Health care planners and providers are becoming increasingly interested in the home as a site of health care delivery. Recent advances in telecommunication technologies have enabled the direct provision of services to patients in the home using tools such as videophones and data transmission over phone lines. However, very little research has been conducted on the attitudes of patients, families and health care providers regarding use of these technologies to provide care (Hailey et al., 2002; Mair and Whitten, 2000).

This paper reports on a study aimed at understanding factors that have an impact on the acceptance and use of health care delivered via home technology. The purpose of this study was to compare nurse-patient interaction using two different video platforms designed for telehome care. One platform uses existing telephone lines (POTS video) and the other uses the Internet (IP video). The specific aims of this study were to: 1) assess the degree of acceptance by nurses and patients of home video visits for nurse-patient interaction; and 2) compare preferences for delivery of home care between the two platforms, between video and live interaction, and between video and less frequent or no interaction.

The study used a quasi-experimental cross-over design. Nurse-patient pairs were assigned to conditions using a pre-determined assignment procedure, alternating each new pair to start with one of the two platforms. Following that session, each participant pair then tested the second platform. Three simulated health problem scenarios, which focused on depression, anticoagulation therapy and diabetes, were created for the study.

Sample. A convenience sample of 26 practicing nurses and 18 volunteers serving as simulated patients participated in the study. Nurse case managers at the Iowa City Veterans Affairs Medical Center (VAMC) served as the nurse sample. Volunteer participants were recruited from the volunteer department at the same facility. Most of the volunteers (72%) were age 70 or older; 61% of the nurses were younger than 50 years old.

Most participants regularly wore corrective lenses (81% of nurses and 94% of volunteers); 11% of volunteers wore a hearing aid; and 17% reported having other hearing problems, while none of the nurses reported hearing problems. The most common nurse specialty was medical (46%), followed by "other" (38%), surgical (12%) and psychiatric (4%). Nurses had an average of 18.9 years experience as an R.N. (standard deviation [SD]=8.7). Forty percent of the volunteer patients (n=6) reported that they were very or somewhat comfortable using a personal computer; 27% (n=4) reported having a personal computer (PC) at home; and 20% (n=3) had Internet access at home. All of the nurses regularly used computers at work, as the study facility uses an electronic medical record system. Although the volunteers received an orientation to the computer from the medical center in order to track their volunteer hours, most did not use the computer on a regular basis while at the medical center.

Description of POTS video and IP video systems. The system selected for the POTS video portion of the study was composed of a television monitor and a camera kit that combined a telephone, microphone and video camera (EHC 200 Videoconferencing Station, manufactured by CyberCare). The audio is full duplex, and the video transmits at 10 to 15 frames per second (30 frames per second is considered "broadcast quality") with a resolution of 176x144 pixels. The unit connects through a standard telephone line using a 33.6K modem and consists of a 13-inch color television-type monitor, the camera kit and a remote control device similar to a television remote control. To establish contact, the nurse activates the system using the remote control to enter the patient's telephone number. The patient at home responds by pushing the start button on the remote control device. During the visit, the nurse and the patient see and talk to each other, with all functions controlled by the nurse. At the end of the interaction, the patient presses the end-call button on the remote. The remote control device has one large green button to start the system and one large red end-call button to turn it off. This facilitates ease of use by older patients who may have limited dexterity or vision. In this study, the calls were placed on commercial telephone lines.

The IP-based teleconferencing system (ViaVideo, manufactured by Polycom) consists of a small video camera with an integrated microphone. The unit mounts on top of a PC monitor and connects to the PC via a USB port. The audio is full duplex, and the camera transmits video at up to 30 frames per second with a resolution of 352x288 pixels. To communicate using this platform, both the nurse and the patient need a PC, the video camera and software, and an Internet connection with a static IP address. To establish contact, the nurse activates the communication software, enters the patient's IP address, and clicks the dial button. When the patient has also activated the software on their PC and has established an Internet connection, the patient's software will recognize the incoming call and will emit an audible ring (analogous to an incoming telephone call). The patient can then click a button to answer the call, and within a few seconds the nurse and patient will be able to see and hear each other. To end the call, the nurse or patient clicks on the end-call button. This study used the hospital computer network for the IP-based interactions.

Data collection protocol. Following approval of the study protocol by the local Institutional Review Board, the facility research committee and local management, a letter of invitation was sent to each nurse case manager. For the volunteer patients, the volunteer coordinator at the VAMC posted bulletins describing the study in volunteer services offices. When potential participants contacted the study coordinator, an appointment time was scheduled.

Each healthy adult volunteer played the role of a patient and was paired with a nurse. Informed consent was obtained from both the nurse and the patient. Seated in separate rooms, each patient-nurse pair conducted two simulated home visits on one of the video units being tested using a script prepared by the investigators. Scripts included typical patient problems addressed during a home care visit. Of three scripts developed for the study, two were used by each nurse-patient pair. Using the script, the nurse conducted a standard set of tasks or assessments that mimicked a home care visit. The nurse and patient each completed a short evaluation rating. The patient-nurse pair then conducted the same two simulated home visits using the same scripts on the second video unit, after which the nurse and patient again completed the same short evaluation rating. Following completion of the two simulated visits, the study coordinator conducted a brief open-ended interview with participants to discuss perceptions of the two platforms. These qualitative responses were recorded in notes taken by the study staff. After completing the study protocol, each participant received $20 or a small incentive.

The three interaction scenarios simulated a nurse interacting with a patient with depression, a patient on anticoagulant therapy and a patient with newly diagnosed diabetes. The scenarios were designed to maximize the features of the video component. The depression scenario required the nurse to observe the patient's facial expressions and body language. The anticoagulant scenario required the nurse to read the patient's medication bottle and to observe the patient's arms for signs of bruising. The diabetes scenario required the nurse to demonstrate the use of an insulin syringe to the patient. Each scenario was designed to be completed within 10 to 15 minutes.

