NIHR Signal Designing successful telehealth interventions

Published on 28 September 2015

This NIHR-funded review identified three general principles for designing effective telehealth programmes for people with long-term health conditions. First, the technologies need to help people living with disease to build effective relationships with doctors, nurses and others. Second, there needs to be a good fit between the technology and everyday routine of the patient. Thirdly, the technology should provide a clear visual record of health results, such as blood glucose readings. The authors used realist review approaches to develop and test theories around what makes some telehealth programmes more successful than others.

For complex programmes, those made up of many interconnected parts, careful design and evaluation are particularly important. This type of study helps commissioners understand better how telehealth might work, in what circumstances and for whom. These three principles will be useful for those planning and evaluating telehealth programmes.

Share your views on the research.

Why was this study needed?

In the UK, long-term conditions such as heart disease, lung conditions and diabetes account for around 60% of all deaths. Telehealth is where people monitor their own health at home and communicate information remotely to health professionals. While evidence is mixed, telehealth has been shown to improve people’s health for some long-term conditions, such as heart failure. It can reduce the number of hospital and GP appointments, which is more convenient for individuals and potentially saves the NHS money. Existing research has focused more on individual technologies or conditions. There is little evidence based guidance for introducing telehealth programmes, understanding how and why they work or designing interventions to make them more acceptable to patients. The NIHR funded this review to identify the mechanisms associated with successful implementation of telehealth interventions in people with three long-term conditions; chronic obstructive pulmonary disease, heart failure and diabetes. These three were chosen as important tracer conditions which had existing telehealth interventions with potential for improved uptake.

What did this study do?

This was a “realist review” – a type of review used to inform evidence-based policy by providing a detailed and practical understanding of how complex interventions work in the real world. The authors used three previous reviews of telehealth in long-term conditions to identify theories and characteristics linked to success and grouped them into themes. Qualitative studies gathering people’s views on telehealth interventions in heart failure, lung disease and diabetes helped refine the themes. Three reviewers independently looked at all of the studies before gathering to discuss and reach consensus on the most important information and themes. Fifteen studies were included in the review, six of which were from the UK.

What did it find?

  • Telehealth can help to build trusting relationships between patient and healthcare professionals. People may feel anxious about taking on greater responsibility for managing their condition. Telemonitoring, such as remotely uploading blood glucose readings for a nurse to monitor and guide treatment, can provide an intermediary step to help people get used to more autonomous forms of self-management.
  • Peer support, when tailored to gender and age, can enhance the effectiveness of telehealth. Peer support was particularly valuable where people’s immediate personal network may not be able to support them in making changes to their illness management.
  • The effectiveness of telehealth interventions was affected by how well the intervention fitted with people’s needs and their daily routine. Adapting interventions to suit people’s needs and environments helped reach those who might otherwise not have accessed traditional face-to-face care.
  • Practical barriers, such as integrating telehealth with existing systems, accessing the internet and space required for telehealth equipment, should be addressed to maximise the chance of successful implementation.
  • Recording data such as blood glucose helped increase people’s awareness and engagement with their condition and care. Visible reminders helped to continue to engage people as their condition improved.

What does current guidance say on this issue?

NICE guidance recommends that people with chronic obstructive pulmonary disease (2010), heart failure (2010), and type 1 diabetes (2004) or type 2 diabetes (2009) are all offered education to help them manage their own condition and treatments. NICE does not have specific guidance on telehealth interventions for these conditions.

What are the implications?

This “realist” review provides practical information to inform the evidence-based design and implementation of telehealth interventions. Even if interventions have been shown to be clinically effective in some contexts, they may be unsuccessful if the factors needed to implement them are poorly understood. Therefore the review’s findings should be used in conjunction with evidence about the clinical effectiveness of particular telehealth interventions to identify and adapt interventions to maximise their impact.

For commissioners wanting more detail on the evidence base for telehealth a useful synthesis of the evidence on telehealth interventions for lung disease, diabetes and heart failure was published in 2013 by the University of York. This places the existing trials in context for a clinical commissioning group and includes a summary of the implications of the Whole System Demonstrator trial, a large recent trial and economic evaluation of telehealth. The suggestion is that local adaptation may offer a better chance of success than a ‘big-bang’ approach and this is supported by the conclusions of this realist review which provides some principles to consider in these local adaptations.

Citation

Vassilev I, Rowsell A, Pope C et al. Assessing the implementability of telehealth interventions for self-management support: a realist review. Implement Sci. 2015;10:59.

