Telehealth literature review
The ever-growing demands for and pressures on health-care services across the UK have led policy-makers to seek an effective and efficient way of managing uncontrolled expenditure in the NHS. Harnessing advanced Information and Communication Technologies (ICT) to support the “business of care” has led, in turn, to the positioning of computers and integrated clinical information systems at the heart of the late-20th-century care delivery management process.
Health telematics
The efforts to embed advanced computing into the health-care sector are today matched by efforts to utilise rapid developments in telecommunication. These could have the potential to revolutionise the health-care system and support new ways of delivering care at a distance.
Focusing on the possibilities and practice of remote delivery of health-care services has led to the emergence of a specialist field within the health-care informatics sphere: health telematics. The general definition of this, as set by the World Health Organization (WHO), is: “Health-related activities, services and systems carried out over a distance by means of information and communications technologies.”
Telemedicine
The term telemedicine became prominent in health-care literature in the early 1990s. The word was created by adding the prefix tele, ancient Greek for “distant”, to medicine. Telemedicine thus means quite literally “medicine practised at a distance”. It is used to describe a range of activities such as remote interactive health-care consultations, provision of Accident and Emergency (A&E) expertise to isolated locations, remote monitoring from home, and education for patients and health professionals. It is now seen as a support tool to aid health-care delivery, similar to the functionality offered by the fax machine or the stethoscope.
The first telemedicine applications were developed in the late 1950s, when interactive video communications technology had limited capability. The result: poor audio, poor imaging and poor reliability, using what was then very costly technology. Consequently there was very limited clinical interest in this emerging practice.
The first generation
However, in the 1970s advancements in computer technology and higher processing speeds and power stimulated renewed interest in further telemedicine trials. The expansion of low-cost telecommunication networks provided another impetus. Rather than merely a skill substitution, telemedicine was seen as an opportunity to change medical practice radically – to provide a seamless delivery of care, especially to remote and under-served communities.
However, despite this promising future, hardly any of the first-generation telemedicine projects – that is, those implemented prior to 1986 – survived beyond the original grant funding cycle. It is claimed that such an outcome was not the result of a failure to achieve stated objectives. Rather, it was a consequence of a combination of factors such as the limitations of the technology of the time and clinicians’ and patients’ unfamiliarity with it and limited experience in its use.
Norway, the UK and the US
Real interest in using telemedicine as a mainstream tool to aid universal service provision to the general population was reawakened in Norway in the early 1990s. The particular health-care needs of its remote centres of population favoured a telemedicine model based on providing real-time video-consultations. This technology was now far more robust and much less expensive, and advances in image digitisation and data compression had made interactive video-conferencing over lower-bandwidth lines possible. This meant that programmes could function without having to use high-cost satellites or other costly options.
In the UK at the same time, there was little support for the development of telemedicine, and minimum activity was noted here. The promotion of value for money through consumerism, plus competition over clients, did not create fertile ground for widespread use of telemedicine, which at that time had yet to prove its economic viability. Within clinical environments, some strongly argued against the adoption of telemedicine as a clinical tool, suggesting that technologists had failed to devote enough time and resources to a systematic evaluation of such applications.
Unlike the reception in the UK, telemedicine remained a popular option in Scandinavia and in the United States where, in 1995, the annual rate of telemedicine consultations overtook that in Norway, shifting the main focus of activity in this field away from Europe to North America. Then the change of government in the UK in 1998 and the publication of the information strategy Information for health placed telemedicine as one of the core services to be offered in a modern, visionary NHS.
Telehealth
A recent trend noted in the literature on telematics developments is the prominence of the term telehealth, which now appears to be preferred over telemedicine when describing the generality of the practice of care over distance. Telehealth is especially favoured in nursing literature as the term itself reflects the importance of an overall multi-disciplinary/multi-professional approach to delivering care rather than emphasising the role of medical practitioners.
