Assessing and enhancing the
public value of telehealthcare
Masterclass - Imperial College London
September 17, 2009
24-Sep-09 D. Protti - University of Victoria 1

A plethora of terminologies and
viewpoints
 Telehealthcare
 Telehealth
 Telemedicine
 Telecare
 Telemonitoring
 Telematics
 Tele…. etc.
 eHealth
 mHealth
24-Sep-09 D. Protti - University of Victoria 2

Cochrane review definition
 'Telehealthcare' has the following elements (adapted
from Miller 2007):
 Information from the patient whether voice, video,
other audio, electrocardiography, oxygen saturation or
other.
 Electronic transfer of such information over a distance.
 There is personalised patient feedback from a
healthcare professional who exercises their skills and
judgement.
 Interventions captured within the terms telehealthcare
include both synchronous and asynchronous (store and
forward) technologies.’
24-Sep-09 D. Protti - University of Victoria 3

EUROPEAN COMMISSION WORKING PAPER
 Telemedicine is the provision of a healthcare service to a
patient in situations where the patient and the health
professional (or two health professionals cooperating on
a specific patient) are not in the same location.
 It involves secure transmission of medical data and
information, such as biological/physiological
measurements, alerts, images, audio, video, or any
other type of data needed for prevention, diagnosis,
treatment and follow-up monitoring of patients.
Telemedicine for the benefit of patients, healthcare systems and society
EUROPEAN COMMISSION STAFF WORKING PAPER
SEC(2009)943 final
June 2009
24-Sep-09 D. Protti - University of Victoria 4

Definition of Telemedicine
• Telemedicine (or telehealth)
- Delivery of healthcare services when the clinician and patient
are at different locations
- Data, images, audio, video
- Excludes tele-education
- Excludes CPR, EMR, HIE and phone calls
• Telemedicine covers five healthcare processes
- Monitoring
- Diagnosis
- Triage
- Consultation
- Procedure
• Telemedicine is part of telecare: patient safety at home
- Fall detectors, bed monitors, panic alarms

e-Health - Definitions
 Claudia Pagliari and colleagues
e-Health is an emerging field of medical
informatics, referring to the organisation and
delivery of health services and information using the
Internet and related technologies. In a broader
sense, the term characterizes not only a technical
development, but also a new way of working, an
attitude, and a commitment for networked, global
thinking, to improve health care locally, regionally,
and worldwide by using information and
communication technology.
24-Sep-09 D. Protti - University of Victoria 6

A new term has entered the arena
 Mobile health (mHealth) is a recently coined term,
largely defined as health practice supported by mobile
devices.
 Mobile health practice includes public health, clinical
medicine, and self-monitoring supported by mobile
phones and personal digital assistants (PDAs).
 Currently active mobile health applications include the
use of PDAs in collecting community health data; using
the mobile phone to deliver health care information to
practitioners, patients, and non-patients; and real-time
monitoring for citizens, both patients and non-patients.
24-Sep-09 D. Protti - University of Victoria 7

Health Informatics, eHealth, TeleHealth, etc.
 It is really all about the use of Information
and Communications Technologies (ICT)
in health and health care delivery to
support the decision making needs of
individuals, their supporters, and their
clinicians.
24-Sep-09 D. Protti - University of Victoria 8

Assessing
the value of
telehealth?
First the good news
24-Sep-09 D. Protti - University of Victoria 9

 Edinburgh City Council has announced it is to spend almost
£1m on telecare this year, more than doubling the amount it
has spent in previous years.
 Edinburgh launched its telecare programme in 2006 and
has invested an average of £400,000 over the past three
years with more than 700 people on the existing telecare
programme.
 The latest plans will mean 1500 people will be supported to
live in their own homes and 700 carers supported in caring for
relatives using telecare systems.
 The Council estimated that its cash injection would save an
estimated 3,000 hospital bed days and 3,000 care home days
per year.
Edinburgh to invest £1m in telecare
Ehealth Insider, 17 Aug 2009
24-Sep-09 D. Protti - University of Victoria 10

