Meeting Report:
Telehealth – for better patient care
Report of the Meeting held on 8th November 2011 at Manchester Conference Centre, Days Hotel, Sackville Street, Manchester
Speaker:Dr Nicholas Robinson, Associate Clinical Director, Long Term Conditions & Telehealth, NHS Direct
Chair:Mr Phil Paterson, Publicity Officer.
Attendance: *, including the chair and speakers.
Abstract
Innovative Telehealth – Supporting new care pathways
NHS Direct has been pursuing a strategy of supporting larger scale Telehealth implementations, using specialised call centre staff carrying out technical triage and focusing on COPD and heart failure patients. Traditionally these services have been community and primary care based. However there are new agendas in the NHS – the need for hospitals to support discharged patients for 30 days will require new relationships and services to be developed. The focus on planned discharge allows new clinical pathways (for instance, chemotherapy patients) to be supported, providing both safer care (out of hospital) and freeing up NHS resources.
Dr Nicholas Robinson is a practising GP and has worked as an NHS GP for 30 years, involving himself in the development of GP computer systems and GP Out of Hours organisations. Within NHS Direct, Dr Robinson is responsible for developing and implementing new services for NHS Direct, supporting patients with long term health conditions in their homes, and helping to improve outcomes. He is involved in the Nottingham City OwnHealth® service and SE Essex Telemonitoring programme as well as the development of a range of innovative products to support remote care.
Presentation
As well as holding the post of Associate Director for Long term Conditions and Telehealth, Dr Nick Robinson continues to work as A GP two days a week, so is aware of the reality of conditions in the NHS. His talk set out to describe current developments in telehealth and telecare, and discuss the motivation for using these methods to help care for patients.
Telehealth simply means looking after patients remotely (from the Greek Tele, meaning at a distance). Dr Robinson posed the question of how long ago the audience thought telehealth might have been used: suggestions varied from a few years up to 20. Dr Robinson later revealed that the first known use of telehealth was described in the Lancet in 1879. A mother with access to one of the early telephones called her doctor to ask about her baby’s cough during the night. The doctor asked for the child to be brought to the phone, and was able to reassure the mother that the cough was not the croup. Instances of remote consultation occurred throughout the 20th century, leading to the emergence of nurse call centres in the 1970’s, and culminating in the UK with the setting up of NHS Direct and NHS Direct Online.
Telecare means monitoring of a person’s environment (for events like fire and flood), while telehealth means monitoring the health of the person (blood pressure, pulse rate, blood oxygen (PO2) etc.). There is another term, social telecare, which describes monitoring which combines elements of both of these; and also telemedicine, which means remote video. In practice, telecare and telehealth monitoring are carried out by different organisations, and the data collected by each is not shared.
The case for considering techniques like telehealth is driven firstly by the changing demographic profile of the population. It is no longer uncommon for a patient 100 years old to receive care from her children who are themselves 80 years old. Another factor associated with longer survival is the existence of complex long-term conditions like hypertension, Chronic Obstructive Pulmonary Disease (COPD), arthritis and mental health problems which together affect 30% of the population. A third factor is the reduced availability of health professionals, as both doctors and nurses take early retirement and are not recruited in sufficient numbers to fill the gap.
The so-called Kaiser-Permanente Triangle (or “Pyramid of Doom”) is a model for long-term care in which patients are grouped into three levels. Level three patients are the 5% with multiple and complex conditions and very limited mobility who need expensive treatment under case management. Level two patients are the 15% who are at high risk and suffer from diseases like COPD but who can be managed at home with substantial professional support. Level one patients are the remaining 80% who may be starting to suffer from problems like hypertension -these are potentially serious but can be managed by self-care with minimal professional support.
Outside of the triangle are those in the general population who are not yet ill. But it is very important to encourage them (by initiatives like the NHS Health Check Programme [1]) to follow a lifestyle which promotes health. This, along with regular health monitoring and early intervention should keep them out of the triangle as long as possible.
Long-term conditions are those that are progressive, incurable and need on-going care. They include arthritis, diabetes, heart failure and COPD; mental health problems and dementia; renal dialysis, cancer and HIV/AIDS; and certain other conditions accounting in total for 65% of deaths worldwide.
Patients, especially those suffering from these conditions, want to feel that they are safe and that someone will notice if they need help. They want information about their illness and the medication they are taking to control it. They now also expect to be able to contact NHS services at home or at work and at any time of day or night.
