Singapore faces an incoming "silver tsunami"--a drastic increase in the proportion of elderly citizens in the population over the coming decades. Reports from both PWC and BMI have called for urgent shifts towards community and home-based care in order to cope with the chronic disease case load from the ageing population. Telehealth--the use of telecommunications technology to remotely deliver healthcare--has streamlined healthcare for developed countries such as the US, the UK, and australia.
Singapore faces an incoming "silver tsunami"--a drastic increase in the proportion of elderly citizens in the population over the coming decades. Reports from both PWC and BMI have called for urgent shifts towards community and home-based care in order to cope with the chronic disease case load from the ageing population. Telehealth--the use of telecommunications technology to remotely deliver healthcare--has streamlined healthcare for developed countries such as the US, the UK, and australia.
Singapore faces an incoming "silver tsunami"--a drastic increase in the proportion of elderly citizens in the population over the coming decades. Reports from both PWC and BMI have called for urgent shifts towards community and home-based care in order to cope with the chronic disease case load from the ageing population. Telehealth--the use of telecommunications technology to remotely deliver healthcare--has streamlined healthcare for developed countries such as the US, the UK, and australia.
1 3 3 4 7 10 12 14 16 20 22 25 Table of Contents The Big Picture Telehealth Now Teleconsultation Telemonitoring Patient Outcomes Patient Engagement and Adherence Patient Satisfaction and Usability Medical Resource Utilisation Cost Electronic Health Records Translations for Singapore Bibliography Singapore faces an incoming silver tsunamia drastic increase in the proportion of elderly citizens in the population over the coming decades. In its wake, healthcare costs are projected to rise dramatically. Though healthcare spending is manageable at current levels, the systemic focus on expensive, once-of acute care threatens its sustainability. Reports from both PWC and BMI have called for urgent shifts towards community and home- based care in order to cope with the chronic disease case load from the ageing population. To address these gaps, MOH Holdings hopes to rely on up-and-coming telehealth systems, that will build on the National Electronic Health Record. Telehealththe use of telecommunications technology to remotely deliver healthcarehas streamlined healthcare for developed countries such as the US, the UK, and Australia. Devices like the Bosch Health Buddy are now industry standards for delivering telehealth, while healthcare providers like the US Department of Veterans Afairs (VA) have had their own telehealth service since a decade ago. In 2013 alone, 603,532 VA patients received treatment through 1,787,181 telehealth consultations from the VA telehealth service. Telehealth services are popular today because chronic care patients stand to gain a host of benets. Apps like the FDA approved DiabetesManager have been clinically shown to improve patient outcomes through measures such as heightening patient engagement and prescribing personalised medical advice. In one randomised trial, diabetics signicantly reduced their HbA1c levels by 1.2% more just by using the app with their doctors on top of usual care measuressignicant in light of the fact that the FDA considers a HbA1c reduction of 0.5% to already be clinically signicant for pharmaceutical diabetes drugs. Telemonitored chronic care patients experience vastly reduced mortality rates. A large telemonitoring trial of 3,230 patients by the UK Department of Health found a signicant 3.7% (p < 0.001) reduction in mortality amongst those telemonitored. This is because telemonitoring works around the clock to automatically point out potentially fatal deteriorations in patients conditions, alerting healthcare professionals to intervene in time. As a direct result of these just-in-time interventions, patients and their payers have experienced sizeable cost savings from avoided hospitalisations and ER visits. One Canadian telemonitoring trial with 95 chronic care patients chronicled annual cost savings of 41% from telemonitoring. These cost savings originated mainly from reduced hospital service utilisation, and translated into CAD$1,557 of savings per patient, per year (p < 0.025). The manifold benets of telehealth services spell good news for Singapores healthcare system. Luckily for Singapore, the connected nature of the city state and its tech savvy citizenry mean that telehealth technologies will be able to reach a majority of patients without further signicant investments in telecommunications infrastructure. The world has moved decidedly into the 21st centuryit is high time that healthcare did too. Executive Summary 1 The Big Picture Demographics have transitioned for developed countries; healthcare systems have not. Even though people are surviving better, having less children, and older on average, healthcare systems around the world are still not equipped to deal with what is being termed the silver tsunamian incoming surge in the number of older adults, many of whom will require continuing medical attention in their golden years. Governments worldwide are upping their healthcare budgets in anticipation of the increased prevalence of chronic diseases amongst their ageing populations, but the structure of healthcare systems today necessitates exponential increases in overall spending just to keep up. Traditionally, healthcare systems have catered to acute, costly, once-in-a-blue-moon care, since not many have managed to live for decades with a chronic disease. chronic care patients and their payers now nd themselves accumulating hefty medical burdens that were only meant to be taken on once, or at most twice in a lifetime. Hospitals themselves are feeling the strain. Many are woefully under-stafed and over-capacity, even as expensive new hospitals are being built to keep up with demand. But as chronic care case loads continue to increase, and place long- term demands on hospitals, it is feared that even building more of them will not help matters. Troubled by this state of afairs, medical professionals having been in search of a solution that would provide afordable, quality healthcare for their patients. One promising answer to their dilemma has emerged, like the answer to a great many others, from the onward march of telecommunications technology. Humankinds continual refusal to be kept apart by the partitions of space and time has given rise to a technology now known as telehealth, or telemedicine. In places like Australia and the United States, the population is so spread out, the distances between people living in remote areas and their doctors so vast, that telehealth is not merely a convenience, but a necessity. In the United States especially, efciency in healthcare is of utmost urgent concernthere, healthcare spending per capita is the highest in the world and healthcare quality the lowest amongst wealthy nations, according to a 2014 Commonwealth Fund report. To that end, the Australian government introduced rebates for telehealth oferings in 2011 via Medicare, Australias universal healthcare insurance programme, and nancial incentives for specialist doctors to conduct video consultations for Australians in remote, non-metropolitan regions. In the UK, the Whole System Demonstrator programme was launched in 2008 by the Department of Health as the worlds largest randomised control trial of telehealth and telecare. In the US, the Department of Veterans Afairs currently runs perhaps the worlds largest telehealth programme for its independent minded veterans. 2000 2030 0 100 200 300 400 500 600 700 800 2012 2015 Non-Communicable Diseases Communicable Diseases Injuries Global Mortality Rates, by Cause D e a t h s
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p e o p l e Non-communicable diseases are set to overtake communicable diseases as the top cause of death globally. Projections by the WHO indicate that non-communicable, chronic diseases will dominate the case load for health systems in the near future, making their current focus on acute care an unsustainable one. Data from the World Health Organisation. But the tide is turning. Medical advancements have meant that chronic diseases are no longer short-term killers, but systems of care for longer-lived patients are still caught in the antiquated model of the past. Trapped in a healthcare system centred around the occasional high-expense hospitalisation, 2 Yet other implementations of telehealth hook up monitoring devices in a patients home that allow doctors and nurses to monitor their condition even after being discharged. Together, these components of telehealth promise to transform the way that patients and healthcare providers communicate and collaborate with each other in keeping patients healthy. World governments are not the only ones with an eye on telehealth. According to a 2012 survey by the Economist Intelligence Unit in 10 developed and emerging economies, approximately 60% of healthcare payers have begun to pay for, or are planning to begin paying for telehealth services by 2015.
