10th Anniversary Article 1: The Next Ten Years of Telecare

This year, on the 10th Anniversary of Telehealth and Telecare Aware, we have invited industry leaders nominated by our readers to reflect on the past ten years and, if they wish, to speculate about the next ten. Here is the first article, with a UK focus, by Dr Kevin Doughty.

Many of us are frustrated at how little progress there has been in the deployment and acceptability of telecare during the past decade. Yet, despite warnings that an ageing population was about to bankrupt the NHS (and health insurance schemes elsewhere in the world), and that access to social care for older people was being withdrawn at such a rate that it could only be afforded by the wealthiest in society, our health and social care systems have just about survived.

But this can’t go on, and in England over the past 12 months:

• Delayed transfers of care have increased by 23%
• There’s been a 25% increase in the number of elective operations cancelled
• The number of ambulances having to queue outside A&E have increased by 54%
• The number of patients waiting more than 4 hours for attention at A&E at major hospitals has fallen to 89% (and below 75% in Northern Ireland, for example, where there is already integrated care) all against a target of 95%

There is simply a lack of capacity in the health and social care system, and an ageing population with increased expectations will only exacerbate the problem, irrespective of how much new money a government of any colour is prepared to put in. Telecare could have been part of the solution for the past decade, but it wasn’t because it was provided as an add-on to an existing system rather than the catalyst for changing the way that care and support are provided.

This could all change very soon, for a number of reasons, including those listed below:

1. The telecare devices and systems have been shown to be robust – and the services that offer them are increasingly associated with better assessment, choices and quality outcomes – and entirely consistent with moving care closer to the individual.
2. They are being replaced by smaller, more energy efficient, and powerful devices in systems that are easier to set up, to use and to deal with when something goes wrong; they are portable, and in many cases, wearable too, so that issues of utility and battery management have been addressed and are no longer reasons to avoid deploying them.
3. Prices have fallen – especially for vital signs monitoring equipment, and for monthly charges or subscriptions that allow people access to data which is actually their own!
4. People are more used to consumer computing devices, such as tablets, smart phones and smart TVs – and they can and will be used increasingly both for telecare applications, and as a hub to link peripherals; they don’t need to look like medical devices and this will help the public to understand, adapt and actually use them to monitor their own health and well-being, which they can now understand better than ever enabling them to take some more responsibility for their own health.
5. The Tele- bit has become much, much easier – not only can we now have ‘always-on’ (and effectively free) communication with everyone, everywhere from our homes, but mobile networks and handsets have moved even more quickly so that fast access is available in most locations, and when we are ‘on the move’. Many of us can and are connected with the world at all times.
6. Equipment is more versatile and aesthetically pleasing – it no longer cries ‘vulnerable’ or ‘disabled’ when it’s looked at but is approaching the point of coolness where the grandchildren would like to borrow it, especially if it can be worn somewhere that is unusual or if it shouts ‘smart’ to everyone who sees it.
7. We are starting to drop words like ‘equipment’ and ‘technology’ to describe telecare systems and electronic sensors and gadgets; these old words are associated with previous centuries; they scare many people off, and make others worried that they might break them, kill someone using them or cause thousands of pounds worth of damage.
8. Assistive technology products that were exclusively for use by relatively few people who had major disabilities are appearing in forms that allow them to be used by the millions of older people who have (perhaps several) minor disabilities but who can benefit significantly from having access to these ‘Aids/Tools for Daily Living’.
9. The amount of information that we can all access through the Internet is so great that almost anyone can search new ways of supporting independence and managing long term conditions, and can compare different products and approaches (and prices) to find exactly the best ways of dealing with the issues that prevent us from achieving our life goals.
10. Individuals are showing a willingness to share their telecare successes with the rest of the world (rather than with their technology company) so that others may learn from their innovations and experiences, both good and not so good.
11. Professionals (including GPs) who have previously shown little interest in embracing telecare systems, are running out of excuses for not recommending and using services that would both improve the lives of their patients and make the lives of carers and others in the health and care sectors easier, enabling them to be more informed and efficient in their working lives.
12. The Point of Care testing that can help identify a disease, or which can be used by individuals to track their own condition without going to a medical facility, are becoming ever easier to conduct and accurate in their outcomes; many use smart phones for processing and for relaying the results to physicians. New devices no longer need a blood sample for testing diabetics regularly or frequently.
13. New models for Digital Caring are emerging which add value and improve the Quality of Life for both patients and their family carers, and prepare us for a world in which a hands-on approach using paid-for carers will be very limited, and which will need to be supported by more smart electronic helpers (which will include robotic devices such as floor cleaners and lawn mowers) that can help to perform functional tasks such as getting up and dressed.
14. The importance of electronic records that can be shared between GPs, emergency services, hospital staff and social care providers is being recognised so that links between systems can be performed securely and appropriately using apps as necessary.
15. The way that we buy things has been transformed by the Internet and by the convergence of TV and information channels; ignoring the potential harm to the high street, it means that people can buy medical technology products or assistive devices irrespective of where they live, and many more people will receive capital payments from the state to help them to do so. The potential for buying a ‘pig in a poke’ will increase and we must accept the risks involved in encouraging people to look for a bargain without understanding issues of usability, interoperability and limited evidence.
16. New and existing telecare service providers are raising their game, and the quality of what they offer, by adopting new and more flexible standards that force them to be more transparent in what they can do, and what they can’t do. The significance of buying a service rather than (or as well as) a range of products is becoming increasingly apparent.
17. Society has changed and is questioning how much support can be offered by the state to deal with problems which are the result of poor decisions on lifestyle, especially when individuals refuse to change. People are more likely to accept rationing of resources on the basis of poor compliance with therapies and lifestyle advice whether in taking medication or from abstaining from the use of recreational drugs, alcohol of tobacco products.
18. The Internet of Things is invading our homes, our cars and most other aspects of our lives. It promises many benefits including energy efficiency, preventive approaches to dealing with household appliances and the connection of all electronic and electrical devices. It will enable smart homes to be truly smart and connected after years of false dawns.
19. New invasive medical devices which monitor cardiac, brain, endocrine system performance in real time and allow closed loop control or intervention and then communicate wirelessly with the relevant physicians, are moving from the lab to the real world; costs are falling making them available to increasing numbers of people as high profile examples of telecare.
20. The value of training and staff development have been highlighted in all reports on failing hospitals, services and agencies. New guidelines will help to ensure that everyone is made aware of the benefits of telecare and assistive technologies and their deployment will be routine as their role become standard and not a special afterthought. This applies in all settings, especially in the individual’s home.

