At a Computer Weekly roundtable debate, in association with Vodafone, healthcare and IT professionals discussed the future of telehealth, the challenges it faces and what must happen to broaden its adoption. Lisa Kelly reports
The benefits of telehealth are widely recognised by patients and medical professionals alike. Patients undergoing long-term treatment can receive medication at home, improving their quality of life and reducing their need to travel, while the technology frees up time and hospital resources for the medical profession. But despite these advantages and the maturity of the technology, telehealth is not as widespread as might be expected.
At a recent Computer Weekly roundtable debate, in association with Vodafone, healthcare and IT professionals discussed the future of telehealth, the challenges it faces and what must happen to broaden its adoption.
Amanda Woodall, a specialist nurse at Greater Manchester Neuroscience Centre, uses telehealth to provide a choice for patients as part of a pilot scheme run by Baxter Healthcare and Vodafone (see box below). "We are dipping a toe in the water, but telehealth has a profound effect on patients' quality of life as it reduces travelling to and from the centre where they have six to eight hours of treatment," she said.
But Paul Rice, associate director of care partnerships and long-term conditions lead at the Yorkshire & Humber Health Innovation and Education Cluster (YHHIEC), questioned whether patients missed the comfort of face-to-face treatment, even if technology enables the same care principles to be delivered.
Woodall acknowledged that patients worry that moving from intensive care to high dependency is a step down as "they are used to a high level of monitoring", but she said although telehealth will not suit everyone, many patients recognise the benefits of receiving treatment at home instead of going to hospital.
Both patients and clinicians believe that responsibility for treatment needs to be clearly determined.
"It should be a joint process with the patient," said Robert Johnstone, a trustee for patient group National Voices. "This is the future for healthcare, but it needs participating patients who are often in a better position to analyse and make decisions about their own healthcare, and there needs to be a change in culture so there is the opportunity to move in this direction with everyone working together."
Drivers for change
The complexity of the NHS makes it difficult to have a widespread driver for introducing telehealth across the UK, so pilots such as that by Baxter/Vodafone are important in proving the financial benefits.
"Telehealth saves one hospital day per month per patient, or 12 per year," Woodall said.
Even where it is difficult to measure return on investment, there are many benefits. "Self-care isn't no care," said Yvonne Bennett, secretary of the patient participation group at Haughton Thornley Medical Centre. "We will never get it 100% right, but if we get 80% treated at home through telehealth, then the 20% who it is not appropriate for can have more time dedicated to them."
Patients can be offered a choice, and every telehealth patient helps the clinical environment, said Woodall. "Following initial training, time is saved for clinicians. We also get the appropriate patients in the beds," she said.
Barriers to adoption
Paul Shannon, consultant anaesthetist at Doncaster & Bassetlaw Hospitals NHS Foundation Trust, said pilots in telehealth are successful, but they rarely expand out to a bigger scale. "It can take seven to 10 years to see the socio-economic benefit from telehealth, and most finance directors want to see a benefit in 18 months," he said.
Feng Li, chair of e-business development at Newcastle University Business School, said there needs to be more discussion on how successful pilots can be scaled up and taken to market.
"Questions about whether the private sector can make money are not being asked. Where will the money come from and who will pay for what and when? If we don't answer these questions, we will still be talking about pilot projects a few years down the line," he said.
Alison Mlot, collaboration manager at Alvolution and Medilink West Midlands, and a representative of the Healthcare Technologies and Medicine Knowledge Transfer Network, said large-scale success will not happen until the integration between health, social and primary care improves because "the area that needs to make the investment might not make the savings".
Rice said there is an issue around allocation of benefits, but that does not mean people are not experimenting. "More and more service models are becoming better understood, but turning that into a cost benefit is difficult," he said.
Johnstone said patients may drive the change, as "more and more budget is coming down to patients and potentially they will have an income to participate in the process".
Patient data security
Steve Lane, UK head of homecare at Baxter Healthcare, worked on the telehealth pilot project at Greater Manchester Neuroscience Centre. He said the trial took into account data security, where patients log in using a unique ID so their information stays secure and goes straight to a specialised nurse to monitor dosage.
"The barrier perceived initially was in not monitoring patients in case the condition dips or improves, but it is possible to monitor within a secure environment. There is a consent form that patients sign surrounding monitoring and data ethics," he said.
Janet Burton from Baxter Healthcare, who also worked on the pilot, emphasised that information was not shared with anyone beyond the consultant and nurse who would have had that information anyway. "The information shared is the same; the speed in sharing it is the difference," she said.
