Telehealth and Telecare Learning Resource

Hull UniversityFaculty of Health and Social Care

Telehealth and Telecare Masters ModuleStudent Number 201106449

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Introduction – this resource will:

Define telehealth and telecare and introduce the wider context of technology in healthcare

Focus on the telehealth application – remote monitoring

Discuss the drivers and barriers to telehealth development and the evidence base for telehealth

Propose future developments Include a Scotland focus, where the

author resides

Wider Context of Telehealth and Telecare

Health and social care are facing a number of significant challenges which are:

An ageing population Increased prevalence of long term

conditions Economic pressures including increased

costs from hospital admissions All of these require alternative ways of

working

In Scotland, it is projected that the number of people aged 75 and over 1

will increase

by 23%

between 2008and 2018

Ageing Population

It is expected that the number of people

will increase

by 33%

between 2008 and 2033

aged 60 – 74 years

aged over 75 years

will increase

by 84%

Ageing Population1

Technology in the form of Telehealth and Telecare may offer solutions

Definitions within both Telehealth and Telecare can differ2

However, in Scotland the Scottish Centre for Telehealth and Telecare (SCTT) has suggested definitions which help to inform staff and users

SCTT Define Telehealth as: 3

“The provision of health services at a distance using a range of digital technologies”

Examples of telehealth are:

Remote monitoring of health data transmitted by patients at a location separate from the professional receiving the data

Videoconsultation between patient and health professional located remotely aiding diagnosis and treatment

SCTT Define Telecare as:3

“The remote or enhanced delivery of care services to people in their home or a community setting by means of telecommunications and computerised services”

Examples of Telecare are:

Wayfinder

Drivers for Development

Health life expectancy is increasing but not as quickly as life expectancy so this produces a gap where health needs will increase4

Long term conditions are often associated with this

A long term condition is a condition which lasts a year or more and affects a person’s life for which there may be a need for continuing care and support5

Long Term Conditions

The Scottish Government has focused on long term conditions to deliver improvement through supported self management, case management and anticipatory care6

This resource will focus on 2 long term conditions in particular as they are relevant to the use of technology which are:

Chronic Obstructive Pulmonary Disease (COPD)

Heart Failure

COPD: Is a lung disease with chronic airflow

obstruction which cannot fully be reversed7

Includes chronic bronchitis and emphysema and often causes anxiety, depression and social isolation

Has a feature of exacerbations or ‘flare ups’ where the condition worsens with increased breathlessness and sometimes infection is present

How prevalent is COPD?

The prevalence rate in Scotland in 2009/10 was 1.97%8

Hospital admissions are common - the current rate for this is 475 per 100,000 population8

Estimates for Scotland, due to the ageing population, are that COPD cases will increase by 33% between 2007 and 2027 to 127,1889

Heart Failure: Is a clinical condition where the heart is

less able to respond to demands for increased output10

Symptoms are often breathlessness on exertion, fluid retention, weight gain and tiredness

Exacerbations are also a feature with increased breathlessness, fluid retention and tiredness

Has a raw prevalence rate of 0.81 per 100 patients11

How can technology assist? Remote monitoring consists of equipment

in the patient’s home allowing the daily transmission of symptom and physiological information e.g. oxygen level, sent securely via broadband or phone line to a clinician who reviews the results and acts on the findings

Daily transmission enables any deterioration in condition to be detected early before a crisis point is reached12. Settings can be individualised for each patient

How can technology assist this? The early detection in deterioration

helps to prevent admissions by allowing early initiation of treatment and assists the patient to manage their condition better through recognition of increased symptoms. It can also support early discharge from hospital

The equipment can often be used to deliver health education which patients can access when required

eHealth Support

Helpdesk and Training

Technical support and

Installation of devices

Telecomms

SupplierHosted Server

Patient with Telehealth

Clinician

Diagram showing an example of the links between patient, clinician , departments and supplier in telehealth remote monitoring

How else can technology assist?

