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The impact of telehealth in clinical practice: Unit C2

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1 The impact of telehealth in clinical practice: Unit C2
Dr Paul Rice David Barrett In the first unit, we had a look at the general drivers for the adoption of telehealth. Specifically, we looked at the impact of rising prevalence of long-term conditions. In this unit, we focus on some of these clinical issues, looking in more detail at long-term conditions and evaluating the potential benefits of telehealth in these and other conditions. The formal learning outcomes for this unit are that by the end of it, you will be able to; Analyse the evidence base for telemonitoring in long-term conditions Describe the clinical applications of telemonitoring, telecoaching and teleconsultation in the care of patients with long-term conditions Throughout this unit, it is important to reflect on your own practice and reflect on how telehealth has – or might – enhance the care that you give to patients.

2 Learning outcomes By the end of this session, you will be able to;
Analyse the evidence base for telemonitoring in long-term conditions Describe the clinical applications of telemonitoring, telecoaching and teleconsultation in the care of patients with long-term conditions

3 The challenge of long-term conditions
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 For the remainder of this unit, we focus on two specific chronic conditions – heart failure and chronic obstructive airways disease. This is partly due to the prevalence and impact of these conditions and partly because telehealth deployments tend to focus on patients with them. However, it’s important to recognise that telehealth could potentially provide benefits to people with any physical or health condition (other notable examples are diabetes, mental health disorders or hypertension). Approximately 1M people in the UK have heart failure (HF), where the heart becomes unable to pump the volume of blood required to meet the body’s demands. Most of these cases are as a result of an acute cardiac event (e.g. Myocardial infarction). HF has a substantial effect on individuals – patients hospitalised with HF have nearly a one in four chance of being readmitted within 30 days of discharge, and five-year mortality can exceed 40%. HF accounts for around 2% of all healthcare costs in the UK COPD accounts for over 1M hospital bed days per year in England. In addition COPD kills people – in 2004, over 27,000 people died of COPD, more than breast and prostate cancers put together. C2/1

4 Levels of LTC management
High Complexity Require case management Level 2: High risk Require disease/care management Level 1: 70-80% of LTC population Require self-care support and management Levels of LTC management It’s important to remember that people with LTCs are not all the same. Their general well-being, quality of life and prognosis can depend on many factors, including the type (and number) of LTCs that they have, their age and their social circumstances. The Kaiser Pyramid categorisation of LTCs (above) provides a useful overview of need. At the top of the pyramid, we have a minority of LTC patients, who have very complex needs and require intensive case management co-ordinated by a healthcare practitioner (e.g. Community matron). Further down the pyramid are patients with less complex needs than level 3, but still require specialist service input. This could be someone with a single LTC or co-morbidities. The majority of LTC patients have level 1 needs. Broadly speaking, the most beneficial interventions for this group are those that promote and facilitate self-care. Patients at each level of the triangle have different needs, for which different interventions are required. In terms of telehealth, we may need to focus low-cost, large scale interventions to promote self-care in level 1 patients, slightly more intensive services for level 2 patients and higher-cost, complex interventions for those patients in level 3. DH, 2012 C2/2

5 The challenge of long-term conditions
Think of patients with long-term conditions that you have cared for; What particular challenges do their LTCs cause them and their families? What characteristics do you see (or would you expect to see) in a high quality LTC care system? Use this space to jot down your own notes about the points above, and interesting points from the subsequent discussion; C2/3

6 Ten characteristics of a high performing chronic care system
Universal healthcare coverage Care free at the point of delivery Focus on the prevention of ill-health Priority is given to supporting self-management Priority is given to primary care Population management is emphasised Care should be integrated The potential benefits of IT should be exploited Care is co-ordinated effectively Characteristics 1-9 linked as part of a coherent strategy Chris Ham (2010). The ten characteristics of the high performing chronic care system. Health, Economics, Policy and Law, 5, pp 7190 doi: /S C2/4

