From compressors, to nebulizers, to peak flow meters, there is no shortage of asthma products to stock the shelves of HME showrooms and pharmacies. Add to that ancillary products, such as air purifiers and allergen control items, and one could devote an entire store just to asthma care.
Such a wealth of product options is hardly surprising when one considers that asthma is the most common chronic disease in the United States. In 1995, it affected more that 15 million persons.
Unfortunately, while there is no shortage of treatment options, up until recently there have been fewer choices for ensuring compliance with treatment.
Lack of treatment compliance can have serious consequences. Each year, asthma causes more than 1.5 million emergency department visits, approximately 500,000 hospitalizations, and more than 5,500 deaths. Missed school days due to asthma account for approximately 14 million school absences per year.1 All total, the estimated direct and indirect costs for the disease were $11.3 billion in 1998.2
However, advances in information technology could improve these numbers and create an opportunity for home health care providers with respiratory disease management programs.
Portable electronic monitoring devices that are used by patients in the home can expand compliance with testing and medication measurements. In addition, the growing acceptance of the Internet as a common part of home life has created an opportunity for real-time monitoring of compliance using several new technological innovations.
There are two questions that must be answered when it comes to monitoring patients’ asthma in the home. First, can the patients, many of whom may not be technologically adept, readily accept and use the new technology? Second, can it be determined that the overall cost of the technology is cost-effective?
Several successful models have demonstrated that telemedicine is redesigning patient treatment through customized and continuous care, rapid sharing of data, coordination of therapy, and evidence-based decision support. For example, a home monitoring program using a personal computer that incorporates spirometry, blood pressure, and pulse oximetry data into a respiratory assessment profile can facilitate the effective management of patients with asthma and lung transplantations by performing initial error detection, exchanging information, and analyzing data trends.3
A recent study4 sought to evaluate the validity of spirometry self-testing during home telemonitoring and assess the acceptance of an Internet-based home asthma telemonitoring system by using the system with asthma patients from a low-income inner-city area that were not computer literate. After a 40-minute training session, the patients completed an electronic diary and performed self-spirometry testing twice a day for 3 weeks. The majority characterized the self-testing procedure as “not complicated.”
Educational Issues
If these patients could easily master using the Internet to transmit spirometry data and symptom reports to their physicians, other patients may encounter few problems. However, there are several educational issues that should be addressed when using electronic asthma monitoring equipment says Jud Schoendorf, MD, MBA, chairman of the American Lung Association of Los Angeles County and chair of the Professional Practices Workgroup of the Long Beach Alliance for Children with Asthma, Long Beach, Calif.
“Electronic monitoring equipment, while promoting accuracy and better disease management, still requires compliance from both the patient and the physician,” he says. “The physician needs to be aware of how and when to respond.”
Also, many newly diagnosed asthma patients are young children, and educational and medical compliance of these patients is an important concern, says Johanna Goldberg, director of Community Outreach and Education at Los Angeles Care Health Plan.
“When a young child is diagnosed with asthma, the entire family becomes involved,” she says. “Asthma management comes from educating children and their parents. Understanding the physiology, the importance of medications, and using devices properly is all part of managing the disease.”
While children are learning more about computer technology in the classrooms, Schoendorf also wonders if both young and old patients will remain as compliant with electronic monitoring once the devices become more common.
“How long are asthma patients going to keep using the new reporting technology once the novelty wears off?” he asks.
Device Options
Currently, electronic monitoring devices serve two important purposes. First, the patient is spared the anxiety of an unexpected task and thus is given a sense of control over the disease. Second, the treating physicians and therapists can collect valuable trend data for long-term therapeutic planning.
For example, one relatively inexpensive device eases patients’ worries of being caught with an empty inhaler by simply tracking the use of medication taken from an MDI. The device has a self-contained microcomputer, which counts and displays the number of inhalations remaining in the inhaler and displays the number of inhalations taken in the current day. The device also stores the number of inhalations taken in each of the last 30 days in its memory and alerts the user when the MDI is nearly empty.