This research has been funded by the EU FP7 Collaborative Research Grant for the EU-WISE project, the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, and the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0108-10011). 

Bibliography

Centre for Reviews and Dissemination. Telehealth for patients with long term conditions. York: University of York; 2013.

NHS Choices. Telecare and telehealth technology. London: NHS Choices; 2014.

NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. CG108. London: National Institute for Health and Care Excellence; 2010.

NICE. Type 2 diabetes: The management of type 2 diabetes. CG87. London: National Institute for Health and Care Excellence; 2009.

NICE. Type 1 diabetes: Diagnosis and management of type 1 diabetes in children, young people and adults. CG15. London: National Institute for Health and Care Excellence; 2004.

WHO. Noncommunicable diseases country profiles 2014: United Kingdom. Geneva: World Health Organization; 2014.

Why was this study needed?

In the UK, long-term conditions such as heart disease, lung conditions and diabetes account for around 60% of all deaths. Telehealth is where people monitor their own health at home and communicate information remotely to health professionals. While evidence is mixed, telehealth has been shown to improve people’s health for some long-term conditions, such as heart failure. It can reduce the number of hospital and GP appointments, which is more convenient for individuals and potentially saves the NHS money. Existing research has focused more on individual technologies or conditions. There is little evidence based guidance for introducing telehealth programmes, understanding how and why they work or designing interventions to make them more acceptable to patients. The NIHR funded this review to identify the mechanisms associated with successful implementation of telehealth interventions in people with three long-term conditions; chronic obstructive pulmonary disease, heart failure and diabetes. These three were chosen as important tracer conditions which had existing telehealth interventions with potential for improved uptake.

What did this study do?

This was a “realist review” – a type of review used to inform evidence-based policy by providing a detailed and practical understanding of how complex interventions work in the real world. The authors used three previous reviews of telehealth in long-term conditions to identify theories and characteristics linked to success and grouped them into themes. Qualitative studies gathering people’s views on telehealth interventions in heart failure, lung disease and diabetes helped refine the themes. Three reviewers independently looked at all of the studies before gathering to discuss and reach consensus on the most important information and themes. Fifteen studies were included in the review, six of which were from the UK.

What did it find?

  • Telehealth can help to build trusting relationships between patient and healthcare professionals. People may feel anxious about taking on greater responsibility for managing their condition. Telemonitoring, such as remotely uploading blood glucose readings for a nurse to monitor and guide treatment, can provide an intermediary step to help people get used to more autonomous forms of self-management.
  • Peer support, when tailored to gender and age, can enhance the effectiveness of telehealth. Peer support was particularly valuable where people’s immediate personal network may not be able to support them in making changes to their illness management.
  • The effectiveness of telehealth interventions was affected by how well the intervention fitted with people’s needs and their daily routine. Adapting interventions to suit people’s needs and environments helped reach those who might otherwise not have accessed traditional face-to-face care.
  • Practical barriers, such as integrating telehealth with existing systems, accessing the internet and space required for telehealth equipment, should be addressed to maximise the chance of successful implementation.
  • Recording data such as blood glucose helped increase people’s awareness and engagement with their condition and care. Visible reminders helped to continue to engage people as their condition improved.

What does current guidance say on this issue?

NICE guidance recommends that people with chronic obstructive pulmonary disease (2010), heart failure (2010), and type 1 diabetes (2004) or type 2 diabetes (2009) are all offered education to help them manage their own condition and treatments. NICE does not have specific guidance on telehealth interventions for these conditions.

What are the implications?

This “realist” review provides practical information to inform the evidence-based design and implementation of telehealth interventions. Even if interventions have been shown to be clinically effective in some contexts, they may be unsuccessful if the factors needed to implement them are poorly understood. Therefore the review’s findings should be used in conjunction with evidence about the clinical effectiveness of particular telehealth interventions to identify and adapt interventions to maximise their impact.

For commissioners wanting more detail on the evidence base for telehealth a useful synthesis of the evidence on telehealth interventions for lung disease, diabetes and heart failure was published in 2013 by the University of York. This places the existing trials in context for a clinical commissioning group and includes a summary of the implications of the Whole System Demonstrator trial, a large recent trial and economic evaluation of telehealth. The suggestion is that local adaptation may offer a better chance of success than a ‘big-bang’ approach and this is supported by the conclusions of this realist review which provides some principles to consider in these local adaptations.

Citation

Vassilev I, Rowsell A, Pope C et al. Assessing the implementability of telehealth interventions for self-management support: a realist review. Implement Sci. 2015;10:59.

