Technology for the evolving world of consumer health

In March 2010, E-Health Insider hosted a roundtable debate sponsored by iSOFT on “technology for the evolving world of consumer health”.

The confluence of an ageing population with an increasing burden of chronic disease and dwindling resources mean there is an urgent need to find new models of healthcare. Yet attempts to roll out telehealth technology have hit numerous barriers. So far, at least, the NHS has not moved beyond pilot projects.

iSOFT believes one reason for failure is that projects have used poor devices and focused on data collection. It recently partnered with Switzerland-based telehealth provider Medic4all with a view to bringing to market end-to-end telehealth and monitoring solutions based on new devices and ‘middleware’ for healthcare professionals to help them digest the data generated.

The round-table’s participants debated the issues, challenging assumptions about demographics and the reasons for the failure of telehealth to take off, and outlining some potential solutions.

Panel members:

An important debate

Linda Davidson opened the debate by outlining some of the central policies and assumptions about self care, out of hospital monitoring, and demographics that are in place today.

“Self care and patient involvement are not just interesting trends,” she said. “They are a necessity in a healthcare system facing unprecedented demand, a squeeze on cash and an impending shortage of staff to fulfill care roles.”

Modern lifestyles put today’s younger generations at risk of poor health through lack of exercise, low level mental health issues such as anxiety and depression and high levels of obesity, she added. “Telecare is sometimes portrayed as a panacea that will arrive like some deus ex-machina, to solve the problem of demand for healthcare outstripping supply – but it clearly isn’t going to achieve that. What contribution can it make, though?” she asked.

Dependency culture

Marlene Winfield from CfH kicked off the discussion with a look at healthcare consumer behaviour. Her central case was that “the NHS is a wonderful service, but it has had an unintended consequence: it had deskilled people from looking after their own health.”

“People take no responsibility for looking after themselves,” she said. “We need a culture change and that will be a bigger challenge than introducing any technology.”

The ability to look after your own health is central to telehealth and telecare, said Gerry Allmark, who has vast experience of trying to make telehealth and telecare work in Newham, which is one of the Department of Health’s Whole System Demonstrator sites. These are undertaking large scale testing of the technology across health and social care.

“Take self assessment,” he said. “Such a lot of effort and work is lost by assessing each individual. They are assessed by the doctor, by the occupational therapist, for telecare, for social support.  A huge amount of cost saving could be achieved by self assessment and by reducing the number of people involved in assessment.

“There is lots of interest in moving towards that. But are people happy to do it? No, they are not. They are used to being serviced.” He predicted that some of the changes already underway -- such as the introduction of individual care budgets -- might start a culture change. “People will need to take more responsibility.”

Other participants agreed that a culture change is underway; not least among health professionals who are now working in multi-professional teams that embrace patients as partners in their care.

Ivan Harrow, from Intel, said: “The evidence shows that 75% of patients with long term conditions would feel more confident managing their own care if somebody had taken the time to explain it to them. That could be a health professional or an expert patient. It is forcing us to look at different ways that care may be delivered.”

Able and willing?

Richard Curry begged to differ. This paradigm could relate only to the top one third of the population that is not only sufficiently educated and organised to follow complex care regimes but also cultured to accept the premise of western medicine, he argued.

There is another third of the population that, as he put it, “do not believe in [traditional western] medicine or are so cognitively injured that they do not understand how to move between receiving a prescription and taking a drug.” They would be neither able nor willing to adopt self care.
“I think the idea of a sea change is laudable,” he said. “But I think we can do a lot by targeting a few people and making a big push rather than by targeting a lot of people with not enough push and seeing them give up. At the moment, the Department of Health spends money on a broad front.”

Curry advocated adopting what he called “orphan diseases” as good test beds. “You have diseases where there are maybe 1,000 people in the country and two consultants and it is very hard to get services,” he said. “Telehealth can reduce their travel [to see health professionals] and get services right to them. There are real short term healthcare gains in terms of reduced call out of emergency GPs and A&E visits.”

Not everybody agreed with this analysis of people’s capacity for self care. Marlene Winfield, for example, said he underestimated people, while Linda Davidson asked who would decide which narrow group of people should benefit from this intensive input.

Gerry Allmark maintained that the Whole System Demonstrators were already selecting small groups who really need services by recruiting volunteers to telehealth and telecare who fall within strict eligibility criteria.

