Note: Descriptions are shown in the official language in which they were submitted.
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SXSTEM FOR PROVIDING COMPREHENSIVE HEALTH CARE AND SUPPORT
BACKGROUND OF THE INVENTION
A. Field of the Invention
The present invention relates to a system for providing affordable, yet
comprehensive, interactive home health care between a central station and
patients at
remote locations. More specifically, it concerns the apparatus, methods,
software, and
techniques to provide the assessment, evaluation, education, privacy, and
support of
an overall health care system within the sphere of interactive video home
health care.
B. Description of the Prior Art
With the aging of America and the ever-increasing costs of health care, there
is
a surge to find alternative methods of treatment. One area that has received
much
attention is in providing long-term health care services to the patient in the
home.
Typically, home care has been provided by the family, by non-professional
support personnel) or by visiting nurses. The day-inlday-out care and support
needed
by a patient at home is often difficult for the family, however, because of
busy work
schedules, lack of proper training, or because the family member responsible
for the
patient's care is elderly or otherwise incapable of coping with the stress of
consistent
patient support. While in-home nurse visits are the preferred method of
patient care,
the high costs of professionally trained personnel as well as the increasing
demand for
such personnel due to the aging population forecasts a future where such
visits would
by necessity be infrequent, short, and expensive. Similar problems may be
predicted
for home visits by non-professional support personnel. While visits by such
non-
professional personnel may be less costly, allowing in theory for more
frequent visits,
the ever-increasing demand of an older population, logistical problems
inherent in
physically traveling to a patient's home, and the potential for inconsistent
training of
such personnel still create a situation where such visits can not match the
consistent
support and medical expertise offered in a hospital or nursing home
environment.
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In the typical home care setting, whether a patient is cared for by family or
by
visiting professional or non-professional health care personnel) most of the
patient's
day is spent alone and isolated without physical and emotional support. Such a
patient
must, for the most part, manage their medicines and other health care needs
independently. In addition, whether the home care is undertaken by the family
or
through home care visits by a nurse professional, there is no one readily
available to
answer medical questions for the patient as they arise or provide timely
feedback and
education as situations develop. Finally, due to the high costs of home
monitoring
equipment, most patients do not have access to the necessary diagnostic
equipment.
Therefore, where the family has undertaken the home medical care, the patient
still
must be frequently transported to a doctor's office or other medical facility
to achieve
adequate evaluation and follow-up.
One potential solution which has received some focused attention lately is in
the
area of interactive telemedicine. Tests and studies begun as early as the mid
'1970's
have consistently shown a dramatic improvement in the physical, emotional, and
psychological well being of patients receiving regular and frequent contact
through
some means of interactive telemedicine. Particularly noteworthy is the overall
increase
in patient recovery rate as a function of frequency of interaction by the
patient with the
doctor. In fact, some tests have indicated as much as a 50% reduction in
hospital
readmissions, a reduction attributed to the teleconferencing aspect of the
telemedicine
home visit concept. Further, where frequent and targeted education is provided
to
patients) the patients show dramatic improvements in their capabilities for
self care and
their ability to function independently.
Despite these clear advantages, the high costs of the early two-way
interactive
video communication models, which involved expensive transmission technology
such
as high speed compression and costly telephone line charges, made use of
interactive
audio and video cost prohibitive for the daily or even more frequent
electronic visits
required to provide effective in-home care to individual patients. Further,
these early
models failed to provide an overall system of health care to address the
comprehensive needs of patients.
An early attempt at providing a means of affordable two-way communications
by way of two-way community antennas, closed circuit television system, or
community
cable television systems is presented in U.S. Patent No. 3,668,307 to Face, et
al. This
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system, however, still requires expensive switching and controller equipment,
making
application to single patient sites cost prohibitive. Other drawbacks of this
system are
that it does not always supply a reliable signal due to limited communication
band
width for two-way video systems, the quality of real-time video communication
or the
ease of access required for daily, in home medical care.
As in the Face et aL Patent, other two-way communication systems proposed to
date focus primarily on the hardware and communication aspects. For example, a
two-
way communication system between a central medical station and each of a
plurality of
subscriber terminals via a community antenna television CATV network is
disclosed in
to U.S. Patent No. 5,434,611. This system involves the placement of a MCA line
controller at the head end of the directional transmission lines of a standard
CATV
network system. Said line controller functions to facilitate simultaneous use
of the
communication lines for medical visits and normal television broadcasts by
assigning
an unused channel for such telecommunications. The MCA system further permits
the
automatic monitoring of patients by initiation of a signal by the central
medical station
or doctor's office. One drawback of such a system is in its failure to
consider the
concerns of patient security and confidentiality posed by a system which
permits
unilateral activation by the central station.
Another drawback, as previously mentioned, is that systems such as those
prescribed in U.S. Patent Nos. 3,668,307 and 5,434,611 concern only the
mechanics
of communication of video and data across bi-directional lines and the basics
of
initiating such communication flow. In so doing, proper consideration has not
been
given to integrating the fundamental components required for an effective,
comprehensive health care program into the mechanics of interactive video
medicine.
