Current models of healthcare are becoming unsustainable all over the world, due to people living longer with chronic diseases, and new costly technologies being developed. The number of people needing care is set to quadruple by 2050, placing extreme demands in terms of costs and provision of care workers.
In Scotland, the government have estimated that if the current requirements for health services are extrapolated to meet this demand, they will need to open a new 300-bed hospital every three years, and by 2050 all school leavers would be needed by the caring professions.
The choices seem stark - pay more, cut back to a bare bones service, or find an alternative. For some time UK health policy has been moving towards better prevention.
Early results are promising
Telehealth uses technology to empower people to manage their own health and wellness. It encompasses a wide range of services ranging from text messaging and telephone-based coaching through to remote monitoring of vital signs. The technologies range from simple devices that people with only the most basic IT skills can use, right up to highly interactive ser-vices linking wireless medical devices to applications on smart phones.
Most systems are built around the need to collect and transmit data from patients, but they could encourage patients to adopt self-care regimes, including better adherence to medications.
Telehealth could help to prevent conditions with high care requirements. Until recently, prevention was the domain of public health, and divorced from mainstream health delivery, but it is now becoming a major driver for the way all healthcare is provided. The US Veterans’ Administration recently reported some remark-able results from their large-scale implementation of telehealth - including a 25%reduction in bed-days of hospital care.
Continua Health Alliance is a non-profit, open industry coalition of healthcare and technology companies which aims to promote telehealth.
First formed in 2006, the coalition brings together technology, healthcare provider, pharma, consultants (including PA Consulting) and academic organisations to work with governments and standards organisations to create a sustainable technical environment for these services.
So what is stopping a wider adoption of telehealth? Some of the obstacles are common barriers in healthcare, such as a paucity of high-quality evidence, limited knowledge (and therefore acceptance) by the professions, and dysfunctional reward systems that pay for work done rather than outcomes achieved.
There are also real concerns around privacy and security for medical information. Other issues are more pertinent to the telehealth arena.
There are concerns about the scalability of current technologies, particularly around the lack of interoperability and integration with core health IT systems. These limitations restrict the scope of services to very specific audiences, creating issues of inequity. The small size of the current market means that the avail-able solutions are often expensive, forcing a focus on patient groups that incur the highest immediate costs at the expense of earlier prevention.
Telehealth could help keep older people healthier and out of hospital for longer - but the technology has to be proven to be worth the considerable investment
Realising the potential of telehealth
Healthcare providers will have to take a pragmatic approach to implementation, building capability and capacity in order to meet the wider expectations for health system reform. This will require:
A vision that sets the development agenda, clearly identifying the benefits and priorities
laying the foundations for scalable services within the limitation of current technology
expanding accessibility by working collaboratively to shape technology enhancements.
Setting the agenda for development
Understanding the clinical and economic drivers behind healthcare needs is vital. This requires populations to be carefully segmented to identify priority targets and use this to select the most appropriate technology platform.
Telehealth services span two potential target groups at two extremes of the spectrum. The first group are those who are likely to experience an expensive care episode in the near future. This model focuses on short term savings from avoidable hospital stays, investigations and urgent treatments. Typically, this involves complex cases in the advanced stages of a chronic disease. The majority of patients are in the over-75 age bracket, which means their ability to use technology is a major issue.
The second scenario is to provide early intervention to help patients improve their lifestyle. In this model, the target population is larger, and typically represents a much younger and active demographic who are more likely adopters of new technology.
The main return from this investment will be seen only in the long term, potentially decades away, and this presents difficulties for investors faced with more immediate priorities. It also poses questions about sustainability as there is a paucity of evidence of the long term outcomes. Deploying effective solutions requires a clear vision for who needs to be targeted, how their needs can best be met by technology and a sense of timing to reach out to people when they are likely to be most receptive to a change. Some clinicians are torn between the value telehealth delivers to a patient and the distraction and load it places on the medical profession. This is typically a symptom of small operations where size prevents consideration of a broader service redesign that could achieve economies of scale.
Telehealth places a new and significant work-load into the clinical domain.
Experience from the UK suggests that a large pro-portion of activity is low level, such as first line investigation of missing or anomalous results.
Automation of some tasks, and filtering others using less costly resources, would address the low ratio of patients to clinicians evident in smaller operations. Investing in larger deployments is critical to achieving scale economies and ensuring telehealth services reach their true potential.
