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1.  Cost-effectiveness of telehealth in people with social care needs: the Whole Systems Demonstrator cluster randomised trial 
Introduction
The Whole Systems Demonstrator pilots introduced telehealth and telecare into three local authority areas using an integrated approach to deliver health and social care to those with high care needs and long-term conditions. Proponents of these technologies have given cost savings as one rationale for advocating their introduction and widespread implementation; proponents have also advocated their potential to improve the quality of life for their users. Until recently, evaluations of telehealth and telecare in high-income countries have been based on relatively small-scale pilots; few such evaluations have been designed as randomised controlled trials. The WSD study was a pragmatic cluster-randomised control trial, representing the largest-scale trial of telehealth and telecare to be carried out in the UK. This presentation focuses on the results of the WSD telecare questionnaire study.
Objectives
To examine the costs and cost-effectiveness of telecare compared to standard support and treatment.
Methods
Economic evaluation conducted in parallel with a pragmatic cluster-randomised controlled trial of Telecare. 2600 people with social care needs participated in a trial of a community-based telecare intervention in three English local authority areas. Approximately half of the participants in the telecare trial also consented to participate in the WSD telecare questionnaire study, which collected information on a number of patient-reported outcome measures and also on the self-reported use of a range of health and social services. Health and social costs were calculated by attaching nationally applicable unit costs to self-reported service use data. The unit costs of telecare support and treatment provided were calculated drawing on administrative and financial data sources and interviews with key informants. The primary outcome for the cost-effectiveness analysis was the quality-adjusted life year (QALY). Secondary outcomes included measures of health-related quality of life and well-being. We employed multivariate analyses to explore the cost-effectiveness of the intervention
Results
The presentation will describe the results of the economic evaluation of telecare, addressing the cost of care and treatment packages used by those participating in the telecare questionnaire study and the results of the cost-effectiveness analysis. These results will be available by the time of the presentation.
Conclusions
These will be available by the time of the presentation.
PMCID: PMC3571183
economic evaluation; social care; cost analysis; telecare
2.  Impact of telehealth on general practice contacts: findings from the whole systems demonstrator cluster randomised trial 
Background
Telehealth is increasingly used in the care of people with long term conditions. Whilst many studies look at the impacts of the technology on hospital use, few look at how it changes contacts with primary care professionals. The aim of this paper was to assess the impacts of home-based telehealth interventions on general practice contacts.
Method
Secondary analysis of data from a Department of Health funded cluster-randomised trial with 179 general practices in three areas of England randomly assigned to offer telehealth or usual care to eligible patients. Telehealth included remote exchange of vitals signs and symptoms data between patients and healthcare professionals as part of the continuing management of patients. Usual care reflected the range of services otherwise available in the sites, excluding telehealth. Anonymised data from GP systems were used to construct person level histories for control and intervention patients. We tested for differences in numbers of general practitioner and practice nurse contacts over twelve months and in the number of clinical readings recorded on general practice systems over twelve months.
Results
3,230 people with diabetes, chronic obstructive pulmonary disease or heart failure were recruited in 2008 and 2009. 1219 intervention and 1098 control cases were available for analysis. No statistically significant differences were detected in the numbers of general practitioner or practice nurse contacts between intervention and control groups during the trial, or in the numbers of clinical readings recorded on the general practice systems.
Conclusions
Telehealth did not appear associated with different levels of contact with general practitioners and practice nurses. We note that the way that telehealth impacts on primary care roles may be influenced by a number of other features in the health system. The challenge is to ensure that these systems lead to better integration of care than fragmentation.
Trial registration number
International Standard Randomised Controlled Trial Number Register ISRCTN43002091.
doi:10.1186/1472-6963-13-395
PMCID: PMC3852608  PMID: 24099334
Telemedicine; Telemonitoring; General practice; Workload; Chronic disease
3.  An organisational analysis of the implementation of telecare and telehealth: the whole systems demonstrator 
Background
To investigate organisational factors influencing the implementation challenges of redesigning services for people with long term conditions in three locations in England, using remote care (telehealth and telecare).
Methods
Case-studies of three sites forming the UK Department of Health’s Whole Systems Demonstrator (WSD) Programme. Qualitative research techniques were used to obtain data from various sources, including semi-structured interviews, observation of meetings over the course programme and prior to its launch, and document review. Participants were managers and practitioners involved in the implementation of remote care services.
Results
The implementation of remote care was nested within a large pragmatic cluster randomised controlled trial (RCT), which formed a core element of the WSD programme. To produce robust benefits evidence, many aspect of the trial design could not be easily adapted to local circumstances. While remote care was successfully rolled-out, wider implementation lessons and levels of organisational learning across the sites were hindered by the requirements of the RCT.
Conclusions
The implementation of a complex innovation such as remote care requires it to organically evolve, be responsive and adaptable to the local health and social care system, driven by support from front-line staff and management. This need for evolution was not always aligned with the imperative to gather robust benefits evidence. This tension needs to be resolved if government ambitions for the evidence-based scaling-up of remote care are to be realised.
doi:10.1186/1472-6963-12-403
PMCID: PMC3532839  PMID: 23153014
Telecare; Telehealth; Whole system redesign; Organisational change; Adoption; Implementation; Ethnographic methods
4.  Development and delivery of an SMS-based remote monitoring and support service: ‘Simple Telehealth’ 
Introduction
Healthcare delivery faces unprecedented pressure due to a combination of an aging population, increasing prevalence of long-term conditions (LTCs), and public spending austerity. To mitigate these pressures, technology is increasingly being utilised to promote self-care and enable remote, less intensive support from healthcare professionals. ‘Telehealth’ is a term used to describe the use of technology to remotely support healthcare and promote well-being. This paper describes the development and impact of one such mobile phone-based application—‘Simple Telehealth’.