For the above factors to be relevant, there will remain a need for an understanding from government down that technology alone cannot be the answer, and that holistic assessments mean understanding people, their lives, their goals and their preferences so that Digital Caring and AT are used to address and overcome the issues rather than as ways of addressing unmet needs and risks.

This is already happening with regard to the way that dementia is being treated. The creation of dementia-friendly communities, cities and charters is highlighting how much everyone can do to build a new way of dealing with long term conditions, and avoiding our dependency on hospitals not as places where complex acute assessments and interventions occur, but as the first (and sometimes only) place to look when a medical or social care problem presents. The need for more resources to be transferred from secondary to primary and community care is accepted (but hasn’t been seen recently in budget transfers).

Despite this, the 20 points above are reasons for optimism for telecare organisations, distributors and service providers, but aren’t really predictions for winners and losers, and for major changes in the way that the health and social care systems operate.

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I continue with some predictions on how things will change over the next 10 years and how they will affect existing players unless they are already thinking how they need to change.

Continuous Monitoring of Activities for Exceptions

QuietCare and Just Checking have shown for over a decade how the use of simple movement detection and door status monitoring can be used in profiling an individual’s lifestyle, especially when they live alone. The 2nd generation telecare services that use this information can be used for assessment purposes or for detecting changes in routine behaviour that can indicate an emerging problem often before there is an accident or a decline in any of the vital signs.

New systems look at the use of electrical appliances (such as kettle or a microwave oven) while others can produce a dashboard of activities based on the monitoring of the bed, the fridge, motion and medication holder or dispenser.

The power of this form of monitoring is slowly being recognised. I predict that the evidence for the success of such systems will become overwhelming, especially when professionals learn which system is best suited to particular people and circumstances, encouraging their use in all sorts of care scenarios from hospital discharge through to the distant care of an independent relative.

