Telehealth and Telecare Learning Resource

1. Telehealth and Telecare Learning Resource Hull University Faculty of Health and Social Care Telehealth and Telecare Masters Module Student Number 201106449 Click arrow to begin

2. This learning resource is interactive. An arrow will appear at the lower right hand side of each page to indicate that the information on the slide is complete. You should then click on the arrow to advance to the next slide.

3. Introduction – this resource will: • Define telehealth and telecare and introduce the wider context of technology in healthcare • Focus on the telehealth application – remote monitoring • Discuss the drivers and barriers to telehealth development and the evidence base for telehealth • Propose future developments • Include a Scotland focus, where the author resides

4. Wider Context of Telehealth and Telecare • Health and social care are facing a number of significant challenges which are: • An ageing population • Increased prevalence of long term conditions • Economic pressures including increased costs from hospital admissions • All of these require alternative ways of working

5. In Scotland, it is projected that the number of people aged 75 and over 1 will increase by 23% between 2008 and 2018 Ageing Population

6. It is expected that the number of people aged 60 – 74 years aged over 75 years will increase will increase by 33% by 84% between 2008 and 2033 Ageing Population1

7. Technology in the form of Telehealth and Telecare may offer solutions • Definitions within both Telehealth and Telecare can differ2 • However, in Scotland the Scottish Centre for Telehealth and Telecare (SCTT) has suggested definitions which help to inform staff and users

8. SCTT Define Telehealth as: 3 “The provision of health services at a distance using a range of digital technologies”

9. Examples of telehealth are: • Remote monitoring of health data transmitted by patients at a location separate from the professional receiving the data • Videoconsultation between patient and health professional located remotely aiding diagnosis and treatment

10. SCTT Define Telecare as:3 • “The remote or enhanced delivery of care services to people in their home or a community setting by means of telecommunications and computerised services”

11. Examples of Telecare are: Wayfinder

12. Drivers for Development • Health life expectancy is increasing but not as quickly as life expectancy so this produces a gap where health needs will increase4 • Long term conditions are often associated with this • A long term condition is a condition which lasts a year or more and affects a person’s life for which there may be a need for continuing care and support5

13. Long Term Conditions • The Scottish Government has focused on long term conditions to deliver improvement through supported self management, case management and anticipatory care6 • This resource will focus on 2 long term conditions in particular as they are relevant to the use of technology which are: • Chronic Obstructive Pulmonary Disease (COPD) • Heart Failure

14. COPD: • Is a lung disease with chronic airflow obstruction which cannot fully be reversed7 • Includes chronic bronchitis and emphysema and often causes anxiety, depression and social isolation • Has a feature of exacerbations or ‘flare ups’ where the condition worsens with increased breathlessness and sometimes infection is present

15. How prevalent is COPD? • The prevalence rate in Scotland in 2009/10 was 1.97%8 • Hospital admissions are common - the current rate for this is 475 per 100,000 population8 • Estimates for Scotland, due to the ageing population, are that COPD cases will increase by 33% between 2007 and 2027 to 127,1889

16. Heart Failure: • Is a clinical condition where the heart is less able to respond to demands for increased output10 • Symptoms are often breathlessness on exertion, fluid retention, weight gain and tiredness • Exacerbations are also a feature with increased breathlessness, fluid retention and tiredness • Has a raw prevalence rate of 0.81 per 100 patients11

17. How can technology assist? • Remote monitoring consists of equipment in the patient’s home allowing the daily transmission of symptom and physiological information e.g. oxygen level, sent securely via broadband or phone line to a clinician who reviews the results and acts on the findings • Daily transmission enables any deterioration in condition to be detected early before a crisis point is reached12. Settings can be individualised for each patient

18. How can technology assist this? • The early detection in deterioration helps to prevent admissions by allowing early initiation of treatment and assists the patient to manage their condition better through recognition of increased symptoms. It can also support early discharge from hospital • The equipment can often be used to deliver health education which patients can access when required

19. Diagram showing an example of the links between patient, clinician , departments and supplier in telehealth remote monitoring Helpdesk and Training Clinician Supplier Hosted Server eHealth Support Patient with Telehealth Technical support and Installation of devices Telecomms

