Breathing new into home care: Texas hospital remotely monitors the pulmonary function of post-transplant pediatric patients.

Find a cost-effective, user-friendly solution to precisely monitor pediatric patients' post-transplant lung function--directly from their homes. George B. Mallory, M.D., associate professor of pediatrics at Baylor College of Medicine and director of the lung transplant program at Texas Children's Hospital, presented this challenge to the hospital's Pulmonary Diagnostics Lab in 2002.

Approximately 60 children in the U.S. receive lung transplants annually, primarily because of cystic fibrosis or pulmonary hypertension. Post-transplant survival is a challenge for this relatively new, hightech procedure. Lungs are more subject to infection and immunologic rejection than any other solid organs. Decreased pulmonary function is an early and critical indicator of possible graft malfunction. Timely and accurate surveillance of lung health is, therefore, essential to good outcomes.

Before coming to Houston, Mallory started the transplant program at St. Louis Children's. He directed medical services there for nine years, during which time he managed the care of 130 pediatric lung-transplant patients. His patients and their parents went home with a conventional spirometer for at-home testing of the volume and velocity of airflow from the children's transplanted lungs.

However, Mallory did not have a direct, automated way to monitor flow-volume curves remotely. Patients' families faxed written logs of the test results. According to Mallory, poor adherence to requests for daily spirometry after patients returned home was a significant problem. Determined to find a better way in Houston, he turned to the Pulmonary Diagnostics Lab to find a technology alternative.

Envisioning a Solution

The essential attributes of an ideal solution were clear. It had to feature an absolutely accurate spirometer that would also be convenient and easy for children and their families to use at home. Also, it had to support real-time, remote access to the test results so Texas Children's could monitor patients' lung function at any time, no matter how far from Houston they live. The ability to conduct remote monitoring was especially important because the hospital's lungtransplant patients come from all over Texas and surrounding states, and potentially from anywhere in the world.

The Pulmonary Diagnostics Lab evaluated portable spirometers from several manufacturers. Respironics, a leader in the respiratory medical device industry, is a distributor of QRS Diagnostic's spirometry devices to the home health care market in the U.S. Its local representative provided QRS spirometers for review.

Respironics demonstrated SpiroCard on a laptop computer. SpiroCard utilizes QRS' patented technology to deliver diagnostics in portable, upgradeable computer cards. The device weighs less than 2 ounces, and a tube to convey airflow from disposable mouth pieces is integrated into it. The device slides into PCs, enabling them to work as full-function medical devices for pulmonary function testing. It digitally saves and stores test results, which can be managed with the Office Medic patient data management software from QRS.

Texas Children's reviewed the technical specifications and literature on SpiroCard and learned that independent testing has verified it exceeds American Thoracic Society accuracy standards. A spirometer must be especially precise at low airflow volumes for pediatric lung-transplant patients. Therefore, hospital technicians tested SpiroCard side-by-side with the $30,000 spirometer in the Pulmonary Diagnostics Lab. It produced comparable results and was the only portable spirometer tested that delivers a level of accuracy at low flows necessary to monitor patients' progress after transplant.

Assembling the Solution

In July 2002, having chosen its preferred spirometry device, Texas Children's explored flow it could he deployed to enable remote access to test results. The hospital had previous experience with pcAnywhere, remote access software from Symantec. The Pulmonary Diagnostics Lab asked QRS to install and test SpiroCard with the Office Medic software on a PC with pcAnywhere and an internal modem. It was successful.

Texas Children's had a solution for at-home spirometry with precise spirometric values, digital data storage and remote monitoring. Technicians could access the children's spirometry results via a modem connection at any time. Geographic distance from Houston would not be a problem or barrier.

QRS assembled a packaged solution including: 1) SpiroCard and the Office Medic software; 2) pcAnywhere; 3) a Compaq Evo notebook computer with an internal modem; 4) complete setup, testing and delivery of the computer with SpiroCard and all the software; 5) a year's supply of pre-calibrated, disposable mouthpieces for SpiroCard; and 6) technical support for the device, the software components and the computer.

With expenses of $200,000 to $300,000 for the care of children prior to a transplant and for the transplant itself, the additional cost of around $6,000 for accurate home-based spirometry and remote monitoring is a modest, incremental investment for payers. Plus, it eliminates the need for many follow-up office visits and repeat visits to a hospital pulmonary diagnostic lab.

Positive Results

Post-transplant patients receive SpiroCard and a notebook PC at the hospital. This gives Pegg Dobmeier, R.N., B.S.N., and the rest of Mallory's team the opportunity to explain the technology to the children and their parents.

The children try SpiroCard at the Pulmonary Diagnostics Lab to ensure that they can use the device correctly. After patients have been discharged, they generally test lung function twice a day for three months. After that, spirometry usually is done once a day. The solution is easy to use, and compliance has been excellent.

With the pulmonary function testing solution the hospital assembled, technicians in the lab can connect to the children's computers to verify that they have performed their spirometry tests and then review the results. Thus, Texas Children's accesses the results right from the lab. So far, the solution has worked well for the 12 school-age children who have received transplants in Houston.

Mallory anticipates that Texas Children's will perform transplants on 15 pediatric patients in 2004 and 20 annually thereafter, making it one of the premier pediatric lung-transplant programs in the world. Our solution for at-home spirometry, combining medical device technology and IT, will be an essential part of the program.

For more information about SpiroCard from ORS Diagnostic, www.rsieads.com/405ht-200

David Blanco, R.P.F.T., is special projects coordinator and educator, Pulmonary Diagnostics Lab, Texas Children's Hospital, Houston. Contact him at dwblanco@texaschildrens hospital.org