Telehealthcare for older people: barriers to large-scale roll-outs


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Kamel Boulos MN. Telehealthcare for older people: barriers to large-scale roll-outs (Round table: Use of technologies to promote healthy aging and improve disability). In: Proceedings of the 1st Barcelona Conference on Healthy Aging (University of Barcelona), Barcelona, Spain, 14-15 November 2013 (invited presentation). URL:

Published in: Health & Medicine, Technology
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  • * 'Under peer review' article mentioned on slide 21 is now published as: Kamel Boulos MN, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: state of the art, concerns, regulatory control and certification. Online J Public Health Inform. 2014; 5(3):e229. DOI:10.5210/ojphi.v5i3.4814 - URL:
    * 'In press' article mentioned on slide 23 is now published as: Dahl TS, Kamel Boulos MN. Robots in health and social care: a complementary technology to home care and telehealthcare? Robotics. 2014; 3(1): 1-21. DOI:10.3390/robotics3010001 - URL:
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  • Brilliant! Well done, Maged! Best regards Jiri
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  • Notes on terminology
    • There are many interrelated, complementary and in some ways overlapping terms and phrase-terms that can be used to describe telehealthcare/homecare solutions. The following ones are only part of the growing and exploding number of terms we have today (listed randomly, not in any particular order):
    – (health/care) telematics, telehealth, telecare, telehealthcare, telemedicine, telepresence, AAL (ambient assisted living), BAN (body area network)/body sensor networks, point of care (PoC) technologies, telemonitoring, (tele)homecare, self-care, mHealth, pHealth (p for pervasive and personalised), AT and domotics, eHealth, digital health, smart homes, distributed healthcare, connected health, wireless health, personal healthcare devices, health apps, cloud (computing) healthcare, patient/consumer health informatics, patient-centred care, expert (empowered) patient, personal health records, etc.
    • Some of these terms are used more in certain contexts to stress or emphasise one particular aspect of the domain, the processes involved and/or the target applications/groups, e.g., mobility (health on the move) as in mHealth/apps, health/care and social care integration as in telehealthcare and AAL (the latter is for older people/independent living), and connectivity as in connected health/care.
    • Some of these terms are more (or less) ‘in fashion’ today than others, and this (term popularity/how fashionable a term is) is always changing; for example, health/medical telematics was very much in fashion more than a decade ago, but not today (telematics describes the type of the core technology: telecommunications + informatics/ICT commonly associated with the other terms in the above list, so it remains a valid term to use today even though it is no longer a very ‘fashionable’ one).
    • Back in 2001-2006, people were busy debating and writing papers and systematic reviews about what is eHealth and how to best define it (including term etymology, semantics, scope and uses). Today we have very many more terms that were introduced or have become more common since then, such as mHealth, etc. but what I personally think we need most are real-world, sustainable, affordable and gracefully scalable services that are useful, work and deliver positive value in a satisfactory manner, rather than (more) fashionable (or non-fashionable) terms to describe them.
