Engrossed in a Super Nintendo game called Packy and Marlon, a 12-year-old girl in San Francisco battles her way through flying rats and acorns while trying to find the right foods to manage her character's diabetes and keep her blood-sugar level in check. Three thousand miles away in Boston, a mother is stuck at home during an ice storm and cannot make it to the hospital to visit her premature baby. She turns on her computer and watches him sleeping peacefully via a video-conferencing system in the hospital's neonatal intensive-care unit. Keeping up with his treatment plan, a patient with chronic heart failure steps on a special scale each morning and sends his weight and vital signs through a telephone modem to his physician at a nearby Chicago hospital.

These days, home healthcare means far more than receiving periodic therapy from a visiting nurse. Patients with chronic health problems are increasingly using innovative technologies and treatment plans to manage their own care while enjoying the comforts of home, and with good effect. Study after study has shown that ascribing more accountability and responsibility to patients who suffer from long-term ailments can result in huge cost savings and better health outcomes.

A survey by the National Center for Disease Statistics reported that in 1994, chronic illnesses and their associated complications-from arthritis and heart disease to hypertension and diabetes-accounted for an estimated 70% of annual personal health costs. As people live longer and the aged population grows, physicians are learning how to incorporate home healthcare into their practices, and home-health programs are exploring new methods of providing affordable care. There is no shortage of technology from which they can choose.

TELEMEDICINE

Take, for example, the cardiac telemanagement program for patients with chronic heart failure at the University of Illinois at Chicago. It is led by Dr. Boaz Avitall and coordinated by Mary Bondmass, a nurse practitioner. Heart failure patients have a high rate of hospital admissions, sometimes as many as three a year. At $2500 per day for each hospitalization of five days, healthcare costs can easily spiral out of control.

Avitall and Bondmass set out to determine whether education and close monitoring could improve the cost situation. In theory such a program would give patients accountability and show them how eating and exercise habits can affect their condition. It would also help physicians monitor their patients' daily status and respond quickly to any problems.

In a study of about 100 patients, Avitall, Bondmass, and their colleagues at the Chicago medical center tested the theory. Participants were taught to use a scale-like device developed by Avitall, which measures blood pressure, heart rate, and weight, then sends the information to a central monitoring system in the hospital via a telephone modem line connected to the scale at home.

If the patient's vital signs stray too far from the allowed level, an alarm sounds at the central monitoring station, where a technologist is on 24-hour duty. When the alarm sounds, the technologist calls the patient and follows an algorithm outlining what type of assistance is needed. If the patient is in acute distress, the tech calls for an ambulance; otherwise the patient is asked to transmit the data again for confirmation, after which a physician calls him or her to arrange any necessary treatment.

The study has resulted in improved quality of life and decreased hospital costs. During the three months preceding the study, 48 patients were admitted to the hospital a total of 46 times, accounting for $456,856 in hospital charges. After three months on the program, the rate of admissions dropped to 10, accounting for a total of $84,245 in hospital charges.

A similar program in San Francisco and nearby communities, run by HiLife Systems, has produced an annual 61% decrease in Medicare claims and 72% reduction in hospital days.

"If these patients can stay out of the hospital, everyone is happy," Bondmass said. "For preventable situations, it's a waste for them to keep coming in, so we're trying to teach them how to avoid it."

VIRTUAL VISITS

Other products with similar principles are flooding the home-health market. A home oxygen monitor developed by Nellcor Puritan Bennett provides two-way communication between patient and care provider through telesurveillance. When a patient is not in compliance with oxygen therapy-for example, the patient disconnects from the oxygen tank-the provider is notified through an existing telephone line in the patient's home.

Likewise, a cardiac monitor inserted under the skin records a heart patient's electrocardiogram during fainting spells known as syncope. External ambulatory heart monitors are normally used for only one week, making it difficult to capture intermittent syncope attacks. The new device, called the Reveal Insertable Loop Recorder and designed by Medtronic, can record EKG tracing for more than a year, which helps physicians diagnose patients who suffer from unexplained fainting.

In another home monitoring advance, a nurse calls a patient from the office and establishes an audio/video connection using resourceLink, a system developed by Help Innovations. During the online visit, the nurse can assess the patient's health, vital signs, and compliance with medication, and offer advice and information to the patient. The system costs providers $5500 for video conferencing equipment and a Windows-compatible computer that runs the patient management software. Each patient unit costs $800. Kansas Medicaid and Blue Cross/Blue Shield of Kansas have agreed to provide some reimbursement, according to Jason Greenwald, a Help Innovations representative.

