1. 1st ISG Masterclass Gerontechnology Eindhoven, may 22nd – 23rd, 2006 International Society for Gerontechnology and the Herman Bouma Foundation for Gerontechnology Telemedicine as a technologyin Gerontology AFranco@chu-grenoble.fr

2. Evidence for the benefits of telemedicine • Hailey al., J Telemed and Telecare, 2002; 8/1: 1-7. • 66 studies from 1996 to 2000

3. Most convincing applications of telemedicine Hailey al., J Telemed and Telecare, 2002; 8/1: 1-7. • Teleradiology (neurosurgical applications) • Telemental health • Echocardiographic images • Teledermatology • Home care • Medical consultations However number of papers had methodological limitations

4. Two modal approaches of telemedicine Video phonic mode (real time communication): teleconsultation, videoconferencing… Computer mode (data, information: real time or postpone communication): actimetry, dialysis data collection…

5. LI2G: Laboratoire interuniversitaire de gérontologie, Grenoble • Program Teleger Grenoble 1994-1998 • Feasibility of videoconferencing in geriatric environment: • Technical, clinical, psychological, law, ethics, economy, of teleconsultation and tele-assistance • Integrated multidisciplinary research • Telegerontology

6. Applications of Telegerontology • Teleconsultation • Surgery • Dermatology • Psychology

7. Videoconferencing device • Standard • Adapted to health care

8. ISDN (RNIS – Numeris (F) • Integrated Services Digital Network • Réseau Numérique d ’Information et de Service • 1 line = 64 kbit/s = insufficient for VC • 2 = 128, 4 = 256, 6 = 384

9. Applications of Telegerontology • Telepsychometry

10. Telepsychometry • Needs • to know if the remote investigation of cognitive or psycho-affective disorders is available for elderly patients • to explore the psychological impact of remote consultations with elderly people

11. Methods (1) • Comparison of a conventional and a video-linked consultation • Included : fifteen geriatric inpatients • Excluded : visual or auditory defects and psychiatric history • Patients gave their oral consent

12. Methods (2) • The order of the two consultations varied randomly, separed by one week • An interview and two psychometric tests were proposed : • MMSE (Folstein 1975) and Clock Face Test (Montani 1997)

13. Methods (3) • A follow-up interview was conducted by an observing psychologist to assess the patient's perception of each consultation • The interviewer and the observer independently rated a scale measuring their impressions

14. Telepsychometry

15. TelepsychometryMONTANI al, Journal of Telemedicine, Vol 2 : 2, 1996, 145-149

16. Scores obtained on the MMSE

17. Scores on the Clock face test

18. Consultations mean duration

19. Telepsychometry • Video-psychometric consultation can be applied successfully with elderly people • Different tests can be used, even the graphic tests • A short decreased performance was observed .../...

20. Telepsychometry • Clinical characteristics can be evaluated • It was judged acceptable by the patients and the psychologist • Quality and efficiency may improve with the training of the clinician

21. Applications of Telegerontology • Telehomecare or Hometelehealth

22. TelehomecareMERRELL RC Telehomecare: where are we ? Telemedicine & e-health 2006;12:79-80 • Decline by 30% in hospital beds. • Decline in average length of stay. • Ponderous shift in care from hospital to ambulatory environment and the home. • Heart failure, diabetes, asthma, COPD • Nursing shortages (1 million in US ?) • Redesign for professional nursing • Telehomecare, a special interest group of the American Telemedicine Association • Overwhelming worldwide interest

23. ViSaDom1997-2000 Purpose • To study the feasibility and utility of videophony by a videoconference based system providing health care at home (Hospital-at-Home) for the elderly patients.

24. ViSaDom Material • Hospital-at-Home in Grenoble • ViSaDom device • ViSaDom network

25. Hospital-at-Home : Agglomeration of Grenoble, France • Continuous and coordinate care are provided for the patients: • Adults and Elderly • Pediatric population • Pregnant women

26. ViSaDom device • The device of videophony • is a video conferencing system, • equipped with a video camera driven from the hospital-at-home offices, • through a telephone ISDN line of 128 Kbps.