Just as a school system is more than the books, the desks, the classrooms, the
library, the teachers, and the class schedules, the effective home health care
system is
more than a collection of raw communication means and devices such as
switches,
cameras, microphones, and computer controller devices. As is true of any
effective
health care system, the comprehensive home health care system conducted via
interactive video must include: a method for assessing and initiating a
patient into the
system; a method for individualized interaction with the patient based on the
patient's
personal and medical history, set protocols, physician directives, updates
based on
patient's past assessments, and standardized training of the medical personnel
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involved; a means for assessing patient progress as judged against established
parameters and learned history gleaned from evaluation of patients system-
wide; a
method for use of assessment data as an automatic trigger to precipitate
communication with and review by a physician to provide the patient with up-to-
date
treatment; a means for identifying and establishing intervention from outside
resources
where indicated; a prescribed method and means for dealing with changes in
condition
and use of such data to automatically update other elements within the system;
a
method and means for using learned patient data and assessments to evaluate
need
and identify and supply proper educational support; a method for initiating
data
collection, storage, and directing the reporting of information; and use of
reported data
to assess specific patient progress as well as to evaluate and adjust overall
system
parameters and standards based on analysis of a collection of overall patient
data and
response.
While U.S. Patent No. 5,441,047 gives cursory mention to some of the aspects
of an overall health care system as applied to use of interactive audiolvideo
communication system such as on-going patient assessment) storage of data,
comparison of data to known patient parameters, reporting of collected data,
the ability
to address patient concerns on an immediate basis, and patient education and
instruction, the focus is again on the technical aspects of collecting,
storing, and
transmitting patient data. There is no teaching as to a method or means of
incorporating these elements into a functioning remote interactive video
health care
system. Nor is there any teaching of the interrelationship of these elements
necessary
to achieve a health care system which will offer the home bound patient the
same, or
even enhanced, benefits of a patient in a traditional medical or nursing home
facility
and thus lacks a principal feature and advantage of the present invention.
Another drawback of the 5,441,047 Patent is in the area of patient
confidentiality. While the inherent problems with patient confidentiality and
privacy are
noted, no effective solution is offered. The invention teaches a communication
system
where a call may be independently initiated from the central station 24 hours
a day.
The solution offered is a suggestion that the parties can deal with the
privacy issues
intrinsic to such a system by agreeing up front to allow for monitoring only
during
prearranged periods. Further, it is implied that concerns regarding a
patient's privacy
should be tempered by the fact that patients in nursing homes or other medical
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institutions enjoy only minimal privacy. One of the key advantages of being
able to
receive treatment within one's own home, however, should be the enjoyment of
increased privacy over such institutional situations. Even if prearranged
times are
agreed to for electronic visits as suggested in the 5,441,047 Patent, it is
easy to
imagine a patient who has merely forgotten the time and is not prepared for
the visit
when the central station switches on the unit. Thus, the teachings of the
5,441,047
Patent lack another important feature and advantage of the present invention.
From the foregoing, it will be appreciated that what is needed in the art is a
method and means for providing a comprehensive home health care system by
means
of interactive audiovisual communication which is affordable; addresses a
patient's
privacy concerns; and offers the patient the advantages of the assessment)
training,
education, personal contact, support, and quality control of a traditional
institutional
health care system.
Accordingly) it is a primary object of the present invention to provide a
fully-
integrated and comprehensive health care system between a patient at a remote
site
and medical or other professional personnel at a central location through the
use of
interactive audiovisual communication.
It is a further object of the present invention to provide some protection of
the
patient's privacy.
Still another object is to provide a two-way interactive audiolvisual home
health
care system which is economical and offers the high quality, real time, full-
motion video
which will best simulate personal contact and, thus, provide the psychological
and
emotional benefits of human interaction as well as the means for enhanced
medical
assessment.
SUMMARY OF THE INVENTION
The present invention relates to a system for providing affordable,
comprehensive,
confidential, and effective health care and support by means of interactive
audiolvideo
communications between a patient or other person in need of physical, social,
or
psychological care or monitoring located at home or other remote site and a
health care
practitioner, clinician, social worker, psychologist, or other such
professional based at a
central location. The term home health care system is intended in its broadest
sense to
include care systems focused on the social, physical, medical, emotional and
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psychological needs of a patient. Similarly, the term patient should also be
considered
in the broad context of a person or client in need of support, care,
monitoring, education
and the like. The focus of the invention is on the assessment, interaction,
training,
education, quality controls, standards, protocols, and the interrelationships
of these
elements as they are employed in the context of an interactive audio/video
health, social,
or psychotogical care system.
Elements that comprise the basic communication package, therefore, are merely
the vehicle through which the health care systems of the present invention are
performed.
Thus, the hardware, switches, cameras, computers, transmission means, and
other such
elements of the basic communication process may be accomplished by various
known
means using off the-shelf technology. For instance, the establishment of
communication
linkages may be achieved by various transmission medium including use of
community
antenna systems, community cable television systems, fiber optics, satellite,
radio
transmission, telephone lines, or through any other mode of communication now
known
1 S or yet to be implemented. A key feature of the present invention,
therefore, is that the
system accommodates multiple transmission mediums. Thus, as various
communication
services become available within a given area or to a particular patient's
home, the system
is capable of adapting to employ the most efficient and effective
communication vehicle.
Another important feature of the present invention is the ability to achieve
signal
transmission which is discrete in both directions, thereby accommodating
privacy
concerns. Further, according to the present invention, it is desirable that
the transmission
of audio, video, and data is accomplished through interactive full motion,
real-time
television or compressed video with minimal video/audio latency. In addition
to providing
the health care worker with an increased ability to assess the patient, such
quality of
transmission will also provide more of the proven benefits of personal
interaction by
making the electronic visit feel more life-like.
The central station includes a computer equipped with a specialized patient
management software or database to facilitate patient visits, patient
assessment, data
management and presentation, education, and the inter-relationship of the
various
segments of the health care system. A monitor or other such videolaudio
display means
is located at the central station to accommodate a video and audio display of
the patient
to the health care professional. Further) a communication device is provided
which is
capable of transmitting data to the remote location. Finally, a camera and
microphone
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or other such video and audio components are mounted so as to generate a
transmittable
image and the voice of the health care practitioner.
