Kamel Boulos MN. Telehealthcare for older people: barriers to large-scale roll-outs (Round table: Use of technologies to promote healthy aging and improve disability). In: Proceedings of the 1st Barcelona Conference on Healthy Aging (University of Barcelona), Barcelona, Spain, 14-15 November 2013 (invited presentation). URL: http://www.healthyageingbarcelona.com/speakers8.html

1. 15 November 2013, Barcelona, Spain
Telehealthcare for older people:
barriers to large-scale roll-outs
Maged N. Kamel Boulos, MBBCh, PhD, SMIEEE
United Kingdom
mnkboulos@ieee.org

2. Quick agenda
• The first half of this presentation will cover the
rationale behind telehealthcare, as well as its
potential and current applications (mainly in the
case of older people), before moving on in the
second half of the presentation to the barriers to
its wide adoption and what needs to be done.
15 November 2013, Barcelona, Spain

3. Tele = at a distance / monitoring and intervening from a remote location

4. Telehealthcare domains and applications
-
Alerts & reminders
http://ecaalyx.org/
http://dx.doi.org/10.3390/ijerph6071947
http://dx.doi.org/10.1016/j.ijmedinf.2011.03.003
http://dx.doi.org/10.3233/TAD-2011-0300

5. Video compilation: AAL (Ambient
Assisted Living) / telehealthcare
• http://youtu.be/Ewoa3vVUa5o
• Length: 7:33
Mr Peter Saraga CBE

6. Key findings from the Whole System
Demonstrator programme (England)
http://www.bmj.com/content/344/bmj.e3874
21 June 2012
The WSD programme was launched in May 2008. It is the largest randomised control trial of
telehealth and telecare in the world, involving 6191 patients* and 238 GP practices across three sites
in England (Newham, Kent and Cornwall). *Conditions covered: heart failure, chronic obstructive pulmonary disease, diabetes
See more at: http://3millionlives.co.uk/about-telehealth-and-telecare#nhs_innovations_expo

8. But WSD results also showed…
• “Second generation, home based telehealth as
implemented in the Whole Systems
Demonstrator Evaluation was not effective or
efficacious compared with usual care only.
Telehealth did not improve quality of life or
psychological outcomes for patients with
chronic obstructive pulmonary disease,
diabetes, or heart failure over 12 months.”
http://www.bmj.com/content/346/bmj.f653
26 February 2013

9. • “The QALY (quality adjusted life year) gain by
patients using telehealth in addition to usual
care was similar to that by patients receiving
usual care only, and total costs associated with
the telehealth intervention were higher.
Telehealth does not seem to be a cost
effective addition to standard support and
treatment.”
http://www.bmj.com/content/346/bmj.f1035
22 March 2013

10. The limitations and pitfalls of generalisation
• Some questions to ask/discuss: would it be correct to generalise from one study,
however large it might be (even a big RCT such as the WSD), which at the end
only evaluated one specific instance of the technology (an American system in
the case of WSD) under specific settings, and to blindly apply the results to the
whole class to which that technology belongs (AAL/telehealthcare in general)
and to all possible settings?
• Not all telehealthcare solutions are the same; there are things they share in
common, but also very unique specifications and successive versions/iterations
for different solutions (technology develops and changes fast), which might
greatly affect the results of any evaluation/user acceptance study.
• By the time you get some evaluation results published, a new, supposedly better
technology/version might have already replaced the evaluated solution on the
market.
• Implementation environment, settings and user profiles can also (greatly) affect
results. For example, in the WSD, they chose sites where there was already a
good deal of healthcare and social care integration, but this is not always the
case everywhere else.
• Should we evaluate telehealthcare interventions in the same ways we evaluate
new drugs (standard RCTs/clinical trials)? (paper for reflection)

11. How do we cure ‘pilotitis’?
http://skollworldforum.org/debate/how-do-we-cure-mhealth-pilotitis-critical-lessons-in-reaching-scale/

12. • Questions asked and addressed at a recent Partners Connected Health
Symposium in Boston (Oct 2013) - quotes (lightly paraphrased) from event news
report at http://mobihealthnews.com/26699/whats-stopping-mobile-healthinterventions-from-scaling/:
– When is it time to stop running pilots and go to scale?
– What challenges does that process offer? Does every provider organisation
have to reinvent the wheel, or can they learn from each others’ pilots?
– For one organisation/site to learn from the other (transferable experiences),
we need to have a very detailed analysis of the work, time, resources and
conditions/settings that go into, and what exactly comes out, of a given
telehealthcare solution implementation, so that others can fully benefit from
what we have done.
– Pilots in clinical settings often fail to track return on investment (ROI).

