TELEHEALTH

Review and Perspectives for Singapore

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Table of Contents
The Big Picture
Telehealth Now
Teleconsultation
Telemonitoring
Patient Outcomes
Patient Engagement and Adherence
Patient Satisfaction and Usability
Medical Resource Utilisation
Cost
Electronic Health Records
Translations for Singapore
Bibliography
Singapore faces an incoming silver tsunamia drastic
increase in the proportion of elderly citizens in the population
over the coming decades. In its wake, healthcare costs are
projected to rise dramatically.
Though healthcare spending is manageable at current
levels, the systemic focus on expensive, once-of acute care
threatens its sustainability. Reports from both PWC and BMI
have called for urgent shifts towards community and home-
based care in order to cope with the chronic disease case
load from the ageing population.
To address these gaps, MOH Holdings hopes to rely
on up-and-coming telehealth systems, that will build on
the National Electronic Health Record. Telehealththe
use of telecommunications technology to remotely deliver
healthcarehas streamlined healthcare for developed
countries such as the US, the UK, and Australia. Devices
like the Bosch Health Buddy are now industry standards
for delivering telehealth, while healthcare providers like
the US Department of Veterans Afairs (VA) have had their
own telehealth service since a decade ago. In 2013 alone,
603,532 VA patients received treatment through 1,787,181
telehealth consultations from the VA telehealth service.
Telehealth services are popular today because chronic
care patients stand to gain a host of benets. Apps like
the FDA approved DiabetesManager have been clinically
shown to improve patient outcomes through measures
such as heightening patient engagement and prescribing
personalised medical advice. In one randomised trial,
diabetics signicantly reduced their HbA1c levels by 1.2%
more just by using the app with their doctors on top of usual
care measuressignicant in light of the fact that the FDA
considers a HbA1c reduction of 0.5% to already be clinically
signicant for pharmaceutical diabetes drugs.
Telemonitored chronic care patients experience vastly
reduced mortality rates. A large telemonitoring trial of
3,230 patients by the UK Department of Health found a
signicant 3.7% (p < 0.001) reduction in mortality amongst
those telemonitored. This is because telemonitoring works
around the clock to automatically point out potentially fatal
deteriorations in patients conditions, alerting healthcare
professionals to intervene in time.
As a direct result of these just-in-time interventions,
patients and their payers have experienced sizeable cost
savings from avoided hospitalisations and ER visits. One
Canadian telemonitoring trial with 95 chronic care patients
chronicled annual cost savings of 41% from telemonitoring.
These cost savings originated mainly from reduced hospital
service utilisation, and translated into CAD$1,557 of savings
per patient, per year (p < 0.025).
The manifold benets of telehealth services spell
good news for Singapores healthcare system. Luckily for
Singapore, the connected nature of the city state and its tech
savvy citizenry mean that telehealth technologies will be
able to reach a majority of patients without further signicant
investments in telecommunications infrastructure. The world
has moved decidedly into the 21st centuryit is high time that
healthcare did too.
Executive Summary
1
The Big Picture
Demographics have transitioned for developed countries;
healthcare systems have not. Even though people are
surviving better, having less children, and older on average,
healthcare systems around the world are still not equipped
to deal with what is being termed the silver tsunamian
incoming surge in the number of older adults, many of whom
will require continuing medical attention in their golden years.
Governments worldwide are upping their healthcare
budgets in anticipation of the increased prevalence of
chronic diseases amongst their ageing populations, but
the structure of healthcare systems today necessitates
exponential increases in overall spending just to keep up.
Traditionally, healthcare systems have catered to acute,
costly, once-in-a-blue-moon care, since not many have
managed to live for decades with a chronic disease.
chronic care patients and their payers now nd themselves
accumulating hefty medical burdens that were only meant to
be taken on once, or at most twice in a lifetime.
Hospitals themselves are feeling the strain. Many are
woefully under-stafed and over-capacity, even as expensive
new hospitals are being built to keep up with demand. But as
chronic care case loads continue to increase, and place long-
term demands on hospitals, it is feared that even building
more of them will not help matters.
Troubled by this state of afairs, medical professionals
having been in search of a solution that would provide
afordable, quality healthcare for their patients.
