This year, on the 10th Anniversary of Telehealth and Telecare Aware, we invited industry leaders to reflect on the past ten years and, if they wish, to speculate about the next ten. We are pleased to publish the following item from Steve Sadler, who has been Chief Technology Officer for the Tunstall Group since 1996.
My reflections on the last decade describe a laying of the foundations for ‘connected care’.
The decade has seen continued and huge pressures on health, care and housing, driven by our living longer and with increasing prevalence of long-term conditions.
We have also seen major disruptions to economies worldwide, affecting their ability to continue funding traditional models of care. The resulting public sector budget constraints are daunting, pushing us to explore technology-enabled transformation of services.
At the same time we are experiencing helpful developments in technology, prompting questions as to how we can do more with IP-connectivity, health apps, internet of things, cloud and big data analytics, to help us to shape solutions that bridge the gap between our needs and our resources.
An Exciting Beginning: So what was so special about the last 10 years? Early in the decade we had seen the first large-scale ‘telehealthcare’ programmes. The USA Veterans Association had reached scale in its CCHT telehealth programmes, with over 10,000 remote patient users, and citing reductions of inpatient stay and emergency room visits by 30% for appropriate patients. VA patient satisfaction levels were reported as greater than 90%.
For telecare, we didn’t need to look further than West Lothian’s pioneering work in Scotland. They presented a very compelling picture of service re-design, in consultation with users, providers, unions and many others. Combinations of home care and telecare were enabling many more people to stay in a home-setting, to the point that care homes were being closed.
On the back of these programmes, we saw the UK in 2005 striding towards funding for technology-enabled care, resulting in the UK Preventative Technology Grants 2006-08. Such new programmes can be exciting, innovative, encouraging, fragmented and occasionally hijacked – PTG was all of these. We all agreed on a need to focus on winning combinations of care and technology, and understandably we also demanded further proof of beneficial outcomes.
The Pursuit of More Evidence: The UK’s Whole System Demonstrator programme was launched in 2008, folding telehealth and telecare into a mixed delivery model, although notably without any tangible plan for integrating the services – ‘tele’ seemed to be the only connection. However, WSD reported exciting outcomes:
“if used correctly, telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs. More strikingly they also demonstrate a 45% reduction in mortality rates”
The later economic analysis was less compelling, with a BMJ article stating:
“QALY [quality of life year] gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher”
Perhaps we were naïve to expect anything else, given that the WSD programme did not exhibit design for optimal delivery of services at scale. For example, we made great play of WSD accessing 3000 patients across 230+ GP surgeries, but why would we expect GPs to redesign and optimize their services for telehealth, perhaps removing alternative, outmoded services, when only a few of their patients were involved. Maybe we should have asked our colleagues in Scotland to take the lead, given their successes in West Lothian (admittedly telecare rather than telehealth).
A persistent theme that emerges is that technology enables care, it doesn’t replace it.
Proactive Care: As we plot a way forward we can see that the story is evolving quickly, this time into a smarter combination of proactive care services and technology.
Spain is an exciting place to go to see this combination in action and at scale. As ever we await full evaluation, so it is too early to draw complete conclusions, but both Catalunya and Andalusia regions are reporting huge successes in helping people to live independently, and in minimising escalations to emergency services. Barcelona region alone has over 100,000 people connected to their ‘teleassistance’ service.
From my own exploration, it seems that the Spanish have a great understanding of the triggers that relate to care escalation, and have taken a very smart, pragmatic approach to the design of services, and to the choice of underlying technology. The related activity in contact centres offers a clue to the services and outcomes – typical UK telecare monitoring centres experience more than 80% inbound calls for alarms and assistance, which contrasts sharply with more than 60% outbound, proactive calls in Barcelona.
Integrated Care: Personal experiences are very powerful in shaping perceptions, and I’m in the age bracket that sits between young and older dependents.
People of my generation are often called upon to help navigate health services, to influence decision making and to signpost the options. My spare time is filled by stories of multiple, unexplained home visits by carers and clinicians, forgotten appointments, the confusions of medication, variable eligibility criteria and seemingly conflicting advice.
What does it mean to have a ‘care team’ for a patient, when this team actually comprises 5 or 6 services that are not all connected by electronic data or any organisation that is apparent to the patient – connected information is key, and I return to this point later.
Inevitably this leaves us with perceptions of lack of integration in care, and our attempts to sew all the threads together can be overwhelmed by the enormity of the task. This is where we should take a leaf from the Barcelona book of smart pragmatism – let’s not try to analyse the entirety, but instead select key areas where we can make a difference and deliver integrated solutions.
One implication is that we do not need to design new, all-embracing technology systems, but instead make smart connections to share information and provoke action at the right points in time.
People first, technology second: In our world of ‘connected care’ we are often coupling human activities with elements of technology, but are we always getting the balance right?