Compliance is a core issue

Dr Shai Misan, who is a medical doctor and gained a PhD by studying how people adopt telehealth, turned this idea around. “I think there is another group to add: those who are taking their medications but not doing it well. This is really all about compliance and the issue is all about how to increase compliance.”

There was already experience of population-wide change, such as the adoption of the telephone, and this was perhaps the key to increasing compliance today, he said. Every home now has a telephone line that can be used not only to transmit data but also to bring patients, carers and health professionals together in video conferences.

He argued that ease of use was the key to getting compliance in telehealth. Devices need to be small and neat and able to transmit data effortlessly, using wireless technology, he argued. This would allow telehealth to extend into the primary prevention arena.

“Providing very easy to use monitoring devices, that will not stigmatise you, will enable us to manage the signs and not the symptoms,” he said, illustrating this by saying it should be possible to treat high blood pressure -- the sign -- before it leads to chest pain that indicates heart suffering  -- the symptom.

All those around the table agreed that this was a complex issue, with access to information about primary prevention and the willingness and skill to use technology both crux points.

Ivan Harrow said everybody should stop stereotyping elderly people.  He recalled visiting a 92-year-old lady in County Cork recently and offering to plug in her television in the bedroom. “She said no, that TV is for when I am old and have to spend time in bed.”

There were countless stories of older people hanging up their falls detector, waiting for some time in the future when they perceived themselves to be old enough to need it. Gerry Allmark said there was another layer to this, pointing out that £80m of preventive technology grants since 2005 had not led to a breakthrough in the UK.

He said: “One of the things that makes me cringe when I visit areas receiving these grants is finding equipment that has been sitting in cupboards for the last five years. Suppliers do not follow up with education about what to do with the equipment and it has not got to the end user. It is service providers who have neglected it.”

Adrian Stevens, managing director of iSOFT UK, Ireland, Scandinavia and Nordic Countries, North Europe Region, argued there is a willingness to adopt technology and an appetite for self care among the public. He said this is exemplified by sales of blood pressure kits from retail pharmacies and the popularity of gadgets such as Wii Fit, which is viewed and marketed as a game but could equally well be regarded as a primary prevention medical intervention.

However, he said there is no strategic vision to make either of these part of the care pathway. “It’s the bit in the middle that’s missing,” he said. This includes getting data to health professionals in a rational format so that they can interpret it and getting results back to patients. “The focus needs to be on total solutions.”

Where’s the money?

Linda Davidson moved the debate to another core issue: money. Currently, savings made in healthcare by keeping someone out of hospital translate into costs for social care in keeping them at home, she said. There is renewed interest in merging and health and social care budgets - but will this work?

Gerry Allmark was pessimistic.”That has been the problem with the Whole System Demonstrators,” he said. “Using prevention and social care to keep people out of hospital: does it create a saving or a bed space for someone else to use?”

The experience in Newham, he said, was that costs continue to mount. “There are 800 people receiving assessed telehealth packages,” he said. “That’s a huge cost.

“The equipment alone costs £2,000 per person and the really big cost is the monitoring. The cost is going up and up and the more people we put on telehealth, the more resources go up. We cannot see the point at the moment where you start seeing savings.”

Greg King from iSOFT was surprised. “This leaves me dumbfounded,” he said. “We can point right around the world to areas where providers are adopting this technology and recognising that it saves them money.”

The issue, he suggested, might be how costs were counted. “It is obvious you have financially higher expenditures at the starting point but, economically speaking, the overall cost of patient management is going down if you consider the hospital recovery days saved or the indirect cost to society in managing the patient face to face at every unbalanced moment.”

Dr Misan added his experience. Visiting a patient with a long term condition at home typically takes 45 minutes. A video conference, by contrast, takes 15 minutes. “You can provide two to three sessions compared to one,” he said.

Meanwhile, Adrian Flowerday mused that the inability to realise savings might be an NHS-specific issue. “Some of the problems with realising savings is that the NHS does not decommission,” he argued. “Commissioners do not understand business.”

Getting the Nike mentality

Linda Davidson then moved the debate on again -- from problems to solutions. “From everything we have heard so far today, it would seem that telehealth is a no brainer in terms of the problems we are facing and that what we need is more of a Nike mentality -- just do it.

“But life is not that simple, especially with public service budgets. So what advice do you have for how we can get a more can do approach?”

