Telehealth and Telecare
What differences might telehealth and telecare mean for us in the years ahead? How can developments like smart phones, cloud based internet and avatar technology be used to improve healthcare? Which patients, with which medical conditions, are likely to benefit most? Are there any problems with introducing modern technology into health and social care systems which have traditionally been provided though direct, face to face contact?
Some possible answers were given at the Second International Congress on Telehealth and Telecare, which featured speakers from the USA, Singapore, Brazil, Australia, New Zealand, Israel, the UK and six other European countries. The Congress, which took place in London in early March 2012, was organised by the King’s Fund, in partnership with the University Medical Centre, Utrecht.
What is Telehealth?
One definition of telehealth was given in the BMJ in 2004 ie ‘the remote exchange of data between a patient at home and their clinician(s) to assist in diagnosis and monitoring, typically used to support patients with Long Term Conditions. Amongst other things it comprises of fixed or mobile home units to measure and monitor temperature, blood pressure and other vital signs parameters (and the answering of targeted questions) for clinical review at a remote location using phone lines or wireless technology. Examples of telehealth devices include: blood pressure monitoring; blood glucose monitoring; and medication reminder systems.’
Since then, as the conference illustrated, there have been developments not only in the technology (including video conferencing, cloud based internet, avatar interaction and smart phones, for example) but also in an understanding that telehealth can change the roles and working practices of both patients and health professionals and that it can also help with lifestyle change ie this is far more than just a technological development. In practice the pilot studies in telehealth conducted so far seem to have been preceded by and/or involved an element of face to face contact with health professionals rather than relying purely on technology and this has usually been seen as mutually valuable by both patients and health professionals.
Long term conditions where telehealth has been employed include Type 2 Diabetes, COPD (chronic obstructive pulmonary disease), depression, hypertension, kidney disease, asthma, cardiovascular disease, chronic fatigue syndrome, neuromuscular diseases, Parkinson’s Disease, breast cancer and prostate cancer.
So how does telehealth work in practise?
Telehealth can work in different ways. One example which uses existing lifestyle technology is ‘Simple Telehealth’ provided by NHS Stoke on Trent It uses mobile phone technology and communicates via texts, to monitor a patient’s long term condition, motivate them, remind them to take medication or trigger a change in therapy. When patients text through their data ‘Florence’ (the service support software) texts back for instance OK; or that’s a bit high, test it again tomorrow; or that’s very high, see your GP. The technology can be used to help with a variety of situations, from motivating and monitoring patients giving up smoking to assessment of hypertension to improved clinical control of asthma. The patient’s health practitioners can also send messages. This isn’t designed for in depth assessment by doctors but has been used by over a thousand patients since June 2010 and received positive patient feedback.
What is Telecare?
Telecare is often used to support older people to continue to live independently in their own homes, for instance by electronically sensing situations when an elderly person might be at risk. There are, for instance, a range of sensors now available, including movement sensors, fall sensors, heat sensors, flood sensors, door and window sensors and enuresis sensors (which detect moisture, without carers needing to physically check, helping preserve the patient’s dignity). Other forms of telecare range from GPS trackers (to help locate people with dementia who might wander off and get lost) to technology enabling a son or daughter in one part of the country to check that their elderly mother or father in another part of the country is taking their medication, if they can’t be physically with them. As such telecare can often provide reassurance to and reduce some of the psychological pressure on carers. Indeed one research report (by Leeds University for NHS Scotland) was entitled, ‘A weight off my mind.’
Telecare can also be used in care homes. For example Roz Eccles described how telecare helped achieve a reduction in falls during a pilot study in NHS Lothian. Other benefits included freeing up staff time and avoiding the need to disturb residents through two hourly checks on their rooms at night. Both residents and staff reportedly valued its use. The technology used included a portable telecare local alarm and falls detectors, chair occupancy sensors and bed occupancy sensors.
Why consider telehealth and telecare?
The pressures on health services like the NHS are well known. We have an ageing population, an increased prevalence of long term conditions (with 70% of NHS expenditure committed to patients with long term conditions) and pressures on both public and private spending. It is natural to explore whether technology might help provide a possible solution.
There are also populations who may be hard to reach (Professor Diane Cox explained the potential value of tele rehabilitation for patients in the Lake District, whose lakes, mountains and tourists can significantly increase journey times to/from conventional treatment). The point was made even more dramatically in the report of a pilot study in Brazil, where telehealth was being used to assist urban and Indian populations in the Brazilian Amazon.
The Benefits of Telehealth
A number of the pilot studies reported at the conference suggested health benefits for patients. These included improved management of the following conditions: hypertension in an Edinburgh study; diabetes in a Birmingham study; depression in a US study; COPD in an Irish study; and asthma in a study from New Zealand. A fuller picture will hopefully be provided once the results of the large scale randomised control trial in three parts of the UK (the Whole System Demonstrator Programme) are published.