Mlot said the sharing of patient data is a much-discussed issue. "The simplistic mind says it is great to share data to see the whole picture, but how far can you cross boundaries to truly integrate care? The next generation will have greater expectations about the efficient sharing of information," she said.
Donna Roberts, relationship manager at North Mersey Health Informatics Service, said patient consent is fundamental in the process of information sharing. "Consent at the beginning of any data sharing needs to be clear or you will hit hurdles," she said.
What needs to be done for telehealth expansion
YHHIEC's Rice said sharing of information needs to improve. "One thing the NHS doesn't do well is share learning with peers. It is about time for us to push this," he said.
Rice added there is no single answer to making telehealth more widely used and there needs to be careful thought about the technology and a change in the balance of power between patient and clinician, but it is important not to set the bar too high. He warned there is a danger in making "lots of short-term stabs at telehealth", which make it difficult to show how wider benefits can be achieved.
Shannon of Doncaster & Bassetlaw Trust said the impetus has to come from the medical profession: "We have antibodies against politicians telling us what to do."
A demand-led solution is most likely to be successful - and solutions that integrate easily with everyday life will win.
"Patients need to be aware of the possibility and knock on doors and push, push, push. It is an education process," said National Voices' Johnstone. "Make telehealth as inclusive as possible and don't design a new bit of kit which is specific and excludes us from mainstream society. Design solutions that work on existing kit, such as mobile technology which is intuitive and easy to use."
Telehealth equipment needs to reflect modern technology - for example, don't rely on using phone lines, because lots of people only have a mobile. "There is no need for old-fashioned 1970s boxes when we can use existing technology such as iPads and mobile phones," said Drew Provan, senior lecturer in haematology at Barts and the London NHS Trust.
A shift in attitudes is needed too. Rice said that many medical professionals still believe they cannot make a decision unless they can "see you, smell you, and touch you".
Burton said teaching patients is key, but it demands an upfront time investment. "To succeed, telehealth requires one-to-one nursing time. While working as a clinical nurse specialist at the John Radcliffe hospital, we found that of the 150 patients on homecare only two chose to come back, but significant one-to-one nursing time had to be invested," she said.
Vodafone's head of healthcare marketing Nicola McLaughlin said: "We are not sure what the mobile technology should look like, but it is important we develop the solutions together, in conjunction with NHS trusts. Patient choice and a bottom-up approach are driving how the trusts have to change."
Case study: Telehealth on trial at Greater Manchester Neuroscience Centre
Baxter Healthcare has been working with Vodafone to provide a patient-reported treatment outcome system for users of its intravenous immunoglobulin (IVIG) treatments.
"We support highly complex patients and have a long history of doing homecare. Telehealth helps keep patients out of a hospital setting," said Steve Lane, UK head of homecare at Baxter Healthcare.
He added that patients requiring such treatment can spend 20% of their lives on an infusion chair, so the telehealth pilot was directed at improving their comfort by treating them at home, while simultaneously satisfying clinicians that the disease was being properly treated and monitored.
"This is a catastrophic disease if it is not well managed and the question I posed was, 'Can we give a monitoring device to get people home?'. That was our starting point, which led to us piloting HTC smartphones with Vodafone," said Lane.
Vodafone provides a managed service based on a mobile web-based patient diary which allows patients to complete questionnaires about their treatment on a mobile phone with results feeding into a secure online database accessed by clinicians.
Lane said the pilot worked on three levels: providing an ongoing assessment of the disease so that patients and clinical nurse specialists were reassured about the monitoring process; asking essential questions before infusion as a safety check; and identifying what products were used in the batch numbers to provide clinical governance and peace of mind.
"The technology gave us unexpected further benefits. It not only allowed patients to be treated at home, but it also delivered improvements around clinical governance and management," he said.
The pilot has received positive feedback from patients and has proved itself to be economically viable.
"Telehealth can be about a box of something that sits in someone's home and costs a lot to set up, but the HTC mobile solution is based on HTML so people can easily log on and it has minimum impact. The pilot has not been running that long, but we are so confident that we will launch in the autumn," said Lane.
The risk of losing paper-based diaries has been removed by completing diaries electronically, and there are huge gains in cutting bureaucracy.
"There is a national immunoglobulin database as it is valuable and it is necessary to know who has what and where it is going. The technology will benefit pharmacists as it will streamline data capture," said Lane.
As telehealth rolls into more therapies, its benefits will increase.
"The upfront investment has already been made by the telecoms companies, so cost is not a barrier and over time more and more applications will be developed," said Lane.
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