The results of the latest and biggest telehealth trial suggest that it should undoubtedly now be taken seriously in today’s medicine. Yet there is real resistance to it in the system, and the barriers need to be removed to ensure telehealth success, say Matthew Rutter and Joe Stringer.
The largest randomised controlled trial of telehealth has started reporting its long awaited results. The outcome is what a number of us have been evangelically preaching for some time: that telehealth has a place in modern medicine.
But are the whole system demonstrator results enough to create the paradigm change in the way that long term conditions are managed, or will we just see more ineffectual pilots and kit piled up in the clinical commissioning group cupboard?
With the results so positive, there is now a real risk that commissioners will rush out and place vast orders with equipment providers without looking at deeper issues and fail to achieve change. The equipment is really only a fraction of the challenge.
As the Department of Health’s initial reports stresses – key to success is integrating the technologies into the care and services delivered. Where telehealth has failed to deliver we typically see there has been no upfront pathway and system redesign or clinical change management to lay the foundations for new ways of working.
An essential element of any successful telehealth deployment is a project management team devoted to achieving whole systems change. WSD or not, there is no silver bullet to working through the concerns of individual clinicians, who tend to fall into four camps.
First are those who question the clinical evidence base. Telehealth has had more pilots than an airline and the WSD programme was intended to back up their results with a large trial. But sceptical clinicians will always find a reason why the evidence is not robust – the trial was too short, it wasn’t piloted in their area, it didn’t cover all diseases, and so on.
Second are the GPs who wonder how to make it work in their practice. How will it fit into the way they already organise visits and clinics? Which patients might benefit? Who will respond to patient alerts? How will upper and lower parameters be set? How can they avoid being inundated with clinical alerts?
Third is the perception – and it is only a perception – that their workload will increase because they will have to go and see patients who aren’t really ill. They want paying for the extra work. In reality, patients go to the practice less because they self manage at home. Hospital visits decline because problems are caught before reaching crisis point. Incentives for telehealth should be worked in at some stage. GPs could be paid through the quality and outcomes framework and a national tariff would allow commissioners to pay acute trusts, community services and primary care.
Fourth is the technology divide. The equipment is no more difficult to use than a kettle or a TV remote. Comments like “my patients won’t get it, it will be too complicated” come from doctors who don’t use technology in their daily lives. We know a meeting is going to go well when a consultant turns up with a smartphone and/or tablet computer. We’ve been in board meetings where people say patients won’t be able to understand how to use telehealth. When we ask people to pull out their mobile phones, the people who believe that patients can do it are the ones who do banking and book holidays on their phone. The ones who think patients won’t get it only switch their phones on to make a call. This leads us to believe that it’s the individual clinician’s own approach to technology that is really the barrier.
Patients’ capabilities should not be underestimated, and they should be allowed the choice. We have seen patients aged 46 to 94 using the technology comfortably, be they house bound, cared for, or independent.
The benefits of telehealth go beyond the widely cited 40 per cent reduction in hospital visits. There are soft benefits too. Patients recognise their own symptoms, take ownership of their disease and change their lifestyle. Family members who act as carers feel confident leaving the house because if there’s an exception in the measurements someone will respond.
We know of consultants who have changed their clinical decisions based on telehealth data brought in by the patient. There’s an undeniable logic that three months’ measurements of vital signs will provide a fuller picture than one-off measurements in outpatients.
Telehealth also improves treatment and management compliance by automatically doing vital health checks on patients who for whatever reason are not doing it themselves. We have sat in a heart failure rehabilitation group led by a sceptical nurse who didn’t believe in telehealth. She made claims that all her patients weighed themselves every day. We asked the group who had weighed themselves that day. Sheepish looks but no hands raised. We then asked who had weighed themselves that week (it was a Friday). Not a single patient. In contrast, if a patient using telehealth doesn’t weigh themselves that morning, they will get a phone call. With so many complications possible, the automatic monitoring of such vital information clearly benefits both clinicians and their patients.
The WSD will help write some of the economic case because it will quantify the level of reduction in admissions to hospital, outpatients and some of the impact on GPs. Using the tariffs we’ll be able to calculate cost savings. We already know that the payback period for one telehealth unit is about 18 months even though the kit is still quite expensive in the UK. In the US, demand has driven the price down which makes the economic case even more compelling.
What the WSD hasn’t told the world is how best to deploy telehealth. Yet how could it? Each health community is different with unique personalities and variations in clinical practice. With such compelling evidence, there is now a real danger that precious money will be thrown at kit, and potentially useful kit will be thrown at a broken system for managing long term conditions. Telehealth deployment can only succeed through large clinical engagement programmes and systematic pathway and service redesign. The WSD project will be resigned to yesterday’s news if commissioners simply go out to market and purchase kit.
The stethoscope was invented in 1816 and is still being used nearly 200 years later, but therein lies the problem of challenging the status quo. Medicine has been practiced as a face to face interaction between doctor and patient ever since. Telehealth is changing that doctor patient relationship.
Key steps to telehealth
- Work with clinicians to redesign clinical pathways enabled by telehealth, not telehealth pathways.
- Commission the service from providers then work with them to redesign services using existing resources (or fewer, where possible) to deliver the new care pathway.
- Engage across the health and social care community to examine the implications for each organisation – they will all be impacted in some way.
- Use risk stratification tools to select patients with the long term conditions and comorbities who are most likely to benefit.
- Procure the kit. Use the equipment provider for maintenance and repairs. There is a plethora of suppliers out there all promising to deliver the same outcome, with costs varying from £20 per patient to over £1,000. You will only know which one to choose once you’ve decided which patient cohort you are targeting (acute monitoring or hands-off wellness).
- Decide how to manage alerts triggered through the telehealth system. Either purchase a managed service (the equipment provider or NHS Direct) or use GP practices for clinical triage.
- Set up a project management office to run the project, roll it out, track the kit going out and monitor the benefits.
- Track the benefits through interviews and performance management reports.
- Integrate systems so that GPs, out of hours services, and consultants can log in and access the data generated by telehealth.
If used correctly telehealth can deliver:
- 15 per cent reduction in A&E visits.
- 20 per cent reduction in emergency admissions.
- 14 per cent reduction in elective admissions, a 14 per cent reduction in bed days.
- 8 per cent reduction in tariff costs.
- Telehealth pilots also demonstratde a 45 per cent reduction in mortality rates.
Source: DH WSD Headline Findings Dec 2011