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Simple Telehealth

** 2012: Beneath the hype of telehealth **


** 2012: Beneath the hype of telehealth **

An insight into the world of telehealth and how it can be effectively used to achieve NHS clinical goals.

Telehealthcare has great potential and can, when applied correctly, assist in the delivery of Department of Health QIPP initiatives.   There are many reports, evaluations and papers for and against the use of telehealth  in various circumstances and the telehealth landscape can seem confusing.  Below I aim to throw a little light on how telehealth ( Simple and triage model ) can be used cost-effectively.

nullOver the past few years the hype around telehealth has run way ahead of its ability to deliver, and in the process has facilitated the procurement of many expensive sets of “kit” by the NHS, without properly consulting or listening to the very front line clinicians they were supposed to assist.  Attempts to “re-engineer” clinical pathways around telehealth were doomed to failure before they started and as Sir John Oldham succinctly puts it: “[NHS] system first, kit last”.  Sir John’s mantra suggests that we should be designing the best clinical system irrespective of any telehealth equipment and then testing if telehealth can assist to improve the clinical and non-clinical outcomes.

Some of these kit based projects still publish positive reports but do not take into account some basic clinical facts or the associated cost-effectiveness.  If this type of telehealth implementation is used without proper risk stratification it is difficult to see how it will be cost-effective and thus sustainable.  Realising that there is a problem with the ‘take our word for it, it will work’ old-style telehealth model, some companies are moving their market position adding flexibility and shifting the focus of application of telehealth kit to more complex cases and some even integrating their offer with risk stratification tools making these kit based companies the ones to seek out for use with the most vulnerable and complex patients. 

However, the realisation that old-style telehealth projects designed around expensive kit and triage teams do not live up to the hype of delivering cost-effective, large scale outcomes that include prevention of deterioration of a long term condition, is hitting home leaving many trusts with telehealth kit stacked on shelves and few actual benefits being banked.  But in contrast, scattered about the NHS are a growing number of potentially cost and clinically effective telehealth projects. But how can you tell the wood from the trees? 

To get to the bottom of why some of these seemingly straight forward projects have delivered little but others have, we need to answer the question “what is telehealth really about”

The hype would have you believe that deploying telehealth to every patient with COPD or CHF or Diabetes who has had one or more hospital admissions in the previous year will result in the prevention of further admissions.   This sounds plausible until you consider well known facts such as regression to the meanwhich shows that the majority of patients in this scenario will have fewer admissions anyway, even without the additional telehealth intervention.   Then of course there is the clinical angle to consider where we really do have to question the clinical validity of what some telehealth systems actually do. The daily collection of streams of biometric data and answering basic questions may sound promising to non-clinicians, however this is another hurdle at which telehealth systems fall as it can be a pointless exercise and in some cases even have unintended negative consequences.  For example, rather than helping me the patient to be concordant, compliant and independent, it can make me dependent on the service as I become used to and enjoy the regular phone calls from triage teams. 

Let’s imagine an ideal world where every patient has maximum concordance and compliance with their clinical advice/treatments, including understanding their symptoms and calling for help when appropriate.  With patients being aware of how to manage their condition(s) and actually doing it, quality of clinical outcomes would be optimised.  Significant productivity and prevention benefits would be realised and in this ideal world there would be no place for the majority of today’s telehealth systems apart from those targeted through impactibility modelling where where equipment can add value, providing clinical insight and evidence based diagnostic interpretation of data. 

Back in the real world, where we patients are not fully concordant or compliant, other types of assistance can help us to move towards the ideal self management scenario. However, the focus must be on helping patients to help themselves to stick to management plans agreed with their responsible health professional.    When we take responsibility for aspects of our own healthcare things change, our health outcome looks better than it would otherwise have been and this in turn leads to less consumption of NHS resources across the entire health economy.  In this scenario where the focus is now the individual, not the "kit" or condition, genuine productivity gains, usually in the form of time saving, are achievable for the provider thereby creating an environment in which everyone shares the benefits. 

nullThe appearance of innovative low-cost self-care apps and telehealth services, such as those encouraged by the Department of Health through the NHS Future Forum Maps and Apps exercise led by Dr Shaibal Roy have considerable potential.  These low cost, versatile hi-tech “apps” and systems will have a similar effect on telehealth as that caused by the personal computer on the mainframe market a long time ago.   A low-cost approach can potentially be rapidly scaled and is not only affordable but by necessity must be focussed on helping me the patient to increase my concordance and compliance with medication, interventions and lifestyle habits in one or more chosen areas.

Looking forward into the era of the CCG, telehealth will be different.  Far from CCGs funding expensive telehealth kit, CCGs will demand that the provider takes responsibility for the improvement of self care.   This changes the dynamics somewhat as the provider then needs to find a solution that will be flexible across a large range of conditions, is affordable at scale (10,000+ patients) and will create enough provider productivity gains to pay for itself in year one.  The question providers and GP Practices are starting to ask is “will this telehealth solution help me to obtain better outcomes and increase the productivity of my team without increasing my costs?”  In other words, will it be clinically beneficial and cost-effective and will those benefits be sustainable? 

To conclude, I would say that we are entering a new and welcome era for telehealth where systems can be seen to provide real and tangible benefits for the provider in the execution of their clinical duties whilst at the same time offering convenience and better outcomes for patients.  Telehealth is already gravitating into two groups, those that bring value by adding some form of clinical analysis for complex patients and those focussed on helping patients to help themselves. The realisation of the illusive potential system wide benefits of telehealth at scale, requires that it must be low cost, quick and easy to use (for patients and their responsible clinicians) and be focussed on increasing independence, concordance and compliance i.e cost-effective. 

Thanks to Professor Ruth Chambers OBE, Sir John Oldham, Dr Shaibal Roy, Dr Geraint Lewis et al, for tireless work promoting the benefits of pragmatic self-care.

Other links

For those using the standard telehealth/triage model here is an essential guide to ensure a cost effective project. Nuffield Trust predictive risk guide for commissioners