The remote site where the patient is located similarly includes a television
or other
video/audio display device for presentation of the voice and image of the
health care
practitioner generated at the central station to the patient at the remote
site. A camera
and microphone or other such video and audio component is similarly fixed in a
location
to achieve a desired view and voice of the patient and for transmission to the
central
station during the electronic home visit. Finally, the remote site may include
a
communication transmission device capable of transmitting data to the central
station.
The monitor at the patient's site may be modified to be capable of remote turn-
on
and tum-off originating from the central location and may further be adapted
with a timed
warning device which will alert the patient of an impending electronic visit
so that the
patient can take care of privacy concerns before the monitor becomes
activated.
Similarly, the remote patient site may include an activation device which may
be used by
the patient to initiate communication with the central station or other
preselected site such
as an emergency care facility should the need arise. Other desirable features
may
include a medical monitoring device which is economical, simple in
construction and use,
and which is capable of sensing or detecting physiological measurements such
as
glucose, blood pressure, respiration, and pulse, and then either immediately
sending such
information to the central station or storing it for future transmission.
Where a particular
choice of equipment or transmission means is preferred for practice of the
present
invention, such will be noted in the following description of the preferred
embodiment.
Key to the home health care system of the present invention is in the
interaction of
the various features to provide a comprehensive health care system. A system
is
provided which begins with initial assessment and evaluation of each potential
patient;
extends through the treatment, on-going assessment, evaluation, response, and
education
of each individual patient within the system; and finally collects and
analyzes the feedback
from each patient and health care professional in the system individually and
as a group
to provide an improved system for each patient in the future.
While the foNowing description focuses on use of the interactive comprehensive
system of the present invention in the application of health or medical care,
it should be
appreciated that this system is also effective for other means of in-home
patient or client
care. For example, a social care model of the system of the present invention
may be
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adopted for use with a client who may not necessarily require medical
treatment or
medical monitoring. in such a case, interactive electronic visits would
proceed according
to the present invention with some minor modification. For instance, services
in such a
case would typically be provided by an aide or social worker rather than by an
registered
nurse or other medical personnel. In this model, the client would be monitored
daily, or
at such other appropriate frequency, to monitor and support the client for
social concerns
such as being certain that they are receiving proper food, shelter, or other
such social
need.
Similarly, a psychiatric model of the system of the present invention would be
staffed by professionals trained in psychiatry, psychology, or other mental
health fields.
individual, family and group therapy sessions could be conducted via the same
interactive
audiolvideo system used in the home health care model. In addition) such
patients could
be monitored daily to assess their mood, oversee their medication, and provide
other
assessment and support.
But for a few minor changes) therefore, it should be appreciated that the
overall
system is applicable to many different areas with these being but a few
examples. It is
with this definition in mind, the following description is provided.
BRIEF DESCRIPTION OF THE DRAWINGS
Fig. 1 shows the basic equipment and set-up at the central location and at
the remote patient site.
Fig. 2 is a block diagram depicting the flow of video, audio, and data
transmission between the central station and the remote patient site according
to one
embodiment of the present invention.
Fig. 3 illustrates the specific flow of signals to and from a particular
patient
site.
Fig. 4 shows a flow chart illustrating a typical flow of steps in enrolling a
new
patient in the health care system according to the present invention.
Fig. 5 shows a sample computer screen reflecting a typical computer-driven
initial patient assessment according to the present invention.
Fig. 6 is a sample of a clinical protocol according to the present invention.
Fig. 7 is a sample of a patient interaction screen illustrating entries of
patient
data against established parameters for that patient.
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Fig. 8 shows a flow chart illustrating the treatment of a single patient using
the
system of the present invention as well as the interaction of the steps.
Fig. 9 provides a representative example of one page of a care plan.
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DES RIPTION OF THE PRESENTLY PREFERRED EMBODIMENT
Reference is now made to the figures wherein like parts are referred to by
like
numerals throughout. With particular reference to Figure 1, the basic
equipment used far the
interactive communication of the present invention is indicated generally at
10. The central
location or central station 11 includes a computer 12 of sufficient speed and
memory capacity
to adequately handle data retrieval, manipulation, storage, and graphical
display of retrieved
patient information, patient history, protocols, and education software.
Alternatively, such
computer 12 may be linked to another device which is capable of providing
these functions.
The computer 12 or linked device will be equipped with patient management
software or a
database to facilitate patient visits, patient assessment) data management and
presentation,
education, and the inter-relationship of the various segments of the health
care system. A
camera 13 and audio component 14 such as a microphone are mounted in such a
fashion as
to be capable of receiving an image and the voice of the health care
practitioner for
transmission to the patient. A modem or other device capable of data
transmission 15 is
provided as well as a video display device such as a monitor 16 for display of
data as well
as display of the video image of the patient transmitted to the central
station 11 from the
remote patient site 17. The video display and audio components should be of
sufficient
quality to ensure a clear presentation of the patient to the health care
professional.
The remote patient's site 17 includes a television monitor or other video and
audio
receiver 98 for life-like display of the image and sound of the health care
professional to the
patient. A camera 19 and microphone 20 are fixed in a location to achieve a
desired view
and clear sound of the patient for transmission to the central location during
the electronic
home visit. Ideally, this camera 19 is equipped with features such as pan,
zoom, and tilt
which may be controlled remotely from the central station 11 to assist the
health care
professional in observing and monitoring certain physical conditions. A data
transmission
device 21 such as a modem may also be desired at the remote patient site. Such
a device
may be used for delivery of data to the central location 11 and may also be
used via an
activation device 22 to initiate a call to the central location 11 or another
location such as an
emergency care facility.
