
ber of cancer survivors with long life expectancy who are debilitated and dependent on complex medical regimens and equipment. These and other complex palliative care patients are in need of a communication tool that would allow them to be monitored and receive comprehensive care at home. This communication tool may involve technological advances that could bring palliative care to a new level, enhancing the communication between clinician and the home-bound patient. With the maturity of the computing and telecommunications technology come new innovations for novel supplementary care. While most teleconferencing solutions pertain to the transfer of electronic medical data (i.e., high resolution images, video, and patient records) from one institution to another, only a small per0885-3924/02/$–see front matter PII S0885-3924(01)00402-X
172
Coyle et al.
centage of such programs can be applied to home health care. Certain low-cost commercially available teleconferencing products, which utilize traditional phone lines, are now being used to aid health care providers with home care patients. Many elements of medical practice are now being accomplished when the patient and health care provider are geographically separated.1 Realtime interactive teleconference clinical consultations are usually used for increasing accessibility to medical care by patients whose demographics restrict care. Health care providers in a growing number of medical specialties, including dermatology, oncology, radiology, cardiology, intensive care, neonatology and home health care, utilize telemedicine.2,3 Tele-rehabilitation is also underway,4 targeted to demographically underserved areas. A recent comprehensive overview on the use of remote telemedicine in psychiatry indicated that tele-psychiatry is reliable and that patients and clinicians report high level of satisfaction.5 Global expectations from telemedicine include the targeting of finances towards primary care, having telemedicine provide easy access to specialists, assuring quality improvement and use of evidence-based medicine, and making admission to the hospitals more appropriate through preadmission telecommunication screening. These outcomes could save money for fewer, technologically more sophisticated hospitals. Telemedicine today is used to provide clinical care for the patients who are at disadvantage of being geographically isolated from the medical community. It is important, however, to remember the needs of patients who, in spite of their close proximity to medical institutions, are isolated due to their medical condition, physical or psychological debilitation, or social limitations. We report a three-month trial involving a single patient and his family, where ongoing communication was enhanced through the use of inexpensive and easy to use video technology. This technology was supported by equipment available in the majority of households.
Case Report A 33-year-old man had an 11-year history of a recurrent primary brain tumor and had been treated with multimodality therapy, including surgery, radiation therapy, and both conven-
Vol. 23 No. 2 February 2002
tional and experimental chemotherapy. Although clinically free of disease, he was wheelchair-bound, and had marked cerebellar ataxia, diplopia, and loss of peripheral vision, profound hearing loss, chronic headaches, periodic auditory hallucinations, impaired swallowing, and repetitive episodes of aspiration pneumonia (making oral intake a hazard). He had a tracheotomy and required ventilatory support at night. He had a central venous access line and a gastrostomy feeding tube (PEG). Although cognitively impaired in memory and concentration, and operating at a 10-year-old level, he was alert and interactive, enjoying family life and social contacts. From August 1998 through December 1999, he had 6 admissions to Memorial Sloan-Kettering Cancer Center (MSKCC), 2 to a rehabilitation center, 1 to a terminal care facility, and 1 to a long term-care facility. In a one-year period he spent a total of two months at home. Both the patient and his family made the decision that quality of life was more important than life prolongation. To achieve this, he asked that he be cared for at home by his parents. His parents strongly supported this decision, as did the palliative care team who knew the patient and family well. He lived with his parents, who were in their early fifties, in a onebedroom New York City apartment. Prior to his discharge home, the family assumed full responsibility for every aspect of his care. This intense training period increased both the staff and parent’s comfort with the discharge plan. This daily physical care involved intermittent tracheotomy suctioning with skin care and dressing change, connection to ventilatory support at night to treat symptomatic hypoxia, PEG tube feedings, care of the central venous access line, identifying fever and hypotension, hanging intravenous fluids and intravenous antibiotics as needed, administering multiple medications via his PEG feeding tubes 3 to 4 times daily, monitoring his pain and administering opioid analgesics, bathing, toilet care, skin care, and assisting in his transfer from bed to wheelchair. In addition there was the need to keep track of equipment and medication. At least one parent must be with him at all times. Following his discharge home, the community nurses reinforced the family training and supported them in his care. The family pre-
Vol. 23 No. 2 February 2002
Audio-Visual Communication in Palliative Care
