Clinical issues in telehealth:Unit M2

Dr Paul RiceDavid Barrett

M2/1

• Conditions most well-suited for telehealth are;– Heart failure: 1M sufferers in the UK– Chronic Obstructive Pulmonary Disease (COPD):

900k diagnosed, actual figure may be closer to 3M

• Telehealth also used to support– Diabetes: 2.6M diagnosed in the UK, with figure

likely to rise to 4M by 2025– Hypertension: most common LTC, present in 7.5M

people in England

The challenge of long-term conditions

M2/2

Levels of LTC management

DH, 2012

The spectrum of remote care

Telecare TelehealthConvergenc

e

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Telecoaching in LTCs

• Remote provision of education, coaching, support and advice (usually via the telephone)

• Can be large-scale, population-wide;– Met Office ‘Healthy Outlook’– NHSD Twitter Feed

• Can be focused on specific individuals;– Pfizer OwnHealth– Barnsley telecoaching service

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• Represents the use of video conferencing to support delivery of care

• Main applications are;– Overcoming geographical barriers– Overcoming logistical challenges– Overcoming lack of ‘on-site’

specialist support

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Teleconsultation

What else is out there?• Teletriage – remote assessment and triage

(NHSD/NHS24 being the best example)• Telerehabilitation – remote support for

rehabilitation and recovery (e.g. Cardiac rehabilitation)

• Health kiosks – Open access, public health facilities, supporting lifestyle and behaviour change

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Telemonitoring models

Input Process Output

Not an emergency service

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Different triage models

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Centralised technical triage, localised clinical triage (below)

Centralised technical and clinical triage (above)

Why telemonitoring should work– Closer monitoring of vital signs and symptoms should

allow for earlier detection of deterioration– Earlier detection of deterioration should allow for earlier

intervention– Earlier intervention should improve outcomes and reduce

reliance on secondary care– Self-monitoring should improve patients’ knowledge and

ability to self-care– Provision of triage and feedback should reassure patients

and their carers– Better information about patient status should allow

practitioners to work more effectively

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Telemonitoring in Heart Failure

• Early signs of deterioration in HF include weight gain and increased breathlessness – these can be detected via telemonitoring

• 2010 Cochrane review demonstrated telemonitoring in HF could reduce mortality by 34% and CHF-related hospitalisations by 21%

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Telemonitoring in COPD• Deterioration may be detected early through a reported

increase in symptoms, reduction in the amount of circulating oxygen or decrease in breathing function

• Some positive research evidence exists: a recent Cochrane review reports lower rates of hospital admissions with telemonitoring, but suggests that more (and better) research is required

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The Whole System Demonstrator• £31M, Department of Health funded study into

telehealth (and telecare) in people with LTCs• ≈3000 participants, with ≈1500 in telehealth

(telemonitoring) arm• Telehealth associated with 45% lower mortality

rates and 20% fewer admissions to hospital when compared to control arm (Steventon et al, 2012)

• Moderate cost savings (£188/year), but that does not include cost of providing the telehealth service

• Approx £90k per QALY gained

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