7 The spectrum of remote care
Convergence Telecare Telehealth On occasions, we talk about telehealth and telecare as if they are entirely separate entities. Of course, this isn’t the case – telecare and telehealth overlap and converge in the same way as social care and healthcare are interrelated and interdependent. There are types of telecare that are quite firmly at the ‘care’ end of the spectrum: pendant alarms and environmental sensors are probably the best examples. At the same time, some telehealth interventions are exclusively clinical tools – the examples at the right of the slide include teleconsultation and implantable monitoring sensors. In the middle though, things get more complicated. For example, if someone with epilepsy has a sensor on their bed to detect fits, is that telehealth or telecare (convention would suggest the latter)? To try and overcome some of these issues, there have been attempts to invent an all-encompassing term that covers everything. One of the best known – but also the most controversial – is ‘Telehealthcare’, a word that is sometimes used to describe a combination of telehealth and telecare, but which is also inextricably linked to one particular provider of services. Regardless of arguments about terminology (which will continue well into the future), the key point from this slide is that healthcare and social care providers need to work in an integrated way to ensure that telehealth and telecare are delivered effectively. C2/5

8 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 Telecoaching is the use of structured telephone support to enhance and promote well-being. It can be used in a host of different ways, most designed to help support people in their own homes and to prevent (or manage) illness. The examples of large-scale telecoaching highlighted above demonstrate how modern communication technologies, such as automated phone calls and social media can be powerful health promotion tools. More on Healthy Outlook can be found at and you can follow NHSD on Most telecoaching services tend to focus on individual patients and their individual needs. The two examples in the slide have a number of similarities – the big difference is that OwnHealth is a privately provided service commissioned by different localities (e.g. Birmingham; Nottingham) and the Barnsley service is provided ‘in-house’ by the NHS. Both provide a range of services based around structured telephone support. At the simplest level, telecoaching can provide post-crisis support, contacting patients post-discharge from hospital to ensure that the right services are in place. Telecoaching can be used to support changes in lifestyle and behaviour. Obvious examples include smoking cessation, weight loss and alcohol intake management. Telecoaching can also provide counselling and other support service – e.g. For people with mental health problems or other long-term conditions. C2/6

9 Telecoaching – “Barnsley Model”
Explain programme & benefits Review risk factors Confirm medical conditions Formulate goals and prioritise Outbound First Call Review progress towards goals Set goals for next time Check confidence level for achieving goals Coach on barriers, triggers, learn from successes Formulate relapse prevention strategy Invite inbound calls if support needed between calls Outbound Follow Up Call The Barnsley model of telecoaching is not unique, but does provide an exemplar of good practice. The slide is self-explanatory but demonstrates how a structured telecoaching programme includes all the elements of a problem-solving approach to care; Patient assessment Identification of patient need Agreement of patient-focused SMART (Specific; Measurable; Achievable; Realistic; Timed) goals Suggest strategies and interventions for achieving goals Review progress and amend goals/strategies as appropriate Essentially then, telecoaching alters the method of delivering care, rather than the care itself. It can overcome geographical boundaries, facilitate self-care and support healthier living and lives. It’s worth also acknowledging that the Barnsley telecoaching model does not exist in isolation. The service runs within an integrated health and social care service that allows for seamless provision of support across the continuum. Inbound Call Patient/client in control of frequency of calls and level of support required C2/7