13. – The problem with using ROI to evaluate pilots is that many of the newest
endeavours in medicine are preventative and/or have expensive startup costs.
So short term ROI can look deceptively bad. An example was offered of a
calculator that is used to evaluate longer-term ROI: http://www.telemedroi.com/#home
– The ‘Big Brother’ problem and what to (best) do with the ‘Big Data’ that is
continuously generated by telehealthcare sensors (need to be sensitive to
individuals’ privacy).
– The need to specifically consider the specific population an intervention is
targeting. Is the user interface one older people will be able to use? Is it available
in the right languages (also think users’ general and health literacy levels here, plus any
special usability/accessibility/other requirements they might have)? That sort of
population targeting can affect the success of an intervention, but it also makes
it harder to use the same strategies at different sites without doing somewhat
repetitive efficacy studies.
– Pilots can build an ‘ecosystem’/accumulate evidence that in the long-term will
help us with better results and better quality care. Do the learning and have a
plan to scale from it. Always start small where you think is the actual need, and
once the adoption results and outcomes are measured, you can scale it into
Quotes (lightly paraphrased) from http://mobihealthnews.com/26699/whatsdifferent markets/sites.
stopping-mobile-health-interventions-from-scaling/

14. Transferable experiences
• The NHS in England is learning
from the US Veterans Health
Administration, home of the
largest implementation of
telehealth anywhere in the
world.
• A report is now available
describing lessons learned from
both sides of the Atlantic and
recommendations for both
organisations:
http://www.2020health.org/dms/2
020health/downloads/reports/202
0vhanhsONLINE_8-3-13FINAL.pdf
Published in March 2013

15. Barriers, challenges and desiderata
Report by the Digital Policy Alliance:
http://dpalliance.org.uk/wpcontent/uploads/2013/01/1301_Telecare-andTelehealth-Briefing.pdf
Published in January 2013

16. Government (UK) warned over
rapid telehealth rollout risks
News headlines from Q1 2013 (UK)

17. Telehealth news headlines from Q3 2013 (UK)

18. Barriers, challenges and desiderata
• Despite its great potential and promises, telehealthcare is facing serious
barriers and challenges in the UK. (Similar issues can be found in other parts of
Europe.)
• The aforementioned Jan 2013 report by the Digital Policy Alliance warned of the
risks of the UK Government’s accelerated telehealth roll-out, and made a series
of recommendations to ensure the roll-out of telehealth & telecare meets the
Government’s objectives of 3 million users and £1.2bn saving over 5 years.
• The report highlighted the following main barriers:
– Skills shortage and lack of sufficient knowledge among stakeholders* of the
capabilities and uses of telehealth & telecare and of the associated professional
standards required to ensure high quality coordinated care;
(* Lack of sufficient knowledge may lead to resistance to change / fear of the new)
– Difficulty of demonstrating that the organisation bearing the cost is also
receiving the benefit (ROI): telehealth & telecare benefit patients by enabling
them to remain at home, live independently for longer and avoid hospital
admissions, but GP practices/NHS commissioners and social service departments
do not always see any (direct/immediate or short-term) financial benefits from
these outcomes; and
– Lack of appropriate multiagency coordination.

19. What needs to be considered and done /
desiderata for success
• There is an urgent need to educate and raise the awareness
of healthcare professionals and other relevant stakeholders
about the benefits and best uses of the different AAL /
telehealthcare technologies on offer.
• Capacity building and training / addressing the ‘skills gap’ /
adopting appropriate instruments for accreditation and
certification of competency of involved staff.
• Quality benchmarking, accreditation and certification should
also be extended to systems (hardware and software),
processes and services, in addition to staff, e.g., following the
models of TeleSCoPE (EU code of practice) and Happtique (US
mobile app certification).
In addition to / beyond:
etc.

