- Email: [email protected]
Telecare, telehealth and telemedicine
European Geriatric Medicine 1 (2010) 193–197
Technology applied to geriatric medicine
Telecare, telehealth and telemedicine S. Stowe a,*, S. Harding b a b
Department of Elderly Medicine, Beckett Wing, St. James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK Morley Health Centre, Corporation Street, Leeds, LS27 9NB, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 April 2010 Accepted 29 April 2010 Available online 8 June 2010
The incorporation of new technologies into the fields of health and social care is already a worldwide phenomenon – despite a lack of evidence to support this practice. Studies thus far have focused on patient satisfaction and feasibility rather than efficacy and cost-effectiveness. Research supporting the usefulness of data collected by lifestyle monitoring systems is required to justify the associated intrusion, particularly in users with cognitive impairment. This group may have the most to gain from devices designed to improve safety in the home, which may enable them to live independently, but are at risk of losing their autonomy. Older people are likely to be disproportionately affected by technological change and geriatricians must be aware of the wide-ranging implications for their patients and practice. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Assistive technology Telecare Telehealth Telemedicine Aged
1. Introduction The global population is predicted to expand with both a shrinking number of economically active and a larger proportion of older people [1]. The fastest increase will be in the ‘oldest old’ aged 85 years and over, with this group projected to quadruple to 5% of the UK population by 2033 [2]. There are wide ranging consequences of an ageing society in terms of health, social care and housing provision and technological solutions to this ‘problem’ are already in use. The number of people with long-term conditions will increase, as previously life-threatening events are better managed. There will be an increased focus on local services and equipment that are patient-centred in design in an attempt to meet demand. However, many physicians may be reluctant to accept change and may lack education in this emerging field and how it affects their patients. In this article, we describe new models of care, including the use of electronic devices in the homes of community-dwelling older adults. 2. Definitions One of the difficulties in this area of gerotechnology is the confusing use of ambiguous terms, which may be used to describe different services by different authors and equipment manufacturers. It is challenging for researchers and clinicians to seek evidence in the literature about their application to everyday practice without an international consensus on terminology [3]. The term ‘assistive technology’ was defined in 2004 by WHO as, * Corresponding author. E-mail address: [email protected] (S. Stowe).
‘an umbrella term for any device or system that allows individuals to perform tasks they would otherwise be unable to do or increases the ease and safety with which tasks can be performed’ [4]. Therefore, assistive technology includes equipment ranging from a simple grab rail to accessible transport and electronic falls detectors. We will be using the terms telecare, telehealth and telemedicine to describe three distinct examples of the use of information and communication technology (ICT) in geriatrics. 3. Telecare We use the definition of telecare used by Barlow et al., ‘the use of communications technology to provide health and social care directly to the user (patient). This excludes the exchange of information solely between professionals, generally for diagnosis or referral’ [5]. Telecare is therefore a tool used by professionals to deliver support to individuals and should be employed to provide a user-centred service that complements – rather than replaces – existing models of care. Most older people want to live in their own home and 35% of those living in care homes could potentially be supported at home with telecare [6]. Norway was the first country to implement an official fee schedule for telecare, making some services reimbursable by the National Health Service in 1996 [7]. In England, the Department of Health embraced telecare and spent £ 80 million on a preventative technology grant since 2006, with a target to provide this service nationally to those who will be eligible by the end of 2010 [8]. It has stated that, ‘telecare is as much about the philosophy of dignity and independence as it is about equipment and services’ and its potential benefits include:
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.04.002
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S. Stowe, S. Harding / European Geriatric Medicine 1 (2010) 193–197
a reduction in ‘unnecessary’ hospital admissions with cost savings; increased quality of life for telecare users by increasing independence and self-management with increased choice; a reduction in caregiver burden; a reduction in falls; a reduction in workforce pressures for health and social services; improved integration of health and social services, including primary and secondary care, voluntary and private care providers; increased access to community palliative care services for those wishing to die in their own home 4. Hierarchy of telecare As telecare services and products are designed with increasing capabilities, they can be described in the following categories: 4.1. First generation devices Fig. 2. Wireless carbon monoxide detector.
