Telehealth. an overview. Supported by the Telemedicine & ehealth Section, The Royal Society of Medicine. Stacey Marney,

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1 Supported by the Telemedicine & ehealth Section, The Royal Society of Medicine Telehealth an overview Professor Brian McKinstry GP and Professor of Primary Care E-Health University of Edinburgh Dr Richard Williams Consultant Physiologist (cardiology) NHS Gloucestershire Charles Lowe Former Telecare and Telehealth Project Manager, Surrey County Council Helen Lyndon Nurse Consultant for Older People & Long Term Conditions, Peninsula Community Health Telehealth is the remote monitoring of a person s health by a trained individual. Telecommunications technology facilitates collection of clinically relevant physiological and psychological data. Telehealth can also collect data on self-care, lifestyle modification and medicine administration, which can be used to encourage and sustain healthy behaviours. Telehealth can be referred to as telemonitoring. Telehealth is distinguished from telemedicine and telecare. Telemedicine is the use of technology to facilitate the remote exchange of information between clinicians to evaluate, diagnose and treat a patient, often with the patient present and active in the consultation. Telecare is used to maintain an individual s independence at home by the monitoring of a person s external environment looking for hazards and adverse events, such as fire, falls, and fits. Stacey Marney, T: E: telemedicine@rsm.ac.uk W:

2 Benefits The principal potential benefit of telehealth is improved patient health, evidenced by lower mortality and fewer emergency admissions (Steventon, et al. 2012). For patients, telehealth can lead to improved quality of life by promoting independence and supporting self-care. For healthcare professionals, telehealth can contribute to the re-design of the care pathway for patients with long-terms conditions. It provides an additional choice from a menu of options clinicians have to support individuals to self-care. It can aid in the early detection of clinical problems, and in the timely initiation of appropriate interventions and treatments. Telehealth has the potential to improve patient outcomes and lower treatment costs (Barrett 2011). Telehealth is popular with patients (Finkelstein & Friedman, 2000; Page, et al. 2007) and an increasing number of clinicians (Gornall 2012). The diagram below illustrates a typical home-based telehealth service delivery model. The patient generates biometric information using a medical device and provides answers in response to questions set on the device. The information is transmitted directly to a secure server which analyses the data against parameters set specifically for that patient by their lead clinician, which may be a General Practitioner, Community Matron, Specialist Nurse, or other key worker. If any of the parameters are breached for example if blood pressure is too high, blood oxygen saturation is too low, weight has risen too much in 24 hours or if the answers to a set of questions about symptoms are unsatisfactory, then an alert is raised immediately with a trained triage worker or directly with the patient s lead clinician. Typically the patient will then receive a telephone call to explore their symptoms in more depth. If the alert is confirmed as requiring further action, the triage worker will notify the patient s lead clinician or, if authorised, may implement the next step in an agreed treatment plan. Next steps may include advising the patient to commence rescue medicines or to seek a consultation with their lead clinician. The patient s progress is then checked regularly via the telehealth service. It should be stressed that telehealth is not an emergency service. It is used to monitor trends in a patient s long-term condition to enable prompt diagnosis of any deterioration and initiation of treatment. Depending on the condition monitored and the context, other service delivery models may be, or become, more appropriate.... but not everyone may benefit In spite of the emerging evidence in support of telehealth, important questions remain to be answered. The benefits of telehealth may not apply to all patients with a particular condition, or improve certain outcome measures, such as quality of life, anxiety or depression (Cartwright, et al., 2013). It seems likely that distinctions will need to be made when assessing the suitability of individual patients (Giordano et al. 2011). It is also important to note that telehealth does not simply work or not work and is most successful when it is integrated as part of the long-term condition pathway, as an additional choice from a menu of options to support patients to self-manage their condition. Its success can also depend on the type of technology used, the patient s condition, the clinical and social context, and the extent to which clinicians are willing to get involved (Car et al 2012).

