What was Chancellor Gordon Brown up to when he announced that the VAT rate on equipment to help older and disabled people live independently would reduce to 5%? Steve Hards reflects. (more…)
Speculation by Steve Hards, concerning the potentially double-edged effect of the Department of Health’s large ‘White Paper pilots: whole system long term conditions (LTC) demonstrator programme’. (more…)
Dr Kevin Doughty, of the University of York’s Centre for Usable Home Technology speculates on the prospects for successful mainstreaming of telecare in the UK. (more…)
An abbreviated version of this article follows, with kind permission of Pavilion Publishing. Visit the homepage of its Journal of Assistive Technologies. You can also download a PDF of the full Telecare, telehealth and assistive technologies – do we know what we’re talking about? article when you have read this extract. The Journal of Assistive Technologies would welcome articles responding to the debates covered in this piece – please submit pieces to be considered for publication to the editor, Chris Abbott at firstname.lastname@example.org The article exposes the current taxonomy problem very well, looking from two directions at the range of technologies in this field. It finishes by suggesting alternative terminology to help resolve the difficulties we now face. Is that the right way forward, or will it just add to the confusion?
Telecare, telehealth and assistive technologies – do we know what we’re talking about?
(Abbreviated version) Authors: Kevin Doughty, Andrew Monk, Carole Bayliss, Sian Brown, Lena Dewsbury, Barbara Dunk, Vance Gallagher, Kathy Grafham, Martin Jones, Charles Lowe, Lynne McAlister, Kevin McSorley, Pam Mills, Clare Skidmore, Aileen Stewart, Barbara Taylor and David Ward (The Centre for Usable Home Technologies (CUHTec) Advanced Telecare Users Group)
The development of telecare services across the UK has been supported by grants from the respective governments of Scotland and Wales, and by the DH in England. New services are being established to sometimes operate alongside existing community equipment services and community alarm services. Elsewhere they are embracing a wider range of services including rehabilitation, intermediate care and health services designed to reduce the use of unscheduled care services. This paper discusses the difficulties in understanding the scope of telecare services, and the definitions of services that will need to be confirmed so that service users can choose appropriately if offered direct payments. Two different service models are offered, one of which uses telehealth as an umbrella term to cover all telecare, e-care and m-care, and telemedicine where the former includes all such services offered in the service user’s home, including those of a medical nature. The second model views telecare alongside assistive technologies and telemedicine as one of three different technology groups designed to make people more independent or to bring care closer to home. There is significant overlap between the three groups, which justifies the introduction of a new term – ARTS (assistive and remote technology services) – to describe this area of support.
There is renewed interest in the role that may be played by community services that are based on technologies that support independence i.e. assistive technologies. Traditional forms of assistive technology include low-tech portable devices such as walking sticks, spectacles and tap turners, to more expensive fixed systems such as stair-lifts, ramps and level-access showers (that are essentially adaptations to the home). Several new items of assistive technology have appeared during the past 20 years, many depending on electronic, computing and telecommunication innovations. Systems such as environmental controllers have enabled profoundly disabled people to operate electrical appliances, motorised door and window openers and other electrical equipment through a personal interface arrangement. [In the UK] the term ‘telecare’ was selected to cover all electronic technologies of a preventive or supportive nature because it had the necessary ‘buzz’ and because it implied a modular approach and a need for a developing telecommunications infrastructure. Although the fundamental purpose of the technology is to avoid unscheduled care incidents and, in particular, the management of long term conditions, it can support independence because it is capable of overcoming the need for people to move prematurely into a nursing home environment. Such technology would appear to be a medical application of telecare, which would be consistent with the new definition of telecare described above. However, remote and regular (but not continuous) vital signs monitoring may be fundamentally different to existing UK telecare systems because the purpose is to collect data rather than offer an automated alarm. In the USA (where there is currently little use made of the UK model of telecare), remote vital signs monitoring systems are known as telehealth systems. The term “telehealth” has therefore been imported into the UK with little thought of how it co-exists alongside the telecare agenda. More perversely, telehealth has in Europe for many years been the umbrella term used for a broad range of technologies which includes telemedicine (the sharing of medical data, including scans and visual images), e-care or m-care (which involves data transfer on a mobile basis) and telecare. The result is that, under the previous model, telecare is a sub-set of telehealth technologies, whilst in the new model, apparently supported by equipment vendors and other bodies, telehealth is a sub-set of telecare.