    • For the sake of clear communication, the following text provides some working definitions for the terms that are used in this presentation (namely, telehealth, telecare and telehealthcare):
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Telehealthcare for older people: barriers to large-scale roll-outs

  1. 1. 15 November 2013, Barcelona, Spain Telehealthcare for older people: barriers to large-scale roll-outs Maged N. Kamel Boulos, MBBCh, PhD, SMIEEE United Kingdom
  2. 2. Quick agenda • The first half of this presentation will cover the rationale behind telehealthcare, as well as its potential and current applications (mainly in the case of older people), before moving on in the second half of the presentation to the barriers to its wide adoption and what needs to be done. 15 November 2013, Barcelona, Spain
  3. 3. Tele = at a distance / monitoring and intervening from a remote location
  4. 4. Telehealthcare domains and applications - Alerts & reminders
  5. 5. Video compilation: AAL (Ambient Assisted Living) / telehealthcare • • Length: 7:33 Mr Peter Saraga CBE
  6. 6. Key findings from the Whole System Demonstrator programme (England) 21 June 2012 The WSD programme was launched in May 2008. It is the largest randomised control trial of telehealth and telecare in the world, involving 6191 patients* and 238 GP practices across three sites in England (Newham, Kent and Cornwall). *Conditions covered: heart failure, chronic obstructive pulmonary disease, diabetes See more at:
  7. 7. But WSD results also showed… • “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.” 26 February 2013
  8. 8. • “The QALY (quality adjusted life year) gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment.” 22 March 2013
  9. 9. The limitations and pitfalls of generalisation • Some questions to ask/discuss: would it be correct to generalise from one study, however large it might be (even a big RCT such as the WSD), which at the end only evaluated one specific instance of the technology (an American system in the case of WSD) under specific settings, and to blindly apply the results to the whole class to which that technology belongs (AAL/telehealthcare in general) and to all possible settings? • Not all telehealthcare solutions are the same; there are things they share in common, but also very unique specifications and successive versions/iterations for different solutions (technology develops and changes fast), which might greatly affect the results of any evaluation/user acceptance study. • By the time you get some evaluation results published, a new, supposedly better technology/version might have already replaced the evaluated solution on the market. • Implementation environment, settings and user profiles can also (greatly) affect results. For example, in the WSD, they chose sites where there was already a good deal of healthcare and social care integration, but this is not always the case everywhere else. • Should we evaluate telehealthcare interventions in the same ways we evaluate new drugs (standard RCTs/clinical trials)? (paper for reflection)
  10. 10. How do we cure ‘pilotitis’?
  11. 11. • Questions asked and addressed at a recent Partners Connected Health Symposium in Boston (Oct 2013) - quotes (lightly paraphrased) from event news report at – When is it time to stop running pilots and go to scale? – What challenges does that process offer? Does every provider organisation have to reinvent the wheel, or can they learn from each others’ pilots? – For one organisation/site to learn from the other (transferable experiences), we need to have a very detailed analysis of the work, time, resources and conditions/settings that go into, and what exactly comes out, of a given telehealthcare solution implementation, so that others can fully benefit from what we have done. – Pilots in clinical settings often fail to track return on investment (ROI).
  12. 12. – The problem with using ROI to evaluate pilots is that many of the newest endeavours in medicine are preventative and/or have expensive startup costs. So short term ROI can look deceptively bad. An example was offered of a calculator that is used to evaluate longer-term ROI: – The ‘Big Brother’ problem and what to (best) do with the ‘Big Data’ that is continuously generated by telehealthcare sensors (need to be sensitive to individuals’ privacy). – The need to specifically consider the specific population an intervention is targeting. Is the user interface one older people will be able to use? Is it available in the right languages (also think users’ general and health literacy levels here, plus any special usability/accessibility/other requirements they might have)? That sort of population targeting can affect the success of an intervention, but it also makes it harder to use the same strategies at different sites without doing somewhat repetitive efficacy studies. – Pilots can build an ‘ecosystem’/accumulate evidence that in the long-term will help us with better results and better quality care. Do the learning and have a plan to scale from it. Always start small where you think is the actual need, and once the adoption results and outcomes are measured, you can scale it into Quotes (lightly paraphrased) from markets/sites. stopping-mobile-health-interventions-from-scaling/
  13. 13. Transferable experiences • The NHS in England is learning from the US Veterans Health Administration, home of the largest implementation of telehealth anywhere in the world. • A report is now available describing lessons learned from both sides of the Atlantic and recommendations for both organisations: 020health/downloads/reports/202 0vhanhsONLINE_8-3-13FINAL.pdf Published in March 2013
  14. 14. Barriers, challenges and desiderata Report by the Digital Policy Alliance: Published in January 2013
  15. 15. Government (UK) warned over rapid telehealth rollout risks News headlines from Q1 2013 (UK)
  16. 16. Telehealth news headlines from Q3 2013 (UK)
  17. 17. Barriers, challenges and desiderata • Despite its great potential and promises, telehealthcare is facing serious barriers and challenges in the UK. (Similar issues can be found in other parts of Europe.) • The aforementioned Jan 2013 report by the Digital Policy Alliance warned of the risks of the UK Government’s accelerated telehealth roll-out, and made a series of recommendations to ensure the roll-out of telehealth & telecare meets the Government’s objectives of 3 million users and £1.2bn saving over 5 years. • The report highlighted the following main barriers: – Skills shortage and lack of sufficient knowledge among stakeholders* of the capabilities and uses of telehealth & telecare and of the associated professional standards required to ensure high quality coordinated care; (* Lack of sufficient knowledge may lead to resistance to change / fear of the new) – Difficulty of demonstrating that the organisation bearing the cost is also receiving the benefit (ROI): telehealth & telecare benefit patients by enabling them to remain at home, live independently for longer and avoid hospital admissions, but GP practices/NHS commissioners and social service departments do not always see any (direct/immediate or short-term) financial benefits from these outcomes; and – Lack of appropriate multiagency coordination.