This research has been funded by the EU FP7 Collaborative Research Grant for the EU-WISE project, the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, and the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-0108-10011). 

Bibliography

Centre for Reviews and Dissemination. Telehealth for patients with long term conditions. York: University of York; 2013.

NHS Choices. Telecare and telehealth technology. London: NHS Choices; 2014.

NICE. Chronic obstructive pulmonary disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update). CG101. London: National Institute for Health and Care Excellence; 2010.

NICE. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. CG108. London: National Institute for Health and Care Excellence; 2010.

NICE. Type 2 diabetes: The management of type 2 diabetes. CG87. London: National Institute for Health and Care Excellence; 2009.

NICE. Type 1 diabetes: Diagnosis and management of type 1 diabetes in children, young people and adults. CG15. London: National Institute for Health and Care Excellence; 2004.

WHO. Noncommunicable diseases country profiles 2014: United Kingdom. Geneva: World Health Organization; 2014.

Assessing the implementability of telehealth interventions for self-management support: a realist review

Published on 25 April 2015

Vassilev, I.,Rowsell, A.,Pope, C.,Kennedy, A.,O'Cathain, A.,Salisbury, C.,Rogers, A.

Implement Sci Volume 10 , 2015

BACKGROUND: There is a substantial and continually growing literature on the effectiveness and implementation of discrete telehealth interventions for health condition management. However, it is difficult to predict which technologies are likely to work and be used in practice. In this context, identifying the core mechanisms associated with successful telehealth implementation is relevant to consolidating the likely elements for ensuring a priori optimal design and deployment of telehealth interventions for supporting patients with long-term conditions (LTCs). METHODS: We adopted a two-stage realist synthesis approach to identify the core mechanisms underpinning telehealth interventions. In the second stage of the review, we tested inductively and refined our understanding of the mechanisms. We reviewed qualitative papers focused on COPD, heart failure, diabetes, and behaviours and complications associated with these conditions. The review included 15 papers published 2009 to 2014. RESULTS: Three concepts were identified, which suggested how telehealth worked to engage and support health-related work. Whether or not and how a telehealth intervention enables or limits the possibility for relationships with professionals and/or peers. Telehealth has the potential to reshape and extend existing relationships, acting as a partial substitute for the role of health professionals. The second concept is fit: successful telehealth interventions are those that can be well integrated into everyday life and health care routines and the need to be easy to use, compatible with patients' existing environment, skills, and capacity, and that do not significantly disrupt patients' lives and routines. The third concept is visibility: visualisation of symptoms and feedback has the capacity to improve knowledge, motivation, and a sense of empowerment; engage network members; and reinforce positive behaviour change, prompts for action and surveillance. CONCLUSIONS: Upfront consideration should be given to the mechanisms that are most likely to ensure the successful development and implementation of telehealth interventions. These include considerations about whether and how the telehealth intervention enables or limits the possibility for relationships with professionals and peers, how it fits with existing environment and capacities to self-manage, and visibility-enabling-enhanced awareness to self and others.

Telehealth is a broad term used to describe communication and information technologies that provide healthcare at a distance. It can be used to enable people to either self-monitor their own health at home or self-manage their condition, where they take more responsibility for deciding any changes to treatment. This can include measuring vital signs – such as blood pressure or blood glucose – and uploading results to a system for health professionals to monitor and change treatment accordingly. Telehealth packages can also include support like remote consultations or peer group support via videoconference. Telehealth can help people to feel in control of their condition, rather than controlled by it, and to have greater engagement with their treatment.

Expert commentary

Telemedicine always seems useful in principle, but it is often hard to see how best to make it work in practice. It can feel at times that the technology itself is driving the agenda, rather than its clinical usefulness. This review has some key points that I can use as a clinician and commissioner when thinking about future investments. It includes a pragmatic approach to what works, building in an understanding of the patient's own context, gentle encouragement of self-management and simple rather than complex measures.

Dr Joe McManners, Clinical Chair, Oxfordshire Clinical Commissioning Group

Author commentary

This realist review identified three key mechanisms for the successful implementation of telehealth interventions to improve people’s management of long-term conditions. First, do the interventions improve or change relationships with professionals and peers so as to enable self-management; second, do the interventions fit with patients’ everyday life and self-management skills; and third, do they offer visual feedback of symptoms to improve and sustain knowledge, motivation, and engagement with network members. Policy makers, practitioners and technology developers need to consider these mechanisms to develop cost-effective ways to assess and improve the implementability of existing and future interventions.

Dr Ivaylo Vassilev, Senior Research Fellow for Health Sciences, University of Southampton