Professor Stanton Newman Professor of Health Psychology and Dean of the School of Health Sciences, City University, London

1. Healthcare
without
Walls
–
transforming
the
way
services
are
delivered
Stanton
P
Newman,
School
of
Health
Sciences
City
University
London

2. STRUCTURE
OF
TALK
•
Purpose(s)
of
TH

3. Background
-­‐
AssisEve
Technologies
Telehealth
(TH):
The
remote
exchange
of
data
between
a
paEent
and
health
care
professional(s)
to
assist
in
the
diagnosis
and
management
of
a
health
care
condiEon(s).
Examples
include
blood
pressure
monitoring,
blood
glucose
monitoring
and
medicaEon
reminders.

4. Range
of
TeleHealth
Technologies
FIXED
Home
telephone
E
mail
Web
or
TV
-­‐
informaEon
and
interacEon
Online
support
group
Passive
telemonitoring
systems
without
feedback
PORTABLE
Mobile
Phone
(calls
&
SMS)
PDA
(Calls,
SMS,
Data,
Picture
&
Video
informaEon)

5. ID168,
W,
77
yrs,
COPD

6. PenetraEon
:
84.5
%
10
Year
Growth
336.8
%

7. The
range
of
purposes
for
introducing
Telehealth

8. Outcomes
at
the
individual
level
–
the
parEcipant
Ability
of
the
person
with
the
chronic
condiEon
to:
Beaer
manage
their
symptoms,
treatment,
and
the
physical
and
psychosocial
consequences
of
their
condiEon
to
appropriately
monitor
their
condiEon
and
seek
help
at
appropriate
Emes
Maintain
independence
over
their
lives
(includes
caregivers)
maintain
quality
of
life
and
psychological
well
being
in
the
face
of
the
chronic
condiEon
Make
the
appropriate
behavioural
changes
to
play
increased
role
in
the
management
of
their
condiEon
8

9. Key
Psychological
processes”
Ability
of
the
person
with
the
chronic
condiEon
to:
Feel
more
in
control
of
their
symptoms,
treatment,
and
the
physical
and
psychosocial
consequences
of
their
condiEon
to
feel
empowered
and
supported
to
have
adequate
knowledge
and
informaEon
regarding
the
condiEon
To
feel
confident
in
their
ability
to
deal
with
the
cogniEve
and
behavioural
changes
required
to
adapt
to
the
demands
and
impact
of
the
condiEon
9

10. Key
clinical
&
system
outcomes
for
the
introducEon
of
telehealth
Ability
of
the
programme
to:
reduce
symptoms
and
clinical
indices
of
the
condiEon
to
reduce
health
&
social
care
uElisaEon
and
costs
to
promote
health
&
social
care
integrated
working
1
0

11. MulEplicity
of
processes
&
outcomes
for
telehealth
intervenEons
Proximal
Distal
Health
Behaviour
Responsibility Knowledge Clinical State Care
change
Utilisation
Patient & Taking
Reduce
carer appropriate Beliefs Adherence Costs
dependency
Participation action
Organisational System re-
Change
Confidence Attendance Isolation organisation
Change
Quality of
Professional Empowerment Disability
Life
behaviour
Independence
1
1

12. Issues
to
address
in
scaling
up
Telehealth

13. OrganisaEonal
Issues
Even
with
“excellent
evidence”
translaEonal
of
evidence
into
pracEce
is
complex
and
requires
organisaEonal
change
at
a
number
of
levels.
Service
innovaEon
needs
to
seen
to
be
compaEble
with
needs
values,
norms
and
ways
of
working
within
the
organisaEon.
RelaEve
power
and
interest
(professional
&
financial)
will
influence
likely
adopEon
Perceived
ownership
of
innovaEon
requires
careful
management
Ongoing
training
&
support
for
hcps
a
necessity
1
3

14. Behaviour
and
ways
of
working
Good
example
of
translaEonal
research
Majority
of
translaEonal
research
has
involved
technologies
not
a
service
innovaEon
involving
“human
capital”
“A
novel
set
of
behaviours,
rouEnes
and
ways
of
working,
which
are
directed
at
improving
health
outcomes,
administraEve
efficiency,
cost
effecEveness
or
user
experience
………….”
Greenhalgh
et
al
2004
1
4