Most exceptions will be due to relatively minor incidents, including occasions when someone has forgotten to let people know that they are going to be away for a few days. The response shouldn’t be the emergency services, nor any telecare team, because their time will need to be reserved for more significant events. It’s an ideal opportunity to use family members or, if there isn’t anyone close by, a volunteer force composed of people who want to give something back to society.

Monitoring Vital Signs

One of the problems with existing medical telecare models is that it involves the patient staying at home to ‘plug themselves into’ a complex system once or twice a day, and following a measurement programme that might involve answering some subjective questions and, perhaps, a scheduled conversation (using video and/or audio).

This is inconvenient and works against the idea that going out, exercising and meeting people is good for well-being and general health. It also perpetuates the idea that the measurement of a small number of vital signs (including blood pressure) at a single instance in time really is the best way to monitor a patient’s status.

Tomorrow’s technologies, which will include tricorders, smart ingestibles (pills), smart implanted devices, smart clothing, smart bedclothes, smart plasters, smart tattoos and body piercings, and a whole range of wearables from hats to shorts and armbands, will provide the means to measure more parameters and continuously. This will avoiding ‘white coat’ issues and, through more sophisticated analytics, and secure telecommunication, will allow the combination of multiple results to provide real-time dashboards of health. These will be supplemented by blood-based point of care testing which will offer further information to the remote physician to include in the monitoring profile. Indeed, new techniques will avoid the need for a blood sample to monitor blood glucose levels and INR. They will use apps, and the latest smart phone technologies to provide the interfacing, the processing and the communication with the remote care professionals.

Extended Use of Text Messaging

The use of SMS for communication was an unexpected bonus for the mobile telecoms companies. Its role in improving healthcare has been proved both in the developed world and in Africa where it provides the only robust way of sending information between distant centres.

Every mobile phone has SMS capability even if it doesn’t have a camera and the intelligence of a smart phone. Phones that have large buttons and large displays are available so that they can be used by nearly all potential users. The cost of sending and receiving texts has also been falling as ‘text bundles’ become available on a Pay As You Go basis.

SMS is being used already by dentists, hairdressers and many hospitals to provide reminders about appointments and this is leading to fewer ‘no shows’. An extension into other areas of health and well-being must be inevitable, and mobiles could therefore become the platform for messaging and coaching that are likely to lead to more innovative (and lower cost) telecare applications.

There is already evidence of SMS being used to reach otherwise inaccessible groups including BME populations enabling health inequalities to be reduced through an extended reach. Similarly, there are published improvements in smoking cessation, diabetes self-management, and asthma control – perhaps warning people about poor air quality, the threat of weather extremes and the need for additional hydration.

Reminders can be used for medication and therapy, and short sharp messages may be ideal for promoting behaviour change using nudge theory principles. It is one of the most personal, and intimate channels, to provide personalised behaviour change information with the potential of engaging people with chronic conditions and interacting with them in such a way that the impact can be monitored.

Perhaps the most impressive existing application is Florence (Flo for short), the SMS system which has rolled out from the NHS in Stoke and which is now being deployed (as Annie) by the Veterans Association in the USA [Veterans Health Administration–Ed.]. The Flo community shares clinical pathways enabling the system to be employed successfully to support many different conditions. Advances and variations of Flo may become ubiquitous for managing long term conditions, public health and in managing many social care issues.

Who do we trust to run our new telecare services?

The telecare services of the future cannot appear to be rocket science.

To survive they will need to be transparent, simple to implement, simple to use and simple for users to understand what is involved. They will not need to be mysterious in any way and will not demand the support of a team of IT professionals – but they will need to offered in such a way that it is clear and obvious what to do when something does goes wrong. There is no reason why they can’t be operated, and the results viewed and interpreted by existing health and social care professionals – nurses and care managers rather than (or as well as) doctors and IT systems administrators.

There will, of course, be quality assurance issues to address but not in ways based on call centre metrics. They can be installed by the teams who currently deliver social care, housing maintenance, community equipment or any of the other handyman services that people need to continue to live independently.

