H E A LT H C A R E
Switch On!
The Case for Telehealth
A DV I S O RY
2 | Switch On! The Case for Telehealth
Switch On!
The Case for Telehealth
The case for assistive technologies is growing,
with a number of successful pilots and trials
across the UK. Telecare is well established,
primarily addressing the care needs of the frail
elderly, whilst telehealth is not yet as widespread.
Telehealth can help monitor people with longterm conditions, enabling timely interventions
that reduce the need for expensive hospital
admissions, as well as improving overall
management of these conditions. However,
for many organisations taking a decision to
implement telehealth is currently a leap of faith.
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network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
Switch On! The Case for Telehealth | 3
As the UK population ages, the number of
On top of this there is latent demand of
people with long-term conditions (LTCs)
those people whose health needs are not
is set to increase sharply, intensifying the
being met under current care models.
demands on an already stretched care
This group may be significant — a recent
system. It is no exaggeration to state that
sampling of Quality and Outcomes
the NHS faces possibly its most difficult ever
Framework (QOF) data to identify patients
challenge — expectations of service quality
registered with chronic obstructive
and availability continue to rise and the
pulmonary disease (COPD) on a GP
system will now have to do more with less.
practice system found about 25–50 percent
of the number one would expect to see
The statistics on LTCs are stark. Almost
given prevalence rates.
one in three of the population currently
has such a condition. LTCs account for
half of all inpatient hospital bed days and
69 percent of the primary and acute care
budget in England. And as people live
longer, the number with a LTC is set to rise
by 23 percent over the next 25 years1.
Definitions are still evolving but for the purposes of this paper, the following
are used:
• Telehealth: equipment and services used to remotely monitor aspects of a person’s
health in their own home.
• Telecare: a combination of remotely monitored passive alarms, sensors, other
equipment and services to help people live independently.
• Assistive technologies: any product or service designed to enable independence for
people with health and care needs, such as LTCs or the frail elderly.
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4 | Switch On! The Case for Telehealth
Technology can help
take the strain
The use of technology to monitor people’s health remotely is increasing. Telehealth can
give an accurate and regular picture of a patient’s health. It enables clinicians to identify
trends and take more timely action to address issues and prevent exacerbations.
Timely and accurate clinical readings
• More frequent and more regular readings taken
• Reduced ‘white coat’ syndrome
83 year old heart patient ‘Mrs E’,
full-time carer to her husband
Better self management
Timely and appropriate care
When Mrs E’s low pulse reading was
• Patient has increased awareness
of their condition
• Greater likelihood of lifestyle
changes being adopted
• Ability to identify trends
• Can intervene to prevent
exacerbations
• Can more easily gauge the
impact of medication changes
received through the telehealth system, a
concerned telehealth nurse rang her. She
learned that the patient had been feeling
weak for a couple of days but had been
too busy caring for her husband to see a
Improved health
doctor. The nurse rang Mrs E’s GP, faxed
• Conditions stabilised — better health
• Less likelihood of exacerbations
over her recent vital signs readings, and
within an hour, the patient was admitted
to hospital where she had a pacemaker
Fewer unplanned interventions
• Reduction of A&E visits and hospitalisation
inserted. In just a few days Mrs E was
back home, feeling better and caring for
her husband, with a potentially serious
situation averted.
Improved quality of life
Cost savings
• Patient feels more in control
• Patient and carer may
experience reduced anxiety
• Patient remains at home
for longer
• Savings through reduction
in unplanned interventions
and hospitalisation
• Shift to less costly interventions
(e.g. nurse visits instead of
GP visits or A&E attendance)
• Savings on medication costs
For more information on the Newham WSD trial
and further case studies and videos please go to:
www.NewhamWSDTrial.org
The feedback from patients and users
Informal carers may also benefit. Whilst
A number of clinicians and care workers
has been very encouraging. Some feel
evidence for carer benefits from telehealth
involved in clinical trials and pilots have also
it empowers them to manage their own
has yet to be published, it is reasonable
been glowing in their praise. But there is
conditions and subsequently address
to draw conclusions from telecare
still a long way to go. Although a number
associated health or social care concerns,
— the Scotland Telecare Development
of primary care trusts (PCTs) are beginning
such as depression over their condition.