Objective
The objective of the Simple Telehealth project was to develop an innovative, low-cost system for remotely supporting healthcare delivery and promoting well-being.
Methods
Simple Telehealth utilises SMS messaging to facilitate communication between patients, health and social care practitioners, and decision support software. Patients use a mobile phone to send and receive messages to and from the service support software (‘Florence’), and are provided with point-of-care testing devices for physiological measurement (such as electronic sphygmomanometers or thermometers). Patients are advised to take regular measurements and text results to Florence in a standard format (e.g. BP 100 60 temperature 36.7). Patients are registered on the Florence server by clinicians using a simple web interface. Florence prompts patients to take readings, receives incoming texts, compares measurements to pre-set parameters and provides automated SMS-based feedback to patients. Florence also sends reminder texts according to a practitioner-defined regime, and enables direct SMS-messaging between practitioners and patients. In addition, Florence acts as a shared repository of patient data that can be viewed by health and social care practitioners to support collaborative working.
Results to date
Since its launch in 2010, over 1000 patients have been registered on Simple Telehealth. The service has been used by 300 clinicians in 45 clinical teams. User acceptability and satisfaction is high, and the system anecdotally provides benefits to healthcare practitioners. Simple Telehealth facilitates large-scale, low-cost telemonitoring programmes utilising existing lifestyle technology rather than bespoke, high-cost systems. It is anticipated that the telemonitoring functionality will bring quality of life and clinical benefits similar to those reported in recent Cochrane Reviews. Giving patients a greater understanding of their health status should also enhance self-care ability and—where appropriate—underpin behaviour change. We believe that Simple Telehealth can reduce the frequency of community visits, bringing immediate productivity savings in consumables and travel costs. In addition, the local health community benefits through reduced tariff costs for A&E attendances and hospital admissions. Micro-cases that simulate the economic benefits of Simple Telehealth have identified potential return on investment ratios of approximately 10:1. Building on initial successes, next-stage developments include enhanced links with social care alarm response services, Bluetooth-enabled physiological measurement and voice recognition functionality for users in whom SMS text entry proves difficult.
Conclusions
Simple Telehealth provides a user-friendly and robust platform for the enhanced monitoring and support of patients with LTCs. Despite—or possibly because of—using basic technologies, the system has proven popular with healthcare professionals and patients alike, and has the potential to deliver substantial efficiency savings to healthcare organisations.
PMCID: PMC3571194
telemonitoring; mHealth; SMS; mobile
5.  Systems architecture for integrated care 
Introduction
Telehealth and telecare projects do not always pay enough attention to the wider information systems architecture required to deliver integrated care. They often focus on technologies to support specific diseases or social care problems which can result in information silos that impede integrated care of the patient. While these technologies can deliver discrete benefits, they could potentially generate unintended disbenefits in terms of creating data silos which may cause patient harm or at least impede the ability of the clinician, carer or even patient to treat the patient in an integrated fashion. For instance, if clinical data (vital signs, assessments, medications, allergies) are captured in a telehealth or telecare system, but not integrated with the patient record in the GP or hospital system (or vice versa), then drug or treatment contra-indications could be missed and the patient put at risk.
Architectures
Telehealth and telecare technologies need to be designed and developed within information systems architectures that support the wider objectives of integrated care. Such architectures should be clear about the integration trade-offs implicit in the technology designs between: practical and earlier delivery of benefits in the short-term versus the ability of the care team in the longer-term to treat the whole patient in a patient-centred and fully integrated manner.
Kaiser
There are several types of integrated information systems architectures. One of these is the one deployed by Kaiser Permanente in the US. Kaiser’s information systems architecture contains the following elements: (a) a fully integrated electronic patient record at its core; (b) operation across care settings; (c) patients’ electronic access to their doctor and health record; (d) population care with whole patient chronic care management (for diabetes, COPD, congestive heart failure, asthma, etc.) with a consolidated disease register; (e) development and real-time deployment of embedded clinical protocols; (f) secure access by remote health facilities; (g) centralised technical standards and architecture alongside local developments (“think globally, act locally”); and (i) analytic tools for high volume, complex data.
Integration
Integration architectures range from full functional integration to data interoperability. In full functional integration architectures, the electronic patient record is at the core. This patient record is the detailed (not summary) record and reflects a complex information system supporting the entire clinical process including: review of clinical data (results, images, documents), assessments, documentation and correspondence, requesting tests, prescribing and administering drugs, clinical decision support with real-time alerts, multi-resource scheduling, care plans and integrated care pathways, research and patient access to his/her record.
The fully integrated healthcare systems architecture applies to, and operates across, patients, clinicians, clinical teams, carers, social workers, GPs, community units and hospitals within the geographical community in which the patient lives and receives care.
Conclusion
The recommended actions for UK telehealth and telecare projects are (a) define your systems architecture and its integration road map; (b) deploy road map and revise systems architecture; and (c) repeat to continuously improve information systems support for integrated care.
PMCID: PMC3571169
telehealth; telecare; systems architecture; integrated health care
6.  Technology we need to think differently to survive 
The financial climate coupled with the ageing population and the effects of increasing long-term conditions lead to one inevitable outcome for health and care systems. The number of people requiring care will increase significantly, whereas the number able to deliver care (both formal and informal carers) will reduce. Is this a challenge or an opportunity?
