The role of remote technologies in healthcare
Health services are under an unprecedented level of pressure, facing backlogs of appointments from the COVID-19 pandemic, rising burdens of chronic diseases, and ageing populations. With limited opportunities to scale up existing services, one solution may be to embrace technologies that could allow healthcare to be provided outside clinics, and which empower individuals to have a larger role in managing their health. We explore the potential of remote technologies, and the issues that still need to be overcome for these to truly have an impact on healthcare.
The virtual doctor will see you now
When face-to-face clinics were suspended during the coronavirus pandemic, the capacity for conducting video consultations was rapidly scaled up across many health services. But now that COVID-19 restrictions have been stepped down, it’s currently unclear whether increased use of video consultations will be a long-term change. In practical terms, video consultations can be more suitable for some groups of patients, particularly for those with mobility issues or from rural areas who may struggle to travel to in-person appointments. They can also enable GPs to assess emergency patients out of hours, to determine if they need to be immediately transferred to hospital.
There is evidence that video consulting, or ‘interactive telemedicine’, can be just as safe and effective in treating chronic health conditions as face-to-face or telephone appointments. In a systematic review carried out by the Cochrane Collaboration, Sasha Shepperd, Professor of Health Services Research at Oxford Population Health, and colleagues assessed data from over 90 clinical trials which compared interactive telemedicine (remote monitoring or real‐time video‐consulting) against face-to-face or telephone appointments for a range of different conditions. ‘Our results found evidence that monitoring via telemedicine improved blood pressure control in people with hypertension, and improved glucose control for people with diabetes’ she said. ‘But while telemedicine has the potential to deliver more frequent and timely healthcare to people with chronic health conditions at a distance, few studies so far have directly assessed the impact of telemedicine on improving access to health services.’
When it comes to mental health, face-to-face appointments may be more appropriate, since the lack of non-verbal cues in remote appointments can make it more challenging for clinicians to identify changes in a patient’s condition. There are also concerns that consulting remotely may make it harder for clinicians and patients to develop and maintain trusting relationships. In addition, the introduction of remote-only or remote-by-default services may lead to widening inequalities and digital exclusion. Video consulting technologies typically rely on high-speed internet connections, yet these may not be available for isolated rural areas and low-income families. Other groups who could be disadvantaged by video consulting include people less comfortable with information technologies (particularly older adults), those with a hearing impairment, and those with limited English.
Ultimately, instead of reducing costs and overheads for healthcare providers, offering video appointments could actually increase burdens on staff, through having to ensure patients understand the technology, troubleshoot issues as they arise, and offer subsequent face-to-face appointments where necessary. Another key consideration is that, when it is not essential to visually see the patient, many of the benefits of video consultations are equally applicable to telephone appointments.
It is notable that despite the increased capacity for video consultations in the UK, take-up remains low. In England, for instance, video and e-consultations combined accounted for fewer than 0.5% of general practice consultations in December 2021, whilst telephone appointments made up 35%.
Trish Greenhalgh, a Professor in Oxford University’s Nuffield Department of Primary Care Health Sciences, recently led a qualitative study to investigate why this is the case, which interviewed both patients and clinical staff.
Our study identified that, in most cases, video consultations offered no relative advantage. Problems could generally be sorted adequately and safely by telephone and an in-person assessment was considered necessary for the remainder. Staff also had variable skills, confidence, and experience in video consulting, and both staff and patients felt that the clinical relationship was more easily initiated and maintained face-to-face.Professor Trish Greenhalgh, Nuffield Department of Primary Health Care Sciences
There’s an app for that
Digital solutions also enable patients to take a greater role in their health outside their doctor’s appointments. In particular, the number of healthcare-related apps developed for smartphones has exploded over recent years: in 2021, both the Apple and Google Play app stores hosted more than 170,000 health-related applications. These have the potential to complement existing care pathways to empower people to manage long-term conditions more effectively. The NHS Long Term Plan aims to develop a range of apps to support particular conditions that work seamlessly with other services and are integrated into patient pathways. These apps could fulfil a variety of different functions, including recording measurements, prompting medication, and offering access to specialist information. More sophisticated digital programmes include MIRA, a digital platform that uses motion tracking sensors to turn physiotherapy exercises for injury rehabilitation into video games, and WaitLess, an app which combines waiting times at urgent care centres with up-to-the-minute travel information to help patients decide where to go for faster treatment for minor injuries.
One condition that could benefit from digital technologies is diabetes, which already accounts for 10% of the NHS budget and could affect one in ten UK adults by 2030. According to a study led by the Health Services Research Unit at Oxford Population Health, web-based and mobile technologies could help improve the wellbeing of individuals with diabetes, and prevent diabetes-related health complications from arising. One of the lead authors Dr David Morley said: ‘Our studies found that web-based and mobile technologies enabled users to get an in-depth sense of how their body reacted to both lifestyle and medication factors, encouraging problem-solving through making changes to their diet and/or activity levels after identifying reasons for blood sugar highs and lows.’