20. How else can technology assist? • Remote monitoring technology also assists staff through building capacity where an increased number of patients can be ‘seen’ through use of the data and visits being made only when necessary

21. Further Drivers for Development • Scottish Government Health, Efficiency, Access and Treatment (HEAT Targets) drive reductions in hospital admissions and bed days13, with use of technology proposed as one of the methods of improving these • Strategy documents are now driving policy to include the use of technology in frontline services • The recent Audit Scotland Review of Telehealth called for NHS Boards to do more to implement telehealth14

22. What does the evidence say? • Evidence in healthcare is important for any development and this includes the use of technology • The NHS has an ethical obligation to provide effective, evidence based care which is also economically sound15 • The use of telehealth has been and continues to be the subject of a significant amount of research

23. Evidence • Evidence comes from different types of research and depending on study method can be classed from good through to weaker quality16 • Randomised controlled trials (RCTs) are seen as high quality due to the presence of a control group which doesn’t receive the intervention • Service evaluations also add to information and for telehealth and have tended to be positive. Although weaker than RCTs they still give useful information particularly about operational management

24. Evidence - some studies for COPD and Heart Failure have shown positive outcomes for:17,18,19 • Improved quality of life • Reduction in hospital admissions and length of stay • Reduction in mortality • Acceptability of equipment by users • Improved knowledge and self care • Reassurance and increased confidence of users • Reduction in costs

25. However... • Despite showing some positives, there has been a call for further research to determine the effectiveness of telehealth. • The result of some reviews, which have combined a number of studies, has been less favourable due to weaknesses in study methods, differing study groups and the outcomes being researched20,21

26. Whole System Demonstrator (WSD)Programme22 • WSD is a large RCT launched in 2008 by the Department of Health, studying telehealth and telecare, involving over 6000 patients • The telehealth section included patients with either COPD, heart failure or diabetes • The outcomes are expected to add significant information to the evidence base which will help the NHS to make decisions about implementation

27. WSD Early Headline Outcomes – December 201122 • “early indications show that if used correctly telehealth can deliver: • a 15% reduction in A&E visits • a 20% reduction in emergency admissions • a 14% reduction in bed days • an 8% reduction in tariff costs • a 45% reduction in mortality rates” • Further information about these findings is to be welcomed

28. Key Challenges to Implementing Telehealth have been defined as: • Staff perceptions and new ways of working23 • Lack of project management23 • The need to recruit appropriate patients23 • Type of technology23 and limited interoperability of equipment24 • Funding23 and high initial set up costs • Ethics, data protection and privacy concerns25 • Short term pilots which fail to mainstream • The need for a robust evidence base

29. Future Development -Addressing the challenges will assist in deploying telehealth to scale through a focus on: • Education of staff24 – including undergraduate programmes, education of patients and carers26 • Effective change management 27 and reassurance of staff about practice • Effective leadership in organisations • Funding availability • Routine consideration of technology in patient assessments and pathways • Standards in record keeping, ethics and eligibility criteria

30. Technology Advances • The pace of technological change offers opportunities for different types of equipment to be considered • Smaller devices such as mobile phone applications offer flexibility over fixed devices • Multiple condition monitoring is important due to increasing rates of multi morbidity – people having more than one long term condition28

31. Conclusion • Recent evaluations, policies and drivers are bringing telehealth to a ‘tipping point’ • Technology has the potential to benefit health and wellbeing across the disease spectrum • It can provide person centred, quality care • It will assist in the challenges faced by health and social care by becoming part of the clinician’s toolkit • The DALLAS Programme will bring the opportunity to deploy telehealth at scale...

32. Delivering Assisted Living Lifestyles At Scale (DALLAS)29 • The Technology Strategy Board is leading the DALLAS Programme • This will commence in April 2012 for 3 years • It will facilitate collaborative working between the NHS, partner organisations and suppliers • The use of technology to improve many older people’s lives in health and everyday living is a prime objective.

