Telehealth and e-care: The next generation of healthcare technologies

By Nick Pryke

Technology thrives in every corner of society; its inescapable ability to connect the world has altered the way people communicate forever. But with patient numbers and levels of care set to rise dramatically in the healthcare sector over the coming years, how can technology revolutionize the patient-doctor dynamic?

“Just as email became a new way of interacting with other people that didn’t replace all other forms of communications such as phone calls and letters, e-care uses new technologies to create a new way of providing care that compliments – but doesn’t replace – all clinic visits.”
-Eric Dishman

Telemedicine has been around - albeit in a rudimentary form - for centuries. In its early manifestations, African villagers used smoke signals to warn people to stay away from their village in times of disease. Again in the early 1900s, people living in remote areas of Australia used two-way radios, powered by a dynamo driven by a set of bicycle pedals, to communicate with the Royal Flying Doctor Service. Fast-forward 100 years, and telemedicine has expanded to include its all-encompassing cousin 'telehealth'.

Unlike telemedicine, which narrowly focuses on communication for the curative aspect of medicine, telehealth - the connection between medical technology and patients in the home setting - encompasses the preventative, pervasive and curative aspects, and stresses a myriad of technological solutions. The truth of the matter, however, is that while these technological innovations are indeed being created by companies here in the US and elsewhere, Europe remains the only market where the necessary governing bodies are doing anything about implementing telehealth on a significant scale and with sufficient funding.

Fortunately, all that could be about to change. Telehealth technologies are evolving to provide both patients and healthcare professionals with real-time, interactive, data-rich health management systems that can engage both patients and their care management teams more fully in the treatment of their conditions. To prove this, the Senate Special Committee on Aging set up its first hearing in six years in April of this year. The hearing, 'Aging in Place: The National Broadband Plan and Bringing Healthcare Technology Home', focused on the spread of broadband throughout the US, how information technology could change the way patients and their doctors relate, the potential for cost savings, and some of the barriers to 'aging in place'.

Industry experts

Mohit Kaushal, Digital Healthcare Director for the Federal Communications Commission (FCC), said at the hearing that one study claimed remote patient monitoring could generate net savings of roughly $200 billion over 25 years from just four chronic conditions. "Although economic studies like these are open to criticism due to the difficulty in quantifying savings," noted Kaushal, "the Veterans Hospital System has implemented its Care Coordination/Home Telehealth Program (CCHT) for 32,000 veteran patients with chronic conditions. The program has resulted in a 19 percent reduction in hospital admissions and a 25 percent reduction in bed days for those veterans who are admitted."

"There is also a significant cost saving associated with these improved clinical outcomes," added Kaushal. "The CCHT Program, at $1600 per patient per year, costs far less than the VHA's home-based primary care services, at $13,121 per patient per year, and nursing home care rates, at $77,745 per patient per year."

You may be asking yourself at this point why there's so much emphasis on the elderly population? Well, as Senator Collins stated at the hearing, the two areas where telehealth would provisionally have most the impact would be in the elderly and rural populations, as they encounter the largest array of problems with healthcare - ranging from travel distance to a lack of specialist care.

 "The benefits of these technologies," said Collins, "both in terms of cost-savings and quality of life are clear. They assume particular significance in rural states like mine, the state of Maine, which have a lack of primary care and speciality physicians and where patients often have to travel long distances to receive healthcare services. Yet the US continues to lag far behind other industrialized nations in the acceleration of these critically important technologies."

The current problem remains that, rather ironically, the rural and elderly populations - and especially those that crossover into both categories - suffer a far higher level of IT illiteracy than those based in the city and under the age of 65. More specifically, with the national average of broadband adoption being around the 65 percent mark, the number of those over the age of 65 that are considered to be broadband literate comes in at a disappointing 35 percent. For the remaining 65 percent, the top three reasons for negating broadband adoption were a lack of digital literacy, the perceived irrelevance of digital content and heightened costs - all solvable issues.

Another factor that raises the levels of IT illiteracy within the rural and elderly populations is the sheer lack of access to broadband structures. It was claimed by the FCC that up to 70 percent of clinicians outside the metropolitan districts don't currently have access to broadband structures and have to pay three to four times more than their urban counterparts.

