Telemedicine: a revolution in care?

The Department of Health (DH) believes that at least three million people with long-term conditions and/or social care needs could benefit from the use of telehealth and telecare services. Implemented effectively as part of a whole system redesign of care, the Government claims that telehealth and telecare can alleviate pressure on long-term NHS costs and improve people’s quality of life through better self-care in the home setting. On 19 January 2012, Paul Burstow, the Minister for Care Services at the time, committed to working with industry, to support the NHS, social care and professional partners in the 3millionlives project, in order to achieve this level of change. A Concordat supporting this commitment was also published.1 The Government’s support for telehealth and telecare was partly fuelled by the initial results of the Whole System Demonstrator (WSD) programme – a large scale randomised control trial which was launched in May 2008, targeting patients with long term conditions such as diabetes, chronic obstructive pulmonary disease (COPD) and heart failure (Telehealth solutions were supplied by Tunstall in Cornwall, Viterion in Kent and Philips in Newham). The ‘headline’ results, first published in December 2011, showed that – if used correctly – telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs. More strikingly, they also demonstrated a 45% reduction in mortality rates.2 At the International Congress on Telehealth and Telecare 2012 (organised by The King’s Fund and the University Medical Center Utrecht), Paul Burstow commented that one of the barriers to uptake of telehealth has been a failure to ‘join up primary and secondary care’ and ‘a lack of patient awareness of the benefits that integrating technology into their care packages can offer’.3 “The WSD project showed that shared decision-making, good, robust care planning, and the use of monitoring technologies, give people back their lives. One patient speaking at the conference described how he had gone from spending 10 months in hospital per year to just 10 weeks, which has transformed his quality of life.” It is a way of revolutionising healthcare, making it more personalised and more joined up,” he said, adding that there is an opportunity to grow the market for telehealth in the UK: “The NHS should be looking at the evidence and engaging with the telehealth industry to support them in redesigning care pathways to help roll out this technology and lower the cost of its introduction. If clinicians and GPs do not buy into this approach, they will be condemning millions of people to lives that are built around the needs of the NHS – with patients constantly going in and out of hospital and in some cases living shorter lives.”3 Senior fellow at The King’s Fund, Nick Goodwin, commented: “I believe that, in three to five years, we will wonder why investment in telehealth was ever an issue in the past. It is definitely the future. “The problem with short-termism in relation to budgets, when finances are under pressure, is that initiatives like telehealth and the integration of health and social care tend to fall away as key priorities... However, we are not going to reach a more sustainable, more costeffective health and social care system until we invest in new technologies or approaches that keep people out of expensive facilities such as hospitals or long-term residential care homes. “We need to re-engineer the system so that people are more able to stay at home, where they feel safe and secure. In the long term this will be a much more sustainable proposition. If we do not make the investment now, it is the future costs that we are building up that we won’t be able to meet.”3

 Cost benefits or cost prohibitive?