First generation devices are the simplest forms of telecare and include a user-triggered alarm button, which relies on the user wearing a portable device such as a pendant or reaching a pull cord in their home [9]. Once activated, the sensor wirelessly communicates a potential emergency to an intelligent receiver in the home (telephone) via radio transmitters. The telephone automatically contacts a call centre or user-designated first contact (Fig. 1). 4.2. Second generation telecare systems Second generation telecare systems utilise a broader range of sensors that detect specific hazards and do not require the user to trigger them. The call centre operative is immediately aware of the location and type of detector that has alarmed and works through a response protocol, which may include calling the user to exclude a false alarm, calling a relative or an appropriate responder, such as an ambulance or fire brigade. The alert is also communicated to the user within the home through an audible alarm, flashing lights and
even vibrating pillows to wake the user from sleep. These devices can also respond to an alert with appropriate remedial action and can be considered reactive rather than just preventative. For example, activating a flood detector may turn off the water supply and noisy appliances that make it difficult to hear alarms in addition to alerting call centre staff. There are many different hazard detectors in use, including smoke detectors, carbon monoxide and natural gas detectors and sensors that react to extremes of temperature (Fig. 2). Another example of such technology is a movement-triggered night light: a passive infrared (PIR) sensor reacts by switching on a light bulb. This cheap and widely available device can be attached to a bedside table or wall and uses technology from home security to reduce risk of nocturnal falls associated with poor lighting. PIR sensors can also be employed as memory aids at property exit points. For example, the sensor is activated as the user approaches their front door and plays a message (prerecorded by a relative) reminding them to take their key, remember their mobile phone or lock the door. In the event of a fall, personal alarms worn as a brooch, watch or pendant connect the user to a call centre and can be used to initiate an appropriate response following a ‘hands-free’ telephone conversation. However, such devices rely on the user being able to call for help. Specific falls detectors, which sense a sudden jolt in movement and change in attitude from vertical to horizontal and are worn as a belt are available [10]. These automatically trigger a call for help and may be useful when a fall is associated with a loss of consciousness or acute confusion and may otherwise predispose to a long lie. Bed and chair occupancy detectors respond to pressure changes and sense when the user is seated or lying down. (Fig. 3) These can be programmed with a timer according to individual user characteristics and respond to a change in usual behaviour, which may accompany an adverse event such as a nocturnal fall or sleep disorder [7]. Similar devices can be employed to respond to seizures and enuresis [10] (Fig. 4). 4.3. Third generation telecare systems
Fig. 1. Community alarm (watch): user must press button to call for assistance. Activated sensor wirelessly connects to telephone.
Third generation telecare systems have yet more complex capabilities and include the measurement, collection and analysis of data in the user’s home which constitutes ‘‘lifestyle monitoring’’. The data are sent to an internet portal that can be accessed by the user, their relatives, carers and professionals to ‘keep an eye’ on the
S. Stowe, S. Harding / European Geriatric Medicine 1 (2010) 193–197
Fig. 3. Chair occupancy sensor used for ‘lifestyle monitoring’.
Fig. 4. An epilepsy sensor.
user. Data are collected continuously, but may not be immediately available to view: some systems upload information during a set period each day. Sensors can be used as a surrogate marker of activities performed by the user and can provide reassurance of their well-being. They can be considered as preventative in that early detection of difficulties may mitigate harm. For example, sensors that monitor the use of kitchen appliances may provide evidence that someone has stopped cooking or replenishing the refrigerator. This could lead to a visit or telephone call to check all is well and increased support, if necessary, and may prevent longer-term malnutrition. Technology can also be a source of interaction with increased access to services for older people. The Internet can be used for grocery shopping, online voting in elections, contact with family via social networking websites and video telephony and accessing educational websites such as NHS Direct and online patient support groups and forums. 5. Ethical and psychological considerations The use of telecare raises the issue of gaining informed consent, particularly when monitoring patients with cognitive impairment. The user may not fully comprehend the principles of how the system operates, why it is needed and how it may affect them. Families and formal care agencies may be very keen for them to
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accept this service to provide reassurance regardless of the intrusion it may cause to an individual. Paradoxically, patients may feel more dependent following the installation of telecare equipment, as they are more inclined to call for assistance rather than cope with minor problems alone. They may find the devices to be stigmatising or embarrassing and remind them of their vulnerabilities. Users may find unattractive equipment makes their home look like a hospital or institution. Conversely, unobtrusive monitoring systems may be equivalent to covert surveillance and impact on privacy. Monitoring systems may provide data useful in future care planning decisions that are contrary to the user’s wishes. For example, evidence may be used by family members to coerce the user into accepting more monitoring, services or a move to an institution. Conversely, monitoring may prove that