HIE Library Papers

It is widely accepted that healthcare providers are coming under increasing pressure to improve the quality of care delivered to patients. This comes at a time when there is a need to curtail healthcare spending fuelled by an increasing incidence of revenue sapping ageing populations, and an explosion of western diseases such as obesity, diabetes, chronic heart failure etc. The healthcare delivery system will be forced to treat larger numbers of patient and resources will come under severe strain.

Simply throwing money at this predicament will not solve the problem. A fundamental change in the management and delivery of healthcare, by leveraging telehealth applications and solutions, is crucial to get the most cost effective and efficient use out of available healthcare resources.

Telehealth has the potential to alleviate the problems facing health delivery in the western world and at the same time aid medical delivery and expertise to developing countries. The main drivers behind the expanding application of telehealth include:

• the need to decrease costs and increase efficiencies in national health systems, which is seen in part in the push to develop regional health systems;
• the desire to improve healthcare services for all, especially in remote areas;
• improvement of workflow and efficiency of medical personnel;
• delivery of more personalised healthcare to patients, meeting needs and requirements with the correct level of care and treatment;
• the increasing demand amongst developed nations for the latest and best in healthcare; and
• increasing consolidation on the demand side, including an increase in the number of hospital Group Purchasing Organisations (GPOs) in the USA.

To alleviate and address these problems, increasing investment in Integrated Healthcare Communication Systems (IHCS) is required. This is necessary to provide a seamless platform on which telehealth solutions can be effectively integrated and deployed. Without such a platform, the development of telehealth will be curtailed and applications will be more difficult to deploy. Telehealth is part of the overall healthcare ICT (Information Communications Technology) solutions that enables healthcare to be pushed out to the edge, for local delivery, and to be more evenly, efficiently and effectively distributed. Telehealth enables the points above to be addressed by:

• reducing the 'hotel' part of hospitalisation — enabling post-operative patients to be monitored at home, and monitoring patients at home with a diagnosed condition which does not require hospitalisation;
• preventative medicine – monitoring people at home, enabling the administration of treatment as soon as a problem is identified;
• cross-fertilisation of knowledge between healthcare professionals — enables treatment to be delivered at a distance, improving skills and knowledge across secondary and primary healthcare facilities whether urban, rural or remote;
• healthcare professionals are enabled to work in locations that are less dependent on distance — in order to specialise practitioners may not necessarily need to move to an urban environment;
• filtering patient referrals — ensuring that patients receive the right level of treatment depending on their condition, its importance and level of urgency;
• automating monitoring processes — physicians only need address patient problems as they occur; and
• allowing more effective use of medical professionals’ time – workflows easier to manage, more effective use of core skills in delivering treatment and less time spent on patients not requiring attention or needing a lower level of care (depending on severity or specialist nature of condition). Patient needs are matched more effectively to healthcare professional skills.

Telehealth delivery

Broadband communication is the underlying technology of choice when discussing telehealth applications. It is certainly important for inter-healthcare provider  communications delivering sufficient bandwidth capacity between sites. Figure 1 (download as 90K PDF) illustrates the communications links between secondary and primary healthcare providers and the delivery of telehealth between them and home sites. The delivery of home care telehealth should not rely on the broadband technology since this can limit the delivery of telehealth to that location. Broadband technology is not universally accessible, particularly in rural and remote areas, and it can also be prohibitively expensive. Some broadband technologies can be delivered to remote locations, such as satellite-based technology, but this is impractical and too costly to deliver extensive home care. Broadband connectivity to the home should not be the common denominator in delivering telehealth. Broadband simply means being able to deliver real-time telehealth applications and the ability to send huge amounts of information in a short space of time.

Telehealth applications should not be developed that automatically rely on broadband connectivity; as it invariably adds no value to the application. There are other solutions to deliver telehealth to the home:

• dial-up and plain old telephone service (POTS) — if real-time communications is not necessary then store and forward based technology can be used to send information on dial-up connections during the night when network usage is low. Dial-up connections can also support real-time communications via the Internet such as web-based services, for example NHS Direct, where an administrator can respond to questions using an on-line chat facility. POTS can even support basic videoconferencing equipment, with low resolution and image renewal, and is adequate for videoconferencing where high picture quality is not a prerequisite. Such videophones are based on H.324 technology; and
• no communication link to the home — a visiting healthcare professional could deliver portable equipment to the home for monitoring purposes, leaving it in the home and regularly retrieving data in person, without the need for a communications link. The patient could also deliver the results or the equipment to their local practitioner, in person, as part of a consultation making use of a data storage device.