Amongst the most enthusiastic are some of the United States largest payers, Aetna, Cigna, UnitedHealthcare, BlueCross, and BlueShield, and employers General Electric and Delta Airlines. Hospitals and healthcare groups across the United States such as the Cleveland Clinic (one of 4 top medical centres in the US) and the Columbia University Medical Centre have also established their own implementations of telehealth services to meet ever growing demands on medical resources. Across the board, stakeholders cite cost savings through reductions in hospital service use and the empowerment of patients to take charge of their own health. This is made possible by the access that patients gain to personalised information and healthcare recommendations through telehealth technologies. In anticipation of consumer demand, Aetna even bought the popular healthcare information application, iTriage, to sharpen their competitive edge. The app boasts some 10 million downloads as of the time of writing. Existing telehealth oferings from the private sector range in scope. Some apps help people monitor their diets, or their diabetes on their smartphone. Other apps allow people to consult a doctor about minor ailments via video call, for a fee. Employers and payers in the US have been enthusiastic about telehealth services 3 Telehealth Now With the global telemedicine business projected to balloon to USD$27.3 billion by 2016, according to a BBC Research report, it is not hard to see the demand for telehealth solutions from increasingly tech savvy consumers. Looking forward, as telecommunications technologies such as smartphones and the Internet continue to become ever more indispensable, consumers young and old will begin to actively demand telehealth services from healthcare providers. A recent survey by FICO, a predictive analytics and decision management software company, revealed that of the 2,239 adult respondents, 80% want to be able to use their smartphones to communicate with their healthcare providers, and nearly two-thirds would prefer to be able to consult their physicians via telehealth, rather than in person. Accustomed to the anytime, anywhere ethos of the smartphone age, consumers across all demographic groups will expect healthcare providers to provide telehealth services by default in the near future. In response to consumer enthusiasm, led by the rise of wearable health trackers such as the Nike FuelBand, tech giants Apple, Google, and Microsoft have announced various mobile health oferings of their own. The Apple HealthKit and Google Fit are set to centrally collate and coordinate health data from a variety of mobile health apps on their respective smartphone platforms, making it easy for smartphone users to share their health data across all of the health-related apps on their phone. At the same time, all three want to be able to directly collect health data from consumers via future releases of smart watches and smart wearables collections. Consumers eager to use telehealth services will soon be spoiled for choice. Telehealth services with proven track records today can be broadly categorised into 3 groups: teleconsultation, telemonitoring, and electronic medical record keeping. Teleconsultation allows patients to consult doctors about non-emergency medical conditions such as pink eye and allergies over an online video link without having to step out of their house. Telemonitoring, on the other hand, helps healthcare professionals keep a close eye on patients recovering from surgery and those dealing with chronic medical conditions. This afords patients their independence and healthcare professionals more time for other patients in greater need of urgent care. In the back, electronic medical record keeping ties the whole system together. It allows healthcare professionals to see a patients entire medical history at a glance, helping them make more accurate and timely diagnoses of conditions. In the following sections, we will systematically review some of the more noteworthy developments in telehealth over the past decade, and then turn our eye to the opportunities these developments present for Singapore. Teleconsultation In jurisdictions where it is permissible, teleconsultation allows patients to consult doctors about non-emergency medical conditions such as pink eye and allergies over an online video link without ever having to step out of their house. Besides the obvious conveniences of being able to stay rested indoors when sick, teleconsultation also allows ill patients to stay quarantined from healthy people, and from other contagious diseases that may be spreading at medical facilities. Furthermore, some teleconsultation services such as Teladoc are even available 24/7, allowing patients to be able to consult someone immediately even in the middle of the night in the case of potential medical emergencies. In places such as the US where general practitioners are in short supply, and doctors generally not consulted unless the medical condition is potentially life-threatening, the establishment of a teleconsultation network can help prevent unnecessary and costly visits to the emergency room (ER). One such initiative in schools and nursing homes in rural Nashville, Georgia allowed non-emergent patients to be treated remotelyambulances were sent out only in the event of a true emergency. In total, the GPT (Georgia Partnership Network) estimates that teleconsultation resulted in 278 avoided ER visits and approximately USD$834,000 4 saved that year. The school and nursing home telemedicine network [Minich-Pourshadi, 2012] helped reduce costly ambulance and hospital admissions charges. It also alleviated part of the load on the often overcrowded ERs, allowing ER staf to spend their time tending to other more urgent incoming cases. Telemedicine services that allow patients to avoid such costly visits to the doctor have been replicated in the private sector, and have proved enormously popular with healthcare payers, employers, and patients alike. For employers, the draw of teleconsultation is obvious subsidising teleconsultation would mean that employees are more likely to stay at work all through the teleconsultation session, instead of having to spend time travelling to and from the clinic, cutting down on productivity losses from medical leave. Payers and employers also experience savings from co-paying for the signicantly less expensive option of teleconsultation. In 2013, Pepsi Bottling Ventures (PBV), the largest bottler of Pepsi-Cola products in the US, reported a 400% return on investment (ROI) by providing employees with non- emergency healthcare through Teladoc, a telehealth service provider. Rather than having to pay an expensive trip to urgent care centres for relatively minor ailments, employees could consult doctors via online video conferencing through Teladoc, resulting in a reported annual USD$200,000 of savings [Teladoc, 2013] in healthcare expenses and employee productivity-retention by PBV. Another case study from Teladoc reports that Rent-A-Center, a US retailer with over 12,300 employees, saved USD$1,289,359 over 2 years by ofering the use of Teladoc to its employees. Similarly, Delta Airlines has partnered up with NowClinic to provide a comparable service for their employees, reporting high employee satisfaction with the efciency of the service. Pharmacies and hospitals have begun jumping on the non-emergency teleconsultation bandwagon as well. Rite Aid, a US pharmacy chain, has begun ofering teleconsultations with NowClinic as a cheaper alternative to hiring a staf practitioner for each of their individual stores. Meanwhile, a group of 4 hospitals in Minnesota and Wisconsin now ofers USD$40 online teleconsultation sessions with nurse practitioners as an alternative revenue stream. Even Google, the tech giant, has initiated a partnership with One Medical, a medical professional network, to ofer by-the-minute medical teleconsultations to the online public through its new expert consultation service, Google Helpouts. The rising popularity and supply of such services reect the enormous cost and productivity savings that telehealth brings to patients, healthcare providers, payers and employers alike. Telemonitoring Telemonitoring, the remote monitoring of chronic care patients by healthcare professionals using telecommunications systems such as video or telephone links, has enormous potential for alleviating doctors workloads over the coming decades. This rendition of telehealth is particularly useful for keeping an eye on patients with chronic conditions such as diabetes, COPD, heart failure, and obesity, as well as for creating a more comprehensive after-surgery care regime. Savings using the Teladoc telehealth service; taken from Teladoc website (gures not to scale) On average, 8% of patients would have visited the ER, 42% urgent care, 1% specialists, 38% their family doctor, and 11% done nothing if they hadnt used Teladoc [Teladoc, 2014]. 5 With telemonitoring systems in place, chronic care patients can receive low-level round-the-clock monitoring. Intuitively, this would help lighten doctors workloads, since telemonitoring can replace doctors appointments in part. Patients save on transportation time and costs from attending doctors appointments, yet gain direct access to their doctors. This means that any sudden developments of symptoms can be reported immediately, instead of at the next belated appointment. But do these benets actually help to lower overall healthcare costs? Will replacing direct care by doctors and nurses with telecare end up harming patients instead of helping them? Can telemonitoring really help free up healthcare resources for more urgent users? These questions about the efectiveness of telemonitoring have been repeatedly investigated by researchers over the past decade. A complaint prevalent in literature is that studies are too small, and of too poor a quality, to determine whether telemonitoring would scale well, and that more studies will be needed to determine whether telehealth is really worth the trouble. This is an understandable concern. The medical profession is known to be resistant to changeill-considered moves on the part of healthcare professionals could potentially cost human lives. But most researchers (probably in a bid to justify the signicance of their work to grant committees) seem to be merely parroting one anothers pessimistic sentiments Analytics Feedback Monitoring Cloud Server Payers Daily Quizzes Reminders Symptoms Patient Data Call for help Patient Nurse Doctor Telehealth Device Computer Instructions Advice Prescriptions Symptoms Patient Data Calls for help Aggregated Data Direct Intervention A general schematic of telemonitoring systems The patient interacts with the telehealth device, keeping a daily log of key clinical data, depending on the condition being monitored. The device in turn quizzes the patient on self-care knowledge, providing the correct answers when answered wrongly. The healthcare team can then look at user provided data and look out for any warning signs of worsening conditions, and stage interventions as needed. 