Professor, Surgery Virginia Commonwealth University USA.
Home telehealth is the use of telecommunications tools to amplify, initiate or replace home health visits in person. Care of patients in the home has a greater application now than at any time since healthcare arrived on horseback. The merits of home healthcare have been extensively studied and validated in terms of cost-efficiency and improved clinical outcomes. The incentive for care at home has several dimensions. Home healthcare can: permit earlier discharge from the very expensive inpatient environment; reduce the need for rehabilitation stays in nursing facilities; and extend the period of independent living outside nursing homes by providing services and by supporting family members engaged in providing care. In disease management, home care can reduce the need for emergency department visits and inpatient stays by early recognition of disease trends, improved compliance with a treatment regimen and better education of patients and families. Standard home health visits can be organised into a system with facilitated access to caregivers through call centres or direct calls to the health agency which has the records of the patient and an awareness of the medical situation.
Home health has been greatly successful mainly due to reduced costs, patient satisfaction and improved clinical outcomes.
The success of home telehealth is of fairly recent vintage and there are many reports of less than successful outcomes. As recently as early 2006, the Agency for Healthcare Research and Quality (AHRQ) reported that despite many studies on the values of home telehealth, there was great need for properly designed studies to test the hypothesis that home telehealth was valid in general and with specific diagnoses. In 2004, Winters and Winters reported that home telehealth could be a promising model for rehabilitation. Jannett in her review of telehealth outcomes and home telehealth in 2004, reported clear improvement in terms of both outcomes and patient education. The overall results for outcomes were mixed but there was a consistent case to be made for cost-effectiveness. In order to evaluate a study to guide decisions relative to an investment in home telehealth, it is prudent to understand this history, proper study criteria and the abundance of articles by true believers as opposed to critics. In fact good decisions by healthcare managers and health systems must come only from the best data.
For Congestive Heart Failure (CHF), Whitten published an early study in 2007 and a more comprehensive assessment in 2009. In order to know the merits of an intervention, there surely must be a study that measures health, economic and social outcomes and carefully explains the technology used in the intervention. In Whitten’s later work, 50 patients were engaged in a programme of telehealth with a strong message of education. All the patients suffered from CHF and were evaluated before the intervention and two months after using well validated survey instruments. The patients had an average of 39 telehealth visits and 14 home visits in the study period. Complaints of shortness of breath fell from 24 to 12 per cent while medication compliance rose to 84 per cent from 49 percent. Improvement in activity, edema, fatigue and hospitalisation were at the p<0.05 significance. The patients found the set-up easy to use and equivalent to face-to-face visits. These outcomes are entirely appropriate measures for CHF management. For diabetes mellitus, the parameter of choice would be Hemoglobin (Hgb) A1c for glycemic control and for hypertension measure of diastolic blood pressure. For asthma, the parameter or interest is avoidance of emergency visits and for chronic obstructive lung disease (COPD), spirometry and hospitalisation would be the data of note. For a home telehealth programme to be worthwhile, the health outcomes should at least be equivalent to home health visits. If the outcomes are not better and not equivalent, there should be some considerable advantage in reducing the overall cost for service. For health systems, avoidance of more advanced service levels is the cost benefit.
Finkelstein in 2006 concluded home telehealth improved clinical outcomes at a lower cost in a study in Minnesota. He compared controls that had a home nurse visit with home nurse plus video sessions and nurse, video and home health monitoring in 53 patients with CHF or COPD. Transfer to a higher level of care, either hospital or skilled nursing facility, was record in 42, 21 and 15 per cent respectively. The advantage of telehealth intervention is striking and the value added by home monitoring is very impressive. Here, the costs are reduced primarily due to the avoidance of a higher level of care.
