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Part 1: PD Development and Enhancement of PD Programs |
Department of Nephrology, Saitama Medical University, Saitama, Japan
Correspondence to: H. Nakamoto, Department of Nephrology, Saitama Medical University, 38 Morohongo, Moroyamamachi, Iruma-gun, Saitama 350-0451 Japan. E-mail: nakamo_h{at}saitama-med.ac.jp
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ABSTRACT |
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 TOP ABSTRACT PATIENTS AND METHODSDISCUSSIONCONCLUSIONSREFERENCES |
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Over recent decades, rapid progress in information and
telecommunications technology has led to the application of these technologies
in the medical field. In 1999, we reported on a telemedicine system (version
1.0) that used an automated peritoneal dialysis machine to collect data on
patients with end-stage renal disease. After 2002, we focused on using
cellular telephones in a new telemedicine system (version 2.0) to monitor
patient data at home, including blood pressure (BP), heart rate, body weight,
urine volume, and blood glucose. By 2003, we had developed a fully automatic
system called I-converter (version 3.0) to collect data from a fully automatic
device and send it via cellular telephone. After the fully automatic device
measures a patient's BP, I-converter sends the data directly to the main
server in our central data center. That server is directly connected to Web
site by application service provider (ASP) technology. Recently, to make the
system simpler, we developed a new version called D-converter (version 4.0).
The telephone used in this new system is a Personal Handy-phone System (PHS).
The PHS has several advantages: high-speed data transmission, low power
output, little electromagnetic interference with medical devices, and easy
locating of patients. The D-converter system uses a small computer and a PHS
card called a Dopa card.
Our telemedicine systems monitor continuous ambulatory peritoneal
dialysis (CAPD) patients at home. For elderly and handicapped patients, these
systems are very advantageous because they reduce visits to the outpatient
clinic. In addition, data can be monitored at the patient's home in real time.
The present paper reports our recent advances in telemedicine systems for CAPD
patients.
KEY WORDS: Telemedicine; CAPD; application service provider; ASP; cellular telephone.
Developments in information technology have been used to great advantage in many fields, including manufacturing, communications technology, network businesses, and medicine. Computer-assisted activity in medicine is increasing in several areas, perhaps most broadly in nephrology and dialysis because of the special characteristics of the population: numbers, complexity, long follow-up, and high cost (1).
Continuous ambulatory peritoneal dialysis (CAPD) is one treatment available for end-stage renal disease (ESRD) patients. In Japan, the proportion of patients treated with CAPD is very low, despite some reports that CAPD has certain benefits: lower mortality, lower cost, and better quality of life (2–6). The main factors that have negatively affected the development of CAPD in Japan are the rapid proliferation of renal units and the appearance of encapsulating peritoneal sclerosis, a serious complication for long-term CAPD patients (4). In addition, CAPD is home dialysis system, and patients must do everything themselves, including solution exchanges, catheter exit-site care, and record-keeping. Almost all CAPD patients have had some troubles with therapy at home during their CAPD life.
Because patients perform their own treatment, safety considerations require that all equipment be failsafe. Safe, easy-to-operate equipment and suitable training may allow patients and relatives to carry out treatments that are usually restricted to medical staff, but a medical support system for these CAPD patients is necessary for backup. A telemedicine system is an effective way of monitoring patient data at home, including blood pressure (BP), heart rate (HR), body temperature, body weight, urine volume, and exercise levels in ESRD patients. The telemedicine system described in the present paper supports our CAPD outpatients at home.
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PATIENTS AND METHODS |
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TOPABSTRACTPATIENTS AND METHODSDISCUSSIONCONCLUSIONSREFERENCES |
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The system was made very simple so that the original patient did not need to use a computer. The number of additional patients using this system was small because of the high cost (US$30,000). However, once installed, maintenance costs for the system were very small. Retrieving the data from APD system cost only 10 cents daily (telephone charges).
VERSION 2.0: TELEMEDICINE USING A CELLULAR TELEPHONE
To popularize telemedicine for all CAPD patients, cost reduction and
miniaturization were imperative. We began by focusing on cellular telephones
for a new version of our telemedicine system.
In 2002, we developed a new system version that used a cellular telephone and application service provider (ASP) technology to monitor patient data (8). Software for the telemedicine system was downloaded directly from an I-mode site (a system developed in Japan) constructed by NTT DoCoMo (Tokyo, Japan). The I-mode site could be contacted by cellular telephone over the Internet. When the software was downloaded from the I-mode site to the cellular telephone, the telephone was able to act as a sort of personal data assistant, collecting and monitoring data (Figure 2).
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This version of the telemedicine system held big advantages for our CAPD patients, especially the ones who were elderly or handicapped. Moreover, it allowed all CAPD patients and all hospitals in Japan to be networked.
Monitoring Data by Computer on the Web: Any time that patients want to check their data, they can use a computer to access the Web site. At the site, they can monitor the raw data or the averages and graphs. All data from the patients are collected by the ASP system and calculated by computer. If members of the medical staff want to see patient data, they can also access the Web site. If data from hypertensive patients suggests trouble, the medical staff receive emergency signals by cellular telephone or computer. They can then call the patient for a consultation by cellular telephone.
