The telehealth revolution is underway, but some hurdles remain
Telehealth has actually been around for a long time. The very first report of telemedicine in a scientific journal was in 1879 in The Lancet. It was a report of a telephone diagnosis, where the doctor held the receiver of the phone to the patient's chest and made a diagnosis from that. Then you have the flying doctor service, which has been around in Australia for 90 years. Why, then, does it not feel like the medical industry has fully embraced the technological shift we’ve seen over the past quarter of a century to its full potential?
To try and find out, Healthcare Global spoke to James Barlow, Professor of Technology and Innovation Management (Healthcare) at Imperial College Business School, and author of 'Managing Innovation in Healthcare'. By his own admission, he has spent the last 15 to 20 years trying to work out why the adoption of ideas is so slow within healthcare, but even he says there’s no one quick answer to that question. “A lot of work I've done has been around remote care to telehealth, to telecare, telemedicine, because it's a very interesting example of a technological innovation, which, at least on paper, offers huge prospects to improve the quality of care,” Barlow says, “and to shift care from expensive settings like hospitals out to the community.
“There have been a huge number of trials and there is an evidence base, yet all countries are finding it immensely difficult to get it adopted as part of a mainstream healthcare system.
“I think we need to make a distinction between telehealth services and what I call ‘telemedicine’, which is much simpler in the sense that it's essentially a patient and a doctor, or specialist, who will be remotely situated. It's all about diagnosis, and triage, and looking at a particular type of data from the patient, which is inherently sort of simpler to put in place than patient monitoring, or monitoring elderly people, in real time, in their own homes or on a mobile basis where you've got much more complex processes involved.
“It usually spills across different parts of the heath and social care system. So there's been a lot of telemedicine in the form of video consultations and simple sort of telediagnostics, going back a long time and obviously right back to the flying doctor service.
“But, as I say, that's easier to put in place because it's basically just a patient and a specialist, and it's doing one thing at a time. It's when you start looking at these telehealth and telecare services aimed at people with multiple chronic conditions, or who are frail and elderly, and you're monitoring different vital signs, movement in the home, medication and compliance. It just becomes an inherently more complex thing to put in place.
“So that is basically why it's difficult to implement. You've got several different parts of the care system involved. As we know, health and social care is very fragmented. There are different financial silos, different sorts of professional silos, and you've got to align all those if it's going to work.”
The complexity of how health services around the world are funded is without doubt one of, if not the biggest barrier to widescale adoption, alongside the fact that no solution or technology has come to the fore which guarantees cost savings for a healthcare provider. The lack of any sure-fire solutions on the market is a problem, but it does appear, at least, that a market and competition is being created when it comes to how specialist medical equipment is now being produced.
“All the big global electronics traders are now involved,” Barlow says. “Back in the early noughties, it was very much specialist companies just making one sensor monitor, for example, for a particular length of time. But now it's Philips, it's Samsung, it's Siemens, all involved in telehealth and telemedicine, and trying to push it. I think the momentum will speed up from now on.”
Barlow was involved in the world’s biggest trial of telehealth and telecare, the Whole System Demonstrators programme, which was funded by the UK Department of Health and finished about six years ago. Despite the scale of that trial, there still wasn’t enough definitive evidence, according to him, and that appears to be part of a wider ambiguity when it comes to understanding the costs and benefits of these systems.
There are, however, some parts of the world, including a few Mediterranean countries, which have pushed ahead in terms of embracing the benefits of telemedicine. “Spain and Italy have got what I would regard as mainstream services,” says the 61-year-old. “The Veterans Health Administration in America does use a lot of telehealth.
“There's a lot of telemedicine, particularly in developing countries where you've got problems with access to doctors, GPs or specialists. There are circumstantial examples of straight telemedicine where the patient and a nurse in a village are talking to a doctor in a hospital in a city. So that, I would say, is becoming mainstream.
“When it's focused on specific conditions and you can roll it out for a particular group of people then I think that does make it easier to implement. It's when it's targeted at a generally frail, elderly population that it becomes much more difficult because there is just so many other factors involved, which would have to be in place.
“You've got to have housing services and home visiting, social care has to be involved, and frail and elderly people have multiple commodities so you're monitoring lots of different medical conditions. It's just a wholly different order of magnitude and complexity when it comes to elderly people.
“What's different now compared to 10 years ago is the fact that more people have got Fitbits and Apple watches, and there's a whole generation of people becoming used to monitoring aspects of their health.