One promising answer to their dilemma has emerged, like
the answer to a great many others, from the onward march
of telecommunications technology. Humankinds continual
refusal to be kept apart by the partitions of space and time
has given rise to a technology now known as telehealth, or
telemedicine. In places like Australia and the United States,
the population is so spread out, the distances between
people living in remote areas and their doctors so vast, that
telehealth is not merely a convenience, but a necessity. In
the United States especially, efciency in healthcare is of
utmost urgent concernthere, healthcare spending per
capita is the highest in the world and healthcare quality
the lowest amongst wealthy nations, according to a 2014
Commonwealth Fund report.
To that end, the Australian government introduced
rebates for telehealth oferings in 2011 via Medicare,
Australias universal healthcare insurance programme, and
nancial incentives for specialist doctors to conduct video
consultations for Australians in remote, non-metropolitan
regions. In the UK, the Whole System Demonstrator
programme was launched in 2008 by the Department
of Health as the worlds largest randomised control trial
of telehealth and telecare. In the US, the Department of
Veterans Afairs currently runs perhaps the worlds largest
telehealth programme for its independent minded veterans.
2000 2030
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2012 2015
Non-Communicable Diseases
Communicable Diseases
Injuries
Global Mortality Rates, by Cause
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Non-communicable diseases are set to
overtake communicable diseases as the
top cause of death globally. Projections by
the WHO indicate that non-communicable,
chronic diseases will dominate the case
load for health systems in the near future,
making their current focus on acute care
an unsustainable one. Data from the World
Health Organisation.
But the tide is turning. Medical advancements have meant
that chronic diseases are no longer short-term killers, but
systems of care for longer-lived patients are still caught in the
antiquated model of the past. Trapped in a healthcare system
centred around the occasional high-expense hospitalisation,
2
Yet other implementations of telehealth hook up monitoring
devices in a patients home that allow doctors and nurses
to monitor their condition even after being discharged.
Together, these components of telehealth promise to
transform the way that patients and healthcare providers
communicate and collaborate with each other in keeping
patients healthy.
World governments are not the only ones with an eye
on telehealth. According to a 2012 survey by the Economist
Intelligence Unit in 10 developed and emerging economies,
approximately 60% of healthcare payers have begun to pay
for, or are planning to begin paying for telehealth services by
2015.

Amongst the most enthusiastic are some of the United
States largest payers, Aetna, Cigna, UnitedHealthcare,
BlueCross, and BlueShield, and employers General Electric
and Delta Airlines. Hospitals and healthcare groups
across the United States such as the Cleveland Clinic
(one of 4 top medical centres in the US) and the Columbia
University Medical Centre have also established their own
implementations of telehealth services to meet ever growing
demands on medical resources.
Across the board, stakeholders cite cost savings through
reductions in hospital service use and the empowerment
of patients to take charge of their own health. This is made
possible by the access that patients gain to personalised
information and healthcare recommendations through
telehealth technologies. In anticipation of consumer demand,
Aetna even bought the popular healthcare information
application, iTriage, to sharpen their competitive edge. The
app boasts some 10 million downloads as of the time of
writing.
Existing telehealth oferings from the private sector range
in scope. Some apps help people monitor their diets, or their
diabetes on their smartphone. Other apps allow people to
consult a doctor about minor ailments via video call, for a fee.
Employers and payers in the US have been
enthusiastic about telehealth services
3
Telehealth Now
With the global telemedicine business projected to balloon
to USD$27.3 billion by 2016, according to a BBC Research
report, it is not hard to see the demand for telehealth
solutions from increasingly tech savvy consumers.
Looking forward, as telecommunications technologies
such as smartphones and the Internet continue to become
ever more indispensable, consumers young and old will
begin to actively demand telehealth services from healthcare
providers. A recent survey by FICO, a predictive analytics
and decision management software company, revealed that
of the 2,239 adult respondents, 80% want to be able to use
their smartphones to communicate with their healthcare
providers, and nearly two-thirds would prefer to be able
to consult their physicians via telehealth, rather than in
person. Accustomed to the anytime, anywhere ethos of
the smartphone age, consumers across all demographic
groups will expect healthcare providers to provide telehealth
services by default in the near future.
In response to consumer enthusiasm, led by the rise of
wearable health trackers such as the Nike FuelBand, tech
giants Apple, Google, and Microsoft have announced various
mobile health oferings of their own. The Apple HealthKit and
Google Fit are set to centrally collate and coordinate health
data from a variety of mobile health apps on their respective
smartphone platforms, making it easy for smartphone users
to share their health data across all of the health-related
apps on their phone. At the same time, all three want to be
able to directly collect health data from consumers via future
releases of smart watches and smart wearables collections.
Consumers eager to use telehealth services will soon be
spoiled for choice.