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In the preferred embodiment, the monitor 18 is modified to make it capable of
remote
delayed tum-on and automatic turn-off. More specifically, the monitor 18 is
equipped with a
signal sensing device capable of detecting a transmitted signal in the form of
a video signal)
audio signal or any other perceptible activation signal; a patient warning
device capable of
producing an alerting signal such as a beep or tone; and a timer mechanism.
When an
activation signal is sent from the central station 11 to a particular remote
patient site 17, the
activation signal is detected by the signal sensing device in the monitor 18.
Upon detection
of such a signal, the patient warning signal and the timer mechanism are
activated. The timer
then begins a countdown of two minutes or whatever preselected interval has
been set. Upon
activation of the warning device, a beep or other warning will sound for a
brief period to alert
the patient that there is an electronic call being initiated from the central
station 11. If
desired, additional warnings may be sounded at preselected times later in the
timer
countdown. At a prescribed interval, the timer will complete its countdown and
the monitor
18 and the camera 19 will be activated.
Other desirable features at the patient site may include a medical monitoring
device
(not shown) which is economical, simple in construction and use, and which is
capable of
sensing, detecting, andlor monitoring certain physiological measurements. A
typical device
would consist of a micro-computer base unit capable of gathering data from
proprietary non-
invasive digital medical diagnostic equipment such as blood pressure
equipment,
thermometers, electronic stethoscopes, peak flow meters, blood glucose
monitors, blood
coagulation monitors, blood cholesterol monitors, pulse oximeter, weight
scales, uterine
activity monitors, electrocardiogram, non-invasive blood pressure, and
infusion equipment.
Ideally, the device would comprise wired slots mounted in a rack frame. One
such slot is
used to connect to a modem or other such communication device. The remaining
slots are
available for connection to desired medical monitoring equipment as
appropriate for a
particular patient's needs. Each such slot is universal allowing any
monitoring function to
take place in a given slot. Software provides the necessary identity of the
function. Through
this modularity approach, a patient is able to purchase or tease only those
monitoring devices
relevant to his or her particular needs.
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Such a medical monitoring device further has the capacity to either
immediately
transmit the collected data via a modem to the central station 11 or store it
for future
transmission. For instance, the homebound patient may take multiple readings
at prescribed
intervals. Each reading would be time coded and stored automatically for
transmission during
the nurses video visit or until a predetermined transmission time. Privacy of
patient data is
protected via software limiting downloading of patient data via telephone
number and pass
coding.
An additional feature in making any such system economical is that it be able
to
incorporate a wide variety of instrumentation and integrate that
instrumentation into the
operation of the unit. This is an important factor, as the ability to
incorporate such °off-the-
shelf instrumentation substantially reduces the cost to the consumer of the
interactive video
medical monitoring system. In addition to accepting "off-the-shelf' medical
monitoring
devices, the ports of the medical monitoring unit of the present invention may
be programmed
to interchangeably accept a variety of "off-the-shelf' instrumentation. This
allows for greater
ease of system operation as a variety of instrumentation modets may be
selected which, for
one reason or another) may be more appealing or necessary to a particular
patient.
For example, while it may be the usual case to take a patient's temperature
reading
from the ear canal, in patients for whom the ear canal is covered or blocked
or painful, it may
be more useful to substitute an oral thermometer. Another desirable
substitution may be in
the use of a finger- or wrist-type pulse and blood pressure unit versus the
arm-cuff type blood
pressure unit. This selection would depend on which type of device is more
convenient for
the particular patient to manipulate. It will be clear from this description
that the ability to
substitute instrumentation and the ability to quickly and rapidly adapt any
available medical
instrumentation to use in the home patient monitoring system is a significant
and beneficial
feature of the Automated Patient Monitoring Device (APMD).
In general, the APMD provides data collection, data storage and data transfer
in
conjunction with home patient monitoring systems. The APMD first functions to
allow the
interconnection of any "off-the-shelf' monitoring device with the unit and to
then acquire
patient data through the monitoring device which is a patient-operated medical
instrument.
The APMD then stores the acquired data for downloading of the data to the
central patient
monitoring site. Alternatively, the APMD can be operated in real time to
acquire data from
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the patient-operated medical instruments and to immediately transmit the
acquired data to
the central site.
One embodiment of the APMD is provided with five ports for accepting patient-
operated medical instruments. The instrument connection ports in this
embodiment are
multiple RS-232 serial data ports, a bi-directional infrared data port (IRDA)
and a port for
interfacing with a radio frequency reception and transmission device. This
variety of
available ports serves to provide the necessary mechanical connection needed
for a wide
range of medical instrumentation. Once the mechanical connection is provided,
however, it
is necessary to ensure that the data type and format provided by the "off-the-
shelf' medical
instrument being connected with the APMD is of a data type and format which
corresponds
to the system transmission device and read-out instrumentation at the central
site.
In order to accomplish this conformation of the "off-the-shelf' medical
instrument data
type and format, the APMD is provided with a programmable central processor
which is
accessed by a laptop computer by a care giver who is installing the "off-the-
shelf' medical
instrumentation. Through the use of the laptop computer, the APMD central
processor is
programmed to read the raw data as transmitted from the "off-the-shelf'
medical
instrumentation and to reconfigure the raw data into a type and form which is
compatible with
the home patent monitoring system and central site. After this conversion it
also may be
convenient or desirable for the received and converted data tobe stored for
future
transmission to the central site.