Digital technologies could also increase access to support for mental health conditions. But of the many mental health and wellbeing-related apps and online programmes already available, few have been rigorously evaluated in clinical trials, making it almost impossible to know whether or not they are effective. Oxford Population Health is helping to address this, including through its involvement with the Minimising Young Children’s Anxiety through Schools (MY-CATS) study. This is using a randomised controlled trial to test whether a parent-led online intervention programme can help prevent high-risk children from developing an anxiety disorder.
Associate Professor Mara Violato from the Health Economics Research Centre at Oxford Population Health, who is leading the cost-effectiveness analysis of MY-CATS, said: ‘Online delivery has the potential to improve the reach of mental health interventions, but without evaluating these systematically, we cannot be sure if they effectively help people, or if they are cost-effective for the health services and the wider society. But if our results are favourable, this model could be expanded to other common mental health conditions in children and to other international settings.’
Health in our hands – apps to power lifestyle change
Besides helping us to manage chronic diseases, health-related apps and digital technologies could bring much wider benefits by supporting all of us to live healthier lifestyles. Whether your goal is to stop smoking, cut down on alcohol or be more active, you’ll almost certainly find an app to help you achieve it. Diet-related apps have proved particularly popular, which may reflect the widespread confusion studies have found among consumers over how to eat healthily. Oxford Population Health has contributed important evidence about the health and environmental benefits of plant-based diets and is involved in the Livestock Environment and People (LEAP) project.
In 2021, the LEAP team launched an online programme called OPTIMISE (Online Programme to Tackle Individuals’ Meat Intake through SElf-regulation) to help people self-monitor their meat consumption, learn about the health and environmental impacts of their meat intake, and set personal meat reduction goals. A controlled trial found that OPTIMISE users more than halved their meat consumption after two months, from a daily intake of 221g to 107g (a 52% reduction). Since then, a real-world test of the programme with a larger cohort found similar results, suggesting that online tools can be effective in supporting motivated individuals to make dietary changes.
The rise of wearable technologies
Digital technologies extend beyond our smartphones and computers, and include the plethora of wearable devices now available to capture health-related data. An estimated 169 million wearable devices were sold worldwide in 2020 and global spending on wearable devices was expected to see 18.1% growth in 2021. These could offer a powerful resource for health research.
Technological advances have resulted in ever-improving wearable devices that can continuously and non-invasively measure various aspects of health, such as physical activity, heart rhythms, and sleep. These offer a much more comprehensive method of understanding health-related traits than traditional means, such as self-reported data sources or snapshot, short-term measurements in the clinic.
Associate Professor Aiden Doherty, Oxford Population Health
Professor Doherty led a recent study involving participants in the UK Biobank, who used wrist-worn accelerometers to record their activity levels. The research team trained a machine-learning algorithm to automatically classify the data from the trackers as being either sleep, sedentary behaviour, light physical activity behaviours, or moderate-to-vigorous physical activity. The algorithm was then applied to activity data recorded from 87,000 UK Biobank participants who were tracked for a median of 7 years for the incidence of heart disease. ‘The results clearly showed that reallocating time from any behaviour to moderate-to-vigorous physical activity behaviours, or reallocating time from sedentary behaviour to any other behaviour, was associated with a significantly lower risk of heart disease’ said Professor Doherty. ‘For an average person, reallocating just 20 more minutes from a typical day to moderate-to-vigorous physical activity behaviours was associated with a 9% lower risk, while reallocating 1 hour per day to sedentary behaviour was associated with a 5% higher risk.’
Growing older gracefully – can remote technologies help us ‘age in place’?
As the global population ages, there is growing interest in whether remote technologies could help older adults to remain independent for longer, rather than be forced to move into institutionalised care. Besides reducing burdens on healthcare systems, enabling people to ‘age in place’ carries various benefits, including greater social connectedness and slower declines in physical and cognitive functionality. Currently, such tools include personal alarms to summon help in an emergency, mobility aids, medication dispensers, and voice-activated telephones. In the near future, we could even see the introduction of humanoid ‘companion robot carers’.
In addition, Big Data approaches are being applied to develop ‘smart homes’, equipped with sensors that non-invasively record information that can include a person’s location, heating and lighting levels, medication use, and food/fluid intake. Using built-in algorithms, these sensors can be trained to spot deviations from a person’s usual activity patterns: for instance more frequent visits to the bathroom could indicate a urinary tract infection, whilst increased difficulty with standing up could suggest a person is at greater risk from falling.