Model 1 – Telehealth Umbrella Model
The original definition of telehealthcare effectively based its sub-sections on the location of the care that was being delivered remotely i.e. the home, some community location, and a medical facility. Telecommunication technologies have matured quickly in the 21st Century. Similarly, information systems and the embedded intelligence in devices have become progressively more sophisticated enabling them to be included in relatively low-cost equipment for the home. This yields a host of new services as shown in Figure 1. Alongside the three components of Telehealth are shown a growing range of Assistive Technologies which, though not requiring any connection to a remote care manager, nevertheless perform a valuable role in helping to overcome unmet needs. Figure 1: The Telehealth Umbrella for Technology
Model 2 – Telecare Umbrella Model
Telecare has become a term used for all preventive technologies that involve the use of electronics, telecommunications and information systems. It can therefore cover the spectrum of applications from alarms through to monitoring of vital signs and activities both in the home and on the move. Thus, if terms such as telehealth were to include all forms of medical monitoring and information, including health coaching, then a broader form of telecare could extend across from environmental through to medical applications. It follows that some electronic aids to daily living, such as prompts, reminders and local alarms, might also be considered to be examples of telecare (as well as being assistive technologies). In the same way, mobile applications of worn or embedded medical devices (such as cardiac arrhythmia monitors) could be considered to be telecare when used in the home but telemedicine if data or alerts are directed to a consultant in a hospital. Figure 2 offers an alternative map of services where telecare becomes the umbrella term with assistive technologies and telemedicine covering a much smaller group of modalities that are associated with housing adaptations and hospital services respectively. Figure 2: The Continuum of Care Technologies Centred on Telecare
Discussion and Conclusions
Perhaps telehealth is a more important concept because everyone needs their health but not everyone will need care. If we used the term “telehealthcare” then perhaps we can avoid confusion because it clearly incorporates both telehealth and telecare. It doesn’t necessarily include traditional forms of Assistive Technologies. Amid the debate, there remains the thought that individual provision of services is required based on a holistic assessment. This is the only way of assuring that the solution is person-centred. As we are discussing equipment and services based on technology, maybe the term PROCESS Technologies (PeRsOn-Centred Equipment & Support Services) could be employed as the umbrella term. Alternatively, the coming together of assistive technologies and ICT (Information and Communication Technologies) might yield a hybrid term such as ARTS (Assistive & Remote Technology Services) which may be acceptable to all. In each case, it may be appropriate to separate the individual elements into their respective roles:
- Functional support – replacing or improving an individual’s ability to perform one or more activities of daily living with devices (including robots) which can compensate for the user’s physical, sensory or intellectual/cognitive deficiencies
- Alerts and alarms – sensors or combinations of sensors which detect situations where the individual’s safety and security (and increasingly health and well-being also) may be at risk
- Monitoring – methods of providing an on-going assessment (or analysis) of an individual’s medical, psychological, well-being, performance or behavioural state so that interventions can be offered before an emergency arises, and
- Interactive and virtual services – systems which overcome the problems of distance and isolation in advising, empowering and, hence, enabling people to become partners in the process of improving their quality of life.
Service providers of the future may need to offer all these services in order to meet the aims of commissioners. Those which reject individual service elements must be clear in advertising what they can and can’t do in order that everyone understands their limitations and/or specialities. Whilst a vision of the future potential for these technologies may be a prerequisite for service development, the adoption of standard definitions will greatly simplify the process of establishing best practice and improving service delivery and integration.
Download the full Telecare, telehealth and assistive technologies – do we know what we’re talking about? article in PDF form. Visit the site of the Journal of Assistive Technologies.