Specifically, the APMD is provided with a 16-bit embedded microprocessor
having
128k of non-volatile memory (NOVRAM), 128k of program memory (UVPROM), and
128k of
static RAM. It is the program memory (UVPROM) which is accessed and programmed
by the
care giver with a laptop computer (or other program source) in order to
program the APMD
to properly receive and format the raw data from the "off-the-shelf°
medical instrumentation
for later transmission. The programming of the memory will vary from
instrument to
instrument depending upon the parameters of construction of the particular
instrument.
Hrnnrever, the care giver will have advance notice of the particular type of
instrumentation to
be used with a particular patient. This advance notice is received during the
analysis of each
patient's medical needs. This advance notice provides sufficient lead time to
allow the
particular programming requirements of any unusual instrumentation that 'may
need to be
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developed. In addition, it will be appreciated by those skilled in the art,
that the ability to
program and reprogram the APMD central processor permits the APMD unit to be
continually
and immediately adjusted to accept the newest developments in medical
instrumentation as
the instrumentation comes on line. In this manner, the patient's needs can be
served
immediately and the APMD can be adapted to meet the changing needs of both the
patient
and the offering of the medical technology instrumentation market.
In operation, a care giver selects a particular medical instrument which is
appropriate
to the specific needs of a patient. The medical instrument is then attached to
one of the RS-
232 ports or the infrared port or radio frequency port of the APMD device and
the laptop
computer is then attached to the APMD via a set-up port. The programming of
the memory
of the microprocessor is then effected to allow the APMD to properly recognize
and reformat
the data received from the now connected "off-the-shelf' medical instrument.
Once the care giver has completed the program memory setup via the laptop
computer, the instrument is interconnected with the memory of the APMD via a
serial port RJ-
12 jack. Upon initiation of the connection, the APMD microprocessor will
determine whether
the data format transmitted by the medical instrument matches the expected
format which has
been programmed into the memory by the laptop computer and care giver. Should
the data
transmitted by the instrument not match the programmed format, an alert or
error message
will be presented to the care giver. This alert will be both audible and
visual taking the form
of a sound file and flashing light-emitted diode or LED.
Once the medical instrument is properly connected to the APMD and in
operation,
patient data will be acquired by the instrument and transmitted via the cable
to the memory
of the APMD where the necessary reformatting of the data can occur. The data
is then
transmitted to the central site for evaluation. Alternatively, the data
received can be stored
in the non-volatile memory (NOVRAM) in conjunction with a time of day and date
and identity
of the instrument from which the data was received. Storage of the data in
this fashion is
used when it is desired to take a number of patient data points through the
course of a day
or week and to then transfer that information in batch form to the central
site for evaluation
and discussion with the patient. This ability to collect and store the patient
data prior to
transmission, minimizes patient inconvenience and minimizes the sense that the
patient is
"attached" to the instrumentation and provides the patient with a sense of
independence and
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control over the monitoring of their health situation. In addition, the
ability to retrieve and
store data prior to transmission and to then offer batch transmission of data
to the central site
permits a substantial reduction in monitoring costs as the central site
medical team interaction
with the patient can be reduced to a singe period in a time interval when all
the data has been
collected and is ready for analysis.
In order to transfer information conveniently, the APMD is provided with an
automatic
answer mode which allows the central site to contact the APMD via modem from
the base
station and to then download any data which has been collected since the last
contact
between the APMD and the central site. The APMD also is provided with an
°originate" mode
which allows the APMD to initiate contact with the central site via modem.
This contact can
be initiated at either a preset time or in response to a pre-programmed
medical event or
condition.
Examples of such conditions could be that the amount of data stored in the
NOVRAM
is near the storage capacity of the NOVRAM and it is necessary to transmit the
data to the
central site in order to permit additional collection of data. Another such
condition may be
that the data being collected by the instrumentation is, for one reason or
another, out of
proper data ranges. In this case the APMD could contact the central site for
data evaluation
in order to determine whether there is a medical event occurring with the
patient or whether
the data being received from the medical instrumentation is in error for some
reason. Yet
another condition which could initiate the APMD contacting the central site is
a pre
programmed medical event. Such an event could take the form of high or low
blood pressure
readings which are outside of a pre-programmed range established by the care
giver through
the laptop computer in the APMD central memory. Another such event could be in
the case
of a patient with diabetes, an indication that the patient's insulin is out of
range and requires
attention.
In this manner, the APMD can be used as a type of emergency medical monitor
which
would allow critical functions of the patient health to be monitored without
continuous invasion
of the patient's Name and privacy. This permits the APMD to be conveniently
used to allow
a patient such as an elderly individual to live and function at home,
independently, while
having their basic well being continually monitored. This monitoring avoids
family members
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being concerned that the elderly individual would be caught up in a medical
emergency at
home without the means to provide notice that medical assistance was needed.
Through the
use of the APMD, the onset of any catastrophic event can be noticed by the
instrumentation
and the central site can be alerted by the APMD using the originate mode.
One embodiment of the APMD is comprised of a wall-mounted 12 volt DC power
supply. RJ-12 jacks are provided for interconnection of a telephone line for
communication
with the central site by the APMD and for interconnection of the laptop
computer in order to
set data format and connection requirements. Serial communications between the
various
components of the APMD are through four dual UARTs (define this term)
operating at 9600
baud. Five of the UARTs devoted to the interconnection of the external medical
instrumentation through RJ-12 modular connectors. Another of the UARTs is
dedicated to
the bi-directional infrared port and another is devoted to the radio frequency
interface. The
last of the UARTs is dedicated to the reprogramming of the APMD with the
laptop. The
modem used in one embodiment is a variation of a Rockwell~ "socket modem"
which can be
removed and upgraded as needed. One embodiment of the APMD operates at the
current
standard of 33.6k voice-over data with standard Hayes modem command sets being
used.