the user is more capable than previously thought and result in their support package being reduced or withdrawn. Families reassured by the telecare service may visit their relative less often, causing more social isolation. Therefore, monitoring may cause more harm than benefit to the user. ‘Wandering monitors’ can be employed to record time spent outside the home and provide objective proof of potentially risky behaviour such as nocturnal walking. These can use PIR sensors at entry points to infer when someone has left the property or provide direct verification of location using satellite global positioning equipment in a mobile phone or watch [7]. Whilst this equipment is intended to keep the user from getting lost, they are tracked (like a criminal), which may be seen as controlling by the user and limit personal freedom. Data may be misinterpreted, for example, walking outside at night may be intentional and purposeful, such as seeking human contact. Telecare packages should be tailored to meet an individual’s requirements by an occupational therapist. The user’s autonomy must be respected in managing hazards and risks in their home environment to promote independence, self-determination and ensure maximum usefulness. They should be offered alternative models of care, including more orthodox means of monitoring, such as frequent visits from carers and wardens. For example, falls detectors and nocturnal enuresis sensors may not be acceptable to some people and therefore become redundant after installation. Perhaps a trial of telecare should precede permanent installation of equipment to confirm its acceptability and usefulness. Safeguarding the confidentiality of patient data is important in its acceptability and the user must give permission for their monitoring data to be accessed by different people, including health and social care professionals and individual relatives. The user must be able to deactivate sensors and data transmission at any time, should they wish. Users may feel monitoring devices are intrusive and a form of spying. Monitoring devices should not contain camera equipment without the explicit consent of the user [11]. Patients’ needs change over time and appropriateness of the service should be reviewed, as should their satisfaction with it. 6. Telehealth Telehealth equipment is used as a tool in the management of long-term conditions in the community to proactively monitor patients and respond promptly to indicators of acute exacerbations. ‘Vital signs’ monitoring is believed to reduce hospital admissions and uses equipment in patients’ homes to identify trends and alert when preset parameters are breached [6]. Users are trained to operate a machine which measures physiological indices such as blood pressure, oxygen saturations, pulse, spirometry, temperature, ECG and blood glucose readings each day in their home. In addition, users can enter subjective information into a touch screen, such as their responses to relevant
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symptom questionnaires and their latest weight. Data collected from a telehealth machine are sent via a telephone line to an Internet portal which can be accessed by health care professionals (such as community matrons, GPs and hospital consultants). The data may not be available immediately for review and therefore does not function as an emergency monitor. However, alarms can be elicited when abnormalities are detected. For example, persistent tachycardia or hypoxia could trigger a telephone call or home visit from a community matron. Responses to alarms are protocol-driven and should be planned in advance in consultation with the patient. Earlier intervention might reduce pressure on acute services and allow patients to avoid hospital admission. Data collected can be used to provide a more accurate picture of disease status over a long period and may save time for clinicians, who can review the information before seeing the patient. Healthcare professionals can then spend more time discussing the patient’s concerns and proposed changes to their management. Potential savings in clinician time may enable greater access to specialist care. Telehealth can also be used in the shorter term as a diagnostic tool to gain objective evidence of paroxysmal pathology. Patients with a previously undiagnosed condition can have their vital signs recorded when symptomatic, which may be enlightening. Patients with COPD may undergo a noninvasive assessment for long term oxygen therapy in their own home using telehealth to provide an accurate picture of their requirements during everyday activities. Another application for telehealth is the support of patients discharged from hospital following an acute illness when they may require a limited period of monitoring in conjunction with intermediate care. Using telehealth may allow improved planning around end-of-life concerns, given that trends predicting terminal decline can be identified. The decision to stop monitoring and even remove the machine should be discussed in advance with the user. One goal of telehealth is to improve quality of life for patients by empowering them to ‘self-manage’ their condition. Users must be willing and able to participate in this service for it to be beneficial. They must accept training on using the equipment and subsequent ‘refresher’ courses to check their ability to avoid common pitfalls occurring. For example, incorrect positioning of a sphygmomanometer cuff produces inaccurate results and cold hands generate falsely low oxygen saturation readings. Some users rush downstairs to the machine every morning so as not to be ‘late’ for their measurements and in doing so have worse readings and symptoms than usual. Devices must be user-friendly and inclusive in design. For example, touch screen buttons should be large enough to be used by those with arthritic hands and voice prompts, as used in satellite navigation systems, should be available for people with visual impairment or illiteracy [10]. Multi-user devices can be used in institutions like care homes or prisons assuming there is no risk of infection. Practical issues such as regular calibration and maintenance of telehealth devices should be explained. For some patients telehealth can be a burden, which encourages them to focus on their illness. They may worry about damaging the equipment or become obsessive about their vital signs. This can create anxiety and exacerbate their problems creating an increase in intervention from healthcare workers. The introduction of technology to replace the ‘nurse’s touch’ may not be welcomed by patients. However, most studies of this area have shown good levels of user satisfaction and it may be reassuring for patients to know that although they feel symptomatic their vital signs are stable. Telehealth might reduce hospital admissions and save costs, but there is no good evidence to support this assumption at present. In a systematic literature review, Barlow et al. concluded
