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Telehealth for dva veterans evaluation
- 1. Sharon Campbell Health Planning and Evaluation 584
- 2. Planned introduction of telehealth services funding for eligible veterans located in remote, regional and outer metropolitan areas of Australia. Will address the barriers in accessing health care in these areas. Will negate the need for long distance travelling for patients. 3 year trial of in home telemonitoring.
- 3. What is Telehealth? ◦ Telehealth technology is used to increase the level of health care access for consumers who live in a rural or remote environment. ◦ Telehealth offers a practical solution for both consumers and practitioners.
- 4. Who is the evaluation for? The evaluation is for DVA in relation to the introduction of trial telehealth programs for DVA clients through the use of in home telemonitoring.
- 5. Stakeholders ◦ Patients ◦ Practitioners ◦ Wider community ◦ DVA ◦ Australian Government
- 6. Evaluation Questions 1. Why has the program been established? 2. Target Groups 3. Aims and Objectives 1. Hospitalisation rates and other health costs 2. Informal care burden and transport costs 3. Admission to residential aged care and impacts on formal sector community care services 4. Cost effectiveness of intervention.
- 7. Evaluation Questions continued 4. What resources are involved 5. What is the programs stage of development 6. What aspects of the programs operating environment i.e. politics, social, environment are important?
- 8. Evaluation perspective ◦ Economic perspective A review of the resources used through the telehealth program. Will there be an impact on the efficiency and the cost of medical care?
- 9. Evaluation Design Randomised controlled experimental design ◦ Subjects-DVA Veterans with specific conditions in a broadband accessible area. ◦ Control group-DVA Veterans with specific conditions in a non-broadband available area (control group)
- 10. Data Gathering Methods The inclusion criteria for both the target population and the control group include having the following conditions and being over the age of 65 (as well as being a veteran): cardiovascular disease (CVD), with a prevalence of 22.8% in the 65+ population; diabetes, with a prevalence of 9.31% in the 65+ population; and chronic obstructive pulmonary disease (COPD), with a prevalence of 17.63% in the 65+ population (Pezzullo, Mitchell, Brown 2010).
- 11. Timelines ◦ Will run over a three year period commencing in 2012. ◦ DVA will receive 3 monthly snapshots of data analysis.
- 12. Resources ◦ Estimated costs of Intervention Component Net Present 2012-13 2013-14 Value Coordination 3393.00 2070.00 1670.00 Telemonitoring 2803.74 3000.00 Data Management 2169.00 1200.00 1200.00 Videoconferencing 46.00 50.00 Data/Voice Cost 865.00 478.00 478.00
- 13. Practical, ethical, political and other issues Financial issues. Training and education of physicians. Infrastructure Support for coordinators Change management
- 14. Strategies for maximising utilisation of the evaluation ◦ Stakeholder and Focus group meetings ◦ Feedback to the sponsor
- 15. Strengths and weaknesses of proposal ◦ Strength- this evaluation will form the basis for a reliable blueprint for measuring program costs. ◦ Weaknesses- hard to generalise about fixed and variable costs across sites. Limited information regarding benefits of telehealth at this stage from a health improvement view.
- 16. Is the evaluation proposal worth backing?
- 17. Australian Medical Association. 2006. On-line and other Broadband Connected Medical Consultations. Available at: http://ama.com.au/node/2508 Cornfield, T. Klecun-Dabrowska,E. 2001. Ethical Perspectives in Evaluation of Telehealth. Cambridge Quarterly of Healthcare Ethics. 10, 161–169 Department of Health and Ageing. 2012. Telehealth Technical Standards Position Paper. Commonwealth of Australia. Dillon,E. Loermans, J. Davis, D. Xu,C. 2005. Evaluation of the Western Australian Department of Health telehealth project. Journal of Telemedicine and Telecare. 11.19-21. Fitzsimmons,D. Thompson,J. Hawley,M. Mountain,G. 2011. Preventative tele- health supported services for early stage chronic obstructive pulmonary disease: a protocol for a pragmatic randomized controlled pilot trial. Trials Journal. 12(6). 1- 9. Gagnon, M. Lamothe,L. Fortin,J. Cloutier,A. Godin,G.Gagne,C. Reinharz,D. 2005. Telehealth adoption in hospitals: an organisational perspective. Journal of Health Organisation and Management. 19(1).32-54. Johnston, B. Kidd, L. Wengstrom, Y. Kearney, N. 2011. An evaluation of the use of Telehealth within palliative care settings across Scotland. Palliative Medicine. 26(2). 152-161. Lancaster, P. Krumm, M. Ribera, J. Klich, R. 2008. Remote hearing screenings via telehealth in a rural elementary school. American Journal of Audiology. 17(2). 114-122.
