eMJA: Celler et al, The potential impact of home telecare on clinical practice

Clinical Practice

The potential impact of home telecare on clinical practice

Home telecare, in which the health status of patients at home is monitored remotely, has the potential to improve care and reduce costs. Its widespread implementation would require fundamental changes in the healthcare system.

Branko G Celler, Nigel H Lovell and Daniel K Y Chan

MJA 1999; 171: 518-521

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Introduction - Telecare in clinical practice - Evidence for cost effectiveness of home telecare - Data security - Conclusions - References - Authors' details
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Introduction

Home telecare is the use of information, communications, measurement and monitoring technologies to evaluate health status and deliver healthcare from a distance to patients at home (Box, Figure 1). In the United States, home healthcare is the fastest-growing healthcare delivery sector^1,8 -- more than 5.9 million Americans received home healthcare services valued at more than $US25 billion in 1996. Only about 50 of almost 1800 US home care agencies are currently active in home telecare, but, driven by changes in healthcare provision and reimbursement policies, many more are participating in trials of cost effectiveness; home telecare is expected to grow dramatically.

Outside the US, the move towards telecare is being driven by the acceptance that national health services have a responsibility to manage the needs of an ageing population.^2,9,10 People aged 65 years and over now represent 12% of the Australian population,¹¹ a figure which will increase to 25% by 2051. Furthermore, average healthcare expenditure per person is currently $2536 per year, but increases almost tenfold for those aged 75 years and over.

The increasing cost of providing healthcare services to an ageing population and changing patterns of use of hospital resources (a rise in admissions but a fall in the average length of stay) are powerful forces for shifting the focus of care from the hospital to the home.

Telecare in clinical practice

The recently completed Australian Coordinated Care Trials¹² identified home telecare as having significant potential for contributing to the management of patients with acute exacerbation of chronic conditions as well as at-risk elderly people living alone at home.

As home telecare may become increasingly relevant as the population ages, it is useful to consider management and clinical service delivery requirements in the context of the need for services. An individual older person may suffer from multiple chronic medical problems, each requiring multiple treatments ranging from medical services to simple functional assistance. For convenience, we chose to describe the need for aged care services in three broad and overlapping age-related categories: preventive healthcare and education for self-management, health maintenance, and health support (Figure 2).

Preventive healthcare: In the first phase, a rapid increase in healthcare costs begins between the ages of 55 and 65 years. This age group coincides with retirement, when many people have the resources, skills and time required to prepare for their old age through participation in preventive healthcare programs and education for self-management. For this group, key questions include:

What will be the effect of using the Internet to create an information-rich environment in the home on the demand for healthcare services?
Can the Internet be used to create a virtual community of the aged where participants are linked through a network of information and communication resources for education, entertainment and access to healthcare?
Can such a virtual community be used to increase social interaction, improve the quality of life and reduce age-related morbidity?

As the ageing community becomes better educated and increasingly able to access high quality healthcare information (through sites such as Healthfinder¹⁴ in the US and HealthInsite¹⁵ in Australia), a reduced demand for primary healthcare services may occur, but little research has been reported; the possibility that the demand on health resources may increase cannot be discounted.

Health maintenance: In the second phase, pre-existing medical problems will require more assiduous management, and new morbidity associated with the chronic and degenerative diseases of old age will emerge. Established general practice and community health services are the cornerstone of primary care, and the development of innovative information technology solutions to support GPs may shift the point of care from the hospital to the home and may provide continuity of care and transparency of data flow across healthcare sectors.

Innovative devices for physiological monitoring in the home of cardiac rhythms, lung function, hypertension and risk of falls may give users greater confidence and security, and could provide healthcare services with 24-hour continuous diagnostic data whenever necessary. We can expect that these healthcare services and facilities will become fully integrated with emerging "smart home" technology (which allows intelligent monitoring and control of the home environment and security requirements) in new housing estates and large scale retirement village developments.

Patient data collected in the home could be automatically collected, analysed and summarised, and inserted directly into an electronic patient record to be reviewed at the next consultation. In the absence of electronic record systems in general practice, data could be collected at a dedicated central server, where they could be viewed over the Web or transmitted to the GP via facsimile. Email reminders of the existence of new data could also be generated automatically.

It is not yet clear who will take responsibility for managing the collection and analysis of data, and coordinating the delivery of healthcare services. GPs, in their gatekeeper role of determining access to specialist services, are well placed to assume overall clinical responsibility, but may need to delegate operational responsibility to community-based service organisations, local community hospitals or commercial service providers.

