The team delivering diabetes care in IDEATel is made up of nurse case managers, endocrinologists, and dietitians working at the Joslin Diabetes Center and the Naomi Berrie Diabetes Center in New York City. These diabetes center-based providers work in collaboration with the primary care providers, who are responsible for the ongoing care of the patients. The nurse case manager plays a pivotal role as the person interacting most frequently with the patient through video-conferencing. The process of care is unique in that it takes place through two parallel, but highly integrated, paths: diabetes care on one side, and guidance and support for the use of the home telemedicine unit on the other.

Telemedicine Visits
At the initial televisit the nurse case manager obtains a comprehensive medical history that emphasizes all aspects germane to diabetes care. At each televisit, initial as well as follow up, the status and needs of the patient are summarized for three clinical domains: diabetes control and complications, hypertension, and dyslipidemia. In addition, patient learning objectives are categorized using a fifteen-item instrument that helps guide the nurse-patient interaction. Finally, after discussing the case with an endocrinologist, a plan that includes medication adjustment and recommendations is formulated. The televisit is documented using an electronic form, which greatly facilitates the process of writing the note and reminds the nurse case manager of the items to be considered. The visit note, with any recommendations for management changes, is transmitted to the primary care provider. Medication changes are made by the primary care provider, not the diabetes team.

Challenges in Providing Telemedicine Care
All new technologies require significant improvements and adjustments when first applied in large scale in the "real world". The IDEATel intervention has been adjusted to deal with several technical obstacles, including:

1. Background noise in the participant’s home. This was solved by providing participants with headsets (earset plus microphone).

2. Poor transmission of the human voice, often accompanied by patient’s hypoacusia. The nurse case managers use a slow, deliberate, and clearly enunciated speech.

3. Disconnects during televisit. A recurrent problem that could be caused by old or inadequate telephone lines. The nurse case manager calms and reassures the participant through the re-connection process, in order to minimize frustration.

IDEATel is delivering care to elderly patients, a population shown to have relatively poor access to computers and believed to have greater difficulty learning new skills, when compared to younger age groups. In addition, the urban component of the study has recruited inner city participants with low literacy and socio-economic barriers, of whom about 60% speak Spanish only.
Even patients with higher literacy may have some difficulty becoming comfortable with a new set of skills and learning the language associated with computers, such as "mouse", link, "and sites". A very frequent observation is that the participant’s learning curve becomes significantly steeper as fears of "breaking the computer" are dispelled.
The IDEATel home telemedicine unit was designed so that the patient would not have to use a keyboard or mouse to connect to the case manager. A launchpad was developed with four large, color-coded buttons. When the nurse case manager calls, the patient only needs to press a green button to establish a videoconference connection. The other buttons are used to upload blood pressure and glucose data, to access the web, and to turn on and off the unit, respectively.

Telemedicine and Nursing
The advent of telemedicine heralds a new important role for the Nurse Case Manager. Telemedicine offers a potential for individualized, frequent contacts between nurse and patient in a novel setting that increases access to care, and may improve patient care in a manner that is cost-effective for the health care system.
Nursing has long prided itself on the values of compassion, provision of personalized care and the ability to individualize care for different patients needs. Although the traditional "laying of hands" is no longer possible in the telemedicine patient visit, the audio and video connections of telemedicine enable a degree of personal interaction not possible through telephone or written communication. And the telemedicine approach spares the patients the time, expense and difficulty of being transported to an office.
Many challenges remain before telemedicine becomes an accepted part of modern medicine. The digital divide must be crossed, particularly for older patients who grew up in an era without computers. Nurses and physicians must adapt to the new technology and be willing to explore new approaches to patient care. Health care payers must assess the costs and benefits of telemedicine to decide whether the technology warrants widespread dissemination in the American medical marketplace. Hence the importance of studies like IDEATel, which is demonstrating the feasibility of providing comprehensive diabetes care through telemedicine to elderly patients who reside in medically underserved areas of rural and inner city New York. An exciting new blending of technology and quality clinical care may await us.

| Top |