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.”