Programme2, and the smaller scale London
to talk about telehealth, only a few have
Others believe that it gives them a better
Borough of Havering Assistive Technology
implemented such an approach, typically
understanding and awareness of their
Pilot project3 claim that 74 percent and
via small-scale pilots, with just a handful
health, which helps motivate lifestyle
88 percent of carers respectively report a
taking the leap to large scale roll-out.
changes such as increased exercise or
reduction in stress levels.
better dietary awareness.
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Switch On! The Case for Telehealth | 5
A growing body
of evidence
Through a series of clinical trials, small
What is the WSD programme?
The results of WSD will help to shape
pilots, systematic and meta-data reviews,
WSD seeks to evaluate the potential
national policy for assistive technologies,
the case for telehealth is starting to
of integrated health and social care
but they will not be available until Spring
strengthen. Many of these trials and pilots
provision, supported by advanced assistive
2011. In the meantime, a small number
attempt to measure changes in indicators
technologies such as telehealth and
of healthcare organisations are starting to
such as hospital admissions, bed days and
telecare. It involves over 6,000 participants
implement telehealth, encouraged by the
quality of life, and some attempt to translate
in three locations (Newham, Cornwall and
findings of pilot studies.
findings into cost savings. The table on the
Kent), with five evaluation themes:
last page of this document, highlights some
of the successes of telehealth. The cost
savings are typically theoretical, based upon
reductions in the number of admissions or
interventions, which would be replaced by
less costly activity.
“We have made a commitment to
• Impact upon service utilisation and costs
across health and social care
• Impact upon the lives of participants
and carers
• Cost and cost-effectiveness of
the service
However, the evidence currently lacks
• Views and experiences of users,
mainstream telehealth services in order
to improve self care and provide services
that enable patients to be more informed,
keep them out of hospital and enhance
their overall well being. This is fundamental
considering our demographics and cost of
services in an ageing population,
scale, statistical significance or robust
carers and professionals involved in
25 percent of whom will be over 65
cost saving data, something that the
the programme
nationally in the next 25 years.”
Department of Health is eager to address
• Impact of change, collaborative working
through its Whole System Demonstrator
and large-scale programmes on the
Carol Williams, Director of Service
(WSD) programme.
organisation and individual
Improvement and Professional Practice
at NHS Cornwall and Isles of Scilly
4
The dilemma facing healthcare
organisations is whether to lose valuable
time by waiting for the full trial results, or
whether to push ahead now.
Diabetes patient, ‘Mr C’
Mr C agreed to take part in the Kent WSD
As a result, Mr C has noticed that his weight
programme. He didn’t like using the telehealth
has decreased steadily and his blood sugar
equipment to begin with but soon got used
readings are more consistently lower than
to it.
before taking part in the programme.
He then found that by taking his readings
Mr C says his wellbeing has improved
regularly he became more aware of his
and that generally he feels healthy.
readings, and his general health.
He is taking better care of himself and
taking regular exercise.
© 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG
network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
6 | Switch On! The Case for Telehealth
Technology is not
a panacea
Although telehealth can enhance the
quality of care and reduce costs, to
realise its full potential, healthcare
providers will have to fundamentally
change the way they work. Remote
monitoring allows the identification of
relevant trends through an individual’s
Prevention and early involvement in tiers of care
Focus on prevention
and early
maintenance
Improved health
outcomes for
patients and
population
vital readings and their responses to
questions posted on the system.
This can lead to more informed
decision-making, earlier intervention and
improved caseload management, which
can both save money and make better
Management
of condition
in most
appropriate
setting
TIIIER
R0
Health
promotion
ER 1
TIE
E
Self
management
Prevention
Prevention
TIER
ER 2
Education
ER
TIE
E 3
use of resources. Prevention and early
Active
management
Support
services
Improved and
managed elective
admission
and expensive care services, as shown in
TIE
E 4
ER
Lifestyle
improvement
Community
intervention
involvement helps reduce the number of
people who require increasingly complex
Screening
programmes
Specialist
intervention
Crisis
management
Care
planning
the diagram opposite.
Movement of resources from Tier 4 towards Tier 0
Reduction of costs and expenditure
By redesigning care pathways, telehealth
An integrated system which features
and other assistive technologies can be
assistive technologies will help
incorporated to achieve more effective ways
professionals realise the potential of
of delivering care. The example opposite
common needs assessment mechanisms,
features patients suffering from COPD.
resulting in more informed referrals for a
variety of services. It can play a vital role
By implementing telehealth for appropriate
in bringing together a full range of clinical
cases post-assessment in tier two — as
services in a community setting, delivered
represented by the orange boxes — the
at a time and place most convenient to the
provider could reduce the costly treatment
patient or user.
required in higher tiers, as well as improving
overall management of the conditions.