The problem is not insoluble, moving to a health and care model, redesigned so that service users are empowered to not simply participate in their own care but deliver their own care, supported by informal carers cannot simply deliver efficiencies but deliver services sustainable into the future. This is supported by the independent evaluation of the national telecare service in Scotland.
Scotland has a national telehealth strategy. Key is the use of digital channels to deliver care services, creating capacity in face to face care services. Scotland has committed significant resources (£80 M) in 2012/2013 to support reshaping care including the deployment of supported technologies into patients homes and has invested significantly in accredited education and training programmes.
The key to success is using technologies already present in peoples homes in an innovative way. Solutions that grow with the user delivering health, care and wellbeing benefits.
PMCID: PMC3571182
national telehealth service; Scotland; digital channels; long-term care
7.  Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? 
Background
Telehealth, as other information and communication technologies (ICTs) introduced to support the delivery of health care services, is considered as a means to answer many of the imperatives currently challenging health care systems. In Canada, many telehealth projects are taking place, mostly targeting rural, remote or isolated populations. So far, various telehealth applications have been implemented and have shown promising outcomes. However, telehealth utilisation remains limited in many settings, despite increased availability of technology and telecommunication infrastructure.
Methods
A qualitative field study was conducted in four remote regions of Quebec (Canada) to explore perceptions of physicians and managers regarding the impact of telehealth on clinical practice and the organisation of health care services, as well as the conditions for improving telehealth implementation. A total of 54 respondents were interviewed either individually or in small groups. Content analysis of interviews was performed and identified several effects of telehealth on remote medical practice as well as key conditions to ensure the success of telehealth implementation.
Results
According to physicians and managers, telehealth benefits include better access to specialised services in remote regions, improved continuity of care, and increased availability of information. Telehealth also improves physicians' practice by facilitating continuing medical education, contacts with peers, and access to a second opinion. At the hospital and health region levels, telehealth has the potential to support the development of regional reference centres, favour retention of local expertise, and save costs. Conditions for successful implementation of telehealth networks include the participation of clinicians in decision-making, the availability of dedicated human and material resources, and a planned diffusion strategy. Interviews with physicians and managers also highlighted the importance of considering telehealth within the broader organisation of health care services in remote and rural regions.
Conclusion
This study identified core elements that should be considered when implementing telehealth applications with the purpose of supporting medical practice in rural and remote regions. Decision-makers need to be aware of the specific conditions that could influence telehealth integration into clinical practices and health care organisations. Thus, strategies addressing the identified conditions for telehealth success would facilitate the optimal implementation of this technology.
doi:10.1186/1748-5908-1-18
PMCID: PMC1560157  PMID: 16930484
8.  Effect of telehealth on quality of life and psychological outcomes over 12 months (Whole Systems Demonstrator telehealth questionnaire study): nested study of patient reported outcomes in a pragmatic, cluster randomised controlled trial  
Objective To assess the effect of second generation, home based telehealth on health related quality of life, anxiety, and depressive symptoms over 12 months in patients with long term conditions.
Design A study of patient reported outcomes (the Whole Systems Demonstrator telehealth questionnaire study; baseline n=1573) was nested in a pragmatic, cluster randomised trial of telehealth (the Whole Systems Demonstrator telehealth trial, n=3230). General practice was the unit of randomisation, and telehealth was compared with usual care. Data were collected at baseline, four months (short term), and 12 months (long term). Primary intention to treat analyses tested treatment effectiveness; multilevel models controlled for clustering by general practice and a range of covariates. Analyses were conducted for 759 participants who completed questionnaire measures at all three time points (complete case cohort) and 1201 who completed the baseline assessment plus at least one other assessment (available case cohort). Secondary per protocol analyses tested treatment efficacy and included 633 and 1108 participants in the complete case and available case cohorts, respectively.
Setting Provision of primary and secondary care via general practices, specialist nurses, and hospital clinics in three diverse regions of England (Cornwall, Kent, and Newham), with established integrated health and social care systems.
Participants Patients with chronic obstructive pulmonary disease (COPD), diabetes, or heart failure recruited between May 2008 and December 2009.
Main outcome measures Generic, health related quality of life (assessed by physical and mental health component scores of the SF-12, and the EQ-5D), anxiety (assessed by the six item Brief State-Trait Anxiety Inventory), and depressive symptoms (assessed by the 10 item Centre for Epidemiological Studies Depression Scale).
Results In the intention to treat analyses, differences between treatment groups were small and non-significant for all outcomes in the complete case (0.480≤P≤0.904) or available case (0.181≤P≤0.905) cohorts. The magnitude of differences between trial arms did not reach the trial defined, minimal clinically important difference (0.3 standardised mean difference) for any outcome in either cohort at four or 12 months. Per protocol analyses replicated the primary analyses; the main effect of trial arm (telehealth v usual care) was non-significant for any outcome (complete case cohort 0.273≤P≤0.761; available case cohort 0.145≤P≤0.696).
Conclusions Second generation, home based telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only. Telehealth did not improve quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months. The findings suggest that concerns about potentially deleterious effect of telehealth are unfounded for most patients.
Trial Registration ISRCTN43002091.
doi:10.1136/bmj.f653
PMCID: PMC3582704  PMID: 23444424
9.  Impact of telehealth on hospital use and mortality: provisional findings from the whole system demonstrator trial 
Introduction
Around the world, efforts are being made to address the increasing prevalence of chronic disease among an ageing population. Some research has suggested that telehealth can improve patient experience, clinical indicators and quality of life, while lowering use of traditional health services. However results are equivocal and many trials have not met robust evaluation standards.