Outcome measures. An investigator-developed instrument was used that addressed patient-nurse communication using the video platforms. All items were scored using a six-point Likert-type scale (1=strongly disagree to 6=strongly agree).

The first aim of the study was to assess the degree of acceptance of home video visits for nurse-patient interaction. For the first analysis, nurse and patient ratings were combined to compare POTS video to IP video (Table 1). The IP video system was rated significantly higher (p≤0.05) in the following acceptance categories: trust that privacy is maintained; video visits as a replacement for nurse home visits; preference for the video visit compared to a nurse home visit; willingness to recommend platform to others who need home care; willingness to use platform if home care was needed; and recommending platform to friends/patients. There were no significant differences between the POTS and IP system ratings for ease of use, visit taking too much time and perceived expense of visit.

A separate analysis was conducted to compare patient and nurse ratings for each system (Table 2). Patients rated the POTS video system significantly more favorably (p≤0.05) than did nurses on: acceptance of video visits as a replacement for nurse home visits; recommending platform to others who need home care; and willingness to use platform if home care was needed. Patients rated the IP video system significantly more favorably (p≤0.05) than did nurses on: ease of use; trust that privacy is maintained; platform as a replacement for nurse home visit; preference for platform as opposed to a nurse home visit; recommending platform to others who would need home care; willingness to use platform if home care was needed; and recommending platform to friends/patients.

The second aim of the study was to compare preferences for delivery of home care between the two platforms, between video and live interaction, and between video and less frequent or no interaction. Because there were no statistically significant differences between nurses and patients in overall preference, nurse and patient ratings were combined for this analysis (Table 3). Overall, 84% (n=37) of the participants preferred the IP video system, 14% (n=6) preferred the POTS video system and 2% (n=1) had no preference. If asked to choose between a face-to-face visit or a video visit, 59% of the participants stated they would prefer a face-to-face visit, while 23% would prefer a video visit (18% had no preference). Nurses and patients diverge somewhat (though not significantly) in their preferred type of visit; 69% of nurses would prefer a face-to-face visit, while 44% of patients said they would prefer a face-to-face visit. Fifteen percent of the nurses would prefer a video visit, while 33% of the patients expressed a preference for video visits, and 15% of the nurses and 22% of the patients had no preference for either type of visit. Finally, if asked to choose between more frequent video visits and less frequent in-home visits, 75% of the participants preferred more frequent video visits. Eighteen percent would prefer less frequent in-home nursing visits, while 7% had no preference. There was no difference in this general pattern between nurses and patients.

Not surprisingly, patients and nurses both preferred the IP video over the POTS system, citing superior visualization. Overall, patients ranked both platforms more favorably than did the nurses on acceptance of home video visits and preferences for more frequent visits relative to less frequent face-to-face visits.

Although the IP platform had higher overall ratings, a critical difference between the two platforms was ease of use. For example, some patients had a difficult time answering the call on the IP video system because they were not familiar or comfortable using a computer. Although the study was initially designed to have both nurses and patients log on to the IP system, technical and end-user difficulties were so common in the first few sessions that the connection was instead established for the participants. Thus, ease of use is a critical consideration when selecting a home technology system.

Although participants preferred more frequent video visits compared to less frequent face-to-face visits, nurses emphasized the value of home visits. In the follow-up interviews, nurses often mentioned the importance of seeing a patient's surroundings and living conditions when conducting a home visit--a task that would be hampered by the narrow field of vision afforded by a video camera. Nurses also mentioned that it can be difficult to assess things like skin color/appearance, edema and wound-healing progress on a video screen. Nurses emphasized the need for personal contact with patients, but they believed the video visits could be a good way to supplement face-to-face visits. For example, one nurse felt the video visits could decrease the amount of in-home visits, but stated, "Patients would be comfortable if they knew a nurse could come out. If a patient is housebound, then they would look forward to video visits. I like the idea of more frequent visits, but I like personal visits [better]." Another nurse agreed that video visits should not replace visits but would be useful between face-to-face visits, saying they would be "much more convenient for quick check-ins." Another nurse said, "Video visits could replace some home visits but not all; for example, you couldn't change a dressing; [you] could do insulin refresher[s] but not the first training." These clinical considerations may be behind nurses' more muted enthusiasm for using interactive video technology for conducting patient home visits.

Home telehealth monitoring devices are quickly being adopted in practice settings, however, few studies have addressed patient, family and health care provider preferences surrounding home care technology. We conclude that ease of use, clinical appropriateness, training and support will likely play deciding roles in future growth of home telehealth.

Supported in part by a grant from VA HSR&D NRI 99-345-1 and the National Library of Medicine, contract N01-LM-6-3548, and a VA HSR&D Career Development award to Dr. Wakefield.

Dr. Wakefield is associate chief of nursing research at the Iowa City VA Medical Center (VAMC). Her research focuses on functional status in the elderly, telehealth, and organizational variables and patient safety.

Mr. Holman is project director at the Iowa City VAMC.

Ms. Ray is research assistant at the Iowa City VAMC.

Ms. Morse is research assistant at the Iowa City VAMC.

Dr. Kienzle is special assistant to the dean and director of the Office of Economic and Business Development at the University of Iowa Carver College of Medicine.

Hailey D, Roine R, Ohinmaa A (2002), Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare 8(suppl 1):1-30.

Mair F, Whitten P (2000), Systematic review of studies of patient satisfaction with telemedicine. BMJ 320(7248):1517-1520.

Nurse and Patient Preferences for Telehealth Home Care