High costs, inconsistent quality, disparities in access, and resource inefficiencies are creating pressure to adopted connected health. Remote patient monitoring is showing positive results and the market for health technologies is growing. However, connected health faces a major hurdle, interoperability, necessary for flexibility and convenience. This is illustrated by a recent disaster response program in Japan.
The Internet, personal computers, smartphones and other electronic devices make information sharing and communication easy, instant, secure and widely available. It is now common to use the Internet for banking, making retail purchases, managing investments, booking travel, or reading a newspaper. Virtually any activity that involves interaction with a customer can be transacted online.
While the practice of medicine is rife with specific technical solutions, healthcare is one of the last industries to use technology to connect with and improve the experience of its customers: patients. However, unsustainably high costs, inconsistent quality and outcomes, disparities in access to services, and resource inefficiencies are changing that. Today, hospitals, providers, insurers, employers and policy makers are looking to health information technologies to better engage patients, deliver consistent high quality, improve adherence to medication and care plans, create new efficiencies and ultimately, improve clinical outcomes.
The tools of this new healthcare technology revolution-smartphones, computers and simple remote health monitoring tools, are engaging patients, facilitating better patient-doctor communication and delivering care where the patient is, when the patient needs it. This new form of healthcare delivery has been dubbed ‘personal connected health’.
Remote patient monitoring
Among the more mature applications of technology in connected healthcare is remote patient monitoring, in which telecommunications and health management devices are deployed by healthcare organisations to collect and share accurate, individual patient physiologic data (i.e. blood pressure, weight, heart rate or blood glucose levels), and quality of life data such as sleep patterns and daily activity. The benefits to patients include remaining or returning to home rather than hospitalisation; ongoing awareness of their health status, which encourages understanding and engagement in health self-improvement; and avoidance of office visits and / or emergency room visits. Remote monitoring also creates a platform for more meaningful discourse between patients and providers. For providers, remote monitoring represents the ability to be alerted automatically of significant changes in a patient’s health status, maximising the time available for preventive action and preserving physician resources for the most serious cases. These types of programmes are showing positive outcomes in managing chronic diseases such as diabetes, cardiovascular disease, stroke and hypertension, which often require ongoing attention to a proper diet, exercise and a care plan.
The Whole System Demonstrator Programme, conducted by the Department of Health in England, looked at the effect of telehealth on hospitalisations and mortality in more than 3,200 people with diabetes, chronic obstructive pulmonary disease, or heart failure. In addition to telemonitoring with biosensors, patients received symptom questions and educational messages from the telehealth unit or a television set top box. Results from a twelve-month analysis, published in the June 2012 issue of British Medical Journal, show that 44.5 per cent fewer patients in the intervention group than in the control group died during the study period Hospital admissions were 10.8 per cent lower in intervention group Emergency Room visits were 14.7 per cent lower, and ER visits were down 20.6 per cent, in the telehealth intervention group Hospital bed days were 14.3 per cent lower per head in the telehealth group Estimated costs savings were 7.7 per cent lower per health in the patients that received telehealthcare.
Since 2006, the Center for Connected Health (CCH) at Partners HealthCare has operated the Connected Cardiac Care Program (CCCP) to non-homebound patients with heart failure. More than 1,000 patients have been enrolled. To date, the programme has demonstrated a reduction in hospital readmission rates of close to 50 per cent and 84.7 per cent of patients reported they were able to gain control over their heart failure while in the programme.
The US Department of Veteran Affairs’ (VA) DiaTel study, published in Diabetes Care (March 2010) compared home telemonitoring together with active medication management with monthly care coordination calls, looking at changes in glycemic control in veterans (analysis group=137) with type 2 diabetes and poor glycemic control. The group receiving telemonitoring and active medication management demonstrated significantly larger decreases in A1C at three months (1.7 vs 0.7 per cent) and six months (1.7 vs 0.8 per cent; p< 0.001 for each) versus those receiving a monthly care coordination telephone call.
A related study published in Journal of the American Medical Information Association (May 2012) re-enrolled some DiaTel study participants to probe the intensity and duration of telemonitoring required to sustain results achieved in the original study. For veterans who had received home telemonitoring or active medication management for six months in the DiaTel study, results were sustained six months later despite receiving less intense subsequent interventions.
mHealth and adherence
According to a 2003 report published by the World Health Organization (WHO), in developed nations, only 50 per cent of patients with chronic diseases take their medication as prescribed and the number is even lower for developing nations. Poor adherence can reduce the effectiveness of medications, jeopardise patient health and lead to burgeoning healthcare costs. While some of the factors that contribute to poor compliance are unlikely to be influenced by mobile health (such as the cost of medication), mobile devices capable of compliance tracking, electronic reminders and simple medication management are demonstrating potential to help stem the tide of lost opportunity due to poor adherence.