- 18. Melanson, L. 2008. Economic analysis of geriatric telehealth services in Alberta. Proquest Dissertations and Theses. Moffatt,J. Eley,D. 2010. The reported benefits of telehealth for rural Australians. Australian Health Review. 34. 276-281. Ovretveit,J. 2010. Evaluating Health Interventions. Open University Press. Berkshire, England. Paget, T. Jones,C. Davies,M. Evered, C. Lewis,C. 2010. Using home telehealth to empower patients to monitor and manage long term conditions. Nursing Times. 106 (45). 17-19. Persaud, D. Jreige, S. Skedgel, C. Finley, J. Sargeant, J and Hanlon, N. 2005. An incremental cost analysis of telehealth in Nova Scotia from a societal perspective. Journal of Telemedicine and Telecare. 11(2). 77-84. Pezzullo,L.Mitchell,S.Brown,H. 2010. Telehealth for veterans. Access Economics. Shore, J. Brooks,E. Savin,D. Manson,S. Libby,A. 2007. An economic evaluation of Telehealth Data Collection with Rural Populations. Psychiatric Services. 58(6). 830- 835 Wade, V. Karnon,J. Elshaug, A. Hiller,J. 2010. A systematic review of economic analyses of telehealth services using real time video communication. BMC Health Services Research. 10.233.
Editor's Notes
- The evaluation of the planned introduction of telehealth services funding for eligible veterans located in remote, regional and outer metropolitan areas of Australia is discussed. On the 29th November 2011, an announcement was made by the Minister for Veterans’ Affairs of a 3 year trial of in home telemonitoring for chronically ill veterans which would allow them to have their health monitored by health professionals without leaving their home. Around 300 veterans will be able to participate in the trial in a number of NBN connected areas, with trial sites to be advised (Department of Veteran’s Affairs 2011).
- Telehealth offers a practical solution for both consumers and practitioners (Lancaster, Krumm, Ribera, Klich 2008). Non face to face health services can offer an alternative to the traditional mode of consultation. Are used as an adjunct to normal medical practiceReplace services which do not compromise the quality and safety of patient care, or the type of care that necessitates face-to-face consultationsAre employed to access medical care services in areas where such services are otherwise unavailable (AMA 2006). The introduction of telemonitoring can assist patients in becoming involved in their own care and also in greater symptom monitoring and management, thereby reducing unnecessary hospital admissions (Johnston, Kidd, Wengstrom, Kearney 2011).
- This evaluation is for the Department of Veterans Affairs (DVA). The telehealth system is planned to provide easier access for DVA entitled persons who are located in remote, regional and outer metropolitan areas of Australia. This initiative will ensure easier access to specialists and reduce the time and expense required to visit specialists in major cities (DVA 2010). The effective evaluation of the telehealth program trial will be one way of ensuring success. Telehealth offers a practical solution for both consumers and practitioners (Lancaster, Krumm, Ribera, Klich 2008). Non face to face health services can offer an alternative to the traditional mode of consultation. Are used as an adjunct to normal medical practiceReplace services which do not compromise the quality and safety of patient care, or the type of care that necessitates face-to-face consultationsAre employed to access medical care services in areas where such services are otherwise unavailable (AMA 2006). The introduction of telemonitoring can assist patients in becoming involved in their own care and also in greater symptom monitoring and management, thereby reducing unnecessary hospital admissions (Johnston, Kidd, Wengstrom, Kearney 2011).