ferred not to have a home health aide and soon asked that the nursing visits be decreased in frequency. However, they remained dependent on daily communication, and reinforcement and support from the palliative care team at MSKCC. The MSKCC palliative care team provided support through daily telephone contacts and 24-hour availability to help problem solve and provide advice. Home visits were made initially every 1–2 weeks, with the time span increased as the patient and his parents became more confident. The family always had the option of admission to MSKCC if a crisis arose at home or if the general care became overwhelming. A routine of daily telephone contacts was established between the patient and his parents, and a MSKCC Supportive Care nurse practitioner. That practitioner was also available to him and his family on weekends and at night. Following this plan of action, the patient had only one 5-day hospital admission in the year 2000. This was related to an acute loss of hearing. Community-acquired rather than hospitalacquired infections were infrequent and, when present, were treated with parenteral antibiotics at home. Daily telephone contacts with the supportive care nurse practitioner became the primary mode of monitoring and support for the patient and his parents. Although community nursing has been available to make home visits, this family felt that it was the strong bond with MSKCC and continuity of care that facilitated the patient’s remaining at home during this prolonged period of time. It was hypothesized that regular visual contact between the patient and his supportive care team would enhance communication and decrease the anxiety and isolation experienced by both the patient and his parents. The patient and his parents were identified as likely to benefit from audio-visual communication for the following reasons: 1) he was essentially home-bound and socially isolated, 2) he had complex medical and psychological needs, 3) his parents bore the primary responsibility for his physical and emotional care, 4) his parents were responsible for managing complex equipment, 5) his parents needed ongoing education and guidance as his symptoms and emotional needs changed, 6) his parents benefited from a sense of shared responsibility for day-to-day decision making around
173
his care, and 7) his parents benefitted from day-to-day support and acknowledgment of a job well done. Because patients on the Palliative Care Service may be beset with numerous neurological deficits, it is sometimes difficult for them to easily visit the hospital. In this patient’s case, the ability to converse with supportive care personnel via the telephone was especially problematic due to his hearing loss. A solution was needed that would aid him and others like him, during the palliative care process. While internet-based solutions are relatively inexpensive and easy to implement, they are limited to personal computer (PC) owners who must deal with the service vagaries of the internet. Therefore, we focused on a solution that would provide video and audio communications via traditional phone lines. A trial of a commercially available audiovisual system that could be placed in a home using standard telephone wires and not require a home computer system, was initiated. After reviewing the available technologies, a commercially available videophone (TeleEye 324 TM, LeadTek Research, Inc., Fremont, CA) was selected. Each unit is an affordable (less than $500) set-top video-conferencing system that combines with a standard television or PC monitor and a regular analog phone line or POTS (Plain Old Telephone System) to create a complete video-conferencing solution. The unit conforms to VideoPhone Standards that specifies a common method for video, voice, and data to be shared simultaneously over highspeed modem connections. Each unit provides a high quality digital CCD (Charge-Coupled Device) camera with full motion video up to 15 frames per second (fps). This is about half the quality of broadcast TV-quality video, which is transmitted at 30fps. Using the on-screen feature menu, one can adjust the quality of video images between a slide-show type experience, with slower motion and very clear pictures to full-motion imaging with less clarity. Each unit connects to either a television or PC monitor and to a standard telephone. The video image can be displayed using three different video display formats and bi-directional audio is established through a telephone handset or speakerphone. The patient and his parents were enthusiastic about the use of the TeleEye. After a trial in the hospital, a home visit was made by his Pain
174
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and Palliative Care attending and Supportive Care nurse practitioner who were familiar with the equipment. The TeleEye was installed in his home connected to a television, and the family was instructed in its use. The same type of set-top videophone attached to a computer monitor was set up in the office of one of our supportive care nurses. At the end of the 3-month trial period the Pain and Palliative Care team could identify the following medical and social benefits to this patient: 1) an immediate impromptu limited general physical exam became possible, 2) “curb side” evaluation with an attending or consultants became possible, 3) the patient’s obvious pleasure at visual contact with clinicians, 4) the oportunity for visual clues for this patient with profound hearing loss improved communication by maintaining and expanding the conversation. From the practitioner’s viewpoint, the TeleEye system also cut down on, although did not eliminate, the need for supportive home visits. As compared to home visits, telecommunication is less comprehensive, but it is more readily available, appears to be less intrusive, and needs less preparation from both parties.