Reice Altomare, Chief Information Officer at Titusville Area Hospital, Pennsylvania, knows this better than most. Working for a small, rural hospital serving its surrounding community, Titusville is exactly the type of hospital that would benefit from telehealth implementation and federal government funding as discussed at the Senate hearing in April. "There are a few major factors that we are challenged with right now," asserts Altomare. "One is the connection issue. Particularly in rural areas, the internet is relatively redundant, which is not what you want if you're looking towards healthcare depending on such a connection.

"Instead, you want two separate broadband fibers coming in, and right now the fibers here cost far too much, especially if you're going to hook up more than one building. Most companies are trying to pay for their R&D and for the build costs, so I understand why it's expensive, but without some type of subsidized program or grant we won't have the connections needed to proceed. On top of that, IT illiteracy also plays a role, but surprisingly, there has been a huge saturation of internet use by folks, even here in rural communities. If you create your portal system and your services for those patients to leverage that knowledge and intuition already gained through using programs like Office and Hotmail, you can start to make a breakthrough.

"Another major hurdle is buy-in. The physicians have to buy into it, and there have been a lot of initiatives in the sector to attempt to get this ball rolling, but there are also plenty of ideas out there in healthcare that are fighting and resisting against this 'new-age' medication as we tend to think of it. Also, the patient doesn't necessarily trust it, so there needs to be a buy-in there. I believe the marketing of telehealth and the convenience of it will eventually change that flow. But for right now, all we're concerned about is how we're going to market this to specialists and to the patients so that they are willing to participate in this new form of care."

Misaligned incentives

What becomes clear is that, while IT illiteracy is an issue that needs to be addressed, it can be done so with little more than a commitment to teaching and training. In line with that is the understanding that if people have a reason to be online, then they are far more inclined to be motivated to do so. The bigger problem, as cited by Altomare and almost everybody else at the 'aging in place' hearing, is re-balancing the Medicare incentive scheme. As it stands, physicians and medical institutions are rewarded on out-of-date, misaligned economic incentives formed before the days of accelerated technology and telehealth devices, where interaction was on a purely face-to-face basis. Senator Wyden, who chaired the Senate hearing, backed this notion.

"The Medicare reimbursement system is flawed," he confirmed. "We saw in the case of the Medicare reform debate that in many respects it rewards efficiency and generally only pays the elderly when they go - in person - to the physician's office. In effect, you have an initiative that rewards volume and the people who come in, regardless of whether or not that is the correct approach. You will have, in my view, a greater expense in Medicare and for taxpayers than you'll have if you take the kinds of technologies that I've offered the committee here today that would allow for people to be cared for in a more constructive way [at home], producing better quality and more timely care at a cheaper price to taxpayers.

"At this point, Medicare barely acknowledges the existence of 'e-care'. It spends over $400 billion a year, of which only about $2 million is spent on these technologies. In particular, such technologies could reduce hospital re-admissions and in turn save the Medicare program financial costs in the years ahead."

The bottom line is that, currently, e-care technology doesn't come with a reward tag. Physicians and institutions will continue to chase volume numbers because that's what pays the bills. Until this is reversed, and Medicare realizes that telehealth and e-care devices could not only save time and improve quality of life, but also save astounding amounts of money, physicians are unlikely to adopt such technology whole-heartedly in the knowledge that it won't help them, or their institutions, financially.

For e-care devices to take their rightful place in this new era of technological innovation, the framework that supports and helps to fund the US healthcare sector needs an overhaul. Returning to Titusville and Altomare, pilot schemes have already witnessed the reversal of attitudes towards reward schemes and the use of e-care devices - almost as soon as the new incentive schemes encouraged it.

"Once we knew that reimbursement schemes would cover e-care costs, we all of a sudden had physicians willing to participate in the program - and the financial aspect was a huge portion of that. The other portion was patient care in general, but once physicians see it in action that goes away because they realize they can provide better care for their patients, particularly the elderly."

Coherence needed

Altomare is far from being in a league of his own when it comes to understanding how the ground currently lies and what needs to change in order for e-care devices and the 'aging in place' scheme to prevail. At the other end of the scale stands Robert Pearl, Executive Director and CEO of The Permanente Medical Group. With a $20 billion organization on his hands, he has to be sure that every decision he makes is not only right for his staff, but more importantly for his patients. And with EMR implementation approaching fast on the horizon, it is fortunate that The Kaiser Permanente Group is well versed in pioneering innovative healthcare.

