Telehealth in the home: NBN remains the gold standard

Preliminary results from several telehealth trials funded under the $20 million NBN-Enabled Telehealth Pilots Program have shown many positives for monitoring older patients living at home, with project leaders agreeing that the quality and reliability of the National Broadband Network (NBN) was clearly superior to other broadband delivery services.

The NBN-Enabled Telehealth Pilots Program was announced by the Labor government in 2012, with the successful bidders beginning the trials in 2013. It was subsequently renamed the Telehealth Pilots Programme by the Coalition government and opened up to any broadband service, including ADSL/ADSL2+ and 3G/4G wireless.

Early results in three of the pilot projects – Flinders University's telehealth in the home for rehab, aged and palliative care; the CSIRO's home monitoring of chronic disease for aged care; and Integrated Living's enhanced aged care for indigenous Australians – were presented at the Information Technology in Aged Care (ITAC) conference in Hobart last week.

RDNS also presented at the conference on results from its Victorian government-funded Broadband Enabled Innovation Project (BEIP). Its federally funded project under the NBN program, called the Integrated Home Telehealth project, is still in its implementation stage.

Project leaders agreed that the NBN was the gold standard, not necessarily just for its speed but for its reliability, with the Flinders University project - which did have some NBN-connected clients but predominantly used 3G and other low-cost technologies - experiencing some traffic snarls when the 3G spectrum was busy.

However, all agreed that while the technology was important, the challenges of telehealth remain the development of sustainable funding models and clinical change management.

Branko Celler, principal scientist at CSIRO Computational Informatics and a pioneer of telehealth provision in Australia, discussed some early findings of one of the two CSIRO projects funded under the program. The home monitoring of chronic disease for aged care project is a multi-site, multi-state project that also involves several Medicare Locals, telehealth device supplier TeleMedCare, internet service provider iiNet and tablet manufacturer Samsung.

Older people living at home were provided with a free internet connection and a TeleMedCare device, which allows for video conferencing and vital signs monitoring through peripherals including blood pressure monitors, pulse oximeters and ECGs.

Professor Celler said patient selection for the trial was based on a minimal model. “We selected any patient who had been hospitalised twice in the previous year. If they had been hospitalised once in each of the last four years, they were also eligible.

“This trial is different from the others in a number of different ways. It is multi-state and multi-site, all clinical conditions were accepted, and all patients initially had to be connected by NBN, although that didn’t happen ultimately.”

In addition to improved health outcomes, the project team is also looking at the effect of telehealth home monitoring on existing clinical models of care and the clinical workforce, as well as how to develop sustainable models.

“The benefit of doing that in a multi-state, multi-site project is that it should be relevant to almost all parts of Australia,” Professor Celler said. “We hope to ultimately contribute to government policy by providing high-quality data and a comprehensive economic benefits analysis and to really look at what are the long-term models that will work.

“We are also trying to add value to telehealth with what we are doing. We are trying to develop new risk classifications and algorithms that will be able to use the vital signs data to see whether a patient is sick or stable.”

The project includes a large amount of data capture, including comprehensive questionnaires completed by the patients, access to hospital, PBS and MBS data on each patient and some private health insurance data as well. This has made the project a complex one and did throw up some barriers, including the tedium of obtaining ethical clearance from six different health services.

Professor Celler said the patients had an average age of around 70, most with primary diagnoses of COPD, coronary heart disease, diabetes and chronic heart failure. Some of the patients fit into more than one category, he said.

“[By monitoring the] vital signs, we definitely know when things are changing. What’s really striking about this work is that the vital signs predict when the patient is getting worse by a significant number of days.

“We can do predictive analysis, which is a very important issue in telehealth, because if you have 100,000 patients monitored … you can see where you can provide enhanced services to them to avoid hospitalisation. The measurements are displayed visually, which makes it easier for clinicians to analyse than just figures.”

CSIRO has captured the patient experience in a Youtube video, with the project showing that they are very comfortable using the technology involved.

“For those using it for six months, the results were very positive, with 92.3 per cent satisfaction about using the TeleMedCare device,” he said. “They were very confident in using it.”

Although 20 per cent of the patients withdrew from the trial, this was predominantly due to social and family issues rather than any difficulty in daily monitoring, he said.

However, GP involvement was one of the unexpected barriers. “GPs needed to approve their patients’ participation, and we had to struggle and plea to get them to sign the consent forms. They were very slow in responding to requests for approval to include their patients in the trial. If they didn’t, we couldn’t enrol the patients. That was a major problem.

“Almost one in two GPs declined to take part. We are not sure why because in previous projects we had high numbers. The main reasons were lack of motivation, lack of commitment, too much effort."

GP preference for receiving regular data on patient progress was also very interesting, he said. Some were none too keen on taking part even though they gave consent. “We had 18 per cent of GPs who didn’t want to know about the project or to access reports. They didn’t want to know about the data."

On the other hand, some were interested in receiving reports, but it was the method they requested that proved amusing for a technology trial. "Eighteen per cent wanted to have online access [to their patient's reports], 27 per cent wanted it emailed and 36 per cent wanted it in hard copy by post.”

