Telehealth and HTA

Risto Roine, M.D., Ph.D.

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Telemedicine• WHO definition for Telemedicine:

“The delivery of healthcare services, where distance is a factor, by all healthcare professionals using information and communication technologies for

- the exchange of valid information for diagnosis, treatment and prevention of disease and injuries,

- research and evaluation,

- and for the continuing education of healthcare providers,

all in the interests of advancing the health of individuals and their communities"

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Background The ageing populations with growing

health needs together with the shrinking labor market and tight budget control create demand for new ways to organize services

Telemedicine and e-health have long shown promise in improving the quality and effectiveness of health care

Yet, telemedicine still makes up only a tiny proportion of overall healthcare activity worldwide

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Numbers of Telemental health consultations in Alberta

(Hailey 2007)

0200400600800

10001200140016001800

1996 2000 2004

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Telemental health clinical consultations per 100,000

(Hailey 2007)

0

10

20

30

40

50

60

Alberta2001

Alberta2005

Canada2001

Canada2004

Finland2005

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• In both Finland and Canada, Telemental health consultations are only a very small proportion of all mental health services

• Use of Telemental health has been particularly significant in areas that are remote from major centres of population.

• However, in both Finland and Alberta there are many rural centres that do not utilize clinical Telemental health

• Telemental health is established, but a niche technology among overall mental health services

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Why is the uptake of telemedicine so slow?

• Bad marketing• Clumsy technical solutions• Lack of reimbursement agreements• Physician resistance to change• Lack of a consumer market• Lack of interoperability and minimum

standards for the technology• New technology around the corner• Lack of robust evidence on effectiveness

and cost-effectiveness

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Recent systematic reviews on telemedicine/e-health

• genetics services• COPD• reduction of MI mortality• diabetes care• pediatric critical care• cystic fibrosis• plastic surgery• medication adherence• substance use disorder• burn care• etc.

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Conclusions in recent studies• Telegenetics may be a useful but prospective, fully powered studies are

needed.• Benefits not clear, larger studies needed. • Telemedicine may improve health outcomes of patients with AMI. However,

heterogeneity in study design and end points of most studies.• Telemedicine appears to be a promising alternative• Telemedicine is a feasible option for pediatric intensivists seeking assistance

in the management of complex cardiac patients.• Insufficient evidence to reach a firm conclusion about the benefits of

telehealth in people with CF, but it remains a promising area for future investigation.

• There is little critical analysis on the benefits and risks of telemedicine. • Future studies using high-quality measurements to assess

medication adherence are recommended to establish more robust evidence.

• The majority of studies reported evidence of clinical effectiveness, which justifies continued research in the field.

• If the significant potentials of telemedicine to assist in the acute triage, management guidance and outpatient care are to be realised, then research needs to be undertaken to provide evidence for such investment

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Why telehealth and telecare?UK Department of Health, Whole System Demonstrator Project

• Potential to make significant health improvements and quality of life impacts for people with a high dependency on the NHS, local GPs, social services and local hospitals.

• Provides a means to increase the availability of NHS clinical support by allowing local practitioners to be in permanent contact with those people less able to look after themselves.

• Can help improve the reach of the services that the NHS provides, looking after those who are often 'invisible' from the main acute services.

• Helps keep people out of hospital and avoids all the pressures this can put on them and their families.

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The Whole System Demonstrator (WSD) Cluster randomised trial

BMJ 2012;344:e3874

• > 3000 patients with COPD, DM, Heart failure• Remote exchange of data between patients and

healthcare professionals• Lower rate of admissions in the intervention group

(43% vs. 48) – partly explained by a short term increase in

admissions in the control group

• Lower mortality rate in the intervention group (4.6% vs. 8.3%)

• No significant difference in secondary care costs

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From rush to realism• UK Department of Health: We know that

telehealth will bring great benefits to patients and that’s why we want to take action as soon as we can

• BMJ Editorial June 2012: Latest evidence does not warrant full scale roll-out of telehealth

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Conclusions To convince decision makers about the full potential of telehealth

good quality studies are urgently needed Non-controlled studies may be sufficient to demonstrate the value of

telemedicine in some instances, e.g. provision of care to remote locations otherwise lacking services

In most cases, however, a direct comparison of telemedicine to a non-telemedicine alternative is necessary

Implementation of a new application should always be linked with subsequent data collection and analysis

The HTA-community should take a stronger role in the evaluation of telehealth applications The research agenda should focus on areas where telehealth

shows most promise and where there is biggest need for new solutions