that less than 1% of the literature on this subject met their inclusion criteria and most studies focused on those with heart failure and diabetes [5]. A recent review by the Cochrane Collaboration concluded that there is little evidence of clinical benefit of telehealth and future research should focus on effectiveness, efficiency and appropriateness [12]. A large government-funded randomised controlled trial is currently under way in England to address this [13]. However, it may be difficult to evaluate a new model for service delivery with conventional methods. 7. Telemedicine: healing at a distance The WHO definition of telemedicine or e-health is, ‘the practice of medical care using interactive audiovisual and data communications. This includes the delivery of medical care, diagnosis, consultation and treatment, as well as health education and the transfer of medical data’ [14]. The first recorded use of telemedicine was by Wilhelm Einthoven, inventor of the ECG. He experimented with transmitting early ECG recordings by telephone in 1906 [15]. Since then, telemedicine has become routine practice in radiology and neurosurgery, as digital images are reviewed by specialists working at distant locations from the patient [16]. Specialties such as gynaecology and urology, which rely more on physical examination than imaging, may be less appropriate for telemedicine [17]. Emergency departments in small hospitals can use telemedicine as an adjunct to urgent specialist referral. For example, digital images can be sent using ‘store and forward’ technology to enhance communication detailing traumatic injuries and hasten the transfer of appropriate patients to tertiary plastic surgery centres. Chronic wound management is another established area of telemedicine, in which dermatologists can review a patient’s skin remotely and advise suitable treatment. It is feasible for GPs to run ‘outreach clinics’ in consultation with hospital specialists from their surgeries using video telephones. Patients may be ‘seen’ more quickly and GPs can gain knowledge and experience of conditions that they may not otherwise be competent to manage. However, there is no evidence that such consultations will reduce hospital follow-up appointments or be cost-saving [16]. Remote consultation can save patients’ time and reduce the cost and inconvenience of travelling to hospital, but can have drawbacks including a major impact on their relationship with the doctor. Some people may find it difficult to communicate freely in the presence of video equipment, especially if they have concerns about confidentiality. It is important that both patient and clinician are aware of who is present at ‘the other end’ of their conversation and whether the consultation is being recorded. Patients should feel able to interject when clinicians are discussing their details in a teleconsultation [18]. Users should be able to choose between a traditional appointment and a teleconsultation without detriment. Some clinicians may object to such new models of working, especially when evidence supporting their safety and efficacy is lacking. Professional resistance to change must be overcome if telemedicine is to reach its potential. Doctors will need training to use the technology and to interact with patients in this way. Furthermore, issues about liability will arise, particularly in joint consultations with primary and secondary or tertiary care. The practice of telemedicine needs to be regulated to protect patients, particularly when they access international services via the Internet. Doctors currently working in the EU can provide telemedicine services to patients from outside their own country without any special licence. Regulators of healthcare across the EU are not obliged to inform each other when they restrict an
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individual’s licence to practice, which may expose patients to unsafe and poor quality care [19]. 8. Conclusions The incorporation of new technologies into the fields of health and social care is already a worldwide phenomenon – despite a lack of evidence to support this practice. Studies thus far have focused on patient satisfaction and feasibility rather than efficacy and cost-effectiveness. Research supporting the usefulness of data collected by lifestyle monitoring systems is required to justify the associated intrusion, particularly in users with cognitive impairment. This group may have the most to gain from devices designed to improve safety in the home, which may enable them to live independently, but are at risk of losing their autonomy. Older people are likely to be disproportionately affected by technological change and geriatricians must be aware of the wide-ranging implications for their patients and practice. Conflict of interest statement We declare we have no conflict of interest. Acknowledgements We would like to gratefully acknowledge the input of Professor Graham Mulley, Department of Elderly Medicine, St. James’s University Hospital, Leeds and Professor Andrew Monk, Director of the Centre for Usable Home Technology, University of York for helpful comments made during the preparation of this article. Images used to illustrate the paper were kindly supplied by the manufacturer Tunstall.
