While telehealth is helping to change the face of clinical practice, it comes with challenges
What is telehealth?
Telehealth is the use of electronic communications and virtual technology to deliver healthcare beyond traditional healthcare settings. It is also known as:
- Remote care.
- Remote monitoring.
- Mobile health.
- Technology-enabled care services.
Telehealth is a delivery model for digital medicine, and may use digital products and services designed to diagnose, prevent, monitor and treat diseases or conditions.
It can involve a broad range of technologies, some of which are already having a positive impact on physiotherapy practice and healthcare delivery, although adoption is uneven across the NHS.
Services may take place through:
- Video or telephone consultation
- SMS communication
- Use of health apps
- Data collection and analysis from home devices, including spirometers, non-invasive ventilators (NIVs), blood glucose monitors and activity/exercise monitors
Telehealth is commonly used to support patients with chronic obstructive pulmonary disease, chronic heart failure, type 2 diabetes, cancer, mental health conditions, and other long-term conditions including musculoskeletal disorders and rheumatic diseases.
What does telehealth aim to do?
- Remotely monitor patients – providing additional information between hospital visits to reveal more accurate trends and themes in outcome measures. This can enable more knowledgeable clinical reasoning and decision-making.
- Overcome geographical barriers – connecting users who are not in the same physical location. This can reduce the time and financial burden involved in repeat hospital visits, which can require patients to take time away from work or education.
- Use technology effectively – employing the options best suited to the user.
- Improve health outcomes – helping with early identification of deterioration, triggering a prompt review, and leading to the initiation or escalation of treatment to prevent further decline. Consistent home monitoring also allows interventions to be evaluated and adapted in a timely manner.
Equipment to support telecare may include:
- Weighing scales
- Pulse oximeters/spirometers
- Blood pressure home monitors
- Apps, including those with validated symptom questionnaires
- Wearable devices, such as activity/exercise monitors
- Mobile devices that connect to other devices using Bluetooth
Spotlight on ‘wearables‘
Wearable technology has the potential to transform how patient data can be captured. It can collect habitual data such as step counts that can be used to inform healthcare practice across settings.
The adoption of wearables remains slow, even though this technology could be used to develop a number of new digital biomarkers that could provide insights into disease onset and progression and enable more targeted patient management. This could transform care for those who currently experience poor health outcomes.
Methods combining a number of wearables (for example, accelerometers, GPS and smartphones) may supplement traditional approaches of assessment by providing objective ways to investigate health variables.
Wearables could also allow clinicians to gain access to well-rounded data instead of snapshot assessments gathered in clinical settings.
Why is telehealth important?
Telehealth is a constantly evolving model of healthcare delivery. It incorporates advancements in technology that are responsive and adaptable to changes in health needs and society.
Its benefits in physiotherapy may include:
- Helping patients to self-manage long-term conditions.
- Empowering patients to become independent
- Reducing hospital stays
- Enabling earlier hospital discharge
- Reducing dependency on primary care
- Making care accessible from anywhere, which reduces the costs to patients in terms of travel, time and loss of work while also eliminating cross-infection risks
- Lowering non-attendance rates
Challenges of telehealth
Telehealth has been shown to be effective but there is less evidence of its impact on service use and costs. Few telehealth evaluations have examined the association between outcomes and costs, and the current evidence base includes studies of poor design and small sample sizes. Much existing evidence is based in the United States and its applicability to the UK is untested.
There are a number of things to consider when setting up a telehealth service.
- How will giving patients direct access to information about their conditions and treatment affect their sense of control over their condition?
- How might telehealth aid shared decision-making?
- What aspects of telehealth could increase an individual’s awareness of and ability to self-manage their condition?
- In terms of data-sharing between patients and health professionals, what aspects of telehealth need to be considered for these practices to be adopted?
- Have you reviewed the research evidence within your health profession to ensure that telehealth is effective at improving outcomes while also being cost-efficient?
- Telehealth requires a strong, reliable internet connection.
- Have you checked the telehealth regulations to ensure your service is compliant with the General Data Protection Regulation (GDPR)?
Patient access to care
- Do you have a clear pathway for referring patients to appropriate care if they are not suitable for telehealth or if their condition does not improve satisfactorily?
- Who might want to use your telehealth service? Variable access to technology due to disability, age or income could lead to some users being marginalised.
Examples of telehealth services
Online physiotherapy consultation
This short film based on a service model in Australia may improve your understanding of how online physiotherapy could be delivered in the UK.
Telehealth in action in a UK physiotherapy practice
Melanie Martin is an advanced physiotherapy practitioner working in rheumatology in London. Melanie designed and trialled a telehealth service to address high demand for her clinic.
Why did you set up the telehealth service?
Follow-up for people with axial spondyloarthritis is generally life-long, hospital-based and medically driven. Patients frequently travel a long distance, sometimes only to report that they are well and that their disease is in remission. Patients can often attend what may be an unnecessary appointment at that moment in their disease course. There is also the potential to miss deterioration in disease status – ie, increased disease activity or flare between hospital visits.
How did you design your telehealth service?
It was a simple service design model. Patients were sent an SMS with a link to a disease-specific Patient Reported Outcome Measure (PROM) five days before their appointment. The results were then reviewed by the physiotherapist (by telephone, video or face-to-face). By reviewing this data, the clinical team could see who might be flaring and need more input. By collecting patient data using electronic PROMs prior to attendance, patients’ disease status could be proactively monitored and consultations arranged (either face-to-face or remotely) when most needed.
Why use PROMs?
PROMs capture disease-specific parameters from an individual’s own perspective. PROMs have the potential to improve the quality of care received. Paper PROM collection in clinic has been sporadic and ineffective, while web-based formats are acceptable and reliable. Capturing this data over time enables the overall control of the patient’s disease to be monitored and optimised as necessary.
How can we be responsive to users’ needs?
This project demonstrated good acceptability and utilisation in clinic with an average patient completion rate of 62.9 per cent. Patients felt they were given more time to complete the questionnaire rather than hastily completing it in clinic. They also felt that the scores did impact on their overall shared decision-making about their care, and the clinician was seen to be using their data to inform discussions about treatment.
What did service users think?
Feedback about the telehealth service was encouraging:
- ‘It made me feel better knowing someone was going to see my scores and there would be a plan.’
- ‘It was pot luck if you got the timing right with your symptoms when completing the form in clinic.’
- ‘At home, when you have time to fill [the form] in, you think about what might have caused the flare.’
Capture of multi-dimensional ePROMs for engagement and monitoring of patients outside the face-to-face setting is an emerging practice for the management of inflammatory arthritis. It has the potential to lead to more flexible and responsive outpatient servicesand informshared decision-making and agreed deferment of appointments when patients are in remission.
Resources to help you consider the design and delivery of telehealth services:
- British Medical Journal
- Digital Health Evidence Standards Framework
- NHS England TECS webpage
- NHS England TECS examples
- NHS website resources
- Topol review
- World Health Organisation
- Melanie Martin
- Lindsay Bearne
- Ashley James
- Jocelyn Choyce
- Dylan Powell
Edited by Daniel Allen