20. TeleSCoPE - Telehealth Services Code of Practice
for Europe
http://www.telehealthcode.eu/images/stories/telehea/pdf/TELESCOPE_2014_CODE_FINAL_PDF__RELEASE_29_OCT_2013.pdf

21. Currently US only
http://www.happtique.com/docs/HACP_Certification_Standards.pdf
See: Kamel Boulos MN, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health
apps: state of the art, concerns, regulatory control and certification. 2013; Submitted Jul ’13 (under peer
review). Link to published paper will be posted in due course on my social media channels (see last slide).

22. What needs to be considered and done /
desiderata for success
Multiagency coordination / healthcare and social care integration
• The integration of health/care and social care has long been identified as
one of the main deficiencies in some existing AAL / telehealthcare
provisions and one of the reasons for their lacklustre results in some
scenarios (See: CommonWell (a project co-funded by the European
Commission, 2008-2012). Beyond Silos – On the way towards integrated
eCare. http://commonwell.eu/beyond-silos-integrated-ecare/).
• After all, AAL is about enabling and supporting the ‘independent living of
older people’, and using a BAN (Body Area Network) for monitoring (and
acting on) vital and other clinical signs and symptoms, although
extremely useful and important, is just one component of any
comprehensive care solution, and not the full solution.
• Robots (not all of them!) bring in the opportunity of addressing the key
issue of ‘integrating health/care and social care’ in comprehensive
solutions that involve both robotics and conventional telehealthcare
technologies.

23. Robotics
• Robotics can potentially provide AAL with the (often missing) ‘social care
component’:
– by assisting older people, including those with different types of disabilities,
in various activities of daily living and domestic chores, and
– by offering them coaching/motivation, companionship/home visits and
other much needed services.
For a detailed discussion of the topic, including the limitations and potential problems associated
with the use of robots for the care of older people and ways of mitigating them, please consult:
Dahl TS, Kamel Boulos MN. Robots in health and social care: a complementary technology to
home care and telehealthcare? 2013; Submitted Oct ’13 (under peer review). Link to published paper
will be posted on my robotics online “scrapbook of links” at: http://tinyurl.com/mnkb-robots

24. Video games and exergames
• Video games and exergames (e.g., Kinect and GPS), particularly
those with a social component (game community / multiplayer),
can also help in many ways.
The Exergamers Wellness Club uses Kinect for Xbox 360
(dancing titles) to help seniors at the St. Barnabas Senior
Centre in Los Angeles stay fit and have fun.
Kinect game revolutionising rehab for stroke
survivors.

25. What needs to be considered and done /
desiderata for success
•
•
•
•
•
Implementing appropriate technical and interoperability standards,* regulation and
increased bandwidth (infrastructure upgrade). (*Standards ensure joined-up health/care
and social care services, as well as future proof telehealthcare services that
are easily expandable and not dependent on a specific manufacturer.)
Sometimes a simpler solution / basic technology is all what is really needed and will
perform better. Introducing the latest, most sophisticated technology should never be the
goal as such (unless really justified / needed to improve an existing situation that cannot
be dealt with satisfactorily with the existing technology), as it might bring in more trouble
than (any needed) benefit, due to increased complexity and costs.
Consider all the “hidden” costs: staff (training, etc.), technical, infrastructure and site
(implementation environment) modification costs. Running, maintenance and upgrade
costs can all be very high, and should be carefully analysed and considered ahead of any
implementation to ensure long-term sustainable success.
Have ‘Plan B’/some ‘system redundancy’ to ensure reliability and robustness, e.g., the
availability and automatic triggering of proper contingency plans and mechanisms for
services that are remotely operated over the Internet to continue functioning safely when
their main Internet connection with patients is broken for whatever reason.
Transform patients’ data into clinically sound decisions and actions by using ‘intelligent’,
evidence-based software that goes beyond threshold-based, single-parameter triggers and alarms.