We can now access some wondrous pieces of technology, and our experiences of the last decade have reinforced that technology is unbeatable when it comes to humdrum, repeatable and precise tasks, and is an increasingly a rich source of data and analytics. We have less evidence that machines offer more to decision-making when it comes to complex, clinical scenarios.
So maybe we ask too much of technology-enablement, and when we talk of integrated care we should perhaps ask technology to:
- Remind – that we should take medication, make that visit to our GP
- Provoke – a call to check we are ok today
- Check – that medication or nutrition or care has been provided
- Monitor – for unexplained events, which in turn provoke preventative actions
- Measure – activity and vital signs
- Orchestrate – our activities within efficient workflows
Hopefully, the focus of NHS Vanguards, NIB and Test Beds is on key aspects of care integration and where technology can help coordinate service delivery.
The new Digital Maturity Self-Assessment Tool produced by the NIB framework is a step towards being paper-free at the point of care. Providers will be asked to self-assess their digital capabilities in the delivery of care, and evidence how effectively they share information with partners.
In relation to TECS, the framework asks “Are health & care professionals able to digitally monitor and care for patients remotely?” Look out for the publication of Local Digital Roadmaps by April 2016.
Inclusion: Assistive technology has continued to operate in separable market segments for much of the last 10 years. For example, telecare has been optimised for older people and selected long-term conditions, but has offered little for people living with physical disabilities. The inverse is largely true for environmental control systems.
Recently we have seen smart combinations of the two, with the result that new supported housing environments are providing real alternatives for people living with very significant physical disabilities. This highlights that we can be more inclusive with our technology-enabled care and housing services if we avoid silo’ed thinking.
Going Digital: It seems that most organisations have plans for ‘going digital’, but this is something of a misnomer; the vast majority of systems are already digital.
In the telecare world this should really be described as a move to internet protocol (IP) connectivity. We already see some territories shifting their wide-area connectivity away from analogue signalling methods over phone lines (to the point of ripping-up copper lines) to IP-enabled connections. This raises economic challenges – vulnerable people with stretched household budgets may not be interested in paying new broadband or cellular fees so that the social alarm industry can just replicate history in an IP world.
The far more interesting question is “what new, compelling services can we provide, which exploit richer data content, and always-on connections?” The shift to IP-connectivity also offers the prospect of greater interoperability, to the point where consumers can select and, maybe, even bring, their own devices.
Furthermore, the devices become platforms on which service providers and consumers can deploy a variety of ‘apps’ that suit their needs. We are already seeing these changes having an effect in supported housing – check out the developments at Hanover, Pegasus and McCarthy & Stone.
Who can deliver? The UK landscape has changed enormously: PCTs removed from the equation; emergence of CCGs; social care under tremendous budgetary pressure; a period of strained capital budgets in housing. This raises the question of which organisations now have the capability to create and sustain large-scale, technology-enabled care programmes.
In numerous territories, and selected UK regions, there is a shift to ‘bundled’ managed services, where the owners of service delivery and technology infrastructure become one and the same.
Perhaps this is most evident within connected care, but is increasingly the case in connected health, where reimbursement has been a long-standing challenge. Here, the attraction of technology is in its repeatability, accuracy and efficiency of monitoring and these are increasingly important to providers of therapies, including ‘big pharma’, rather some intermediary authority.
Where next for Assistive Technology?
Dr Kevin Doughty delivered a very good article in these columns earlier in the year, and I will avoid any attempt to repeat Kevin’s arguments here. Instead, I will make a brave attempt at a few predictions for the next 10 years!
- the smart combination of technology and care that is already apparent in Spain will become the norm
- devolution shifts power and forces the squeezing of resources
Regulatory constraints on systems, information and services will not lessen – but they will get smarter:
- standards will continue to evolve so that we can incorporate ‘bring your own device’, wearables and IoT applications in life-critical settings
- this will come about through smarter system design
- we will see standards and regulatory bodies evolving, to meet the demands of faster technology cycles
The hype around smart devices and wearables will not lessen
- expect to see more ways that you can ‘control your home from your phone’
- we will see greater convergence of ‘connectivity ecosystems’, thereby removing a barrier to purchase and reinvigorating growth in connected person and connected home technology
- smart homes and IoT move up the maturity curve, and wearables become truly useful with average use extending from the current 6 weeks to 6 months
We will see the wider adoption of pay for outcomes, resulting in…
- large-scale technology-enabled care services in both health and care
The way we innovate will continue to evolve
- co-creation by users, suppliers, providers will become commonplace
- more emphasis on ‘the art of the possible’ and rapid prototyping, less analysis
Consumer becomes the king, with:
- a shift to consumer or patient-owned data, associated with the simplification of informed consent
- avoidance of data flood, where smarter analytics deliver actionable information
- consumer ownership of care and health budgets
- emphasis on trusted guidance and signposting to services and technology
So hold on to your hats, it will be an exciting ride through the next decade!
Chief Technology Officer, Tunstall Group