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References [1] Bloom DE, Canning D. Global demographic change: Dimensions and economic significance 2005, http://www.globalhealth.harvard.edu/WorkingPapers.asp. [2] Dini E, Goldring, S. Estimating the changing population of the ‘oldest old’. Pop Trends 2008;132:8–16. [3] Martin S, Kelly G, Kernohan WG, McCreight B, Nugent C. Smart home technologies for health and social care support. The Cochrane Collaboration; 2009. [4] World Health Organisation. Glossary of terms for community health care and services for older persons, 2004. [5] Barlow J, Singh D, Bayer S, Curry R. A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions. J Telemed Telecare 2007;13:172–9. [6] Department of Health. Older people and disability division. building telecare in England. London, 2005. [7] Botsis T, Demiris G, Pedersen S, Hartvigsen G. Home telecare technologies for the elderly. J Telemed Telecare 2008;14:333–7. [8] Department of health delivering 21st century IT support for the NHS. National Strategic Programme. London, 2002. [9] Brownsell S, Blackburn S, Hawley MS. An evaluation of second and third generation telecare services in older people’s housing. J Telemed Telecare 2008;14:8–12. [10] Blythe MA, Monk AF, Doughty K. Socially dependable design: the challenge of ageing populations for HCI. Interacting Comput 2005;17:672–89. [11] Fisk MJ. Telecare equipment in the home. Issues of intrusiveness and control. J Telemed Telecare 1997;3:30–2. [12] Currell R, Urquhart C, Wainwright P, Lewis R. Telemedicine versus face-to-face patient care: effects on professional practice and health care outcomes. The Cochrane Collaboration; 2010. [13] http://www.wsdactionnetwork.org.uk/. [14] http://www.who.int/eht/eHealthHCD/en/. [15] Strehle EM, Shabde N. Arch Dis Child 2006;91:956–9. [16] Hailay D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare 2002;8:1–7. [17] Rinde E, Balteskard L. Is there a future for telemedicine? Lancet 2002;359: 1957–8. [18] Watts LA, Monk AF. What happens in remote consultation. Int J Technol Assess Health Care 1999;15:220–35. [19] Fitzgerald R. Medical regulation in the telemedicine era. Lancet 2008;372: 1795–6.
Technology applied to geriatric medicine
Telecare, telehealth and telemedicine S. Stowe a,*, S. Harding b a b
Department of Elderly Medicine, Beckett Wing, St. James’s University Hospital, Beckett Street, Leeds, LS9 7TF, UK Morley Health Centre, Corporation Street, Leeds, LS27 9NB, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 April 2010 Accepted 29 April 2010 Available online 8 June 2010
The incorporation of new technologies into the fields of health and social care is already a worldwide phenomenon – despite a lack of evidence to support this practice. Studies thus far have focused on patient satisfaction and feasibility rather than efficacy and cost-effectiveness. Research supporting the usefulness of data collected by lifestyle monitoring systems is required to justify the associated intrusion, particularly in users with cognitive impairment. This group may have the most to gain from devices designed to improve safety in the home, which may enable them to live independently, but are at risk of losing their autonomy. Older people are likely to be disproportionately affected by technological change and geriatricians must be aware of the wide-ranging implications for their patients and practice. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Assistive technology Telecare Telehealth Telemedicine Aged
1. Introduction The global population is predicted to expand with both a shrinking number of economically active and a larger proportion of older people [1]. The fastest increase will be in the ‘oldest old’ aged 85 years and over, with this group projected to quadruple to 5% of the UK population by 2033 [2]. There are wide ranging consequences of an ageing society in terms of health, social care and housing provision and technological solutions to this ‘problem’ are already in use. The number of people with long-term conditions will increase, as previously life-threatening events are better managed. There will be an increased focus on local services and equipment that are patient-centred in design in an attempt to meet demand. However, many physicians may be reluctant to accept change and may lack education in this emerging field and how it affects their patients. In this article, we describe new models of care, including the use of electronic devices in the homes of community-dwelling older adults. 2. Definitions One of the difficulties in this area of gerotechnology is the confusing use of ambiguous terms, which may be used to describe different services by different authors and equipment manufacturers. It is challenging for researchers and clinicians to seek evidence in the literature about their application to everyday practice without an international consensus on terminology [3]. The term ‘assistive technology’ was defined in 2004 by WHO as, * Corresponding author. E-mail address: [email protected] (S. Stowe).
‘an umbrella term for any device or system that allows individuals to perform tasks they would otherwise be unable to do or increases the ease and safety with which tasks can be performed’ [4]. Therefore, assistive technology includes equipment ranging from a simple grab rail to accessible transport and electronic falls detectors. We will be using the terms telecare, telehealth and telemedicine to describe three distinct examples of the use of information and communication technology (ICT) in geriatrics. 3. Telecare We use the definition of telecare used by Barlow et al., ‘the use of communications technology to provide health and social care directly to the user (patient). This excludes the exchange of information solely between professionals, generally for diagnosis or referral’ [5]. Telecare is therefore a tool used by professionals to deliver support to individuals and should be employed to provide a user-centred service that complements – rather than replaces – existing models of care. Most older people want to live in their own home and 35% of those living in care homes could potentially be supported at home with telecare [6]. Norway was the first country to implement an official fee schedule for telecare, making some services reimbursable by the National Health Service in 1996 [7]. In England, the Department of Health embraced telecare and spent £ 80 million on a preventative technology grant since 2006, with a target to provide this service nationally to those who will be eligible by the end of 2010 [8]. It has stated that, ‘telecare is as much about the philosophy of dignity and independence as it is about equipment and services’ and its potential benefits include:
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.04.002
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S. Stowe, S. Harding / European Geriatric Medicine 1 (2010) 193–197
a reduction in ‘unnecessary’ hospital admissions with cost savings; increased quality of life for telecare users by increasing independence and self-management with increased choice; a reduction in caregiver burden; a reduction in falls; a reduction in workforce pressures for health and social services; improved integration of health and social services, including primary and secondary care, voluntary and private care providers; increased access to community palliative care services for those wishing to die in their own home 4. Hierarchy of telecare As telecare services and products are designed with increasing capabilities, they can be described in the following categories: 4.1. First generation devices Fig. 2. Wireless carbon monoxide detector.