Telehealth services with proven track records today
can be broadly categorised into 3 groups: teleconsultation,
telemonitoring, and electronic medical record keeping.
Teleconsultation allows patients to consult doctors about
non-emergency medical conditions such as pink eye and
allergies over an online video link without having to step
out of their house. Telemonitoring, on the other hand, helps
healthcare professionals keep a close eye on patients
recovering from surgery and those dealing with chronic
medical conditions. This afords patients their independence
and healthcare professionals more time for other patients in
greater need of urgent care. In the back, electronic medical
record keeping ties the whole system together. It allows
healthcare professionals to see a patients entire medical
history at a glance, helping them make more accurate and
timely diagnoses of conditions.
In the following sections, we will systematically review
some of the more noteworthy developments in telehealth
over the past decade, and then turn our eye to the
opportunities these developments present for Singapore.
Teleconsultation
In jurisdictions where it is permissible, teleconsultation allows
patients to consult doctors about non-emergency medical
conditions such as pink eye and allergies over an online
video link without ever having to step out of their house.
Besides the obvious conveniences of being able to stay
rested indoors when sick, teleconsultation also allows ill
patients to stay quarantined from healthy people, and from
other contagious diseases that may be spreading at medical
facilities. Furthermore, some teleconsultation services such
as Teladoc are even available 24/7, allowing patients to be
able to consult someone immediately even in the middle of
the night in the case of potential medical emergencies.
In places such as the US where general practitioners
are in short supply, and doctors generally not consulted
unless the medical condition is potentially life-threatening,
the establishment of a teleconsultation network can help
prevent unnecessary and costly visits to the emergency
room (ER). One such initiative in schools and nursing homes
in rural Nashville, Georgia allowed non-emergent patients
to be treated remotelyambulances were sent out only in
the event of a true emergency. In total, the GPT (Georgia
Partnership Network) estimates that teleconsultation resulted
in 278 avoided ER visits and approximately USD$834,000
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saved that year. The school and nursing home telemedicine
network
[Minich-Pourshadi, 2012]
helped reduce costly ambulance and
hospital admissions charges. It also alleviated part of the load
on the often overcrowded ERs, allowing ER staf to spend
their time tending to other more urgent incoming cases.
Telemedicine services that allow patients to avoid such
costly visits to the doctor have been replicated in the private
sector, and have proved enormously popular with healthcare
payers, employers, and patients alike. For employers,
the draw of teleconsultation is obvious subsidising
teleconsultation would mean that employees are more likely
to stay at work all through the teleconsultation session,
instead of having to spend time travelling to and from the
clinic, cutting down on productivity losses from medical
leave. Payers and employers also experience savings from
co-paying for the signicantly less expensive option of
teleconsultation.
In 2013, Pepsi Bottling Ventures (PBV), the largest bottler
of Pepsi-Cola products in the US, reported a 400% return
on investment (ROI) by providing employees with non-
emergency healthcare through Teladoc, a telehealth service
provider. Rather than having to pay an expensive trip to
urgent care centres for relatively minor ailments, employees
could consult doctors via online video conferencing through
Teladoc, resulting in a reported annual USD$200,000 of
savings
[Teladoc, 2013]
in healthcare expenses and employee
productivity-retention by PBV. Another case study from
Teladoc reports that Rent-A-Center, a US retailer with over
12,300 employees, saved USD$1,289,359 over 2 years
by ofering the use of Teladoc to its employees. Similarly,
Delta Airlines has partnered up with NowClinic to provide
a comparable service for their employees, reporting high
employee satisfaction with the efciency of the service.
Pharmacies and hospitals have begun jumping on the
non-emergency teleconsultation bandwagon as well. Rite Aid,
a US pharmacy chain, has begun ofering teleconsultations
with NowClinic as a cheaper alternative to hiring a staf
practitioner for each of their individual stores. Meanwhile,
a group of 4 hospitals in Minnesota and Wisconsin now
ofers USD$40 online teleconsultation sessions with nurse
practitioners as an alternative revenue stream. Even Google,
the tech giant, has initiated a partnership with One Medical, a
medical professional network, to ofer by-the-minute medical
teleconsultations to the online public through its new expert
consultation service, Google Helpouts. The rising popularity
and supply of such services reect the enormous cost
and productivity savings that telehealth brings to patients,
healthcare providers, payers and employers alike.