- Stakeholders considered to be important in relation to the proposed evaluation and implementation of telehealth services for DVA, includes, DVA clients, government agencies, carers and physicians, as well as the Department of Broadband, Communications and the Digital Economy (Pezzullo, Mitchell, Brown 2010).
- The telehealth program has been reviewed for use due to the increasing burden of long term conditions for patients with chronic illness (Paget, Jones, Davies, Evered, Lewis 2010). The main rationale for the introduction of telehealth has been to decrease costs, improve efficiency and increase access in health care delivery (Wade, Karnon, Elshaug, Hiller 2010). The reason for this evaluation is to provide an economic analysis of introducing a telehealth intervention into existing veteran’s care programs (Pezzullo, Mitchell, Brown 2010). The target groups in this evaluation of telehealth medicine will be veterans eligible for DVA benefits in rural areas with particular chronic diseases, such as, cardiovascular disease, diabetes and chronic obstructive pulmonary disease (COPD). It has been estimated that almost half of Australia’s elderly population have one of these conditions. This target group of veterans and a control group of veterans with similar conditions (but not receiving the telemonitoring) was chosen as they were identified as an effective target for telehealth interventions as there is good data availability for these groups (Pezzullo, Mitchell, Brown 2010). The aims and objectives of the study are to evaluate the implementation of the pilot program of the telehealth program from an economic point of view and review costs of healthcare and other economic considerations (Pezzullo, Mitchell, Brown 2010) and compare the new method of health monitoring with the standard methods of monitoring. The following outcomes will be achieved at the end of the trial: 1. Hospitalisation rates and other health costs2. Informal care burden and transport costs3. Admission to residential aged care and impacts on formal sector community care services4. Quality of life, measured using the ‘burden of disease’ units of disability adjusted life years (DALYS) and converted to dollars using the value of a statistical life year.These aims and objectives will be realised through trial information collected. (Pezzullo, Mitchell, Brown 2010)
- What resources are involvedIn order to effectively conduct monitoring of telehealth services a TeleMedCare (TMC) Health Monitor will be used in the patients home. The local GP providing healthcare in conjunction with a nurse coordinator. Video monitoring equipment will also be used to allow veterans to have consultations with their GP or nurse coordinator. The costs are discussed further in this presentation.What is the programs stage of developmentThe telehealth in home program being reviewed by the Department of Veteran’s Affairs has not commenced as yet. The pilot program is set to commence in 2012-13 and 2013-14 and will run in three early sites (Pezzullo, Mitchell, Brown 2010). At this stage trial sites are to be advised and it is envisaged that around 300 veterans with the specific conditions of congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease and diabetes and those who have complex care needs and are at risk of an unplanned hospitalisation will be included in the trial (DVA 2011). What aspects of the programs operating environment ie politics, social, environment are important?The effect that demographic ageing has on Australian Government spending will be to increase it from 7.5% of GDP in 2010 to 12.8% of GDP by 2050 The number of Australians aged over the age of 65 in Australia in 2010 represented 13.5% of the population, in 2050 this is expected to rise to 22.6%. Australians aged over 85 will increase in percentages also, therefore as veterans will increase in numbers of those aged over 85 soon then DVA will also be facing increased costs of care for this group of veterans (Pezzullo, Mitchell, Brown 2010).
- The accurate identification and measurement of telehealth costs are essential steps in performing economic evaluation and also policy and planning. This can assist in identifying areas of inefficiency to assist in a better allocation of resources. The calculation of fixed and variable costs is also useful to determine the best scale of operation, for example from an economic point of view if total costs are mainly fixed, then evaluators will know that average costs will fall more as frequency of utilisation increases (Melanson 2008). The aim of economic evaluations is to discover how many resources are consumed through the use of an intervention (Ovretveit 2010). Economic analysis is of central importance to telehealth programmes due to its main rationales of decreasing the cost of delivering health care, making a more efficient use of the health workforce as well as improve timely and equitable access to services (Wade et al. 2010). The effect of telehealth programs is that they may increase the efficiency and decrease the cost of medical care in rural, remote and underserved populations (Shore et al. 2007). In a cost analysis related to healthcare there are three main areas that a cost analysis can be based on, these include: 1. The provider’s perspective-only those costs incurred by the provider2. The patient’s perspective- this looks at costs incurred by the patient in receipt of the health services. 3. The societal perspective- this looks at total costs of the healthcare services, so includes costs incurred by the patient and the provider to review the total impact on services (Melanson 2008). Melanson (2008) also found that studies into the cost benefit of telehealth have found in the past that from both a provider and patient point of view reduced costs associated with travel were found, as well as reduced travel time. As DVA provides reimbursement for transport, meals and accommodation costs for those veterans who travel for health services then this will be a point of interest in studies that are conducted in this area (Pezzullo, Mitchell, Brown 2010).
