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| Home : Volume 24 : Winter 1997-98 : | |
| Engineering the evolution of health care | |
It's been said that telemedicine started with the first set of heath care instructions sent over the telegraph. As far as it has come from that point, health care delivered via telecommunications is about to leap again and then some. Dubbed the "new frontier" of health care delivery, telecare promises to bring more needed services more frequently and less expensively to the average person. Patients with HIV/AIDS, diabetes and other chronic diseases or conditions are among test groups receiving "tele-services."
Professor Patricia Flatley Brennan is researching the use of computer networks to provide the presence of a nurse whether it is through counseling or teaching and education. With a $1 million grant from the National Library of Medicine and the National Institutes of Nursing, Brennan and co-investigators David H. Gustafson, industrial engineering, UW-Madison, Shirley M. Moore, Case Western Reserve University and Ralph O'Brien, Cleveland Clinic Foundation, are designing a customized Internet computer support system called HeartCare.
Professor of the School of Nursing and Industrial Engineering Patricia Flatley Brennan.
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Most cardiac artery bypass graft (CABG) patients are discharged 96 hours after heart surgery. HeartCare will help them from the moment they go home through their 12 or more weeks of cardiac rehabilitation.
"Twenty years ago, if you had open heart surgery you were in the operating room for eight hours, on ventilator for two to three days and in the intensive care unit (ICU) for a week. The whole hospital stay was two to three weeks," Brennan explained. "Today you're in the operating room for three hours, on the ventilator for an hour, in the ICU for eight hours and you're home in four days."
That means that some things nurses did for patients in the hospital, such as monitoring discharge preparation, and watching cardiac rhythm, patients now have to do at home. Most people don't get home nursing care after cardiac surgery and are not sick enough for a doctor to visit until four to six weeks after surgery. Brennan said the HeartCare system will be a mechanism to help patients make the transition from hospital to home to recovery.
The system uses the World Wide Web to tailor specific instructions not only to the number of days after surgery, but to an individual's preferred style of information. Nurses build a web page for the patient for each of the first six days after discharge and then one new page for every three days after that. Then it progresses to a new page every week for three weeks and a new page every two weeks for the remaining recovery period.
"We will see them two to three times while they are in the hospital and then send them home with the system," Brennan said. "As soon as they are home they have a resource for recovery and e-mail to a nurse and physician."
In addition to detailed recovery instructions, patients will have links to forums where they can discuss topics with other patients. People more interested in scientific explanations will get links to places like the National Institutes of Health. Those that like more behavioral explanations will be pointed to other resources.
The system will run on a secure computer in a newly fitted lab in the Mechanical Engineering Building. The patients will be 500 miles away in Cleveland, Ohio. The test group involves 120 men and women receiving standard post-operative care. They will be randomly divided to receive either HeartCare or an audiotape coaching program for comparison. Some patients will serve as a control group by receiving a data-collection-only visit from the research nurse. Patient outcomes to be measured will include physical function, symptom distress, psychological distress, perceived family function and adherence to cardiac risk behavior modification at four points in time.
Brennan's background in both nursing and industrial engineering make her particularly well suited for the investigation. She earned a bachelor's and master's of nursing and an MS and PhD in industrial engineering from UW-Madison. In the fall of `96 she accepted an appointment as full professor in the Department of Industrial and Systems Engineering and the School of Nursing. She received the first Moehlman Bascom professorship, established by Lillian S. Moehlman to support faculty with expertise in any area of nursing. Brennan started her research in the 1970s. She and her research team developed, implemented and evaluated a community-based computer network called ComputerLink. It was designed to provide information, communication and decision support to homebound persons and their caregivers. Her work parallels that of her former graduate advisor David H. Gustafson. Gustafson's research involves the development and testing of new systems to improve the quality and reduce the cost of health and social services.
Ideally, Brennan would like the HeartCare system to run on Internet2, a proposed high-speed, dedicated network for researchers.
"It would be so much better if we could conduct the program on a system like that. Some of the information we will be dealing with is very time sensitive. It also has legal implications regarding privacy issues," Brennan said. "If an Internet2 is built, we could take this program nationwide."
Brennan said programs like HeartCare have ramifications for the entire health care system. Ultimately, the entire clinical work process will have to be re-engineered. Society, she said, is forcing people to take more control over their behavior. She sees a health care system that makes better use of patients as clinical resources. Educated patients through will be better able to help clinicians treat them.
"If this works, by the time a patient gets to the clinic, they will be
a lot smarter and a lot sicker because they will only have come to the
clinic if they need to be there. That changes what we do in nursing
practice. No longer will we think 40 percent of patients are in for
things we don't need to see," she explained, "Now maybe only 20
percent will be like that. Nurses will be busier and working with
people with more complex diseases and hopefully, people will be able
to tell us more about their case."
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