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29 December 2011

From hospital care to home care – the promise of Connected Health

Filed under: challenge, Connected Health, converged medicine, healthcare, mHealth, usability — David Wood @ 12:01 pm
  • At least one in four hospital patients would be better off being treated by NHS staff at home

That claim is reported on today’s BBC news website.  The article addresses an issue that is important from several viewpoints: social, financial, and personal:

NHS Confederation: Hospital-based care ‘must change’

The NHS in England must end the “hospital-or-bust” attitude to medical care, says the body representing health service trusts.

At least one in four patients would be better off being treated by NHS staff at home, figures suggest.

2012 will be a key year for the NHS as it tries to make £20bn in efficiency savings by 2015, according to the head of the NHS Confederation, Mike Farrar.

Ministers say modernising the NHS will safeguard its future.

Mr Farrar said: “Hospitals play a vital role but we do rely on them for some services which could be provided elsewhere.

“We should be concentrating on reducing hospital stays where this is right for patients, shifting resources into community services, raising standards of general practice, and promoting early intervention and self-care.

“There is a value-for-money argument for doing this, but it is not just about money and the public need to be told that – this is about building an NHS for the future.”

Mr Farrar said the required changes included treating frail people in their homes, and minimising hospital stays wherever possible.

Politicians and NHS leaders must show the public how these changes could improve care, rather than focusing on fears over the closure of hospital services, he added.

“Many of our hospitals know that the patients that they are treating in their beds on any given day could be treated better – with better outcomes for them and their families – if they were treated outside of hospitals in community or primary care,” he told BBC Radio 4’s Today programme.

Mr Farrar told Today that people had become used to “the hospital being a place of default” and that primary and community healthcare services had sometimes been under-funded.

But he said even where clinicians knew that better care could be provided outside of hospitals, and politicians accepted this privately, the public debate had not helped individuals understand that…

Some of the replies posted online are sceptical:

As a medical doctor based in hospitals, I believe this will not work logistically. Patients are sent to hospitals as they don’t get the specialist care in the community as the skills/services are inadequate/not in place. Patient attitudes must change as many come to a+e against GP advice as they don’t have confidence in community care…

As long as the selfish British public can’t be bothered looking after their own relatives and see hospitals as convenient granny-dumping centres, there is absolutely no way this would work.

There can not be a perfect solution. Not every family can care for a sick person full time, often due to them working. Hospital care may not be a perfect, yet in some cases it does free relatives to be able to work.  Outsourcing care too has a major downside, my wife has done that for years. 15 mins twice a day, can hardly be called acceptable if you apply some form of dignity to the patient.

I saw too many patients I nursed(often elderly or with pre-existing health conditions) kept in hospital too long because no one to care for them at home/wider community. This wasn’t great for them but also blocked an acute bed for someone else. In recent years the pendulum’s swung too far the other way: too many patients discharged without adequate support…

In summary: care in the community would be better in many, many cases, but it’s demanding and challenging:

  • There are social challenges: relatives struggle to put their own lives and careers on hold, to act as caregivers.
  • There are financial challenges: funding for medicine is often preferentially directed to large, centralised hospitals.
  • There are skills challenges: observation of complicated chronic health conditions is more easily carried out in the proximity of specialists.

However, the movement “from hospital care to home care” continues to gather steam – for good reason.  This was a major theme of the mHealth Summit I attended earlier this month in Washington DC.  I was particularly struck by a vision articulated by Rick Cnossen, director of worldwide health information technology at Intel:

In the next 10 years 50% of health care could be provided through the “brickless clinic,” be it the home, community, workplace or even car

As reported in the summary article by Kate Ackerman, “mHealth: Closing the Gap Between Promise and Adoption“:

Cnossen said the technology — such as mobile tools, telehealth, personal health records and social networking — already exists to make this possible. He said, “We have the technology. … It’s time to move out on it.”

Fellow speaker Hamadoun Toure, secretary general of the International Telecommunication Union took up the same theme:

Mobile phones will increase personal access to health information, mHealth and broadband technology will improve data collection and disease surveillance, patient monitoring will improve and become more prevalent, and remote consulting and diagnosis will be enhanced, thanks to low-cost devices.

“In the near future, more people will access the Internet through mobile devices than through fixed devices,” Toure said. “We are witnessing the fastest change in human history, and I believe (we have) a great opportunity for social development.”

Connected health technology enables better remote monitoring of personal medical data, earlier warnings of potential relapses, remote diagnostics, quicker access to technical information, better compliance with prescription regimes, and much, much more.

But Kate Ackerman raises the question,

So if the technology already exists and leaders from both the public and private sectors see the need, why has progress in mobile health been slow?

It’s an important question.  Intel’s Rick Cnossen gives his answer, as follows:

“The challenge is not a technology problem, it’s a business and a workflow problem.”

Cnossen said, “At the end of the day, mHealth is not about smartphones, gadgets or even apps. It’s about holistically driving transformation,” adding, “mHealth is about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviors…”

He said health care clinicians can be resistant to change, adding, “We need to introduce technology into the way to do their business, not the other way around.”

Cnossen also said that payment reform is essential for “mHealth to survive and thrive.” He said, “We should not be fighting for reimbursement codes for each health device and app. That is ultimately a losing proposition. Instead, we must fight for payment reform to pay for value over volume, regardless of whether the care was provided in a bricks and mortar facility or was it at the home or virtually through electronic means.”

Personally, I would put the emphasis differently:

The challenge is not just a technology problem, it’s also a business and a workflow problem

Moreover, as the technology keeps on improving, it can often diminish the arguments that are raised against its adoption.  Improvements in quality, reliability, miniaturisation, and performance all make a difference.  Improvements in usability may make the biggest difference of all, as people find the experience in using the new technology to be increasingly reassuring.

I’ll finish by noting an excerpt from the keynote at the same conference by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services:

This is an incredible time to be having this conversation. When we talk about mobile health, we are talking about taking the biggest technology breakthrough of our time and using it to take on one of the greatest … challenges of our time. And while we have a way to go, we can already imagine a remarkable future in which control over your health is always within hand’s reach…

This future is not here yet, but it is within sight. And I look forward to working with you to achieve it.

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