Health support: The third phase is characterised by increasing frailty, and the increasing intervention of GP and community services to support elderly people in their homes. Unobtrusive monitoring of changes in mobility or patterns of use of selected domestic services in the home (Figure 1) may provide sensitive indicators of changes in health status. This unobtrusive monitoring, together with appropriate emergency alarm services and continuous ambulatory monitoring of selected physiological parameters, will provide the GP with advance warning of deterioration in health status, and thus allow optimum coordination of preventive health services.

Again, GPs are well placed to assess the level of frailty and risk at which telecare monitoring and support can be recommended to patients and their carers. If the objective is the prevention of acute episodes leading to hospitalisation and high cost care, careful management of the evolving risk will become essential so that appropriate clinical and community resources can be mobilised in a timely fashion. These alarm processes can be partly automated through use of medical expert systems to identify and communicate to the clinician significant changes in health status.

Home telecare technologies

Home telecare technologies have been reviewed by several authors,^1-4 and fall broadly into three generations.
First-generation systems are designed to reduce anxiety among elderly and high-risk patients and reduce their use of primary healthcare services. Typical technologies include personal alarm systems and emergency response telephones that make a voice connection between the patient and the response centre whenever a pendant alarm button is pressed.
Second-generation systems can generate alarms without the intervention of the patient, on the suspicion that something may be wrong. These systems can continuously monitor a large number of variables sensitive to changes in functional health status (Figure 1), and generate an alarm when significant changes are observed.⁵ With an intelligent decision-support system using robust algorithms, false alarms are unlikely.

These second-generation systems are unobtrusive, do not require direct patient participation and can be integrated with evolving "smart home" technology for home automation, security and environmental control. New developments include sensor arrays worn by the patient and capable of measuring factors such as temperature, respiration, electrocardiogram and skin blood flow.⁶ Ambulatory data can be transmitted to a local computer or specialised controller via low cost telemetry before transmission to a central computer. Local intelligence can be used to detect emergencies and long term trends in health status can be identified and acted upon at the response centre.

Third-generation systems attempt to deal with issues of loneliness and quality of life of patients by creating a virtual community of clients, carers, healthcare providers and other community services, connected via the telephone, interactive television, and the Internet. In our laboratory, we are investigating the integration of third-generation systems with Internet and Web technology,⁷ both for communication and for management and control of monitoring services.

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Evidence for cost effectiveness of home telecare

Very few studies to evaluate the cost effectiveness of home telecare have been published, and fewer still relate to Australia. According to a recent report by the United Kingdom Audit Commission,¹⁶ about 40% of total hospital and community health service expenditure is on people aged over 65 years, and those aged over 75 years occupy more than 50% of all available hospital beds. The Royal Commission on Long Term Care reported that it costs �454 a week on average for full-time residential care and �250 a week for private home care.⁹ Therefore, there is strong economic justification for transferring resources from residential to home-based care. There is also substantial evidence that heathcare outcomes and quality of life improve when healthcare services are home based.^9,16

A UK report, Technologies for telecare in the home,¹⁷ concluded that, for a typical Community Health National Health Service Trust (similar to a Division of General Practice and associated Area Health Service), 15% of home visits could be replaced with telecare, saving �1.26 million per annum in the first year, after accounting for establishment and operating costs. A retrospective review of home nursing visits in the UK similarly suggested that 14%-16% of these visits could be replaced by telecare services;¹⁸ a similar and very comprehensive study in the US concluded that 46% of all activities carried out by on-site nursing could reasonably be replaced by telenursing.¹⁹

Studies of the cost-effectiveness of home telecare are most compelling for chronic conditions. In 1988, a trial of telephonic cardiac surveillance of post-infarct patients²⁰ found that cardiac death or arrest was decreased by 29% in the monitored group when compared with the control group. In addition, control subjects were 2.4 times more likely to be clinically depressed, and they returned to work less quickly. A US study of patients with chronic disease demonstrated savings of over $8000 per patient, arising from a reduction of costs from $100 for conventional visits to $15-$40 for telecare services.²¹ In another study, on cardiac rehabilitation for congestive heart failure in the home, a 74% reduction in readmission rates was demonstrated at 90 days.²²

Detecting delirium

Mrs P is 85 years old and has mild dementia. She lives alone at home and receives home care and Meals on Wheels. In the past six months, Mrs P has twice been admitted to hospital because of increasing confusion (delirium). The first episode was found to be caused by a newly introduced medication, and the second was due to urinary sepsis. After the second admission, continuous home monitoring of behavioural patterns was introduced.