6 despite the signicant body of quality literature available today. To the other stakeholders in the healthcare sector, uninitiated in the unique self-deprecatory language of scientic literature, most research would paint a deceptively pessimistic view of telehealth technologies, even if they were efective. Throughout this section, we report on 3 major, closely scrutinised, rigorously tested renderings of telehealth by the United Kingdoms Department of Health, the Bosch Health Buddy, and the United States Department of Veterans Afairs. Each of them has found success in their health system in their own way; collectively, they pave the way for other future telemonitoring systems to come. United Kingdom Whole System Demonstrator (WSD) Launched in 2008 by the UK Department of Health, the WSD sought to nd out whether the use of technology as a remote intervention make[s] a diference [DH, 2011] . The WSD collected 12 months worth of data on 6191 patients in Newham, Kent, and Cornwall, cluster-randomised into telemonitored and usual care groups. Of these patients, there were 3030 with diabetes, heart failure, or COPD. Each region was free to use its own implementation of telemonitoring systems, the rationale being that the WSD was to test the efectiveness of the whole gamut of telemonitoring systems that could exist in the real world. Data from the WSD is being analysed by researchers at City University London, the University of Oxford, the University of Manchester, Nufeld Trust, Imperial College London, and the London School of Economics. Its results are being published in successive papers over the years following the study. The Department of Health claims that preliminary results from the WSD have indicated a possible 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tarif costs, as well as a 45% reduction in mortality rates [DH, 2011] with the use of telehealth. Bosch Health Buddy The Bosch Health Buddy was rst designed by IDEO, a leading design and consulting rms, for the Health Hero Network in 1998. It is an extremely simple telehealth device, consisting solely of 4 large buttons and a liquid crystal display that displays diferent options for each button depending on the screens immediate context. During development, designers did not assume that users would be familiar with conventional electronic user interfaces, since a large proportion of the user base consists of elderly patients. Since then, Health Buddy has been acquired by Bosch as part of its expansion into telehealth technologies. Studies have shown that the use of Health Buddy can signicantly reduce ER visits and hospital days, and produce corresponding savings on healthcare costs. It was awarded the silver Medical Device Excellence Award in 2000, and was recognised as one of the best Products of 2000 by Business Week. United States Department of Veterans Afairs The VA is the largest telehealth provider in the US, and arguably, in the world. Pilot trials of telehealth services were rst undertaken in 2000-2003 in the southwest US so as to better reach veterans living in remote regions. After it was proven that telehealth was a viable replacement for in-person care, the scheme was rolled out to the rest of the VA. Today, the VA ofers 3 major telehealth and telemonitoring services to its veterans. Its Clinical Video Telehealth (CVT) service ofers real-time video consultations for 44 clinical specialities such as tele-intensive care, tele- mental health, and tele-cardiology. The Home Telehealth (HT) service is the archetypal telemonitoring service, where chronic care patients receive care and support at home from remote healthcare professionals. Lastly, its Store and Forward Telehealth (SFT) service allows clinical images to be captured and forwarded to medical specialists for review at a later time. In 2013, 11% of the US veteran population received some form of healthcare through telehealth, with 603,532 participating patients and 1,787,181 telehealth consultations performed in that year alone [VA, 2013] . 7 Patient Outcomes Will telehealth bring about only insignicant improvements to the health of chronic care patients? Will replacing direct healthcare with telecare harm, instead of help patients? Most studies on telehealth report on patient outcomesand those that do generally report that telemonitoring improves patient outcomes. According to a 2010 review of studies on video telehealth services, 91% of studies found that video telehealth services produced patient outcomes equal to or better than those that did not involve video telehealth [Wade et al., 2010] . Diabetes is one example of a chronic condition that can be efectively managed with help from telemonitoring. With diabetes, irregularities in insulin production or uptake leads to glucose building up in the bloodstream, resulting in a host of other possible medical complications, such as heart disease, vision loss, and kidney disease. Unfortunately, diabetes cannot be curedonly managedmaking telemonitoring an attractive long-term option for diabetics. Several large scale studies on the efect of telemonitoring on patient outcomes have been conducted. These studies most often use the level of haemoglobin A1c, or glycated haemoglobin, as a proxy measure of long term blood glucose concentration, and thus how severe a patients diabetes is at the time of measurement. In the Columbia University Informatics for Diabetes Education and Telemedicine project (IDEATel) project, a 2007 telehealth study of 1,665 elderly diabetics living in medically underserved parts of New York City and New York State, patients in the study who were given additional telehealth support were found to have managed their diabetes better than those given only usual care. On the provided telehealth system in the study, telemonitored patients were able to interact with nurse case managers via video call or online messaging, upload their blood glucose and blood pressure data for monitoring, access their own clinical data, and access an educational diabetes care website created specially for the project. All this contributed to the improved patient outcomes. Compared to the usual care group, those with telemonitoring support managed to further lower their mean haemoglobin A1c (p = 0.006), systolic and diastolic blood pressure (p = 0.001), and LDL cholesterol (p < 0.001) levels by statistically signicant amounts [Shea, 2007] , showing that diabetes can be better managed with the proper application of telemonitoring. 3 years after the IDEATel study was published, DiabetesManager, a medical mobile application, emerged on the market, becoming the rst app to gain FDA approval -5 -4 -3 -2 -1 0 Systolic Diastolic Telemonitoring Usual Care Mean Change in Blood Pressure Levels C h a n g e
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m g / d l Results from the IDEATel Project show that telemonitoring helps in diabetes management The levels of A1c, blood pressure, and cholesterol decreased signicantly more in telemonitoring patients than in usual care patients. The means that the severity of diabetes in the telemonitoring patients has been reduced signicantly in comparison from better disease management through telemonitoring. Data taken from [Shea, 2007]. -1.0 -0.8 -0.6 -0.4 -0.2 0.0 Baseline A1c 7.0% Total C h a n g e
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% Mean Change in HbA1c Levels 8 for the coaching and treatment of diabetes 2 in 2010. The application allows patients to enter data important for diabetes management, such as blood glucose levels, carbohydrate intake, and medications, and then automatically responds with personalised educational, behavioural, and motivational [Quinn et al., 2011] suggestions for patients to better manage their condition. These automated messages are occasionally supplemented by electronic messages from Educators at WellDoc. Patients also receive an electronic action plan every 6 weeks as a personal and physician pre-visit summary. In addition, the data is stored online, accessible to both the patient and their primary care physician through a web portal. The efcacy of DiabetesManager has been veried in a trial by researchers at the University of Maryland School of Medicine, and published in Diabetes Care, the top-ranked journal in the eld of diabetes treatment and care. The trial randomised 163 patients into 4 groups with varying levels of the use of DiabetesManager and primary care physician (PCP) involvement. After 12 months of monitoring, it was found that the patients in 2 of the groups (CO, CPDS) using DiabetesManager had reduced their A1c levels signicantly [Quinn et al., 2011] more than the group that was not using it (UC). Those who were not using telemonitoring experienced a mean A1c change of -0.7%; those who were using DiabetesManager by themselves (CO) experienced a greater mean -1.6% change in A1c (p = 0.003), while those who were using DiabetesManager in tandem with their PCP (CPDS) through the web portal (p < 0.001) experienced an even greater mean A1c change of -1.9%. These results are especially notable in light of the fact that the FDA considers a minimum reduction of 0.5% in A1c to already be evidence that a diabetes drug is efective [PWC, 2014] . On average, patients in these 2 telemonitoring groups experienced statistically signicant 0.9% and 1.2% additional reductions in A1c compared to the control group, showing that proper telemonitoring-aided self-care can be just as, or even more efective than taking some diabetes drugs. As of 2012, DiabetesManager was reaching at least 300,000 diabetics in the US alone, according a Bloomberg report. The health management potential of telehealth extends just as well to other chronic conditions, such as obesity. After initially losing weight in weight loss programmes, most participants of these programmes regain the lost weight again within 3-5 years [Haugen et al., 2007] , making efective long- term weight maintenance regimes extremely attractive to those who want to get slim, and stay slim. To investigate whether telemonitoring is a viable solution for weight maintenance, researchers in Colorado recruited 87 individuals who have successfully lost weight in the Colorado Weigh weight loss programme to take part in a trial of a telemonitoring weight maintenance programme. This programme was meant as a replacement programme, targetted at individuals who preferred not to commit to the traditional 6-month weight maintenance programme, which met fortnightly. Participants were divided into 3 groups: 1 group of 31 had chosen to enrol in the traditional programme; another group of 31 had chosen to enrol in the telemonitoring program; the last group of 25 had chosen not to enrol in either programme, but had agreed to be included in the study. Participants in both the traditional and the telemonitoring DiabetesManager, an FDA-approved medical mobile application, was found to have a consequential treatment efect when used by patients and their PCPs. A study from the University of Maryland found that the telemonitoring app was efectual in helping diabetics manage their condition. Data taken from [Quinn et al., 2011]. -3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0.0 CPDS CPP CO Usual Care Mean Change in HbA1c Levels C h a n g e