First generation devices are the simplest forms of telecare and include a user-triggered alarm button, which relies on the user wearing a portable device such as a pendant or reaching a pull cord in their home [9]. Once activated, the sensor wirelessly communicates a potential emergency to an intelligent receiver in the home (telephone) via radio transmitters. The telephone automatically contacts a call centre or user-designated first contact (Fig. 1). 4.2. Second generation telecare systems Second generation telecare systems utilise a broader range of sensors that detect specific hazards and do not require the user to trigger them. The call centre operative is immediately aware of the location and type of detector that has alarmed and works through a response protocol, which may include calling the user to exclude a false alarm, calling a relative or an appropriate responder, such as an ambulance or fire brigade. The alert is also communicated to the user within the home through an audible alarm, flashing lights and
even vibrating pillows to wake the user from sleep. These devices can also respond to an alert with appropriate remedial action and can be considered reactive rather than just preventative. For example, activating a flood detector may turn off the water supply and noisy appliances that make it difficult to hear alarms in addition to alerting call centre staff. There are many different hazard detectors in use, including smoke detectors, carbon monoxide and natural gas detectors and sensors that react to extremes of temperature (Fig. 2). Another example of such technology is a movement-triggered night light: a passive infrared (PIR) sensor reacts by switching on a light bulb. This cheap and widely available device can be attached to a bedside table or wall and uses technology from home security to reduce risk of nocturnal falls associated with poor lighting. PIR sensors can also be employed as memory aids at property exit points. For example, the sensor is activated as the user approaches their front door and plays a message (prerecorded by a relative) reminding them to take their key, remember their mobile phone or lock the door. In the event of a fall, personal alarms worn as a brooch, watch or pendant connect the user to a call centre and can be used to initiate an appropriate response following a ‘hands-free’ telephone conversation. However, such devices rely on the user being able to call for help. Specific falls detectors, which sense a sudden jolt in movement and change in attitude from vertical to horizontal and are worn as a belt are available [10]. These automatically trigger a call for help and may be useful when a fall is associated with a loss of consciousness or acute confusion and may otherwise predispose to a long lie. Bed and chair occupancy detectors respond to pressure changes and sense when the user is seated or lying down. (Fig. 3) These can be programmed with a timer according to individual user characteristics and respond to a change in usual behaviour, which may accompany an adverse event such as a nocturnal fall or sleep disorder [7]. Similar devices can be employed to respond to seizures and enuresis [10] (Fig. 4). 4.3. Third generation telecare systems
Fig. 1. Community alarm (watch): user must press button to call for assistance. Activated sensor wirelessly connects to telephone.
Third generation telecare systems have yet more complex capabilities and include the measurement, collection and analysis of data in the user’s home which constitutes ‘‘lifestyle monitoring’’. The data are sent to an internet portal that can be accessed by the user, their relatives, carers and professionals to ‘keep an eye’ on the
S. Stowe, S. Harding / European Geriatric Medicine 1 (2010) 193–197
Fig. 3. Chair occupancy sensor used for ‘lifestyle monitoring’.
Fig. 4. An epilepsy sensor.