  18. 18. What needs to be considered and done / desiderata for success • There is an urgent need to educate and raise the awareness of healthcare professionals and other relevant stakeholders about the benefits and best uses of the different AAL / telehealthcare technologies on offer. • Capacity building and training / addressing the ‘skills gap’ / adopting appropriate instruments for accreditation and certification of competency of involved staff. • Quality benchmarking, accreditation and certification should also be extended to systems (hardware and software), processes and services, in addition to staff, e.g., following the models of TeleSCoPE (EU code of practice) and Happtique (US mobile app certification). In addition to / beyond: etc.
  19. 19. TeleSCoPE - Telehealth Services Code of Practice for Europe
  20. 20. Currently US only See: Kamel Boulos MN, Brewer AC, Karimkhani C, Buller DB, Dellavalle RP. Mobile medical and health apps: state of the art, concerns, regulatory control and certification. 2013; Submitted Jul ’13 (under peer review). Link to published paper will be posted in due course on my social media channels (see last slide).
  21. 21. What needs to be considered and done / desiderata for success Multiagency coordination / healthcare and social care integration • The integration of health/care and social care has long been identified as one of the main deficiencies in some existing AAL / telehealthcare provisions and one of the reasons for their lacklustre results in some scenarios (See: CommonWell (a project co-funded by the European Commission, 2008-2012). Beyond Silos – On the way towards integrated eCare. • After all, AAL is about enabling and supporting the ‘independent living of older people’, and using a BAN (Body Area Network) for monitoring (and acting on) vital and other clinical signs and symptoms, although extremely useful and important, is just one component of any comprehensive care solution, and not the full solution. • Robots (not all of them!) bring in the opportunity of addressing the key issue of ‘integrating health/care and social care’ in comprehensive solutions that involve both robotics and conventional telehealthcare technologies.
  22. 22. Robotics • Robotics can potentially provide AAL with the (often missing) ‘social care component’: – by assisting older people, including those with different types of disabilities, in various activities of daily living and domestic chores, and – by offering them coaching/motivation, companionship/home visits and other much needed services. For a detailed discussion of the topic, including the limitations and potential problems associated with the use of robots for the care of older people and ways of mitigating them, please consult: Dahl TS, Kamel Boulos MN. Robots in health and social care: a complementary technology to home care and telehealthcare? 2013; Submitted Oct ’13 (under peer review). Link to published paper will be posted on my robotics online “scrapbook of links” at:
  23. 23. Video games and exergames • Video games and exergames (e.g., Kinect and GPS), particularly those with a social component (game community / multiplayer), can also help in many ways. The Exergamers Wellness Club uses Kinect for Xbox 360 (dancing titles) to help seniors at the St. Barnabas Senior Centre in Los Angeles stay fit and have fun. Kinect game revolutionising rehab for stroke survivors.