There is growing support for telehealth from the Government, clinicians and patients. However, further investigation of how to release potential cost-benefits may be called for, in order to aid its wider adoption. A follow-up paper to the initial WSD headline findings was published in The British Medical Journal (21 June 2012),4 which reiterated the positive conclusions that telehealth can reduce deaths and emergency hospital care. However, it added a note of caution that the estimated scale of hospital cost savings ‘may not be sufficient to offset the cost of the technology’. The paper stated that, during the study period, significantly fewer (43%) of intervention patients were admitted to hospital compared with 48% of control patients. Significantly fewer (4.6%) intervention patients died compared with 8.3% of controls. This equates to about 60 lives over a 12 month period. There were also statistically significant differences in the mean number of emergency hospital admissions per head (0.54 for intervention patients compared with 0.68 for controls) and the mean hospital stay per head (4.87 days for intervention patients compared with 5.68 days for controls), although the authors said these findings should be interpreted with caution. These differences remained significant after adjusting for several factors that could have influenced the results. However, the authors pointed out that these effects appear to be linked with short-term increases in hospital use among control patients, the reasons for which are not clear. They also said that the estimated cost savings are ‘modest’. The results suggest that telehealth reduces mortality and helps patients avoid the need for emergency hospital care, the authors concluded. This may be because telehealth helps patients better manage their conditions and avoid a worsening of symptoms that may need emergency care. Other possibilities are that telehealth changes people’s perception of when they need to seek additional support. However, they stressed that these benefits need to be balanced against the cost of the technology itself and the level of savings that can be achieved. In an accompanying editorial, Josip Car, director of the Global eHealth Unit at Imperial College London, and colleagues, commented that this latest evidence ‘does not warrant full scale roll-out, but more careful exploration’. Although factors that might be important for successful telehealth can be described, they added: “We need more clarity on how to interpret the relative contributions of these elements.” They suggested that policy makers, commissioners, and guideline developers should help ensure that the research agenda focuses on areas where telehealth shows most promise. “There is great potential but also still much to be done,” the authors concluded. According to Ileana Welte, UK divisional director at Bosch Healthcare, which currently participates in one of the largest telehealth programmes in the world, the findings of the WSD report published in BMJ are ‘encouraging’ and should drive increased adoption of telehealth and telecare. She said: “While this is a breakthrough study for telehealth in the UK, there are several mitigating factors that do need to be considered with regard to cost savings findings. For example, telehealth devices and monitoring solutions varied among the study sites. These differences could lead to significant variations in implementation and operations cost which could impact cost savings data. We expect that the next release of findings will address these variances and how they impacted cost data. “In addition, our experience with similar populations also shows that optimal impact of a telehealth programme is observed between 18 months and two years – while this study looked at follow up time of only one year. “The overall findings are positive and it is now important that the full results are published as quickly as possible to provide Government, health professionals, industry and, most importantly, patients with conclusive proof that telehealthenabled integrated care works, while delivering better patient outcomes at lower cost.” While the study highlights a need to further understand how the technology can be rolled out most cost-effectively, there are a variety of other studies which claim to highlight the benefits of telehealth and identify cost savings. In more than 30 international studies, including several in the UK, Bosch Healthcare also claims to have provided evidence that telehealth enabled integrated care produces significant cost savings in addition to quality and clinical improvement. A list of some of these studies can be found at: www.boschtelehealth. co.uk One such study, conducted in the US by Baker et al, from Stanford University, found significant savings among patients who used the ‘Health Buddy’ telehealth programme, which was associated with spending reductions of approximately 7.7%-13.3% ($312-$542) per person per quarter. The authors said the results suggest that: “Carefully designed and implemented care management and telehealth programmes can help reduce healthcare spending” and “such programmes merit continued attention by Medicare”. In the UK, two Trusts (the Berkshire Healthcare NHS Foundation Trust and Heatherwood and Wexham Park Hospitals NHS Foundation Trust) have joined forces to introduce a telehealth system which is successfully reducing unplanned hospital admissions and is expected to save £1 million per year. The COPD service, which operates in east Berkshire, has undertaken a yearlong telehealth study as part of a new admission avoidance initiative, which was offered in addition to an existing early supported discharge service. The results of the study have shown that, on average, 25 admissions to hospital are avoided every month, saving approximately 1,800 bed days a year and equating to a financial saving of £900,000 in 12 months. (This is based on the mean average hospital length of stay of six days and the mean average cost of an admission for a COPD patient not requiring Non-Invasive Ventilation [NIV] or intubation of £3000.) The study also reported improved self-management among COPD patients who use the telehealth system. “Telehealth is helping to reduce the number of hospital admissions for our patients as it enables early reporting of symptoms which show a deterioration in their condition,” explained Joanne King, COPD advanced nurse practitioner. “We are also finding that our patients are becoming better educated about their condition because they have a regular reminder of the warning symptoms. As a result, they are more confident at selfmanaging their condition and are providing us with the right information much more quickly when we do call them.” Sixty-five patients enrolled on the study. The telehealth system calls the patients twice a week and asks them five questions set by the service about their respiratory symptoms. The patients then use the telephone keypad to answer questions and the information is sent back to the team at their base in King Edward VII Hospital in Windsor. On average five of the 65 calls result in an alert, of which only one or two require a home visit by a member of the team. The study records how many alerts are triggered, the number of contacts per patient following the alerts, the treatment that was initiated and the consequence of the episode i.e. admission avoided or admission to hospital. Prior to the introduction of the telehealth initiative in September 2011, 14 admissions were avoided on average each month. Over 12 months, the service prevented about 300 admissions to hospital, nearly double the total number of admissions avoided between October 2010 and September 2011. Pam Marriner, respiratory physiotherapist, added: “The telehealth system complements the admission avoidance service. It has been wellreceived by patients and has led to increased reporting and more effective use of specialist resources. The cost savings are significant when you consider the annual cost for the team is approximately £130,000.”