10 Teleconsultation Represents the use of video conferencing to support delivery of care Main applications are; Overcoming geographical barriers Overcoming logistical Overcoming lack of ‘on-site’ specialist support Which of your care interventions would suit teleconsultation? It’s important to discuss terminology at this stage. What we call ‘teleconsultation’ (i.e. The use of video technology to support consultation between practitioners or between practitioners and patients) is what many others call ‘telemedicine’. The reason we don’t is simply that practitioners other than medics utilise teleconsultation, so we don’t believe that it should have a profession-specific label. The categories on the slide and some of the examples discussed in the accompanying videos demonstrate that teleconsultation can have a number of useful applications. However, it’s important to recognise that it has to fit within a specific clinical niche. Certain healthcare interventions cannot be carried out without face-to-face and/or often hands-on interaction with a patient (example might be auscultation of the chest or application of a dressing) – these will always require a physical presence. At the other end of the spectrum, there are some interactions (e.g. Motivation and advice giving) that can be provided via the telephone – in these cases, it’s difficult to see where the extra cost of video technology provides a ‘value-add’. Nonetheless, teleconsultation can allow for service delivery that overcomes geographical and logistical barriers. It’s also one of the few applications of remote care technologies that has been formally supported by a clinical body. In 2009, the American Heart Association and American Stroke Association issued joint guidelines providing reassurance that telemedicine/teleconsultation in acute stroke care was a safe and effective modality of care. The full guideline can be found at C2/8

11 Why teleconsultation works in stroke assessment
The expertise to provide acute stroke care is not available everywhere 24/7 Telephone consultation isn’t good enough 38% of patients treated in a community hospital with phone consultation support had deviations from treatment protocol (Uchino, 2010) Video consultation is good enough to safely prescribe treatment Uchino K, et al (2010) Protocol Adherence and Safety of Intravenous Thrombolysis After Telephone Consultation With a Stroke Center. Journal of Stroke and Cerebrovascular Diseases 16:6; C2/9

12 The use of teleconsultation in stroke care

13 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 NHS Direct delivers over 12M interactions per year across England – about 5M telephone assessments and 7M online symptom checkers. We class this activity – and similar work done by NHS Direct Wales and NHS24 in Scotland as ‘teletriage’. Teletriage is a classic application of telehealth (in that the patient and the advisor – sometimes a computer algorithm – are geographically separate), and demonstrates the success and cost efficiencies that can be yielded by operating at large scale. The delivery of teletriage in the UK is facing a period of major upheaval with the move to ‘111’ services. However, the likely direction of travel is a towards greater use of clinical decision making software to support staff, and encouragement of ‘automated self-triage’ using apps ( and online support ( Telerehabilitation has been defined as the use of information and communication technologies in the provision of rehabilitation (Hill, 2010 – accessible at There are a wide range of potential applications, but current projects involve – for example – speech therapy, physiotherapy, pulmonary and cardiac rehabilitation. Health kiosks are pieces of equipment that provide simple health checks to multiple users. They usually allow for measurement of weight, BMI, body fat, blood pressure, pulse and – in more advanced models – cardiovascular risk. The is an argument over whether or not health kiosks fall under the heading of ‘telehealth’ or not. They certainly promote well-being using technology, and may become a more familiar sight in health clinics and in the high street. C2/11

14 Telemonitoring models
Not an emergency service The input stage of telemonitoring can include any indicators of well-being that are felt to be clinically appropriate. For example, in a patient with heart failure, monitoring of weight may help detect any fluid retention and monitoring of blood pressure/pulse will help assess the impact of cardiac medication. Similarly, COPD patients may benefit from monitoring oxygen saturations. A range of questions can also be asked to assess any symptoms (e.g. “Are you feeling more breathless than usual today?”). Information is sent (either through a landline or mobile phone connection) to a central server, beginning a series of triage processes. The first step is automatic triage by the system software. This will flag up any technical issues (e.g. system faults; missing information) and potential clinical issues. Clinical issues will be identified through the detection of any abnormal findings or symptom reports (e.g. Unexpected weight gain or blood pressure going up or down beyond set parameters). Any technical or clinical issues are flagged as ‘alerts’ and assessed by support staff or – in some service models – a central team of healthcare practitioners. This results in the output stage of telemonitoring. A phone call to the patient may be required to remind them to take readings or check on well-being. A technician may be requested to fix or replace the system or a frontline healthcare practitioners (e.g. A community matron) may be asked to carry out a visit. The most important point to remember about most telemonitoring services is that they are not an emergency service. Triage response may only operate 9-5, Monday-Friday; this means that hypothetically, a patient may transmit abnormal findings on a Friday night, and there would not be a response until the following Monday! This needs making clear to patients, and they need to be reminded of how to summon emergency help (i.e. NHSD;999). Input Process Output C2/12