27. ViSaDom principles • It allows to communicate orally and visually with the patient(s) at home from the hospital. • It permits to see oneself, to pass on documents, to show wounds, and to take photos. • The patient has the initiative to call the center and is free to answer or not when he is called.

28. Carer’s Station Patient’s Station Open ISDN Office 128 kbit/s Closed Hospital SAMU 38 Home ViSaDom Network Département de Médecine Communautaire du C.H.U. de Grenoble1 – Pr Alain FRANCO france telecom R & D

29. Prototype in the Office • Touch screen PC • Joystick for the remote CCD Camera • Microphone and loudspeakers • Color Printer

30. ViSaBox at patient’s home • High contrast LCD • Remotely controlled system and camera • Wireless Headphones • Wireless keyboard

33. Method • Randomized selection • 30 patients of HaH, 16 have the videophone device , 14 controls. • Investigations: • functional dependence (ADL), • health state (KARNOFSKY), • depression and anxiety (Hospital Anxiety and Depression Scale) • open interviews were conducted.

34. Results: communications • Four categories of communications were identified : • patient’s or family’s education, • forwarding of medical data, • forwarding of logistic information, • cooperative work between the general practitioner, nurse, patient at home and hospital practitioner in the hopital-at-home offices.

35. Direction of communication : H -> home 48 % home -> H 52% Average time spent per patient : 6’ per call Range = 1’ - 19’ Average duration of use per patient : 46.7 days Range = 12 - 86 Users : patients, nurses, caregivers, GP, hosp. doctors,... Results: communications

36. Case (1) • An 89-year-old man • Irreducible dislocation of Total Hip Prosthesis • Rehablitation in the home • Care of heel pressure sore • Six weeks follow-up using ViSaDom • 24 communications • Regular participation of the spouse

37. Case (2) • A 73-year-old woman • Post-laparotomy abdominal wound • Programmed care • Wound dressing • Thirteen weeks follow-up • 30 communications

38. ViSaDom: screen photography

39. ViSaDom: screen photography

40. ViSaDom: screen photography • Évaluation and follow-up of wounds, sores, and burns (depth, color, etc.) • Provision of assistance to the nurse during home health care

41. Case (3) • Supervision during artificial nutrition • Training of the caregiver

42. Case (4) • Peritoneal fluid tap • Medical information • Multidisciplinary consultations • Assistance in decision making

43. Case (5) • Drug compliance and patient education

44. Results: Anxiety scale (HADS) Patients Control The anxiety score is significantly lower for the patients with videophony than for the control patients (p<0.05). 16 14 12 10 8 6 4 Week1 Week 4 Week12

45. Health care professionals: Tool in medical decision making Tool in health care coordination (/ joint follow-up by doctor-nurse) Tool for education Patients: Breaking isolation feeling of rapid and close communication with the professionnal carer. New relations with health caregivers => feeling of security. Results: opinionsL. NICOLAS, Presse médicale, 2005

46. Discussion • Interest in establishing visual links. • Virtual visit « to the patient’s bedside ». • Respect of patient’s autonomy and privacy. • Factors facilitating communication: - Type of pathology - Infrequent visits - Without any obstacle related to aging Allen A, Journal of Telemedicine and Telecare 1999; 5

47. Discussion (2) • Ethics and legal aspects: • Responsibility • Security • Confidentiality • Precaution • Clarity • Benifits Hervé C, Informatique et Santé 1996; 8 Ordre National des Médecins: www.ordmed.org/

48. FINKELSTEIN SM, al: Home telehealth improves clinical outcomes at lower cost for home healthcare. Telemedicine & e-health 2006;12:128-136 58 pts; C 8/19; V 3/14; V+M 3/19 NS

49. FINKELSTEIN SM, al: Home telehealth improves clinical outcomes at lower cost for home healthcare. Telemedicine & e-health 2006;12:128-136

50. Conclusion • Large number of communications could help in taking medical decisions at a remote site in real time. • The teleassistance allows new aspects in medical and nursing practices as well as better coordination in real time instead of delayed time • The teleassistance increases for the patients the feeling of safety.