Aims and objectives
The whole system demonstrator was a large cluster randomised trial aimed at a broad assessment of the impact of telehealth on a population with Chronic Obstructive Pulmonary Disease (COPD), heart failure or diabetes. This study considers the impact of telehealth on services other than hospital care, including primary care and social care.
Methods
Novel data linkage techniques aimed to allow participants to be tracked in data sets collected from several hundred general practices and three local authorities. The outputs from a predictive model were used to adjust for differences in case mix between intervention and control groups. We assessed the impact of telehealth on numbers of visits to general practice surgeries, numbers of hours of home care from the local authority, and admission to residential care over twelve months.
Results
Under embargo.
Conclusions
Under embargo.
PMCID: PMC3571135
telehealth; evaluation; primary care; social care
10.  Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial 
Age and Ageing  2013;42(4):501-508.
Objective: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial.
Participants and setting: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England.
Design: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat.
Data sources: trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service.
Main outcome measures: the proportion of people admitted to hospital within 12 months. Secondary endpoints included mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs.
Results: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were not statistically significant (odds ratio: 0.90, 95% CI: 0.75–1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant.
Conclusions: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months.
International Standard Randomised Controlled Trial Number Register ISRCTN43002091.
doi:10.1093/ageing/aft008
PMCID: PMC3684109  PMID: 23443509
telecare; assistive technology; randomised controlled trial; administrative data; older people
11.  ‘Letting Go’: delegating responsibility for non-clinical tasks in a telehealth service 
Introduction
The implementation of telehealth into the delivery of chronic conditions management within Hywel Dda Health Board has provided an opportunity to enhance close working relationships with Carmarthenshire County Council’s well-established telecare team. The responsibilities of the telecare team were initially limited to the installation and removal of telehealth devices in patients’ homes and training on its use but as the use of telehealth has widened, an increasing number of non-clinical tasks, several of which were previously undertaken by clinical staff, have been delegated to members of the telecare team and linked to the monitoring centre. In addition, all the tasks associated with managing and administering the patients on the telehealth system backend are undertaken by the chronic conditions management administrative support team within the Health Board.
Aims and objectives
This presentation will describe our experience of bringing together clinical and non-clinical staff from two separate organisations to deliver a more appropriate, comprehensive and timely telehealth service to patients. It will explain how strong working relationships have developed, the importance of a clear understanding of different roles within the team and the need for building trust and confidence in colleagues, resulting in the clinical nurse specialists ‘letting go’ and responding to change that supports effective monitoring and still providing quality care. We will report on the lessons learned during the process, from both staff groups’ perspectives and the patient’s perspective, as tasks previously undertaken by clinicians have shifted to non-clinical staff.
Results
Our current approach to telehealth has evolved into a model which ensures that the specialist nursing team are able to focus solely on delivering quality clinical care enabled and supported by telehealth where appropriate. All the non-clinical tasks are now undertaken by the telecare team staff and chronic conditions management administrative support and include:
Installing devices in patients’ homes and providing education and training
First-line monitoring/triage of uploaded patient data Escalation of clinical alerts to nursing team by Telephone
Resolving technical alerts and missing uploads/data
Provision of refresher training to patients as required (telephone-based or face-to-face)
Responding to patient or nurse-reported technical problems, including battery/faulty device replacement
Providing advice on home set-up e.g., recommending changes
System administrator, patient administration and management function of backend
The results of patient and staff questionnaires seeking feedback on our model will be given together with an economic evaluation comparing the current approach, which utilises telecare and specialist staff to deliver the service compared to the previous delivery model using specialist nursing staff only. We will also show that through embedding telehealth into a well-established community specialist nursing service has the following impact and outcomes:
Patients to take more responsibility for their day-to-day care
Nurses to monitor patients remotely and contact those who need support reducing the number if inappropriate home visits
Reducing travelling for the nursing service
Improving relationships between patient and nurse
Supporting carers
Conclusions
We have embedded our telehealth service into existing service models which have now been enhanced utilising a partnership approach and ensuring the best use of the skills and expertise, across the organisations involved. This has been a key factor in developing an efficient, effective and sustainable approach.
PMCID: PMC3571134
partnership; comprehensive; timely telehealth service
12.  Exploring the impact of telehealth on the work of frontline health professionals within the Whole System Demonstrator study 
Introduction
A central aim of the Whole System Demonstrator (WSD) programme is to find out how telehealth can help people manage their own long-term health conditions and to evaluate the potential benefits of this technological intervention within a randomised control trial. However, the adoption of this intervention at local level will entail significant changes in practice of care, in the division of health care work and in traditional professional-patient relationships and so will be contingent on the support of frontline health professionals directly responsible for its delivery. This was the rationale behind this theme 4 sub study within the Whole System Demonstrator evaluation study.
Aims and objectives
To examine health professionals’ views and experiences of implementing telehealth and their retrospective judgements of barriers and facilitators to its success.
Methods
We undertook a 2-year qualitative longitudinal study. The method of data collection was semi-structured in-depth interviews with a purposive sample of frontline health professionals. The first year comprised baseline qualitative interviews with key health professionals directly involved in the delivery of telehealth in three Whole System Demonstrator sites: the London Borough of Newham, Cornwall and Kent. Interview participants included community matrons, teleheath monitoring nurses and general practitioners who deliver care to patients with long-term conditions. Follow-up interviews were conducted around one year later, prior to the end of the study and all interview data were thematically analysed and managed by NVivo.
Results
Currently under embargo by DH.
Conclusions
Currently under embargo by DH.