15. Professional
Issues
Professional
ways
of
working
ingrained
and
onen
defended.
Rewards
associated
with
acEvity/skills
embedded
in
organisaEon
Flexible
working
not
hallmark
of
many
health
care
professions
Hierarchy
well
established
Costs
of
retraining
require
support
and
perceived
loss
of
funding
to
other
areas
1
5

16. Professional
concerns
Concerns
over
clinical
responsibility
and
liability
Reimbursement
on
fee
for
service
is
disincenEve

17. Health
Care
professional
paEent
relaEonship
CHF
Telehealth/telephone
&
Nursing
PracEce
Removes
on
of
the
key
features
of
nursing
pracEce
–
proximity
(vision
&
touch)
providing
support
(including
family)
Support
for
behaviour
change/self
management
TEMPORAL
ISSUE:
Coming
to
know
the
paEent
appears
to
take
place
parEcularly
during
face-­‐to-­‐face
contacts
at
the
beginning
of
the
care
trajectory.
If
relaEonships
with
paEents
are
well-­‐established,
‘seeing
the
paEent’
becomes
less
important
and
a
first
assessment
of
the
seriousness
of
paEents’
complaints
can
be
done
by
phone.

18. CHF
Telehealth/telephone
&
Nursing
PracEce
ReducEon
in
vision
removes
stereotypes
driven
by
visual
presence
Removes
rapid
judgements
based
on
vision
Emphasis
on
auditory
clues
and
capacity
to
listen
Others
who
can
give
support
to
paEents’
self-­‐care
tend
not
to
be
acEvely
enrolled
in
providing
or
supporEng
care.

19. CHF
Telehealth/telephone
&
Nursing
PracEce
Telemonitoring
transforms
self-­‐care
into
an
obligaEon.
If
daily
measurements
not
received
then
reminders
sent.
Introduces
a
daily
surveillance
of
paEents’
health
condiEon
that
enables
quality
control
over
the
paEent’s
self-­‐care.
The
increased
temporal
nearness
to
paEents
facilitates
a
form
of
care
in
which
paEents
receive
immediate
care
(medicaEon
or
hospital
admission)
in
a
case
of
medical
crisis.
QuesEon
as
to
what
this
does
to
the
relaEonship
between
paEent
and
health
care
professional

20. Different
forms
of
care
in
face-­‐to-­‐face
and
telehealth-­‐care
services
for
heart-­‐failure
paEents
Face-­‐to-­‐face
services
Telehealth-­‐care
services
Physical
proximity
Digital
proximity
–
intermiaent
monitoring
–
daily
monitoring
–
open
communicaEon
–
protocol-­‐driven
communicaEon
–
medical
intervenEons
and
advice
–
control
and
advice
–
nurse
as
counsellor
–
nurse
as
surveillant
–
psycho-­‐social
care
through
dialogue
–
psycho-­‐social
care
through
video
–
self-­‐care
as
opEon
–
self-­‐care
as
obligaEon
Contextualised,
Individualised,
Personalised
care
that
Immediate
care
that
consEtutes
heart
failure
as
illness
ConsEtutes
heart
failure
as
disease

21. Telehealth
-­‐
Evidence
Base

22. Telehealth
-­‐
ExisEng
Evidence
Base
limited
by
Methodology
&
short
term
follow
up
•
CriEcisms
of
the
literature:
-­‐
pilot
projects
-­‐
short-­‐term
outcomes,
do
not
assess
long-­‐term
or
rouEne
use
of
technologies
-­‐
studies
do
not
meet
robust
evaluaEon
criteria
(Bensink
et
al
2006;
Barlow
et
al
2007;
Whiaen
et
al
2007)

23. The
Evidence
Base
as
a
Barrier
Some
posiEve
paEent
reported
outcomes
(QoL)
not
sufficiently
persuasive
to
those
who
retain
clinical
and
managerial
responsibility
for
paEent
care
To
demonstrate
clinical
benefits
in
some
condiEons
requires
years
of
follow
up.
Few
studies
perform
long
term
follow
up
to
demonstrate,
enduring
behaviour
change
or
clinical
benefits
&
reducEons
in
morbidity
&
mortality
2
3

24. The
Quality
of
Evidence
as
a
Barrier
Davalos
et
al
2009

25. Overall
Aim
of
WSD
EvaluaEon
Aim:
to
provide
a
comprehensive
evaluaEon
of
the
addiEon
of
telecare
and
telehealth
to
whole
systems
re-­‐design.
Project
planned
to
assess
up
to
6,000
individuals
and
up
to
660
carers
with
a
variety
of
methods
and
levels
of
analysis.