Risk stratification tools for identifying suitable patients are becoming increasingly more accurate, but this means complex information needs to be pulled in from disparate sources.
It is no coincidence that many of the early tele-health adopters, such as the Veterans’ Administration, are organisations that use information from electronic patient records to identify and manage their patients.
Without such tools there is an increased risk of wasting resources on people who are unlikely to benefit.
Work within limits of current technologies
Initial investments typically focus on areas where there is confidence of a return. The greatest potential appears to lie somewhere in the middle of the patient risk spectrum, where a relatively large number of people may become the more complex cases of tomorrow, and thus offer a relatively fast return on investment.
However, this group is also likely to have very different technology preferences to higher risk groups, typically needing services that fit with amore active lifestyle.
The largely proprietary nature of current technologies forces a choice, or leaves the provider with significant overheads from managing multiple remote
monitoring systems. The future holds the possibility of more flexible monitoring platforms, able to service a range of channels, supporting‘mHealth’ solutions.
Reaching out to people when they are most receptive to change requires careful integration with wider clinical pathways, so that opportunities to engage patients are not wasted. Many early trials have failed to be adopted into a mainstream service because they are seen as a ‘bolt-on extra’ rather than a comprehensive transformation of the care system.
Building clinical leadership around a shared vision is vital to bring about change, and appropriate incentives will be needed for widespread adoption among clinicians..
Fragmentation of healthcare systems significantly slows adoption. Ultimately, it requires system-wide reforms to adjust for the fact that the party that pays is often not one that gains. In the meantime, adoption will centre on payer-provider systems, such as the NHS as well as the comprehensive private systems like Partners HealthCare and Kaiser Permanente.
Building a telehealth service requires a clear vision for growth, an understanding of service maturity to drive improvements and a commercial strategy for moving beyond the limitations of cur-rent technology platforms.
Expanding telehealth use in stages is likely to be a realistic approach, with trials in certain conditions or demographic groups being tested first. This will help demonstrate the limits of existing technology investments, and where whole new capabilities would be required.
Innovation will open up new opportunities butwill often be constrained by the legacy of earlier technology choices. Organisations investing in telehealth should seek to carry their vision forward into commercial arrangements, ensuring that sup-pliers remain incentivised to continue to develop solutions. Often the scale of investment required will mean collective purchasing at a regional or national level will be required.
The telehealth vision should also provide the commercial foundations for growth, particularly in building more flexible solutions and fixing a commitment for the incorporation of standards for interoperability as they become available. This will allow operators to be freed from proprietary constraints to provide the sort of integrated services needed to deliver at scale.
Collaboration shapes technology enhancements
New technical and professional standards need to be created in order to open access and enable ser-vices to work across organisational boundaries.
Governments have to help steer this process in order to provide the scale of customer demand to justify industry investment.
Technical standards that enable different technologie sto work together are essential. This offers users a choice of technologies, opening the possibility of developing solutions to meet minority interests and reducing repeated development costs associated with bespoke developments.
The formation of the Continua Health Alliance and the publication of the first interoperability guidelines for personal health and wellness technologies are signs progress is being made on this front.
The writing is on the wall for those suppliers still holding out with proprietary offerings. Adoption will ultimately be supported through effective regulation and incentives, such as the criteria for ‘meaningful use’ that have been incorporated into the US investments in healthcare reform.
The groundwork has been laid for telehealth to play its part in creating sustainable healthcare services. Delivering on this early promise will mean taking bold steps in building capability and capacity, recognising the limitations of existing technologies and laying the foundations for scalable services.
George MacGinnis is a member of PA’s eHealth team and works within the NHS to develop use of personal health technologies. George is vice-chair of the Continua Health Alliance’s Use Case Working Group, leading work to establish more consumer-ready connected health services.
Henry Rivera, managing consultant, is an expert in Assistive Technologies for Social and Health Care applications, with over 20years’ experience in the development of IT and Innovation. Over the past seven years Henry’s main focus has been on using innovation to advance the delivery of health and social care across England.
Michael Dillon has supported implementation of the UK’s largest telehealth services. He led the development of standards based information sharing solutions now being adopted across the NHS to support integrated working across services and care teams. He has played a key role in developing the next generation integrated telehealth and telecare solutions being proposed by one of the largest solution providers in Europe and in use by some of Europe’s largest providers of health and social care.
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