Telemonitoring
Telemonitoring, the remote monitoring of chronic
care patients by healthcare professionals using
telecommunications systems such as video or telephone
links, has enormous potential for alleviating doctors
workloads over the coming decades. This rendition of
telehealth is particularly useful for keeping an eye on patients
with chronic conditions such as diabetes, COPD, heart failure,
and obesity, as well as for creating a more comprehensive
after-surgery care regime.
Savings using the Teladoc telehealth
service; taken from Teladoc website
(gures not to scale)
On average, 8% of patients would have
visited the ER, 42% urgent care, 1%
specialists, 38% their family doctor, and 11%
done nothing if they hadnt used Teladoc
[Teladoc, 2014].
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With telemonitoring systems in place, chronic care
patients can receive low-level round-the-clock monitoring.
Intuitively, this would help lighten doctors workloads, since
telemonitoring can replace doctors appointments in part.
Patients save on transportation time and costs from attending
doctors appointments, yet gain direct access to their doctors.
This means that any sudden developments of symptoms
can be reported immediately, instead of at the next belated
appointment. But do these benets actually help to lower
overall healthcare costs? Will replacing direct care by doctors
and nurses with telecare end up harming patients instead
of helping them? Can telemonitoring really help free up
healthcare resources for more urgent users?
These questions about the efectiveness of
telemonitoring have been repeatedly investigated by
researchers over the past decade. A complaint prevalent
in literature is that studies are too small, and of too poor a
quality, to determine whether telemonitoring would scale
well, and that more studies will be needed to determine
whether telehealth is really worth the trouble. This is an
understandable concern. The medical profession is known
to be resistant to changeill-considered moves on the part
of healthcare professionals could potentially cost human
lives. But most researchers (probably in a bid to justify the
signicance of their work to grant committees) seem to
be merely parroting one anothers pessimistic sentiments
Analytics
Feedback
Monitoring
Cloud Server
Payers
Daily Quizzes
Reminders
Symptoms
Patient Data
Call for help
Patient Nurse Doctor
Telehealth
Device
Computer
Instructions
Advice
Prescriptions
Symptoms
Patient Data
Calls for help
Aggregated
Data
Direct Intervention
A general schematic of telemonitoring systems The patient interacts with the telehealth device, keeping a daily
log of key clinical data, depending on the condition being monitored. The device in turn quizzes the patient on
self-care knowledge, providing the correct answers when answered wrongly. The healthcare team can then look
at user provided data and look out for any warning signs of worsening conditions, and stage interventions as
needed.
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despite the signicant body of quality literature available
today. To the other stakeholders in the healthcare sector,
uninitiated in the unique self-deprecatory language of
scientic literature, most research would paint a deceptively
pessimistic view of telehealth technologies, even if they were
efective.
Throughout this section, we report on 3 major, closely
scrutinised, rigorously tested renderings of telehealth by the
United Kingdoms Department of Health, the Bosch Health
Buddy, and the United States Department of Veterans Afairs.
Each of them has found success in their health system in
their own way; collectively, they pave the way for other future
telemonitoring systems to come.
United Kingdom Whole System Demonstrator (WSD)
Launched in 2008 by the UK Department of Health, the
WSD sought to nd out whether the use of technology
as a remote intervention make[s] a diference
[DH, 2011]
. The
WSD collected 12 months worth of data on 6191 patients
in Newham, Kent, and Cornwall, cluster-randomised into
telemonitored and usual care groups. Of these patients,
there were 3030 with diabetes, heart failure, or COPD.
Each region was free to use its own implementation
of telemonitoring systems, the rationale being that the
WSD was to test the efectiveness of the whole gamut of
telemonitoring systems that could exist in the real world.
Data from the WSD is being analysed by researchers
at City University London, the University of Oxford, the
University of Manchester, Nufeld Trust, Imperial College
London, and the London School of Economics. Its results
are being published in successive papers over the years
following the study. The Department of Health claims that
preliminary results from the WSD have indicated a possible
15% reduction in A&E visits, a 20% reduction in emergency
admissions, a 14% reduction in elective admissions, a 14%
reduction in bed days and an 8% reduction in tarif costs, as
well as a 45% reduction in mortality rates
[DH, 2011]
with the use
of telehealth.
Bosch Health Buddy The Bosch Health Buddy was rst
designed by IDEO, a leading design and consulting rms, for
the Health Hero Network in 1998. It is an extremely simple
telehealth device, consisting solely of 4 large buttons and a
liquid crystal display that displays diferent options for each
button depending on the screens immediate context. During
development, designers did not assume that users would be
familiar with conventional electronic user interfaces, since a
large proportion of the user base consists of elderly patients.