In an attempt to contextualize the potential effectiveness of e-care devices and tehehealth in general, Pearl describes how The Permanente Medical Group works with technology in three parts. The first concerns itself with ensuring that EMRs are fully integrated within its healthcare system to allow for all medical history to be planted in one, single medical record that can be accessed at any time. The second comes in the form of innovative Internet-based tools that allow patients to make appointments, order prescriptions and check laboratory data online and at their convenience.

Specific to Kaiser Permanente, the website -kp.org - allows patients to schedule their needs securely through electronic tools, while physicians and medical staff can view patient account progress in real-time and update schedules and records accordingly. The final part of Pearl's process deals with video functionality that allows the linking up of doctor to doctor or doctor to patient video calls. This is not strictly new innovation, as plenty of industries have been utilizing video conferencing for some time now, but it does allow decisions to be made on the spot and in a time-conscious fashion.

However, for all that The Permanente Medical Group does to push technological progress, Pearl agrees that the notion of a re-structured incentive and funding scheme is the only true way forward. "I do not believe that quality medical care can be provided without advanced information technology systems in the 21^st century," commits Pearl. "It's very difficult to implement such a system. You need every physician's office, you need your hospitals, pharmacies, laboratories, radiology; that's a lot of individuals all correctly using a common electronic system. They have to have both coordination of what they're going to put into place, coordination of the data flow amongst themselves and then how they're going to use the information that comes out of the EMR at the end.

"To do that requires both technological and leadership coherence. Unfortunately for most of America, that simply doesn't exist. I sometimes speak about the fact that US healthcare most closely resembles the 19^th century cottage industry in England, where you had fragmentation and a payment mechanism that rewarded volume over outcomes and was typically paper-based. It's a large transition from that cottage industry to the 21^st century."

"However, I believe this will change soon," offers Pearl, "although it will probably take at least a decade to do so. I also believe that it will require patients to demand the same level of outcome and convenience in healthcare that they demand in the rest of their lives. I often use the example of a person who travels to another country and takes out their ATM and expects that the machine will know exactly how much money is in that bank account in whatever country they came from; it will know the exchange rate and will deliver them local currency. Essentially, patients will want that same level of convenience from their healthcare that they receive from the rest of their daily lives."

This idea of convenience certainly permeates throughout almost every argument in favour of e-care and remote patient monitoring. In terms of financial convenience, the FCC recently released data that confirmed that remote patient monitoring and e-care devices could save the healthcare industry upwards of $700 billion over the next 15 to 25 years. Combine that with the fact that due to aging and its links with chronic disease, healthcare already accounts for 17 percent of America's GDP - and by 2020 it is predicted that it will account for 20 percent - and it soon becomes glaringly obvious that e-care could not only help the healthcare industry, but the economy of the country as a whole.

While elderly patients with chronic conditions account for roughly 10 percent of Medicare patients, they take up a staggering 85 percent of Medicare costs. By implementing e-care devices and remote patient monitoring, increased communications in medical technology has the ability to keep seniors more mobile at a far lower cost, which is the ultimate intention of the 'aging in place' program.

Once this can be placed in an achievable position, the next step becomes an ability to balance an environment that places a priority on patients' concerns and the particular combination of conditions affecting them, versus a greater stress on patients, their families and caregivers to assume a larger role in identifying and articulating their healthcare concerns and interests. It is here that technology and knowledge should coincide and perfect the balance.

E-care devices

To ensure this happens, Eric Dishman, Intel Fellow and Director of Health Innovation Policy for Intel's Digital Health Group, has spent the past 10 years working with institutions, patients and technology wizards at Intel to provide the necessary data, technologies and evidence to persuade the federal government and the relevant healthcare bodies that e-care is the only way forward. Considered one of the pioneers of e-care devices, Dishman has focused his efforts on what he refers to as "taking healthcare off the mainframe", and concerns himself with an understanding of how behavior can be measured and monitored in a meaningful way through the use of next generation e-care devices.

Having worked with 1000 elderly households across 20 countries in the past 10 years, Dishman and his team have managed to come up with various disruptive technologies to aid independent living. Perhaps the biggest motivator for this was when Dishman noticed in 1999 that, while everyone else was worrying about old computers going bust on millennium night, demographers were worried about the fact that, for the first time in decades, there were more elderly people on the planet than there were young ones. Dishman labelled this 'Y2K plus 10', as the metaphorical tidal wave of elderly to-be-patients was building up but not due to crash down on the healthcare system for another 10 years. Unfortunately health reform has given little consideration to this 'age wave' of baby boomers about to enter the healthcare system.