PMCID: PMC3571179
Whole System Demonstrator; telehealth; health professionals; qualitative
13.  TeleHealth Improves Diabetes Self-Management in an Underserved Community 
Diabetes Care  2010;33(8):1712-1717.
OBJECTIVE
To conduct a 1-year randomized clinical trial to evaluate a remote comprehensive diabetes self-management education (DSME) intervention, Diabetes TeleCare, administered by a dietitian and nurse/certified diabetes educator (CDE) in the setting of a federally qualified health center (FQHC) in rural South Carolina.
RESEARCH DESIGN AND METHODS
Participants were recruited from three member health centers of an FQHC and were randomized to either Diabetes TeleCare, a 12-month, 13-session curriculum delivered using telehealth strategies, or usual care.
RESULTS
Mixed linear regression model results for repeated measures showed a significant reduction in glycated hemoglobin (GHb) in the Diabetes TeleCare group from baseline to 6 and 12 months (9.4 ± 0.3, 8.3 ± 0.3, and 8.2 ± 0.4, respectively) compared with usual care (8.8 ± 0.3, 8.6 ± 0.3, and 8.6 ± 0.3, respectively). LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group compared with usual care. Although not part of the original study design, GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group (9.2 ± 0.4, 7.4 ± 0.5, and 7.6 ± 0.5, respectively) compared with usual care (8.7 ± 0.4, 8.1 ± 0.4, and 8.1 ± 0.5, respectively) in a post hoc analysis of a subset of the randomized sample who completed a 24-month follow-up visit.
CONCLUSIONS
Telehealth effectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population.
doi:10.2337/dc09-1919
PMCID: PMC2909047  PMID: 20484125
14.  What's happening now! Telehealth management of spinal cord injury/disorders 
Context
Spinal cord injury and/or disorders (SCI/D) is a costly chronic condition. Impaired mobility, and lengthy travel distances to access specialty providers are barriers that can have adverse impact on expenses and quality of care. Although ample opportunities for use of telehealth technologies exist between medical facilities, and from clinical to home settings, field experience has largely been focused on home telehealth services to promote better patient self-management skills and improve clinical outcomes.
Findings
This paper provides an overview of published literature on use of telehealth technologies with the SCI/D population. Presentation of case studies describe telehealth as a potential strategy for addressing disparities in providing quality care, and explore comprehensive management of multiple health issues in individuals with SCI/D. Experiences of providers in both private sector health-care systems and VHA medical facilities are described. Development of telehealth clinical protocols and adaptive devices that can be integrated with equipment to accommodate for the functional limitations in the SCI/D population are discussed as necessary for expansion of use of telehealth services. Rigorous research studies are lacking. As use of this technology spreads and issues surrounding implementation are addressed, we look forward to increased research to assess and evaluate its efficacy in the SCI/D population.
Conclusion/clinical relevance
Telehealth in the home setting appears to be able to help persons with SCI/D remain in the community. As the use of telehealth increases, research will be necessary in both clinical and home settings to assess its efficacy in improving outcomes in the SCI/D population.
doi:10.1179/2045772311Y.0000000003
PMCID: PMC3127362  PMID: 21756573
Telehealth; Veterans; Spinal cord injuries; Preventive care; Accessibility
15.  Using telecare in the development of learning disability services in Gloucestershire 
Gloucestershire Learning Disability Partnership is a collaborative service of NHS Gloucestershire and Gloucestershire County Council. It serves over 2500 people with a learning disability and is currently working to incorporate telecare and telehealth into its mainstream services. We believe this proposed presentation would fit under the Developing Applications at Scale category. The Partnership Commissioners recognising the internal barriers to effecting telecare and telehealth applications commissioned a service from external providers which substantially improved service and reduced costs as compared with in-house telecare assessments and implementation. A new partnership was established with two external providers: Allied Health care/Tunstall. Their work is exemplified in the attached case study. The Learning Disability Partnership is now able to commission the evaluation of requirements, establishing the baseline and effecting the necessary changes in a continuous stream. This is now being rolled out across the county for learning disability services.
The presentation would follow the following format: The barriers to success: the internal barriers which prevented telecare and telehealth from happening. How we get in our own way to making change happen.How we commissioned around the barriers and achieved success.The case study and other examples of significant service improvements and savings.The next generation:At the front end of services the partnership is now actively using teleprompting, geofencing and GPS systems to facilitate the enablement of people with a learning disability and enhance their abilities to be independent. Service users express delight in having control of their own lives versus having ‘support workers’ follow them around (DVD available).Q and A. The main presenter would be Chris Haynes, an accomplished international speaker winner of the Queens Golden Jubilee Medal for Public Service and currently Joint Commissioner of Learning Disability Services.
There will be representatives from Allied and Tunstall on hand to discuss their involvement and how it works.
PMCID: PMC3571180
partnerships; value for money; independence; commissioning; success
16.  Effectiveness and cost-effectiveness of a telehealth intervention to support the management of long-term conditions: study protocol for two linked randomized controlled trials 
Trials  2014;15:36.
Background
As the population ages, more people are suffering from long-term health conditions (LTCs). Health services around the world are exploring new ways of supporting people with LTCs and there is great interest in the use of telehealth: technologies such as the Internet, telephone and home self-monitoring.