Referring now to Figure 2, depicting one embodiment of a communication link
between a central station 11 and a remote patient site 17 according to the
present invention.
Audio) video, and data information is carried over a public or private
transmission medium
of coaxial cable, twisted pair copper, microwave, POTS, fiber optic cable, or
infrared laser,
ADSL, HDSL) or other transmission medium now known or not yet implemented;
such
transmission medium indicated generally at 23. The particular transmission
medium chosen
in any particular instance will depend on factors such as the availability and
costs of the
various options in a given area.
In a presently preferred embodiment, coaxial cable or fiber optic is used as
the
transmission medium for the audio and video signal as it is readily available,
cost effective,
and offers the ability to carry the transmissions on a discrete line thereby
safeguarding
patient privacy. In this embodiment, a video signal, which originates at the
base site 28 is
transmitted to a receiver 33. The signal is then fed to the video distribution
amplifier 24
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where the signal is distributed to the picture-in-picture 25 and to the
transmitter 26. A video
signal is received from the central station 11 and combined in the picture-in-
picture 25 unit.
- Both videos from camera 13 (central station 11 ) and base site 28 are
displayed on monitor
16, permitting the health care professional to view the patient and
themselves.
The video signal from camera 13, which has been fed via the distribution
amplifier 24
to the transmitter 26, is then united with an audio signal from microphone 14
which has been
picked up at the microphone 14 and sent via audio cable directly to
transmitter 26. Both
signals are then transmitted via coaxial cable or fiber optic 23 to a receiver
27 at a base site
28. This base site 28 serves as a central receiving area within a
neighborhood, apartment
building, or other area central to a group of patients accessing the system.
From the receiver 27, the audio and video signals are fed into a multi-point
switcherlrouter 29 of variable capacity. Substantially simultaneously with the
transmission
of the audio and video signals, a data signal originating at the central
station 11 is sent via
a communication device 15 over a telephone network to a communication device
30 located
at the base site 28. This data signal is encoded with an address identifying
the particular
patient address being accessed. At the switchlrouter 29, the audio, video, and
data signals
are directed to each individual patient site, such as the site marked 17.
Thus, as a signal
comes in from the central station 11, the switch/router 29 is utilized to
identify the particular
patient address encoded in the signal and then switch the transmission from
the base site 28
to that particular patient site 17. Figure 3 illustrates the specific flow of
signals to and from
a particular patient site.
Alternatively, when audio, visual, and data signals are received at the base
site 28
from an individual patient site 17, the switch/router 29 will direct the
signals either to the
central station 11 or to another remote patient site 31 within that switching
network. Where
the signals are switched and routed to the central station 11, the audio/video
signals flow to
a transmitter 32 where they are transmitted via coaxial cable or fiber optic
to receiver 33, to
the picture-in-picture 25 and displayed on monitor 16. By first receiving the
signals from the
central station 11 or a remote patient site at a central base site 28 location
equipped with a
receiver and transmitter) it is not necessary to place an expensive modulator
at each remote
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patient site 17. Any data signal originating from a remote patient site 17 is
transmitted by
telephone network from communication device 30 to communication device 15.
In addition to address identification, the switch/router 29 at the base site
28 also
permits one-way broadcast format from the central station 11 in real time to
ail of the patients
at a particular switching site simultaneously. Such broadcast means may be
very effective
in providing on-going education or updates of information.
If the chosen transmission medium 23 is other than a publicly-switched network
of
coaxial cable, the central station and remote patient information may be
transmitted
simultaneously by means of dedicated coaxial or fiber optic cable. In the case
of fiber optic
cable, non-compressed audio, video, and data information is transmitted via an
analog or
digital transmitter directly onto a fiber optic cable on a specific frequency
and received at
either the central station 11 or the remote patient site 17. Radio frequency
(RF) equipment
is employed for data transmission coincident with video and audio. In each
such case, a
discrete transmission tine exists in both directions maintaining privacy of
all such
transmissions. tn the case of a publicly-switched network, such as that
discussed above as
a prefer-ed embodiment, audio, video, and data transmissions between the
central station
11 and the patient site 17 are placed on a specific frequency and transmitted
directly, or via
a controlled switching/routing station, between the two points. Signals are
not available to
any other site on the network. Privacy and control is maintained by the
switchlrouter 29 and
may include additional signal scrambling devices (not depicted).
The database located at the central station 11 further provides for security
and
confidentiality. Each patient's name and picture, as well as the patient's
assigned patient
identification number, is listed in the database to provide verification upon
connection that
the proper patient is being seen by the health professional. Therefore, when a
particular
patient is called up either by name or patient identification number at the
central station 11,
a picture of that patient will be displayed on the screen to the health care
professional
allowing for easy and certain identification once the connection is made with
the patient. To
further provide system integrity, the database is password protected. All
nurses or other
health professionals must use a password and an assigned user ID to access
patient records
or conduct an electronic home visit with a given patient. Use of the password
and user lD
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upon sign-on to the system will serve as a digital "signature." Once a patient
visit on the
system is complete and the nurse or other professional has signed off, the
patient information
cannot be altered, assuring the integrity of the patient file and
accountability and
responsibility for the actions taken. One supervisor is selected per central
station site. Only
this person is allowed access to secured areas of the software.