VERSION 3.0: I-CONVERTER DATA COLLECTION SYSTEM WITH CELLULAR TELEPHONE
Patients on CAPD usually recorded their data in a notebook. Version 2.0 of
our telemedicine system used a computer system instead of a notebook. Version
2.0 was good for monitoring patient data at home, but patients still had to
input the data by themselves. Some of the patients using that system suggested
that the system should be able to download the necessary data from automated
devices such as the BP monitor, glucose monitor, scale, and so on.
To move data from a fully automatic device to the cellular telephone, we developed a new data collection system (9) called I-converter ("Internet-mediated converter"). Figure 3 shows this system advance. After the patient measures his or her BP with a fully automatic device [HEM-705IT: Omron Life Science, Tokyo, Japan (10)], I-converter is connected between the device and the cellular telephone. When the connection is complete, a green signal switches on. The user then pushes the I-converter button, and the data (BP, HR, and time) are downloaded directly into the memory of the cellular telephone (Figure 3).
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VERSION 4.0: D-CONVERTER DATA COLLECTION SYSTEM WITH PHS
Many patients were now using our system to send data to the server, but
only a small number of patients were using the cellular telephone to check the
data. More often, they were using a computer to check the Web site. Also,
almost all patients were using the telemedicine system only at home. To make
the system easier, we developed a new version called D-converter ("Dopa
card–mediated converter"). The type of telephone used in this new
system version is the PHS, a system developed in Japan that uses the NTT
telephone network. The PHS has several advantages: high-speed data
transmission, low power output, little electromagnetic interference with
medical devices, and ease in locating patients.
The D-converter system uses a small computer and PHS card, and operates in almost the same way that I-converter does, but no cellular telephone is involved (Figure 4). D-Converter can connect directly to the automated BP monitoring device—or to the automatic glucose checker (Onetouch Ultra: J&J, Tokyo, Japan), the automatic scale (Omron HBF-354IT: Omron Life Science), and the pedometer (Omron HJ-720IT: Omron Life Science)—and download the data, sending the data directly to the server in our data center. When patients want to check their data, they can use a computer to visit the Web site.
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In 2006, some CAPD patients in Japan were using this latest telemedicine system to monitor their BP, HR, body weight, blood glucose, and exercise level. Many of our patients with hypertension, diabetes, metabolic syndrome, and nephritis were using the system.
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DISCUSSION |
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TOPABSTRACTPATIENTS AND METHODSDISCUSSIONCONCLUSIONSREFERENCES |
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In 2002, we tried to develop a system that all CAPD patients could use, because we wanted to make telematic monitoring services available to support all uremic patients. The system we foresaw needed to be simple and very easy to manage, even for elderly and handicapped patients. For ease of use, we constructed a system that used a cellular telephone as a data collection device. All data were collected by cellular telephone and sent directly to a server in the NTT DoCoMo data center (8).
Earlier, trials of a telemedicine system for ESRD had been reported. Moncrief and Sorrels (11,12) reported the Texas Telemedicine Project (TTP) in Giddings, Texas, which was designed to evaluate the economic practicality of delivery of medical care through bidirectional interactive video. But that project was designed for patients on hemodialysis, not on CAPD.
From March 1990, dialysis patients were monitored and primary care was delivered through the electronic medium. The TTP offered an avenue for the physician participants to explore the best delivery system for successfully deploying telemedicine in the practice of nephrology. The patients quickly became comfortable with interactive health care delivery, and they preferred it as a means of receiving primary care and continuous physician monitoring during dialysis treatments. From this large-scale project, it was concluded that telematic health care delivery would be successful if the patient–physician relationship were to closely mimic face-to-face contact (11,12).
This report was the first of a telemedicine system used for a large number of dialysis patients. Recently, other publications have reported the efficacy of a telemedicine system to monitor home hemodialysis (13,14). Computer-based videoconferencing systems interface with dialysis machines and clinical information systems to create a paperless medical record, which includes screen captures of vascular access images and a database of dialysis parameters, among other data.
Telemedicine for the care of dialysis patients is being studied and used routinely in centers throughout the world (11–14); however, telemedicine to monitor home CAPD patients is little reported. Recently, Gallar et al. (15) reported the usefulness of a telemedicine system for 18 months of follow-up in stable patients in CAPD. Daily costs after installation of the system were low, and patients and medical personal saved time, the renal unit saved on physical space, and everyone saved on transportation. Gallar's report and ours demonstrates that a telemedicine system holds big advantages for the management of CAPD outpatients.
We speculate that, in future, telemedicine systems will come to be used more routinely in medicine. We believe that our telemedicine system provides ESRD patients on CAPD with supervised autonomy.
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CONCLUSIONS |
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TOPABSTRACTPATIENTS AND METHODSDISCUSSIONCONCLUSIONSREFERENCES |
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REFERENCES |
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TOPABSTRACTPATIENTS AND METHODSDISCUSSIONCONCLUSIONSREFERENCES |
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This article has been cited by other articles:
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  D. Chiu, P. Ande, R. A. Coward, and A. Woywodt The times they are a changin'--the Internet and how it affects daily practice in nephrology NDT Plus, August 1, 2009; 2(4): 273 - 277. [Full Text] [PDF]
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