Telehealth applications also, it is said, incorporate heterogeneous technologies and services that cut across boundaries between different professions, including medicine, health promotion and administration, social services and information specialists.
While the published literature on telehealth is evidently increasing, an Australian study argues that its effectiveness is currently limited because it still remains outside mainstream health care. This report quotes critics who perceive telehealth as a peripheral activity and simply a novelty for technology enthusiasts.
e-Health
The major (cost) benefits of telehealth, the authors claim, will not be realised unless telehealth is perceived as an integral part of a larger domain, that of ehealth. The study indicates that, with the relentless convergence of technologies and the consequent increase in our ability to perform multiple functions with those technologies, it is unwise to solely emphasise the distance factor – the tele in telehealth.
The term e-Health was barely in use before 1999, yet now seems to encompass not only digital health care and Internet medicine but virtually anything related to computers and health care. It covers the use of digital data transmitted electronically for clinical, educational and administrative applications, both face to face and at a distance.
Some argue that e-Health is actually being driven by non-professionals – patients asserting themselves as equal partners in health-care decision-making who, along with their demand for empowerment through access to health-care information and knowledge, are pushing forward new developments in services.
Assistive technology
Assistive Technology (AT) is another term used for a range of products that are set to enhance and support people regaining and maintaining their independence. AT is defined as:
… any item, piece of equipment, product or system that is used to increase, maintain or improve the functional capabilities and independence of people with cognitive, physical or communication difficulties. This broad definition incorporates an incredibly large number of devices, ranging from “low-tech” mobility devices such as walking sticks to “high-tech” speech synthesisers or stair-climbing wheelchairs. These technologies can be used to support a wide range of user needs and to support people to maintain their independence.
Audit Commission 2004
For advice on assistive technology, see Practical thinking about technology for people with dementia.
Telecare
Another new term, telecare is defined as “the delivery of health and social care to individuals within the home or wider community, with the support of devices enabled by information and communication technologies”. It is therefore concerned with the provision of care and community support to a patient at a distance. Such provision of care includes: “… monitoring the daily living of individuals at risk, by harnessing telecommunication to other technologies ranging from television cameras to alarm systems”. Telecare is based on the premise that people should be able to participate in the community as much as, and for as long as, possible.
Risk management through the monitoring of (in)activity, using sensors either on the body or in the environment (e.g. the home), is but one element of telecare. The other is information provision where information is “pushed” by a service provider (appointment reminders, for example) or “pulled” by the client from a designated health-care portal. This information can be delivered in a variety of ways including via the telephone (fixed or mobile), through the Internet or cable or satellite TV or via public information kiosks.
Community Alarms
The best-established risk-management-type telecare service currently in use in the UK is the network of Community Alarms, which provides 24-hour support for clients in their homes. Such a system typically involves a wireless “panic button” and pull cords around the home, which enable users to raise the alarm and to initiate requests for assistance via hands-free telephones connected to an operator in a control centre.
Despite the robustness and the success of Community Alarms, its main flaw is that it relies on users to initiate requests for assistance. This makes the system operationally redundant in cases where users are unaware that there is a problem requiring external intervention, are too ill (unconscious) or are mentally incapable of taking action to initiate contact with the control centre.
In response to such concerns, recent technological developments have enabled the upgrading of the first generation of Community Alarms, and in a number of test sites across the UK, this technology is being evaluated and implemented.
Potential
Life-style sensors may yet prove to be the best, proactive, preventative way to intervene before emergencies occur. Thus there is major economic/market potential for the development of this technology by commercial organisations.
However, it may be argued that, in some cases, technology-dominant living solutions may be not only inappropriate but detrimental to people’s health and well-being, by depriving them of opportunities for physical and mental exercise. As ever, sound clinical decision-making is needed to ensure that the right balance is maintain between the ‘smart environment’ and the need for human interaction.
For a full a full list of references contact Shařon
Sharôn Levy