26. WSD
EvaluaGon
Cluster
RCT
design
Group
A
Group
B
Group
C
Group
D
Social
Care
needs
Social
Care
needs
receive
usual
care
Social
Care
needs
Social
Care
needs
receive
usual
care
receive
telecare
receive
telecare
(CONTROL
GROUP)
(CONTROL
GROUP)
LTCs
receive
usual
care
LTCs
receive
usual
care
LTCs
receive
telehealth
LTCs
receive
telehealth
(CONTROL
GROUP)
(CONTROL
GROUP)

27. Total
Numbers
recruited
Target
5721
Recruited:
5831
1200
IntervenEon
Control
1117
1111
Control
IntervenEon
2881
2949
1057
49%
51%
1010
1000
800
775
760
600
Newham
1535
Cornwall
400
26%
2228
38%
200
Kent
2067
36%
0
Cornwall
Kent
Newham

28. Total
Numbers
recruited
1750
1625
1605
Control
IntervenEon
1500
1324
1276
1250
TeleCare
2600
TeleHealth
1000
45%
3230
55%
750
500
250
0
TeleHealth
TeleCare

30. Is
Telehealth
for
all
Onen
assumed
that
Telehealth
is
applicable
to
all
individuals.
Significant
proporEon
reject
telehealth
ApplicaEon
of
Telehealth
and
Telecare
may
be
less
appropriate
to
some
individuals
-­‐
favour
more
paternalisEc
approach
ApplicaEon
of
Telehealth
more
appropriate
in
condiEons
that
require
significant
monitoring
(e.g.diabetes,
CHF).
3
0

31. • “Our
assump*on
that
all
those
who
were
eligible
would
want
the
technology
proved
to
be
the
biggest
challenge
in
the
recruitment
process.”
(MarEn
Scarfe,
Project
Director
Newham)
hap://www.wsdacEonnetwork.org.uk/news/from_the_dh_pilots_update/
december_2009_wsd.html

32. WSD
:
Key
qualitaEve
themes
from
those
not
wanEng
to
trial
the
equipment
• PercepEons
of
health,
self-­‐care
and
dependency
• Views
on
technology
and
operaEonal
factors
• ExpectaEons
and
experiences
of
changes
in
service
provision
and
use

33. Non-­‐parEcipants:
Threats
to
health,
self-­‐
care
and
independence
• “I
think
you
feel
like
you're
not
in
control
of
your
life…
from
how
he
explained
it,
you
tended
to
have
to
do
your
blood
test
every
single
day…
I
try
to
be
a
bit
more
relaxed
and…
I
just
felt
it,
it
did
put
a
bit
more
pressure
on
me…”
(ID31,
W,
61
yrs,
Diab)

34. • “I
stood
at
my
front
door
the
other
day
and
I
thought,
'really,
truly,
this
world's
not
for
me
now,
it's
too
complicated,'
…
you
don't
speak
to
anybody,
you
get
buaons
you
push
and
press.
I've
got
a
mobile
phone
but
I
wouldn’t
even
know
how
to
use
it.”
(ID27,
W,
79,
diab)

35. • “…we
have
such
good
contact
with
our
district
nurses
and
our
supporEng
teams
around
us.
I
mean,
I've
only
got
to
phone
the
hospice
and
somebody
will
come
out…we've
got
so
many
contacts
around
us.”
(wife
of
ID134,
M,
70
yrs,
COPD)