user. Data are collected continuously, but may not be immediately available to view: some systems upload information during a set period each day. Sensors can be used as a surrogate marker of activities performed by the user and can provide reassurance of their well-being. They can be considered as preventative in that early detection of difficulties may mitigate harm. For example, sensors that monitor the use of kitchen appliances may provide evidence that someone has stopped cooking or replenishing the refrigerator. This could lead to a visit or telephone call to check all is well and increased support, if necessary, and may prevent longer-term malnutrition. Technology can also be a source of interaction with increased access to services for older people. The Internet can be used for grocery shopping, online voting in elections, contact with family via social networking websites and video telephony and accessing educational websites such as NHS Direct and online patient support groups and forums. 5. Ethical and psychological considerations The use of telecare raises the issue of gaining informed consent, particularly when monitoring patients with cognitive impairment. The user may not fully comprehend the principles of how the system operates, why it is needed and how it may affect them. Families and formal care agencies may be very keen for them to
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accept this service to provide reassurance regardless of the intrusion it may cause to an individual. Paradoxically, patients may feel more dependent following the installation of telecare equipment, as they are more inclined to call for assistance rather than cope with minor problems alone. They may find the devices to be stigmatising or embarrassing and remind them of their vulnerabilities. Users may find unattractive equipment makes their home look like a hospital or institution. Conversely, unobtrusive monitoring systems may be equivalent to covert surveillance and impact on privacy. Monitoring systems may provide data useful in future care planning decisions that are contrary to the user’s wishes. For example, evidence may be used by family members to coerce the user into accepting more monitoring, services or a move to an institution. Conversely, monitoring may prove that the user is more capable than previously thought and result in their support package being reduced or withdrawn. Families reassured by the telecare service may visit their relative less often, causing more social isolation. Therefore, monitoring may cause more harm than benefit to the user. ‘Wandering monitors’ can be employed to record time spent outside the home and provide objective proof of potentially risky behaviour such as nocturnal walking. These can use PIR sensors at entry points to infer when someone has left the property or provide direct verification of location using satellite global positioning equipment in a mobile phone or watch [7]. Whilst this equipment is intended to keep the user from getting lost, they are tracked (like a criminal), which may be seen as controlling by the user and limit personal freedom. Data may be misinterpreted, for example, walking outside at night may be intentional and purposeful, such as seeking human contact. Telecare packages should be tailored to meet an individual’s requirements by an occupational therapist. The user’s autonomy must be respected in managing hazards and risks in their home environment to promote independence, self-determination and ensure maximum usefulness. They should be offered alternative models of care, including more orthodox means of monitoring, such as frequent visits from carers and wardens. For example, falls detectors and nocturnal enuresis sensors may not be acceptable to some people and therefore become redundant after installation. Perhaps a trial of telecare should precede permanent installation of equipment to confirm its acceptability and usefulness. Safeguarding the confidentiality of patient data is important in its acceptability and the user must give permission for their monitoring data to be accessed by different people, including health and social care professionals and individual relatives. The user must be able to deactivate sensors and data transmission at any time, should they wish. Users may feel monitoring devices are intrusive and a form of spying. Monitoring devices should not contain camera equipment without the explicit consent of the user [11]. Patients’ needs change over time and appropriateness of the service should be reviewed, as should their satisfaction with it. 6. Telehealth Telehealth equipment is used as a tool in the management of long-term conditions in the community to proactively monitor patients and respond promptly to indicators of acute exacerbations. ‘Vital signs’ monitoring is believed to reduce hospital admissions and uses equipment in patients’ homes to identify trends and alert when preset parameters are breached [6]. Users are trained to operate a machine which measures physiological indices such as blood pressure, oxygen saturations, pulse, spirometry, temperature, ECG and blood glucose readings each day in their home. In addition, users can enter subjective information into a touch screen, such as their responses to relevant
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symptom questionnaires and their latest weight. Data collected from a telehealth machine are sent via a telephone line to an Internet portal which can be accessed by health care professionals (such as community matrons, GPs and hospital consultants). The data may not be available immediately for review and therefore does not function as an emergency monitor. However, alarms can be elicited when abnormalities are detected. For example, persistent tachycardia or hypoxia could trigger a telephone call or home visit from a community matron. Responses to alarms are protocol-driven and should be planned in advance in consultation with the patient. Earlier intervention might reduce pressure on acute services and allow patients to avoid hospital admission. Data collected can be used to provide a more accurate picture of disease status over a long period and may save time for clinicians, who can review the information before seeing the patient. Healthcare professionals can then spend more time discussing the patient’s concerns and proposed changes to their management. Potential savings in clinician time may enable greater access to specialist care. Telehealth can also be used in the shorter term as a diagnostic tool to gain objective evidence of paroxysmal pathology. Patients with a previously undiagnosed condition can have their vital signs recorded when symptomatic, which may be enlightening. Patients with COPD may undergo a noninvasive assessment for long term oxygen therapy in their own home using telehealth to provide an accurate picture of their requirements during everyday activities. Another application for telehealth is the support of patients discharged from hospital following an acute illness when they may require a limited period of monitoring in conjunction with intermediate care. Using telehealth may allow improved planning around end-of-life concerns, given that trends predicting terminal decline can be identified. The decision to stop monitoring and even remove