- The evaluation design that will be used to provide evaluation of the effectiveness of the telehealth program is a randomized controlled experimental design (Ovretveit 2010). The review of the efficacy of the telehealth monitoring program for DVA veterans with specified conditions will concern a comparison between those veterans, in a National Broadband accessible area with other veterans who will not receive the service due being in a non-national broadband area (control group). Therefore the comparator is the absence of the intervention, which is standard care services as currently provided (Pezzullo, Mitchell, Brown 2010). The strengths of this design are noted as being able to provide a greater level of reliable and valid information than other designs and results from this type of design are very credible. Weaknesses around this design include, being expensive, taking time, the evaluators must have experience, skill and statistical expertise. This type of design does not view patients experiences subjectively.
- Exclusion of data will apply for the above mentioned patients who contract different illnesses over the review period. Other exclusion criteria will include, prior or current involvement in other Telehealth initiativescognitive impairment to the extent that it impedes the ability to participateunwilling to participate and use Telehealth technologyexsistence of co-morbidities which require ongoing intervention from other community nursing servicespatient unable or unwilling to provide written or oral informed consent(Fitzsimmons, Thompson, Hawley, Mountain 2011). Due to the fact that there are four objectives of the trial data will be collected for these as follows: 1. Hospitalisation rates and other health costsThis objective will be measured by the proportion of patients who are re-admitted to hospital with the conditions noted for inclusion in the study, either during, or six months following their discharge from Telehealth monitoring services. The information will be collected via analysis of patient completed self reporting diaries and hospital admission data (Fitzsimmons, Thompson, Hawley, Mountain 2011). 2. Informal care burden and transport costsData will be obtained through unscheduled health care support which is required to further manage their conditions, this will be undertaken using a paper format self-reporting diary for the telemonitoring support service and community Nursing staff, GP and hospital activity. Transport costs will be calculated via patient reporting and ambulance data (Fitzsimmons, Thompson, Hawley, Mountain 2011). 3. Admission to residential aged care and impacts on formal sector community care servicesData will be collected via paper based forms and diaries from patients and through analysis of data obtained from residential aged care in relation to targeted groups. (Fitzsimmons, Thompson, Hawley, Mountain 2011)4. Cost effectiveness of intervention The costs and outcomes will be collected for each individual patient who is recruited to the pilot trial. The data which will be collected will have a focus on the usage of emergency and home based care undertaken by participants. Quality of life (QALY) questionaries will also be measured using the EuroQol 5 Dimensions questionnaire. This can be combined with mortality data to produce quality adjusted life years (QALYs). This is a simple questionnaire to administer and can be built into self-completed patient diaries. The data on service usage to enable cost analysis will be accessed from routine data systems of acute and primary care providers and the local authority (Fitzsimmons, Thompson, Hawley, Mountain 2011).
- The intervention will be over a three year period which is expected to commence in the later half of 2012. It is recommended that the intervention trial continues for three to five years, this is due to the fact that there are very few telehealth studies that are longitudinal in nature and few that provide more than 24 months of data and very few who provide useable cost data (Pezzullo, Mitchell, Brown 2010).