3 Evidence There is good evidence supporting telehealth as an effective clinical intervention for some conditions, including: COPD is amenable to telehealth management because lung function deteriorates with every exacerbation. Prevention of an exacerbation, therefore, is a key goal in management of the condition. Also, once exacerbations begin to require unplanned hospitalisation, they tend to get steadily more frequent unless action is taken. One early trial involved patients with COPD-related respiratory failure requiring long-term oxygen therapy or mechanical ventilation, or both. Case managers alternated physical visits to the patient s home with virtual home visits via telehealth to conduct reviews and reduced the need for hospital admission by 39.8% in the intervention group compared with usual care (Bourbeau, et al., 2003). Diabetes control can be improved with telehealth, according to a 2009 systematic review of 26 studies involving 5069 patients, leading to reduced hospital admissions and duration of stay (Polisena, et al., 2009). Heart failure tends to go through acute phases and patients benefit from improved risk stratification at an early stage to address potential exacerbations. A systematic review and meta-analysis of telemonitoring programmes for patients with chronic heart failure (CHF) found that telemonitoring led to a 34% reduction in risk of all-cause mortality (p<0.0001), 21% reduction in the proportion of patients hospitalised due to CHF (p=0.008), and 9% reduction in the proportion of patients hospitalised for any cause (p=0.02) (Inglis et al 2010). Telehealth has also been found useful for reaching patients who are without access to home- or clinic-based heart failure management programmes (Clark et al 2007). However, not all telehealth trials involving heart failure patients have reported positive results, with at least one trial reporting no reduced mortality or reduced hospitalisations with telemonitoring compared with usual care (Chaudhry, et al. 2010). The rebuttal to these negative findings has been that the study designs may not have been appropriate to capture the complexity of telehealth (Bonell, et al., 2012) and that many trials reporting negative results have still recognised the potential for telehealth and called for further research. Whole System Demonstrator (WSD) programme, launched in May 2007, was the largest randomised control trial of telehealth in the world, involving 3,154 patients (with one of three conditions: diabetes, heart failure and COPD) and 179 GP practices across three sites: Newham, Kent and Cornwall. Early results indicate that, if used correctly, telehealth can deliver substantial clinical benefits (Steventon, et al. 2012). However, as these benefits started to occur early in the study, mainly during a period immediately post randomisation and before the telehealth equipment had been installed, these results require confirmation (Car, et al., 2012). Control Group (n=1584) Intervention Group (n=1570) Absolute difference (95% CI) % difference (95% CI) Mortality (%) 8.3 (n=131) 4.6 (n=72) 3.7 ( 5.4 to 2.0) 44.5% ( 65.3% to 23.8%) Emergency admissions (%) 0.68 (1.41) 0.54 (1.16) 0.14 ( 0.23 to 0.05) 20.6% ( 33.8% to 7.4%) Elective admissions 0.49 (1.31) 0.42 (0.99) 0.07 ( 0.15 to 0.01) 14.3% ( 30.6% to 2.0%) A&E visits 0.75 (1.58) 0.64 (1.26) 0.11 ( 0.21 to 0.01) 14.7% ( 28.0% to 1.3%) Bed days 5.68 (15.10) 4.87 (14.35) 0.81 ( 1.84 to 0.22) 14.3% ( 32.4% to 3.9%) Tariff costs 2448 (4099) 2260 (4117) 188 ( to 98.8) 7.7% ( 19.4% to 4.0%) Ongoing Research Clinical trials are currently investigating the use of telehealth in a wide range of physical and psychological conditions. The Department of Health (DoH) has also introduced 3 Million Lives as a successor to the WSD programme. The DoH believes that at least three million people with long-term conditions and/or social care needs could benefit from the use of telehealth and telecare services. To achieve this level of change the DoH of Health is working with industry, the NHS, social care and professional partners in a Three Million Lives campaign designed to develop the uptake of telehealth at scale and pace, removing some of the barriers to delivery by ensuring telehealth is a cost-effective option for the prevention of unplanned admissions. However, the DoH recognises that scaling up and normalising telehealth within the NHS is a formidable challenge.