© 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG
network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
Switch On! The Case for Telehealth | 7
Redesigning the COPD process
TIER 0
TIER 1
TIER 2
TIER 3
Severe COPD
S
Population
At risk
population
Screening
& spirometry
Clinical
assessment
E
E
E
E1
KEY
S
Start
E
End
TIER 4
Pulmonary
rehabilitation
and oxygen
therapy
Specialist
planned
assessment
Elective
admission
E
Pallaitive
care
E
E
Moderate
COPD
Oxygen
therapy
Mild COPD
Pulmonary
rehabilitation
Crisis
assessment
E
E
E
E
Acute
emergency
admisison
E
Admission
avoidance/
early
discharge
Case Study: NHS Cornwall & Isles of Scilly WSD Programme
Such a bold step can break down traditional
COPD patient ‘Mr B’, frequently
He agreed to enrol on the WSD
barriers between different parts of the
attending A&E
programme and was issued with
health and social care system, putting
The patient had a lung problem which
equipment to measure his oxygen levels
the patient firmly at the centre of the
meant that he had attended A&E five
and blood pressure and was asked to
care model.
times in the previous six months. He was
answer a series of health questions that
continually on antibiotics and unable to
the equipment monitor would ask him
The case for integrated care in the UK,
withdraw from steroids. He recognised
each day.
including the role of Integrated Care
that his admissions were probably the
Organisations (ICOs), is made in a
result of his anxiety as when he got to
The patient fully believes the equipment
companion piece to this publication
hospital he was mainly given oxygen
has contributed to changing his life. Being
A Bold Step Forward.
before being sent home. He was afraid to
able to check his oxygen levels when he
venture out in case he had an attack.
is feeling unwell has calmed him and if
his levels are low he relaxes and uses
his oxygen. He was assessed as suitable
for short term oxygen and since being
supplied with that he is now venturing out
and walking up the steep hill to his cottage
— a feat he had not attempted in the five
years he has lived there. He has to stop
six or seven times — but he can do it.
He has gone two months without
antibiotics and has not attended A&E since
being on the programme.
NHS Cornwall & Isles of Scilly programme office
e-mail: [email protected]
© 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG
network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
8 | Switch On! The Case for Telehealth
Overcoming barriers
to implementation
Although assistive technologies are
pathways, people and systems, upgrading
making their way on to the agenda of
outdated phone lines at user’s homes,
organisations to identify those who are
PCTs and local authorities, there is still a
monitoring and maintenance costs. These
most likely to benefit.
general reluctance to bring telehealth into
costs are offset by savings and efficiencies
mainstream use, due to the perceived
in a number of areas such as reduced
costs, concerns over acceptance by
hospital admissions, avoided referrals,
different monitoring models and decide
staff and patients, and the complexities
reduced transportation costs, increased
which model, or combinations of models,
of implementation.
caseload and reduced visits. Taking a
is right for them. Will readings be
conservative view and from a standing
monitored by community matrons, GPs,
To some organisations in the UK, telehealth
start, to implement telehealth services for
dedicated call centres, other frontline
is perceived as relatively expensive, in
COPD patients in a typical PCT population
professionals, or a mix of these?
terms of both set-up and running costs.
without the additional costs of integrated
Some see this as a hindrance to early
care, we would expect the realisable
adoption and are waiting for the kind of
savings from the reduction in hospital
systems will need to be achieved if the
rapid price falls associated with most
admissions alone to pay for the telehealth
full potential of integrated working is to
innovations. As this market matures we
service within one to two years. Some
be realised.
expect to see an increase in service and
pilots have demonstrated a much faster
solution offerings as opposed to the pure
ROI and some advocates would predict
product offerings that dominate the market
much more aggressive 6–12 month return.
today. And the potential market size for
telehealth is significant.
• Accurate patient data is required for
• Organisations will need to consider
• Interoperability and integration of
• Organisations need to establish legal
frameworks that allow information sharing
and governance to be established.
However, the benefits of telehealth are
unlikely to be realised instantly. In addition
• There have been some negative
15.4 million people in England have a
to the initial set-up costs, there is, as
patient views which indicate that some
LTC. Making an assumption that just
mentioned earlier, a need to redesign care
people may be reluctant to adopt the
20 percent of these people would benefit
pathways and adopt integrated care. Such
technology. For example “I am not sick
from telehealth indicates the potential
a move may seem too daunting to some
enough to need this” or “I don‘t want to
for over three million installations.
health providers. There are a number of
be reminded that I’m ill”.