One way the NHS can improve the patient experience is to offer better pathways, e.g. to ensure continuity of care from hospital admission to discharge and care at home. 30-day support after discharge for planned admissions is now mandatory: this will be the case for all admissions from April 2012.
The need for long-term support in times where resources are limited opens up the possibility of using telehealth / telecare techniques. There is a good evidence base for using them to support chronic care management, involving patients in their own care, and supporting them by giving them the means to learn about and monitor their condition. Perhaps surprisingly, there is less evidence for case management, evidence-based care pathways and sharing data between organisations. The evidence comes from a number of sources but will be underpinnedby results from the King’s Fund Whole Systems Demonstrator Action Research Network[2].
Virtually unchanged in the last 20 years, telehealth monitoring equipment is able to monitor blood pressure, pulse rate, blood oxygen levels and temperature. Thus if a COPD patient has increased heart rate and temperature and reduced blood oxygen,a message can be sent electronically to a call centre for evaluation. The call centre may then refer the problem to nurses to handle, and the GP will later be informed that an intervention has taken place.
Currently 10,000 patients are being monitored by telehealth (far less than the 1.2 million under telecare): the focus is on congestive cardiac failure (CCF) and COPD. Some of the challenges to the success of the project so far are that it does not operate 24/7; patients with various disabilities are excluded; patients are only covered in the home; and clinical engagement has been limited.
Telehealth does seem to offer clear benefits to patients by helping them to stay healthy and to know more about their own illness. The data collected is potentially valuable for research, although the volume of data generated (e.g. by continuous PO2 monitoring) is challenging. Telecare has also proven its value, and could be even more useful if integrated with telehealth. But it will be necessary to convince both doctors and patients that telehealth offers focused services based on patient needs and is not just a cost-saving exercise.
Costs are a major issue. It is estimated that it costs £500 to call an ambulance, £25 for a patient to visit their GP, £20 to call NHS Direct, £10 to call the new 111 service (due to replace NHS Direct), £1 for a telehealth ‘consultation’, but only 13p for a purely digital assessment. This means that telehealth would be affordable for a condition like CCF which affects 1% of the population, but not for diabetes which affects 8%. There are practical issues about exactly how connectivity would be achieved, e.g. would it be through a mobile device or through a broadband hub? If the latter, would it be through an existing domestic hub, or would a separate one need to be installed?
Results from a questionnaire given by North Yorkshire PCT to patients in their telehealth project[3] were positive, with three quarters of patients saying that it gave them peace of mind and nearly two thirds saying there was nothing they disliked about it. Perhaps surprisingly, only 1% said they would prefer a nurse to visit.
Questions of consent and confidentiality will need to be addressed: where there is no face-to-face contact, ensuring the identity of the patient is a particular problem. But the rapid advances in ‘very personal computers’ (smart mobile phones) must make the idea of telehealth seem very attractive for the future.
Issues & Discussion
Members of the audience voiced concern that the routine use of telehealth might reduce the amount of personal contact between GP and patient and damage the relationship between the two parties. As a GP, Dr Robinson felt that the concept of the doctor providing personal care was a thing of the past. Only with the help of technology would the GP be able to provide more focused care for the patient. There might be a worry that the doctor would be swamped by all the additional data that is collected, but in fact it is filtered by the triage system and the GP is only alerted when necessary.
What can we learn from experience outside England? Telecare has been very successful in Scotland, although it must be remembered that the population is smaller (six million) and more scattered so conditions are somewhat different. Also in Japan much use has been made of robotics to help care for an ageing population. It will be a challenge to introduce telehealth on a large scale in Englandbecause funding will be limited and in the short term it will have to be run in parallel with existing systems.
Standards are likely to be another issue – four incompatible telecare systems are known to be in use though provided by a single supplier. It may be that standards will be imposed for telehealth in the same way that SNOMED CT is to become mandatory for health records.
Security was another concern, but Dr Robinson reassured audience members that the data collected in the home was not sensitive and could not in any case be related to the patient. Data collected via a mobile phone could be more vulnerable to attack.
So while we await the results from WSDAN with interest, it does seem very likely that many if not most of us will be able to evaluate telehealth on a personal basis at some time in the not too distant future.
END
[1]
[2] – see WSDAN
[3]
Rapporteur: Tom Sharpe.
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