Discussion The technology of teleconferencing spans several decades, dating back to the first videophone announced by AT&T at the 1964 World Fair. However, due to its high cost and limited availability, it failed to attract buyers. In the late 1960s and early 1970s, teleconferencing was applied to applications such as telemedicine, distance learning, and criminal justice in an attempt to add credibility to the technology. In the 1970s, about a dozen companies attempted to introduce teleconferencing products. However, it had limited commercial success.6 In the 1980s manufacturers began developing teleconferencing solutions using proprietary standards in an effort to increase their market share. Companies using such proprietary solutions could not interoperate with other proprietary systems. This, again, abated any widespread acceptance of the technology. However, by the late 1980s, teleconferencing consumers, equipment manufacturers, and service providers realized that open standards were necessary. The International Telecommunications
Vol. 23 No. 2 February 2002
Union (ITU), in turn, began developing a series of recommendations, known as the H-series, which would comprise the core technologies for multimedia teleconferencing.7 By the 1990s, improvements in compression algorithms, affordable desktop computers and software, economically priced systems, the availability of leased and switched telephone services, and the adoption of the ITU’s H-series standards stimulated the interest in teleconferencing solutions.7,8 One should be aware, however, that proliferation of easily accessible private patient information for multiple members of the medical team rises a question of legal and ethical responsibilities to protect patient’s rights and confidentiality.9,10 Today, 39 states have laws or regulations governing telemedicine.11 Further research is being conducted on existing telemedicine systems, with both private and public sectors learning about the benefits. Allowing isolated practitioners to consult specialists and communicate with colleagues, as well as participate in research and clinical projects, and advance their clinical skills, are the areas of telemedicine research focus. Transmission costs are now relatively low and equal to that of a phone call, with typical hardware costs under $500 per station. Institutions and medical centers throughout the world are taking advantage of this reliable and economical technology. Typical examples of teleconferencing solutions today include a hospital health care facility in Minnesota whose “telemedicine network exists to improve access of specialists to rural locations, particularly emergency coverage, to provide continuing education for physicians, nurses, and other providers and employees.”12 An academic medical center in Michigan uses the technology to provide community and patient education on caring for the chronically ill elderly, as well as persons with disabilities (i.e., traumatic brain injury, spinal cord injury).13 A rehabilitation center in Missouri uses interactive video-conferencing to conduct one-on-one training between a rural mental health generalist and a neuropsychologist in an academic medical center.14 A hospice facility in Missouri uses teleconferencing to augment specialized non-interventional care given to terminal patients.15 A Tele-psychiatry clinic uses teleconferencing to provide psychiatric care to rural areas. Services include group
Vol. 23 No. 2 February 2002
Audio-Visual Communication in Palliative Care
as well as individual therapy, medication checks, and initial evaluation to children and adults in Kansas.16 Additionally, programs in tele-ophthalmology, tele-mammography, tele-radiology, and tele-pathology are other common uses of this technology.17–20 While there exists many applications and solutions, utilization of this technology should focus on increasing the quality of patient care.21 With further trials planned for this year, we hope the audio-visual system will have an impact on patient care in the palliative care service.
175
search and program development. Psychiatr Serv 2000;51(12):1522–1527. 6. Rosen E. The history of desktop telemedicine. Telemedicine Today 1997;5(2):16–17, 28. 7. Irakliotis LJ. Multimedia communications defy boundaries of space, time. OE Reports 1997 (October). http://spie.org/web/oer/october/oct97/multimedia.html. 8. Videoconferencing System Manufacturers.http: //www.integrated1.com/videoeqp.html. 9. Walter GF, Matthies HK, Brandis A, von Jan U. Telemedicine of the future: teleneuropathology. Technol Health Care 2000;8(1):25034. 10. Nohr LE. Telemedicine and patient’s rights. J Telemed Telecare 2000;6(Suppl 1):S173–S174.
Conclusion Organizations deploying teleconferencing systems must make key decisions. These decisions include cost, availability, quality of service, security, and transmission services, among others. Palliative care may benefit from this technology, as an additional tool bringing a different level of palliative care to the patient’s home. This may be helpful in providing state of the art palliative care for the most complex palliative care patients, isolated in their homes by their medical conditions.