Adrian Flowerday was quick to bring up QIPP – the quality, innovation, productivity and prevention agenda that the Department of Health is promoting as a way of making savings without care deteriorating as it has done in previous times of financial hardship. “Telehealth offers things in all these areas,” he said. “It’s a quick QIPP win.”

These macro arguments on QIPP were valid, said Marlene Winfield. But from the other end of the spectrum, there needed to be a real patient pull as well. “There needs to be some pressure coming from the patient world.” She suggested using social marketing to get this going.

Adrian Flowerday agreed. “We are getting some fantastic feedback from patients,” he said. Richard Curry liked this theme and suggested that some of the charities working around specific long term conditions could be involved.

“They are perceived as honest brokers who are working for the patient with no other agenda,” he said. However, he pointed out that many charities were hampered from getting involved as their income is based on donations that were raised to fund a cure -- not a support mechanism.

“I had a support mechanism for people with [a particular condition],” he said. “I could not get its society to take it on because the charity commissioners would have been down on them like a ton of bricks.”

King suggested market mechanisms would also have a role. “We are also seeing insurance companies engaging in managing their members through home care monitoring in Europe and we are seeing large employers actively engaging in such programmes in Europe and the US.

“Local community pharmacies in many countries are actively engaged in offering remote monitoring and out of hospital monitoring services. Players like telco companies are starting to offer telehealth services as part of a core set of services to deliver to consumers. This will positively involve citizens in consuming health services with out of pocket payments.”

Making better use of patient networks

Conventional patient interest charities are no longer the only patient voice and Linda Davidson pointed out that there are other, newer forms of peer-to-peer networks that need to be considered.

“The internet has generated terrifically powerful patient groups and ways for patients to voice their opinions about the services they are receiving,” she said. “My perception is that the authorities are still uneasy about these kinds of things. How can the Department of Health and NHS embrace them?”

The consensus was that the case for involving patients in the design and delivery of care was self evident - but hard to achieve. However, the whole system demonstrator project in Newham has already made use of patient groups to recruit patients to the trial of telehealth -- a known area of difficulty.

Gerry Allmark said: “We used Age Concern who were already known and trusted by older people. Age Concern already invited them to focus groups. As soon as we had Age Concern on board, we started bringing in the people.”

Greg King took this a stage further. He said: “One of the exciting things that healthcare is going to be able to take advantage of are converging technologies such as internet TV, Facebook, Twitter and video conferencing. These can all be used to deliver healthcare to wherever the patient is – and make it relevant to them.”

End to end solutions

However, King argued that development would not just be driven by technology. “We have had the technology for some time. Now the infrastructure is there,” he said. “The problem so far is that we have been implementing the technology as single components rather than end to end solutions. The market is now becoming aware that end to end solutions are what is needed.”

This is being tried in Northern Ireland, where telehealth is now being rolled out to 5,000 people with long term conditions. “This is based on a partnership between the providers of the box, the providers of the software and so on,” said Gerry Allmark.

It is also taking a three to four year view on reaping the benefits. “From a balance sheet perspective, one year or four years technology amortization is significantly different,” said Dr Misan. This brought Linda Davidson to the thorny question of regulation. “What else needs to happen to shift from gadget to the service?” she asked.

Dr Misan answered. “One of the things we have to be aware of is that we are talking about medical devices,” he said. And that meant applying for certification to the relevant regulatory bodies. “That’s to ensure quality but let’s also remember we are in the healthcare domain and there are legal issues.”

The problem for suppliers is that each component of an end-to-end solution requires certification by a different authority. “We do not have a regulatory framework geared towards partnership,” said Marlene Winfield. She added: “There are also trust and confidence issues, not just patients trusting the technology but health professionals trusting patients to use it properly. These need to be addressed too.”
One way of addressing these issues might be to use technologies that are already tried and tested and now trusted too. Nearly every participant pulled an iPhone or Blackberry from their pocket during the tea break in the middle of the event.

“It’s pervasive and convenient,” said Greg King. “My healthcare management is not convenient and it needs to be. I would like to see the IT industry and healthcare create a new ecosystem in healthcare, one that extends to all the places that these devices take me.”

That would imply appropriate applications for different patients built on a common platform -- possibly, if Marlene Winfield has her way, Healthspace; the NHS’ own health organiser cum prototype patient health record platform.

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