Barriers to Home Telecare
As the population ages, care for chronic conditions is becoming a larger focus of the healthcare system. Already, chronic conditions require 75% of the available healthcare resources (Hoffman, Rice, & Sung, 1996; Wolff, Starfield, & Anderson, 2002), with that number expected to increase as the baby boomer generation moves through their golden years and research provides ways to extend life despite significant medical complications. At the same time, the system is facing a shortage of healthcare personnel such as nurses (Clarke & Cheung, 2008), which is likely to exacerbate the problem of providing affordable, quality care. The combination of an increased focus on chronic care, personnel shortage and the development of increasingly expensive medical techniques to improve health outcomes are also causing a crisis in the cost of healthcare, with no clear solution in sight.
Technology has the potential to significantly reduce the strain on the healthcare system by automating many of the routine tasks, using decision support tools to screen health data for emerging problems and enabling patients to take a larger role in their own health management. Home telecare could significantly contribute to the solution by providing patients with an increased ability to manage their own health from the comfort of their own homes and communicate with their healthcare providers before minor problems escalate. Such systems have the potential to reduce the need for face-to-face (F2F) visits, reduce the frequency of hospitalization and emergency room visits (Paré, Jaana, & Sicotte) and increase the patient's ability to remain in their homes for longer (Barlow, Singh, Bayer, & Curry, 2007).
However, although numerous projects have been initiated and developed through the research stages, very few have transitioned into commercially viable systems (Grigsby et al., 2002). There are several reasons for this transition failure. In particular, commercial telecare systems must address issues regarding reimbursement for installation, maintenance, and electronic provider services (Whitten & Buis, 2007). In addition, healthcare providers themselves must be convinced that the systems will not substantially increase their workload (Whitten & Mackert, 2005), and that the new mode of healthcare delivery will result in payment for their time and effort. Finally, telecare systems need to be capable of addressing a wide array of health conditions and basic issues while supporting patient mobility and independence to be practical outside of the research environment. The remainder of this section addresses the barriers to telecare commercialization in more detail.
The current economic model of healthcare evolved in response to more traditional modes of healthcare delivery and does not currently support many of the costs associated with home telecare. Thus, health insurance frequently does not reimburse healthcare providers for time spent responding to non-F2F health consultations. In addition, prior to supporting reimbursement of the system itself, health insurance organizations will require significant evidence demonstrating improved outcomes and/or cost effectiveness of equivalent care, the ability to handle the complexity of real-world care, and adequate redundancy within the system to reduce the potential for harm should the system fail or provide inadequate care in unforeseen circumstances. These requirements necessitate extensive, well controlled usability and efficacy studies. However, to date most of the studies evaluating outcomes for home telecare systems have been too limited in size or methodology to provide strong evidence either for or against the system. The quantitative studies that avoid significant methodological flaws have produced mixed evidence for the efficacy of these programs (Barlow et al., 2007; Dellifraine & Dansky, 2008; Finkelstein et al., 2004; Hersh et al., 2006; Paré et al.), although they have generally reported good patient acceptance (Finkelstein et al., 2004; Liddy et al., 2008). Additionally, the existing home telecare systems tend to address specific chronic disorders such as congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), diabetes, hypertension and telepsychiatry (see (Stachura & Khasanshina, 2007) for a review). While some of these projects have demonstrated improved outcomes, they do not address the complexity of care for chronic disorders in populations with frequent comorbid disorders such as depression (Lyness et al., 2996). Insurers are unlikely to be willing to support multiple home telecare solutions to address the variety of patients, and patients are unlikely to accept the redundancies that multiple systems would likely require. Thus, viable telecare solutions will need to be flexible enough to accommodate a range of comorbid disorders within a given patient.
A second potential barrier to the widespread adoption of home telecare is the issue of provider acceptance. Healthcare providers, and doctors in particular, are likely be the gatekeeper of home telecare (Whitten & Mackert, 2005); most patients are likely to first hear about a given system through their physician, and the system won't be useful unless the doctor agrees to actively participate. Although many evaluations of home telecare systems have indicated favorable reports of provider acceptance (Bratton, 2001; Liddy et al., 2008), these evaluations are subject to significant sampling bias; the provider's willingness to take part in an evaluation of a specific system suggests they are likely to support the use of home telecare in general. More general evaluations of healthcare providers' attitudes toward home telecare suggest that many physicians have concerns about telecare's potential increase in their workload and the likelihood of payment for the time they spend interacting and monitoring these systems, although nurses are more inclined to view the systems favorably. In addition, similar to insurance organizations, healthcare providers are likely to have concerns about potential legal issues regarding home telecare's ability to manage medical complexity and avoid harm to the patient without requiring such close management by the physician as to render the system unusable.
Finally, a commercially viable system will likely need to be highly extensible to support multiple chronic conditions and provide support for basic underlying issues such as adherence to the health management plan. The majority of chronic conditions either directly result in further health deterioration through their systemic impact (for example, diabetes tends to result in additional chronic problems such as hypertension, heart disease and kidney failure, among others), indirectly result in additional problems such as depression and anxiety and obesity due to lack of mobility, or occur at a time of life when additional problems are likely as a simple consequence of aging. Most existing home telecare systems focus on a single condition such as CHF or diabetes mellitus. While this simplifies system development and evaluation in a research environment, these systems are unlikely to prove viable in the real world due to their lack of extensibility.
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- Clarke, S. P., & Cheung, R. B. (2008). The nurse shortage: where we stand and where we're headed. Nursing management, 39(3), 22-7;
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- Liddy, C., Dusseault, J. J., Dahrouge, S., Hogg, W., Lemelin, J., Humbert, J., et al. (2008). Telehomecare for patients with multiple chronic illnesses: Pilot study. Canadian family physician Médecin de famille canadien, 54(1), 58-65.
- Lyness, J., Bruce, M., Koenig, H., Parmelee, P., Schulz, R., Lawton, M., et al. (2996). Depression and medical illness in late life: Report of a symposium. Journal of the American Geriatric Society, 44, 198-203.
- Paré, G., Jaana, M., & Sicotte, C. Systematic review of home telemonitoring for chronic diseases: the evidence base. Journal of the American Medical Informatics Association : JAMIA, 14(3), 269-77.
- Stachura, M., & Khasanshina, E. (2007). Telehomecare and Remote Monitoring: An Outcomes Overview. . Retrieved June 1, 2008, from http://18.104.22.168/search?q=cache:PW4sl-hq944J:www.advamed.org/NR/rdonlyres/2250724C-5005-45CD-A3C9-0EC0CD3132A1/0/TelehomecarereportFNL103107.pdf+Telehomecare+and+Remote+Monitoring:+An+Outcomes&hl=en&ct=clnk&cd=1&gl=us&client=firefox-a.
- Whitten, P., & Buis, L. (2007). Private payer reimbursement for telemedicine services in the United States. Telemedicine journal and e-health : the official journal of the American Telemedicine Association, 13(1), 15-23.
- Whitten, P. S., & Mackert, M. S. (2005). Addressing telehealth's foremost barrier: provider as initial gatekeeper. International journal of technology assessment in health care, 21(4), 517-21.
- Wolff, J. L., Starfield, B., & Anderson, G. (2002). Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of internal medicine, 162(20), 2269-76.
Submitted by Christine E. Bredfeldt, Ph.D.