In March 2012, researchers from the Stanford Prevention Research Center reported that smartphone applications raised awareness of how to improve health in a group of 31 adults, ages 45-77, who had never used a smart phone before the study. Study participants were supplied with phones pre-loaded with an application targeting one or more objectives: increased walking decreased sitting time or improved diet. The participants were trained and instructed to use the phones for eight weeks. Three-quarters of the participants reported that the apps helped track the target behaviour, and two-thirds said they were motivated to make improvements. More than 96 per cent said the smartphones were a fast, efficient means of gaining information.
Other studies have shown that simple text messaging programs can improve adherence to antiretroviral therapy regiments for people with HIV / AIDS and asthma medication in teens. Another study improved prenatal care for at-risk pregnant women.
Connected health technology market
The global mobile health applications market is expected to grow at a compound annual growth rate of 24 per cent from 2010-2014, according to research by Technavio, while a 2011 report published by ABI Research predicted that, fueled by the use of connected wearable devices, there will be more than one billion health-related mobile app downloads annually by the year 2016. Berg Insight reported that, globally, approximately 2.2 million patients used a home-based remote monitoring device as of the end of 2011 (not including devices that connect via smartphones or PCs) and estimated the number to reach 4.9 million by 2016. In addition, they predict the number of home health monitoring devices using cellular connectivity will hit nearly 2.5 million in 2016. In terms of the market as a whole, MarketsandMarkets projects the global healthcare IT market will reach US$162.2 billion in 2015, a 10.2 per cent compound annual growth rate from the 2010 value of US$99.6 billion.
The good news in connected health is that patients are using technology to manage their health, connect with their healthcare providers and participate in supportive, interactive communities in record numbers.
Interoperability: A challenge to the vision
While there is still much research to be done, plenty of support exists for remote patient monitoring, texting programmes and other forms of connected health. Further, by many accounts the availability of connected health technologies is growing by leaps and bounds. However, a fundamental vision for connected health is that users—be they providers, payers, employers, or consumers—will be able to create novel, customized systems for health management according to their specific needs. With the number of devices, apps and services being introduced, it is a major challenge to ensure that technologies are interoperable. Users must be able to easily connect different types of devices and technologies as well as swap out devices that perform the same function for a different model or manufacture. A lack of interoperability between technologies could thwart adoption as well as limit the efficiency and effectiveness of technology-enhanced care. Examined from another perspective, interoperability is a necessary technological underpinning of a robust connected health market, and more importantly, successful clinical programmes. A remote monitoring programme developed to help survivors of the Great East Japan Earthquake illustrates this point.
Disaster Cardiovascular Prevention network (D-CAP)
Following a disaster, medical support for survivors must shift from emergency medical treatment to daily disease management to mitigate health risks associated with stress and environmental changes (Noji 292). Experience from the 1995 Kobe earthquake in Japan shows that 14 per cent of fatalities were realized after victims had initially survived the event (Hays). Further, living in an evacuation camp is associated with several factors that can increase cardiovascular risk (WHO 42), and studies have demonstrated increases in cardiac events in the immediate hours and weeks after an earthquake. Long-term impacts of disaster on cardiovascular events has also been observed: researchers at Tulane University concluded in a study published in January 2010 that chronic stress following Hurricane Katrina contributed to a 300 per cent increase in heart attacks in New Orleans—more than two years after the event.
After the Great East Japan Earthquake of 2011, Dr Kazuomi Kario, Chairman of Cardiovascular Medicine at Jichi Medical University in Tochigi, Japan, was concerned about elevated cardiac risk in survivors. He contacted medical device manufacturer A&D Medical about developing a remote monitoring programme for evacuees at a camp in the town of Minami-Sanrikucho, in the Miyagi Prefecture, which had suffered enormous losses in the earthquake and subsequent tsunami.
Complicating care at Minami-Sanrikucho was the fact that the disaster site lacked basic services such as electricity, water and sewer for the first three months, limiting the capability to monitor and treat patients and access medical records to assess pre-existing cardiovascular disease. A rapid solution was needed.
The Disaster Cardiovascular Prevention Network (D-CAP) was developed to remotely monitor the blood pressure of evacuees in campsites, with a goal to prevent cardiac events in survivors identified as “high risk.” The program consisted of examinations and risk assessments to stratify high-risk patients, defined as having systolic blood pressure above 180 mmHg. Screening of 1,500 evacuees identified 400 people with elevated cardiac risk, who were enrolled in the D-CAP program (26.6 per cent of screened evacuees). Patients with persistent symptoms were evaluated by physicians and prescribed oral medications as needed.