Remote monitoring technology also assists staff through building capacity where an increased number of patients can be ‘seen’ through use of the data and visits being made only when necessary

Further Drivers for Development

Scottish Government Health, Efficiency, Access and Treatment (HEAT Targets) drive reductions in hospital admissions and bed days13, with use of technology proposed as one of the methods of improving these

Strategy documents are now driving policy to include the use of technology in frontline services

The recent Audit Scotland Review of Telehealth called for NHS Boards to do more to implement telehealth14

What does the evidence say?

Evidence in healthcare is important for any development and this includes the use of technology

The NHS has an ethical obligation to provide effective, evidence based care which is also economically sound15

The use of telehealth has been and continues to be the subject of a significant amount of research

Evidence Evidence comes from different types of

research and depending on study method can be classed from good through to weaker quality16

Randomised controlled trials (RCTs) are seen as high quality due to the presence of a control group which doesn’t receive the intervention

Service evaluations also add to information and for telehealth and have tended to be positive. Although weaker than RCTs they still give useful information particularly about operational management

Evidence - some studies for COPD and Heart Failure have shown positive outcomes for:17,18,19

Improved quality of life Reduction in hospital admissions and

length of stay Reduction in mortality Acceptability of equipment by users Improved knowledge and self care Reassurance and increased confidence

of users Reduction in costs

However...

Despite showing some positives, there has been a call for further research to determine the effectiveness of telehealth.

The result of some reviews, which have combined a number of studies, has been less favourable due to weaknesses in study methods, differing study groups and the outcomes being researched20,21

Whole System Demonstrator (WSD)Programme22

WSD is a large RCT launched in 2008 by the Department of Health, studying telehealth and telecare, involving over 6000 patients

The telehealth section included patients with either COPD, heart failure or diabetes

The outcomes are expected to add significant information to the evidence base which will help the NHS to make decisions about implementation

WSD Early Headline Outcomes – December 201122

“early indications show that if used correctly telehealth can deliver:

a 15% reduction in A&E visits a 20% reduction in emergency admissions a 14% reduction in bed days an 8% reduction in tariff costs a 45% reduction in mortality rates” Further information about these findings is

to be welcomed

Key Challenges to Implementing Telehealth have been defined as:

Staff perceptions and new ways of working23

Lack of project management23

The need to recruit appropriate patients23

Type of technology23 and limited interoperability of equipment24

Funding23 and high initial set up costs Ethics, data protection and privacy

concerns25

Short term pilots which fail to mainstream The need for a robust evidence base

Future Development -Addressing the challenges will assist in deploying telehealth to scale through a focus on:

Education of staff24 – including undergraduate programmes, education of patients and carers26

Effective change management 27 and reassurance of staff about practice

Effective leadership in organisations Funding availability Routine consideration of technology in patient

assessments and pathways Standards in record keeping, ethics and eligibility

criteria

Technology Advances The pace of technological change

offers opportunities for different types of equipment to be considered

Smaller devices such as mobile phone applications offer flexibility over fixed devices

Multiple condition monitoring is important due to increasing rates of multi morbidity – people having more than one long term condition28

Conclusion Recent evaluations, policies and drivers are

bringing telehealth to a ‘tipping point’ Technology has the potential to benefit

health and wellbeing across the disease spectrum

It can provide person centred, quality care It will assist in the challenges faced by

health and social care by becoming part of the clinician’s toolkit

The DALLAS Programme will bring the opportunity to deploy telehealth at scale...

Delivering Assisted Living Lifestyles At Scale (DALLAS)29

The Technology Strategy Board is leading the DALLAS Programme

This will commence in April 2012 for 3 years

It will facilitate collaborative working between the NHS, partner organisations and suppliers

The use of technology to improve many older people’s lives in health and everyday living is a prime objective.

