Where next for telehealth? Reflections from our international congress

Comments: 5

Last week The King's Fund hosted its second International Congress on Telehealth and Telecare that brought together policy-makers, academics, professionals, users, innovators and industry from all over the world, both face-to-face and online. What did we learn over the three days?

The first day focused on problems with designing and implementing studies that evaluate telehealth interventions. In our own overview of the impact of telehealth we found that the majority of studies have shown a positive impact across a range of criteria (including cost-effectiveness). However, the quality of the evidence varies and its sheer diversity in terms of technology used, patient group supported, and outcome measures assessed makes comparison highly problematic. The result of these difficulties means there is a lack of understanding of the impact of telehealth and how to successfully apply and adopt new technologies in practice

The second day started with direct messages of government support for telehealth from Paul Burstow and Stephen Johnson. Drawing on the headline findings from the Whole System Demonstrators and the subsequent 3 Million Lives initiative speakers argued that not only was it 'morally right' to offer such care, but that it was also the smart thing to do in terms of reducing the cost-burden on the care system in the long-term. This vision was supported by the experience of three evaluation sites – Cornwall, Kent and Newham – who were all keen to roll out the use of telehealth. The apparent coming together of evidence with belief was music to the ears of the converted.

We heard many stories about the issues, problems and successes experienced with new technologies. From these, a number of key 'laws' for successful telehealth adoption began to emerge of which my top five (in no particular order) are:

  • keep it simple for patients and carers to use, and for professionals to adopt
  • tailor the service to the specific needs of the user; consider how they might best use and accept new technology
  • enhance human contact by better connecting patients to family, friends and care professionals; users must feel safe, secure and empowered
  • embed an IT infrastructure to act as the bedrock of better care through integrated information systems
  • build relationships and networks to influence behaviours, build alliances, and overcome the significant mismatch of motives that exist between patients, carers, professionals, commissioners and industry.

The last of these is arguably the most important. There is an acute need in all care systems to work across a diversity of competing interests towards more mutually beneficial relationships that improve people's lives.

The third day of the congress will be remembered for the carefully crafted presentation on the cost-effectiveness of telehealth in the Whole System Demonstrator trial by Catherine Henderson from the London School of Economics. In five crucial minutes the world of telehealth was seemingly turned upside down as Catherine explained how the undoubted benefits to patients in the trial came at a significant financial cost. Knee-jerk reaction to the findings must be put on hold, however, until the full peer-reviewed studies are published in the British Medical Journal and the time is taken to fully digest and understand these cost implications.

What was clear from the innovations presented at the congress is that the capabilities of new technologies – especially smart phones, tablet computers and the internet – make those deployed in the trial look old hat. The research evidence lags well behind technological innovation and care systems are very slow to adopt new ways of working. What is needed is 'simultaneous innovation' where the system changes to keep pace with technology. Unlikely, of course, but this shines a light on the fact that 90 per cent of the problem in adopting new ways of working is cultural, behavioural and systemic.

Learning the right lessons from the Whole System Demonstrator pilots is important. In terms of the substantial wider evidence on cost-effectiveness, the evidence presented at the congress bucks the trend by providing what appear at this point to be negative results. A thorough look at the findings is required, as the keynote speech by Adam Darkins shows, huge benefits at both a patient and system level can be achieved. We should not attempt, said Adam,  to 'build a pyramid from the top-down' by focusing solely on the complex, high-cost, patients where interventions are expensive and difficult to deploy; instead we should move forward by building alliances and networks and focusing on high-volume and low-cost solutions.

Comments

#1108 Paul Rice
Co-Director Long Term Conditions Theme
Health Innovation and Education Cluster Yorkshire and Humber

Balanced plain speaking as usual Nick. I think a number of us were very surprised by the LSE analysis on the cost-effectiveness of Telehealth (and can we please call it remote telemonitoring) when the general balance of evidence from other deployments is favourable in terms of cost effectiveness. There will undoubtedly be a better time and a better place to delve into the detail of how the analysis was conducted and the results arrived at as full articles are published. I was left with a couple of broader thoughts and reflections reconfirmed. Surely it has never been about the technology but about its application, the opportunity to do some things better (the rationale for the majority of teleconsultation applications where geographical distance and inexpert clinical judgement deliver suboptimal outcomes) and to do better things - to actively engage the experts in long term conditions management - the person themselves, their carers and community - to enable them to better understand the relationship between their decisions about diet, smoking, exercise, medicines adherence, and its impact on their health status. The physiological measurements - the vital signs - that track and trend, predict and confirm crises, exacerbations and decompensations are critical data items. There is no power however in data alone; rich and contextual information and actions and decisions that take place because of access to that information are the game changers. It is about clinical quality where with timely clinical information and patient insight under and over prescribing are less likely to occur in community settings. Its about new consultation skills where potentially vulnerable people are contacted in priority need order and where plain old telephone calls are used in conjunction with that same timely clinical information and patient insight to schedule care and contact appropriately. It is about those same service users being proactively coached to manage their own health status and using rich digital information sources and social networking with others whom they share clinical and contextual affinity to secure advice, solace and companionship. Above all its not about single naive solutions but customised, personalised and contextualised ones that blend the best of timely medical knowledge with an understanding of me, my preferences, my attitude to risk, my propensity to adapt and change, because the person with a long term condition has huge potentiality which to all our costs in a system like the NHS we continue too often to ignore. The Telehealth revolution is upon us, and much as we have exploited the benefits of technology in many other aspects of our lives we will do so also in health. Short term resource limiting steps include the costs of technology, interoperability and misaligned incentives but if we are fully and truly to realise its benefits we need to address the bigger issue of the redundancy of the curative biomedical model at the start of a 21st century. Living with complex multiple co-morbidities is the challenge of the day. Professional workflows need to change, integrated team working matching need with competence and expertise will mean we do better service responses more often but if we are going to do more better things we need to see Telehealth and Assistive Living as part of the broader opportunity to deliver a shared care revolution.

#1109 Margaret Coles
Physiotherapist
MovingTherapy

I was a 'virtual' attendee and was profoundly grateful for the knowledge shared. It was immensely relevant for my profession as a physiotherapist as we utilise technology to coach patients in self-care.

I saw this coming in 2008 and after retirement from the NHS set to work to innovate this service. I have drawn together relevant and effective knowledge and engaged with ordinary people in a web site promoting health and well-being, especially for Long Term Condition service users. As a consultant, I also provide a strategy for providers and commissioners to tackle our most pressing need, namely to manage this population utilising technology as part of the answer.

#1110 Rupert McShane
Old Age Psychiatrist

Nick - Your excellent blogs talk only about telehealth. I missed the conference so wonder....

1. Can you say when results about telecare are due?

2. Do you know if the impact of cognitively frailty - surely the elephant in the room given that the benefits of telehealth seem to depend on 'using it properly' - will be published?

3. And can you say how many people DID use it properly

Many thanks

#1111 Nick Goodwin
Senior Fellow
The King's Fund

Rupert

Unfortunately I don't have the answers to your questions. The research team are due to publish their first wave of findings in the BMJ soon and I am unsure what aspects will be covered. I know the research has been comprehensively undertaken and that really useful knowledge will emerge to predict which sorts of people are more/less likely to welcome and/or use new technologies well. Some information about this was in Stan Newman's speech that I think you can go back to review. My hope is, given the significant wealth ofmaterial that I know the research teams have gained, that there is enough time and commitment for the in depth questions and issues to be fully explored and reported.

Nick

#39854 telemedicine
telemedicine
telemedicine

A very good looking site and very informative too.

Add new comment