Knowing when the inhaler is nearly empty without such a device is difficult as patients cannot look inside inhalers to see how much medication is left. Shaking or floating the inhaler is only guesswork and can leave patients unprepared. With this device, they always know exactly how many inhalations are left in the canister at all times.5
Mechanical devices for serial monitoring of lung function such as the peak flow meters, are also quite useful in managing asthma. Most peak flow meters are robust and provide reproducible results essential for serial monitoring. However, they often vary in accuracy, and, because they provide only a single effort-dependent index of ventilatory function, they have limited application in the initial assessment of respiratory diseases.
However, as the data collection increases, peak flow monitoring becomes useful for following trends in lung function, quantifying response to treatment, and identifying trigger factors in asthma.
Recently, manufacturers developed several small, inexpensive, yet accurate battery-powered devices—some of which are capable of accurately measuring several indices of ventilatory function, and downloading the results together with the date and time to a computer to facilitate subsequent analysis by the physician.6
With continued advances in flow sensor technology, these inexpensive electronic portable spirometers could someday replace traditional peak flow meters.
Portable Devices Using Telemetry
Because there are devices that combine spirometers (peak flow) and pulse oximeters with an enhanced internal memory chip to accommodate delayed data transmission, home health care providers can extend the benefits of daily monitoring to patients suffering from a range of chronic diseases, even when they are away from home.
One such device can transmit physiological data directly from measurement devices used by patients with respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) using a standard telephone line. For disease management companies currently receiving daily physiological data from patients via hand-written journals or interactive voice response (IVR) methods, this device can eliminate inaccurate readings, costly human errors, and noncompliance issues.
The device also includes an enhanced flash memory chip, enabling it to store approximately 30 days of collected data. This is a key feature for seamlessly incorporating a home-based monitoring unit into a patient’s lifestyle, providing the freedom to leave the home while daily biometric data variances are recorded. The data can be transmitted when the patient returns home or obtains access to a standard phone line.
Electronic Daily Diary
A tool used in many studies is the daily patient diary. This process has been automated with an electronic daily diary software system that runs on patients’ personal home computers. Patients can download the software from the manufacturer’s Web site before entering their readings. Once the software is downloaded, months of data can be saved in files on the computer.
Because the device allows patients to record their peak flow readings in an electronic format, generating graphs of daily readings is simple. Patients can then print out those graphs to show their physicians at a later date, or email the peak flow readings to the physician. This record of peak flow readings and symptoms enables physicians to make important decisions about their patients’ asthma treatments.
To use this program, patients simply follow the following three steps:
Step 1. Set the dates for the peak flow graph using the pull-down menus. The start date can be today’s date or patients can change that date to fill in previous peak flow readings that have been recorded earlier. The ending date could be the date of the next visit to their physician.
Step 2. Enter the personal best rate data as determined by the physician.
Step 3. Select the date for the peak flow reading being entered. Each day, the current date will appear, but the patient can change this date if the reading being entered is from another day in the past. Then, by clicking on the “Make Entry” bar, a window will appear asking the patient to type in the reading and any other symptom or medication notes the patient may want to save. Once everything is typed in, clicking on “OK” will enter the reading.
Once entered, the reading will automatically be plotted on a green, yellow, or red zone graph based on the personal best that was entered. It will also list the reading and notes in the “Diary Listing” section. The “traffic light” will then light up with a zone color and a message will appear below it to alert the patient to the asthma action needed based on the current peak flow reading.7
Another software system for asthma patients that may be used on any desktop computer, Palm OS, or Pocket PC device and can be accessed through any Web browser plots peak flow readings, drug usage, and nocturnal and exercise-induced asthma.8
Acceptance
Despite promising results, these new technologies have encountered some resistance. While some internists welcome the influx of home health care technologies, others remain skeptical, citing concerns about privacy, impersonal care, and reimbursement issues. Some physicians worry that a patient could make a mistake using the technology and transmit incorrect information. Other physicians fear that if nurses do most of the day-to-day monitoring, physicians will not properly review the data and will lose touch with their patients.