Does the article tease out all the problems? Although there is a reference to ‘proactive calling’ in one of the diagrams it does, to me, seem to omit one sense of ‘telecare’ which is widely used, particularly since the profile that Ontario Telecare has obtained. In this sense telecare is used to mean giving phone-based and online health advice to the public, as in the manner of the UK’s NHS Direct service. To what extent this type of service should be included in the taxonomy and, if so, how it should be called, should form part of our debate.
Further comment from Kevin Doughty
Just for clarification on the phone helpline angle, my view is that Telecare includes all services that rely on technology to help support a person in the own homes from a distance. A telephone helpline which offers advice on medical conditions (e.g. NHS Direct) can therefore be considered to be telecare as much as a complex video surveillance system that detects problems and initiates interventions through ‘smart home’ technology, domestic robots or an emergency response team.
Not telecare, but a terminology issue as it refers to the target client group for telecare/telehealth companies. When I read about ‘the elderly’ or worse, the near-meaningless, ‘the vulnerable’, I imagine that the writer is probably hardly out of their twenties or thirties, or still has that mindset. If you want to alienate your potential clients, this is the language to use.
A brief read, with an American perspective, but with interesting survey results. Baby boomers? Older people? Senior citizens? Elders? What would you like to be called in your middle and later years? by Rita R. Robison.
Janet Brown, for the American Speech Language Hearing Association made this comment about its policy on ‘telehealth’, posted on Google Video. It’s good to see that she shows a sensitivity to the uncertainties of the terminology.
What a great way to make policy announcements!
Nottingham PCT aims to monitor around 800 people each year with long-term conditions such as chronic obstructive pulmonary disease and congestive heart failure, using Tunstall equipment. Press release.
[Comment: This is the third press release in recent times to headline the word ‘mainstreaming’ in the context of a deployment that is bigger than the usual pilot study. Is ‘mainstream’ now becoming redefined to mean ‘large scale pilot’? Surely something isn’t mainstream until it is routinely offered to everyone who could benefit from it? I’ve flagged this item for the ‘Terminology’ category because perhaps the meaning of ‘mainstream’ should be part of the terminology debate.]
Here are two free reports you should consider downloading.
First, The Center for ConnectedHealth’s 2007 Progress Report. Good if you want a wide-ranging look at current remote health monitoring and care delivery trends in the US. [And in Second Life…I wonder if not being able to fly or grow a tail count as health problems in that virtual world?] Interesting stuff, and you can download it from this page on the Center’s website.
Second, there’s the S2S (Strategies to Solutions) discussion paper, called Technology to Support the Ageing Global Population 2007 to 2027. It is 25 pages of balanced, well written information that ranges over assistive technology [a term used in its broad sense – compare with this post] including health- and care-related AT, and highlights various issues for society and emerging technology. You have to join the S2S mailing list to get it, but don’t let that put you off. Get it here.
With a bit of editing and a slightly revamped commentary this video could become a useful introduction to telecare and telehealth for the public. However, people who know me will anticipate that I have a huge problem with Norfolk’s conflation of ‘assistive technology’ with telecare and telehealth, hence I’ve also categorised the video under ‘terminology’.
Let’s get this straight: ‘assistive technology’ is a very broad term for any equipment that helps compensate for some form of functional impairment. Or, as the Foundation for Assistive Technology (FAST) defines it, “Assistive Technology (AT) is any product or service designed to enable independence for disabled and older people.” A few shots at the beginning of the video imply that they understand this, but it soon slips into referring to the telecare and telehealth as AT. Although can be regarded as a subset of AT, there is no implication that AT has a remote component in any way, which is the key defining characteristic of telecare, telehealth, telemedicine, etc. When I was contracted to work at the Department of Health I frequently reminded civil servants and Ministers not to refer to telecare as ‘assistive technology’ and I thought that eventually the message did get through. At least by the time the Preventative Technology Grant conditions were published. And now it raises its head again…
OK, rant over! My thanks to Saneth Wijayaratna of Telemedcare Ltd for alerting me to the 7 minute video.