References 1. Tieman J. Monitoring a good opportunity. Telemedicine grows as method to reach poorly served regions. Mod Healthc 2000;30(43):75–78, 80. 2. Rosenfeld BA, Dorman T, Breslow MJ, Pronovost P, Jenckes M, Zhang N, Anderson G, Rubin H. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med 2000;28(12):3925–3931.
11. Rothouse M. Providers issue brief: telemedicine. Issue Brief Health Policy Track Serv 1999;28:1–11. 12. Allina Health System/Rural Health Alliance Telemedicine Network. Telemedicine Information Exchange. http://tie.telemed.org/ProgramListings. asp?ID109http://www.allina.com. 13. Caregiver College; Physical Medicine and Rehabilitation. Telemedicine Information Exchange. http:// tie.telemedicine.org/ProgramListings.asp? ID 1337 http://www.dmc.org. 14. Missouri TeleRehabilitation Center. Telemedicine Information Exchange. http://tie.telemed.org/ ProgramListings.asp?ID1266 http://www2.kumc.edu /telemedicine. 15. Doolittle G. A POTS-based telehospice project in Missouri. Telemedicine Today 1997;5(4):18–19. 16. KUMC Telepsychiatry Clinic. Telemedicine Information Exchange. http://tie.telemed.org/ProgramListings.asp?ID1266 http://www2.kumc.edu/ telemedicine. 17. Tuulonen A, Ohinmaa A, Alanko HI, et al. The application of Teleophthalmology in examining patients with glaucoma: a pilot study. J.Glaucoma 1999;8(6):367–373. 18. Maitz GS, Chang TS, Sumkin JH, et al. Preliminary clinical evaluation of high-resolution telemammography system. Invest Radiol 1997;32 (4):236–240.
3. Doolittle GC, Allen A. Practising oncology via telemedicine. J Telemed Telecare 1997;3(2):63–70.
19. Ruggerio C. A teleradiology primer. Telemedicine Today 1998;6(6):36–42.
4. Palsbo SE, Bauer D. Telerehabilitation: managed care’s new opportunity. Manag Care Q 2000; 8(4):56–64.
20. Wheeler T. Telepathology’s slow start. Telemedicine Today 1999;7(1):37–39.
5. Frueh BC, Deitsch SE, Santos AB, et al. Procedural and methodological issues in telepsychiatry re-
21. “Telemedicine: A Brief Overview.” The American Telemedicine Association. http://www.atmeda. org/news/overview.htm (23 June 1999).
Journal of Pain and Symptom Management
171
Palliative Care Rounds
Audio-Visual Communication and Its Use in Palliative Care Nessa Coyle, RN, MS, Natalia Khojainova, MD, John M. Francavilla, MS, and Gilbert R. Gonzales, MD Pain and Palliative Care Service (N.C., N.K., G.R.G.) and Department of Neurology (J.M.F.), Memorial Sloan-Kettering Cancer Center, New York, New York, USA
Abstract The technology of telemedicine has been used for over 20 years, involving different areas of medicine, providing medical care for the geographically isolated patients, and uniting geographically isolated clinicians. Today audio-visual technology may be useful in palliative care for the patients lacking access to medical services due to the medical condition rather than geographic isolation. We report results of a three-month trial of using audio-visual communications as a complementary tool in care for a complex palliative care patient. Benefits of this system to the patient included 1) a daily limited physical examination, 2) screening for a need for a clinical visit or admission, 3) lip reading by the deaf patient, 4) satisfaction by the patient and the caregivers with this form of communication as a complement to telephone communication. A brief overview of the historical prospective on telemedicine and a listing of applied telemedicine programs are provided. J Pain Symptom Manage 2002;23:171– 175. © U.S. Cancer Pain Relief Committee, 2002. Key Words Audio-visual communication, telemedicine, TeleEye, palliative care
Introduction Complex palliative care patients are often home-bound, and cared for by family members guided by community nurses and with the back-up of a palliative care team. Face-to-face contact with physicians is infrequent and may occur through clinic visits, if the patient is able to travel, or through occasional home visits. With advances of medicine, previously lethal diseases like cancer and AIDS have become chronic conditions. There is a growing num-
Address reprint requests to: Gilbert R. Gonzales, MD, Pain and Palliative Care Service, Memorial SloanKettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA. Accepted for publication: May 8, 2001. © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
ber of cancer survivors with long life expectancy who are debilitated and dependent on complex medical regimens and equipment. These and other complex palliative care patients are in need of a communication tool that would allow them to be monitored and receive comprehensive care at home. This communication tool may involve technological advances that could bring palliative care to a new level, enhancing the communication between clinician and the home-bound patient. With the maturity of the computing and telecommunications technology come new innovations for novel supplementary care. While most teleconferencing solutions pertain to the transfer of electronic medical data (i.e., high resolution images, video, and patient records) from one institution to another, only a small per0885-3924/02/$–see front matter PII S0885-3924(01)00402-X
172
Coyle et al.