  24. 24. What needs to be considered and done / desiderata for success • • • • • Implementing appropriate technical and interoperability standards,* regulation and increased bandwidth (infrastructure upgrade). (*Standards ensure joined-up health/care and social care services, as well as future proof telehealthcare services that are easily expandable and not dependent on a specific manufacturer.) Sometimes a simpler solution / basic technology is all what is really needed and will perform better. Introducing the latest, most sophisticated technology should never be the goal as such (unless really justified / needed to improve an existing situation that cannot be dealt with satisfactorily with the existing technology), as it might bring in more trouble than (any needed) benefit, due to increased complexity and costs. Consider all the “hidden” costs: staff (training, etc.), technical, infrastructure and site (implementation environment) modification costs. Running, maintenance and upgrade costs can all be very high, and should be carefully analysed and considered ahead of any implementation to ensure long-term sustainable success. Have ‘Plan B’/some ‘system redundancy’ to ensure reliability and robustness, e.g., the availability and automatic triggering of proper contingency plans and mechanisms for services that are remotely operated over the Internet to continue functioning safely when their main Internet connection with patients is broken for whatever reason. Transform patients’ data into clinically sound decisions and actions by using ‘intelligent’, evidence-based software that goes beyond threshold-based, single-parameter triggers and alarms.
  25. 25. • Today, one can easily buy very many wireless sensors on the market with their essential software drivers (for connectivity and data collection from the sensor), and then connect them to a local hub and remote server, but that (alone) won’t make for a useful AAL/telehealthcare solution or solve anything serious clinically speaking. We should be well past this stage in the second decade of the 21st century.
  26. 26. ‘Intelligent’, evidence-based software beyond threshold-based, single-parameter triggers and alarms • Clinically safe, reliable and ‘intelligent’ (evidence-based) software remains necessary to reason with the ‘big data’ that are continuously generated: in realworld scenarios we are speaking about 100s (or 1000s) of older people being monitored by the same service at the same time, so it is indeed big data/ ‘infoglut’, and there are also serious issues of liability here, since we are dealing with human lives, as well as issues of service scalability and sustainability. • The software has to make those data instantly useful and actable upon for clinicians (and patients), and has do so in a timely manner, often in real- or nearreal-time, with minimal false positives and false negatives. It also needs to highlight as early as possible any unfolding clinical events, subtle deterioration or other relevant developing trends in patient’s condition. • This ‘intelligent’ software (not to be confused with the essential drivers and basic sensor connectivity/networking or ‘plumbing’ software) can make a real difference, but is not as easy to acquire (as the sensors and their basic software) from the general market or to develop and tune in-house. • Anyone with the right skills can do system procurement and plumbing, but not everyone can deliver a useful, safe, reliable, scalable and sustainable service (note the difference between ‘system’ and ‘service’).
  27. 27. “There isn’t too much information, but it is a challenge to turn that information into understanding” —Larry Smarr Without the appropriate ‘intelligent’, evidence- and knowledge-based software to reason with those data, we risk giving a false (dangerous) reassurance that everything is being monitored and under control, while in reality this is not the case!
  28. 28. Selected resources • • • • David Lindeman: Interview: lessons from a leader in telehealth diffusion: a conversation with Adam Darkins of the Veterans Health Administration. Ageing Int 2011; 36(1): 146-154 – (alt) Katharina Spitalewsky et al: Potential and requirements of IT for Ambient Assisted Living technologies: results of a Delphi study. Methods Inf Med 2013; 52: 231–238 – Maged N. Kamel Boulos: Telehealthcare for older people with comorbidity: lessons from eCAALYX and project walk-through (2013) Maged N. Kamel Boulos: Telehealthcare promises and challenges (2009) (see also:
  29. 29. Follow me: /mnkboulos – /IJHGeo – G+ – @mnkboulos – @IJHGeo
  30. 30. Appendix: Additional notes on cost effectiveness Cost effectiveness is not always a tiebreaker as such, especially when the other (more cost effective) options on the table are not viable or sustainable in the long run (e.g., due to specialised workforce shortages/increasing demands by consumers). In some cases, cost effectiveness/ROI might not be immediate or available in the short term, but might still happen in the long term. Also, sometimes the less cost-effective option carries with it some unique and compelling advantages that are not found in other conventional solutions, e.g., benefits related to clinical safety and reliability/outcomes or quality of care, etc., as seen, for example, in telerobotic surgery (da Vinci). Telehealthcare solutions might be replacing one workforce skills shortage (healthcare professionals) with another (but perhaps the latter telehealthcare skills shortages can be more easily addressed). Telehealthcare solutions might not improve quality of life over/above other existing options (as reported in a study by Newman et al, 2013 in BMJ2013;346 doi:, but there might still be a strong case for their adoption when other factors are considered.