37. Withdrawal
from
using
telehealth
&
telecare?
Withdrawal
reason
Telecare
N
(%)
Telehealth
N
(%)
Deceased
155
(5.85%)
164
(5.08%)
Physical
or
mental
illness
24
(0.92%)
50
(1.55%)
ResidenEal
or
nursing
care
68
(2.62%)
13
(0.40%)
No
longer
wishes
to
be
in
the
control
group
58
(2.23%)
69
(2.14%)
No
longer
wishes
to
be
in
the
intervenEon
group
and
19
(0.73%)
211
(6.53%)
rejects
the
equipment
aner
trying
for
a
period
No
longer
wishes
to
share
data
0
6
(0.19%)
No
longer
wishes
to
parEcipate
as
quesEonnaire
is
too
7
(0.27%)
8
(0.25%)
onerous
Moved
out
of
area
to
non-­‐parEcipaEng
GP
pracEce
19
(0.73%)
33
(1.02%)
Absence
from
home
or
loss
of
contact
10
(0.38%)
12
(0.37%)
Problem
with
equipment
(e.g.
equipment
broken,
no
3
(0.12%)
11
(0.34%)
longer
working,
misused)
No
reason
given
8
(0.31%)
15
(0.46%)

38. Significant predictors of withdrawal
from Telehealth
1. ParEcipants
in
the
intervenEon
group
more
likely
to
withdraw
2. Older
age
categories
increased
the
odds
of
withdrawal
3. Non-­‐white
BriEsh
ethnic
group
less
likely
to
withdraw
4.
More
co-­‐morbid
condiEons
greater
chance
of
withdrawal

39. Why
withdraw
from
using
telehealth
&
telecare?
Withdrawal
reason
Telecare
N
(%)
Telehealth
N
(%)
Deceased
155
(5.85%)
164
(5.08%)
Physical
or
mental
illness
24
(0.92%)
50
(1.55%)
ResidenEal
or
nursing
care
68
(2.62%)
13
(0.40%)
No
longer
wishes
to
be
in
the
control
group
58
(2.23%)
69
(2.14%)
No
longer
wishes
to
be
in
the
intervenGon
group
and
19
(0.73%)
211
(6.53%)
rejects
the
equipment
aQer
trying
for
a
period
No
longer
wishes
to
share
data
0
6
(0.19%)
No
longer
wishes
to
parEcipate
as
quesEonnaire
is
too
7
(0.27%)
8
(0.25%)
onerous
Moved
out
of
area
to
non-­‐parEcipaEng
GP
pracEce
19
(0.73%)
33
(1.02%)
Absence
from
home
or
loss
of
contact
10
(0.38%)
12
(0.37%)
Problem
with
equipment
(e.g.
equipment
broken,
no
3
(0.12%)
11
(0.34%)
longer
working,
misused)
No
reason
given
8
(0.31%)
15
(0.46%)

41. Differences by
long term condition
TH participants receiving telehealth kit for minimum 90 days- WSD
2.5
6
strongly
agree
2.0
1.5
5
moderately
agree
1.0
0.5
4
mildly
agree
*
p
<
0.05
0.0
*
p
<
0.05
-­‐0.5
3
mildly
disagree
-­‐1.0
-­‐1.5
2
moderately
disagree
-­‐2.0
-­‐2.5
1
strongly
disagree
-­‐3.0
increased
privacy/ care
personnel
kit
as
enhanced
care
saEsfacEon
accessibility
discomfort
concerns
subsEtuEon
COPD
1.358
4.858
0.664
a,b
4.164 -­‐1.667
a
1.833 -­‐1.154
2.346
-­‐0.066
3.434
1.867
5.367
a
b
Diabetes
4.743
1.243
4.382
0.882
2.150
-­‐1.350
2.498
-­‐1.002
3.112
-­‐0.388
5.137
1.637
b
a,b
Heart
Failure
4.752
1.252
3.949
0.449
1.966
-­‐1.534
2.496
-­‐1.004
3.385
-­‐0.115
5.266
1.766