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% Telemonitoring 9 programmes kept diet and activity logs. Fortnightly, while traditional participants met up in small groups with registered dieticians, the telemonitoring participants met online with the dieticians one-on-one. After the 6 month programme, participants in the telemonitoring weight maintenance programme were found to have signicant diferences [Haugen et al., 2007] (p = 0.003) in mass change from the group not in either programme, with the telemonitoring group having lost 0.6 kg, and the non-enrolled group having gained 1.7 kg on average. In addition, the weight loss in the telemonitoring group was not signicantly diferent from that of the traditional group (p = 0.92), meaning that the telemonitoring weight maintenance programme could be a viable alternative for the traditional weight maintenance programme. The results were clearly in favour of telemonitoring [Steventon et al., 2012] . Compared to the 8.3% mortality in the usual care group, the telemonitoring group had a far lower mortality rate of 4.6%, since daily telemonitoring had allowed healthcare professionals to catch warning signs of worsening conditions early. Telemonitoring of chronic care patients in the WSD resulted in a signicant 3.7% (p < 0.001) [Steventon et al., 2012] reduction in mortality, a testament to the life- saving potential of telemonitoring. Bosch Health Buddy A study in the US Northwest on the efectiveness of telemonitoring using the Health Buddy system has shown similar reductions in patient mortality through the use of telemonitoring. 2 batches of 1,767 total Medicare beneciaries with congestive heart failure, chronic obstructive pulmonary disease, or diabetes mellitus were tracked for a year each while they were using the Health Buddy telemonitoring device in their homes. These patients were then individually matched with demographically, geographically, and diagnostically similar Medicare beneciaries that were not using telemonitoring as a means of managing their conditions as a basis of comparison. Across the 2 batches of patients, usual care patients experienced a 23.0% mortality rate, while patients using the Health Buddy system experienced a 20.3% mortality -1.0 -0.5 0.0 0.5 1.0 1.5 2.0 Neither Telemonitoring Traditional Mean Change in Mass After Weight Maintenance Programme C h a n g e
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k g Telemonitoring is just as efective as traditional weight maintenance programmes. Individuals in a telemonitoring programme lost signicantly more weight than those not enrolled in a weight maintenance programme, and lost about the same amount of weight as those in a traditional programme. Data taken from [Haugen et al., 2007]. United Kingdom Whole System Demonstrator (WSD) A component study in the WSD found that telehealth programmes could potentially lower mortality rates in chronic care patients. Between May 2008 and November 2009, the study tracked 3,230 diabetes, chronic pulmonary disease, and heart failure patients randomised into usual care and telemonitoring groups. 0 2 4 6 8 10 Telemonitoring Usual Care Mortality Rates in WSD Usual Care and Telemonitoring Groups M o r t a l i t y
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% Telemonitored chronic care patients in the UK WSD study experienced lower mortality rates than their usual care counterparts. Data taken from [Steventon et al., 2012]. 10 rate, with a signicant (p < 0.05) [Baker et al., 2011] mean reduction in mortality of 2.7% in the telemonitoring group when compared to the usual care group. With telemonitorings proven track record in managing chronic conditions, it is no wonder that more and more big names in the healthcare and tech industries are jumping aboard to provide telemonitoring services to patients. For instance, the Cleveland Clinic, regularly ranked amongst the top 4 medical centres in the United States, has rolled out a Heart Care at Home telemonitoring programme for patients who have just been discharged for heart disease or surgery. Patients can get home sooner after hospitalisation without worrying about their prognosis, or sudden deteriorations in their condition. Vigilant medical professionals are a mere button press awayall day, every day. Patient Engagement and Adherence How has telemonitoring charted such outstanding statistics in chronic care patient outcomes? A cornerstone of telemonitoring systemsits commitment to assisting patients in living independentlycould well be Ingredient X. Many studies [Hibbard et al., 2013] have been conducted on the efect of patient engagement (that is, how actively involved a patient is with their own health care) on patient outcomes, care experiences and costs. The consensus? The more engaged a patient is with the process, the more likely the patient is going to turn out healthier while also paying signicantly less for their healthcare. This engagement could come in many forms, including patients keeping track of their own health data, attending the recommended health checkups for their age, and communicating regularly about their health status with their primary care physician. The upshot of active patient engagement is that the numerous informed lifestyle choices patients make as a result add up to greater control over their own conditions. Drugs that are causing averse reactions, or not working well get switched out for more efective ones. Patients get better at recognising when they should be seeking low- level consultations, and when they should be hospitalised for more worrying symptoms. This is knowledge that could drive down healthcare costsstudies have shown [Hibbard et al., 2013] that highly engaged patients tend to have lower rates of costly hospitalisations and ER visits than those who are unengaged. Furthermore, there is a substantial body of evidence [Hibbard et al., 2013] testifying to chronic care patients adhering better to their self-care and self-monitoring regimes the more engaged they arecrucial in helping keep patients conditions under control. But patient engagement and adherence have been notoriously difcult to sustain in the long term. People stop taking their medication once they start getting better, cease monitoring their health metrics the moment they think theyre healthier, and give up quickly on healthcare routines that are deemed to not be worth the bother in the short term. Unfortunately, chronic conditions eponymously require a consistent, persistent, level of management that human nature just cannot (and will not!) sustain over the decades that a patient has to live with the condition. These are problems that telemonitoring is fully equipped to solve. By tapping into our instinctual need for social acceptance, telemonitoring can peer pressure chronic care patients into taking better care of themselves. The 0 5 10 15 20 25 Telemonitoring Usual Care M o r t a l i t y
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% Mortality Rates in Health Buddy Usual Care and Telemonitoring Groups Chronic care patients using the Health Buddy telemonitoring device experienced lower mortality rates than their matched pair counterparts. Data taken from [Baker et al., 2011]. 11 Time / Months 12.0 12.5 13.0 13.5 14.0 S c o r e knowledge that there is another person checking daily to see if you have performed your self-care for the day motivates better in the long term than a massive, but short-lived guilt trip at a doctors appointment every few months. Telemonitoring also lowers the inertia patients experience in performing self-care measures by making it easier and more convenient for them to perform their self-care. With telemonitoring, patients can rely on automated systems to remind them to perform their self-care and take their medication instead of having to laboriously keep track of it themselves. These social and logistical incentives for patient engagement and adherence in telemonitoring make a diference. In (the previously mentioned) Colorado Weighs ancillary weight maintenance programme, telemonitored participants were much less likely to drop out halfway than traditional participants. While the traditional programme patients had to commute fortnightly to their lessons at the medical centre, telemonitoring patients could just attend these sessions online without the hassle of having to leave the house. Researchers further found that telemonitoring participants rated the telemonitoring programme to be signicantly (p = 0.0001) [Haugen, 2007] more convenient than their traditional counterparts did theirs. The convenience of being able to participate in the weight maintenance programme from home encouraged participants to stick to their regimes over the long term. As the studys authors noted, [o]ne of telehealths main strengths is its capacity to help make health care consumer-friendly and adapt to the needs of the individual, rather than demanding the individual adapt to the health care system. [Haugen, 2007] Bosch Health Buddy Healthcare researchers in the Netherlands conducted a study on the efects of telemonitoring (via Health Buddy) on engagement and adherence in heart failure patients. In the trial, 382 patients were randomised into telemonitoring and usual care groups, and their self-reported engagement and adherence metrics recorded at 0, 3, 6, and 12 months from the start of the study. 6 of the metrics tracked improved signicantly more for those who were telemonitored [Boyne et al., 2013] . Telemonitored patients were found to have signicantly better disease- specic knowledge, self-care (how well they take care of their own health), and self-efcacy (how condent they 0 3 6 12 9 0 3 6 12 9 Time / Months *lower is better 15 17 19 21 23 S c o r e Self-Care* 0 3 6 12 9 Efect of Health Buddy Telemonitoring on Patient Engagement Metrics Heart failure patients get more engaged with their health when using the Health Buddy telemonitoring device. Patients were quizzed on their knowledge on heart failure using the Dutch Heart Failure Knowledge Scale, their self-care behaviour using the European Heart Failure Self-Care Behaviour Scale, and their self-efcacy (their condence and perseverance in their self-care) using the Barnason Efcacy Scale. Patients in the telemonitoring group showed signicant improvements in their scores for all these measures during the study after the scores were adjusted for their starting values. Data taken from [Boyne et al., 2013]. Usual Care Telemonitoring 50 51 52 53 54 55 56 S c o r e 12 are of being able to succeed in their self-care). They also adhered better to daily weighing, the use of medication, and uid restriction. However, telemonitoring did not seem to produce much of an efect on some other adherence metrics. For 3 of the metrics (appointments, abstinence from smoking, and abstinence from alcohol), adherence levels were high from the very beginning, making it difcult to achieve any incremental efect on these metrics. The other 2adherence to the salt restricted diet and physical exerciseproved difcult for both the usual care and telemonitoring regimes to change. These resistances will require perhaps more sophisticated handling to resolve. Researchers reported that with the telemonitoring system in place, telemonitoring patients spent less time