Since then, Health Buddy has been acquired by Bosch as
part of its expansion into telehealth technologies.
Studies have shown that the use of Health Buddy can
signicantly reduce ER visits and hospital days, and produce
corresponding savings on healthcare costs. It was awarded
the silver Medical Device Excellence Award in 2000, and
was recognised as one of the best Products of 2000 by
Business Week.
United States Department of Veterans Afairs The VA is the
largest telehealth provider in the US, and arguably, in the
world. Pilot trials of telehealth services were rst undertaken
in 2000-2003 in the southwest US so as to better reach
veterans living in remote regions. After it was proven that
telehealth was a viable replacement for in-person care, the
scheme was rolled out to the rest of the VA.
Today, the VA ofers 3 major telehealth and
telemonitoring services to its veterans. Its Clinical Video
Telehealth (CVT) service ofers real-time video consultations
for 44 clinical specialities such as tele-intensive care, tele-
mental health, and tele-cardiology. The Home Telehealth
(HT) service is the archetypal telemonitoring service, where
chronic care patients receive care and support at home
from remote healthcare professionals. Lastly, its Store and
Forward Telehealth (SFT) service allows clinical images to be
captured and forwarded to medical specialists for review at
a later time.
In 2013, 11% of the US veteran population received
some form of healthcare through telehealth, with 603,532
participating patients and 1,787,181 telehealth consultations
performed in that year alone
[VA, 2013]
.
7
Patient Outcomes
Will telehealth bring about only insignicant improvements
to the health of chronic care patients? Will replacing direct
healthcare with telecare harm, instead of help patients? Most
studies on telehealth report on patient outcomesand those
that do generally report that telemonitoring improves patient
outcomes. According to a 2010 review of studies on video
telehealth services, 91% of studies found that video telehealth
services produced patient outcomes equal to or better than
those that did not involve video telehealth
[Wade et al., 2010]
.
Diabetes is one example of a chronic condition that can
be efectively managed with help from telemonitoring. With
diabetes, irregularities in insulin production or uptake leads to
glucose building up in the bloodstream, resulting in a host of
other possible medical complications, such as heart disease,
vision loss, and kidney disease. Unfortunately, diabetes
cannot be curedonly managedmaking telemonitoring an
attractive long-term option for diabetics.
Several large scale studies on the efect of telemonitoring
on patient outcomes have been conducted. These studies
most often use the level of haemoglobin A1c, or glycated
haemoglobin, as a proxy measure of long term blood glucose
concentration, and thus how severe a patients diabetes is at
the time of measurement.
In the Columbia University Informatics for Diabetes
Education and Telemedicine project (IDEATel) project, a 2007
telehealth study of 1,665 elderly diabetics living in medically
underserved parts of New York City and New York State,
patients in the study who were given additional telehealth
support were found to have managed their diabetes better
than those given only usual care.
On the provided telehealth system in the study,
telemonitored patients were able to interact with nurse
case managers via video call or online messaging, upload
their blood glucose and blood pressure data for monitoring,
access their own clinical data, and access an educational
diabetes care website created specially for the project.
All this contributed to the improved patient outcomes.
Compared to the usual care group, those with telemonitoring
support managed to further lower their mean haemoglobin
A1c (p = 0.006), systolic and diastolic blood pressure (p =
0.001), and LDL cholesterol (p < 0.001) levels by statistically
signicant amounts
[Shea, 2007]
, showing that diabetes can be
better managed with the proper application of telemonitoring.
3 years after the IDEATel study was published,
DiabetesManager, a medical mobile application, emerged
on the market, becoming the rst app to gain FDA approval
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Results from the IDEATel Project show that telemonitoring helps in diabetes management The levels of A1c, blood pressure, and
cholesterol decreased signicantly more in telemonitoring patients than in usual care patients. The means that the severity of diabetes in
the telemonitoring patients has been reduced signicantly in comparison from better disease management through telemonitoring. Data
taken from [Shea, 2007].
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for the coaching and treatment of diabetes 2 in 2010.
The application allows patients to enter data important
for diabetes management, such as blood glucose levels,
carbohydrate intake, and medications, and then automatically
responds with personalised educational, behavioural, and
motivational
[Quinn et al., 2011]
suggestions for patients to better
manage their condition. These automated messages are
occasionally supplemented by electronic messages from
Educators at WellDoc. Patients also receive an electronic
action plan every 6 weeks as a personal and physician
pre-visit summary. In addition, the data is stored online,
accessible to both the patient and their primary care
physician through a web portal.