D-CAP registrants received electronic identification cards and were encouraged to measure their own blood pressure at automated stations within the evacuation camp. The data were sent via wireless communication to a data server and relayed to Jichi Medical University, about 200 kilometers away. Clinicians monitored the data and alerted on-site physicians by phone of any significant developments. Subsequently, high-risk patients were moved from the evacuation camp into temporary housing provided by the government and provided with individual blood pressure monitors that store a month of readings. Data can be downloaded at the hospital and then uploaded to D-CAP’s data center.
Participating companies and their component devices include A&D Medical - Automatic blood pressure monitors; Alive Inc. - Gateway firmware; Ryoto Electro Corp. - data server; Panasonic – PC; Toppan Forms - Patient ID Cards; Qute - Web application development; Intel - Project coordination. An important aspect of the program’s launch was pre-existing interoperability between all devices. The component products had been certified by Continua Health Alliance, a global non-profit organisation that publishes guidelines for plug-and-play connectivity of personal health devices and services. The guidelines conglomerate technology standards in use on an international scale.
The most important outcome of this program is that D-CAP has been credited with saving lives. Every one of the 400 ‘high risk’ D-CAP evacuees is still living today and the program remains in operation.
Pre-existing interoperability among the component products facilitated a time from conception to launch of just two weeks, or 12 man-weeks, at a cost of US$27,000. In interviews conducted with participating companies, representatives from Intel and Panasonic estimated that without pre-existing interoperability, launching the D-CAP program would have taken twelve weeks, or 72 man-weeks, at a cost of US$166,000. According to these estimates, deploying interoperable technologies reduced launch time by 84 per cent, or ten weeks, and saved US$139,000.
While the cost savings were certainly significant, it is the 10-week launch advantage that is clinically important in light of documented elevated cardiac risk in earthquake survivors and people living in evacuee camps. D-CAP has not provided estimates for cardiovascular events averted or lives saved, but one can easily conceive of the risk to these 400 earthquake survivors had they received no specialized screening or cardiac monitoring—or the additional care that resulted from screening and monitoring—for two and a half months following the event. Further, the cost savings derived from pre-existing interoperability in the D-CAP program would fund five additional programs of the same size (without accounting for economies of scale), providing monitoring for another 2,000 patients.
The D-CAP program speaks to the clinical advantages, and even necessity, of interoperability—and allows us to envision the thorny challenges of implementing connected health in a market lacking interoperability.
In order to maximise the potential of technology-enabled health and wellness, a rich and varied ecosystem of interoperable personal connected healthcare devices is necessary. Mobile apps, remote blood pressure cuffs, pedometers, glucometers and computer networking systems that relay and store vital patient information must all have the ability to work interchangeably, to ensure adoption, retention and maximum results for patients and providers. Further, electronic home healthcare solutions must offer consistent and simple connectivity so that they function together with any device or within any network.
Continua Health Alliance is working to establish a global, secure, plug-and-play market in connected health for more effective health management, patient engagement and better outcomes. In addition to publishing standards-based guidelines for interoperability and security, Continua certifies and provides brand support for connected health products, sponsors events and collaborations to support technology and clinical innovation, and works with employers, payers, governments and care providers as a facilitator.
The need for interoperability seems to be most evident to organisations that serve large numbers of people, such as governments and NGOs. Continua is working closely with two national, government-run telehealth programs, recently welcomed a division of the U.S. Department of Defense as a new member, and was welcomed to the United Nations agency International Telecommunication Union. But the pressure to bring plug-and-play connected health technologies must also come from private-sector healthcare buyers.
With new opportunities come new challenges. The clinical evidence is mounting in favor of connected health, but the healthcare industry and its partners in the telecommunications, medical device and pharmaceutical industries must address the vital role of interoperability in the connected health revolution.
Continua wishes to acknowledge Dr. Kazuomi Kario, Professor and Staff Physician at the Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan, for his responsiveness and creativity on behalf of survivors of the Great East Japan earthquake, as well as D-CAP participating physicians and companies, without which this program would not have been possible.
1. Hays, Jeffrey. “Kobe Earthquake Death and Damage.” Facts and Details, 2009. Web. 3 July 2012 http: / / factsanddetails.com / japan.php?itemid=863&catid=26&subcatid=161
2. Noji, Erik K. “Disaster Epidemiology.” Emergency Medicine Clinics of North America, 4.2 (1996) 292. Print.
3. Tulane University. “Post Katrina Stress, Heart Problems Linked.” Tulane University. 2012. Web. 3 July 2012 http: / / tulane.edu / research / discovery / story-katrina-heart-attacks.cfm
4. World Health Organisation, Western Pacific Region. The Great East Japan Earthquake: A Story of a Devastating Natural Disaster, a Tale of Human Compassion; March 11, 2012, WHO, 2012. Print.
Charles (Chuck) Parker was previously with Masspro and VHA, Inc. and has served organisations such as CMS, Bridges to Excellence and the Office of the National Coordinator for Healthcare IT. He holds a Master of Science in Healthcare Informatics.