Further Reading

This resource covers the main points of an assignment which explores the use of technology in healthcare in the form of telehealth and telecare with a focus on telehealth remote monitoring

The following slides contain references and, where applicable, weblinks for further reading. In addition the full assignment is available on request

References 1 Scottish Government. (2011a) ‘The Scottish Health Survey Topic Report – Older

Peoples’ Health’ [Online]. Available from: http://www.scotland.gov.uk/Publications/2011/11/24083430/5 [accessed 16/12/11]

2 Kerr, B., Hurst, K., Clark, S., Dorrian, C. & Muir. L. (2011) ‘Telehealthcare and mental health’ [Online]. Available from: 00631 FINAL Telehealthcare and mental health revised 300311.pdf via www.google.co.uk [accessed 27/12/11]

3 SCTT (Scottish Centre for Telehealth and Telecare). (2011) ‘Information for Professionals What is Telehealth – Definitions’ [Online]. Available from: http://www.sctt.scot.nhs.uk/telehealth.html [accessed 15/11/12]

4 Scottish Government. (2011b) ‘Health of Scotland’s population – Life Expectancy’ [Online]. Available from: http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/TrendLifeExpectancy [accessed 16/12/11]

5 Scottish Government . (2009a) ‘Improving the health and wellbeing of people with LTC in Scotland : A national action plan’ [Online]. Available from: http://www.scotland.gov.uk/Publications/2009/12/03112054/4 [accessed 27/10/11]

6 Scottish Government. (2009b) ‘LTCC: High Impact Changes’ [Online]. Available from: http://www.scotland.gov.uk/Publications/2009/03/06084301/0 [accessed 23/12/11]

7 WHO. (2011) ‘Chronic Respiratory Diseases, COPD – Definition’ [Online]. Available from: http://www.who.int/respiratory/copd/definition/en/index.html [accessed 16/12/11]

References 8 Scottish Public Health Observatory. (2011) ‘Wellbeing and Disease, Chronic Obstructive

Pulmonary Disease’ [Online]. Available from: http://www.scotpho.org.uk/home/Healthwell-beinganddisease/copd/copd_keypoints.asp [accessed 27/12/11]

9Audit Scotland. (2007) ‘Managing Long Term Conditions’ [Online]. Available from: http://www.audit-scotland.gov.uk/utilities/search_report.php?id=552 [accessed 16/12/11]

10 SIGN. (2007) ‘SIGN Guideline 95, Management of Chronic Heart Failure’ [Online]. Available from: http://www.sign.ac.uk/guidelines/fulltext/95/index.html [accessed 16/12/11]

11 Information and Statistics Division Scotland. (2011) ‘Quality and Outcomes Framework, 2010/11 QOF Prevalence Data’ [Online]. Available from: http://www.isdscotland.org/Health-Topics/General-Practice/Quality-And-Outcomes-Framework/2010-11/Register-and-prevalence-data.asp [accessed 23/12/11]

12 Maric, B., Kaan, A., Ignaszewski, A. & Lear,S. (2009) ‘A systematic review of telemonitoring technologies in heart failure’, European Journal of Heart Failure [Online], 11, 506–517.Available from: http://eurjhf.oxfordjournals.org/content/11/5/506.full [accessed 23/12/11]

13 Scottish Government. (2011c) ‘Scotland Performs: NHSScotland’ [Online]. Available from: http://www.scotland.gov.uk/About/scotPerforms/partnerstories/NHSScotlandperformance [accessed 16/12/11]

14 Audit Scotland. (2011) ‘A Review of Telehealth in Scotland’ [Online]. Available from: http://www.audit-scotland.gov.uk/utilities/search_report.php?id=1709 [accessed 16/12/11]

15 Webb, C. & Roe, B, ed. (2007) Reviewing Research Evidence for Nursing Practice, [Reflections on the Past, Present and Future of Systematic Reviews], Blackwell Publishing, Oxford

References 16 Centre for Reviews and Dissemination. (2008) ‘Systematic Reviews’ [Online]. Available from:

http://www.york.ac.uk/inst/crd/index_guidance.htm [accessed 23/12/11] 17 McLean, S., Nurmatov, U., Liu, J., Pagliari, C., Car, J. & Sheikh, A. (2011) ‘Telehealthcare for

chronic obstructive pulmonary disease’. Cochrane Database of Systematic Reviews, Issue 7. Art No.:CD007718. DOI:10.1002/14651858.CD007718.pub2

18 Inglis, S., Clark, R., McAlister, F., Ball, J., Lewinter, C., Cullington, D., Stewart, S. &, Cleland. (2010) ‘Structured telephone support or telemonitoring programmes for patients with chronic heart failure’ Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.:CD007228. DOI: 10.1002/14651858. CD007228.pub2.