in contact with the nurses in charge, despite their improvements in engagement and adherence metrics over and above that experienced by the usual care patients, who were monitored closely by the nurses. This suggests that telemonitoring could efectively take over some part of the tedious patient monitoring and education from nurses, leaving them free to tend to other, more urgent, matters. More importantly, patients gain a bigger stake in taking better care of their own long- term health, which could reduce the number of costly hospitalisations that they have to undergo. Patient Satisfaction and Usability Chronic care patients now have a new way of keeping themselves healthy in the long-term, with some ingenious help from modern technology. But also salient to the discussion is the fact that many chronic care patients also rank amongst the elderlya demographic known to be rather reluctant in picking up new technology. If the majority of telemonitorings target demographic is hesitant in adopting its technology, will telemonitoring be able to reach out efectively to a majority of chronic care patients? Further, medical traditionalists are (rightfully) concerned with how patients will perceive being ofered indirect telemonitoring care, instead of the traditional direct care ofered at medical care facilities. Though telemonitoring is just as, or even more efective than traditional care in many circumstances, will patients feel like they are receiving sub- standard care through telemonitoring because of the physical absence of healthcare professionals? These concerns about usability and patient reception have been echoed in telemonitoring literature. As a -1 0 1 2 3 4 5 6 Estimation Importance S c o r e Change in Adherence to Medication 0 2 4 6 8 Estimation Importance S c o r e Change in Adherence to Fluid Restrictions -2 0 2 4 6 8 10 12 Estimation Importance S c o r e Change in Adherence to Weighing Efect of Health Buddy Telemonitoring on Patient Adherence Metrics Telemonitoring Usual Care Heart failure patients adhere better to their self-care regimens with the help of Health Buddy. Adherence was measured using the Heart Failure Compliance Scale, which takes into account the 6 measures of appointment- keeping, medication, sodium restriction, uid restriction, daily weighing and exercise. Telemonitored patients were found to adhere signicantly better to daily weighing and uid restrictions, and estimated the importance of medication to be higher after using Health Buddy for 12 months. Data taken from [Boyne et al., 2013]. 13 consequence, they have been repeatedly investigated as part of numerous telemonitoring trials, both independently and federally funded, to elucidate the viability of telemonitoring in the context of its target demographics. The Medicaid-supported IDEATel study (see Patient Outcomes) that demonstrated the merits of telemonitoring in diabetes management also conducted surveys of patient and physician satisfaction with the system. According to the authors, all 346 telemonitored patients who responded to the survey gave uniformly high satisfaction ratings of 4 out of 5 or higher on each of the 26 questions on the survey about the telemonitoring programme [Shea, 2007] . 116 physicians to some of these patients also indicated a generally high level of satisfaction [Shea, 2007] with the telemonitoring programme. These high satisfaction ratings from physicians and patient were not easily won. Of the studys participants, more than half reported annual household incomes of USD$20,000, approximately 79% reported that they did not know how to use a computer prior to the study, and all participants were elderly, being of age 55 and above. Despite being the antithesis of the young and tech-savvy demographic that would take immediately to telemonitoring technology, these patients were still able to benet immensely (and contentedly, to boot) from using the telemonitoring system. United States Department of Veterans Afairs and Bosch Health Buddy In a 2010 interview with Ageing International, Adam Darkins, Chief Consultant for Telehealth Services at the VA, observed that although shifting healthcare services to the realm of the digital may make it seem more impersonal in theory, telehealth actually supports relationships between the patient and the care coordinator [Lindeman, 2010] in practice. Far from short-changing the patient by depriving them of contact with healthcare providers, telehealth and telemonitoring services actually bring patients and physicians closer together on a daily basis, facilitating more frequent bite-sized conversations that can help further ne- tune and personalise patients treatment regimes. Darkins also notes that most resistance (when there has been any) came from clinicians initial reservations about this relatively new mode of treating patients. On the other hand, patients were relatively enthusiastic and satised with its telemonitoring services from the very start. Even when the VA was just starting to roll out its telemonitoring services in 2006, a survey of 42,460 early adopters already indicated a mean 86% satisfaction [Darkins et al ,2008] with its telemonitoring services. Of the many patients that the VA telehealth service has treated, 90% [Lindeman, 2010] would be happy to continue with using the telehealth services that the VA ofers instead of reverting to in-person care. These telehealth services were not just usable by the entire demographically diverse spectrum of patients served by the VA, but also widely accepted by patients and physicians involved with the programme. One of the reasons the telehealth programme found such a warm reception amongst patients was the uncomplicated push-button devices that the telehealth service provided for patients. Such devices are simple in the extremeone of them has just four big buttons and a LCD screenthey just work. Patients need only think about their health when using the device, and not about how to use or troubleshoot complicated technology. So the vast majority of patients have neither qualms nor difculty with receiving healthcare through telemonitoring servicesthis even includes patients who are not traditionally known to be particularly technologically inclined. Moreover, upon having experienced the conveniences of telemonitoring Patients with the VA health service welcome the use of telemonitoring in their healthcare delivery. Data taken from [Darkins et al., 2008]. 90% of patients want to continue with telemonitoring 14 care, many patients are loath to part with it [Darkins et al., 2008] . Not only are telemonitored patients living healthier and happier thanks to telemonitoring technology, they are also gaining deeper and more productive relationships with their doctors and caregivers. Medical Resource Utilisation One of the major benets of telemonitoring is that the health information provided to patients through the platform helps them make wiser health care decisions. These smarter individual decisions on the micro-level can translate into considerable improvements to efciency in the healthcare sector, on the macro-level. These efciencies have been well-documented in many large studies of telemonitoring systems. They work both by encouraging proper use, and reducing unnecessary use of hospital resources. Patients who are unsure about medical resources available to them can learn about their options through daily contact with healthcare professionals on the telemonitoring system. On the other hand, patients unsure about the signicance of a particular symptom can check with healthcare professionals before checking themselves into a medical facility. This can save patients and payers a potentially costly and unnecessary trip to the hospital, where patients may also be exposed to contagions that may further exacerbate their condition. At the same time, this helps hospitals free up resources being infringed upon by non- emergent cases. For instance, researchers on the Columbia University IDEAtel project (see Patient Outcomes) observed that the telemonitored diabetes patients from medically underserved regions tended to end up having better managed conditions, and claiming more benets from Medisave than those who only experienced usual care [Shea, 2007] . The authors hypothesised that these patients had been less aware than the average patient of the healthcare options available to them, and that the increased contact with healthcare professionals through the telemonitoring system allowed these patients to seek out more appropriate care than they would have on their own. Previously unsure and uninformed, these underprivileged patients were able to acquire a higher level of care more appropriate to their conditions, and stay healthier in the long-term with the help of telemonitoring. Inversely, a large integrated healthcare delivery and nancing system in Pittsburgh, Pennsylvania found that they could reduce unnecessary hospital service utilisation by ofering a telemonitoring programme to chronic care patients. In their pilot study, case managers were assigned to chronic care patients to support their self-management and self-care measures, ensure patients adhere to their medical regimens, and consult on any medical concerns patients may have. Telemonitoring Usual Care -20 -15 -10 -5 0 5 ER Visits Readmissions Admissions C h a n g e
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% Change in Hospital Service Usage, 2009-10 The UPMC, a large integrated healthcare delivery and nancing system in Pittsburgh, Pennsylvania, was able to reduce hospital service usage and improve patient adherence to self-care measures through a telemonitoring programme. Data taken from [Rosenberg et al., 2012]. This yielded benets for patients and the healthcare system alike. Diabetes patients who were being telemonitored were tracking their disease metrics (e.g. HBA1c levels, eye exam, etc.) more closely than their usual care counterparts. The health system, in turn, was seeing signicantly fewer ER visits and readmissions from the telemonitored patients in the second year of the trial (p < 0.05) [Rosenberg et al., 2012] . By all counts, medical resources were being employed more appropriately, as case managers worked to actively close the gaps in patients pre- existing care and ensure that patients did not need to be unnecessarily hospitalised. 15 United States Department of Veterans Afairs In their landmark 2008 study, 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, the VA published 4 years worth of telehealth service performance data collected across 43,432 patients. One of their main ndings was the drastic reduction in the frequency and length of hospital stays amongst telemonitored patients. Comparing data from the year preceding and following 17,025 patients recruitment into the telemonitoring programme in 2006-07, the authors found that the telemonitoring programme signicantly cut hospital service utilisation [Darkins et al, 2008] regardless of the condition the patient was being monitored for. These results are due to the fact that home telemonitoring systems allow care coordinators to maintain low level surveillance on the conditions of many patients at once. This helps them keep track of patient self-care and any warning symptoms of rapidly deteriorating conditions that may arise. Darkins, head of the VA telehealth service, describes this as just-in-time [Lindeman, 2010] carenot unlike a tsunami warning system. Just like how tsunami warnings can save thousands of lives by getting people to evacuate early, telemonitoring systems can warn of impending deteriorations, enabling healthcare professionals to stage life-saving interventions before the big wave hits, and patients decline to such a state where they have no choice but to be hospitalised. Telemonitoring signicantly reduced utilisation of hospital services for all conditions monitored. Most of the patients being telemonitored for the more common chronic conditions saw the inside of a hospital 20-30% less times than when they were not being telemonitored. Patients being telemonitored for mental health conditions saw more drastic reductions of 40-60%. Data taken from [Darkins et al., 2008]. 2,800 patients Change in Utilisation by Condition due to Telemonitoring, 2006-07 -60 -50 -40 -30 -20 -10 0 O t h e r