If one in three of these people has
factors which contribute to the complexity
one less hospital admission per year
of implementing assistive technologies:
at an estimated cost saving of £2,000
per admission, £2 billion could be
saved annually.
• The engagement of frontline
professionals in the implementation of
assistive technologies is fundamental.
However, decisions are increasingly taken
Many may be sceptical and others slow
at local levels and local business cases
to adopt, seeing it as undermining their
need to be compelling. In developing a
autonomy, but those who embrace it
business case, organisations need to feel
will see benefits. With greater emphasis
confident that the investment will lead
on GPs as commissioners and the
to realisable savings and demonstrable
possibility of challenging budgets, early
efficiencies in an acceptable timescale.
adopters will reap benefits through
There are areas of expenditure that must be
reduced hospital spend and ultimately
considered, over and above the cost of the
better outcomes, with likely slowing of
technology; for example the integration of
progression through the tiers of need.
© 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG
network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
Switch On! The Case for Telehealth | 9
Expanding the opportunity
To date, telehealth use has tended to be
Information should be shared or integrated
The danger is that, in a period of austerity,
focussed on long-term use by patients with
with patient care records, enabling care
it may not be seen to offer enough of a
established disease — COPD, heart failure
managers to record details and access
“quick win.” Health professionals should
or diabetes. But there is further potential
data, which should improve real-time
however realise that the rising costs of
for short-term use for newly diagnosed
monitoring and decision-making. Data
reactive care are unsustainable, and that
patients, those undergoing changes to
from telehealth systems should be used
telehealth offers a highly effective way to
medication or after discharge from hospital.
with workforce scheduling tools to help
manage patients in the community at
And whilst there is widespread use of
professionals organise their patient
lower cost.
telecare for the frail elderly, there remain
workloads more effectively. It should be
opportunities which have yet to be fully
linked with handheld devices such as a
realised such as for use with people with
BlackBerry or smartphone, giving greater,
dementia, mental health needs, or children
quicker access to detailed, accurate,
and adults with disabilities.
up-to-date patient data for professionals.
In establishing funding, we could look to the
Telehealth has the potential to save
they are likely to be more demanding,
trend of personal investment in healthcare
the NHS many billions of pounds, while
seeking out doctors who facilitate access
— a potential model for the future could
also improving quality of life and the
to technology for their families. As living
be one where a level of government
management of health for millions of
with a long-term condition becomes
spend can be topped-up by consumers.
patients. It can only achieve such a goal
the norm the use of technology will be
Some high street chemists already sell
as part of a wider, fundamental change in
essential to negotiate a way through
a range of personal health devices,
health and social care with greater focus on
the system in an informed, responsive
for example blood glucose monitors
primary, preventative and integrated care.
way rather than the passive paternalism
and blood pressure monitors, some
There also needs to be greater integration
of today. Telehealth and telecare offer
supplemented with online information.
of patient data and utilisation of modern
autonomy and self determination to
“As the Web 2.0 generation mature
technology to enable remote working.
patients and the best physicians will
Whilst telehealth has shown improved
Those prepared to embrace this approach
foster that opportunity.”
quality and cost savings when deployed
can benefit from a truly patient-focused
alone, it can become a far more powerful
service that empowers professionals and
Hilary Thomas, Professor of Oncology
tool when linked to existing systems.
makes better use of resources.
and KPMG Health Team
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network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
10 | Switch On! The Case for Telehealth
Evidence of the effectiveness
of telehealth
The table below highlights some of the successes of telehealth, although the cost savings are typically theoretical, based upon reductions
in the number of admissions or interventions, which would be replaced by less costly activity.
