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Simple Telehealth

2. Background – what telehealth is


2. Background – what telehealth is

Learning outcomes – you will be able to:

  1. Understand how the terms telehealth, telecare and telemedicine are used.
  2. Describe the range of clinical applications for which telehealth may be suitable.
  3. Appreciate how mobile phone texting has developed as a simple telehealth option.

Telecare and telehealth involve the use of some form of technology to assist people in their lives.

Telehealth is a combination of equipment, monitoring and response that can help individuals to remain independent at home.1 So telehealth is a means of relaying specific physiological data from patients in their homes to clinicians in hospital, general practice or community / mental health settings, to support objective decisions about their clinical management.  It can enable a clinical team to establish a ‘virtual ward’ of specific patients with remote monitoring of their vital signs. When telehealth is in place a patient’s vital signs and/or test results are available to clinicians caring for them from afar - in real time or close to real time2; and patients are much more aware of how their body is functioning.

Telecare is a subdivision of assistive technology; assistive technology is ‘any item, piece of equipment or system that is used to increase, maintain and improve the functional capabilities and independence of people with cognitive, physical or communication difficulties.’3,4 So this might include jar openers, bath seats or stairlifts. When a telephone network is used, the assistive technology might be described as ‘telecare’, meaning that the monitoring is via communication over a distance by telephone – which might relate to someone’s personal safety, security and home environmental risks or their health. Telecare includes the use of electronic sensors and aids that make a home environment safer so that people can live there independently for longer.

Telemedicine is an ambiguous term. It sometimes is confined to the use of sensors and electronic means of communication from one clinician to another, to aid diagnosis and clinical management, typically by a booked videoconferencing arrangement between GP and consultant for a shared patient consultation.5 Elsewhere telemedicine has a wider application and is defined as ‘distance medicine using information and communication technologies to examine, monitor, treat and care for patients over a distance…both within and between all kinds of health care institutions as well as to monitor and provide support to patients living at home’6,7 or even a clinician picking up a telephone to relay information to a patient!

The national vision for telehealth is that every person with a long term condition(s) should be routinely considered to utilise appropriate technology to help them or their carers, as well as health and social care professionals better manage their condition. So if telehealth is effective it should enable appropriate planned interventions for patients with greatest need and improve the quality/timeliness of the delivery of their care, thus improving or at least sustaining their health outcomes and reducing costs from avoided hospital emergency admissions and outpatient activity, or shorter stays in hospital.

The added advantages of telehealth from a patient’s perspective is their increased ability and confidence to self manage their health condition(s), the improved behaviours learned during use of telehealth which should continue after telehealth is withdrawn (e.g. ongoing home monitoring of BP) once the patient is empowered and understands the significance of the improved results, and their improved access to health care if they have commitments that limit usual access arrangements e.g. because they are carers, work shifts or away from home base.

Telehealth readings can signal an impending crisis and enable the patient to seek help in advance of the deterioration of their condition; as well as their overseeing clinicians responding to relayed alerts. Patients may learn to recognise triggers that tend to derange the measures of their health that they are recording – such as stress triggering a raised blood pressure, or a rushed activity lowering their oxygen saturation level (SATs); then they can learn to avoid creating these triggers. Dual management plans between the patient and their clinicians can allow the patient to start an intervention as previously agreed with their GP or practice nurse, e.g. for those with chronic obstructive pulmonary disease (COPD) to start taking standby prednisolone and/or antibiotic medication when there is a deterioration in their condition.

There are many suppliers of telehealth, so the type of equipment and the nature of set ups varies across the country, and from patient to patient. A home based set of equipment would typically include any or all of: weighing scales, blood pressure meter, pulse oximeter, peak flow meter, glucometer (depending on purpose of the telehealth), and way of asking/relaying information about the patient’s symptoms and condition and how they are feeling. More specialist additions are ECG, urine analyser, or coagulation meter. Some are connected via telephone landline or mobile phone to a non-clinical triage centre which requires specialist installation; others relay recordings via encrypted wireless and patients can take the equipment home or to work or away on holiday. Portable and personal ECG monitors have been trialled for the early detection of cardiac ischaemia and arrhythmias generate alarm messages about the patient’s heart function to a central web server that transmits messages in turn to the attending physician. Telehealth can be set up so that monitoring systems allow patients with complex conditions to remain at home or be discharged early from hospital, and these require staff to triage readings sent in at a monitoring centre to trigger appropriate actions according to readings transmitted. In these systems, the patient is a passive recipient of care.

As clinicians have become more familiar with telehealth, there has been a move to cheaper and simpler equipment such as mobile phone texting that can give sufficiently good information to clinicians about patients’ healthcare. The type and range of telehealth equipment should match patient needs and preferences and be justified by: the risk of deterioration of their long term condition, ability for a change in medication to prevent deterioration and availability of other interventions to reverse that deterioration and maintain them in better health.

The evolution of the simple telehealth mobile phone texting service Florence (or Flo) has been developed in Stoke-on-Trent and the intellectual property is owned by the NHS. It has grown from applications relating to basic reminders for patients (e.g. to take medication) and self reported information gathering (e.g. vital signs such as blood pressure), to enabling the provision of sophisticated clinical care underpinned by dual management plans agreed by clinician and patient. The evolution was driven by trials of clinical applications, such as that focused on improving clinical management of hypertension in general practice, funded by the Health Foundation.8,9

In the initial evaluation of the innovative clinical application for hypertension, we found that simple telehealth is an acceptable and effective tool in reducing patients’ blood pressure in general practice settings8 and that patients love the personal support and flexibility offered by Flo.9

So Flo was developed to help patients to manage their long-term conditions or change lifestyle habits in order to improve their clinical management or state of health. Flo is different to other types of telehealth in many ways, because it is simple. Using text messaging, the only equipment required for many situations is an ordinary mobile phone, although for some conditions monitoring equipment such as a sphygmomanometer may also be lent to patients. Flo sends reminder messages to patients, advice messages, and also asks the patient questions, and for some conditions, asks the patient to text in their readings such as blood pressure. All text messages are free for the patient, as the NHS pays the cost. Patients love the support that they get from Flo and become more confident about co-managing their condition and less likely to contact their clinician unnecessarily.

Flo requires commitment from the patient to make some effort to improve their own health, whether by making lifestyle changes, or by regularly sending in texted responses to questions or readings of vital signs. Flo reinforces a dual management plan agreed between the clinician and the patient, but is not a substitute for normal clinical care. The experience over the last three years development period in primary, community, acute hospital and mental health care settings, has been that patients gain more understanding of their condition through Flo, are more confident about their condition, do not feel the need to consult their clinician(s) as frequently, and their condition(s) becomes more stable as they learn to adhere to advice /agreed intervention(s) which previously were quickly forgotten.

CPDQSo are you starting to understand about the range of telehealth applications and equipment that exist? Does the idea of keeping itsimple (like Flo) appeal to you?