Martin Hefford Sapere Research Group (Friday, 10.00, Telehealth/mHealth) See the related video: http://www.slideshare.net/secret/1msf1AYsNLJlSW Congestive Heart Failure and Chronic Obstructive Pulmonary Disease are two chronic conditions that have important impacts on both the quality and length of life of individuals and on utilisation of health services. In the context of limited health funding, workforce restrictions, and an ageing population, there is increasing interest in the use of remote monitoring technologies to improve the quality of life of patients with these conditions, and to reduce unplanned use of hospital services. In 2009 Lake Taupo Primary Health Organisation (PHO), Lakes District Health Board (DHB) and Healthcare of New Zealand Ltd, entered into a strategic partnership to pilot telehealth devices to support chronic care management in the Lake Taupo community, using a small randomised control trial approach, with ten patients in each arm. Sapere Research Group was commissioned to independently evaluate the 12 month pilot, and found good evidence that the telehealth remote monitoring technology was accepted by both Maori and non-Maori participants; that quality of life was significantly better in the telehealth group than in the control group; and some indications of a trend toward improved survival in the telehealth group. Hospitalisations were reduced in both the control (-19%) and telehealth group (-25%). Results should be considered tentative given the small numbers in the trial, but are consistent with findings of improved survival, quality of life and cost savings from recent international reviews. The impact of the telehealth intervention may have been partially masked by the simultaneous implementation of the Healthright disease management programme.

1. Telehealth support for patients
with long term conditions:
evaluation of a rural pilot
Presentation at HINZ Conference, 25 November 2011

2. 2
Overview of presentation
• Background
Telehealth
The pilot
• Evaluation
• Findings
• Reflections

3. 3
Why Telehealth?
• Can‟t afford to build more hospitals:
 How do we do a better job of keeping people out?
• We need a new venue for care delivery:
 By 2015, the home will be the hub of care*
 How do we maintain wellness at home?
• Better use of doctors and nurses:
 New models of care
• Patients/clients are expecting more
 Increasingly driving their own care
* Naomi Fried, VP Kaiser
Permanente

4. 4
What is Telehealth?
Telehealth technology enables people to monitor their
own heart rate, blood pressure, lung function, weight,
temperature, health diary and questionnaires from
home
• Complex patient focus
• Individualised trends and
alerts setting
• Self-management tool
• Single, shared or mobile use

5. 5
Clinical Data

6. 6
Setting up the pilot
• 2009 partnership between Lakes DHB, Lake Taupo
PHO, Healthcare NZ and Freedom Health Technologies
• Acknowledgement to Lakes DHB and Lake Taupo as
innovation leaders
• They took a risk- first to fund, implement and test telehealth
in New Zealand
• Vision to reduce demand on hospital services

7. 7
Pilot Methodology
• Deployed 1 October 2009
• Randomised controlled trial structure
• 10 patients in trial arm and 10 in matching control
• COPD or CHF and enrolled in HealthRight
(chronic care programme)
• Concluded September 2010

8. 8
Series of implementation
activities
• Establish legislative & regulatory requirements
• Commission Sapere for evaluation framework with
Ethics Committee approval
• Develop telehealth programme methodology
 HCNZ, PHO and client requirements
 Design clinical & technical support framework
• Installation and training
 PHO staff and patients/whānau
• Evaluation

9. 9
Legislative & Regulatory
requirements
• Telehealth is classified as medical device
• Manufacturers need to meet their countries
requirements prior to export
• Australia TGA
• NZ Medsafe
• Healthcare requirements to both
 NZ Medsafe/Electricity Act and vendor Telemedcare
• Key requirement post market surveillance

10. 10
Clinical Support Guidelines

11. Technical support
• Supported Freedom Health Technology
• Objective proactive early detection issues and to
adhere to post surveillance legislative requirements
• Included installation, daily technical support and
software upgrades/maintenance
• Clients/PHO staff accessed 0800 number
• Trained PHO “super-user”

12. Telehealth training
• Different requirements for PHO staff, clients and
whanau
• PHO staff
 Telehealth monitor
 Telehealth web support
 Clinical and Technical support structure
• Clients and whanau
 Telehealth monitor and technical support

13. 13
Change management
• Staff
Telehealth as enabler (not a stand alone
function)
• Clients
Not an emergency device
Self management educator

14. 14
Speed Bumps
• Implementation learnings
Regulatory „stamina‟: Australian
regulatory approval caused ~12 month
implementation delay
„Be prepared‟: Vendor‟s first
implementation in NZ, e.g. initial
synchronisation issues

15. 15
From the patients‟ view...
• In the words of William Hall...