Reimbursement is probably the single largest concern keeping physicians from embracing these types of monitoring technologies. The average cost to the patient for these devices ranges from $40 to $150 with little reimbursement available from third-party payors. However Medicare has begun limited coverage of some devices,9 and device manufacturers are working to expand this by educating payors about how these types of devices will save money in the long run.
 In the always growing and changing HME market, companies that stand still get left behind. That is one of the reasons why manufacturers, such as CHAD Therapeutics, Chatsworth, Calif, constantly work on ways to expand. Dealer/Provider spoke with President and CFO Earl Yager about the company’s dedication to innovation.How has CHAD grown through the years?
By being a technological leader in the oxygen niche of the respiratory care market. We develop and market innovative products that improve the quality of life for oxygen patients while at the same time reduce the operating costs of the home care providers who service those patients. In addition, our conservers have a proven record for reliability, which further enhances their cost-effectiveness. Why did the company decide to introduce a pneumatic conserver?
CHAD had always been focused on electronic conservers. However, when Tom Jones became CEO in 1998, he recognized that we needed to offer a full line of oxygen conservers to be responsive to our customers’ needs. We started by developing a new line of electronic conservers with state-of-the art features followed by the introduction of the CYPRESS OXYPneumatic® conserver in the summer of 2002. We can now offer a complete family of oxygen conservers to meet both patients’ and home care providers’ needs and preferences. What are the benefits of pneumatic vs electronic conservers?
In general, pneumatic conservers are lighter than electronic conservers and do not require batteries, while electronic conservers are more precise in their oxygen delivery, thus conserving more oxygen and allowing more ambulatory time for patients and greater operating cost savings for the home health care provider. CHAD’s CYPRESS conserver allows the use of a standard single lumen cannula while most other pneumatic conservers require the use of more costly dual lumen cannulas. In addition, the CYPRESS conserver provides greater than 3:1 oxygen conservation where most other pneumatic units can deliver only 2:1 savings, a significant advantage for patients and providers. What areas do you see CHAD moving into in the future?
We recently entered into a series of product development and licensing agreements that are directed toward the development of products in two areas. The first is to expand and enhance CHAD’s product lines in our core oxygen business. The second is to develop some innovative new products that address potential applications in the growing sleep disorder market. What one aspect of business do you believe is the most important to a successful manufacturer/provider relationship?
Besides being a technological leader, I believe our ability to respond to the marketplace and our focus on respiratory products allow CHAD to anticipate and react to the changing business environment and our customers’ needs and preferences. We are a relatively small company when compared to some of our competitors, but we have been successful by maintaining our focus and being responsive to our customers’ demands. | |
Kathleen M. Norulak, RRT, RCP, is the owner of Pulmonary Education and Testing Services, a consulting organization in Torrance, Calif.
References
1. Mannino DC. Surveillance for asthma—United States, 1980-1999. Morb Mortal Wkly Rep MMWR. 2002;51:10-17.
2. US Department of Health and Human Services. Data fact sheet asthma statistics. Public Health Service. 1999:1-4.
3. Szalados JE. Telemedicine allows care to reach the farthest outposts. Advance for Managers of Respiratory Care. 2002;5:42-44.
4. Finkelstein J, Cabrera MR, Hripcsak G. Internet-based home asthma telemonitoring—can patients handle the technology? Chest. 2000;117:148-155.
5. Electro Magnetic Solutions. The Doser works in conjunction with your inhaler. Available at: http://www.doser.com. Accessed June 5, 2002.
6. National Asthma Council Australia. Leading the attack against asthma. Available at: http://www.nationalasthma.org.au. Accessed June 5, 2002.
7. Respironics Inc. AsthmaMentor electronic daily diary software. Available at: http://www.respironics.com. Accessed June 5, 2002.
8. Health Engage. The power of better health. Available at: http://www.healthengage.com. Accessed June 5, 2002.
9. Palmer I. Products for providing home care remotely. ACP-ASIM Observer (American College of Physicians-American Society of Internal Medicine); July 2001.
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