 In August 1996, Norway became the first
country to implement an official telemedicine fee
schedule making telemedicine services
reimbursable by the national health insurer.
 Telemedicine is widely used in Northern Norway which is
characterized by a scattered population and a scarcity of health
service specialists, most of whom are in Tromsø.
 Since the late 1980’s, Norway has had
experience in a wide range of areas including:
teleradiology, telecare, telepsychiatry, and the
electronic delivery of laboratory results.
24-Sep-09 D. Protti - University of Victoria 11

Telemedicine Case Study:
U.S. Veterans Administration
How Many Patients? How Did They Do It?
• Home Telehealth (monitoring): 21,000 patients • Care coordination program
General Telehealth (VTC): 17,000 patients • Enterprisewide CPR system
• Store and Forward (diagnosis): 7,600 patients • Telemedicine incorporated
But their total eligible population is 70 million! in existing health services
What if they extended this to well patients?
• Financially self-sustaining
Benefits Reported? in each local network
• Fewer bed days • Standard processes for
implementation and treatment
• Fewer outpatient visits
• National contracts for devices
• Better access to care in remote areas and applications
• Lower travel costs • Federal Supremacy allows
• Better sharing of expertise clinicians to practice across
state lines

Assessing
the value of
telehealth
The less
good news
24-Sep-09 D. Protti - University of Victoria 13

 Telehealth has great potential to improve
access to care but its adoption in routine
health care has been slow. The lack of
clarity about the value of telehealth
implementations has been one reason
cited for this slow adoption.
Cusack CM et al.
The value proposition in the widespread use of telehealth
Journal of Telemedicine and Telecare 2008
24-Sep-09 D. Protti - University of Victoria 14

 A recent Manhattan Research survey found that 39% of doctors
said they have communicated with patients online, up from 31%
in 2007 and 19% in 2003.
 However, a survey of Rhode Island physicians and electronic
health record software vendors found little use in the state of
readily available online tools and a general reluctance among
doctors to adopt such tools.
 A large percentage of the state's doctors treat older patients,
and "people believe that our aging population can't connect with
that."
 No health insurance companies in the state are paying for online
patient communication and that doctors are reluctant to take on
work they will not be reimbursed for.
 Liability issues also deter doctors in the state from
communicating online with patients.
Rhode Island Doctors Reluctant To Embrace Online Communication
Providence Business News
July 27, 2009
24-Sep-09 D. Protti - University of Victoria 15

The Business Case for Telemedicine
• The evidence base for telemedicine is weak
- AHRQ study
• Store-and-forward services: "the evidence for their efficacy is mixed"
• Home monitoring: "required additional resources and dedicated staff"
• VTC: "most effective for verbal interactions"
- JAMIA study
• Effects on patients' conditions: inconclusive
• Patient compliance is high
• Effect on resource utilization is mixed
• Minimal evidence of economic benefit
• The current evidence emphasizes
• soft benefits (quality, patient satisfaction, access)
• indirect economic benefits

The Telemedicine Hype Cycle
Off the Hype Cycle:
• Teleradiology
• Call centers
Teledermatology
Telepathology
Continua Home Health Monitoring (Wired)
Kiosks Videoconferencing
Mobile Health
Telecardiology
Monitoring
Remote ICU E-visits
Technology Peak of Trough of Slope of Enlightenment Plateau of
Trigger Inflated Disillusionment Productivity
Expectations
Maturity

Enhancing
the value
of
telehealth
24-Sep-09 D. Protti - University of Victoria 18

How Gartner Evaluates
Telemedicine Applications
• Adoption and Readiness • Potential Impact
for Adoption - Potential financial impact
- Market penetration • How much money will it save for
• What percentage of care delivery patients, providers and payers?
organizations in North America - Potential clinical impact
and Western Europe are using • Will the application help clinicians
this application? provide better quality care?
- Patient readiness
• Will patients want to use
the application? • Time to Value
- Clinician readiness - How soon is the application likely
• Will clinicians want to use it? to provide a return on investment?
- Market readiness
• Will payers want to pay for it?
- Technological readiness
• Is the application experimental
or mature?
- Vendor maturity
• Is it sold by start-up companies
or well-established vendors?

