The effects of redesigning the IDEATel architecture on glucose uploads.

The objective of this evaluation was to determine the effect of redesigning the Informatics for Diabetes Education and Telemedicine (IDEATel) telemedicine architecture on the average upload delay and on the average number of glucose uploads to a central database. These two measures positively influence our ability to deliver timely and accurate patient care to the study population. The redesign was also undertaken to improve the patients' experience in using the system and thereby increase the frequency and timeliness of their self-monitoring behavior. Using the total number of glucose uploads, we compared the delay in glucose upload times according to the type of home telemedicine unit the study participants used and the region where the participants lived. The participants were Medicare beneficiaries with diabetes living in medically underserved neighborhoods in New York City and rural Upstate New York. The populations in these two regions differed considerably in terms of ethnicity, language spoken (Spanish, English), and education level. Participants who had Generation 2 (Gen 2) (mean = 10.75, SD +/- 7.96) home telemedicine units had significantly shorter upload delay times (p < 0.001) as measured in days than those participants with Generation 1 (Gen 1) (mean = 22.44, SD +/- 11.18) and those who were upgraded from Gen 1 (mean = 20.67, SD +/- 8.85) to Gen 2 (mean = 14.93, SD +/- 9.37). Additionally, the delay was significantly shorter for participants living upstate (mean = 24.14 days, SD +/- 11.95 days) than downstate (mean = 15.30 days, SD +/- 7.87 days), t (975) = 13.98, p < 0.01. The system redesign made a significant impact in reducing glucose upload delays of IDEATel participants. However, upload delays were significantly impacted by the region where the participants resided.

A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus.

BACKGROUND: Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness. METHODS: The authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels. RESULTS: In the intervention group (n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c > or =7% (n = 353). In the usual care group (n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18% (p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c > or =7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York. CONCLUSION: Telemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up.

The role of nurses in installing telehealth technology in the home.

Home telehealth involves the use of video conferencing or remote monitoring equipment in patients' homes. The installation of hardware and training of patients has historically been performed by nurses, typically RNs. This article examines the experience of RNs as telehealth installers in the Informatics for Diabetes Education and Telemedicine (IDEATel) project, where RNs were responsible for the installation of the Home Telemedicine Units (HTUs) and for training patients in the use of the HTUs, blood pressure cuffs, and fingerstick glucose meters. Average installation and training time was 166 minutes (SD 51 min). Structured interviews with RN installers revealed that patient education and training accounted for roughly two thirds of the in-home time. Technology-related problems, especially those related to telecommunications, were the primary cause of installation difficulties. Thematic analysis of installer interviews identified eight major themes and confirmed the importance of both clinical and technical knowledge during the telehealth installation process.

Developing computer skills and competencies in seniors.

We developed a training protocol for elderly participants of a home telemedicine study, grounded in prior usability research. The training aimed to reduce barriers in developing system mastery. Our findings are indicative of both the promises and challenges involved in bridging the digital divide. Sixteen participants of a diabetes study were trained to use the computer applications.

Usability in the real world: assessing medical information technologies in patients' homes.

OBJECTIVE: This paper presents an approach to usability evaluation of computer-based health care systems designed for patient use in their homes. Although such devices are becoming more prevalent, there is very little known about their usability. DESIGN: The theoretical foundations for the methods are discussed. The approach incorporates a cognitive walkthrough usability evaluation and new methods for usability testing that can be conducted in patient's homes. The method was applied to the IDEATel intervention, a multi-institution randomized controlled trial of the feasibility, acceptability, and clinical utility of a home-based telemedicine system for diabetic Medicare population. The usability study was designed to assess barriers to optimal use of the system. The focus was both on dimensions of the interface and on dimensions of patient skills and competency. The usability field research involved testing 25 patients in their homes using the system. The analysis included a range of video-analytic methods of varying levels of granularity. RESULTS: The usability evaluation revealed aspects of the interface that were sub-optimal and impeded the performance of certain tasks. It also found a range of patient-related factors such as numeracy and psychomotor skills that constituted barriers to productive use. CONCLUSIONS: A multifaceted usability approach provided important insight regarding use of technology by an elderly chronic-care patient population and more generally, for understanding how home health initiatives can more effectively use such technology.

A cognitive framework for understanding barriers to the productive use of a diabetes home telemedicine system.

Telemedicine has the potential to transcend geographic and socio-cultural barriers to the delivery of high quality health care to the medically underserved populations. However, there are significant cognitive and usability barriers. This paper presents a multifaceted cognitive evaluation of the IDEATel diabetes education and telemedicine program. The evaluation included a cognitive walkthrough analysis to characterize task complexity and identify potential problems as well as field usability testing in patients' homes. The study revealed dimensions of the interface that impeded optimal access to system resources. In addition, we found significant obstacles corresponding to perceptual-motoric skills, mental models of the system, and health literacy. The objective of this work is to contribute to a design framework so that participants with a wide range of skills can better manage their chronic illnesses.