Telemedicine System for Home Automated Peritoneal Dialysis

Hidetomo Nakamoto,1 Masato Hatta,2 Akira Tanaka,3 Kenshi Moriwaki,1 Kazuya Oohama,1 Kazuyo Kagawa,2 Ken Wada,3 Hiromichi Suzuki1

We have developed a new telemedicine system to monitor elderly and handicapped patients that use an automated peritoneal dialysis (APD) system to perform continuous ambulatory peritoneal dialysis (CAPD) at home. The system has two parts: (1) a data collection and transport system, and (2) an interview system (“View Send” system). The former is assembled from the APD cycler, an automated blood-pressure recorder, and a scale. The latter is a combination of a digital camera, television, and set-top box (a kind of computer). The APD system contains recording and data transport junctions, a monitoring device, and a data tabulation function. All data collected by the APD system are sent directly in real time to the physician’s office. Patients can easily use this telemedicine system to contact the medical staff at the Saitama Medical School CAPD center and to consult concerning their condition. Furthermore, the staff can directly change the CAPD schedule (dose and duration). Seven patients, including some who are older than 90 years or who are handicapped, have been using this telemedicine system for between 1 and 6 months (average: 3 months). From our recent experience, our tentative conclusions are that (1) elderly and handicapped patients benefit from this system by being able to maintain CAPD without major problems and accidents; (2) other problems are mainly due to simple mistakes such as accidentally pushing the on and off switches; (3) quality of life is improved for the patients.

Key words

Telemedicine, automated peritoneal dialysis, home, elderly

Introduction

Telemedicine is the remote consultation between physician and patient by means of a videoconferencing system. Remote communication by telephone, and more recently by e-mail, has become commonplace between dialysis patients—especially hemodialysis patients—and their physicians and medical staff. Telemedicine for the care of dialysis patients is now being studied and used routinely in several centers throughout the world. Recent advances in technology are leading to more integrated systems, including multimedia video-camera systems supported by digital computers.

In 1996, Mitchell et al (1) published the first study of the clinical application of renal telemedicine. They reported that telemedicine has a valuable place in the management of hemodialysis patients treated in satellite dialysis units. In contrast, as far as we know, few reports exist of telemedicine systems being used in the treatment of peritoneal dialysis patients.

In the present study, we introduce a newly developed telemedicine system. The aims of our study were (a) to develop a new telemedicine system for patients using an automated peritoneal dialysis (APD) system to perform CAPD at home; (b) to examine whether such a system will effectively and safely monitor elderly and handicapped patients undergoing CAPD; and (c) to ensure the efficacy of the system in producing a beneficial effect on quality of life and reducing problems and accidents.

Materials and methods
Construction of a new telemedicine system by using an APD system

Figure 1 shows our newly developed telemedicine system. The system is composed of two different systems including (a) a data collection and transport system and (b) an interview system (“View Send” system).

The APD system can be seen in the right-hand lower corner of the PD-mini Remote System panel in Figure 1. This APD system contains recording and data transport functions, a monitoring device, and a data tabulation function.

The scale is show immediately above the APD system. This scale is used for measurements of body weight.

In the left-hand lower corner of the same panel, the set-top box is seen. The modem and view transport system are installed in this box. As needed, it sends all data, views, and voices to the physician.

The Host Computer System panel shows the host computer system on the hospital side of the connection. This system consists of a host computer, a video camera, and an integrated services digital network (ISDN) system. Using it, we can connect directly to the APD system in the patient’s home and obtain all data every day. Furthermore, we can directly change the schedule of the APD system—dose and duration of CAPD—using this telemedia system.

Network system for the telemedicine system

In the right-hand corner of Figure 2, a nephrologist consults with a general physician in an affiliated hospital (in the middle of the figure), or with remote CAPD patients being followed at the main hospital. The general physician can consult with remote CAPD patients being followed at the affiliated hospital. Patients living remotely from the main hospital can attend the affiliated hospital periodically for routine follow-up: examinations of physical condition, blood chemistry, chest x-rays, electrocardiogram (ECG), and so on. The patients receive drugs prescribed by the nephrologist as required. In an emergency, data are available in the main hospital, and the nephrologist can order the necessary medications.