16. 16

17. 17
Evaluation
• Sapere commissioned to independently develop
evaluation framework & evaluate 12 month pilot
to inform future use of telehealth in NZ
• Research questions focused on identifying:
1. Acceptability and usefulness
2. Impact on health outcomes
3. Impact on health service utilisation
4. Impact on clinical practice

18. 18
Important context
• Small numbers so data easily skewed
• Need 200 to 500 patients for statistical
significance
• „Supercharged‟ usual care with specialist family
nurses (HealthRight)
• High threshold for testing telehealth efficacy

19. 19
Data Sources
• Telehealth website: patient quality of life and
clinical indicator data
• Lakes PHO & DHB: service utilisation data
• Interviews of patients and healthcare staff:
insights on acceptability & usefulness of the
telehealth from user perspective

20. Findings: impact on self
management
„The machine tells me a lot…it changes your whole life‟
Increased awareness, confidence, wellbeing
Facilitated self management through better
understanding of disease & quick feedback
“…helped W notice which foods elevated his blood
sugars and blood pressure”- HealthRight nurse

21. Findings: ease of use
„It took only a few hours to become familiar with the unit‟
• Universally reported as easy to use
• Most indicated that it took less than a day to learn
how to use
• Developed a daily routine around monitoring

22. Findings: acceptability to
Māori
„It‟s like my new security blanket‟
• Technology adopted readily
• Some reported that whānau felt more confident
• Involved whānau in self management through
telehealth
• Suggested whānau measurements
‘A whanau measurement screen would be great for other
members - other family members all have medical
conditions – asthma, hypertension, diabetes, etc.‟

23. Findings: health outcomes
• Substantial but non-significant trend
towards reduced mortality in telehealth
group
• 4/10 in control group died vs 1/10 in
intervention group

24. 24
Findings: quality of life
• Quality of life significantly better in the telehealth group compared to
control group
St George COPD (0=best, 100=worst)
60
50
40
Telehealth
30 Control
20
10
0
Baseline Pilot 12

25. 25
Findings: quality of life
K10 questionnaire (20=best, 30+= worst)
25
20
15
Telehealth
Control
10
5
0
Baseline Pilot 12
• Quantitative findings congruent with patients‟ comments

26. Outcomes: clinical
measures
• Mean blood pressure, FEV1, heart
rate, blood oximetry and weight for the
control and telehealth group showed no
obvious patterns of change

27. Findings: utilisation
• Decrease hospitalisations in both
groups, slightly greater for telehealth
(↓25% vs ↓19%)
• Found no impact on ED admissions
• Impact on ambulance use at 6 months –
but data not available at 12 months
• Healthright chronic care programme may
have masked impact

28. Findings: GP visits
„Saved money by not going to GP so often‟
• Most telehealth patients spontaneously reported fewer
visits to GP
• But data did not support this
• Telehealth ↑3%, control ↓19%
• Data skewed by one telehealth individual who had 26
primary care visits
„I used to see doctor every second or third day, now
it‟s every 6-8 weeks‟

29. Process learnings
• Reported that telehealth data made earlier
detection of exacerbations and trend
monitoring easier
• Thought it helped patients develop better self-
management
• Some patients became very concerned about
small changes in measurements
• Questionnaires felt to be too long and
intrusive
• Frustrations inherent in the introduction of new
technologies
• Telehealth portal easy to use

30. Reflections
• Telehealth as adjunct to HealthRight
• Did not involve substituting face-to-face
with telehealth care
• But small trial which did not make
complete redesign of model practicable,
cost effective or advisable
• For maximum benefit need change in
clinical practice

31. 31
Conclusions
• Telehealth can be successfully applied in a NZ
community to aid chronic disease management
Evidence telehealth was accepted by both Māori
and non-Māori participants
Clear positive impact on quality of life
Impact on health utilisation and mortality less clear
• Consistent with results of larger overseas
studies- these generally find statistically
significant positive impacts from telehealth

32. 32
Postscript
• Taking these learnings, we have now
implemented telehealth in the Eastern Bay
of Plenty
• Partnership between HCNZ, EBPHA, Bay of
Plenty DHB
• Enabler within the broader Te Whiringa Ora
service

33. 33
Who is Healthcare NZ?
We have more than 40 branch offices • 20 year track record
throughout New Zealand and provide
home-based support, chronic care • 40 branches throughout NZ
management, specialist nursing, training
and advanced health technology • 6,500 staff, >17,000 clients
services
• Services include:
– Community Nursing
– Home-based support
– Complex case
management
– Telehealth
– Mental Health
– Intellectual and physical
disability support

34. About Sapere Research Group Limited
Sapere Research Group is one of the largest expert consulting firms in Australasia
and a leader in provision of independent economic, forensic accounting and public
policy services. Sapere provides independent expert testimony, strategic advisory
services, data analytics and other advice to Australasia’s private sector corporate
clients, major law firms, government agencies, and regulatory bodies.
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For information on this report please contact:
Name: Martin Hefford
Telephone: +64 4 915 7593
Mobile: +64 272949132
Email: MHefford@srghealth.com
34

35. 35
Questions
Further information: mhefford@srgexpert.com or
rosemary.burns@healthcarenz.co.nz