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% 16 United Kingdom Whole System Demonstrator (WSD) Besides experiencing signicantly lower mortality rates (see Patient Outcomes), telemonitored chronic care patients in the British WSD telemonitoring trial were also in hospital signicantly less frequently (p < 0.05), and for shorter stays each time than their usual care counterparts [Steventon et al., 2012] . Telemonitored patients experienced 10.8% fewer hospital admissions, 20.6% fewer emergency admissions, 14.7% fewer ER visits, and 14.3% shorter hospital stays than those under usual care regimens, on par with the statistics published by the VA. Paired with the nding of reduced mortality rates, these results show that telemonitoring lets us have our cake, and eat it too. Not only will patients stay healthy and alive for longer, hospitals can also devote less of their already limited resources towards treating deteriorations that were entirely preventable in the rst place. Cost Given the relatively novel place telemonitoring occupies in the public imagination, it is not unreasonable for patients, payers, and healthcare professionals to be questioning whether this newly-fangled technology is truly worth it. But as telemonitoring emerges from its infancy, it has become increasingly clear that its return-on-investment (ROI), both nancial and medical, is attractive enough that pre-eminent healthcare providers, like the Cleveland Clinic and the VA (Department of Veterans Afairs), are extending their telehealth services immediately following their own successful prior trials of the technology. In 2008, Emily Seto, a researcher at the Centre for Global eHealth Innovation in the University Health Network of Toronto, Canada identied and reviewed 10 published trials that investigated the economic viability of home telemonitoring for heart failure patients. Studies varied in how they conducted cost analyses, but most considered costs from hospital admissions, nurse telemonitoring and intervention, telemonitoring equipment and upkeep costs, etc. All 10 trials had found cost reductions, of up to 68.3% from using telemonitoring over usual care [Seto, 2008] . Four years later in 2012, researchers in neighbouring Montral followed this up in a 21-month trial with 95 chronic care patients, citing the prior review as inspiration. Their implementation of telemonitoring resulted in cost savings of CAD$1,557 per patient per year, shaving of 41% of annual usual care costs [Par et al., 2013] . Included in these calculations were the costs for nurse home visits, hospitalisations and ER visits, telemonitoring equipment purchase and maintenance, nurse salaries, and staf training costs. The bulk of cost savings came from the shorter, and less frequent hospital stays that the telemonitored patients experienced. Because telemonitoring systems alert 40 42 44 46 48 50 Usual Care Telemonitoring Patient Admittance Proportions P r o p o r t i o n
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% 0.0 0.2 0.4 0.6 0.8 Usual Care Telemonitoring ER Visits Emergency Admissions Change in Hospital Service Utilisation I n s t a n c e s
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H e a d Medical resource utilisation by chronic care patients can be reduced with the help of telemonitoring technologies. Participating researchers in the WSD found signicant reductions (p < 0.05) in patient admittance proportions and instances of emergency admissions and ER visits for telemonitored patients. They also tended to have shorter hospital stays once admitted. Data taken from [Steventon et al., 2012]. 17 programme for their chronic care patients [Rosenberg et al., 2012] . The authors reported that following the success of their telemonitoring trial in 2010, the UPMC planned an 8-fold expansion of the telemonitoring programme to 240 practice sites owned by the UPMC by 2012. United Kingdom Whole System Demonstrator (WSD) Other trials of telemonitoring systems did not report such positive ndings. In the UK WSD telemonitoring trial, a component study undertaken by researchers from the London School of Economics and the University of Oxford found that while telemonitoring yielded benets for patients, the calculated probability of it being cost-efective was low. Instead of conducting the straight-forward cost-benet analysis used by other researchers, this WSD component study used an indirect measure of cost-efectiveness known as the incremental cost per quality adjusted life year (QALY). A QALY is rated on a scale of 1 to 0, with 1 representing perfect health, and 0 representing death. By combining scores for a patients mobility, discomfort, self-care abilities, anxiety and depression, and day-to-day activities, one can theoretically determine how a year in the life of the patient 0 100000 200000 300000 400000 Usual Care Telemonitoring Cost Calculation Breakdown T o t a l
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C A D $ Technology Costs Home Telemonitoring Costs Hospitalisations ER Visits Home Visits by Nurses healthcare professionals to the early signs of a patients deterioration, resultant just-in-time interventions help prevent costly, repeated hospitalisations from happening over the long term. Other cost savings also come from the patient becoming more engaged with their own self-care, adhering better to medication regimens, and keeping healthier with a lessened need for serious interventions in the long-term. Encouraged by these ndings, payers and healthcare providers have started trying to nd ways of integrating telemonitoring into their pre-existing local health systems. One example is the patient-centred medical home, a telemonitoring trial set up by the UPMC, an integrated healthcare delivery and nancing system serving 1.8 million insurance plan members in Pittsburg, Pennsylvania. In their trial implementation of telemonitoring for 23,900 chronic care patients covered by their health plan, the payof from the reduced utilisation of medical and pharmacy services (reported earlier) more than ofset the cost of hiring telemonitoring case managers and setting up and maintaining the telemonitoring infrastructureso much so that they were able to gain a 160% ROI from investing in the telemonitoring With telemonitoring, the Canadian health system saved CAD$1,557 per patient, per year (p < 0.025). Patients paid CAD$2,641 less in hospital fees (p < 0.0005) when telemonitored, but these savings were ofset somewhat by the cost of implementing the telemonitoring system, which came to CAD$870 per patient per year. Data taken from [Par et al., 2013]. 0 10 20 30 40 50 60 70 80 S c a l v i n i N o e l L e h m a n n J e r a n t F i n k e l s t e i n D i m m i c k B e n e t a r M y e r s J o h n s t o n Time / Months C o s t
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% Cost Savings from Telemonitoring Heart Failure Patients All 10 studies reviewed in Setos 2008 paper reported cost savings from telemonitoring heart failure patients. On average, these studies found cost savings of 26.4% from using telemonitoring over usual care methods. Data taken from [Seto, 2008]. 18 measures up against a year of perfect health. To nd the incremental cost per QALY, researchers then divided the additional cost from telemonitoring a patient (~1,110) by the additional QALYs experienced by telemonitored patient (~0.012), working out to an incremental cost per QALY of 92,000. According to recommendations from previous studies, payers are likely to be willing to pay up to 30,000 per additional QALY, making the 92,000 gure only 11% [Henderson et al., 2013] likely to be cost-efective. But despite the advanced methods of analysis used in their study, authors acknowledge that there are methodological aws present in their study design that could have led to inaccurate results. For example, the gure used to calculate diferences in medical service usage costs between the 2 groups was less of a precise measurement, and more of a rough estimate. Unlike other studies, service use in this study was calculated based on patients own estimates of service use, rather than logged by the researchers themselves. It is likely that the cost benets of telemonitoring could have been grossly underestimated because of this uncertainty, since other studies that meticulously logged these service utilisations found that the greatest savings from telemonitoring came in the form of reduced service use. Moreover, unlike most other large-scale studies on telemonitoring, the WSD left it up to local sites to decide on their own design of telemonitoring systems instead of implementing a uniform system across the entire study population. This is little diferent from aggregating data from small studies, a complaint common of telemonitoring studieseach site was unlikely to have achieved the true economies of scale the study of 3,230 patients was actually capable of. This is hinted at by the abnormally high cost of telemonitoring per patient per annum (1,847 = USD$2,751 in this study, vs. the VAs counterpart of USD$1,600 [Darkins et al., 2008] ), as well as the extremely high variation in telemonitoring costs across the study population. These high uncertainty margins call into question the 0 100000 200000 300000 400000 500000 600000 Computer Hardware and Peripherals Computer Software Installation Contractor Costs WSD Telemonitoring Component Cost Ranges C o s t