15 Different triage models
Centralised technical triage, localised clinical triage (below) We’ll come back to some of the service design issues in a later unit, but it’s worth having a quick think about how the information from telemonitoring systems is processed and triaged. Let’s take an example – imagine that Mr Smith (an 83 year-old) with COPD and Heart Failure – has recorded his vital signs and answered symptom questions this morning. When he was enrolled onto the system, his normal limits for systolic blood pressure were between 100 and 140mmHg. This morning, his systolic blood pressure is 90mmHg, so how will this information be dealt with. The first stage is automated triage. The telemonitoring system itself will recognise that the blood pressure reading of 90mmHg is outside permitted limits and generate an alert. This alert will probably be first seen by a member of staff providing technical triage. This member of staff will be looking out for and dealing with technical issues such as readings not being taken at all, faults reported by the system or abnormal readings that are obviously technical – not clinical – in nature (e.g. A patient weight of 5kg). Mr Smith’s low BP has been labelled as a clinical issue, so is outside the scope of the technical triage service. This is where things can become complicated! Some telemonitoring services provide local clinical triage. In this service model, all clinical alerts are sent straight to the existing frontline practitioners (e.g. Community matron; specialist nurse) to be dealt with. In Mr Smith’s case, the frontline practitioner might decide to give him a ring or pay him a visit. Other services adopt a centralised clinical triage approach in which a designated team of ‘telemonitoring nurses’ triage data, filter out any less significant clinical issues (e.g. By phoning Mr Smith) and only passing on to frontline practitioners those alerts that require a face-to-face intervention. We’ll discuss the strengths and weaknesses of these different approaches later in the day. Centralised technical and clinical triage (above) C2/13

16 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 In previous slides, we’ve looked at a broad approach to telemonitoring and discussed an examples of it in action. Now we need to look at the potential benefits of such an approach. There are – as the slide above suggests – six main assumptions that support the use of telemonitoring, so let’s look at them in relation to Mr Smith from earlier. The first three assumptions are all linked and come under the broad heading of ‘averting deterioration’. Firstly, someone like Mr Smith, with COPD and Heart Failure is likely to have periods of exacerbation or decompensation. Assumption number 1 is that if we monitor physiological indicators (e.g. Weight; oxygen saturations), then we will be able to detect early signs of deterioration (e.g. An increase in weight suggesting fluid retention). Assumption number 2 is that by spotting deterioration early, we can intervene early (examples might be prescribing an increase in diuretics or commencing antibiotics). Assumption number 3 is that some of these early interventions will actually help to reduce the need for hospital care (i.e. Avert an admission). Some will argue, that assumptions 4-6 are more important than 1-3. Assumption number 4 is that if Mr Smith monitors signs and symptoms every day, he will gain a better understanding of his health and his condition. This will enhance his ability to self-care and reduce his reliance on formal healthcare. Assumption number 5 is that the support and reassurance of the telemonitoring service will decrease Mr Smith’s anxiety. Finally, from a practitioner perspective, Mr Smith’s community matron may need to visit him less because she/he can monitor his well-being remotely. We’ll discuss the various merits of these assumptions during the session. C2/14

17 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% We’ve already discussed the impact that heart failure can have on people, and discussed some of the things we might use telemonitoring for in patients like Mr Smith. Heart failure was one of the first conditions where the benefits of telemonitoring were examined in depth. An early study – TEN-HMS in 2005 – showed a one-year decrease in mortality from 45% in the control group to 29% in the telemonitoring group. The evidence base has grown to such a point that a Cochrane review in 2010 suggested mortality benefits and reduction in admissions linked to telemonitoring. That’s not to say that all the evidence is positive. There have been two recent studies – TIM-HF and Tele-HF – that have shown little or no clinical benefit linked to telemonitoring (we’ll discuss some of the possible reasons for this in the session). It is important to recognise that in terms of clinical guidelines, both NICE and the European Society of Cardiologists have discussed telemonitoring as part of heart failure care, and both organisations agree that the evidence base is still not strong enough to recommend the intervention. One area of particular interest in heart failure telemonitoring is in the field of implantable monitors that measure indicators such as pulmonary artery pressure. There have already been studies of the use of implantable monitors to guide the management of heart failure, with extremely positive results. C2/15

