Nick Goodwin: Can we justify the investment in telehealth and telecare?

Nick GoodwinLast week The King’s Fund hosted the International Congress on Telehealth and Telecare to a packed audience of 350 delegates with another 1600 from 59 countries watching remotely. The main attraction was some early findings from the Department of Health’s Whole System Demonstrator (WSD) Pilot Programme – the largest cluster randomised control trial (RCT) of telehealth ever conceived.
 
To the disappointment of some of the delegates, early DH insights into the findings were thin on the ground. Trial results were, however, reported as “encouraging,” including reductions in hospital admissions for people with COPD and a positive trend in the overall impact on system cost effectiveness.
More detailed findings emerged outside the main congress hall. Positive experiences were reported from the three localities in which the field trial was conducted:  patients, carers, nurses, and family practitioners reported positive experiences in using telehealth in Newham; in Cornwall it was reported that the technology worked safely, protected privacy and had developed good interoperability between the different e-health applications and data sets; in Kent, telehealth was thought to have been particularly beneficial in relieving the burden on carers, with the locality keen to roll out the approach.
 
But was such a large scale evaluation necessary to support the need for telehealth and telecare? International delegates at the congress were somewhat startled at size of the investment in the WSD Pilots – more than £31 million – of which about 12% went on the evaluation itself. Whilst the WSD trial was seen as ground breaking, doubts were raised as to its overall value and to that of RCTs in general: they are expensive and time consuming; they remain contextually specific and therefore difficult to generalise to other regions and countries, and the research evidence produced will soon be out of date due to the fast moving nature of technological innovation.

The conclusion I reached is that research and evaluation needs to be much more closely aligned with innovators and decision makers to enable them to utilise the best available evidence in “real-time.” Traditional research and evaluation studies are not conducted to facilitate such rapid knowledge transfer and those at the “coal face” of delivery rarely listen to it when it comes. New methodologies and approaches are needed and this will only come to fruition through better co-operation between scientists, professionals, product developers, and policy makers.

The evidence base is essential to support the effective transition to a new way of working, but its limitations can too often be used as an excuse to do nothing.  The time for system redesign is now.

Nick Goodwin is a senior fellow at the King’s Fund.

This blog also appears on the King’s Fund website at http://www.kingsfund.org.uk/blog/

  • berg206

    Isn't the quality of evidence a red herring? Research and evaluation have been conducted on telecare/telemedicine for some time. There are good trials, good systematic reviews, and even good meta-analyses. There are also excellent qualitative studies, ethnographies, economic evaluations, demonstration projects, pilot studies, proof of concept research, and so forth. Every kind of evidence is voluminous here. The problem is that health and social care services have shown little appetite for actually utilizing these systems – and if there's appetite for doing something in healthcare informatics then the quality of evidence has rarely been an obstacle in the past. The relative failure of telemedicine/telecare to normalize in healthcare in the UK, US, Canada and elsewhere probably lies elsewhere and is almost certainly unrelated to evidence.

  • George Macginnis

    Nick is right to conclude that that research and evaluation needs to be much more closely aligned with innovators and decision makers. The clue to the future is in the idea of innovation – researching a dynamic environment. Dynamic due to the rate of change of the technology, but also because the essence of successful IT-enabled change is to build learning from experience into the implementation, something that proves difficult under the strictures of a randomised control trial.
    Consider two landmark studies in telehealth – the Whole System Demonstrators in England and the US Veterans Administration’s Care Coordination Home Telehealth Study (Darkins et al, 2009). The VA study reported the effects of providing a service to a cohort of 17,000 patients and comparing their service utilisation to a more general population. The results look impressive, and came at a cost of just $1600 per year. That’s around $27M total costs. In contrast, the Whole System Demonstrators provided active telehealth and telecare services to around 3000 people at a total programme cost of £31M, or just over £10,000 per patient, an order of magnitude higher than the VA study. Consider also that for the 3000 people spread across three separate areas with a base population of over 1 million, it would be hard to say that they really provided a scale that would truly impact the ‘whole system’. Yet if you follow the direction of travel in the VA, you would see how capacity in other areas is affected by their successful telehealth and other services.
    This costs of service comparison may be unfair, but it does go to show how much of an overhead is involved in generating ‘medical grade’ evidence. If the problem is patient care, would you rather have finished the year having touched 17,000 patients or just 3,000?
    Going forward, commissioners need to be more open to challenging whether the approach to generating evidence is proportionate to the risks. Healthcare seems stuck in a paradigm driven by drugs trials, where there are risks that justify the extremely cautions RCT approach to generating evidence. While there is undoubtedly a place for randomised controlled trials in understanding telehealth, there much that can be achieved through other forms of experimentation.