42. Predictive validity of acceptability:
TH participants receiving telehealth kit for minimum 90 days- WSD
2.5
6
strongly
agree
2.0
1.5
5
moderately
agree
**
p
<
0.001
1.0
0.5
4
mildly
agree
**
p
<
0.001
p
>
0.05
**
p
<
0.001
0.0
**
p
<
0.001
**
p
<
0.001
-­‐0.5
3
mildly
disagree
-­‐1.0
-­‐1.5
2
moderately
disagree
-­‐2.0
-­‐2.5
1
strongly
disagree
-­‐3.0
increased
care
personnel
enhanced
care
privacy/discomfort
kit
as
subsEtuEon
saEsfacEon
accessibility
concerns
Completed
1.3720
4.872 .7192
4.219 -­‐1.6232
1.877 -­‐1.1103
2.390 -­‐.0926
3.407 1.8599
5.360
Rejected
Kit
3.740
.2400
2.917
-­‐.5833
2.767
-­‐.7333
2.811
-­‐.6889
2.544
-­‐.9556
4.411
.9111

43. PotenEal
for
cost
savings
resulEng
from
the
introducEon
of
telehealth

44. What
is
the
proposiEon
Widespread
introducEon
for
all
health
care
recipients
SelecEve
introducEon
for
those
in
a.Remote
and
difficult
to
access
environments
b.
SelecEve
condiEons
that
require
close
monitoring
c.
SelecEve
condiEons
and
age
groups
that
are
high
health
care
users
Purpose:
a.
savings
in
reduced
health-­‐care
uElizaEon,
fewer
face-­‐to-­‐face
visits
b.to
improve
health
care
outcomes
c.
reduce
inconvenient
travel
for
paEents
d.increase
convenience
of
health
care
professionals
e.
to
change
the
culture
of
health
care

45. What
severity
level
to
target
Reducing
other
health
care
costs
such
as
transport
&
GP
visits
may
not
show
short
term
cost
reducEons
in
many
condiEons
ExcepEon
is
in
those
condiEons
that
have
a
high
frequency
of
hospital
visits
e.g.
heart
failure
Re
hospitalizaEon
rate
is
very
high
(2%
within
2
days,
20%
within
1
month,
and
50%
within
6
months)
Seto
et
al
2008
SystemaEc
review:
Cost
reducEons.
were
mainly
aaributed
to
savings
from
reduced
hospitalizaEon
with
telemonitoring
compared
to
usual
care

46. When
to
introduce
Telehealth
into
the
health
service
Increasing
care
need
older
Current
policy
–perceived
greater
economic
return
ReducEon
in
hospitalisaEon.
But
older
and
less
tech
savy
But
fails
to
change
the
culture
and
train
and
integrate
telehealth
into
standard
care
Early
change
the
culture
and
train
and
integrate
telehealth
into
standard
care.
Younger
&
more
tech
savy
Greater
possibility
of
establishing
cultural
change
Liale
care
need
younger

47. Costs
as
a
Barrier
savings
in
reduced
face
to
face
visits
Low
TH
costs
High
face
to
face
visit
costs
High
TH
costs
Low
face
to
face
costs
Cusack
et
al
2008
The
iniEal
cost
of
the
telemonitoring
equipment
may
be
an
obstacle
to
widespread
use
of
telemonitoring
for
HF
and
other
chronic
disease
management

48. Possible
savings
in
Specific
Environments
SimulaEon
of
cost
savings
in
4
se{ngs
in
USA
1. emergency
departments,
2. prisons
(correcEonal
faciliEes),
3. nursing
home
4. physician
offices
savings
achieved
via
a
reducEon
in
transfers
of
paEents,
prisoners
and
nursing
home
residents
to
and
between
emergency
departments
and
physician
offices.
savings
in
reduced
health-­‐care
uElizaEon,
specifically
from
fewer
face-­‐to-­‐face
physician
office
and
emergency
department
visits
and
from
a
reducEon
in
duplicate
and
unnecessary
tesEng
Cusack
et
al
2008

49. Possible
savings
in
Specific
Environments
Area
No
of
instances
Cost
Saving
Transport
–
emergency
room
850,000
$537
mil
Transport
–
Prisons
to
ER
40,000
$60.3
mil
Prison
physician
visits
$210
mil
Transport
Nursing
home
-­‐ER
387,000
$327
mil
Nursing
Home
physician
visits
6.87
mil
$479
mil
NATIONAL
IMPLEMENTATION
$4.28
bil
Cusack
et
al
2008

50. What
are
the
range
of
costs
that
need
to
be
taken
into
account
Fixed
costs:
Equipment
etc
(capital
costs),
depreciaEon,
faciliEes
(e.g.
call
centre).
Variable
costs:
Maintenance
and
repairs,
installaEon,
admin
support,
training
etc
Unintended
Costs
:
Increased
surveillance
leads
to
beaer
detecEon
and
potenEally
increased
costs
of
care
.