It is important, however, that new technologies do not become additional responsibilities for carers to manage. Oxford Population Health has investigated this by conducting in-depth surveys and interviews of carers for people with dementia. Professor Crispin Jenkinson, co-investigator for the study, said: ‘Most of the carers we surveyed expressed positive experiences in using assistive technologies, such as remote monitoring, safety alarms, talking clocks, and electronic medication dispensers. These provided reassurance to carers, while increasing safety and autonomy of the person with dementia. Furthermore, assistive technology allowed carers to redeploy time to more meaningful activities and interactions with the person with dementia.’
Bringing the hospital home
Even when equipped with all the best technology available, accidents and sudden illnesses can still happen. Currently, many older adults in this situation are sent to hospital which can present the risk of developing an infection and/or delirium, disrupt existing routines, reduce capacity, and accelerate the transition to living in a care home. This also puts pressure on hospital resources, yet a large proportion of these cases do not require highly specialised treatment (such as surgery) and could potentially be managed in the community. These include falls, urinary tract infections, dehydration, and exacerbation of chronic conditions, such as diabetes and chronic obstructive pulmonary disease.
In these situations, an alternative is the ‘Hospital at Home’ model, where hospital-standard care is provided to patients in their homes. As in a hospital ward, patients have access to a multi-disciplinary team that includes nurses, paramedics and occupational therapists, besides medicines, oxygen and intravenous treatments. Hospital at Home models are already operating in a few areas of the UK, both to shorten in-patient hospital stays, and to prevent admission to hospital in the first place. The model is not designed for acute or serious conditions (such as a heart attack), and patients can still be transferred to hospital if necessary.
Besides optimising healthcare resources, the Hospital at Home model aligns with the general preference among older adults to receive hospital-level care in their home, as long as the outcomes for them are similar. To find out whether this is the case, Professor Sasha Shepperd led a clinical trial involving over 1000 older adults who had been referred for hospital admission, for non-critical reasons. After consenting to take part, the participants were randomly allocated to either Hospital at Home or hospital admission.
‘After six months, there was very little difference between the two groups in the proportion of participants who had died, new cognitive impairment, the impact on daily living activities, or new chronic conditions’ she said. ‘Furthermore, Hospital at Home care was associated with slightly fewer patients moving into residential care after treatment, a reduced risk of developing acute confusion, and greater satisfaction with care. This provides strong evidence that caring for older people at home can be as good, or better, than hospital care.’ A follow-up economic assessment found that Hospital at Home was also less costly than hospital admission, with an average cost reduction of £2,265 per patient (reduced from an average hospital cost per patient of £17,390 to £15,124 for Hospital at Home).
A question of trust
However, since remote technologies within healthcare depend on collecting, storing, and transferring individual data, a key challenge facing its wider adoption is gaining confidence and acceptance from the public. According to Angeliki Kerasidou, Associate Professor in Bioethics at Oxford Population Health’s Ethox Centre, the increasing number of partnerships between healthcare services and private, profit-driven companies that supply digital technologies could potentially undermine public trust.
In the UK, the public’s concern with and apprehension regarding the sharing of their health data with bodies outside the NHS, and particularly with commercial entities, is well documented. What is needed are clear guidelines to assist health services to set governance arrangements that place the common good at the core of the partnership.’Associate Professor Angeliki Kerasidou, Oxford Population Health
This trust will also be essential if data collected by remote technologies is to benefit health research. As Professor Doherty said: ‘The vast volume of valuable information from wearables on the health of UK citizens is currently inaccessible for research of relevance to clinical practice and public health policy. If large numbers of users of wearable devices and health-related apps shared their data, and this was linked to their records in healthcare databases, such a linked dataset could transform our understanding of the causes and consequences of diseases.’ However, many challenges need to be overcome first to realise this vision, including establishing trust and transparency, developing consent procedures, harmonising data across devices, linking to relevant databases, and establishing how and where data should be stored, besides who should have access.
In addition to ethical concerns, there are also practical issues that can affect uptake of remote technologies. In his surveys of carers of people with dementia, Professor Jenkinson found that a common concern was the cost implication of testing new assistive technology devices, especially as dementia progressed. ‘Potentially, a centrally-funded repository of assistive technology devices that carers could borrow, trial and return when they are no longer useful for a person with dementia may help overcome some of the concerns of carers and reduce waste of resources’ he said.
In any case, as Professor Greenhalgh says, the usefulness of remote technologies is heavily dependent on each patient’s individual circumstances. ‘Even when the underpinning infrastructure is established, the question of whether digital technologies are appropriate for an individual patient requires a case-by-case assessment. This should take into account the specific health issue being addressed, the patient’s general health and comorbidities, their digital literacy and home set-up, the strength of the clinical relationship, and, where relevant, the capabilities of healthcare staff.’