Hat tip to Mike Clark for alerting this editor to a particularly important run of recent papers on digital health that suggests that we have at last turned the corner from the seemingly endless enquiries of the “does it work?” type, to asking instead “how can it be made best to work?”.
We’ll start with perhaps one of the most unequivocal papers on the benefits of telehealth this editor can remember – a review by a team from the Mayo Clinic of controlled trials between 1990 and 2014 of digital health for managing cardiovascular disease. It is entitled “Digital Health Interventions for the Prevention of Cardiovascular Disease: A Systematic Review and Meta-analysis”. The results found were that “digital health interventions significantly reduced CVD outcomes”. It makes great reading. Another smaller academic study of an NHS Croydon implementation for both CHF & COPD also showed positive results, and strong patient appeal specifically, too.
Another paper, just published by Stephen Agboola of Partners Healthcare, and colleagues from Boston US, entitled “Heart Failure Remote Monitoring: Evidence From the Retrospective Evaluation of a Real-World Remote Monitoring Program”, further supports the benefits of telehealth for managing CHF. However, benefits disappeared after the 120-day telehealth usage ended, as discussed by Jonah Comstock of mobihealthnews – important lessons to be learned there, relating perhaps to what follows in this post.
(Though not an academic study, it’s worth perhaps also recording en passant a Health Recovery Solutions (HRS) claim that they reduced the 30 day readmission rate for 130 congestive heart failure patients by 53%, from 8.0% to 3.8%, over a period from July 2014 to February 2015.)
Moving on then to a paper by Trisha Greenhalgh and colleagues entitled “What is quality in assisted living technology? The ARCHIE framework for effective telehealth and telecare services”. This paper concludes that many past telehealth implementations have not been optimised for effectiveness. In particular “Installed technologies were rarely fit for purpose. Support services for technologies made high (and sometimes oppressive) demands on users.” It proposes six principles for effective implementation concerning, that an implementation should be:
- ANCHORED in a shared understanding of what matters to the user;
- REALISTIC about the natural history of illness;
- CO-CREATIVE, evolving and adapting solutions with users;
- HUMAN, supported through interpersonal relationships and social networks;
- INTEGRATED, through attention to mutual awareness and knowledge sharing;
- EVALUATED to drive system learning.
…with the acronym ARCHIE, a name that those of us of a certain age into robots when young will remember fondly (although it has now also been subsumed by Wigan’s robot ambassador).
Directly related to this paper is one by Carl May, Professor of Healthcare Innovation in the faculty of Health Sciences, University of Southampton, entitled “Making sense of technology adoption in healthcare: meso-level considerations”, that looks at telecare. It frequently references the ARCHIE framework. For those without the time to read it, here are what this editor thought of as the three most important sections:
We need to consider how using ‘new technology’ to mediate between the needs of patients and their families may not compensate for the withdrawal of human relations in healthcare delivery, and how shifting burdens of workload and capacity in ‘technological’ care may mean the redistribution of work amongst patients, families, and wider social networks, possibly ending with them carrying burdens that they are not strong enough to bear.
Telecare systems do so much more than provide care. They form a vehicle by which assumptions about demands and eligibility for care, workforce structure, and organisation, shifting burdens of treatment and care, can be articulated and embedded in practice.
The ARCHIE framework brings a new set of ethical standards to understanding these. However, it is important, too, to consider the mesolevel dynamics that shape these processes. Ideas about demand, choices about services, expectations of patients, and requirements of healthcare workers all form a set of moral and political assumptions that are frequently left outside from debates regarding patient empowerment through new healthcare systems.
Finally also just published is a very important paper by Ivaylo Vassilev and colleagues primarily from the University of Southampton (plus Sheffield & Bristol) entitled “Assessing the implementability of telehealth interventions for self-management support: a realist review”. This has a slightly different take on the same issue to Trisha Greehalgh’s in that they identified three concepts which suggested how telehealth worked to engage and support health-related work.
- Relationships: whether or not and how a telehealth intervention enables or limits the possibility for relationships with professionals and/or peers. Telehealth has the potential to reshape and extend existing relationships, acting as a partial substitute for the role of health professionals.
- Fit: successful telehealth interventions are those that can be well integrated into everyday life and health care routines. They need to be easy to use, compatible with patients’ existing environment, skills, and capacity, and that do not significantly disrupt patients’ lives and routines.
- Visibility: visualisation of symptoms and feedback has the capacity to improve knowledge, motivation, and a sense of empowerment; engage network members; and reinforce positive behaviour change, prompts for action and surveillance.
As a long-time implementer of both telecare and telehealth, these contributions are great to read. Although no newbie presenter should ever leave out of their first presentation the picture from the cover of the April 1924 Radio News (“The Radio Doctor – maybe!”), or fail to mention that the first teleconsultation took place in the 1882, practical digital health in its entirety is actually a very recent phenomenon, so we have much to learn. These papers, moving from the “does it work?” to the “how to make it work best?” are a great contribution; they help us to face the diminishing band of sceptics with increased confidence.