Denis Protti

24-Sep-09 D. Protti - University of Victoria 1

Assessing and enhancing the public value of telehealthcare

Masterclass - Imperial College London

September 17, 2009

D. Protti - University of Victoria 224-Sep-09

A plethora of terminologies and viewpoints

Telehealthcare

Telehealth

Telemedicine

Telecare

Telemonitoring

Telematics

Tele…. etc.

eHealth

mHealth


Cochrane review definition

'Telehealthcare' has the following elements (adapted from Miller 2007):

Information from the patient whether voice, video, other audio, electrocardiography, oxygen saturation or other.

Electronic transfer of such information over a distance.

There is personalised patient feedback from a healthcare professional who exercises their skills and judgement.

Interventions captured within the terms telehealthcareinclude both synchronous and asynchronous (store and forward) technologies.’


EUROPEAN COMMISSION WORKING PAPER

Telemedicine is the provision of a healthcare service to a patient in situations where the patient and the health professional (or two health professionals cooperating on a specific patient) are not in the same location.

It involves secure transmission of medical data and information, such as biological/physiological measurements, alerts, images, audio, video, or any other type of data needed for prevention, diagnosis, treatment and follow-up monitoring of patients.

Telemedicine for the benefit of patients, healthcare systems and societyEUROPEAN COMMISSION STAFF WORKING PAPER

SEC(2009)943 finalJune 2009

Definition of Telemedicine

• Telemedicine (or telehealth)

- Delivery of healthcare services when the clinician and patientare at different locations

- Data, images, audio, video

- Excludes tele-education

- Excludes CPR, EMR, HIE and phone calls

• Telemedicine covers five healthcare processes

- Monitoring

- Diagnosis

- Triage

- Consultation

- Procedure

• Telemedicine is part of telecare: patient safety at home

- Fall detectors, bed monitors, panic alarms


e-Health - Definitions

Claudia Pagliari and colleagues

e-Health is an emerging field of medical informatics, referring to the organisation and delivery of health services and information using the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a new way of working, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology.


A new term has entered the arena

Mobile health (mHealth) is a recently coined term, largely defined as health practice supported by mobile devices. Mobile health practice includes public health, clinical

medicine, and self-monitoring supported by mobile phones and personal digital assistants (PDAs).

Currently active mobile health applications include the use of PDAs in collecting community health data; using the mobile phone to deliver health care information to practitioners, patients, and non-patients; and real-time monitoring for citizens, both patients and non-patients.

Health Informatics, eHealth, TeleHealth, etc.

It is really all about the use of Information and Communications Technologies (ICT) in health and health care delivery to support the decision making needs of individuals, their supporters, and their clinicians.



Assessing the value of telehealth?

First the good news

Edinburgh City Council has announced it is to spend almost £1m on telecare this year, more than doubling the amount it has spent in previous years.

Edinburgh launched its telecare programme in 2006 and has invested an average of £400,000 over the past three years with more than 700 people on the existing telecareprogramme.

The latest plans will mean 1500 people will be supported to live in their own homes and 700 carers supported in caring for relatives using telecare systems.

The Council estimated that its cash injection would save an estimated 3,000 hospital bed days and 3,000 care home days per year.

Edinburgh to invest £1m in telecare

Ehealth Insider, 17 Aug 2009


In August 1996, Norway became the first country to implement an official telemedicine fee schedule making telemedicine services reimbursable by the national health insurer. Telemedicine is widely used in Northern Norway which is

characterized by a scattered population and a scarcity of health service specialists, most of whom are in Tromsø.

Since the late 1980’s, Norway has had experience in a wide range of areas including: teleradiology, telecare, telepsychiatry, and the electronic delivery of laboratory results.


Telemedicine Case Study:

U.S. Veterans Administration

How Many Patients?

• Home Telehealth (monitoring): 21,000 patientsGeneral Telehealth (VTC): 17,000 patients

• Store and Forward (diagnosis): 7,600 patients

Benefits Reported?

• Fewer bed days

• Fewer outpatient visits

• Better access to care in remote areas

• Lower travel costs

• Better sharing of expertise

How Did They Do It?

• Care coordination program

• Enterprisewide CPR system

• Telemedicine incorporatedin existing health services

• Financially self-sustainingin each local network

• Standard processes for implementation and treatment

• National contracts for devices and applications

• Federal Supremacy allows clinicians to practice across state lines

But their total eligible population is 70 million!

What if they extended this to well patients?

http://www.va.gov/


Assessing the value of telehealth

The less

good news


Telehealth has great potential to improve access to care but its adoption in routine health care has been slow. The lack of clarity about the value of telehealth implementations has been one reason cited for this slow adoption.

Cusack CM et al.

The value proposition in the widespread use of telehealth

Journal of Telemedicine and Telecare 2008


A recent Manhattan Research survey found that 39% of doctors said they have communicated with patients online, up from 31% in 2007 and 19% in 2003. However, a survey of Rhode Island physicians and electronic

health record software vendors found little use in the state of readily available online tools and a general reluctance among doctors to adopt such tools.

A large percentage of the state's doctors treat older patients, and "people believe that our aging population can't connect with that."

No health insurance companies in the state are paying for online patient communication and that doctors are reluctant to take on work they will not be reimbursed for.

Liability issues also deter doctors in the state from communicating online with patients.