the machine should be discussed in advance with the user. One goal of telehealth is to improve quality of life for patients by empowering them to ‘self-manage’ their condition. Users must be willing and able to participate in this service for it to be beneficial. They must accept training on using the equipment and subsequent ‘refresher’ courses to check their ability to avoid common pitfalls occurring. For example, incorrect positioning of a sphygmomanometer cuff produces inaccurate results and cold hands generate falsely low oxygen saturation readings. Some users rush downstairs to the machine every morning so as not to be ‘late’ for their measurements and in doing so have worse readings and symptoms than usual. Devices must be user-friendly and inclusive in design. For example, touch screen buttons should be large enough to be used by those with arthritic hands and voice prompts, as used in satellite navigation systems, should be available for people with visual impairment or illiteracy [10]. Multi-user devices can be used in institutions like care homes or prisons assuming there is no risk of infection. Practical issues such as regular calibration and maintenance of telehealth devices should be explained. For some patients telehealth can be a burden, which encourages them to focus on their illness. They may worry about damaging the equipment or become obsessive about their vital signs. This can create anxiety and exacerbate their problems creating an increase in intervention from healthcare workers. The introduction of technology to replace the ‘nurse’s touch’ may not be welcomed by patients. However, most studies of this area have shown good levels of user satisfaction and it may be reassuring for patients to know that although they feel symptomatic their vital signs are stable. Telehealth might reduce hospital admissions and save costs, but there is no good evidence to support this assumption at present. In a systematic literature review, Barlow et al. concluded
that less than 1% of the literature on this subject met their inclusion criteria and most studies focused on those with heart failure and diabetes [5]. A recent review by the Cochrane Collaboration concluded that there is little evidence of clinical benefit of telehealth and future research should focus on effectiveness, efficiency and appropriateness [12]. A large government-funded randomised controlled trial is currently under way in England to address this [13]. However, it may be difficult to evaluate a new model for service delivery with conventional methods. 7. Telemedicine: healing at a distance The WHO definition of telemedicine or e-health is, ‘the practice of medical care using interactive audiovisual and data communications. This includes the delivery of medical care, diagnosis, consultation and treatment, as well as health education and the transfer of medical data’ [14]. The first recorded use of telemedicine was by Wilhelm Einthoven, inventor of the ECG. He experimented with transmitting early ECG recordings by telephone in 1906 [15]. Since then, telemedicine has become routine practice in radiology and neurosurgery, as digital images are reviewed by specialists working at distant locations from the patient [16]. Specialties such as gynaecology and urology, which rely more on physical examination than imaging, may be less appropriate for telemedicine [17]. Emergency departments in small hospitals can use telemedicine as an adjunct to urgent specialist referral. For example, digital images can be sent using ‘store and forward’ technology to enhance communication detailing traumatic injuries and hasten the transfer of appropriate patients to tertiary plastic surgery centres. Chronic wound management is another established area of telemedicine, in which dermatologists can review a patient’s skin remotely and advise suitable treatment. It is feasible for GPs to run ‘outreach clinics’ in consultation with hospital specialists from their surgeries using video telephones. Patients may be ‘seen’ more quickly and GPs can gain knowledge and experience of conditions that they may not otherwise be competent to manage. However, there is no evidence that such consultations will reduce hospital follow-up appointments or be cost-saving [16]. Remote consultation can save patients’ time and reduce the cost and inconvenience of travelling to hospital, but can have drawbacks including a major impact on their relationship with the doctor. Some people may find it difficult to communicate freely in the presence of video equipment, especially if they have concerns about confidentiality. It is important that both patient and clinician are aware of who is present at ‘the other end’ of their conversation and whether the consultation is being recorded. Patients should feel able to interject when clinicians are discussing their details in a teleconsultation [18]. Users should be able to choose between a traditional appointment and a teleconsultation without detriment. Some clinicians may object to such new models of working, especially when evidence supporting their safety and efficacy is lacking. Professional resistance to change must be overcome if telemedicine is to reach its potential. Doctors will need training to use the technology and to interact with patients in this way. Furthermore, issues about liability will arise, particularly in joint consultations with primary and secondary or tertiary care. The practice of telemedicine needs to be regulated to protect patients, particularly when they access international services via the Internet. Doctors currently working in the EU can provide telemedicine services to patients from outside their own country without any special licence. Regulators of healthcare across the EU are not obliged to inform each other when they restrict an
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individual’s licence to practice, which may expose patients to unsafe and poor quality care [19]. 8. Conclusions The incorporation of new technologies into the fields of health and social care is already a worldwide phenomenon – despite a lack of evidence to support this practice. Studies thus far have focused on patient satisfaction and feasibility rather than efficacy and cost-effectiveness. Research supporting the usefulness of data collected by lifestyle monitoring systems is required to justify the associated intrusion, particularly in users with cognitive impairment. This group may have the most to gain from devices designed to improve safety in the home, which may enable them to live independently, but are at risk of losing their autonomy. Older people are likely to be disproportionately affected by technological change and geriatricians must be aware of the wide-ranging implications for their patients and practice. Conflict of interest statement We declare we have no conflict of interest. Acknowledgements We would like to gratefully acknowledge the input of Professor Graham Mulley, Department of Elderly Medicine, St. James’s University Hospital, Leeds and Professor Andrew Monk, Director of the Centre for Usable Home Technology, University of York for helpful comments made during the preparation of this article. Images used to illustrate the paper were kindly supplied by the manufacturer Tunstall.
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