centage of such programs can be applied to home health care. Certain low-cost commercially available teleconferencing products, which utilize traditional phone lines, are now being used to aid health care providers with home care patients. Many elements of medical practice are now being accomplished when the patient and health care provider are geographically separated.1 Realtime interactive teleconference clinical consultations are usually used for increasing accessibility to medical care by patients whose demographics restrict care. Health care providers in a growing number of medical specialties, including dermatology, oncology, radiology, cardiology, intensive care, neonatology and home health care, utilize telemedicine.2,3 Tele-rehabilitation is also underway,4 targeted to demographically underserved areas. A recent comprehensive overview on the use of remote telemedicine in psychiatry indicated that tele-psychiatry is reliable and that patients and clinicians report high level of satisfaction.5 Global expectations from telemedicine include the targeting of finances towards primary care, having telemedicine provide easy access to specialists, assuring quality improvement and use of evidence-based medicine, and making admission to the hospitals more appropriate through preadmission telecommunication screening. These outcomes could save money for fewer, technologically more sophisticated hospitals. Telemedicine today is used to provide clinical care for the patients who are at disadvantage of being geographically isolated from the medical community. It is important, however, to remember the needs of patients who, in spite of their close proximity to medical institutions, are isolated due to their medical condition, physical or psychological debilitation, or social limitations. We report a three-month trial involving a single patient and his family, where ongoing communication was enhanced through the use of inexpensive and easy to use video technology. This technology was supported by equipment available in the majority of households.
Case Report A 33-year-old man had an 11-year history of a recurrent primary brain tumor and had been treated with multimodality therapy, including surgery, radiation therapy, and both conven-
Vol. 23 No. 2 February 2002
tional and experimental chemotherapy. Although clinically free of disease, he was wheelchair-bound, and had marked cerebellar ataxia, diplopia, and loss of peripheral vision, profound hearing loss, chronic headaches, periodic auditory hallucinations, impaired swallowing, and repetitive episodes of aspiration pneumonia (making oral intake a hazard). He had a tracheotomy and required ventilatory support at night. He had a central venous access line and a gastrostomy feeding tube (PEG). Although cognitively impaired in memory and concentration, and operating at a 10-year-old level, he was alert and interactive, enjoying family life and social contacts. From August 1998 through December 1999, he had 6 admissions to Memorial Sloan-Kettering Cancer Center (MSKCC), 2 to a rehabilitation center, 1 to a terminal care facility, and 1 to a long term-care facility. In a one-year period he spent a total of two months at home. Both the patient and his family made the decision that quality of life was more important than life prolongation. To achieve this, he asked that he be cared for at home by his parents. His parents strongly supported this decision, as did the palliative care team who knew the patient and family well. He lived with his parents, who were in their early fifties, in a onebedroom New York City apartment. Prior to his discharge home, the family assumed full responsibility for every aspect of his care. This intense training period increased both the staff and parent’s comfort with the discharge plan. This daily physical care involved intermittent tracheotomy suctioning with skin care and dressing change, connection to ventilatory support at night to treat symptomatic hypoxia, PEG tube feedings, care of the central venous access line, identifying fever and hypotension, hanging intravenous fluids and intravenous antibiotics as needed, administering multiple medications via his PEG feeding tubes 3 to 4 times daily, monitoring his pain and administering opioid analgesics, bathing, toilet care, skin care, and assisting in his transfer from bed to wheelchair. In addition there was the need to keep track of equipment and medication. At least one parent must be with him at all times. Following his discharge home, the community nurses reinforced the family training and supported them in his care. The family pre-
Vol. 23 No. 2 February 2002
Audio-Visual Communication in Palliative Care
