Telehealth is increasingly being advocated as a way to monitor patients remotely and better manage long-term health conditions. The Nuffield Trust was part of the largest randomised controlled trial in this area, “the Whole System Demonstrator” (WSD) – the initial results were published earlier in the summer.
We held a seminar with practitioners, researchers and funders to discuss the remaining research that needs to be done, post WSD. Priorities were identified as; understanding the current and potential size of the telehealth market, which patients are most suitable for telehealth and the business and service models. Methods of involving patients in development of services appear to be underdeveloped.
Meanwhile, the new clinical commissioning groups (CCGs) and providers still have a difficult task in making evidence-based decisions about telehealth.
The evidence so far does not give a simple ‘yes’ or ‘no’ answer. Even the results from randomised controlled trials can be ambiguous and context dependent.
The WSD trial concluded that telehealth was associated with fewer emergency hospital admissions and deaths, but it was inconclusive about impacts on hospital costs. Telehealth could have different impacts in other settings, for example, if services are designed differently.
Decisions about investment should reflect patient outcomes as well as costs. However WSD results on quality of life and other patient-reported outcomes have not yet been published by the peer-review journals (watch this space). The danger is that decision making is being overly driven by impacts on emergency admissions as a result.
One new piece of evidence is available – a study about the reasons given by patients for not wanting to participate in the WSD trial has been published. This showed that telehealth was thought to pose problems for some patients – for example, it might not fit with existing ideas about self care or daily schedules.
The available research does not answer every question. This does not mean nothing should be done. Many changes have been introduced in health care with much less evidence than currently exists for telehealth. The question is about how to proceed rationally in light of what is currently known.
Some degree of caution is probably needed. Systems of home-based patient monitoring such as those tested in the WSD trial can involve significant investment. WSD produced no evidence of cost savings (indeed, as the cost of operating the telehealth system has not yet been taken into account, there may have been cost increases).
The money invested in telehealth could be spent on other services, so what is the rationale for investing in telehealth rather than in something else? And why should more advanced technology be used in place of other methods such as regular phone calls?
Telehealth is more than just the box. Whether it is a good idea depends on what services are already in place. It’s possible that telehealth could help existing resources to be used more efficiently. For example, it might increase the number of patients community nurses can work with – though effects on community nursing have not been assessed.
Telehealth may spur on the development of better information systems or fit with existing strategies towards patient self management, education, or supported discharge from hospital. Or it might not.
What’s already clear is that, if cost savings are a goal, then future telehealth services will need to do better than the WSD. This might mean changing business models or changing the design of services. The voices of patients should be heard. And as more research is published, the debate about how best to “do” telehealth will need to evolve.
One option is to monitor impacts over time to make sure improvements are on track, and modify service delivery models as needed. Methods using administrative data and matched controls have been developed to monitor impacts – we are already testing these in an evaluation of telehealth in North Yorkshire.
For CCGs and providers, there are no easy answers. This may not be surprising given that telehealth is about a change in services rather than technology.