As Prof Mike Short pointed out recently, 2016 is the tenth anniversary of the start of the Whole System Demonstrator (WSD) programme that in retrospect, because of poor trial design, probably slowed the uptake of digital health in the UK more than any other single action. It seems appropriate therefore to look at how telehealth* has fared over that period, and perhaps even more importantly, is poised for the next ten years.
The mistakes of the WSD are well documented (eg here, here & here) – suffice it to say that it proved beyond all reasonable doubt, at least to this editor, that unlike medicine-based interventions, which seem less sensitive to their care pathway, digital health delivers most of its benefit through enabling a different, patient-centred care delivery, so every digital health intervention needs to be evaluated holistically, and in its own care pathway. Sadly over the ten years, much of the academic work looking at the benefits of telehealth has continued to evaluate the technology in the time-honoured way that medicines have been evaluated, with predictably largely equivocal results.
Those of us who have delivered telehealth projects though have a sense of disconnect as, time and again, a focused implementation – not a pilot – in which the staff delivering the service understand that it will be a permanent change for which they need radically to change the way they deliver care, yields huge returns on investments through savings typically in the 50-90% region. We are biased though – finding a way of evaluating these benefits objectively is a challenge that largely remains for the academic community. This TechCrunch article on How the Digital Health Revolution will become a reality offers one pointer to the challenge “The second piece to unlocking the digital health potential is the recognition and development of new care settings. Think about care everywhere, not just in the hospital.” (This evaluation dilemma is well expressed in the King’s Fund’s excellent 1st January review of health technologies which concludes: “Ask too much or give too few opportunities for real-world testing and we risk protecting an outdated status quo. Ask too little and we risk spending public money on something ineffective.”)
So, apart from this editor, who thinks that telehealth is beneficial then? One pointer is the various US-based insurance companies now seeing it as a way of motivating healthier lifestyles, reducing costs and improving patient outcomes. In the UK, we reported on the involvement of AXA, BUPA and Aviva last May. Clearly they see the financial benefits.
Perhaps another pointer is the vested interests now seeking to stop telehealth – nothing is feared more than the truth, and the way for example the Texas Medical Board is seeking to water down telehealth services suggests that some clinicians are beginning to rate the potential harm that telehealth will do to their practices, bypassing no-longer-necessary (chargeable) physical appointments, to be serious.
Patients have twigged the benefits too – a recent Aviva survey that we reported on before Christmas for example showed 47% of UK patients would be happy to see their doctor virtually via telehealth visits rather than face-to-face, and more than two thirds (67%) of UK adults agree they would be happy for a long-term medical condition (such as diabetes or heart disease) to be managed through remote patient monitoring. Last October the Telegraph carried an article claiming half of all UK adults now use a gadget or some form of technology to manage their health, with a third of over 65s doing the same.
PwC’s Primary care in the New Health Economy: Time for a makeover report’s top conclusion is that “Consumers no longer require face time with their physicians; 60 percent said they would be willing to try a virtual doctor’s visit.” The growing attractiveness is underlined by a Berg Insights report in December that “The number of remotely monitored patients grew by 51 percent to 4.9 million in 2015”. Frost & Sullivan’s recent report suggests continued growth of 13.2% pa in the US through 2020. EU plans are to spend 954 million on eHealth (an EC category that primarily telehealth & mHealth) in 2014-2020. A December JAMA Surgery paper reporting on post-operative US Veterans showed that 69% preferred the telehealth follow-ups to in-person follow-ups.
A different take, emphasising the importance of good communication, resulted in the astonishing claim by Daniel Mongiardo, MD, former Lieutenant Governor of Kentucky and Physician at Lifecore Recovery, specifically regarding uninsured US residents that “in one year, we were able to reduce the cost of healthcare by over 80 percent, reduce hospitalizations by 92 percent, and emergency room visits by 87 percent by communicating.” The mHealth Intelligence article attempts to link this with app usage, although the year referred to seems to be 2000. Nevertheless, there is an important point here as telehealth vastly improves clinician:patient communication.
Another interesting aspect of telehealth is that it has now broken free from the original perception of being best for monitoring major long term conditions like COPD & CHF to having many uses including treating some conditions. A recent paper in the journal Telemedicine and e-Health for example concludes that telemedicine is a clinically and cost-effective method for treating mental health issues. This is supported by a GP article quoting a US systematic review of 11 randomised controlled trials encompassing 1,500 patients which concluded that there was ‘no difference’ in the benefits and harms of second generation antidepressants over CBT for patients with major depressive disorder. As diseases such as cancer transition to long term conditions, telehealth is embracing these too. (For a more lighthearted approach to recent tech innovations, see the EIU’s The Future is Here.)
And there’s no shortage of guides to how to do the job properly either, such as the EU’s ACT project’s ‘cookbook’. There’s even a new telehealth organisation in the UK to help, too: the Telehealth Quality Group (TQG).
Across the world, health costs are a major concern, emphasised by an EIU global health report saying that 39% of respondents to their recent survey said the cost of healthcare in their country was the most pressing healthcare challenge they faced, so MedCityNews’ video clip of Frost & Sullivan’s Nancy Fabrozzi in discussion with Neil Versel is particularly apposite; she suggests the concept of ‘patient enragement’ at rising face:face medical costs which will drive the use of automation in the profession…which brings us on to a key area that will influence the future.
The same Frost & Sullivan’s report quoted above also mentions that “Providers who offer data filters and analytics to support the use of RPM systems are likely to thrive” A recent conversation with the CEO of a US-based provider of data analytics revealed a (yet to be published) 30% improvement in the ability of telehealth to reduce unplanned hospital admissions through effective use of analytics, resulting in the ability to predict CHF exacerbations up to seven days before they happen. There can be little doubt that the development of sophisticated algorithms will hugely improve both patient outcomes and the profitability of telehealth implementations, as well as removing a major concern of the medical community at the manpower needed manually to review vital signs data.
The increasing sophistication with which telehealth is used to change behaviour is an area that will continue to generate benefits as we reported earlier.
Worth a just brief mention too because we have also covered it previously is the huge reduction in the cost of hardware and the increasing migration of vital signs sensors into standard smartphones & watches, the classic example being Leman Micro’s chip (which Chris Elliott will be demonstrating in a smartphone at the RSM’s Recent Developments in Digital Health event on February 25th.)
Another pointer is this interview with Keith Longtin, General Manager of Wind Product, GE which suggests one way that people’s health may be managed in the future. The sheer number of variables monitored in the average wind turbine, and the number of turbines being monitored suggests that if we want to instrument humans (and why stop there, pets too), the task is clearly very possible. Of course there’s a long way to go before our healthcare system is as connected as the diagrams in Keith’s video, a point well made by this video of the (US) healthcare system…sponsored by Philips who coincidentally were chosen by this editor’s team when bidding for the WSD for Newham in 2006.
Hat tips to Prof Mike Short in particular, Dr Nicholas Robinson & Dee O’Sullivan.
*One trend is immediately evident to anyone reading recent reports: that telehealth is currently taking over the concept of telemedicine too – and indeed the delineation of the two between synchronous & asynchronous treatment is becoming increasingly blurred so, for this article at least, the term telehealth covers both.