33. Further Reading • This resource covers the main points of an assignment which explores the use of technology in healthcare in the form of telehealth and telecare with a focus on telehealth remote monitoring • The following slides contain references and, where applicable, weblinks for further reading. In addition the full assignment is available on request

34. References • 1 Scottish Government. (2011a) ‘The Scottish Health Survey Topic Report – Older Peoples’ Health’ [Online]. Available from: http://www.scotland.gov.uk/Publications/2011/11/24083430/5[accessed 16/12/11] • 2 Kerr, B., Hurst, K., Clark, S., Dorrian, C. & Muir. L. (2011) ‘Telehealthcare and mental health’ [Online]. Available from: 00631 FINAL Telehealthcare and mental health revised 300311.pdf via www.google.co.uk [accessed 27/12/11] • 3 SCTT (Scottish Centre for Telehealth and Telecare). (2011) ‘Information for Professionals What is Telehealth – Definitions’ [Online]. Available from: http://www.sctt.scot.nhs.uk/telehealth.html [accessed 15/11/12] • 4 Scottish Government. (2011b) ‘Health of Scotland’s population – Life Expectancy’ [Online]. Available from: http://www.scotland.gov.uk/Topics/Statistics/Browse/Health/TrendLifeExpectancy [accessed 16/12/11] • 5 Scottish Government . (2009a) ‘Improving the health and wellbeing of people with LTC in Scotland : A national action plan’ [Online]. Available from: http://www.scotland.gov.uk/Publications/2009/12/03112054/4 [accessed 27/10/11] • 6 Scottish Government. (2009b) ‘LTCC: High Impact Changes’ [Online]. Available from: http://www.scotland.gov.uk/Publications/2009/03/06084301/0 [accessed 23/12/11] • 7 WHO. (2011) ‘Chronic Respiratory Diseases, COPD – Definition’ [Online]. Available from: http://www.who.int/respiratory/copd/definition/en/index.html [accessed 16/12/11]

35. References • 8 Scottish Public Health Observatory. (2011) ‘Wellbeing and Disease, Chronic Obstructive Pulmonary Disease’ [Online]. Available from: http://www.scotpho.org.uk/home/Healthwell-beinganddisease/copd/copd_keypoints.asp [accessed 27/12/11] • 9Audit Scotland. (2007) ‘Managing Long Term Conditions’ [Online]. Available from: http://www.audit-scotland.gov.uk/utilities/search_report.php?id=552 [accessed 16/12/11] • 10 SIGN. (2007) ‘SIGN Guideline 95, Management of Chronic Heart Failure’ [Online]. Available from: http://www.sign.ac.uk/guidelines/fulltext/95/index.html [accessed 16/12/11] • 11 Information and Statistics Division Scotland. (2011) ‘Quality and Outcomes Framework, 2010/11 QOF Prevalence Data’ [Online]. Available from: http://www.isdscotland.org/Health-Topics/General-Practice/Quality-And-Outcomes-Framework/2010-11/Register-and-prevalence-data.asp [accessed 23/12/11] • 12 Maric, B., Kaan, A., Ignaszewski, A. & Lear,S. (2009) ‘A systematic review of telemonitoring technologies in heart failure’, European Journal of Heart Failure [Online], 11, 506–517.Available from: http://eurjhf.oxfordjournals.org/content/11/5/506.full [accessed 23/12/11] • 13 Scottish Government. (2011c) ‘Scotland Performs: NHSScotland’ [Online]. Available from: http://www.scotland.gov.uk/About/scotPerforms/partnerstories/NHSScotlandperformance [accessed 16/12/11] • 14 Audit Scotland. (2011) ‘A Review of Telehealth in Scotland’ [Online]. Available from: http://www.audit-scotland.gov.uk/utilities/search_report.php?id=1709 [accessed 16/12/11] • 15 Webb, C. & Roe, B, ed. (2007) Reviewing Research Evidence for Nursing Practice, [Reflections on the Past, Present and Future of Systematic Reviews], Blackwell Publishing, Oxford