51. VA
RetrospecEve
matched
comparison
group
study
of
TelerehabilitaEon
LAMP:
(Low
ADL
Monitoring
Programme)
Technologies
to
promote
independence
&
skills
to
remain
living
at
home
Programme
targets
people
with
mulEple
co-­‐morbidiEes
&
in
this
study
with
funcEonal
deficits
Matched
control
group
–
techniques
to
avoid
selecEon
bias
Bendixen et al 2009

52. VA
RetrospecEve
matched
comparison
group
study
of
TelerehabilitaEon
–
Cost
Differences
at
12
months
Bed
Days
Clinic
Visits
Emergency
Nursing
Total
room
Visits
Home
Admission
LAMP
-­‐
$804,268
+
$890,814
+
$415
-­‐
$2,414
+
$44,537
CONTROLS
-­‐
$677,732
+
$220,458
-­‐
$4082
-­‐
$15,470
-­‐
$476,824
Bendixen
et
al
2009

53. Saving
Lives
&
Improving
care
does
not
necessarily
imply
a
cost
saving
The
net
effects
of
improving
care
and
reducing
mortality
may
be
to
increase
costs
e.g.
heart
failure:
Improvements
in
the
diagnosis
and
treatment
of
MI
led
to
an
increasing
number
of
paEents
surviving
with
a
damaged
myocardium
who
may
subsequently
be
at
risk
of
developing
heart
failure.

54. Increasing
numbers
with
heart
failure
partly
because
of
improved
care
1. Heart
failure
is
essenEally
a
disease
of
the
elderly
.
Ageing
populaEon
will
lead
to
increase
in
HF
2. MI
common
and
rates
of
survival
increasing
-­‐
heart
failure
is
an
inevitable
sequel
in
a
significant
proporEon
of
survivors.
1. Base-­‐case
esEmate
(post-­‐MI
heart
failure
accounts
for
20%
of
heart
failure
cases):
1. Direct
healthcare
costs
-­‐
£125–181
million
2. Nursing
home
costs
of
£27
million;
2. Upper
esEmate
(post-­‐AMI
heart
failure
accounts
for
50%
of
the
total):
1. Direct
healthcare
costs
of
£313–453
million
2. Nursing
home
costs
of
£68
million.

55. Do
we
know
how
it
works

56. Different
models
of
how
TH
works
will
have
cost
implicaEons
Is
all
the
informaEon
required
for
management
sent
to
the
health
care
professional
for
a
decision
PotenEally
disempowering
Changes
relaEonship
of
HCP
to
surveillance
Unlikely
to
increase
self
care
5
6

57. Is
InformaEon
sufficient
1.)
The
implicit
model
of
TH
underlying
most
studies
2.)
A
simple
model
of
TH
including
self-­‐care
as
a
mediaEng
variable
3.)
An
elaborated
model
of
TH
including
self-­‐care
and
its
cogniEve
precursors
as
mediaEng
variables
Knowledge
a
b
c
a
a
Self-care f
b
QoL/ Clinical
Telehealth
Behaviour Outcomes
d
e
Self-efficacy

58. Conclusions
and
recommendaEons
re
scaling
up
Be
clear
about
the
desired
objecEves/outcomes
and
the
Emeline
for
their
realisaEon
Plan
and
manage
the
organisaEonal
change
required
Engage
professionals
and
address
concerns
InsEtute
training
early
on
in
process
Present
advantages
to
potenEal
parEcipants
–
use
clinicians
PotenEally
select
parEcipants
Be
clear
if
and
when
any
cost
savings
will
be
realised
Assess
processes
&
outcomes
so
as
to
drive
improvements
to
the
service
5
8

59. Thank
you
Stanton.Newman.1@city.ac.uk