In terms of cost, the results seem to show the service is economically viable. “We did some costings and came up with a figure for the full Monty - top of the line telehealth management - which comes out to about $12 a day,” he said. “There were low-cost tablet solutions available … so you could get it down to about $2 or $3 a day. There is a huge opportunity for telehealth here that we can capture.”

On the NBN, he said it was substantially better than alternatives. “Connections through ADSL and WiFi imposed an additional workload and I can reinforce the view that the NBN is gold. Things work, the quality of the service was maintained, the quality of the video conferencing is unmatched.”

Telehealth for older indigenous people

Indra Arunachalam, strategic projects manager at home and community care provider Integrated Living, said it was the NBN, not 3G, that made a real difference in telehealth delivery. “It is the gold standard and everyone wants it,” she said.

The Integrated Living project involved providing home monitoring to older indigenous people living in Armidale and Coffs Harbour in regional NSW, Toowoomba in southern Queensland and the suburb of Goodna, which lies between Brisbane and Ipswich.

Using Tunstall equipment, participants monitored their own vital signs, including temperature, blood pressure, weight, pulse, oxygen levels, blood glucose levels and peak flow rate, with the data then transmitted to a central location for nurse-led triage management.

Ms Arunachalam said the nurses were able to quickly respond to out-of-range readings either by phone call or video conference. Data was also available to the participants themselves and to their GPs, who were also able to intervene earlier.

She gave two examples of positive benefits: one a 57-year-old who was quickly diagnosed with a chest infection and prescribed antibiotics rather than having to present at hospital, and another involving a 63-year-old woman who was able to avert an emergency because she was self-monitoring and knew what triggers to look out for.

Participants were confident in the tablet and monitoring equipment as it was easy to use, and Ms Arunachalam said it proved to be very suitable for older Aboriginal people's auditory and visual learning preferences.

However, compliance with the monitoring was different by site, she said. A monitoring plan was developed for all participants, but in two sites the plan was created by a nurse rather than a GP. The trial showed that GP-developed monitoring plans had significantly greater compliance rates than RNs' plans.

Overall, the project demonstrated the ability of broadband-enabled telehealth to improve healthcare services, she said. “It enabled flexible and responsive home monitoring by RNs. It facilitated more accurate and timely diagnosis by GPs and improved access to vital signs data and trends.

“It reduced the need for GP and RN home visits and patients were happy that they didn’t have to waste a lot of time travelling or waiting in a GP’s waiting room. Telehealth costs half as much as face-to-face consults with GPs for regular monitoring.”

Nurse triaging was effective, she said, and in every telehealth site, the nurses have spoken very highly of the technology.

“It also allowed relationships to develop between older Aboriginal people and the RNs and GPs involved. Patients reported positive feelings in knowing that they were being cared for regularly.”

Consumer devices for home care

Flinders University took a slightly different tack with its project, plumping for low-cost equipment rather than the top of the range technology used by the CSIRO and Integrated Living. It is using a mixture of iPads, 3G internet and apps like Fitbit to provide home telehealth for rehab, aged care and palliative care in the home.

For rehab patients, apps have been developed to encourage correct exercises and for a falls diary, along with video conferencing capabilities and self-assessment apps. The project also included speech pathology through Vidyo and an electronic whiteboard, all on an iPad over 3G.

Flinders University's Kate Swetenham said the design of the palliative care project developed largely from the patients involved. They were provided with an iPad loaded with a self-assessment app, along with a case conference capability from Vidyo to enable three-way video conferences with palliative care nurses, GPs and specialists.

For palliative care patients, being able to see their progress mapped was “incredibly confronting”, she said, but they found that the ability to see their GP talk to specialists and the palliative care nurse “incredibly satisfying”.

They also appreciated the ability to stay at home and not have to travel to appointments, she said. “For palliative patients, travel to appointments is a nightmare; travel can be agony."

There were some challenges, including training participants in using three-way video conferencing, and part way through the trial the Heartbleed vulnerability was discovered, necessitating the reconfiguration of all of the iPads.

Traffic over 3G was also a problem at times, Ms Swetenham said. However, one of the main elements being studied in this trial was sustainability and economic viability, and according to Flinders' project leader Alan Taylor, low-cost, sustainable telehealth provision is achievable for certain patients using over the counter technology.

Integrated home care

Mat Tyler, project manager for telehealth and eHealth at RDNS, was not able to provide results of his organisation's trial as it is still in its implementation stage, but said it involves using Samsung devices supported by Tunstall, along with Precedence Health Care's cdmNet chronic disease management solution.

This trial involves a range of partners and plans to use telehealth to provide integrated GP and nursing care to patients in Victoria, Tasmania and NSW.

He was able to show a video of a patient named James, an American-born 81-year-old living alone in Kingston, Tasmania, who very happily uses a tablet and cdmNet to monitor his wellness in association with an RDNS nurse and his GP.

The widower said he was very comfortable using the technology and was most impressed with its ability to allow him to stay in his home and retain his independence.

Mr Tyler said the results of RNDS's BEIP project backed this up. “We did a survey before the BEIP project, which showed that 34.2 per cent of people were confident using technology,” he said. “After the BEIP project, that was up to 80 per cent.

“It showed our fleet costs were reduced, as was nurse travel time, and it identified the support model required to effectively deploy telehealth solutions as business as usual.”

Posted in Aged Care

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