Telehealth: possibilities and practicalities of next-generation healthcare services A leadership perspectives white paper Recommended next steps for business executives and healthcare professionals Issue 6 in a series
Executive Summary An ageing population in developed countries and an expanding middle class in developing ones leaves few untouched by a growing demand for healthcare services. Demand far outpaces the professional and financial resources available. In fact, healthcare reform tops the political agenda in nearly every country. Driven by government mandates and consumer demands, the introduction of new and cutting-edge technology and services, such as electronic health records and telehealth solutions, will be a crucial component of curing the ails facing the healthcare industry. Next-generation healthcare ICT is a tool that improves access and quality of care, streamlines operations, and helps curbs costs. In the UAE, one in four deaths is currently attributed to cardio vascular disease. It is a known fact that 80% of these deaths are preventable through lifestyle modification and remote monitoring, which could be achieved in part through telehealth systems deployment and m-health devices. Business case overview Like any new field, telehealth means many things to many different people. Experts in the field define it as the use of a digital network to provide healthcare to a patient who is in a different physical location from the medical expert. So, no matter where a patient or provider is located, care can be given through the use of teleheath technology. The solutions used to connect clinicians and patients range from high-end videoconferencing units to webcams built into laptops, and healthcare-specific home devices which allow patients to collect and share data about their own vital signs using a consumer mobile phone. A number of technologies fall into the category of telehealth and as the technology advances, more avenues will be created. Currently, most are used independently of each other, but eventually all will become part of the everyday workflow of healthcare providers. Produced by du enterprise marketing in association with Ovum, a preferred knowledge partner
Video conferencing for healthcare Technologies range from expensive high resolution Polycom or Cisco units that are restricted to a single location within a consultation room, to the use of laptop webcams through voice and video over IP (VoIP) services. As telcos and mobile providers build video capabilities into smartphones as well, video conferencing becomes truly mobile. Today, most providers which utilise video conferencing have their large equipment in a fixed location, typically a telehealth room which is in a separate location from where medicine is typically practiced. These providers log into the video conference system and collaborate with colleagues in different locations (possibly in different countries), discussing patient cases, sometimes with patients in the room, sometimes without. Video conferencing is used for patient care, but it is also used for administrative or educational tasks. It can be delivered as a managed service by leading telco operator partners, such as du. New video conferencing models have been introduced in the past year or so, which connects patients in their homes to providers in their offices. Using a VoIP user interface, physicians conduct online consultations with patients, and for the majority of questions or follow-ups a patient s computer screen is sufficient. (Healthcare insurance companies in the US have already started to offer such services to their members.) Industry analysts forecast that as video conferencing technology continues to improve and the price-points decline, this more consumer-friendly and mobile model will become more prevalent than the current video conferencing experience. Remote patient monitoring The Dubai Health Authority every year receives an average 15,000 outpatients who suffer from some form of cardio vascular disease. Currently, a patient, typically elderly with a chronic condition such as congestive heart failure (or diabetes, which is another high-incidence disease in the UAE), or one who has just been hospitalised and needs to be monitored for a short period to avoid a hospital readmission, is sent home without medical supervision. Using a telehealth device which typically plugs into a phone or Internet line, it is possible to supervise patients remotely, by transmitting data collected from peripherals such as a weight scale, blood pressure cuff or glucometer. Patients are also sent SMS messages to remind them to check their vital signs daily or more, depending on their doctor s recommendations.