Dishman and his team have evolved some extremely effective technologies from everyday items. The telephone, for example, has been transformed into "surreptitious technology for the elderly that can tell them when to take medication". Amongst its uses, Dishman boasts that it can be used as a cognitive test by monitoring phone usage of elderly patients over a given period of time, and then analysing the time it takes them to recognize who's on the other end of the phone by up to one tenth of a second. In doing so, the subsequent data can be used to detect the onset of dementia.

As if that wasn't clever enough, the phone can also be used to measure quietness of voice, which can detect for Alzheimer's and Parkinson's disease and what Dishman refers to as "phone touch" - where detecting, recording and monitoring how a patient's hand tremors change over time can alert physicians and caregivers to the onset of arthritis. Moving on from the phone, Intel have also produced what has become known throughout the e-care world as 'shimmer technology'; a microchip placed conveniently around a patient's ankle with various plug-ins to record a person's walking stride, gate and stride length in a 'real world' context.

As an evolution of shimmer technology, Dishman has also produced a 'magic carpet' that can be placed in the home or care setting. A carpet with embedded sensors, it functions in almost the same way as the ankle microchip, except that it includes weight distribution and tracking with its data.

According to Dishman, the point of these technologies is two-fold. Firstly, the collected data can be interpreted to depict if a patient is more likely to fall in a specific setting, and if so why and how that fall came about. Secondly, it allows Intel to collect - for the first time in healthcare history - actual kinetic data outside of the clinical setting that can be used to understand the subtle changes occurring that lead to a fall type specific to elderly patients.

With these technologies, Dishman aims to remove 50 percent of care to the home in the next 10 years, stating: "it is achievable, moral and should be done for quality of life." Yet he is quick to assert that such health technology is not meant to replace the doctor-patient relationship, but rather to enhance it using new tools. "Just as email became a new way of interacting with other people that didn't replace all other forms of communications such as phone calls and letters, e-care uses new technologies to create a new way of providing care that compliments - but doesn't replace - all clinic visits," he said.

At the hearing, Dishman also outlined the four biggest barriers to telehealth implementation. With the obvious two being the aforementioned current incentive scheme and the fact that the large majority of healthcare investment goes straight into R&D and diagnostics for drugs instead of e-care technologies, the remaining two carried just as much weight. Workforce and technology related infrastructure entered in as a third barrier, with Dishman citing a lack of preparation on behalf of hospital professionals and consumers at home to be sufficiently trained to comprehend the technology on a workforce level. The FCC's national broadband plan also needs to be maintained over a more substantial period of time - decades not years - to ensure that the infrastructure gains strength and doesn't crumble once its inceptors retire.

Dishman referred to the final barrier as a lack of 'imagination' on behalf of the providers and government. As it sits, physicians can't imagine what e-care can do for the relationship with their patients as they simply have never experienced it before. Combined with this is the reality that currently no one owns an e-care strategy. For all the right incentives, investments and lateral thinking available - if there is no owner, there is no decision-maker.

Continuing Dishman's analogy of taking healthcare off the mainframe, the advantages of e-care become increasingly obvious to see, whilst unfortunately peeking into the cracks of the current chronic healthcare system. What we are left with are too many clear-cut contrasts. Where the 'mainframe' is reactive, e-care is proactive; where one concerns itself with periodic, 15-minute examinations, the other pervasively monitors 24 hours a day, seven days a week. One utilizes purely biological data, the other a myriad of biological, psychological and behavioral data. And the list goes on. Ultimately, in a world that survives side-by-side with technology, it's about time it was applied to our healthcare. As Mohit Kaushal put it at the Senate hearing: "It's only once we've done this that we can transform what is currently 'sick care' into 'healthcare'."

Fast Facts

• Elderly healthcare currently counts for 17% of the US' GDP
• E-care devices could save the industry $700 billion over the next 15-25 years
• The average national Broadband adoption is 65%

The iPad

Boasting on the move, wireless connectivity and the now standard Apple interactive touch screen, the iPad is already working its magic in the world of healthcare. Of course its countless 'apps' software will allow remote connectivity with on-site computers and patient data, but the real challenge of the iPad will be how it helps connect patients outside the hospital setting with the necessary physicians and aftercare staff.

