Four practices in West Lothian, Scotland may have experienced a future model for caring for people with long-term conditions.
The practices were involved in a small-scale telemedicine pilot for managing patient care remotely that began in March 2008 with 30 COPD patients. This February, NHS Lothian announced a roll-out of the pilot to 400 people across its area.
Funded by NHS Lothian and the Scottish government, the telehealth programme works by giving patients an Intel Health Guide device, allowing them to be monitored in their homes.
The easy-to-use device runs a questionnaire each day asking patients about their symptoms. When prompted, patients use medical peripheral devices including peak flow meters and pulse oximeters.
The information collected is transmitted via an online interface, flagging up to clinicians any patients at potential risk.
Dr Brian McKinstry from the Ashgrove Health Centre in West Lothian is a GP at one of the four practices. Thirteen of his COPD patients, aged from late 40s to mid-70s, were enlisted, and he says that they received a better level of care than COPD patients who did not participate.
'It made our treatment more evidence-based. It alerted to us the frequency of exacerbations that had previously gone unnoticed. Intervening early meant we could deal with the patient more appropriately,' he says.
The information was sent to a call centre that would then notify the practice to contact the patient if certain thresholds were exceeded.
But at Ashgrove Health Centre, practice nurse Lesley Cunningham opted to check the results herself via a webpage. Ms Cunningham took a lead in the day to day running of the pilot and would call patients at risk of a worsening of their condition for more information.
Associate medical director of NHS Lothian Dr Brian Montgomery says practice nurses took the lead in two of the practices. 'When we've talked to groups, it's been seized on by nurses and associated health professionals,' he says.
NHS Lothian has an established interest in telecare with older people who are monitored in their home by the use of devices such as alarm buttons. The foray into telehealth was the next step, says Dr Montgomery. And COPD was the obvious choice of long-term condition.
'We have quite a high COPD prevalence in Lothian and it's on the increase. Some people have frequent exacerbations, so the hope was that we could improve their quality of life. The knock-on benefit is to reduce hospital admissions,' he says.
Telemedicine has been part of the wider picture in Scotland since the launch of The Scottish Centre for Telehealth in 2006. Dr McKinstry says that it helped having the centre on-side during the pilot to explain common IT glitches and to offer expertise.
The 10-month pilot demonstrated a number of advantages to practices. Reporting symptoms daily has built a databank about patients' conditions and has changed how some patients are managed.
'When we started, only some patients had antibiotics and steroids at home to use as necessary. By the end, they all did. The use of antibiotics and steroids has doubled,' says Dr McKinstry.
Many patients became more confident and knowledgeable about their condition and they reported feeling reassured that they had direct access to the practice nurse.
The pilot also revealed areas of concern. The amount of work involved alarmed Ms Cunningham at the start: 'It had a quite a major impact on my day-to-day work.' However, she says that this lessened as she became more comfortable with the new way of working.
One in five people in Scotland has a long-term condition and this number will rise because of the ageing population.
Given that the Intel devices cost about £1,000 each, telehealth could be more costeffective for the NHS than multiple hospital admissions. But savings would be seen in secondary care, not general practice.
Cost-effectiveness is an element of the evaluation now taking place. Some of the 400 patients in the roll-out phase will be enrolled in a randomised, controlled trial. Half will be COPD patients and the remainder will have other chronic conditions, such as cardiac disease.
After the initial pilot, changes were made before the next phase. Thresholds for alerts have risen and, instead of patients' results going to a call centre, they will go to a specialist team of nurses and physiotherapists working across NHS Lothian.
The monitoring device has also been updated to include video consultations.
Dr McKinstry says the potential of telehealth is enormous. There is even the possibility of it running on mobile phones, but more research is needed. 'I'm positive that this is the future, but we want to know which conditions it works best for.'
COPD AND TELEHEALTH
- COPD affects over three million people in Britain and is the second largest cause of emergency hospital admissions.
- Patients with a chronic disease account for 52 per cent of all GP appointments and 60 per cent of the total health and social care spend.
- An estimated 17.5 million people live with chronic disease in Britain, a figure that will rise as the population ages.
- The Intel Health Guide device works with various medical peripheral devices such as glucose meters.
- It can provide educational content to patients about chronic conditions.
- Initial pilots using the device have run in the UK, the US and the Netherlands. Further EU pilots are planned.
- The Lothian programme of 400 patients is one of the largest telemedicine schemes in the UK.