Telehealth for long term conditions
BMJ 2012; 344 doi: 10.1136/bmj.e4201 (Published 21 June 2012)
Cite this as: BMJ 2012;344:e4201
- Josip Car, director, Global eHealth Unit1,
- Kit Huckvale, PhD student in mHealth1,
- Hermie Hermens, professor of telemedicine2
Latest evidence doesn’t warrant full scale roll-out but more careful exploration
Almost 50 years of innovation in telehealth have seen great progress in tackling a wide range of conditions using a variety of technologies and covering a wide range of outcomes. Although this work shows great promise, it also creates challenges for interpretation. The uncertainties in defining terms like “telehealth” reflect broader difficulties in interpreting the complex interplay of technology, service designs, clinical input, and patient involvement. New studies can challenge existing findings as much as they corroborate them. For example, two recent large scale trials of telehealth for heart failure found no benefit,1 2 whereas previous meta-analyses suggested reductions in mortality.3 4 5 To this we can now add the initial findings of one of the largest telehealth and telecare studies ever conducted: the UK Whole System Demonstrator trial (doi:10.1136/bmj.e3874).6
Telehealth does not just “work” or “not work.” Particular interventions may be successful, but this depends on many factors, including the specific contributions of the type of technology and of the context, such as the willingness and ability of clinical staff to change their care processes; the disease stage and severity of disease in the patients involved, their social backgrounds, and their needs and expectations; the predictive power of any monitoring data that are collected; and, indeed, the endpoints that are used to specify success.4 7 The research agenda established by systematic reviews of telehealth consistently argues for study designs that can generate insights into the active components within the black box of telehealth interventions.8 9 Although factors that might be important for successful telehealth can be described (box), we need more clarity on how to interpret the relative contributions of these elements. This concern is intimately bound up with uncertainties about the cost, quality, and safety of telehealth interventions, their effects on patient-clinician relationships, and their scalability and sustainability.
Key considerations for telehealth interventions
Remote clinical care enabled by technology supported information sharing and communication between patients and clinical staff. Interventions should:
- Extend or enable a clearly articulated disease management strategy for a specific group of patients at a particular stage of their illness
- Deal with one or more concrete needs that patients consider important and be able to enhance quality of life and clinical outcomes
- Promote convenience for patients and clinicians by allowing flexibility in monitoring and interaction with clinical services
- Support meaningful clinical care, using tools such as decision support for autonomous pre-emptive action and exception based monitoring for clinicians
- Be a dispassionate technology choice that is matched to the goals of the intervention and balances cost and functionality, including scenarios that allow patients to use their own smart phones or computers for monitoring
- Be easy to use for patients and clinicians, reflecting the best of modern usability design that people expect from consumer devices. Interventions should specifically consider elements of design that promote sustained use
- Be accessible to those with disabilities, limited dexterity, and those who do not speak English
- Be integrated into clinical computer systems because the information generated will need to outlive the technology used to generate it
- Be backed up by appropriate resources for staff as well as training, monitoring, and technical support for participants
- Enable appropriate delegation by clinicians of responsibility for monitoring—to control workload and cost and to manage risk
- Be designed to be gradually integrated into standard pathways for care using a phased approach to roll-out. Where appropriate interventions should replace, rather than add to, existing ways of working
These uncertainties must be resolved no matter how desirable it might seem to roll out telehealth. Although frustrating for patients and industry advocates, evidence based policy making is particularly needed when health systems are facing unprecedented resource pressures. The UK Department of Health is therefore to be commended for, in 2008, funding the Whole System Demonstrator project to be one of the largest telehealth (and telecare) trials ever conducted. The early findings of the telehealth component will be complemented over the following months by economic analysis and by qualitative exploration of the implementation process and participant experiences.