The delivery of telehealth to patients can also incorporate locally provided applications and solutions that do not require equipment being installed at a patient’s home. The delivery of telehealth solutions could be conveniently situated at local sites that could reduce the need to travel further afield:

• a multi-media kiosk able to perform telehealth applications could be installed at appropriate sites such as pharmacists or fitness centres
• local practitioner surgeries could be developed as local hubs for telehealth provision, particularly in more remote and rural areas, enabling patients to utilise more complex telehealth applications that cannot be supported at home and may require medical personnel intervention.

Delivering telehealth home care must take into consideration those people accessing the services and applications. When designing applications and the telehealth services it becomes necessary to consider how they will be used and who will use them. It is impractical to develop a plethora of equipment doing the same things but designed for different people. It is necessary to understand that some users may not be technology savvy, or that equipment might be used by less dexterous people such as the elderly or the disabled, and furthermore whether it can be used by blind or deaf people. These are all questions that need to be addressed in delivering telehealth to the home. To be successful it needs to be an inclusive technology. There are limits to the extent that inclusiveness can be incorporated into telehealth equipment and services, but building in as much as possible will ensure that economies of scale in delivering telehealth are more likely to be achieved.

Telehealth Barriers

There are many more barriers to telehealth delivery than the design of equipment and penetration of broadband connectivity, ones that are not necessarily financially dependent. Chief among these are:

• insurers’ reluctance to reimburse for telehealth services;
• regulatory and reimbursement policies that fail to encourage innovation or greater efficiency;
• physicians’ reluctance to use “new and often inconvenient” telehealth technologies;
• lack of ICT knowledge and usage amongst healthcare professionals; and
• fragmented supply side and the attendant barrage of incompatible devices and technologies; and
• low penetration of integrated healthcare communications systems, enabling seamless intra-and inter secondary and primary healthcare connectivity.

In the US diagnostic and consultative teleradiology is almost universally reimbursed, without requiring direct interaction between patient and physician. By contrast, Medicare will cover consultations (non-radiology); office visits, psychotherapy and pharmacological management provided via telehealth only if the services are provided with interactive audio and video. The US healthcare system is far from satisfying that stipulation.

Hence, physicians’ traditional reluctance to change combined with a desire to protect their turf, and the insurance companies’ reluctance to reimburse at this point, mean that any market strategy used in the US must take into account the education of physicians and healthcare workers, and the need to increase their technology comfort level. These issues are not exclusive to the USA; reluctance permeates many other countries, both in terms of reimbursement and willingness to utilise telehealth, and measures need undertaking to deal with these issues.

Keys to success

Changing the face of healthcare delivery will take time and a phased approach will be required. There are many steps to follow and challenges to overcome in the not too distant future. If telehealth solutions continue to develop in isolation and on an ad hoc basis they will simply replace present day medical processes and procedures, which is of no long-term value. In order for telehealth to deliver its capabilities new lines of thinking will be required:

• technological advances ultimately drive the development of telehealth, but technology should not be the ultimate driving force. Moulding telehealth to the needs of patients, carers, and medical professionals will be more important;
• companies developing telehealth solutions need to incorporate these thoughts in their planning, so involving members from patient and medical professional bodies and organisations is necessary;
• greater acceptance of telehealth is also essential; telehealth market participants must work to educate users and governments to the benefits and opportunities •Reimbursers must understand that store and forward telehealth technology works and is no more risky than real-time applications, if correctly utilised;
• governments should ensure that medical professionals receive sufficient ICT training and access to PC-based IT solutions, and bring some cohesiveness to the delivery of national and international healthcare IT infrastructure; and
• system integrators and other IT suppliers provide an ideal platform to integrate the innovative work of small telehealth companies and deliver large scale end-to-end telehealth applications and services. Now is the time for them to tackle the healthcare market.

There are many other lines of thinking that will need to be followed. Without them it will be difficult for telehealth applications to be considered as anything more than delivery of stand-alone solutions. For telehealth to truly attain its potential it must become more encompassing and penetrate most areas of healthcare delivery. Otherwise expected workflow improvements, dissemination of healthcare expertise, delivery of more specialised local care and home care, etc will remain unrealised.

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