26. • Today, one can easily buy very many wireless sensors on the market with their essential
software drivers (for connectivity and data collection from the sensor), and then connect
them to a local hub and remote server, but that (alone) won’t make for a useful
AAL/telehealthcare solution or solve anything serious clinically speaking.
We should be well past this stage in the second decade of the 21st century.

27. ‘Intelligent’, evidence-based software beyond
threshold-based, single-parameter triggers and alarms
• Clinically safe, reliable and ‘intelligent’ (evidence-based) software remains
necessary to reason with the ‘big data’ that are continuously generated: in realworld scenarios we are speaking about 100s (or 1000s) of older people being
monitored by the same service at the same time, so it is indeed big data/
‘infoglut’, and there are also serious issues of liability here, since we are dealing
with human lives, as well as issues of service scalability and sustainability.
• The software has to make those data instantly useful and actable upon for
clinicians (and patients), and has do so in a timely manner, often in real- or nearreal-time, with minimal false positives and false negatives. It also needs to
highlight as early as possible any unfolding clinical events, subtle deterioration or
other relevant developing trends in patient’s condition.
• This ‘intelligent’ software (not to be confused with the essential drivers and basic
sensor connectivity/networking or ‘plumbing’ software) can make a real
difference, but is not as easy to acquire (as the sensors and their basic software)
from the general market or to develop and tune in-house.
• Anyone with the right skills can do system procurement and plumbing, but not
everyone can deliver a useful, safe, reliable, scalable and sustainable service
(note the difference between ‘system’ and ‘service’).

28. “There isn’t too much information, but it is a challenge to
turn that information into understanding” —Larry Smarr
Without the appropriate ‘intelligent’, evidence- and
knowledge-based software to reason with those
data, we risk giving a false (dangerous) reassurance
that everything is being monitored and under
control, while in reality this is not the case!

29. Selected resources
•
•
•
•
David Lindeman: Interview: lessons from a leader in
telehealth diffusion: a conversation with Adam
Darkins of the Veterans Health Administration. Ageing
Int 2011; 36(1): 146-154 –
http://dx.doi.org/10.1007/s12126-010-9079-7 (alt)
Katharina Spitalewsky et al: Potential and
requirements of IT for Ambient Assisted Living
technologies: results of a Delphi study. Methods Inf
Med 2013; 52: 231–238 –
http://dx.doi.org/10.3414/ME12-01-0021
Maged N. Kamel Boulos: Telehealthcare for older
people with comorbidity: lessons from eCAALYX and
project walk-through (2013) http://www.slideshare.net/sl.medic/mnkb-12mar2013aalinnovateuk
Maged N. Kamel Boulos: Telehealthcare promises and
challenges (2009) http://www.slideshare.net/sl.medic/telehealthcarepromises-and-challenges (see also:
http://ecaalyx.org/healthcybermap.org/publications/BoulosInterop3rdME-HIConfBeirutLeb31Mar10.zip)

30. Follow me:
/mnkboulos –
/IJHGeo – G+ –
@mnkboulos –
@IJHGeo

31. Appendix: Additional notes on cost effectiveness
Cost effectiveness is not always a tiebreaker as such, especially when the
other (more cost effective) options on the table are not viable or
sustainable in the long run (e.g., due to specialised workforce
shortages/increasing demands by consumers).
In some cases, cost effectiveness/ROI might not be immediate or available
in the short term, but might still happen in the long term. Also, sometimes
the less cost-effective option carries with it some unique and compelling
advantages that are not found in other conventional solutions, e.g.,
benefits related to clinical safety and reliability/outcomes or quality of
care, etc., as seen, for example, in telerobotic surgery (da Vinci).
Telehealthcare solutions might be replacing one workforce skills shortage
(healthcare professionals) with another (but perhaps the latter
telehealthcare skills shortages can be more easily addressed).
Telehealthcare solutions might not improve quality of life over/above
other existing options (as reported in a study by Newman et al, 2013 in
BMJ2013;346 doi: http://dx.doi.org/10.1136/bmj.f653), but there might
still be a strong case for their adoption when other factors are considered.