Methods/Design
This study aims to evaluate the effectiveness and cost-effectiveness of a telehealth intervention delivered by NHS Direct to support patients with LTCs. Two randomized controlled trials will be conducted in parallel, recruiting patients with two exemplar LTCs: depression or raised cardiovascular disease (CVD) risk. A total of 1,200 patients will be recruited from approximately 42 general practices near Bristol, Sheffield and Southampton, UK. Participants will be randomly allocated to either usual care (control group) or usual care plus the NHS Direct Healthlines Service (intervention group). The intervention is based on a conceptual model incorporating promotion of self-management, optimisation of treatment, coordination of care and engagement of patients and general practitioners. Participants will be provided with tailored help, combining telephone advice from health information advisors with support to use a range of online resources. Participants will access the service for 12 months. Outcomes will be collected at baseline, four, eight and 12 months for the depression trial and baseline, six and 12 months for the CVD risk trial. The primary outcome will be the proportion of patients responding to treatment, defined in the depression trial as a PHQ-9 score <10 and an absolute reduction in PHQ-9 ≥5 after 4 months, and in the CVD risk trial as maintenance or reduction of 10-year CVD risk after 12 months. The study will also assess whether the intervention is cost-effective from the perspective of the NHS and personal social services. An embedded qualitative interview study will explore healthcare professionals’ and patients’ views of the intervention.
Discussion
This study evaluates a complex telehealth intervention which combines evidence-based components and is delivered by an established healthcare organisation. The study will also analyse health economic information. In doing so, the study hopes to address some of the limitations of previous research by demonstrating the effectiveness and cost-effectiveness of a real world telehealth intervention.
Trial registration
Current Controlled Trials: Depression trial ISRCTN14172341 and cardiovascular disease risk trial ISRCTN27508731.
doi:10.1186/1745-6215-15-36
PMCID: PMC3906859  PMID: 24460845
Cardiovascular disease risk; Depression; Randomized controlled trial; Telehealth
17.  Outcome data for the remote patient monitoring over three years of over 1000 patients in Northern Ireland with a long-term chronic illness 
Over a period of four years Alere Connected Health’s (ACH) management and specialist telehealth nurses have designed, implemented and delivered a completely new and re-engineered model of community care for people with long-term conditions (LTC) that has resulted in the delivery of a full ‘end to end’ clinical telehealth managed service monitoring over the period for over 1000 patients from two NHS Trusts in Northern Ireland. ACH were commissioned to develop programmes to deliver chronic disease monitoring and from the outset it was clear that the Department of Health was looking for a ‘service delivery’ partner rather than a ‘kit provider’. This regional telehealth programme in partnership with Belfast Health and Social Care Trust and South Eastern Health and Social Care Trust managed patients with one or more long-term conditions, their main chronic conditions being COPD, CHF and Diabetes. This new model of care has now been commissioned by the NHS in Northern Ireland as a National telehealth monitoring service awarding a 6-year contract for the monitoring of several thousand people with a LTC. The ACH telehealth service is ‘technology agnostic’ and can be used with point of care devices from any manufacturer, making it easier for commissioners and users that are already familiar with a particular telehealth product or manufacturer.
During the four-year programme the ACH team developed an innovative web based activity database and telehealth management system software (TMS) in order to gather additional data from and about the patients care in order to determine more accurate programme evaluation data. The data gathered involved clinical, technical and statistical information in order to determine patient utilisation, return on investment (ROI) information and programme outcomes not usually derived from most commercial telehealth ‘back-end’ web server solutions. (In the process the ACH nursing team won two National Awards for ‘Innovation and Partnering’ with the NHS.) A number of significant outcomes and goals have been achieved during the past four years about service delivery and clear evidence suggests that telehealth home patient monitoring can be used as a method of reducing hospital admissions, it appears to promote patients to become better self managers of their long term condition and ultimately enjoy a better quality of life, whilst delivering cost efficiencies to the health care provider. This resulted in fewer unnecessary appointments with their GP.
Patients have reported high levels of satisfaction with the service and health providers are happy that they have been able to concentrate their attention on the patients that really need them. All in all it’s a “win-win situation”. Some of the programme findings and outcome data are as follows: 60% saving of COPD patient unplanned hospital admissions33% saving of CHF patient unplanned hospital admissions32% of patients escalated during ‘out of hours’After a period of three years telehealth monitoring of (n=766 COPD patients) equalling some 3% of the Northern Ireland COPD population, the unplanned hospital admission rate for COPD patients reduced from 42% to 9%.
PMCID: PMC3571196
outcome-data; managed-service; transformation; innovation; database
18.  Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial 
Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.
Design Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat.
Setting 179 general practices in three areas in England.
Participants 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009.
Interventions Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients’ diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.
Main outcome measure Proportion of patients admitted to hospital during 12 month trial period.
Results Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P<0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P=0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference −0.64 days, −1.14 to −0.10, P=0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group.
Conclusions Telehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect.
Trial registration number International Standard Randomised Controlled Trial Number Register ISRCTN43002091.
doi:10.1136/bmj.e3874
PMCID: PMC3381047  PMID: 22723612
19.  Can teletechnology improve patient experience and reduce the use of health care resource? 
Introduction
By 2050 it is estimated that there will be 16 million people over the age of 65 years. With the expansion in the older population and improvements in health care the number people living with a chronic health condition (Long Term Condition, LTC) is increasing. Many people will have more than one LTC e.g. diabetes and cardiac disease. With pressure on the health economy and available resources increasing, managing as many people outside of hospital as appropriately possible is essential. The white paper “Our health our care our say” (DH 2006), challenges local health and social care communities to deliver more care closer to the patients own home. The Kent Telehealth pilot study, undertaken in 2005, investigated whether the use of Telehealth in the UK health care setting could replicate the outcomes of the Veterans Administration programme in the US.