The information from the peripherals is sent to a hub device which then sends the data to the patient s healthcare provider. Nurses are then able to check on their patients daily, from the office. Analytics makes it easy for clinicians to see which patients have gained or lost weight, or see whose blood pressure has increased. If there is a negative change or if no data have been sent, the nurse or doctor can access an online patient directory to SMS or call the patient and follow-up. If needed, the patient may be emailed an appointment to come into the clinic. M-Health Mobile health is healthcare that is enabled by mobile devices, partially through telehealth, but partially as its own separate technology. Still in its infancy, it entered the healthcare scene in 2009 and shows great potential on a global scale. As mobile phones have become more prevalent in high growth countries like the UAE, the ratio is often more than one phone per person and in developing countries people are more likely to have access to a mobile phone than to a computer and applications for smartphones continue to grow, the uses for m-health also increase exponentially. From texting appointments or medication reminders to patients, to keeping a daily log of food intake and exercise through an iphone application, m-health is already occurring. For example, the mobile information service Text4Baby is a public/ private partnership launched overseas earlier this year. Expectant mothers sign up and based on the timeline of their pregnancy, they are texted various pre-natal health tips. In the UAE, du has pioneered m-health services as an employee benefit that allows staff have their health monitored. Using a du SIM-fitted EMH (Ericsson Mobile Health) kit, physicians can remotely monitor employees with cardiovascular illnesses such as congestive heart failure and chronic obstructive lung disease. In addition, it offers monitoring in the areas of lifestyle management, personal wellness and will eventually include diabetes-monitoring. A key advantage of telehealth is that patients can stay in a familiar environment in their home or community, while getting medical attention. This minimises the social disruption they may face on top of their health problems. In cases where telehealth has been adopted, evidence suggests its long-term usage leads to better patient outcomes and improved cost efficiency of healthcare provision. Drivers and barriers of telehealth Drivers Improved quality of life Reduction of hospital; admissions Speedier hospital discharge Help in screening ailments Wider access to medical care Barriers Lack of a sustainable reimbursement model Stakeholder apprehension Controversial effectiveness Insufficient regulatory framework Concerns about patient data Produced by du enterprise marketing in association with Ovum, a preferred knowledge partner
1. Improved patient outcomes Telehealth holds the potential to improve patients quality of life by cutting down on visits to their doctor or clinic, and the frequency and length of hospitalisation. It also gives individuals wider access to care, because an expert physician can be remote from the patient yet is still able to offer consultation and treatment using telehealth and telemonitoring systems. 2. Improved quality of life The fact that patients can stay in their homes tends to have a positive effect on a person s well-being. In the case of home monitoring, patients are equipped with their own self-treatment plans. This adds a sense of independence and freedom for patients and results in increased compliance with medication and a reduction in the need to be seen by their local doctor, be it in form of primary care or a home visit. 3. Reduction of hospital admissions Because telemonitoring allows the identification of health issues as and when they occur, it allows early therapeutic interventions that reduce the risk of more costly measurements such as hospitalisation or emergency room visits. It also reduces the risk of a patient contracting infections in a hospital setting. 4. Speedier hospital discharge With the availability of continued monitoring at a patient s home, telehealth allows the shortening of the length of hospitalisation by discharging patients earlier than would otherwise be advisable. This can translate into significant cost savings for healthcare providers and payers alike. 5. Help in screening ailments and faster channelling to the appropriate physician Telehealth is also beneficial as a screening facility to triage all medical problems in remote and rural areas and enable doctors to determine more quickly which health professional a patient should see next. 6. Wider access to medical care Particularly in sparsely populated areas, telemedicine can help to compensate for the shortage of healthcare professionals and can improve the efficiency, quality and timeliness of healthcare service provision. 7. More cost-efficient provision of healthcare Telemonitoring can contribute significantly to more cost-efficient provision of healthcare. With a decline in the unit cost of devices, so telehealth will become more accessible to the public, which means an increase in the level of preventative medicine and early remediation of ailments.
Telehealth solutions pose different levels of demand on infrastructure Demand on Infrastructure Audio/video-based e.g Telepresence Data-based e.g Transmission of vital signs Text-based e.g Medication reminders Voice-based e.g Teleradiology In order to be able to run more advanced telehealth solutions, the underlying technology infrastructure namely access to broadband must be in place. The more sophisticated and mission-critical a telehealth solution has to be, the more demands it puts on the network in terms of reliability, speed, and the ability to prioritise data. For example, a solution which is purely based on receiving a reminder to take medication puts comparatively few demands on the network and could be done via a standard mobile SMS. Different telehealth applications require more bandwidth than others. Very basic services, where a caller requests health advice and information over the phone and simple forms of text-based telehealth services, do not require a broadband connection and can be done via the