BACKGROUND
Conventional mechanisms of care delivery typically demand proximity of the patient, doctors, nurses and equipment thereby raising the cost and complexity of healthcare. In recent years there has been great enthusiasm to adopt information communication technologies (ICT) for promoting efficient and cost-effective health care delivery. Telehealth has been much heralded as a promising ICT intervention to reduce the need for proximity and thereby help in bridging the gap between the demand and supply of health care personnel. Unfortunately, in reality there have been significant problems across the board with technology selection, scalability and sustainability. Growth in telehealth has often been driven by governments or vendors, looking at the issue of telehealth implementation and design from a biased view, laced with liberal doses of wishful thinking. Real-world implementations have struggled due to lack of focus on the end-users and the absence of a viable financial model. Sadly, the global landscape is therefore littered with the remains of defunct telehealth programs that could not survive past the period of the start-up funding. This paper focuses on one element of this complex problem – the question of choosing the right technology for a given health issue, keeping in mind usability, communications infrastructure, and the existing workflow of health care delivery.
Current mechanisms of health care delivery reflect a highly complex map of intertwined dependency factors. Efforts to employ a common ICT infrastructure model across these diverse environments may lead to significant delay, confusion and reluctance in the user community. A conceptual approach we have presented elsewhere (Ramkumar & Babu, 2010) attempts to break down a given healthcare context into a workflow of transactions and map the nature of related information flow on the basis of content, size, urgency in provisioning the data and the type of user interaction (Figure 1). The resulting matrix should help in assessing cost-effective technology approaches for a given health program as well as revealing the program structure which is optimal given existing infrastructure and end-user need.
Figure 1. Process to map the nature of information exchange in care cycle
This paper extends our concept to map out the requirements for telehealth in the context of a specific disease and target demography. An important area where telehealth has been evolving is in management of chronic diseases such as congestive heart failure (CHF), asthma and diabetes where the patient is monitored remotely while at home, and necessary management changes are made utilizing a telelink, typically a telephone line. We will consider the example of congestive heart failure and review in detail the process of telemonitoring, highlighting important findings from the literature and applying a technology application matrix as a guide to technology selection, use and evaluation.
CHF has been a significant clinical problem worldwide. It is a major target of home telemonitoring efforts in Western countries such as the United States where CHF is a prominent cause for hospital admissions, mortality and healthcare costs. Over 1 million cases of congestive heart failure cases were hospitalized in 2007 (Rosamund, 2007) with 262,282 deaths being attributed to CHF in 2006 (Lloyd-Jones, 2010). In many instances where the patient survives the initial admission for heart failure and is discharged from the hospital, the subsequent clinical course is punctuated by repeated declines in the clinical status, which leads to re-hospitalization or even death. The impact is great not only in loss of lives, but also loss of productive life years to society and economic loss to the patient’s family. The cost burden of health care for CHF was $39.2 billion in the USA in 2010, including an estimated $4.1 billion in lost productivity from patients dying in 2010 (Lloyd-Jones, 2010).