Methods
The pilot examined the role of Telehealth in supporting users and their carers, and assessed its impact on hospital admissions, length of stay, GP contact and nursing visits. Patients acted as their own controls. SF12 and QuIL were used for the qualitative evaluation. Health Ethics approval was granted. All participants provided informed consent. Those meeting the eligibility criteria—of at least one LTC (diabetes, COPD, heart failure) were recruited, equipment was provided to record their vital signs. Vital signs parameters were agreed for individual users with their clinician. Data were automatically uploaded to a web based server, accessible to health care staff responsible for the care of the individual. The frequency of data review was dependent on the service delivery model and appropriate communications were undertaken with the user to facilitate any change in their agreed management plan.
Results
Two hundred and fifty users were recruited, data were available for 202 users for the final analysis. There were 88 less A&E visits and 536 bed days were saved. If admitted the length of stay was shorter by up to 4 days. There was a 28% reduction in calls to the GP, a 23% reduction in visits to the surgery, and an 18% reduction in home visits. It has been estimated that over a six-month period, Telehealth intervention saved an average of £1878 per user (£1038 to £2718, p=0.01). Using Hospital Episode Statistics estimates savings that could be generated across Kent (2006–2007 prices) could be £7.56 million (CI £4.18 million to £10.942 million) annually. Users reported an increased peace of mind, increase quality of life with increased empowerment and self management with improvements in SF12 scores improved for General Health +5.7, for Physical health +8.7.
Conclusions
Telehealth is a potentially valuable adjunct in the management of people with LTCs. Patients become more empowered and independent and as a result, reduced their reliance on primary and secondary care. There is the potential for significant financial gains to be realised, through improved working and reduction in attendance at hospital for admission and or outpatient consultations. Patient quality of life also improved which impacts on how and when they interact with services.
PMCID: PMC3571165
telehealth; long-term conditions; patient experience
20.  The inCASA project: improving the quality of life and social care for the ageing population 
This paper describes an ICT platform aiming to support the well-being of frail elderly people and facilitate them to stay longer and more healthily in their own home. Its principal characteristic is the combination of Telehealth and Telecare monitoring in a unified way, allowing the simultaneous health, mental and psychological status evaluation of an elderly person. For this purpose the platform enables the deployment of services to follow-up the patient’s health status based on a set of monitored parameters per disease, to track the suitability of the in-house environmental conditions and finally to profile user’s habits and diagnose deviations from their usual activities.
The inCASA project implements such platform based on a Service-Oriented Architecture which relies on the Hydra Middleware. Hydra is receiving measurements from proprietary Telehealth and Telecare gateways deployed in the home premises and transforms them into Health Level 7 (HL7) compliant data. Platform developers may add business logic and create healthcare applications on top of the Middleware without getting involved with low-level communication issues with the various types of sensor devices and their protocols. Another core module of the architecture is the Smart Personal Platform (SPP) in which the patient data are forwarded from Hydra, stored and analyzed. SPP includes a reasoning mechanism responsible for the comparison of retrieved measurements with specified thresholds per monitored parameter and per patient. Furthermore, this mechanism detects deviations from the stored habits profile of each user which is dynamically built based on history data. Either in the case of thresholds exceeding or in the case of habits profile deviation, alerts are generated and classified based on their severity. Both data and alerts are available in the back-end user interface of the platform, the so-called Consumer Application interface which is the single point of access for the inCASA operators. In this Web Application, there is an integrated view of Telecare (e.g. movement, habits) and Telehealth (e.g. body weight, blood pressure) data offering also graphical and statistical facilities. Forwarded from the SPP alerts are presented real-time on screen by the Consumer Applications and, if this is the case, other relevant actions take place too, like SMS sending to relatives, doctors and/or operators.
inCASA is an EU co-funded pilot project with a combination of industry and academic partners and has already deployed its pre-mature solution to five European pilots (hospitals or social services). The primary measurable indicators during the pilots include the overall elderly patient satisfaction with the provided services, enhancement of their self-reliance and living conditions and the added value of this service model (i.e. reduced hospitalization of patients and/or response times to emergencies). First results are already collected and satisfy the doctors/operators aim for Telehealth-Telecare integration. One of their main targets that can be supported by the aforementioned integration is the early detection of health deterioration triggered by deviation in user’s habits. In our presentation, we will report on latest results and discuss challenges and benefits of the Telehealth and Telecare monitoring combination.
PMCID: PMC3571144
telehealth; telecare; service-oriented architecture; habits profiling; assisted-living
21.  Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study 
Background
Telehealth (TH) and telecare (TC) interventions are increasingly valued for supporting self-care in ageing populations; however, evaluation studies often report high rates of non-participation that are not well understood. This paper reports from a qualitative study nested within a large randomised controlled trial in the UK: the Whole System Demonstrator (WSD) project. It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial.
Methods
Qualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention (n = 19), or who withdrew from the intervention arm (n = 3). Participants were recruited from the four trial groups (with diabetes, chronic obstructive pulmonary disease, heart failure, or social care needs); and all came from the three trial areas (Cornwall, Kent, east London). Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home. Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes.
Results
Barriers to adoption of TH and TC associated with non-participation and withdrawal from the trial were identified within the following themes: requirements for technical competence and operation of equipment; threats to identity, independence and self-care; expectations and experiences of disruption to services. Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderstandings. Respondents’ views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping. Finally, participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued.