36. References • 16 Centre for Reviews and Dissemination. (2008) ‘Systematic Reviews’ [Online]. Available from: http://www.york.ac.uk/inst/crd/index_guidance.htm [accessed 23/12/11] • 17 McLean, S., Nurmatov, U., Liu, J., Pagliari, C., Car, J. & Sheikh, A. (2011) ‘Telehealthcare for chronic obstructive pulmonary disease’. Cochrane Database of Systematic Reviews, Issue 7. Art No.:CD007718. DOI:10.1002/14651858.CD007718.pub2 • 18 Inglis, S., Clark, R., McAlister, F., Ball, J., Lewinter, C., Cullington, D., Stewart, S. &, Cleland. (2010) ‘Structured telephone support or telemonitoring programmes for patients with chronic heart failure’ Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.:CD007228. DOI: 10.1002/14651858. CD007228.pub2. • 19 Cleland, J., Louis, A., Rigby, A., Jansenns, U. & Balk, A. (2005) ‘Noninvasive Home Telemonitoring for Patients with Heart Failure at High Risk of Admission and Death. The Trans-European Network-Home-Care Management System (Ten HMS) Study’ Journal of the American College of Cardiology vol 45, no.10 • 20 Polisena, J., Tran, K., Cimon, K., Hutton, B., McGill, S., Palmer, K. &, Scott, R. (2010) ‘Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis’ Journal of Telemedicine and Telecare (16) pp120-127 • 21Bolton, C., Waters,C., Peirce, S. &, Elwyn, G. (2010) ‘Insufficient evidence of benefit: a systematic review of home telemonitoring for COPD’, Journalof Evaluation in Clinical Practice [Online], DOI: 10.1111/j.1365-2753.2010.01536.x, first published online 16 September 2010. Available from: http://onlinelibrary.wiley.com/doi/10.1111/jep.2011.17.issue-6/issuetoc [accessed 27/12/11] • 22 Department of Health. (2011) ‘Whole System Demonstrator Programme Headline Findings’ [Online]. Available from http://www.kingsfund.org.uk/blog/wsdan_results.html [accessed 23/12/11]

37. References • 23 Joseph, V., West, R., Shickle, D., Keen, J. & Clamp, S. (2011) ‘Key challenges in the development and implementation of telehealth projects’ Journal of Telemedicine and Telecare vol 17, no.2 ; 71-77 • 24 Giordano, R., Clark, M. & Goodwin, N. (2011) ‘WSD Action Network, Perspectives on Telehealth and Telecare’ [Online]. Available from: http://www.kingsfund.org.uk/publications/articles/th_perspectives.html [accessed 23/12/11] • 25 Kaplan, B, &, Litewka, S. (2008) ‘Ethical Challenges of Telemedicine and Telehealth’ Cambridge Quarterly of Healthcare Ethics 17, pp 401-416 • 26 Carers Scotland. (2011) ‘Telehealthcare A Training Toolkit’ [Online]. Available from: http://www.carersuk.org/component/k2/item/2382-telehealthcare-a-training-toolkit?qh=YTo3OntpOjA7czoxNDoidGVsZWhlYWx0aGNhcmUiO2k6MTtzOjg6InRyYWluaW5nIjtpOjI7czo1OiJ0cmFpbiI7aTozO3M6NjoidHJhaW5zIjtpOjQ7czo3OiJ0cmFpbmVkIjtpOjU7czo3OiJ0b29sa2l0IjtpOjY7czoxNjoidHJhaW5pbmcgdG9vbGtpdCI7fQ%3D%3D [accessed 27/12/11] • 27 Faife, D. (2008) ‘All in the mind? Reflections on developing an assistive technology/telecare service as a model for change management, creative thinking and workforce development;learning from the Norfolk experience’ Journal of Assistive Technologies [Online] Vol 2, issue 1, March 2008. Available from: http://web.ebscohost.com/ehost/results?sid=766f3799-8ba3-4c30-ba7efd21ffa28a7f%40sessionmgr114&vid=2&hid=112&bquery=(JN+%26quot%3bJournal+of+Assistive+Technologies%26quot%3b+AND+DT+20080301)&bdata=JmRiPXJ6aCZ0eXBlPTAmc2l0ZT1laG9zdC1saXZl [accessed 27/12/11]

38. References • 28 Scottish School of Primary Care. (2011), ‘Multimorbidity in Scotland, Multimorbidity Research Programme’ Slide Pack received via e-mail from enquiries@chain-network.org.uk • 29 Technology Strategy Board. (2011) DALLAS: ‘Delivering Assisted Living Lifestyles At Scale’ [Online]. Available from: http://www.innovateuk.org/ourstrategy/innovationplatforms/assistedliving/dallas-delivering-assisted-living.ashx [accessed 2/1/12]