Referring now to Figure 4, entrance of a patient into the comprehensive health
care
system of the present invention begins with an initial assessment of a
potential patient,
depicted generally at 33. This in-person initial assessment serves to collect
initial
information about the patient which is later entered into the database to
become a basis for
the patient's disease management, education, and plan of care. This initial
meeting will also
serve to personalize the interaction, answer patient and family questions
about the system,
and identify other important data such as referring physicians. Based on this
initial data) it
will be determined whether or not the remote system of health care is
appropriate for a
particular patient at that time 34.
Upon acceptance of a patient into the system, equipment needs are evaluated,
the
patient is given pertinent information, certain forms are completed for the
patient file) and an
in-depth assessment meeting is scheduled 35. The next step is an approximately
two-hour
meeting with the patient to complete a detailed assessment form 36. Such an
assessment
may be computer driven to accumulate information such as that depicted in the
representative
computer screen as illustrated in Figure 5. The required equipment such as a
television,
microphone, cabling, and medically monitoring devices are then installed and
the patient is
carefully trained on their use and on what to expect during a typical
electronic home visit 37
(Fig. 4). The detailed information gleaned from the in-depth patient
assessments are entered
into the computer database at the central station 11 and the electronic
patient fife is
established 38.
An initial rapport-building visit may take place at this time, but, prior to
the first on-line
patient clinical visit, the nurse or other health care professional generates
suggested doctor's
orders 39. These suggested doctor's orders are developed from the
appropriately approved
clinical protocols based on that patient's medical history and the patient
information
developed during the patient assessment. Within the home health care system of
the present
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invention, protocols are established for treatment, assessment, and evaluation
of patients
based on various physical and psychological disease criteria. The protocols
are part of the
system database and are readily accessible to the health care professional as
patients' needs
arise. Figure fi provides a sample of a typical protocol according to the
present invention.
Once suggested doctor's orders 39 are developed, they are presented to the
patient's
physician for additions, edits, and approval. Once the doctor's orders are
signed (Fig. 4, 39),
they are entered into the patient's clinical record in the software and
patient on-line clinical
visits may begin. In addition to patient histories and doctor's orders 39,
parameters of
acceptable ranges for each patient's vital signs (blood pressure, pulse,
temperature, blood
sugar, weight, height, lab values) as established by the patient's physician
are entered into
the software to further serve in the proper assessment and evaluation of the
patient. As an
on-line visit occurs with a given patient, vitals, weights and other such
information is either
automatically transferred to the central station or is manually entered by the
nurse
professional togged into that record and conducting that patient visit. The
date and time of
such readings and entries is also automatically indicated at that time
providing a thorough
and accurate record. An example of entries of such patient data within an
active on-tine
patient interaction screen is illustrated in Figure 7. When a patient's vital
sign or other such
reading falls outside of the acceptable range based on the set parameters
entered into the
electronic patient file in the database, a warning alert may be activated
either visually,
audibly, or both at the central station 11.
in addition to providing immediate access to medical and personal information
relevant
to a particular patient during the on-line visit, the database either
directly, or by link to another
resource, provides access to educational modules which are relevant to that
particular
patient's needs. These patient education modules may be stored on CD ROM,
cassette,
diskette, videotape, hard drive, or any other storage medium. In a preferred
embodiment,
these -educational segments are confined to a minimal time period such as
three to five
minutes. It has been discovered that providing patient information in
frequent) yet brief)
segments is more effective in achieving the educational goal. Other patient
education and
disease management skill training aids may include on-line slide shows,
equipment
demonstration, illustrations, photographs, and live expert health care
professional
presentations. Where a group of patient users are grouped through a
switchlrouter at a base
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station, the education tapes relating to general matters or professional
presentations may be
presented in broadcast format to the entire group or ail of those who are
interested.
Most importantly, the database is designed such that information in a patient
file, as
well as events which occur spontaneously during an on-line visit, may
automatically trigger
the presentation of educational materials via the in-place communication
system to the
patient. For example, if a patient's vital readings indicate a problem with
high blood pressure,
the database can be programmed to recognize this problem and initiate the
selection and
presentation of educational segments on control of blood pressure to that
patient. It will be
appreciated that a health professional may also manually select educational
materials for the
patient depending on feedback from the patient during the on-line visit.
Through planned interaction of the patient assessment program, the set
parameters,
the established protocols, the education components, and the trained
personnel, the home
health care system of the present invention provides a comprehensive medical
program for
each individual patient. Figure 8 shows an overview of the home health care
system of the
present invention by following a patient through the system. As previously
indicated, as a
patient enters the health care system, a thorough assessment is made and
detailed
information regarding the patient is collected. This initial personal contact
also serves to
familiarize and personalize the system and its personnel to the patient. The
collected data
is then entered into the database at the central station and becomes the
patient's electronic
file. At that time, an assessment is made of that patient's needs, which
triggers the
development of a care plan. (Fig. 9 provides a representative example of one
page of such
a care plan. These care plans are approved core plans based on specific
indications of the
patient. )
The patient's physician then reviews the patient's information and the core
care plan
and provides initial physician orders, revising the care plan as appropriate
for that patient,
identifying acceptable parameters for vitals and other measurements, and
providing other
medical directives such as medication orders. The initial physician orders,
the patient data
from the initial assessment, libraries containing information and educational
support
materials, and relevant approved clinical protocols are all linked within the
database so as
to support the nurse or other health care professional in making decisions as
to how to
conduct the interactive home visits with a particular patient. The nurse,
assisted by the
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database program, assimilates all of this information and these resources and
creates a
computer-driven "To Do° list which will serve as a guide for the
electronic visit including items
such as questions to ask, observations to make, vitals to check, and
medications to dispense.