Conclusions
These findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake. These insights have implications for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction. It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation.
doi:10.1186/1472-6963-12-220
PMCID: PMC3413558  PMID: 22834978
Telehealth; Telecare; Patients’ perspectives; Non-adoption; Non-participation; Barriers; Qualitative research; Whole System Demonstrator
22.  Gerontechnology: Providing a Helping Hand When Caring for Cognitively Impaired Older Adults—Intermediate Results from a Controlled Study on the Satisfaction and Acceptance of Informal Caregivers 
The incidence of cognitive impairment in older age is increasing, as is the number of cognitively impaired older adults living in their own homes. Due to lack of social care resources for these adults and their desires to remain in their own homes and live as independently as possible, research shows that the current standard care provisions are inadequate. Promising opportunities exist in using home assistive technology services to foster healthy aging and to realize the unmet needs of these groups of citizens in a user-centered manner. ISISEMD project has designed, implemented, verified, and assessed an assistive technology platform of personalized home care (telecare) for the elderly with cognitive impairments and their caregivers by offering intelligent home support services. Regions from four European countries have carried out long-term pilot-controlled study in real-life conditions. This paper presents the outcomes from intermediate evaluations pertaining to user satisfaction with the system, acceptance of the technology and the services, and quality of life outcomes as a result of utilizing the services.
doi:10.1155/2012/401705
PMCID: PMC3318209  PMID: 22536230
23.  A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol 
Background
Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.
Methods
The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.
Discussion
If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.
Trial registration number
ISRCTN: ISRCTN90940049
doi:10.1186/1748-5908-7-7
PMCID: PMC3274470  PMID: 22280501
24.  Developing the best model for telemonitoring triage: experiences and insights 
Introduction
The demographic, clinical and financial pressures faced by healthcare providers have led to the adoption of innovative methods for delivering care, such as telehealth. If telehealth can be considered as an ‘umbrella’ term, encompassing all applications of technology to remotely support healthcare and promote well-being, then ‘telemonitoring’ can be viewed as a specific application linked to remote monitoring of physiological measures, signs and symptoms. A maturing clinical evidence base—including two positive Cochrane Reviews (Inglis et al., 2010; McLean et al., 2011)—coupled with increased awareness and improving technology, has led to an increase in telemonitoring adoption over the past few years. However, though the number of telemonitoring deployments is rising, there remains uncertainty in regards to the most effective model of delivery. This presentation focuses specifically on the different models that exist for triaging and responding to the data generated by patients receiving telemonitoring.
Aims and objectives
To outline the broad service model common to telemonitoring deployments (input, process, and output)
To highlight the different approaches to generating, triaging and responding to clinical and technical alerts
To discuss the strengths and weaknesses of different approaches to triage and response
To share real-world experiences of developing and implementing different models of triage and response
Results
The presenters have been involved with telemonitoring deployments utilising a range of different service models. The presentation will describe this spectrum of models, ranging from ‘closed-loop’ systems where triage and response is largely automated, through to centralised telemonitoring teams providing expert clinical triage. Each model has its own strengths and weaknesses. For example, automated systems will reduce costs, but may lessen the ‘human’ elements of care often valued by patients. Conversely, a centralised team of nurses offering clinical triage and response is likely to give added value to a telemonitoring service, but at the cost of substantial financial outlay. Many models of delivery sit within these polar opposites, and the relative strengths and weaknesses of key examples will be discussed. In addition to a theoretical overview, the presentation will also allow for the discussion of real-world experiences of developing and operationalizing different models of triage and response. Examples from Yorkshire and the Humber will be discussed, and delegates will be asked to share their own experiences and perspectives. A specific example from a GP practice in Yorkshire will also highlight how models of triage and response can be tailored to dovetail with existing processes.
Conclusion
The successful adoption of telemonitoring at scale requires a clear understanding of the optimum service model for a specific deployment. This presentation will provide a pragmatic overview of the models available for triage and response, allowing delegates to consider the best structure for telemonitoring deployment in their own localities.
PMCID: PMC3571187
teleheath; triage; telemonitoring
25.  The effect of Telehealth on disease-specific quality of life in patients with heart failure: the Whole Systems Demonstrator Telehealth Questionnaire Study 
Introduction
Primary studies and systematic reviews that have examined the effect of Telehealth (TH) on Health-Related Quality of Life (HRQoL) typically conclude that TH leads to quality of life improvements. The evidence base on which such conclusions rest is characterised by methodologically weak studies that generate equivocal findings. The effectiveness of TH, in terms of quality of life benefits, has yet to be substantiated in high-quality trials.
Aims
Using data from the WSD Telehealth Questionnaire Study we assessed the impact of TH on disease-specific HRQoL, generic HRQoL and psychological outcomes (anxiety and depression) in patients with heart failure, over a 12-month period.
Design
The WSD Telehealth Questionnaire Study is pragmatic cluster-randomised controlled trial evaluating a broad range of patient-reported outcome measures. Participants were recruited from three Sites in the UK (Cornwall, Kent and Newham). The current analyses focus on participants with heart failure.
Methods
Over 500 participants with heart failure completed measures of disease-specific HRQoL (MLHFQ), generic HRQoL (UK SF-12; EQ5D), anxiety (Brief STAI) and depression (CESD-10) at baseline. Follow-up assessments were conducted at 4 and 12 months.
Results
Primary and sensitivity analyses will be presented for the heart failure cohort and interpreted in light of existing WSD findings that examine generic HRQoL in a pooled clinical sample comprising participants with heart failure, COPD and diabetes. Specific findings from the WSD Telehealth Questionnaire Study are embargoed until these analyses have been peer-reviewed and accepted for publication.
Conclusions
Conclusions cannot be released until the analyses have been peer-reviewed and accepted for publication.
PMCID: PMC3571121
telehealth; heart failure; quality of life; Whole System Demonstrator

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