Although equipment costs may seem steep, Greenwald said the system quickly pays for itself and saves both the provider and patient money by eliminating the need for traditional nurse visits, each of which costs about $100. Greenwald cites the case of a 72-year-old woman recovering from a heart attack who had five ER visits and two hospitalizations in one year, resulting from anxiety and failure to take medications correctly.

The patient was put on a resourceLink telehome management plan and educated about medications, diet, stress reduction, and depression, via virtual nurse visits. After one year of using the system, she had only one ER visit and no hospitalizations. Home-care costs alone were cut by 35%, despite increasing the number of "visits" by 54%, according to a case study prepared by HELP Innovations (see table).

Yet another product, Healthdesk Online, distributed by HBOC, connects the patient to the provider by computer. Software specifically designed for diabetics allows patients to send information regarding blood-glucose level, meals, and exercise directly to the physician. And based on the established treatment plan programmed into the software, Healthdesk gives daily and weekly feedback in the form of charts and graphs. The software and a one-year online subscription costs $100. After the first year, the patient pays about $4 a month for the online subscription, according to Meredith Hall Vaughn, a Healthdesk spokesperson. Health insurance companies are not yet including this system in their coverage, she said.

Even the government is beginning to participate in high-tech home health-care. The Department of Defense is considering using a system called C-Phone, which includes video phone technology, data transport from medical devices, and call-center software. The $4.7 million application will be used for telehealth disease management of about 150 military employees. Using interactive voice and video, nurses at a call center will manage patients with chronic obstructive pulmonary disease through the patient's television set and existing telephone line.

JUST FOR KIDS

Children and infants are also benefiting from home-health technology. Through the CareLink program, parents of premature infants hospitalized at Beth Israel Deaconess Medical Center in Boston can check on their babies from home 24 hours a day. A three-year study of the telemedicine application has been funded by a $2.8 million grant from the National Library of Medicine's Telemedicine Initiative.

The system is not meant to replace physical visits, but rather to add another dimension to the communication between parent and child, said Dr. Jim Gray, director of newborn services. Caring for a fragile premature infant can be difficult in many ways, causing anxiety in parents who may not feel confident in their ability to provide for the child. Once parents watch and learn through the virtual medium how the NICU staff cares for the baby, they become more comfortable with the idea of bringing the infant home, according to Gray. Conversely, when the baby comes home, the NICU physicians and staff pediatricians can conduct a virtual visit with the family, observe the child, and answer parents' questions.

"When you send patients home, you cut the umbilical cord between the staff and the families," he said. "With these technologies, we can export the core of expertise that exists within the NICU as well as among the pediatricians in the hospital."

Older children are the intended beneficiaries of the SuperNintendo game Packy and Marlon. Designed by Steve Brown, the CEO of Health Hero Networks, the game's purpose is to teach children about their disease in a way that appeals to them.

"We're looking for ways to motivate children to do things that help them stay healthy," Brown said. "The key is to make things extremely simple and rewarding. This approach builds all the information we want kids to understand in their real life into characters of a video game.

Taking insulin, choosing the right foods, and measuring blood sugar are critical in progressing to higher levels in a game that teaches children about diabetes. Each level of the game occurs at a different meal time, with the first level beginning just before breakfast. The opening sequence takes the player to summer camp, where rats and mice have taken over the entire camp, kidnapped the camp counselors, and scattered supplies everywhere.

Through 24 action-packed levels of the game, the player finds supplies and disposes of flying critters, all the while managing her diabetes by balancing the right foods with the blood-sugar level. The mock blood sugar level fluctuates if she deviates from the prescribed plan, and the player plunges into the perilous red zone.

"The game works without explanation and kids learn by trial and error, figuring out what they need to do to win," Brown said. "They develop instinct and habit in thinking about what's in their food before they choose the right one. They start thinking ahead of time."

The game, which costs about $70, is distributed through a pharmaceutical company to care providers as part of a starter kit for children. Kids can also find the game at children's hospitals, education centers, and some doctors' waiting rooms. A similar game for pediatric asthma is also on the market.

TEACHING INDEPENDENCE

With all this new technology to choose from, doctors must first learn how to integrate a home-health system into their practice. Dr. David Goodman of HiLife Systems in South San Francisco suggests first identifying patients who are suffering from long-term or chronic ailments. The next step is to involve patients in programs that teach them how to better care for themselves.

The key is to sustain patients' involvement and participation in their own health so they can see measurable benefits, and maintain close communication with care providers.

"A home-health system can be defined as somewhere between your mother living with you and www.chestpain.com," Goodman said.