Remote Monitoring:
Great Potential but Minimal Usage
Market Potential Potential Patient Market Technological Vendor
penetration financial clinical readiness readiness readiness maturity
impact impact
Home health monitoring <1% Very high Very high Very high Low Moderate Low
Remote ICU <1% High High High Moderate Moderate Moderate

Remote Diagnosis and Triage:
Early Commercialization
Market Potential Potential Patient Market Technological Vendor
penetration financial clinical readiness readiness readiness maturity
impact impact
Telepathology (static) <1% High Low NA Moderate High Very high
Teleradiology/remote 30-50% High Moderate NA Very high Very high Very high
PACS
Call centers for remote 10-20% High High High Low Very high Very high
triage

Remote Consultation and Procedure:
Beware the Hype!
Market Potential Potential Patient Market Technological Vendor
penetration financial clinical readiness readiness readiness maturity
impact impact
E-visits <1% High Moderate Very high Moderate Moderate Moderate
Videoconferencing 1-5% High Moderate High Moderate Moderate Moderate
Telesurgery 0% Low Low Very low Very low Low Very low

Adoption, Impact and Time to Value
High
Teleradiology
Call Centers
Standard Essential
Current Adoption
Time to Value
Short
Telecard. Services Video teleconferencing Medium
E-visits Long
Telepath. (static)
Telederma-
tology
Transformational
Nice to Have Home Health
Monitoring (wired)
Remote ICU
Low Clinical Kiosks Mobile Health Monitoring
Low High
Potential Impact

Conclusion
24-Sep-09 D. Protti - University of Victoria 24

Telemedicine Drivers and Inhibitors
Drivers Inhibitors
Patients: Financial:
• Keep patients at home, avoid • Reimbursement
admission to nursing homes • Financial justification
• Easier access to specialist care • Perverse incentives
Staff: Staff:
• Use scarce resources more • Clinician resistance
effectively
• Staffing
• Skills transfer
• Legal and licensing
Organization:
Technical:
• Reduce travel costs
• Integrating data with EMRs
• Make money by offering new
services/reaching more patients • Cost and availability of
infrastructure and connectivity

EUROPEAN COMMISSION WORKING PAPER
Barriers to the wider deployment of telemedicine
1. Confidence in and acceptance of telemedicine
services
 Telemedicine changes traditional working methods and brings
new ways of practising medicine and delivering care.
 New roles for health professionals, new skills and new actors
(e.g. telemedicine call centres) appear in the process of
healthcare delivery.
 Understanding and implementing these changes in an
acceptable and coherent manner is essential to enable wider
deployment.
24-Sep-09 D. Protti - University of Victoria 26

EUROPEAN COMMISSION STAFF WORKING PAPER
2. Legal clarity
 Typical examples of the legal obstacles that wider
deployment of telemedicine is facing are the need for
physicians to be registered in all EU countries where they
are providing services via telemedicine (e.g. interpretation
of radiographs received via teleradiology), or the legal
requirement for all medical acts to be carried out in the
physical and simultaneous presence of the health
professional and patient.
 By not recognising telemedicine services specifically (the
definition of healthcare services often does not include the
concept of “at a distance”), most Member States
discourage its wider use.
24-Sep-09 D. Protti - University of Victoria 27

EUROPEAN COMMISSION STAFF WORKING PAPER
3. Technical issues and facilitating market deployment
 Issues linked to infrastructure, such as access to broadband and
the ability for the provider to enable full connectivity across the
European territory from urban, highly-populated areas to
remote, rural, scarcely-populated areas, still represent a major
challenge.
 The security of the network, the reliability and accuracy of
certain types of telemedicine applications (for instance, using
GSM lines to measure certain vital signs) are additional
challenges.
 On the other hand, for other types of telemedicine solutions, for
instance the remote monitoring of cardiovascular implantable
electronic devices, reliability and accuracy of the measurements
are considered to be sufficient.
24-Sep-09 D. Protti - University of Victoria 28

 “There is evidence that, when combined with
proper organisation, leadership and skills,
telemedicine and innovative Information and
Communication Technologies (ICT) can help to
address some of the societal challenges to
Europe’s healthcare systems. Its benefits range
over different levels, from individual patients,
through healthcare systems as a whole and to
the wider European economy.”
Telemedicine for the benefit of patients, healthcare systems and society
EUROPEAN COMMISSION STAFF WORKING PAPER
SEC(2009)943 final
June 2009
24-Sep-09 D. Protti - University of Victoria 29

Finite
24-Sep-09 D. Protti - University of Victoria 30