The efcacy of DiabetesManager has been veried in a
trial by researchers at the University of Maryland School of
Medicine, and published in Diabetes Care, the top-ranked
journal in the eld of diabetes treatment and care. The trial
randomised 163 patients into 4 groups with varying levels
of the use of DiabetesManager and primary care physician
(PCP) involvement.
After 12 months of monitoring, it was found that
the patients in 2 of the groups (CO, CPDS) using
DiabetesManager had reduced their A1c levels
signicantly
[Quinn et al., 2011]
more than the group that was not
using it (UC). Those who were not using telemonitoring
experienced a mean A1c change of -0.7%; those who were
using DiabetesManager by themselves (CO) experienced
a greater mean -1.6% change in A1c (p = 0.003), while those
who were using DiabetesManager in tandem with their PCP
(CPDS) through the web portal (p < 0.001) experienced an
even greater mean A1c change of -1.9%.
These results are especially notable in light of the fact
that the FDA considers a minimum reduction of 0.5% in A1c
to already be evidence that a diabetes drug is efective
[PWC,
2014]
. On average, patients in these 2 telemonitoring groups
experienced statistically signicant 0.9% and 1.2% additional
reductions in A1c compared to the control group, showing
that proper telemonitoring-aided self-care can be just as, or
even more efective than taking some diabetes drugs. As
of 2012, DiabetesManager was reaching at least 300,000
diabetics in the US alone, according a Bloomberg report.
The health management potential of telehealth extends
just as well to other chronic conditions, such as obesity.
After initially losing weight in weight loss programmes, most
participants of these programmes regain the lost weight
again within 3-5 years
[Haugen et al., 2007]
, making efective long-
term weight maintenance regimes extremely attractive to
those who want to get slim, and stay slim.
To investigate whether telemonitoring is a viable solution
for weight maintenance, researchers in Colorado recruited
87 individuals who have successfully lost weight in the
Colorado Weigh weight loss programme to take part in a
trial of a telemonitoring weight maintenance programme.
This programme was meant as a replacement programme,
targetted at individuals who preferred not to commit to the
traditional 6-month weight maintenance programme, which
met fortnightly.
Participants were divided into 3 groups: 1 group of 31 had
chosen to enrol in the traditional programme; another group
of 31 had chosen to enrol in the telemonitoring program;
the last group of 25 had chosen not to enrol in either
programme, but had agreed to be included in the study.
Participants in both the traditional and the telemonitoring
DiabetesManager, an FDA-approved
medical mobile application, was found to
have a consequential treatment efect
when used by patients and their PCPs. A
study from the University of Maryland found
that the telemonitoring app was efectual in
helping diabetics manage their condition.
Data taken from [Quinn et al., 2011].
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Telemonitoring
9
programmes kept diet and activity logs. Fortnightly, while
traditional participants met up in small groups with registered
dieticians, the telemonitoring participants met online with the
dieticians one-on-one.
After the 6 month programme, participants in the
telemonitoring weight maintenance programme were found
to have signicant diferences
[Haugen et al., 2007]
(p = 0.003) in mass
change from the group not in either programme, with the
telemonitoring group having lost 0.6 kg, and the non-enrolled
group having gained 1.7 kg on average. In addition, the
weight loss in the telemonitoring group was not signicantly
diferent from that of the traditional group (p = 0.92), meaning
that the telemonitoring weight maintenance programme
could be a viable alternative for the traditional weight
maintenance programme.
The results were clearly in favour of telemonitoring
[Steventon et al., 2012]
. Compared to the 8.3% mortality in the usual
care group, the telemonitoring group had a far lower
mortality rate of 4.6%, since daily telemonitoring had
allowed healthcare professionals to catch warning signs of
worsening conditions early. Telemonitoring of chronic care
patients in the WSD resulted in a signicant 3.7% (p < 0.001)
[Steventon et al., 2012]
reduction in mortality, a testament to the life-
saving potential of telemonitoring.
Bosch Health Buddy A study in the US Northwest on the
efectiveness of telemonitoring using the Health Buddy
system has shown similar reductions in patient mortality
through the use of telemonitoring.
2 batches of 1,767 total Medicare beneciaries with
congestive heart failure, chronic obstructive pulmonary
disease, or diabetes mellitus were tracked for a year each
while they were using the Health Buddy telemonitoring
device in their homes. These patients were then individually
matched with demographically, geographically, and
diagnostically similar Medicare beneciaries that were
not using telemonitoring as a means of managing their
conditions as a basis of comparison.