standard PSTN and 2G mobile networks. More advanced solutions, such as a telepresence solution where a remote-based clinician follows a surgical procedure will require a network that is capable of transmitting high levels of data in both directions, with minimum latency (<50 ms primary, <120 ms back-up), and high reliability. As an example, real-time medical videoconferencing often requires a minimum bandwidth of 384 kbps (provided by three ISDN lines), whereas store and forward telemedicine (asynchronous transmission of still images, sounds or video) say involving the use of an otoscope, a device which allows images from the ear, nose and throat to be captured and transmitted to a distant site for review, can be accomplished using a dial up 56 kbps modem connected on a normal telephone line. Data traffic can be compressed, transmitted and decompressed of course, which is particularly applicable in teleradiology where X-ray and radiography images can be sent cleanly and efficiently across data communications links at compression ratios of between 3:1 and 10:1. Produced by du enterprise marketing in association with Ovum, a preferred knowledge partner
In August 2010 The Federal Communications Commission (FCC), an independent agency of the US government, published Health Care Broadband in America which contains detailed analysis of healthcare broadband requirements and which sets out health data file sizes and the bandwidths required to support particular download times. Text of single clinical doc (HL7 CDA format) Text of single clinical doc (PDF) Ultrasound Standard chart (health patient) X-Ray Chest radiography 0.025 0.050 0.200 5 10 16 X-Ray DownloadTimes Seconds 5 30 60 300 Mbps Needed (actual) 16 Mbps 3 Mbps 1 Mbps < 1 Mbps MRI DownloadTimes Seconds 5 30 60 300 Mbps Needed (actual) 72 Mbps 12 Mbps 6 Mbps 1 Mbps 64-Slice CT Scan Download Times Seconds 5 30 Mbps Needed (actual) 4800 Mbps 800 Mbps MRI 45 60 300 400 Mbps 80 Mbps PET scan Mammography study (4 images) 100 160 64-slice CT scan Human genome (sequence data only) Cellular pathology study (6 slices) 3,000 3,000 25,000 Megabytes (not to scale) Diverse set of technologies for telehealth Without a doubt, healthcare is going mobile. Considering that just over a decade ago mobile use was essentially banned within hospitals and physicians offices, mobile technology now seems to be the one area in which healthcare IT faces few barriers to end-user adoption. The convenience that mobile devices offer is simply too compelling, and the technology is moving fast as new apps become available by the day. There is an eclectic group of vendors, including niche providers and well-established telco, hardware and software brands such as GE, AT&T, Sprint, Verizon, and Fujifilm all busy marketing their emerging telehealth apps and services: GE Healthcare has publicised the extension of its healthcare IT portfolio to mobile devices and tablet PCs, demonstrating how an Apple ipad and iphone can remotely access GE s Centricity Advance and Centricity Practice EHR solutions. AT&T has made several enhancements to its Healthcare Community Online, including a mobility interface enabling smartphones to securely access patient information from anywhere at all times, access to 58 pre-integrated applications including those for managing diseases or handling claims paperwork and software that analyses patient information and brings evidence-based medicine to providers at the point of care. Fujifilm Medical Systems has demonstrated Synapse Mobility, a mobile application enabling remote access to the company s interactive three-dimensional medical images from handheld mobile devices.
Sprint has announced a partnership with Ideal Life, a manufacturer of home monitoring equipment. They will codevelop, certify, and co-market a version of the Ideal Life hub to transmit health data over Sprint s network and expand Ideal Life s portfolio with embedded wireless devices. Verizon Wireless and Zipit Wireless have introduced the Zipit Enterprise Critical Messaging Solution, a twoway paging system that consists of a messaging device, a cloud-based hosted environment, and a communications infrastructure aimed at pager customers including those in a healthcare setting. Such product and service announcements suggest this is an industry segment with very good growth prospects, on the back of a strong albeit still latent demand. There is much need for such solutions. For instance, diabetes is a top offender in the area of escalating prevalence and cost amongst the most typical chronic diseases, particularly in the UAE. With the second-highest diabetes rate in the world, treatment eats up an estimated 40% of the UAE national healthcare budget, it was reported in 2007. Yet, diabetes is a disease that can be effectively managed at a relatively low cost when a patient is taught how to be in charge of their ailment. This is a complex task which can hardly be completed during a brief hospital stay as a person newly diagnosed with diabetes has to learn around 150 different tasks in order to reach disease self management. It requires a lot of coaching, which can be effectively delivered via telehealth. If a chronic disease such as diabetes isn t managed, patients are likely to develop secondary health issues such as blindness, heart disease or possibly stroke, all of which are far more expensive and resource-intensive to treat. A simple SMS telehealth texting approach can be used to change behaviour. Other advances are being made with m-health diabetes management applications that involve transmitting blood glucose readings wirelessly from a Bluetooth-enabled blood glucose meter to a compatible mobile phone running a specialised application. The mobile sends the information over the telco network into a secure database. These results can then be accessed via a portal on a smartphone, or online, by the patient and their GP or other care provider. This is the sixth in a regular series of Leadership Perspectives White Papers, produced by du enterprise marketing in association with Ovum, a preferred knowledge partner. For more information, please email leadershipseries@du.ae or visit www.du.ae Produced by du enterprise marketing in association with Ovum, a preferred knowledge partner