Patient visits are set up for predetermined intervals such as daily, twice
daily, or even
more frequently. A contact is initiated by the health care professional
entering their password
and user ID into the computer at the central station and then accessing a
particular patient's
records. The data signal travels along the transmission tine to a
switch/router at a base
location near the remote patient site where the electronic address for that
patient -is
recognized and the transmission is directed to that patient's home monitor.
The video sensor
in the monitor senses the video signal, starts the timer countdown, and sounds
an alert to
remind the patient that a visit is about to commence. Such an alert will allow
the patient to
take care of privacy concerns and ready themselves before the monitor and
camera activate.
If desired, additional warning signals may sound at specified intervals up to
the point where
the audio/video equipment is automatically activated and the visit begins.
When the health care professional contacts the patient via the interactive
televideo
system, they will perform the tasks on the "To Do" list with electronic "check-
off" as each task
is completed. Where available) a medical monitoring device in the patient's
home will
automatically send digital information as to certain vital signs as ordered by
the physician.
Such tasks can also be pertormed manually by the patient with the direction of
the health care
professional. As the patient and the professional interact) there is an
opportunity to respond
to immediate concerns or developing problems. Where the health care
professional believes
that education of the patient or the family would be helpful, the system is
linked to supply
appropriate education modules which can be sent to the patient at that time or
at a later
agreed upon time. In addition, the database may be programmed to automatically
direct such
education materials to the patient via the communication link upon the
recognition of certain
criteria if that is desired.
The computer-assisted visit will document activity, information, prescribed
education,
medication taken, and changes in condition. In addition, the system allows for
the nurse to
comment with additional notes or observations. Where a pre-set parameter is
exceeded,
that parameter will highlight in red or in some other appropriate fashion
which will alert the
professional and the database program may also make automatic notation of the
exceeded
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parameter. The database may also be programmed to alert the health
professional of other
changes in a patient's condition. When the database signals a nurse or the
professional
observes a change in the patient's disease process, a change of condition form
is prompted
on the screen at the central station which will document the need for
intervention. The
system will also permit the nurse to record a portion of the patient's visit
to disk or videotape
if it is believed that such a pictorial record will assist in further
evaluation of the patient's
problem.
At the end of the visit, reports such as Physician Reports, Activity Logs, or
Change of
Condition Reports will be either automatically triggered or a professional can
initiate
production of certain reports. Where a patient's condition warrants) the
database may
automatically trigger a report to the physician seeking re-evaluation of the
patient or possible
intervention. Where there are no immediate triggering events, a physician
report will be
triggered on some pre-set interval, such as every sixty days, to ensure
continued physician
follow-up and review. These physician reports will contain a digital data
summary of all of the
patient information and may even include a video clip of the patient where
such is useful. At
the automatic sixty-day physician evaluation or at an earlier time where
circumstances
warrant, the physician may issue new orders which will then be entered into
the patient
database and trigger a new "To Do" list.
Beyond the specific patient contact) the health care system of the present
invention
provides system-wide assessment and education. Central stations may be
networked to
allow on-line training sessions for health care professionals. On-line, on-
site, and computer
training modules, as well as a training manual, are furnished on areas such
as:
~ Orientation ~ Emergency Management
~ Home Health Policies & Protocols ~ Adult Education Techniques
~ Patient Enrollment ~ Non Emergency Management
~ Case Management ~ Management of Non-Compliant Patients
~ Patient Assessment Interviews ~ Gluality Assurance and Improvement
~ Documentation ~ Patient Discharge Protocol
~ Patient EducationlDisease Manag. ~ Prof. Coordination & Consultation
~ Televideo Nursing Techniques ~ Computer Use/ Equip. Troubleshooting
~ Patients with Special Needs
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A specialized training program for the professionals involved in the system
leads to
consistent and quality care throughout the system and ensures that when one
professional
must fill in for another, the patient will not be traumatized by the change.
System-wide assessment also ensures quality medical care to each patient. With
a
defined method of record keeping and report generation, it is possible to
compare and
contrast the records and results of several health care systems operating
according to the
current invention to achieve an improved method of care for each of the
systems and, thus,
for each of the patients. On some regular basis, a central management may
gather and
analyze data from all databases in the central system to a central database.
Insight gained
from this analysis may then be shared with individual system users to improve
the database
and methods of treatment within all systems and thus lead to continually
improved quality of
care. For example, if a nurse in one location is able to care for a patient
with COPD in 15
minutes a day with satisfactory patient outcomes, while other nurses routinely
need 25
IS minutes, analysis of the difference will be triggered leading to increased
efficiency and quality
of care by the sharing of the more effective procedures with all other nurses.
Similarly) where
there is an undesirable result with the current procedures, the situation will
be identified and
corrected to the benefit of all other patients. This system of checks and
balances also serves
a purpose in risk and liability management. For instance, where potential
risks of omission
are identified, they can be established as automatic °triggers" in the
case management
software to assure that televideo nurses are reminded and such omissions can
be avoided.
It should be appreciated that the comprehensive home health care system of the
present invention is capable of being incorporated in the form of a variety of
embodiments,
only a few of which have been illustrated and described above. The invention
may be
embodied in other forms without departing from its spirit or essential
characteristics. The
described embodiments are to be considered in alt respects only as
illustrative and not
restrictive and the scope of the invention is, therefore, indicated by the
appended claims
rather than by the foregoing description. Afl changes which come within the
meaning and
range of equivalency of the claims are to be embraced within their scope.