Department of
Veterans Affairs,
Office of Care
Coordination
Services,
Washington5
17,025 patients
• 25% reduction in numbers of bed days of care
• 19% reduction in numbers of hospital admissions
• Mean satisfaction score rating of 86% after enrolment into the program
Benefits demonstrated
Gartner: eHealth for
a Healthier Europe6
A randomized
trial of home
telemonitoring in a
typical elderly heart
failure population in
North West London:
results of the Home­
HF study
Owais Dar et al7
meta data review of
60 clinical studies
across 11 eHealth
technologies
randomised controlled
trial of 182 elderly
patients with heart
failure
• 83% reduction in the 90 day readmission rate for congestive heart failure
• 25% reduction in average number of bed-days for admissions for
chronic conditions
• 25% reduction in prescribed medication costs
• 19% reduction in hospital admissions for chronic conditions
• 55% reduction in hospital admissions for congestive heart failure
• Similar outcome to ‘usual’ specialist care, but reduced clinic and
emergency room visits and unplanned heart failure re-hospitalisations at
little additional cost
• Although there was no change in overall health-related quality-of-life as
measured through the EQ5D, quality-of-life measured through the disease
specific Minnesota living with heart failure questionnaire improved slightly
• Approx. 25wte of CM time released for every 53 patients equating to a
saving of £12,465.60 per annum
• 12% reduction in number of CMs visits to patients
• Patients reported that they liked the service, were less anxious, and
felt supported
• 72% reduction in 999 calls
• 56% reduction in GP visits
• 75% reduction in A&E visits equating to a total saving of £13,092 per
annum for 53 patients
• 83% reduction in hospital admissions equating to a saving per annum
of £847,000
NHS Direct & NHS
South East Essex
‘At home, not alone’
COPD Telehealth
Project8
80 COPD patients
Sheffield NHS
Primary Care Trust:
Telehealth Case
Study9
30 high risk COPD
patients
• 50% reduction in COPD hospital admissions saving the PCT £30,000
to £40,000
• 80% reduction in home visits to COPD patients
Orchard Medical
Centre, Bristol:
Telehealth in a GP
Setting Case Study10
18 CHF patients with
severe or advanced
form of illness
•
•
•
•
46% reduction in hospital admissions
67% reduction in A&E attendances
16% reduction in visits to GP surgery
All patients reported increased reassurance and improved quality of life
Quality of life
Findings
Cost
Trial population
Interventions
Study
¸
¸
¸
¸
¸
¸
¸
¸
¸
¸
¸
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network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
Switch On! The Case for Telehealth | 11
Sources 1
http://www.dh.gov.uk/en/Healthcare/Longtermconditions/tenthingsyouneedtoknow/index.htm
2
Evaluation of the Telecare Development Programme – Final Report. January 2009 – Crown copyright 2009
3
Assistive Technology (AT) – London Borough of Havering Case Study – DH document
4
http://www.tunstall.co.uk/News-and-Events/Latest-news/Cornwall-Mainstreams-Telehealth-Solutions-Following-Successful-Department-of-Health-Pilot
5
Care Coordination/Home Telehealth: The Systematic Implementation of Health Informatics, Home Telehealth, and Disease Management to Support the Care
of Veteran Patients with Chronic Conditions
http://www.liebertonline.com/doi/pdfplus/10.1089/tmj.2008.0021
6 Gartner: eHealth for a Healthier Europe (se2009.eu)
http://www.se2009.eu/polopoly_fs/1.8227!menu/standard/file/eHealth%20for%20a%20Healthier%20Europe.pdf
7 Owais Dar eta al. A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home-HF study.
European Journal of Heart Failure (2009) 11, 319–325
8 NHS Direct & NHS South East Essex ‘At home, not alone’ COPD Telehealth Project Final Evaluation
http://www.telecareaware.com/images/pdfs/nhsd-essex-final-eval-telehealth-26Feb10.pdf
9 Sheffield NHS Primary Care Trust Telehealth Case Study http://www.tunstall.co.uk/assets/Literature/managing_longterm_conditions__sheffield_pct.pdf
10 Orchard Medical Centre, Bristol: Telehealth in a GP Setting Case Study
http://www.tunstall.co.uk/assets/Literature/Case%20Studies/managing_chf__orchard_medical_centre.pdf
© 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG
network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
kpmg.co.uk
Switch On! The Case for Telehealth | 12
Contact
Mark Britnell
Head of Health for the UK & Europe
+44 (0) 20 7694 2014
[email protected]
Helen Isaac
Associate Director
+44 (0) 20 7311 1582
[email protected]
Roberta Carter
Partner, Health Advisory
+44 (0) 20 7311 4190
[email protected]
Frank Harburn
Associate Director
+44 (0) 20 7311 6395
[email protected]
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affiliated with KPMG International Cooperative,
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KPMG and the KPMG logo are registered trademarks
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Publication name: Switch On! The Case for Telehealth
Publication number: RRD-200343
Publication date: June 2010
© 2010 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG
network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.