- In order to effectively conduct monitoring of telehealth services a TeleMedCare (TMC) Health Monitor will be used. The local GP providing healthcare in conjunction with a nurse coordinator. Video monitoring equipment will also be used to allow veterans to have consultations with their GP or nurse coordinator. In order to effectively conduct monitoring of telehealth services a TeleMedCare (TMC) Health Monitor will be used in the patients home. As the TMC comes with all monitoring equipment such as scales and glucose meters these items are not costed separately. The local GP providing healthcare in conjunction with a nurse coordinator. Video monitoring equipment will also be used to allow veterans to have consultations with their GP or nurse coordinator (Pezzullo, Mitchell, Brown 2010).Resources needed to manage this evaluation effectively include: Coordination- GP Practices with Nurse Coordinators will be encouraged to participate. If this service is not available then other flexible community provision of coordination services can be reviewed. Equipment- The TMC health monitor will be used for patient monitoring and costs around $3000 to purchase per person. The monitor can measure such things as weight, blood pressure and glucose monitoring. Video conferencing equipment will also be required at the GP Practice. Data transmission will need to be looked at in terms of provision through the NBN network, currently the only provider with plans is iinet.
- The implementation of telehealth is considered to be a major innovation at the technological level as well as cultural and social levels. Barriers which have impeded the implementation of telehealth include financial and technological dimensions. Other concerns are a lack of physicians familiarity with technology as well as inefficient change management. Due to the fact that physicians are the main end users of telehealth their acceptance of this technology is a major challenge for the ongoing sustainability of telehealth networks (Gagnon, Lamothe, Fortin, Cloutier, Godin, Gagne and Reinharz 2005). The training and education of physicians in the actual use of the technology is an important issue, this will apply to patients and their families in this case as the telemonitoring equipment will also be located in the patients home (Johnston, Kidd, Wengstrom, Kearney 2011). Other studies in the area of telehealth have indicated that for the development of telehealth initiatives the infrastructure to support the use of telehealth needs to be improved, this includes the range of broadband coverage to support its use in all areas (Johnston, Kidd, Wengstrom, Kearney 2011). In Australia, broadband coverage is being slowly extended across regional areas (DVA 2011). It has been noted in previous studies in this area that support from senior management is crucial to the implementation of individual projects and contributed significantly to the overall success of the telehealth project. In order to keep the project going continued support for coordinators is required (Dillon, Loermans, Davis, Xu 2005).
- In order to maximize utilisation of the evaluation stakeholder and focus groups will be targeted; these include the Veterans and Veterans Families Counselling Service, local GPs and Nurse Practitioners involved in the ongoing care of the identified veterans who will participate in the trial, in conjunction with representatives from DVA. The DVA will be provided with feedback on all aspects of the program at regular stages throughout the program evaluation. This will include information on cost analysis including incurred costs and savings in relation to the program by all parties (Persaud et al. 2005).
- Strengths A strength of the evaluation of the telehealth program is that the research generated will address the need for a reliable blueprint for measuring program costs, this can then be used for future review and to undertake more comprehensive economic evaluations (Melanson 2008).Weaknesses A difficulty in examining costs related to telehealth programs is that fixed and variable costs can be varied across different sites which makes generalisation of cost savings difficult (Shore et al. 2007). Another weakness in the evaluation proposal will be the limited review of the benefits of telehealth from a health improvement view and not just a cost improvement view (Melanson 2008) therefore other questions to ask with regards to the implementation of the telehealth system would be to ascertain whether or not it is clinically effective and does it provide positive health outcomes for the patient? (Cornfield and Klecun-Dabrowska 2001).
- Telehealth plays a significant role as a part of the national eHealth agenda. From an economic and healthcare perspective there is a strong argument to support the strategic rollout of telehealth services across Australia, and to provide ongoing funds for this important service (Department of Health and Ageing 2012). The current evidence base to support technology adoption and implementation is limited and needs to be reviewed further (Fitzsimmons, Thompson, Hawley, Mountain 2011). Studies have shown that for those people living in remote locations there is a need due to the current service provision demands of needing to travel for investigations, treatment and follow-up care and that the introduction of telehealth could reduce the impact of having to deal with the physical and emotional upheaval of travelling whilst ill (Johnston, Kidd, Wengstrom, Kearney 2011). There have also been a lack of review of the benefits of telehealth for rural and remote patients in Australia and there is a need to build on work already undertaken (Moffatt, Eley 2010). Therefore there is a need to further investigate the feasibility of implementing further telehealth services and to continue undertaking study into this area.