Telehealth Acceptance and Implementation

Following Normal Technology Introduction Pathways.

A number of recent meetings in the UK have focussed on the progress of Telehealth, Telecare and Telemonitoring from academic and commercial organisations as well as joint programmes under various UK government support programmes, notably the raft of programmes funded by the Technology Strategy Board, TSB. Several common themes have emerged:

• There is good agreement that these “Tele” based systems offer the opportunity for increased
  Primary Care.
• Disappointment at the low level of system acceptance and placements.
• There is a strong political push based on the Primary Care initiatives that are seen as providing possible cost savings for the NHS.
• There are issues on sources of funding and budgets for these services and whether this should be provided by Central (NHS) or more local (Social Services & County Councils) sources.
• There are silo budget issues within the NHS and the conflict of NHS savings versus loss of local revenues.
• The real cost benefits or costs of the various systems and approaches have not been analysed objectively. Even if costs are increased the approach might release resources to resolve other resource critical healthcare issues.

This note is intended to suggest that the current situation is in no way new. In fact the position mirrors several other healthcare implementations over the last few decades where the lessons and troubles in order to achieve success and the present day status might well have been forgotten and newcomers to the sector will be unaware of these past instances.

The most important feature is perhaps that the concept of Telehealth on a high scale is in reality rather new. Although aspects have been discussed for at least a decade it has been a mix of product push and philosophical drive rather than determining the level of end user, i.e. patient or person, demand. The position is made clearer through consideration of the Technology Development S-Curve. This analytical technique can be applied to any new technology but has proved particularly useful in major technology shifts in healthcare.

The analysis examines the resources expended over time for development of the technology in relation to

• Basic achievability of the technology or concept [Does it work] - Functionality.
• Application of the core technology and how modifications [Bells & whistles, joining with other technologies, new applications, etc.] enhance the utility of the technology - Features.
• Impact on market development from embryonic to mature over time.
• All in relation to user demands and acceptance with the increasing level of product performance.

It is worth seeing the basic format ahead of analysing the application to Telehealth and other Tele-related systems: Figure 1. I have immediately suggested the approximate position for Telehealth.

Figure 1. Basic Technology Development S-Curve Concept.

Source: Adams Business Associates.

The two broken lines are of prime significance:

• The Yellow line is when the technology is just ready for commercial use.
• The White line is the level of user expectation and/or demand. This will be low to start with in the absence of knowledge but rapidly move ahead of the Features and perceived product performance until Maturity in the market is reached.

It is worth noting the time scale of Technology Adoption, which is always slower than expected by those involved with the technology and implementing its commercial exploitation. In many cases it requires a long research phase before the Features make it viable for wider use:

• Molecular Diagnostics was slow to develop outside of research until a simpler method was invented (PCR Amplification) and then it took 20 years before it began moving into routine testing.
• Biosensors have been under development since at least the 1970s but still have limited general application because the features have in most cases not met user needs or been shown not to be significantly better than other technologies in use or developed after Biosensor Functionality was demonstrated.
• It is also forgotten the furore when it was proposed that patients could self-test for Glucose to manage their Diabetes.
• In more modern times a similar situation is seen with self-testing for Anti-Coagulant monitoring testing with self-adjustment of drugs for its control.
• In many aspects the recent (last thirty years!!) history of Point-of-Care Testing (POCT) in the UK has relevance for implementation of Telehealth with its complexity of technical aspects, silo budgets, conflict of management of the testing and equipment as well as protection of job security ahead of the “better good for the NHS and patient”.

The range of Tele systems that are discussed is confusing for those involved in the sector let alone the clinicians that will drive such products and systems and the public that will be the ultimate users and beneficiaries. It is necessary to separate out products that are in use or being trialled for use by sick patients (Glucose & Anticoagulant monitoring, COPD, CHD, etc.), those that are designed to allow for home care for those with chronic conditions (Assisted Living for such as Dementia, Alzheimer's Disease patients) and the longer term goal of care for people currently well (particularly the elderly). The issue becomes clearer by positioning the present status of the different applications of Tele-Assisted Healthcare on the technology SCurve.

Figure 2. Possible Technology Development S-Curve for Telehealth Systems.

Some features of this early market development are seen and confirm where the sector is today:

• The market potential is much higher than being observed.
• People are starting to use the products but stop using them after a short period of time. *
• Design issues are seen - good technically but poor from a user perspective.
• End users unclear on the benefits of products and/or unaware of their availability.
• There is not a clear recognition by end users of why they need such products.
• There is a disconnect between Industry perception of need and consumers actual needs. [COMODAL project].
• Patient Pathway based economic analysis has not been rigorous and not patient centric with stratification to select those that will really benefit from Telehealth systems.
• The main driver toward Primary Health care with use of Telecommunications is political with commercial assistance in a market where the belief is that the NHS is there to care.
• Commercialisation is mostly led by relatively small companies that have held back market development of delivery of a complete service package that requires high investment.
• Major companies see an opportunity to extend their business and enter the market only to find returns are slower than expected and then exit. In addition, there are regulatory and other hurdles to be jumped that they do not find attractive and exit the market: O2, BT and now Apple, Microsoft, Samsung as well as Google are or have been active in the sector.
• It is also true that out of these new entrants to the health sector there will develop new major players as they bring their specialised systems [Apps. Internet, etc.] as Features advances.

* “Eighty percent of health apps are abandoned within two weeks,” Marco Della Torre, vice president of product science at Basis Science Inc. told the 7th Annual USC Body Computing Conference last year. Because many of these products operate without consumer intention, designers of wearable health devices cannot fall into the “build it and they will come” mentality. The industry must find a way to truly engage users and create sustained healthy behaviours. It is not enough to simply wear these devices as accessories and log the results in silo. The tracked data needs to be feed into a trusted platform and reported back to population health managers so they provide incentives to propel continued activity.”

Alongside the early stage of market development is the importance of the balance of Product [Analytical & Clinical Performance, Usability, Cost Effectiveness (value)] and Company elements [Reliability, Technical and Services Support, Financial Sustainability, etc.] in acceptance of the technology. The major item missing for faster acceptance of any of the applications is a use that solves a strong existing unresolved problem for the patients or the medical fraternity. This highlights the reluctance of large parts of the market, from any age group, of people that do not see that they have a problem where use of the Tele-technologies will solve. Referring back to the Technology S-Curve history shows that innovative technologies are first accepted through solving a previously unsolved problem or need with subsequent wider adoption in other areas because the technology has been proven and more readily replaces legacy technologies and uses.

Although for at least the last century or more it has normally happened that new innovative technologies develop in the way being seen for Telehealth in its many possible applications the short term goal is being affected by drivers and constraints. These aspects need to be considered by companies, large and small, not only in developing products but also business plans that take into account the reality of market development as described above. Some of these aspects are summarised in Figure 3.

Figure 3. Business Dynamics for Adoption of Telehealth Systems.