The best database for the measured effect of home telehealth is through the Veterans’ Administration (VA) in the US. It is generally considered that the huge VA databases almost never support the excited results of early reports on clinical interventions. The story for telemedicine is quite different. In 2004 a VA study from Connecticut reported 104 patients with CHF, pulmonary disease or diabetes mellitus in a randomised controlled trial of home telehealth. The reduction in bed use was significant at p<0.0001 and use of the emergency department p=0.023. Hgb A1c decrease was significant at p<0.0001 and patient satisfaction at p<0.001. Therefore, the intervention was a success with clinical outcomes, patient perception and cost. Continuing the VA experience, which has been very carefully collated and studied, Barnett in 2007 reported that for diabetes mellitus Care Coordination/Home Telehealth, the growing VA system was cost-effective in one-third of 370 respondents. In this instance, the technology of the VA system was evolving. DelliFraine in 2008 did a metanalysis of 29 articles out of 154 potentially acceptable reports and found better outcomes for CHF or psychiatric diagnoses but discerned that there was a tremendous impact of the technology on outcome. Telehealth is not the same all over. The instrumentation is crucial to success. The educational materials are, of course, important. The quality of the medical care product is highly relevant. Telehealth in its interpretation and implementation calls for a careful assessment of the equipment, hardware, middleware and software plus a clear set of instructions for patient and training of the personnel. These elements are perhaps best applied in the VA again as described by Darkins in 2009. Between 2003 and 2007 the VA Coordinated Care / Home Telehealth (CCHT) programme has treated 31,750 patients. In a recent cohort of 17,025 there was a 25 per cent reduction in bed days and a 19 per cent drop in admissions with an 86 per cent satisfactory rating by the patients. The telehealth cost was US$ 1600 per patient per annum. The plan is for CCHT to provide 50 per cent of all non-institutional care for the VA by 2011.
The older papers do not provide enough evidence on the efficacy of home telehealth. However, the newer ones that report large numbers of patients are clearly better. At this juncture, there are no analyses or reviews of strong evidence in the Cochrane Library. However, there surely will be soon for home telehealth and when available decision makers can consider their choices with Level I evidence. In the meantime, careful reading of what is published will allow sound decisions in evidence based medicine as to technology, programme design and the setting of both clinical and financial expectations.
An interesting paper by Gagnon followed the course of a programme in Canada and concluded that decision makers needed to be involved in the scientific outcomes of a programme as it evolved to make the best decisions for ultimate success. Home telehealth like any other endeavour can fail to meet the expectations of patients, medical personnel, clinical outcome predictions, cost containment or profit. Success requires a clear understanding of the product, service and market. Patients will readily accept a well-designed service as equivalent to a face-to-face intervention if they feel empowered, have improved access and confidence. The technology of the imaging devices, sensors, video and transmission must of course be thoughtful for patient and family concerns and abilities. Health workers will accept a telehealth programme if it makes their work easier, better and more rewarding. They are likely to make a system work that is technically reliable and intuitive. Long technical delays or lost connections will doom a programme while professional connectivity will make success much more likely. For the health worker, if telehealth is just extra work acceptance will be less. The expectations of home health physiological sensors or monitoring for improved clinical outcomes will not be met if the education, implementation and operation of the programme fail. Next, we must also consider money.
It is logical that improved diabetic management, wound management, airway management, heart failure regimens etc. lead to lower costs. However, administrators may only see the cost of the telehealth equipment and technical personnel. In order to avoid the temptation to economise on equipment and technical support, it is quite important to write into a plan a way to track savings to offset the cost. The overall business plan should include Return on Investment (ROI), amortisation, depreciation of equipment and staff training. It is, of course, unrealistic to assume that telehealth system will work, as it seemed in the advertisement, without providing proper task-specific modification, training and technical support. Furthermore, there must be careful consideration as to the scale of the service in the business and operational planning. Installing a very expensive telehealth system for a handful of patients will never look good in a cost analysis. This is where the ROI estimate becomes crucial. The successful plan must recruit enough patients to be cost-effective. Pilot efforts may be expensive in terms of initial costs but their value comes later as the full plan incorporates lessons learnt from the pilot study in terms of the application intended.
In the current economic climate in general and for medicine in particular, there is no likelihood that an enhancement in care that is prohibitively expensive can come to reality. Any innovation really should reduce costs through better health outcomes or some economy of service. Home telehealth need not add any expense to aggregate patient care if the system is well-researched, designed, implemented and monitored for an appropriate patient population. Success of home telehealth can be defined and assured by the stakeholders (parties, patients, caregivers, public and fiduciaries) by careful reading, planning and administration. The extension of telemedicine to the home is least expensive when it is appended to an existing telemedicine programme and an existing information system to share some resources Therefore, health systems with those programmes in place are most likely to succeed. Home telehealth appended to an existing home health programme is also favoured for success as in the case of the VA system. Home telehealth is like all permutations of telemedicine programmes in that they are most expensive as a stand-alone. As part of a mature electronic medical record effort in a health system with a salutary experience in home health, a home telehealth programme should flourish and show early sustained profit. It is the right thing to do for patients and, in this case the right thing to do for patients is the best thing to do for health system finances.
Ronald Merrell is Professor of Surgery at Virginia Commonwealth University in Richmond, Virginia. He has been a long time researcher in telemedicine supported by NASA with an emphasis on technology, the surgical suite and remote environments. He is an editor-in-chief of Telemedicine and e-Health, the official journal of the American Telemedicine Association