Across the 2 batches of patients, usual care patients
experienced a 23.0% mortality rate, while patients using
the Health Buddy system experienced a 20.3% mortality
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
Neither Telemonitoring Traditional
Mean Change in Mass After
Weight Maintenance Programme
C
h
a
n
g
e

i
n

M
a
s
s

/

k
g
Telemonitoring is just as efective
as traditional weight maintenance
programmes. Individuals in a telemonitoring
programme lost signicantly more weight
than those not enrolled in a weight
maintenance programme, and lost about
the same amount of weight as those in a
traditional programme. Data taken from
[Haugen et al., 2007].
United Kingdom Whole System Demonstrator (WSD)
A component study in the WSD found that telehealth
programmes could potentially lower mortality rates in
chronic care patients. Between May 2008 and November
2009, the study tracked 3,230 diabetes, chronic pulmonary
disease, and heart failure patients randomised into usual
care and telemonitoring groups.
0
2
4
6
8
10
Telemonitoring Usual Care
Mortality Rates in WSD Usual Care
and Telemonitoring Groups
M
o
r
t
a
l
i
t
y

/

%
Telemonitored chronic care patients in the
UK WSD study experienced lower mortality
rates than their usual care counterparts.
Data taken from [Steventon et al., 2012].
10
rate, with a signicant (p < 0.05)
[Baker et al., 2011]
mean reduction
in mortality of 2.7% in the telemonitoring group when
compared to the usual care group.
With telemonitorings proven track record in managing
chronic conditions, it is no wonder that more and more big
names in the healthcare and tech industries are jumping
aboard to provide telemonitoring services to patients. For
instance, the Cleveland Clinic, regularly ranked amongst the
top 4 medical centres in the United States, has rolled out a
Heart Care at Home telemonitoring programme for patients
who have just been discharged for heart disease or surgery.
Patients can get home sooner after hospitalisation without
worrying about their prognosis, or sudden deteriorations in
their condition. Vigilant medical professionals are a mere
button press awayall day, every day.
Patient Engagement and Adherence
How has telemonitoring charted such outstanding statistics
in chronic care patient outcomes? A cornerstone of
telemonitoring systemsits commitment to assisting patients
in living independentlycould well be Ingredient X.
Many studies
[Hibbard et al., 2013]
have been conducted on the
efect of patient engagement (that is, how actively involved
a patient is with their own health care) on patient outcomes,
care experiences and costs. The consensus? The more
engaged a patient is with the process, the more likely the
patient is going to turn out healthier while also paying
signicantly less for their healthcare.
This engagement could come in many forms, including
patients keeping track of their own health data, attending
the recommended health checkups for their age, and
communicating regularly about their health status with their
primary care physician.
The upshot of active patient engagement is that the
numerous informed lifestyle choices patients make as a
result add up to greater control over their own conditions.
Drugs that are causing averse reactions, or not working
well get switched out for more efective ones. Patients get
better at recognising when they should be seeking low-
level consultations, and when they should be hospitalised
for more worrying symptoms. This is knowledge that could
drive down healthcare costsstudies have shown
[Hibbard et al.,
2013]
that highly engaged patients tend to have lower rates
of costly hospitalisations and ER visits than those who are
unengaged.
Furthermore, there is a substantial body of evidence
[Hibbard
et al., 2013]
testifying to chronic care patients adhering better to
their self-care and self-monitoring regimes the more engaged
they arecrucial in helping keep patients conditions under
control.
But patient engagement and adherence have been
notoriously difcult to sustain in the long term. People stop
taking their medication once they start getting better, cease
monitoring their health metrics the moment they think theyre
healthier, and give up quickly on healthcare routines that
are deemed to not be worth the bother in the short term.
Unfortunately, chronic conditions eponymously require a
consistent, persistent, level of management that human
nature just cannot (and will not!) sustain over the decades that
a patient has to live with the condition.
These are problems that telemonitoring is fully equipped
to solve. By tapping into our instinctual need for social
acceptance, telemonitoring can peer pressure chronic
care patients into taking better care of themselves. The
0
5
10
15
20
25
Telemonitoring Usual Care
M
o
r
t
a
l
i
t
y

/

%
Mortality Rates in Health Buddy
Usual Care and Telemonitoring Groups
Chronic care patients using the Health
Buddy telemonitoring device experienced
lower mortality rates than their matched
pair counterparts. Data taken from [Baker
et al., 2011].