ferred not to have a home health aide and soon asked that the nursing visits be decreased in frequency. However, they remained dependent on daily communication, and reinforcement and support from the palliative care team at MSKCC. The MSKCC palliative care team provided support through daily telephone contacts and 24-hour availability to help problem solve and provide advice. Home visits were made initially every 1–2 weeks, with the time span increased as the patient and his parents became more confident. The family always had the option of admission to MSKCC if a crisis arose at home or if the general care became overwhelming. A routine of daily telephone contacts was established between the patient and his parents, and a MSKCC Supportive Care nurse practitioner. That practitioner was also available to him and his family on weekends and at night. Following this plan of action, the patient had only one 5-day hospital admission in the year 2000. This was related to an acute loss of hearing. Community-acquired rather than hospitalacquired infections were infrequent and, when present, were treated with parenteral antibiotics at home. Daily telephone contacts with the supportive care nurse practitioner became the primary mode of monitoring and support for the patient and his parents. Although community nursing has been available to make home visits, this family felt that it was the strong bond with MSKCC and continuity of care that facilitated the patient’s remaining at home during this prolonged period of time. It was hypothesized that regular visual contact between the patient and his supportive care team would enhance communication and decrease the anxiety and isolation experienced by both the patient and his parents. The patient and his parents were identified as likely to benefit from audio-visual communication for the following reasons: 1) he was essentially home-bound and socially isolated, 2) he had complex medical and psychological needs, 3) his parents bore the primary responsibility for his physical and emotional care, 4) his parents were responsible for managing complex equipment, 5) his parents needed ongoing education and guidance as his symptoms and emotional needs changed, 6) his parents benefited from a sense of shared responsibility for day-to-day decision making around
173
his care, and 7) his parents benefitted from day-to-day support and acknowledgment of a job well done. Because patients on the Palliative Care Service may be beset with numerous neurological deficits, it is sometimes difficult for them to easily visit the hospital. In this patient’s case, the ability to converse with supportive care personnel via the telephone was especially problematic due to his hearing loss. A solution was needed that would aid him and others like him, during the palliative care process. While internet-based solutions are relatively inexpensive and easy to implement, they are limited to personal computer (PC) owners who must deal with the service vagaries of the internet. Therefore, we focused on a solution that would provide video and audio communications via traditional phone lines. A trial of a commercially available audiovisual system that could be placed in a home using standard telephone wires and not require a home computer system, was initiated. After reviewing the available technologies, a commercially available videophone (TeleEye 324 TM, LeadTek Research, Inc., Fremont, CA) was selected. Each unit is an affordable (less than $500) set-top video-conferencing system that combines with a standard television or PC monitor and a regular analog phone line or POTS (Plain Old Telephone System) to create a complete video-conferencing solution. The unit conforms to VideoPhone Standards that specifies a common method for video, voice, and data to be shared simultaneously over highspeed modem connections. Each unit provides a high quality digital CCD (Charge-Coupled Device) camera with full motion video up to 15 frames per second (fps). This is about half the quality of broadcast TV-quality video, which is transmitted at 30fps. Using the on-screen feature menu, one can adjust the quality of video images between a slide-show type experience, with slower motion and very clear pictures to full-motion imaging with less clarity. Each unit connects to either a television or PC monitor and to a standard telephone. The video image can be displayed using three different video display formats and bi-directional audio is established through a telephone handset or speakerphone. The patient and his parents were enthusiastic about the use of the TeleEye. After a trial in the hospital, a home visit was made by his Pain
174
Coyle et al.
and Palliative Care attending and Supportive Care nurse practitioner who were familiar with the equipment. The TeleEye was installed in his home connected to a television, and the family was instructed in its use. The same type of set-top videophone attached to a computer monitor was set up in the office of one of our supportive care nurses. At the end of the 3-month trial period the Pain and Palliative Care team could identify the following medical and social benefits to this patient: 1) an immediate impromptu limited general physical exam became possible, 2) “curb side” evaluation with an attending or consultants became possible, 3) the patient’s obvious pleasure at visual contact with clinicians, 4) the oportunity for visual clues for this patient with profound hearing loss improved communication by maintaining and expanding the conversation. From the practitioner’s viewpoint, the TeleEye system also cut down on, although did not eliminate, the need for supportive home visits. As compared to home visits, telecommunication is less comprehensive, but it is more readily available, appears to be less intrusive, and needs less preparation from both parties.
