Independent consultant cardiologist Dr Lance Forbat, whose work using telehealth monitoring Telecare Aware has reported a number of times, responds to the recent headline on the Mayo Clinic study that telehealth monitoring appeared to treble death rates and points out that in comparing monitoring people at home with and without telehealth monitoring they were not comparing like-for-like.
If I do a twice daily ward round on my patients and look at the physiological signs recorded by the nurse and take a history, possibly pick up on unnoticed issues that my years of experience detect, I would like to think I make an impact on the outcome of patients’ illnesses as well as their sense of well being…
If I am not there and the juniors are inexperienced, or the locum does not appear or is less experienced, and the nurses are concerned, I would expect them to ask for advice from another source. Particularly on out of hours times or on weekends when We know that morbidity and mortality is highest.
Now, with remote monitoring technology, I do a virtual ward round of my patients with similar problems to the hospital ones who are at home using telehealth. I get digitised data stored and relayed almost real time if desired, both pictorially and numerically. I have more than the ward round data in a robust format. I can set alerts. I can ask questions tailored to the individual. Should I stop this because a study compares apples with pears?
No, of course not. Using the appropriate technology and recording the relevant information tailored to the patient is going to lead at least to equivalent care and outcomes, but improved quality. The latter may be hard to measure but it is much easier to appreciate. It’s like comparing eating from a fast food outlet and home cooking!
Just as the mobile phone led to the smart phone on which I write this and much of my work now depends, telehealth monitoring will become the norm. We are now living in a consumer-led society and technology is here and must be harnessed. There may be some ‘luddites’ out there, but what care would you expect for your relatives? The wait and see approach is not the way forward.
The technology is giving us the opportunity to plan and redesign services. Yes, it may feel threatening at first. But most people have, and expect to be able to work, a remote control or programme the washing machine or dishwasher. Most have someone who can help if they cannot manage.
There needs to be better use of data already collected from services that have been shown to give value and to compare apples with apples.
Dr. Lance N. Forbat
As Dr Forbat has rightly pointed out the biggest issue with this study is its design. There is a big flaw in the design which renders it virtually worthless. First they’ve done block randomisation without explaining how they ensured that the standards of care in clinics involved were at the same level. No matter how similar Tesco stores are a customer can be treated differently by two different branches in the same town. There are many influential factors involved.
Secondly the providers and patients were not blinded while the assessors were made blinded! ridiculous! How possible! In the protocol they explain as an assumption that tele-monitoring can help! what if staff or providers had the same assumption and allocated all critically ill patients to the intervention group hoping a better outcome for them! Don’t practitioners always want the best outcome for their patients? Interestingly assessors met with the patients face-to-face while still were blinded! Probably they asked the patients: “please hide any telehealth equipment you have in case I see them! By the way, don’t speak about them either even if they bother you or make you uncomfortable etc!”
Steve has mentioned that the way they’re going about telehealth is worrying for the industry. He’s right! But I think there’s something bigger at stake here. Do really GPs use what Pulse presents as evidence to make clinical decisions? They come across extremely biased! If you’re presenting evidence it means you’re appraising it. The first thing an appraiser should look for is to find out if a study is tainted with bias. What if the appraiser is biased?!
Managing Director – Care Harmony Solutions
Also Post-graduate Student at the University of Oxford