For more than a decade, high hopes have been pinned on telehealth technology to help the U.S. health care system serve the rising population of patients 65 and older, who will number 72 million by 2030. Information-technology-based applications for health care have steadily extended the reach of providers beyond the hospital and clinic walls, offering rural patients more control and better quality treatment in places where hospitals are few and far between. But Americans are aging faster than our health infrastructure can handle, says David Lindeman, Director of the CITRIS Health Care Initiative. He anticipates that in the absence of effective solutions, quality of care will decline, costs will rise, and inequity of access will intensify. Can the telehealth systems scale to meet the demand?
One roadblock to telehealth is the conservative nature of patients and medical practices themselves. Visits to the doctor’s office can provide a sense of comfort and familiarity particularly among older adults, even though many of these individuals could benefit from a ‘telehealth’ visit. The transition to remote treatment and monitoring would require potentially unfamiliar new behaviors from patients, including the use of mobile phones and wearable digital devices to track their activities and vital systems.
Another challenge is uncertainty about how practitioners and hospitals should best be compensated for telehealth services. Providers also need to establish standards for protecting patient privacy while using telecommunications and social networking technologies that enable real-time communication and data access. The practices and mindsets for interacting with the online, mobile, data-generating patient are not common elements of medical school training.
Birthe Dinesen, a visiting scholar at CITRIS, says the first step to addressing these challenges is to better understand them through research. Her research interests lie in the use of telemedicine for post-surgical care and home-based care for patients with chronic diseases. Dinesen recognizes that policymakers and administrators will require reliable evidence of telehealth’s efficacy before investing the significant resources needed to bring new policies, infrastructure, and programs online.
The largest study of telehealth technology to date, the Whole System Demonstrator Programme (WSDP) conducted in the United Kingdom by the National Health Service between 2008 and 2011, examined 3,200 patients with heart failure, diabetes, or chronic obstructive pulmonary disease (COPD). Half of these patients were assigned to treatment plans that used telehealth devices to record weight, pulse oximetry, or blood glucose and automatically submitted results to monitoring centers for daily analysis.
“The results were interesting but mixed,” says Dinesen, an associate professor at Aalborg University in Denmark where she heads the Laboratorium of Telehealth and Telerehabilitation. While patient mortality dropped 54 percent with the telehealth follow-up—a tremendous improvement—the program was not found to be as cost-effective as projected and many of the patients did not perceive the benefits of telemedicine.
“I think expectations may be set unrealistically high,” says Dinesen, who has worked in the field since 2001. “We have always said that telehealth will provide better care, better access, and be less expensive. But all three goals might not be achieved in every case. And they might not all be achieved at the same time.” The WSDP study also revealed a strength and limitation of telehealth research itself: while the telehealth research tools can be individually tailored to a patient’s needs, a randomized control study requires that the therapy provided is identical in each case. “If a patient has arthritis and cannot use a touch screen tablet, the tablet will still be provided as part of the research study,” says Dinesen. Furthermore, once a study has begun, the specific technology introduced must remain the same even if new devices or models become available.
These challenges and the diverse perspectives needed to address them spawned the launch of the Transatlantic Telehealth Research Network (TTRN) at CITRIS earlier this summer. The network’s focus is the development of new diagnosis, prevention, and treatment technologies for patients to use in their own homes. Drawing pioneering members from Denmark, Boston, Cleveland, Sacramento, and Berkeley, this international research platform brings physicians, nurses, administrators, engineers, computer scientists, psychologists, and other interdisciplinary experts together to address key questions in telehealth technology. TTRN brings a multidisciplinary, multinational approach to developing new research methods by pooling insights from the domain expertise and unique patient populations of each participating organization.
The research aims to understand patients’ level of technical literacy and determine how best to motivate individuals to participate in these types of telehealth studies.
One distinct benefit for the U.S.-based members is access to research findings from the highly structured and socialized Danish medical system. Every citizen in Denmark is assigned a unique ID number and all medical records are managed in a single database. Conducting studies with large data sets for populations with particular conditions such heart disease is therefore much simpler to achieve than in the United States.
TTRN has already launched a foundational study, called Teledi@log (pronounced tele-dialogue), examining the role of telerehabilitation for heart patients and their family caregivers. Dinesen and her colleagues at Cleveland Clinic and UC Davis Medical Center are surveying 225 cardiac patients about the effects of recovering from a heart attack on their daily life, work, and travel.
Insights from the Teledi@log study and a second TTRN study on cardiac patients have the potential to inform the gadget revolution as well. Until recently, telehealth monitoring and communication devices were large, cumbersome, and dedicated to specialized functions. The widespread popularity of smartphones—including a growing number of older adult users—allows health researchers to design and test applications that are less intrusive, easier to tailor to individual preferences, and more engaging through games and educational apps, leading the way to better health outcomes for all.
by Gordy Slack