Discussion The technology of teleconferencing spans several decades, dating back to the first videophone announced by AT&T at the 1964 World Fair. However, due to its high cost and limited availability, it failed to attract buyers. In the late 1960s and early 1970s, teleconferencing was applied to applications such as telemedicine, distance learning, and criminal justice in an attempt to add credibility to the technology. In the 1970s, about a dozen companies attempted to introduce teleconferencing products. However, it had limited commercial success.6 In the 1980s manufacturers began developing teleconferencing solutions using proprietary standards in an effort to increase their market share. Companies using such proprietary solutions could not interoperate with other proprietary systems. This, again, abated any widespread acceptance of the technology. However, by the late 1980s, teleconferencing consumers, equipment manufacturers, and service providers realized that open standards were necessary. The International Telecommunications
Vol. 23 No. 2 February 2002
Union (ITU), in turn, began developing a series of recommendations, known as the H-series, which would comprise the core technologies for multimedia teleconferencing.7 By the 1990s, improvements in compression algorithms, affordable desktop computers and software, economically priced systems, the availability of leased and switched telephone services, and the adoption of the ITU’s H-series standards stimulated the interest in teleconferencing solutions.7,8 One should be aware, however, that proliferation of easily accessible private patient information for multiple members of the medical team rises a question of legal and ethical responsibilities to protect patient’s rights and confidentiality.9,10 Today, 39 states have laws or regulations governing telemedicine.11 Further research is being conducted on existing telemedicine systems, with both private and public sectors learning about the benefits. Allowing isolated practitioners to consult specialists and communicate with colleagues, as well as participate in research and clinical projects, and advance their clinical skills, are the areas of telemedicine research focus. Transmission costs are now relatively low and equal to that of a phone call, with typical hardware costs under $500 per station. Institutions and medical centers throughout the world are taking advantage of this reliable and economical technology. Typical examples of teleconferencing solutions today include a hospital health care facility in Minnesota whose “telemedicine network exists to improve access of specialists to rural locations, particularly emergency coverage, to provide continuing education for physicians, nurses, and other providers and employees.”12 An academic medical center in Michigan uses the technology to provide community and patient education on caring for the chronically ill elderly, as well as persons with disabilities (i.e., traumatic brain injury, spinal cord injury).13 A rehabilitation center in Missouri uses interactive video-conferencing to conduct one-on-one training between a rural mental health generalist and a neuropsychologist in an academic medical center.14 A hospice facility in Missouri uses teleconferencing to augment specialized non-interventional care given to terminal patients.15 A Tele-psychiatry clinic uses teleconferencing to provide psychiatric care to rural areas. Services include group
Vol. 23 No. 2 February 2002
Audio-Visual Communication in Palliative Care
as well as individual therapy, medication checks, and initial evaluation to children and adults in Kansas.16 Additionally, programs in tele-ophthalmology, tele-mammography, tele-radiology, and tele-pathology are other common uses of this technology.17–20 While there exists many applications and solutions, utilization of this technology should focus on increasing the quality of patient care.21 With further trials planned for this year, we hope the audio-visual system will have an impact on patient care in the palliative care service.
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search and program development. Psychiatr Serv 2000;51(12):1522–1527. 6. Rosen E. The history of desktop telemedicine. Telemedicine Today 1997;5(2):16–17, 28. 7. Irakliotis LJ. Multimedia communications defy boundaries of space, time. OE Reports 1997 (October). http://spie.org/web/oer/october/oct97/multimedia.html. 8. Videoconferencing System Manufacturers.http: //www.integrated1.com/videoeqp.html. 9. Walter GF, Matthies HK, Brandis A, von Jan U. Telemedicine of the future: teleneuropathology. Technol Health Care 2000;8(1):25034. 10. Nohr LE. Telemedicine and patient’s rights. J Telemed Telecare 2000;6(Suppl 1):S173–S174.
Conclusion Organizations deploying teleconferencing systems must make key decisions. These decisions include cost, availability, quality of service, security, and transmission services, among others. Palliative care may benefit from this technology, as an additional tool bringing a different level of palliative care to the patient’s home. This may be helpful in providing state of the art palliative care for the most complex palliative care patients, isolated in their homes by their medical conditions.
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