The big change may be in who looks after OUR data and who can then look at this information. Security will be paramount but so will be the nature of the organisation which controls the particular ‘clouds’ in which they reside. They need to be trusted, and that means having a reputation that is not driven primarily by a need to satisfy the bottom line, the shareholders or other external stakeholders. Patients, and their families, need to be convinced that the guardians of their personal health data are not going to rip them off, leak their details to a life insurance company, nor give the heads up to another organisation who can try to cross-sell other lifestyle products.

Unfortunately, there are few types of organisations that have not crossed the line in recent years in the ways that they deal with their customers.

Is there anyone who has not disputed their mobile phone (or fixed line) bill? Is there anyone who suspects that they have been overcharged by a gas or electricity supplier? Do technology companies only think about taking your money and making it simpler to buy their products with their own ‘banks’ (such as iTunes) some of which have such poor security features that they almost encourage identity fraud. I wont bother considering the reputations of estate agents, politicians, insurance companies, PPI claim lawyers or conventional banks.

So who is left? I suspect that most people trust the good old NHS, their local authority, housing associations, charities (and some not-for-profit organisations), as well as those who already take charge of our data whether in national databases (CSC, Orion etc) or in GP record systems (TPP and EMIS, for example). Perhaps organisations will have to be clear about who they are, who their directors are, and what they will and wont do with our data in order to gain the confidence of the public and of commissioners. Brand will always be important.

Digital Prescriptions and Procurement

People, their advocates, and their health and social care professionals will benefit from improved decision support tools that help them to interpret ambitions, preferences and the solutions to address the issues that prevent them achieving their ambitions and preferred outcomes. These will necessarily include assistive devices and a range of tools that make tasks simpler or safer, or which help to address the many minor disabilities that come with age.

To avoid exploitation, and the likelihood that many people will choose products that may look and sound cool, but which don’t actually address their needs, there will need to be much greater clarity when describing digital healthcare and electronic aids to daily living.

Many new products, which are not medical devices, may offer useful information concerning physical or mental health, or they might indicate a change in some measure of well-being. More of these devices (as well as hundreds of apps) will be approved by the appropriate official bodies, giving people a means of using their own platform devices (such as smart phones, tablet devices and wearables) bringing to an end the significance of old fashioned stethoscopes, sphygmomanometers and peak flow meters.

Replacement devices covering the widest possible range of sensors and actuators will be smaller, better looking and with little resemblance to today’s industrial designs.

They may be available from web retailers such as Amazon but need to be offered with lots of warnings about interoperability, the need for specialist installation and a responder service. It follows that comparison websites (such as the Vivo Guide) will be important in helping the public to find the best device solutions for assisted living but also in promoting the service elements that will ensure that they actually work properly, so that the utilisation remains excellent along with the outcomes. There will be a significant role for independent advice, and for ensuring that professionals have access to impartial advice and evidence of device success.

The Reliability of Mobile

Many younger people, especially those who are not home owners, have given up their landlines in favour of smart phones with 3G or 4G connection capability that can deliver them Internet and video connections away from their homes.

As SIM options improve, and the limitations of single networks become familiar, new solutions not only give a reliable form of data communication that can be used for most telecare applications, but also give the line checking capability that has previously been available only in the security industry. It follows that fixed line telecare services will come under increasing pressure from mobile equivalents. Smart sensors will have their own data SIM enabling them to be programmed and reprogrammed remotely on a device by device basis.

It follows that the market will move steadily in the direction of mobile devices for those people who are not house-bound and who live in areas where there is a strong and reliable mobile signal from at least one of the major networks.

Mobile telecare is already essential to many applications including GPS where the location of vulnerable individuals may be needed because they may lack spatial awareness. In the same way, those who are at risk of convulsive seizures and other medical emergencies need to detect problems on the move as well as at home. People who have a fear of falling may also be persuaded to go out and exercise if supported by mobile telecare in the form of a pendant or portable alarm with GPS as well as impact (fall) detection.

Several devices will integrate through a mobile hub to offer more complete telecare solutions, and with battery capacities increasing, and opportunities for charging wirelessly or through converting movement into power, will be able to operate continuously for weeks at a time.