4 Why is interest in telehealth increasing? Healthcare systems globally are facing major challenges such as ageing populations, increasing numbers of people living with long-term conditions, patients in remote areas or with limited mobility, and increasing expectations for patient-centred healthcare. A fundamental change in the way that we deliver health care is required in order to address this rise in long-term conditions and the multi-morbidity predicted over the next 10 years (DoH 2012). Telehealth offers potential solutions to these challenges, especially when used appropriately (Roehr, 2013). Many chronically ill patients are ideal candidates for telehealth, especially those willing and able to share decision-making and manage their own long-term conditions. But simply adding telehealth to usual NHS care is unlikely to achieve its potential without national service redesign, clinical engagement, and patient involvement. Whilst a substantial body of evidence supports telehealth, it is not unequivocal evidence. However, the scales appear to be tipping in favour of telehealth, certainly for some conditions and some patients. It is increasingly recognised that telehealth is a complex intervention that requires other changes in care delivery in order to be fully effective. But it is i mportant that telehealth finds its feet on the basis of addressing clinical needs rather than be adopted as a technology-driven-solution in search of a problem. A positive outcome in ongoing trials should demonstrate the clinical benefits and enable the NHS to wield a more persuasive argument to clinicians and commissioners. But a key issue is the need for a revolution in how we support the management of long-term conditions in the future. By necessity this will need to encourage the mass adoption of healthy lifestyles and radical improvement in the education of people to use the right service at the right time. A rapid implementation of telehealth and self-care at scale and pace could form an important part of the revolution required. Events November 2013 Telemedicine & ehealth 2013: Ageing Well how can technology help? 27 February 2014 Recent developments in digital health 10 April 2014 Playing games, using apps, promoting wellbeing 5 June 2014 Reducing hospital stays through good local co-ordination All events at Royal Society of Medicine, 1 Wimpole Street, LONDON W1G 0AE, unless otherwise stated. Further information is available from the Telemedicine & ehealth Section,

5 References Barrett D (2011). Telemonitoring heart failure patients in Hull: estimation of cost savings resulting from reduced hospital admissions in , www2.hull.ac.uk/pgmi/pdf/nhs Hull Telemonitoring savings report _June 2011_(UoH Final).pdf Bonell C, Fletcher A, Morton M, et al. (2012). Realist randomised controlled trials: A new approach to evaluating complex public health interventions, Social Science and Medicine, 75(12): Bourbeau J, et al. (2003). Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention, Archives of Internal Medicine, 163(5):585-9 Car J, et al. (2012). Telehealth for long term conditions, British Medical Journal, 344:e4201, Published 21 June 2012 Cartwright M, et al. (2013). Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study), British Medical Journal, 346:f653 Chaudhry SI, Mattera JA, Curtis JP, et al. (2010). Telemonitoring in Patients with Heart Failure, New England Journal of Medicine, 363: Clark RA, et al. (2007). Telemonitoring or structured telephone support programmes for patients with chronic heart failure: systematic review and meta-analysis, British Medical Journal, 334(7600):942-5 DoH (2012). Long Term Conditions Compendium of Information: Third Edition, Department of Health, Gateway Ref: 17485, Finkelstein J & Friedman RH (2000). Potential role of telecommunication technologies in the management of chronic health conditions. Dis Manage Health Outcome, 8:57-63 Giordano R, et al. (2011). Perspectives on telehealth and telecare: Learning from the 12 Whole System Demonstrator Action Network (WSDAN) sites, The King s Fund, Gornall J (2012). Does telemedicine deserve the green light?, British Medical Journal, 345:e4622, Published 10 July 2012 Inglis SC, et al. (2010). Structured telephone support or telemonitoring programmes for patients with chronic heart failure, Cochrane Database of Systematic Reviews 2010, Issue 8, CD Pare G, et al. (2007). Systematic review of home telemonitoring for chronic diseases: the evidence base, J Am Med Inform Assoc, 14: Polisena J, et al. (2009). Home telehealth for diabetes management: a systematic review and meta-analysis, Diabetes Obes Metab, 11: Roehr B (2013). Telehealth can be beneficial when used properly, say experts, British Medical Journal, 346:f1995 Steventon A, et al. (2012). Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial, BMJ 2012;344:e3874, Published 21 June 2012 We would like to thank InHealthcare and Medvivo for sponsoring this flyer. This leaflet has been produced with contributions from these sponsors who had no input into content version: June 2013