Data obtained from the newly developed telemedicine system

Figure 3 shows changes in ultrafiltration volume and body weight obtained from the data transport system for a 90-year-old female patient.

Clinical applications of telemedicine in CAPD

We are now considering applying this telemedicine system for these types of patients:

Elderly patients undergoing CAPD, especially those living alone.
Elderly patients undergoing CAPD who cannot attend the hospital by themselves.
Handicapped patients who have difficulty attending the hospital regularly by themselves.
Patients who attend a hospital that lacks specialists in caring for patients undergoing CAPD.

We are currently using this telemedicine system with seven elderly and handicapped patients undergoing CAPD. For example, one patient is a 90-year-old woman who lives alone and performs CAPD by herself. This woman performs her CAPD exchanges and self-care well, but cannot attend our hospital by herself. Every Monday and Thursday, we contact her and use the data transport system to check her CAPD data. When we find problems with her data, we use the View Send system to reach her for a talk. We can have a videoconference with her. Although she cannot understand a computer system, she uses the telemedicine system perfectly.

Discussion

In the present study, we introduce a newly developed telemedicine system and present its functions. Furthermore, we report the indications for and benefits of this telemedicine system for patients undergoing CAPD. We expect that this system has great advantages for the maintenance of CAPD patients, especially elderly and handicapped patients, who use an APD system.

Computer-assisted medical activity is increasing in several fields, with wide use in nephrology and dialysis owing to the unique characteristics of this patient population [number, complexity, length of follow-up, and cost (2)]. Previously, the proportion of patients treated by home hemodialysis was increasing, given the expectation that home hemodialysis would have lower mortality and offer better quality of life (3,4). However, the prevalence has been decreasing recently. The main factors negatively affecting the development of home hemodialysis were the rapid proliferation of renal units and the appearance of CAPD.

Agroyannis et al (5) hypothesized the combination of home hemodialysis with a telematics monitoring service for the support of end-stage renal failure patients who need hemodialysis treatment at home or in a satellite center. According to the data collected in practical use (6,7), disturbances in the function of hemodialysis were visible and audible in the central control station, and user messages were always observed. The predominant characteristics of telemedicine are its fast two-way electronic network, which provides interactive communication between doctors and patients.

The Texas Telemedicine Project offered an avenue for physician-participants to explore the best delivery system for successful use of telemedicine in medical practice. Between April 1991 and April 1993, the Texas Telemedicine Project sponsored contact and records management. During this period, 1500 patient contacts were documented. Patients quickly became comfortable with the interactive healthcare delivery and preferred it, not only for continuous monitoring by a physician during dialysis treatments, but also as a means of receiving primary care. This large-scale project concluded that telemetric healthcare delivery would be successful when the patient–physician relationship most closely mimicked face-to-face contact (8,9).

New computer-based videoconferencing systems are capable of interfacing with dialysis machines and clinical information systems to achieve a paperless medical record, including screen captures of vascular access images, a dialysis parameter database, and so on (10). Along these lines, our newly developed telemedicine system will lighten the load in CAPD patient care.

Conclusion

Our recent experiences leads us to conclude that (a) elderly and handicapped patients benefit from this system by being able to maintain CAPD without major problems and accidents; (b) other problems are mainly due to simple mistakes such as accidentally pushing the on and off switches; (c) quality of life is improved for the patients.

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Corresponding author:

Hiromichi Suzuki, md, Department of Nephrology, Saitama Medical School, 38 Morohongo, Moroyama-machi, Iruma-gun, Saitama 350-04965 Japan.

From: 1Department of Nephrology, Saitama Medical School, Saitama, Japan, and 2JMS Co. and 3Melon System Co., Tokyo, Japan.