Increased Role of Video Communication

A combination of improved communication bandwidths available both at home (through ADSL) and on the move (through increasing availability of 4G services) have made video calls a reality, and with it a practical implementation of 3rd generation telecare. This must mean more telecare services offering video communication, with many transforming monitoring centre call handlers into video call assistants, making calls more personal and helping lonely people to engage more effectively with their support workers.

The opportunities are enormous including video tele-concierge options in the community where a monitoring centre can answer the door bell and provide remote admission to healthcare workers including district nurses, paramedics and domiciliary carers, but also to visitors for whom they can provide security checks. Opportunities for relieving loneliness and social isolation may be numerous.

We are already seeing people who have tablet devices or laptops use Skype (or other video messaging apps including Facetime) to add video to their free phone calls – and the idea of keeping in touch with relative and friends in distant lands is attractive across the generations. Using this technology for virtual visits to a primary care centre will be attractive to older people, and to anyone with a physical disability, or an injury (or wound) that affects their mobility, or who is ill and who might pass on their disease by travelling on public transport or by appearing in person at the medical centre.

In practice, these systems may lack some of the security requirements for medical consultation, they might also require extra clinician time to ensure that the lighting levels are right, and they might also fail to provide a context for a diagnostic interview or for review of symptoms. For example, an older person who is unsure of the technology might ask a neighbour in to check on the set-up, and who might still be present when the clinician begins to talk about very private or personal factors. Indeed, for a meaningful appointment, the clinician may require a close-up of a part of the body. They might also find use in confirming fall events and in ensuring that people’s medication adherence improves.

I predict that video monitoring centre call handlers could become the human in the loop, making sure that everything is in place before committing the valuable time of the clinician.

This arrangement will require multiple cameras or cameras that can be operated remotely to zoom, pan and tilt enabling the nurse or physician to see their preferred view. These would work very well with dedicated set-top boxes that can allow those who have no computer (or who don’t fancy using a computer) the opportunity to use their own (probably large screen) television with a special handset.

The same technologies could be used by fire fighters, police and paramedics (plus other community groups) to triage emergencies in the field. Similarly, they will allow properties to be surveyed as part of a risk assessment, and then used to protect vulnerable people from antisocial groups who might be gathering outside their homes.

Social Robots

Exoskeletons will have a profound impact on the mobility of people who have hip, or knee problems, or who have lost muscle strength, or who have osteoarthritis. They will quickly compete with old technologies such as stair lifts and will empower people to break out of their own homes and to regain their independence.

They are not telecare, but perhaps key components of robotic devices that will enable people to remain in their own homes supported by a new form of assistive technology which will have local intelligence and a connection to the outside world both through the Internet, and through more dedicated communication channels to a monitoring centre.

These social robotic assistants will have clear functions of support, helping people with particular deficits to remain in control whilst managing the risks of sudden problems by providing alarms and summoning appropriate help. They will be watch-dog robots that provide mobile security and devices that help people to perform intimate tasks including dressing and undressing, bathing and toileting.

An existing group of social robots on wheels provide teleconference capability. They can follow the individual around the house, offering reminders and advice as appropriate.

It remains to be seen if this version of mobile Internet will be more attractive to having a screen (with cameras and Internet access) in every room either as the ubiquitous TV or embedded in items of furniture such as the bathroom or lounge mirror.

They could be linked to the bathroom scales and to other appliances in the home, as smart homes finally come of age thanks to the Internet of Things and universal connectivity. Maybe not traditional telecare, but with some poetic licence, and a ten year forward view, something that could well be included within the general term telecare.

Will any of these services be called telecare in 2025?

I would like to think so; it’s taken at least 10 years for the public (and many professionals) to understand what is meant by telecare – it would take another 10 years to get used to a new term.

So let’s keep telecare.

Maybe we can abbreviate it to TeleC where the C could stand for Care, but it could equally stand for Community, for Condition Management, for Change (in the context of behaviour) for Connected, or for Comfort.

Hopefully, all Telecare Aware readers will still be around in 2025 and able to watch me eat my words!

Dr Kevin Doughty is the Director of the Centre for Usable Home Technologies and also the Director of Smart Systems for WHATcare Solutions, the technology trading arm of the Carers Trust.