The highlight of the initial findings is reduced mortality in patients offered telehealth—an absolute reduction of 3.7% (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75), or about 60 lives over a 12 month period.6 This welcome finding needs a plausible explanation of how it was achieved (and can be replicated), especially because numbers of admissions were essentially unaltered in the intervention group, and existing evidence on the impact of telehealth on mortality is either mixed or lacking.12 7 10
The demonstrator trial combines three conditions—diabetes, chronic obstructive pulmonary disease (COPD), and heart failure—and was powered on a pooled analysis of effect. However, when there are questions about mechanisms of action and the relative contribution of subgroups to the ultimate findings, this strategy deserves further thought. For example, in England, the number of annual hospital admissions where diabetes is recorded as the primary diagnosis is about half that of admissions for COPD, despite diabetes being more than twice as prevalent. Telehealth related changes for patients with COPD might, therefore, have a greater effect on pooled estimates of hospital activity, particularly when the relative excess of patients with COPD in the demonstrator study group (compared with population prevalence) is taken into account. Furthermore, only a third of those invited to participate did so. Is telehealth particularly attractive for patients with COPD, and if so, why? There will also be questions, particularly if the pooled economic analysis is unfavourable, about whether targeting particular groups, perhaps by disease severity, might have been advantageous. These questions will not be answered by the current study.
Does the demonstrator trial provide convincing evidence for commissioning a national roll-out of telehealth? The findings reported to date suggest not, although we recommend caution until the full data are released. Does it provide justification for initiatives like “3millionlives”—the UK Department of Health’s plan to bring telehealth and telecare to three million people with long term conditions and complex care needs—not to proceed?11 Equally not: the evidence base is essentially unchanged and uncertainties remain. If it is politically expedient and makes sense in terms of how commissioners wish to innovate to meet patient needs then perhaps that is justification enough for the 3millionlives project. But we’re not sure. The difficulty of interpreting complex studies with nuanced findings, like the demonstrator trial, does not make decision making easy, but neither does it mean that the research is unnecessary.
Some unanswered questions will need new trials, but others can be dealt with by other routes. For example, the wealth of data generated by telemonitoring combined with data from electronic health records provides an important opportunity for large scale observational analyses, and that could include 3millionlives.12 Policy makers, commissioners, and guideline developers should help ensure that the research agenda focuses on areas where telehealth shows most promise. There is great potential but also still much to be done.
Cite this as: BMJ 2012;344:e4201
- Research, doi:10.1136/bmj.e3874
- Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
- Provenance and peer review: Commissioned; not externally peer reviewed.
Chaudhry SI, Mattera JA, Curtis JP, Spertus JA, Herrin J, Lin Z, et al. Telemonitoring in patients with heart failure. N Engl J Med2010;363:2301-9.
CrossRefMedlineWeb of Science
Koehler F, Winkler S, Schieber M, Sechtem U, Stangl K, Bohm M, et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation2011;123:1873-80.
FREE Full Text
Chaudhry SI, Phillips CO, Stewart SS, Riegel B, Mattera JA, Jerant AF, et al. Telemonitoring for patients with chronic heart failure: a systematic review. J Cardiac Fail2007;13:56-62.
CrossRefMedlineWeb of Science
Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, et al. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database Syst Rev2010;8:CD007228.
Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, et al. Home telemonitoring for congestive heart failure: a systematic review and meta-analysis. J Telemed Telecare2010;16:68-76.
FREE Full Text
Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S, et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ2012;344:e3874.
FREE Full Text
Polisena J, Tran K, Cimon K, Hutton B, McGill S, Palmer K, et al. Home telehealth for chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Telemed Telecare2010;16:120-7.
FREE Full Text
Black AD, Car J, Pagliari C, Anandan C, Cresswell K, Bokun T, et al. The impact of eHealth on the quality and safety of health care: a systematic overview.PLoS Med2011;8:e1000387.
McLean S, Nurmatov U, Liu JL, Pagliari C, Car J, Sheikh A. Telehealthcare for chronic obstructive pulmonary disease. Cochrane Database Syst Rev2011;7:CD007718.
Takahashi PY, Pecina JL, Upatising B, Chaudhry R, Shah ND, Van Houten H, et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med2012; published online 16 April.
Department of Health. A concordat between the Department of Health and the telehealth and telecare industry. 2012.www.3millionlives.co.uk/pdf/Concordat%20-%20FINAL.pdf.
Ekeland AG, Bowes A, Flottorp S. Methodologies for assessing telemedicine: a systematic review of reviews. Int J Med Informat2012;81:1-11.