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wildly across diferent sites in the UK WSD trial, likely causing low precision in the nal cost-efectiveness estimate. Only ranges were reported; other important statistical information on these costs, such as their means and standard deviations, were not reported in the 2013 paper, making it difcult to discern the true statistical signicance of nal cost-efectiveness estimates. Data taken from [Henderson et al., 2013]. The UPMC, an integrated healthcare delivery and nancing system serving 1.8 million insurance plan members in Pittsburgh, Pennsylvania reports a 160% ROI from telemonitoring. Researchers found that they were able to save $9.75 per patient per month by ofering a telemonitoring service to chronic care patients on their health plan. Savings from reduced medical and pharmacy utilisation amounted to a signicant $15.84 per patient per month (p < 0.01). Data taken from [Rosenberg et al., 2012]. Reduced Medical Service Utilisation Reduced Pharmacy Service Utilisation Net Cost Avoidance Telemonitoring Costs -$4.73 -$11.11 -$9.75 +$6.09 160% ROI 19 statistical signicance of the calculated cost efectiveness value. This is an acknowledged weakness of the study, and after using lowered telemonitoring cost estimates and taking into account some extent of the economies of scale that telemonitoring systems are capable of, the study hypothesised that it was 61% likely [Henderson et al., 2013] that a generalised telemonitoring system would be cost-efective. Bosch Health Buddy A study in the US Northwest that showed that the Health Buddy could lower mortality rates in chronic care patients (see Patient Outcomes for study details) also found that healthcare costs for these patients were also signicantly reduced compared to those who were not telemonitored. In this particular study, cost estimates were derived from patients Medicare claims data, but the cost of the Health Buddy device and other monthly telemonitoring costs were not accounted for in the nal analysis. After a 2 year study period, researchers determined that quarterly healthcare spending had declined on average by $511 (p < 0.01) [Baker et al., 2011] for telemonitored patients, or 7.7%-13.3%. The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare claims, evaluated this same telemonitoring programme independently, and found slightly more conservative cost reductions of 6.0%-8.1%. Analysing the data by condition, the studys authors found that patients with congestive heart failure experienced the greatest amount of cost savings per quarter, of USD$1,009 (p < 0.01), followed by those with COPD, of USD$726 (p < 0.05), and nally those with diabetes, of USD$519 (p < 0.05) [Baker et al., 2011] . These results are consistent with the ndings of the VA on the reductions in medical service usage by condition (see Medical Resource Utilisation). Since cost savings come primarily from service use reductions, results from these two studies corroborate in showing that telemonitoring can result in better outcomes despite decreased spending on healthcare. United States Department of Veterans Afairs According to internal data from the VAs Telehealth Service, the average cost to provide telemonitoring services for each patient was USD$1,600 per annum in 2008 [Darkins et al., 2008] . As VA researchers emphasise, the rates for traditional care that performs similar functions is USD$13,121 per annum within the VA, and USD$77,145 per annum for market-rate nursing home care. In comparison, telemonitoring looks to be an extremely attractive option for the VA in providing healthcare for all their veterans. Going forward, as telemonitoring technologies mature, the cost savings that this innovative healthcare delivery solution will bring to healthcare systems around the world can only get more attractiveand while it is not a panacea for the worlds ageing problems, telemonitoring could take much of the heat of of governments and payers in being able to pay for adequate healthcare for each ageing citizen. Many more lives will be at stake in the near future, in view of the projected increase in chronic disease loads. Healthcare providers cannot aford to lag behind in adopting life-saving technology that has been proven, over and over, to keep patients healthier in the long-term without putting additional loads on the healthcare system. As Adam Darkins of the VA opined in an interview, telemonitoring has advanced far enough today to make the cost worthwhile for -1200 -1000 -800 -600 -400 -200 0 Congestive Heart Failure Chronic Obstructive Pulmonary Disorder Diabetes Mellitus Cost Savings via Health Buddy Telemonitoring, by Condition C h a n g e
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$ Telemonitoring with Health Buddy can result in reductions in healthcare spending for chronic care patients. Patients with congestive heart failure stand to experience the greatest amount of cost savings per quarter, of USD$1,009 (p < 0.01), followed by those with COPD, of USD$726 (p < 0.05), and nally those with diabetes, of USD$519 (p < 0.05). Data taken from [Baker et al., 2011]. 20 both public and private healthcare systems. Said Darkins, The federal government has the ability to make strategic investments that are not necessarily dependent on the next quarters nancial returns, as can be the case in the private sector. I believe that telehealth has now proved itself in the home care environment, and the systems and technologies that are available are robust enough that they can be used more widely in non-governmental sectors. Electronic Health Records Operating in the digital realm ofers the healthcare industry another boon to the conveniences of telemonitoring and teleconsultation. By moving doctor-patient interactions to the virtual world, information exchanged during these interactions can be held for future reference, collated over time in the cloud to form a complete electronic health record (EHR) of each individual that can then be shared with all healthcare providers with an internet connection. Integrated well, an EHR will give doctors access to relevant and complete medical information on each patient. A doctor seeing a new patient for the rst time can make a more informed diagnosis of a patients condition based on not just their new symptoms, but also their medical past. If the patient does not have the capacity to communicate with healthcare providers (for example, right after a serious accident), timely access to the allergy information and medical history documented on an EHR can prove invaluable in helping doctors quickly prescribe appropriate medications and course of treatment. Switching to EHRs also minimises errors in medical documentation. For one, turning to EHRs means that mistakes in interpreting doctors written advice could be eliminated, preventing inaccurate record keeping and the mis-prescription of medications. A 2006 report from the US National Academy of Sciences Institute of Medicine estimates that avoidable medication mistakes (such as messy handwritings) kill 7,000 people and injure more than 1.5 million people annually in the US alone. These mistakes crop up mainly during the prescription and administration stages, but can easily be avoided by switching to legible, unambiguous electronic prescriptions. For another, the presence of an EHR could allow patients access to their own health records. This could be instrumental in keeping medical records accurate and up to dateas Dave deBronkart (or e-Patient Dave, as he is known to his blog readers) discovered after his brush with cancer, the records that hospitals keep of patients can be wildly unreliable. When deBronkart had decided to start a personal health record after his recovery, he obtained his records from his hospitals computer system as a starting point. He was shocked to discover that those records contained conditions I never had, an allergy I never had, and did not contain an allergy I do have. Worse, missing from those records were important information such as lab and radiology data from his stays at the hospital. In an interview with HealthIT.gov, a US government website set up to educate medical professionals and the public about EHR use under Obamacare regulations, deBronkart stressed the importance of patients being able to access and update their own medical records whilst they are healthy. Otherwise, were a medical crisis to hit, patients run the risk of being treated with unsuitable medication, and healthcare professionals run the risk of facing a malpractice suit. Another HealthIT.gov interviewee, Regina Holliday, holds inaccessible medical records responsible for her husbands end-of-life sufering. After her husband was diagnosed with end-stage kidney cancer, Ms. Holliday had to ght the hospital for access to his medical records, so that she could take better care of him in his last days. It took 21 days to get to them, at a time when his life span was measured on a timescale of mere weeks. When she nally read it, [she] was astounded because it was lled with actionable data that would have impacted his care and created a better living condition for him, and for [them]. Had there been a centralised EHR system accessible to both doctors and patients, Ms. Holliday and her husband could have been engaged, active participants in his end-of-life care, instead of feeling unempowered in the face of the unknown. In the long term, the data that centralised EHRs collect from patients could help make healthcare more holistic 21 than it is today. Its biggest strength is personalisation, made possible by the colossal amount of data collated from individuals that could aid big-data researchers in devising individualised treatment regimens. In his interview with Ageing International, Darkins of the Veterans Afairs Telehealth Service stated that in order for a telemonitoring system to achieve success of a kind of the VAs, a vital prerequisite is to have an electronic patient record. Physicians can tweak patients medications if the EHR shows that the medication has not been efective. Longitudinal trends in a chronic care patients condition can allow for just-in-time interventions to be staged, and for costly hospitalisations to be prevented. Michael Seid, a professor of paediatrics at the Cincinnati Childrens Hospital Medical Center, describes this as the bodys check-engine light. His research suggests that patients tend to withdraw from society and avoid leaving the house in the days before are ups. Tracking these warning signs has helped his team reach out to patients with chronic gastrointestinal troubles before they crash. Beyond just personalising treatments for those who are already sick, EHRs can also be a big help for healthy peopleor those who think they are healthy. Chronic diseases are more prevalent in certain subsets of the population, especially those with genetic or environmental pre-dispositions. If these factors can be identied early from patients EHRs, then they can be automatically advised to go in for the relevant health screenings more regularly than the general population. As things stand, evidence on current models of health screening show that they may not be cost-efective in the long-term [Cohen et al, 2008] , or even benecial for most [Joelving, 2012] . Prevention may not necessarily be better than cure. Encouraging health screenings for the general population is just not cost-efective, since the incidence of most chronic diseases is too low to be worth the screening costs when averaged over the entire population. Worse, with some chronic diseases such as slow-growing prostate cancer, diagnosing and treating the patient is likely to cause more monetary and medical harm than good. Because the cancer progresses so slowly, the tumour may not have troubled the patient in their lifetime. But once it gets diagnosed, the combination of invasive tests and toxic chemotherapy may just kill the patient before their time has come. To increase the efcacy and