One day, the monitoring system recognised that Mrs P's pattern of behaviour was significantly different than usual, and so it alerted her GP. The GP recognised that this could be a new episode of delirium and arranged an urgent geriatric review.

The geriatrician found that Mrs P was constipated and had urinary retention. Mrs P was admitted to hospital and given an enema, and she was able to void. Her mid-stream urine microscopy result was clear. She was sent home on the same day, and her behaviour pattern returned to baseline.

A possible long hospital admission was avoided by early identification and intervention in a medical emergency.

Data security

Ethical issues arising from home telecare and the storing and accessing of clinical data by multiple providers are complex, but are reviewed (at least in the European context) by Stanberry.^23,24 Implementation of home telecare services requires informed consent, must be voluntary and must complement, not exclude, traditional methods of healthcare delivery. Moreover, individuals are entitled to assurance that personal information will not be subject to unauthorised access, and will be used only for the purposes it has been collected for. This requires procedures and processes to ensure that personal data can only be accessed by those authorised to do so.

Automatic encryption of data should be mandatory for any transmission of identified patient data. Web-based security, fuelled by the explosive growth in e-commerce, is now dependent on two standards, Secure Sockets Layer and Secure Electronic Transaction, which must be implemented if patient data are to be transmitted via the Web.

These security systems depend on the exchanging or sharing of keys, which must be protected from access by others. The strength of any cryptographic system depends on key- distribution techniques and the existence of a trusted third party to manage the process. Who will become the trusted third party in Australia is yet to be resolved.

Home heart monitoring

Mr D (aged 75 years) lives alone on a farm outside a small country town, and has known ischaemic heart disease. Because of his remoteness, it is inconvenient for him to have regular medical consultations. He has had several episodes of angina but has never had an infarct.

Recently, Mr D suffered a prolonged episode of chest pain, and attended his nearest hospital clinic. This is manned by a nurse after hours, and is some distance away from the nearest doctor. The nurse recorded an electrocardiogram (ECG) and transferred the information via the Internet to a cardiologist, who made a diagnosis of unstable angina.

Mr D was admitted overnight to a local community hospital, given the appropriate management, and reviewed by his own doctor the next day. He was instructed on the use of a simple ECG monitoring device capable of transmitting ECG recordings over the telephone.

Mr D returned home secure in the knowledge that his condition would be monitored, and that medical services would receive and act upon subsequent anginal attacks.

Conclusions

The interaction and evolution of home telecare technologies with smart home technology, and advanced communications (Internet and Web) services into the home may lead to an increased capacity for self-management through improved education and enhanced perceptions of personal security and safety. As home telecare technology evolves, data collected in the home, in the surgery, or even in the routine pattern of daily life, may be analysed and used to help better coordinate the delivery of healthcare services.

Implementation of home telecare will require fundamental changes in every sector of the healthcare services as GPs, hospitals and specialists adjust to different modes of service delivery, often based on the transfer of data and information and telemedicine diagnosis and consultation, and driven by patient demands for a greater role in shared decision making.

For clinicians to become significant participants and leaders in these changes, they will need to become fully integrated in a communications network based on Web and Internet technologies. The effective incorporation of such networks in clinical practice, however, will require a major paradigm shift among clinicians and the active involvement of the medical colleges, academic institutions and government.

Widespread implementation of home telecare, however, may not be limited by the availability of technology, which is becoming less costly and more effective every year, but rather by inertia and resistance to change within the healthcare system. Large-scale trials to compare quality of life and healthcare outcomes of a matched cohort of elderly subjects, some supported through home telecare and others supported through conventional healthcare services, are required to provide evidence that home telecare leads to a clear diminution of acute-care episodes, improved quality of life and reduced age-related morbidity at reduced cost.

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Authors' details

Centre for Health Telematics, University of New South Wales, Sydney, NSW.
Branko G Celler, BSc, BE, PhD, Professor, and Co-Director;
Nigel H Lovell, BE, PhD, Senior Lecturer, and Deputy Director.

Prince of Wales Hospital, University of New South Wales, Sydney, NSW.
Daniel K Y Chan, MB BS, FRACP, Senior Staff Specialist Geriatrician.

Reprints will not be available from the authors.
Correspondence: Professor B G Celler, Centre for Health Telematics, University of New South Wales, Sydney, NSW 2052.
B.CellerATunsw.edu.au

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