By Nigel H. Lovell & Stephen J. Redmond
In developed countries, chronic disease now accounts for nearly 80% of healthcare expenditure and nearly an equivalent percentage of disease-related deaths. The burden of chronic disease (often, but certainly not exclusively, associated with aging) includes asthma, hypertension, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Over the past half century there has been an epidemiological shift in disease burden from acute to chronic diseases that has rendered acute care models of health service delivery inadequate to address population health needs.
In response to these changes in disease demographics and the economic imperatives caused by an aging population, service delivery models are shifting their focus from episodic care to continuity of care, from institutional care to community and homebased care, and from disease treatment to disease prevention. To support this change of focus, information and communications technology (ICT) infrastructure is required to facilitate shared services such as virtual health networks and electronic health records, knowledge management (care rules and protocols, scheduling, information directories), as well as consumer-based health education, demographic data, clinical signs monitoring and evidence-based clinical protocols.
The application of a broad range of ICT as it applies to managing disease and wellness is termed “telehealth.” It is broader than the concept of “telemedicine,” which is typically defined as a system of healthcare delivery in which physicians examine patients through the use of telecommunications technologies – that is, remote diagnosis. Telehealth incorporates a wider range of health-related activities including patient and provider education, point-of-care diagnostics, clinical decision support services, and most importantly, provides tools for self-management of disease and wellness.
The work of our research group in the telehealth area dates back some 15 years. We began by designing appropriate technologies for use in primary health care. There are many examples of ICT applications in chronic disease management. However, many are ill-conceived in that they are driven by the underlying technology and not by a clinical problem that needs to be addressed.
Specifically, in 2001, we began to trial home telecare technology for the management of chronic disease. At that time, much rhetoric existed about the perceived patient benefits and potential cost savings of the “tele” word when applied to healthcare. How important is the clinical need in terms of improving health care and reducing current costs? Does the proposed technology impact significantly on the clinical problem? Is there adequate input from all stakeholders including patient groups and end-user representatives? Surprisingly, in many forums the questions that were being asked then are still being asked today.
Over the last eight years the telehealth technologies developed at UNSW have been commercialized in Australia by a start-up company (TeleMedCare Pty. Ltd., http://www.telemedcare.com.au) and extensive product and clinical trials have been undertaken both in Australia and the U.K. While it was, and still is, an evolving process, appropriate home telehealth technologies were engineered into health care solutions that were then integrated with existing health service delivery models. These systems were researched, constructed and trialled. A range of health management solutions are now being sold and deployed throughout Australasia and the U.K. to hospitals, local health authorities, residential aged care facilities, community care centers, medical insurers, health and lifestyle centers and individuals.
In more recent times, the telehealth space has attracted interest from bigger multinational companies. Examples include the Viterion product from Bayer-Panasonic, HomMed from Honeywell, TeleStation from Philips and the PHS600 from Intel- GE. In general, all the units are designed to record clinical indicators of a patient’s health status including weight measurement, single lead electrocardiogram, blood pressure, spirometry, body temperature and oxygen saturation (pulse oximetry). Some systems provide feedback to patients, including medication reminders and measurement scheduling, as well as video conferencing.
Just as the clinical interventions when managing chronic and complex disease require a holistic approach, so too does the home telehealth approach. There exists no single silver bullet for design of an effective telehealth system. The chronic disease conditions by their nature are complex and multi- factorial – and so too are the requirements for a telehealth management system. The critical issue in deploying a usable system is to firstly have a deep understanding of the healthcare sector and to use this understanding to appropriately hide the layers of complexity from the endusers. A patient interacts with the system by way of scheduled measurements and medications reminders. By default, a clinician views management reports from only his or her patients with adverse or deteriorating clinical measurement trends.
From a systems viewpoint, to make such complex tasks appear simple and be time and cost effective requires a convergence of many factors – integration of innovative, low-cost sensors to perform clinical measurements , scheduling for medications and measurements, a longitudinal history of past measurements and appropriate tools including targeted patient education to facilitate patient self-management, remotely maintainable client-side software, and web services for case management by health care workers and administrators.
Research and trials in Australia and the U.K. have clearly demonstrated that the TeleMed- Care system is a viable and important way of providing monitoring and follow-up care to patients suffering the burden of chronic disease. Studies have shown that nearly 90% of the care a person needs to manage a chronic disease must come directly from the patient. Self-management interventions, such as self-monitoring, patient education and feedback, and decision making lead not only to improvements in health outcomes, but also to increased patient satisfaction and reductions in hospital bed days and carer visits. By way of example, the Veteran’s Health Administration (VHA) in the U.S. ran an extended trial of rudimentary telehealth equipment from 2003-2007. In a study group of over 17,000 patients, the introduction of home telehealth demonstrated a 25% reduction in numbers of bed days of care, 19% reduction in numbers of hospital admissions, and mean satisfaction score rating of 86% after enrollment into the program. This was also associated with considerable projected cost savings.
Another essential, on-going task is the development of a decision support framework to enhance the healthcare giver’s review of the remotely acquired monitoring data and to support the clinical decision-making experience. The amount of clinical information that can be generated from a telehealth monitoring system is substantial. Analysis of these data and correlation with clinical history by the decision support system will be used to highlight important sections of patient results, provide summary analyses and recommendations, and will assist in the efficient review and risk stratification of multiple patient results. The healthcare giver will automatically be alerted if any of the monitored data indicates deterioration in the health status of a patient. Furthermore, outputs from the decision support system can be used to influence changes in work flow.
The path to creating a comprehensive and holistic home telehealth system is hugely integrative and complex. It is only now after a decade of intense development and trialling that we are beginning, in a controlled and automated way, to effectively and efficiently close the clinical care management loop. Such modifications to the clinical care workflow will flag the way for the next generation of home telehealth.
Nigel H. Lovell , Ph.D. Stephen J. Redmond, Ph.D. University of New South Wales Australia firstname.lastname@example.org
President of Virtual Reality Medical Institute (VRMI) in Brussels, Belgium. Executive VP Virtual Reality Medical Center (VRMC), based in San Diego and Los Angeles, California. CEO of Interactive Media Institute a 501c3 non-profit Clinical Instructor in Department of Psychiatry at UCSD Founder of CyberPsychology, CyberTherapy, & Social Networking Conference Visiting Professor at Catholic University Milan.