cost-efectiveness of preventive health screenings, a more targeted approach must be taken. This is where an EHR comes in useful. With an accurate EHR in place, people that exhibit risk factors for certain diseases, such as age or family history of the disease, can be identied automatically by the system. Paired with an efective telehealth system, these people can be called in automatically for health screenings more frequently than the general population, making the most of available medical resources and preventing over-diagnoses. To achieve these ends, EHRs need to accrue comprehensive patient information from institutional and personal sources. The push for such open-access, comprehensive EHRs has already started online. US legislators explicitly recognised the value of EHRs when enacting their latest rounds of healthcare reform, and have set up an integrated EHR access website known as the Blue Button Connector. This website provides Medicare patients with complete access to their health records from their healthcare and insurance providers. Patients can get access to their own medical records with just a few clicks of the mouse. These open-access electronic health records will contribute to fullling the meaningful use clause of Obamacare regulations, in which physicians are required to make use of patient-provided data in treating them. Patients empowered with access to their own EHRs are likely to get engaged, and stay engaged with keeping themselves healthy in partnership with their healthcare providers. Coupled with data-driven technologies, the predictive power of EHRs gets better the more people use it. With the growing amounts of data coming in from physicians, patients and telehealth platforms, algorithms become ever more accurate in pin-pointing aggregate trends to provide personalised and afordable healthcare for each individual. 22 Indeed, this weak link in the healthcare system has been acknowledged by MOH Holdings, which owns all of Singapores public healthcare assets. MOH Holdings highlighted in the 2012 HIMSS conference that Singapores primary care services are not well integrated with those for intermediate and long-term care (ILTC), resulting in frequent readmissions and disproportionate pressures on the acute and tertiary care sector. After chronic care patients are discharged following hospitalisations, no efective coordinating system currently exists to make sure they stay healthy, and out of the hospital. Also highlighted by the local Agency for Integrated Care (AIC), a subsidiary of MOH Holdings, was the lack of patient condence in the care capabiilties of the ILTC system when being transferred after discharge. The disconnect between primary, acute, and ILTC services constitutes a serious gap in the existing healthcare system. In light of research that suggests that half of all healthcare spending for chronic care patients originate from hospital service use costs [Henderson et al., 2013] , the increasing prevalence of chronic disease threaten to strain not just the nances, but also the resources of the system. Already, Given Singapores position as an ageing and technologically-advanced city, telehealth applications will become vital over the next few decades in ensuring that healthcare costs remain under control for the island-state. Here, the percentage of those aged 65 and above is set to nearly double to 23.1% in just 6 years [BMI, 2014] . The government has pledged to expand state expenditure on healthcare to cover 40% of the national aggregate. Though globally touted as a shining beacon of medical efciency, the view from the inside is not as rosy. While public healthcare spending currently constitutes just 4% of national GDP, it is on the rise. The ageing population is putting nancial pressure on patients, payers, and the public sector to nance the resultant increase in chronic disease case loads. Recent reports from both PriceWaterhouseCoopers (PWC) and Business Monitor International (BMI) warn that the current focus on acute care in the local healthcare system will quickly become deleterious in the face of the growing number of chronic care patients. The BMI, in particular, recommended shifts towards sustainable community and home-based care methods in its Q3 2014 Singapore pharmaceuticals and healthcare report. Translations for Singapore 5% 5% 4% 4% 3% 3% 2% 2% 1% 1% 0% The proportion of those aged 65 and above is projected to double to 23.1% in 2020 in just 6 years. Data from the UN. 0 - 4 5 - 9 10 - 14 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 - 94 95 - 99 100+ Female Male Projected Population Pyramid, 2014 -2020 by 5-year Age Group 2020 2014 23 local hospitals and nursing homes are facing issues such as severe bed shortages and a shortfall of qualied medical professionals in the intermediate and long-term care sectors [BMI, 2014] . To close this gap, MOH Holdings is already looking towards harnessing telehealth services from the agile private sector [Muttitt et al., 2012] as a means of mitigating costs. In view of the technologys proven track record in streamlining costs, the healthcare system will be able to signicantly reduce hospital readmissions and ER visits for chronic care patients without compromising on care standards. What makes telehealth services even more promising for the nation is the preponderance of telecommunications technology ownership by individuals, which could result in even greater cost-savings than currently documented. 2013 data from the Infocomm Development Authority suggests that 87% of Singaporeans have access to the Internet at home, meaning that online telehealth services will result in little to no additional infrastructure costs to patients and payers. Even more encouraging is the fact that a majority of Singaporeans have an expressed interest in using digital health services the 2014 McKinsey Digital Patient survey indicated that more than 75% of respondents in Singapore want access to quality digital healthcare services. One of the few required infrastructure investments for telehealth services in Singapore has already been pioneered in the public sector. Forming the backbone of all future telehealth services will be the National Electronic Health Record (NEHR), accessible to all healthcare providers in Singapore. This lays the foundation for future private sector solutions that can cater then specically to the diverse needs of each healthcare provider. Further developments in local telehealth services will have to come from the bottom-up, rather going from the top- down as in the case of the NEHR. While the public sector is able to establish consistent and portable standards important for data-intensive telehealth solutions such as the NEHR, the private sector, with its natural adaptability, is better at nding exact ts for the needs of individual healthcare providers. The resulting smorgasbord of compatible telehealth applications, such as teleconsultation, telemonitoring, and personal electronic health records, will allow healthcare providers to collaborate with patients in their ongoing treatment using patient-provided health data. MOH Holdings hopes to be able to collect such data via its web portal, healthy.sg. It is currently in a limited beta, and caters to all individuals, regardless of whether they have known conditions. Most of the metrics it currently tracks focus on diet and exercise data for healthy people. Whether the government portal will be able to sustain engagement with healthy patients in getting them to consistently input health data over the long-term remains to be seen. Other eforts towards implementing telehealth systems for Singaporean patients are promising, though fragmented. Most healthcare providers have already recognised the potential of such programmes in the local context, and are looking to expand on existing initiatives in the near future. For instance, hospitals such as Changi General are already ofering their own small scale telemonitoring services for their chronic care patients, while Tan Tock Sengs NHG Eye Institute ofers a programme for patients to be referred to eye specialists via teleconsultation from Hougang Polyclinic. Pilots have also been started at Khoo Teck Puat Hospital for using teleconsultations for stroke and geriatric patients. Meanwhile, local organisations such as the Agency for Integrated Care and TOUCH Diabetes Support have expressed interest in being able to provide telehealth services to the chronic care patients that they serve. Integrated properly into the health system, these telehealth services will provide accessibility and convenience to patients and healthcare providers at each step of the way. For minor ailments that do not require in-person examinations, patients could book virtual appointments to consult with their GP face-to-face without ever stepping out of their house. In-person appointments could also be made in advance at the click of a button, helping patients avoid long waiting times in the doctors ofce with other contagious patients. In the long run, small practices and medical groups stand to gain increased patient retention and loyalty through the convenience of telehealth services. 24 Using the health data collected through frequent encounters with GPs, people can be recommended to attend health screenings for specic diseases based on their personal medical backgrounds and risk factors. If diagnosed, patients can be easily referred to specialists, who will have immediate access to therelevant medical history of the patient. Furthermore, properly implemented telehealth platforms will allow healthcare professionals to securely message their colleagues and patients without worrying about having their patients valuable medical data stolen by hackers. As opposed to normal, unsecured messaging platforms such as SMS and email, platforms compliant with standards such as HIPAA and PDPA protect sensitive medical data with all the ease of the former. Should a patient require urgent hospitalisation, acute care professionals will have the complete records of patient allergies and pre-existing conditions, collated over a lifetime. The time and costs of handling administrative paperwork in hospitals can also be reduced with the help of the integrated electronic record, since many patient details for admission can automatically be retrieved from the centralised record. Home telemonitoring may become the norm for chronic care patients, who require low levels of care over long stretches of time, and the occasional just-in-time intervention to prevent deteriorations from escalating into costly hospital stays. Hospital stays themselves can be shortened for patients with the appropriate care-support system for home telemonitoring care, making acute care more afordable for patients while alleviating bed shortages in local hospitals. Only by putting in place these integrated helper technologies can Singapores healthcare system begin to cater for the burgeoning healthcare needs of tomorrow. Large trials in other developed countries have made it clear telehealth is the way to go for efective, afordable healthcare for everyone. 25 coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. 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