“There’s a generation of people now who are comfortable with the idea of monitoring their health and the data being looked at by other people, or more sophisticated algorithms that can interpret what's going on from the data.”
As the population changes and becomes more accepting of change, then the more likely it is that change will begin to happen in earnest.
Barlow is in no doubt that things are improving slowly in terms of global uptake, but he still reckons we are at least a decade away from seeing fully-integrated telehealth systems becoming mainstream around the world.
“Version two of remote care then I think will be focused on elderly people, and that hasn't happened yet,” he adds. “I think it is a sort of 10-20 year horizon to get remote care for elderly people fully-embedded in health and social care systems.
“It's not the technology or the actual users of telehealth that are the barrier. It's the organisational and funding issues that are the big challenges, and reorganising services for elderly people is a massive problem for health systems around the world – and you need to do that around the technology, so that's the big challenge.”
Getting ready for cloud data-driven healthcare
As healthcare continues to recognise the value of data and digital transformation, many organisations are relying on the cloud to make their future-forward and data-centric thinking a reality. In fact, the global healthcare cloud computing market was valued at approximately $18 billion and is expected to generate around $61 billion USD by 2025.
At the forefront of these changes is the rapid adoption of cloud-based, or software-as-a-service (SaaS), applications. These apps can be used to handle patient interactions, track prescriptions, care, billing and more, and the insights derived from this important data can vastly improve operations, procurement and courses of treatment. However, before healthcare organisations can begin to dream about a true data-driven future, they have to deal with a data-driven dilemma: compliance.
Meeting regulation requirements
It’s no secret that healthcare is a highly regulated industry when it comes to data and privacy – and rightfully so. Patient records contain extremely sensitive data that, if changed or erased, could cost someone their life. This is why healthcare systems rely on legacy technologies, like Cerner and Epic EHRs, to manage patient information – the industry knows the vendors put an emphasis on making them as secure as possible.
Yet when SaaS applications are introduced and data starts being moved into them, compliance gets complicated. For example, every time a new application is introduced into an organisation, that organisation must have the vendor complete a BAA (Business Associate Agreement). This agreement essentially puts the responsibility for the safety of patients’ information — maintaining appropriate safeguards and complying with regulations — on the vendor.
However, even with these agreements in place, healthcare systems still are at risk of failing to meet compliance requirements. To comply with HIPAA, U.S. Food and Drug Administration 21 CFR Part 11 and other regulations that stipulate the need to exercise best practices to keep electronic patient data safe, healthcare organisations must maintain comprehensive audit trails – something that gets increasingly difficult when data sits in an application that resides in the vendor’s infrastructure.
Additionally, data often does not stay in the applications – instead healthcare users download, save and copy it into other business intelligence tools, creating data sprawl across the organisation and exposing patient privacy to greater risk.
With so many of these tools that are meant to spur growth and more effective care creating compliance challenges, it begs the question: how can healthcare organisations take advantage of the data they have without risking non-compliance?
Yes, healthcare organisations can adhere to regulations while also getting valuable insights from the wealth of data they have available. However, to help do this, organisations must own their data. This means data must be backed up and stored in an environment that they have control over, rather than in the SaaS vendors’ applications.
Backing up historical SaaS application data directly from an app into an organisation’s own secure cloud infrastructure, such as AWS or Microsoft Azure, makes it easier, and less costly, to maintain a digital chain of custody – or a trail of the different touchpoints of data. This not only increases the visibility and auditability of that data, but organisations can then set appropriate controls around who can access the data.
Likewise, having data from these apps located in one central, easily accessible location can decrease the number of copies floating around an organisation, reducing the surface area of exposure while also making it easier for organisations to securely pull data into business intelligence tools.
When healthcare providers have unfettered access to all their historical data, the possibilities for growth and insights are endless. For example, having ownership and ready access to authorised data can help organisations further implement and support outcome-based care. Insights enabled by this data will help inform diagnoses, prescriptions, treatment plans and more, which benefits not only the patient, but the healthcare ecosystem as a whole.
To keep optimising and improving care, healthcare systems must take advantage of new tools like SaaS applications. By backing up and owning their historical SaaS application data, they can do so while minimising the risk to patient privacy or compliance requirements. Having this ownership and access can propel healthcare organisations to be more data-driven – creating better outcomes for everyone.