This post continues the focus on the terminology problems.
Watch this 6½ minute video of US Senator for South Dakota John Thune advocating (successfully) an increase in funding for telehealth in October 2007. It is interesting to observe his superordinate use of the term ‘telehealth’, with ‘telemedicine’ sometimes seeming to be used interchangeably, and sometimes subordinately to it when contrasted with ‘telehomecare”.
I’m grateful to Marnee Brick, a speech therapist, for spotting this video. As an ex-speech and language therapist I am delighted to see that she is promoting online therapy. See her site: TinyEYE.
However, I do have a problem with her construction of online speech therapy under ‘telehealth’ in her blog. As I’ve mentioned previously, the terminology issue here is not with ‘tele’. It’s what comes after: is speech therapy is a health or an education-related discipline – or something else? This was a debate going on in the UK from at least the ’60s. She also uses the term ‘telespeech’ and ‘telepractice’.
Ascom is perfectly entitled to name its nurse call system anything it wants. But does it fit within the range of your construct of ‘telecare’? It doesn’t sit comfortably in mine. Read their Ascom Telecare IP – Nurse Call System information and leave a comment if you want to react.
United Response, a UK charity supporting people with learning disabilities and mental health problems, terms its use of telecare equipment ‘telesupport’. Is this a reasonable, or even a useful, coining, maybe?
As regular Telecare Aware readers will know, Wireless Healthcare is a favourite source of articles, so it is a pity that in this commercial report they have produced they chose to perpetuate the use of the pejorative term ‘elderly’ instead of the less value-laden ‘older people’. Wireless Healthcare’s story on the report [Page URL “http://www.wirelesshealthcare.co.uk/wh/news/wk05-08-0003.htm” reported to be compromised by malware 16 March 2015].
As part of the terminology campaign, I am posting links to real-world stories that illustrate ways in which terms related to this field are being used. My intention in highlighting these items is not to imply that the people who use the terminology in that way are somehow wrong: they are entitled to use it in any way they see fit. My intention is to say to the worldwide telecare/telehealth community “Look – people are using the words in these ways. Is it helpful, or not? Is there a need to have some internationally agreed definitions to refer to?”
Often, it seems to me, the problem arises not with the use of ‘tele’, which means ‘at a distance’ or ‘remote’, which is a common denominator in all these things, or even with the prefix ‘e’ to denote ‘electronic’ or ‘internet’, but with the other part of the usage – what is ‘health’, ‘care’ or ‘medicine’ in these contexts?
Here are five items to start off with. When you have finished browsing them, follow the link in the navigation bar to the main Terminology page.
No Clear Consensus on Telemedicine Market Size
“…telehealth (also called eHealth) marketplace — which includes telemedicine…”
AMD Telemedicine press release
Assembly of First Nations and Canada Health Infoway Funding Decision Transforms First Nations Access to Health Care
“Currently about 100 First Nations across Canada use telehealth technologies for clinical consultation, continuing professional education, health promotion, health care management and administration.”
German industry group publishes telemedicine standards
“Leading German electronic association the VDE has published a new set of standards for telemedicine to spur the development of telecare and telemonitoring.”
Birmingham PCT to extend telecare to 27,000
“Birmingham East and North PCT together with NHS Direct and Pfizer Health Solutions launched Birmingham OwnHealth, a nurse-led telephone care management programme, in April 2006.”
One call a day…
“…telephone checking and visiting services in Orange were desperate for volunteers…relies on a Telecare call every day to check on her welfare.”
As promised in the ‘themes for 2008’, I’m turning the spotlight this year on the issues surrounding the use of telecare, telehealth, telemedicine, etc. and the taxonomy of services and devices in this field. Make use of the new starting page (added to the navigation bar above) and of the new ‘Terminology’ category which will make it easier to search for all related posts.
Take a few minutes to read the introductory page, and then follow the link to an article that gets us off to a great start.