With over 100 'iMedical apps' already available in the Apple online shop, perhaps the most successful is Epocrates; an app designed to fill its user in on everything from drug interaction and clinical trials through to pill identification and infectious disease treatments. Within its extraordinary bank of medications, Epocrates also houses over 600 herbal medicines and updates medical news and drug contents. Healthcare professionals are already using it nationwide, so it's use by the patient population should provide a significant change in the dynamic between patients and doctors.

SHIMMER technology

Dishman and his team at Intel have been researching and creating Sensing Health with Intelligence, Modularity, Mobility and Experimental Reusability technology - or SHIMMER technology to save your breath - with astounding results in recent years. The technology, which is designed to be lightweight, wearable and connected to Bluetooth-enabled monitors, can track the gait and motion of patients in an effort to better understand and prevent falls, which often lead to rapid health deterioration in the elderly.

Currently being used by the team at Intel in conjunction with what they are calling their 'magic carpet', the SHIMMER ECG works by picking up the weight, angle and pressure of a person's step, and has allowed physicians and research staff to be able to predict falls in the home and care setting through real-time, kinetic data. In addition to this, they are also trialling their Mobile Clinical Assistant (MCA). Complete with Bluetooth, a built-in camera, an RFID reader and software to track inventory and other electronic records, the MCA aims to add to workflow efficiency to the hospital environment while keeping patients interacting with their prognosis.

Electronic band-aid

The Bluetooth enabled band-aid works on behalf of both paramedics and patients. Not only will it allow paramedics to ascertain a patient's blood type, allergies and overall priority of the patient thanks to a small screen embedded into the plaster - giving text display and real-time colour coding regarding the patients status - but it also gives a complete picture concerning the number of injured parties and their relative severities by pooling all the information within the system and relaying it back to the A&E department, allowing them to prep the necessary drugs, equipment and human resources well in advance of receiving the casualties.

On the patient side, the electronic band-aid will allow doctors to wirelessly alter prescriptions straight to the patient without them having to go to a pharmacy or back to their doctor. For the elderly and rural populations at least, this kind of technology could improve quality of life and reduce travel days exponentially.

Vital Monitoring System

The Vital Monitoring System allows medical staff to remotely view the vital signs of patients under their care without having to be in the same location. Strapped onto the wrist, the handy device is designed to check body temperature, pulse rate and blood pressure. From there, the data is transferred wirelessly to a digital chart for later review and access. In the unfortunate but unavoidable occasions where a patient's vital signs change significantly, the Vital Monitoring System sends a trigger to the member of staff, who can then immediately see to that patient and administer the necessary care. Not only will technology such as this improve patient comfort and anxiety, but it will also allow for more efficient time management on behalf of the medical staff.

Philips' 'Simplicity' concept

Shown off at Philips' annual event in London, UK, the company unveiled two new concept technologies that aim to improve the flow of information to patients. The first sees the transformation of a standard room divider into a fully operational computer that displays key patient data and allows doctors to explain procedures with the help of interactive diagrams. Think somewhere along the lines of a projected, interactive touch screen that patients can view from their beds, and you start to realize how useful the concept could be.

The second concept is aimed at expected mothers. Known as the Philips blanket, it is placed over the stomach of the mother-to-be before a fully 4D scan is created and displayed on a circular display or wall for all to see - without the hassle of an ultra-scan at the hospital. Expected mothers will also be able to compare and morph previous scans to put together a timeline of their little one's progress. Still very much in the early development stages, Philips hopes both these technologies could improve hospital life for patients in the next five to 10 years.

Breaking down barriers

Eric Dishman outlines the four biggest barriers to e-care implementation

Imagination

Providers find it hard to imagine and comprehend what is possible past the physician to physician dynamic. Once they do, the world of e-care design can flourish.

Incentive

The current Medicare incentive scheme is out-of-date. Realign incentives with pay-per-outcome instead of pay-per-volume and e-care will catch on.

Investment

With the large majority of investment going on R&D and drug diagnostics, e-care needs to attract investors in order to enter the industry and make itself known.

Infrastructure

In a workforce context, both professionals and consumers need to be trained in using e-care devices. In a technological context, the FCC's Broadband plan needs to be maintained over time so ensure it doesn't stagnate.

“I do not believe that quality medical care can be provided without advanced information technology systems in the 21st century.”
-Robert Pearl