There also appears to be evidence that telehealth can help patients understand and take greater control of their condition. For example in a Salford pilot reported by Katherine Grady, there were measurable clinical outcomes, including weight loss, and in addition patients reported increased confidence about how to reduce their own risk of type 2 diabetes.
Telehealth is also seen as having potential to help patients adopt healthier lifestyles, as in the Swedish ‘Renewing Health’ programme, which combined health coaching with online management of patient data to help patients become more actively involved in their own health and healthcare.
Paul Burstow MP, Minister for Care Services in England, added another dimension. People with long term conditions can find themselves facing an endless succession of doctors appointments and nurses visits, significantly reducing their independence. Telehealth can potentially free time for them to pursue their own lives, rather than spending hours in NHS waiting rooms.
This was illustrated by a speaker who was a patient with multiple long term conditions, including heart disease, stroke, hypertension and Parkinson’s. He explained that he used to spend 8 – 10 months a year as an in patient in hospital. When he was back at home he spent much of his time waiting for the GP or District Nurse to visit. He wasn’t able to plan his own life as he spent so much time waiting for health professionals to visit. At first he had doubts as to whether telehealth could help. However, it has given him greater peace of mind (enabling rapid changes to be made to his medication if needed), has reduced the time in hospital as an in patient to 5 weeks a year, and has given him greater independence and control over his life, enabling him, with help from his carer, to go shopping, do some gardening, visit his friends and become a member of the telehealth support network.
Until recently, in the UK, there had been questions as to the quality of the research which had been conducted, for instance as to how rigorous and robust the research methodology had been or how far small pilot studies with enthusiastic doctors and patients would be replicable on a larger scale.
However, the recent Whole System Demonstrator programme has aimed to address these concerns. Randomised Control Trials (the gold standard for medical research) have taken place in Cornwall, Kent and Newham in East London and the results are due to appear in peer reviewed journals over the next few years. Initial indications are that WSD helped achieve a reduction in both hospital admissions and mortality. Similar studies in the US showed reduced time spent in hospital too but also an increase in clinic attendance.
Some issues and Concerns
Not all patients have been comfortable with the idea of telehealth. Professor Stan Newman explained that some have been concerned this is a government cost cutting measure, which might result in less face to face care. Some have been put off by the technology – ‘I don’t want to push more buttons’ as one patient put it. Some were uncomfortable with a constant reminder of their condition and some felt it would make them more dependent on health services. All this suggests that how telehealth is presented and explained to patients is very important.
Some doctors have also had concerns. As Professor Jeremy Wyatt explained these include concerns about the quality of the evidence available (although the Whole System Demonstrator study should address this); about possible false positive or false negative results (as with some medical screening programmes) meaning additional, unnecessary workload; about whether there are established protocols; and about the changes in working practice (with more responsibility delegated to the patient, nurses and/or call centres). There are also questions as to whether telehealth is likely to be more effective in treating certain diseases or certain patients – and whether certain types of telehealth are more effective than others (for example depending how invasive they are, if a device is needed at home and whether or not they are wireless).
A number of speakers explained that technology alone doesn’t bring change, there needs to be a change in the way health and care services are designed and delivered and this may prove a challenge. Speakers who had piloted WSD explained that challenges ranged from the logistics of data collection to winning the hearts and minds of health professionals (some of whom might see telehealth as a threat to their jobs). Scaling up from small scale pilots was seen as a further challenge, as was ensuring data collected could be accessed by the people who needed it (ie interoperability between information systems). As Arina Burghouts explained problems could arise if telemonitoring information could only be found in the telemonitoring system, whereas the other medical information about the patient was stored in a separate hospital information system.
Dr Nick Goodwin advised there are also questions about the variables involved (such as location, demographics, the nature of the control group and the type of impact measures used) and about what has really made the difference (the technology or the human contact in setting up and using the technology – as he asked, was it the technology or the tlc)? This is a possible example of the Hawthorne effect (where people change their behaviour due to the attention they are receiving from the researchers rather than what is actually being researched). As Professor Newman pointed out the WSD programme was a complex study, with complex findings and therefore open to different possible interpretations.
The UK government and Department of Health both appear committed to developing Telehealth and Telecare and have set the target of achieving three million patients accessing telehealth and telecare over the next five years – in the 3 Million Lives project. The project was launched in 2012.
The Second International Congress on Telehealth and Telecare took place at the King’s Fund, London from March 6th–8th 2012. Further information from the conference is available on the King's Fund website.
Conference Report published March 2012.