Rhode Island Doctors Reluctant To Embrace Online CommunicationProvidence Business News

July 27, 2009

The Business Case for Telemedicine

• The evidence base for telemedicine is weak

- AHRQ study• Store-and-forward services: "the evidence for their efficacy is mixed"

• Home monitoring: "required additional resources and dedicated staff"

• VTC: "most effective for verbal interactions"

- JAMIA study• Effects on patients' conditions: inconclusive

• Patient compliance is high

• Effect on resource utilization is mixed

• Minimal evidence of economic benefit

• The current evidence emphasizes

• soft benefits (quality, patient satisfaction, access)

• indirect economic benefits

The Telemedicine Hype Cycle

Technology Trigger

Peak ofInflated

Expectations

Trough of Disillusionment

Slope of Enlightenment Plateau of Productivity

Maturity

Telepathology

Videoconferencing

Remote ICU

Home Health Monitoring (Wired)

Telecardiology

Continua

Kiosks

E-visits

Teledermatology

Mobile Health

Monitoring

Off the Hype Cycle:

• Teleradiology

• Call centers


Enhancing the value

of telehealth

How Gartner Evaluates

Telemedicine Applications

• Adoption and Readiness for Adoption

- Market penetration

• What percentage of care delivery organizations in North Americaand Western Europe are using this application?

- Patient readiness

• Will patients want to usethe application?

- Clinician readiness

• Will clinicians want to use it?

- Market readiness

• Will payers want to pay for it?

- Technological readiness

• Is the application experimentalor mature?

- Vendor maturity

• Is it sold by start-up companiesor well-established vendors?

• Potential Impact

- Potential financial impact

• How much money will it save for patients, providers and payers?

- Potential clinical impact

• Will the application help clinicians provide better quality care?

• Time to Value

- How soon is the application likelyto provide a return on investment?

Remote Monitoring:

Great Potential but Minimal Usage

Market

penetration

Potential

financial

impact

Potential

clinical

impact

Patient

readiness

Market

readiness

Technological

readiness

Vendor

maturity

Home health monitoring <1% Very high Very high Very high Low Moderate Low

Remote ICU <1% High High High Moderate Moderate Moderate

Remote Diagnosis and Triage:

Early Commercialization

Market

penetration

Potential

financial

impact

Potential

clinical

impact

Patient

readiness

Market

readiness

Technological

readiness

Vendor

maturity

Telepathology (static) <1% High Low NA Moderate High Very high

Teleradiology/remote

PACS

30-50% High Moderate NA Very high Very high Very high

Call centers for remote

triage

10-20% High High High Low Very high Very high

Remote Consultation and Procedure:

Beware the Hype!

Market

penetration

Potential

financial

impact

Potential

clinical

impact

Patient

readiness

Market

readiness

Technological

readiness

Vendor

maturity

E-visits <1% High Moderate Very high Moderate Moderate Moderate

Videoconferencing 1-5% High Moderate High Moderate Moderate Moderate

Telesurgery 0% Low Low Very low Very low Low Very low

Standard Essential

Nice to HaveTransformational

Adoption, Impact and Time to ValueC

urr

en

t A

do

pti

on

Potential Impact

TeleradiologyCall Centers

Video teleconferencingTelecard. Services

E-visits

Telederma-tology

Telepath. (static)

Clinical Kiosks

Remote ICU

Home Health Monitoring (wired)

Mobile Health MonitoringLow

Low

High

High

Time to Value

Short

Medium

Long


Conclusion

Telemedicine Drivers and Inhibitors

DriversPatients:

• Keep patients at home, avoid admission to nursing homes

• Easier access to specialist care

Staff:

• Use scarce resources more effectively

• Skills transfer

Organization:

• Reduce travel costs

• Make money by offering new services/reaching more patients

InhibitorsFinancial:

• Reimbursement

• Financial justification

• Perverse incentives

Staff:

• Clinician resistance

• Staffing

• Legal and licensing

Technical:

• Integrating data with EMRs

• Cost and availability of infrastructure and connectivity


EUROPEAN COMMISSION WORKING PAPER

Barriers to the wider deployment of telemedicine

1. Confidence in and acceptance of telemedicine services Telemedicine changes traditional working methods and brings

new ways of practising medicine and delivering care.

New roles for health professionals, new skills and new actors (e.g. telemedicine call centres) appear in the process of healthcare delivery.

Understanding and implementing these changes in an acceptable and coherent manner is essential to enable wider deployment.


EUROPEAN COMMISSION STAFF WORKING PAPER

2. Legal clarity

Typical examples of the legal obstacles that wider deployment of telemedicine is facing are the need for physicians to be registered in all EU countries where they are providing services via telemedicine (e.g. interpretation of radiographs received via teleradiology), or the legal requirement for all medical acts to be carried out in the physical and simultaneous presence of the health professional and patient.

By not recognising telemedicine services specifically (the definition of healthcare services often does not include the concept of “at a distance”), most Member States discourage its wider use.



3. Technical issues and facilitating market deployment Issues linked to infrastructure, such as access to broadband and

the ability for the provider to enable full connectivity across the European territory from urban, highly-populated areas to remote, rural, scarcely-populated areas, still represent a major challenge.

The security of the network, the reliability and accuracy of certain types of telemedicine applications (for instance, using GSM lines to measure certain vital signs) are additional challenges.

On the other hand, for other types of telemedicine solutions, for instance the remote monitoring of cardiovascular implantable electronic devices, reliability and accuracy of the measurements are considered to be sufficient.


“There is evidence that, when combined with proper organisation, leadership and skills, telemedicine and innovative Information and Communication Technologies (ICT) can help to address some of the societal challenges to Europe’s healthcare systems. Its benefits range over different levels, from individual patients, through healthcare systems as a whole and to the wider European economy.”

Telemedicine for the benefit of patients, healthcare systems and society


SEC(2009)943 final

June 2009


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Denis Protti

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