19 Cleland, J., Louis, A., Rigby, A., Jansenns, U. & Balk, A. (2005) ‘Noninvasive Home Telemonitoring for Patients with Heart Failure at High Risk of Admission and Death. The Trans-European Network-Home-Care Management System (Ten HMS) Study’ Journal of the American College of Cardiology vol 45, no.10

20 Polisena, J., Tran, K., Cimon, K., Hutton, B., McGill, S., Palmer, K. &, Scott, R. (2010) ‘Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis’ Journal of Telemedicine and Telecare (16) pp120-127

21Bolton, C., Waters,C., Peirce, S. &, Elwyn, G. (2010) ‘Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD’, Journal of Evaluation in Clinical Practice [Online], DOI: 10.1111/j.1365-2753.2010.01536.x, first published online 16 September 2010. Available from: http://onlinelibrary.wiley.com/doi/10.1111/jep.2011.17.issue-6/issuetoc [accessed 27/12/11]

22 Department of Health. (2011) ‘Whole System Demonstrator Programme Headline Findings’ [Online]. Available from http://www.kingsfund.org.uk/blog/wsdan_results.html [accessed 23/12/11]

References

23 Joseph, V., West, R., Shickle, D., Keen, J. & Clamp, S. (2011) ‘Key challenges in the development and implementation of telehealth projects’ Journal of Telemedicine and Telecare vol 17, no.2 ; 71-77

24 Giordano, R., Clark, M. & Goodwin, N. (2011) ‘WSD Action Network, Perspectives on Telehealth and Telecare’ [Online]. Available from: http://www.kingsfund.org.uk/publications/articles/th_perspectives.html [accessed 23/12/11]

25 Kaplan, B, &, Litewka, S. (2008) ‘Ethical Challenges of Telemedicine and Telehealth’ Cambridge Quarterly of Healthcare Ethics 17, pp 401-416

26 Carers Scotland. (2011) ‘Telehealthcare A Training Toolkit’ [Online]. Available from: http://www.carersuk.org/component/k2/item/2382-telehealthcare-a-training-toolkit?qh=YTo3OntpOjA7czoxNDoidGVsZWhlYWx0aGNhcmUiO2k6MTtzOjg6InRyYWluaW5nIjtpOjI7czo1OiJ0cmFpbiI7aTozO3M6NjoidHJhaW5zIjtpOjQ7czo3OiJ0cmFpbmVkIjtpOjU7czo3OiJ0b29sa2l0IjtpOjY7czoxNjoidHJhaW5pbmcgdG9vbGtpdCI7fQ%3D%3D [accessed 27/12/11]

27 Faife, D. (2008) ‘All in the mind? Reflections on developing an assistive technology/telecare service as a model for change management, creative thinking and workforce development;learning from the Norfolk experience’ Journal of Assistive Technologies [Online] Vol 2, issue 1, March 2008. Available from: http://web.ebscohost.com/ehost/results?sid=766f3799-8ba3-4c30-ba7efd21ffa28a7f%40sessionmgr114&vid=2&hid=112&bquery=(JN+%26quot%3bJournal+of+Assistive+Technologies%26quot%3b+AND+DT+20080301)&bdata=JmRiPXJ6aCZ0eXBlPTAmc2l0ZT1laG9zdC1saXZl [accessed 27/12/11]

References 28 Scottish School of Primary Care. (2011), ‘Multimorbidity in Scotland,

Multimorbidity Research Programme’ Slide Pack received via e-mail from enquiries@chain-network.org.uk

29 Technology Strategy Board. (2011) DALLAS: ‘Delivering Assisted Living Lifestyles At Scale’ [Online]. Available from: http://www.innovateuk.org/ourstrategy/innovationplatforms/assistedliving/dallas-delivering-assisted-living.ashx [accessed 2/1/12]