Wednesday, November 3, 2010

Telemedicine: more than what the doctor ordered

Several years ago, I cared for an elderly woman with heart failure, diabetes, and high blood pressure who had at least one major health problem at every office visit. I'd get her blood sugar levels under control only to find that her blood pressure had risen dangerously. I'd adjust blood pressure medications only to find her short of breath with swollen legs—a sign of worsening heart failure—at her follow-up appointment. The trouble was, I had no idea how well she followed my instructions in between visits which occurred every month or two. Had her blood pressure been soaring at home for the past few weeks or only during the hour she was in my office? I had no way of knowing.

Family physicians often have a tough time monitoring chronic health conditions, which leads to poor management of those conditions. Only half of the 65 million Americans with hypertension have achieved good control, according to a recent commentary in the American Journal of Managed Care. And it's not hard to understand why: A patient's blood pressure at an office visit may not be an accurate reflection of what the reading typically is at home; in fact, it's often much higher, leading doctors to coin the term "white coat hypertension." Knowing this, doctors are often reluctant to increase medication doses or add new medications; we're afraid of lowering blood pressure too much, which can make patients lightheaded and cause them to stop taking their medications altogether.

Given this unacceptable situation, family doctors need to adopt a new model of care that includes more frequent contacts with patients and adjustment of medications based on blood pressure monitoring at home, stress the authors of the AJMC paper who are affiliated with the University of California at San Francisco. They suggest that hypertensive patients receive home monitors to check their blood pressure on a daily basis and record the readings in a paper or electronic log. Nurses, medical assistants, or other "health coaches" should call patients every two weeks in between office visits to check on their blood pressure readings and provide counseling on lifestyle changes, such as starting an exercise program or reducing dietary sodium. If a patient's home blood pressure readings are too high, a medication dose can be increased using standard protocols that are pre-approved by the doctor. This model is supported by research: A 2008 study published in the Journal of the American Medical Association found that patients who received home blood pressure monitors and regular contacts from a pharmacist through a secure Web site were significantly more likely to achieve blood pressure control after one year compared to patients who weren't monitoring themselves.

Of course, remote monitoring or telemedicine for chronic health conditions has applications beyond blood pressure management. Remote devices can send the results of blood sugar readings or body weight measurements, in addition to blood pressure readings, from your home directly to your doctor's office. Studies conducted by the Veterans Health Administration have demonstrated that daily body weight measurements on scales remotely linked to doctor's offices can help reduce re-admission rates for heart failure patients, a major factor in reducing ballooning health care costs. In fact, 12 states now require that health insurance plans cover telemedicine services, and 25 states reimburse doctors for telemedicine services through their Medicaid programs.

Even in states that don't mandate coverage for home health monitoring, many health insurers are introducing pilot programs that provide free equipment to selected patients, provided that their doctors show they're utilizing the data to improve care. If you have high blood pressure or another chronic health condition that might benefit from monitoring in between office visits, it's worth checking with your doctor and insurance provider about options that could be available to you at little or no cost.


The above post was first published on my Healthcare Headaches blog at

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