18 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 If you did a straw poll of organisations with telemonitoring services, you would almost certainly find that the majority of patients recruited are those with COPD. The reasons for this seem sensible – COPD patients are prone to periods of rapid deterioration (exacerbation) which could be prevented by early intervention and enhanced ability to self-care. Local evaluations of telemonitoring services for COPD patients do bear out these ideas, with high levels of user satisfaction and impressive reports of reductions in hospital admissions. The clinical research evidence is not quite as convincing. A Cochrane review in 2011 suggested that telemonitoring could be linked to reductions in admissions (but not mortality), but with the caveat that much more research was required. An example of the mixed messages coming from the evidence base was presented at a recent respiratory congress – a randomised controlled trial carried out Scotland suggested that when COPD care is already optimised, telemonitoring provides no additional benefits; ( Again, telemonitoring is COPD is not advocated in any official clinical guidelines – a result of the rather equivocal evidence base. For a professional body view, it’s worth having a look at the British Thoracic Society overview of telehealth in general, published back in C2/16

19 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 The lack of clarity regarding the evidence base led to the Department of Health commissioning the largest randomised controlled trial of telehealth (and telecare) to date. The Whole System Demonstrator (WSD) recruited a total of 6000 people across three sites (Kent, Cornwall and Newham). The telehealth (telemonitoring) side of the study had 3000 participants (1500 in the intervention group; 1500 in the control) with a primary diagnosis of heart failure, COPD or diabetes. The results summarised above are impressive, particularly in relation to clinical benefit. However, the study stills leaves use with a number of unanswered questions, most notably related to which groups benefit the most (the WSD doesn’t tell us whether the heart failure, COPD or diabetes patients did best). It’s also important to recognise that the WSD has not convinced everyone of the benefits of telehealth. The overall evidence base still remains confused (for example, a US study published in early 2012 showed three times higher mortality rates in patients with telemonitoring!) and there remains much cynicism. However, there is no doubt that when used on the basis of patient need, it provides a popular, effective and innovative method of supporting and enhancing care. There are two key papers related to the telehealth element of the WSD. The first deals with the clinical outcomes (Steventon et al, 2012 – available from and the second describes how telehealth was not associated with any changes in quality of life (Cartwright et al, available from C2/17

20 What we still don’t know…
Even if we assume broad benefits of telemonitoring in LTCs, we still don’t really know; Which groups benefit the most How long remote monitoring should remain in situ for The best clinical model for implementation What we should be measuring Why it works! Whether it is more effective than other areas for investment The diagram on the right of the slide demonstrates the disease trajectory for many people with heart failure; from diagnosis through to death. The purpose of the slide is to highlight that not all people with heart failure will be at the same stage of the disease process, but we have no clear idea on whereabouts telemonitoring will work best. The same is true of the use of telemonitoring in people with COPD or other long-term conditions. Similarly, we have no real idea on whether telemonitoring works better in people with more or less severe symptoms, older or younger people, men or women. We don’t even know for sure why telemonitoring works: if could be mostly to do with the ability to spot deterioration, or the encouragement of self-care or the reassurance of someone ‘keeping an eye on you’. Most likely, it is a combination of all these factors, but we can’t be sure. There are a range of other ‘unknowns’. We’re not sure whether it is more important to monitor vital signs such as blood pressure, or symptoms such as breathlessness, or a combination of both. We don’t know which triage model works best or how long systems should be deployed for. Overall, there is much more research required to find out how best to use telemonitoring. Goodlin, S. J. J Am Coll Cardiol 2009;54: C2/18

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