11
Time / Months
12.0
12.5
13.0
13.5
14.0
S
c
o
r
e
knowledge that there is another person checking daily to see
if you have performed your self-care for the day motivates
better in the long term than a massive, but short-lived guilt
trip at a doctors appointment every few months.
Telemonitoring also lowers the inertia patients experience
in performing self-care measures by making it easier and
more convenient for them to perform their self-care. With
telemonitoring, patients can rely on automated systems
to remind them to perform their self-care and take their
medication instead of having to laboriously keep track of it
themselves.
These social and logistical incentives for patient
engagement and adherence in telemonitoring make a
diference. In (the previously mentioned) Colorado Weighs
ancillary weight maintenance programme, telemonitored
participants were much less likely to drop out halfway than
traditional participants. While the traditional programme
patients had to commute fortnightly to their lessons at the
medical centre, telemonitoring patients could just attend
these sessions online without the hassle of having to leave
the house.
Researchers further found that telemonitoring participants
rated the telemonitoring programme to be signicantly (p
= 0.0001)
[Haugen, 2007]
more convenient than their traditional
counterparts did theirs. The convenience of being able to
participate in the weight maintenance programme from home
encouraged participants to stick to their regimes over the
long term. As the studys authors noted, [o]ne of telehealths
main strengths is its capacity to help make health care
consumer-friendly and adapt to the needs of the individual,
rather than demanding the individual adapt to the health care
system.
[Haugen, 2007]
Bosch Health Buddy Healthcare researchers in the
Netherlands conducted a study on the efects of
telemonitoring (via Health Buddy) on engagement and
adherence in heart failure patients. In the trial, 382 patients
were randomised into telemonitoring and usual care groups,
and their self-reported engagement and adherence metrics
recorded at 0, 3, 6, and 12 months from the start of the
study.
6 of the metrics tracked improved signicantly more for
those who were telemonitored
[Boyne et al., 2013]
. Telemonitored
patients were found to have signicantly better disease-
specic knowledge, self-care (how well they take care of
their own health), and self-efcacy (how condent they
0 3 6 12 9 0 3 6 12 9
Time / Months
*lower is better
15
17
19
21
23
S
c
o
r
e
Self-Care*
0 3 6 12 9
Efect of Health Buddy Telemonitoring on Patient Engagement Metrics
Heart failure patients get more engaged with their health when using the Health Buddy telemonitoring device. Patients were quizzed
on their knowledge on heart failure using the Dutch Heart Failure Knowledge Scale, their self-care behaviour using the European Heart
Failure Self-Care Behaviour Scale, and their self-efcacy (their condence and perseverance in their self-care) using the Barnason
Efcacy Scale. Patients in the telemonitoring group showed signicant improvements in their scores for all these measures during the
study after the scores were adjusted for their starting values. Data taken from [Boyne et al., 2013].
Usual Care Telemonitoring
50
51
52
53
54
55
56
S
c
o
r
e
12
are of being able to succeed in their self-care). They also
adhered better to daily weighing, the use of medication, and
uid restriction.
However, telemonitoring did not seem to produce
much of an efect on some other adherence metrics. For
3 of the metrics (appointments, abstinence from smoking,
and abstinence from alcohol), adherence levels were high
from the very beginning, making it difcult to achieve any
incremental efect on these metrics. The other 2adherence
to the salt restricted diet and physical exerciseproved
difcult for both the usual care and telemonitoring regimes
to change. These resistances will require perhaps more
sophisticated handling to resolve.
Researchers reported that with the telemonitoring
system in place, telemonitoring patients spent less
time in contact with the nurses in charge, despite their
improvements in engagement and adherence metrics over
and above that experienced by the usual care patients, who
were monitored closely by the nurses.
This suggests that telemonitoring could efectively
take over some part of the tedious patient monitoring
and education from nurses, leaving them free to tend to
other, more urgent, matters. More importantly, patients
gain a bigger stake in taking better care of their own long-
term health, which could reduce the number of costly
hospitalisations that they have to undergo.
Patient Satisfaction and Usability
Chronic care patients now have a new way of keeping
themselves healthy in the long-term, with some ingenious
help from modern technology. But also salient to the
discussion is the fact that many chronic care patients also
rank amongst the elderlya demographic known to be rather
reluctant in picking up new technology. If the majority of
telemonitorings target demographic is hesitant in adopting
its technology, will telemonitoring be able to reach out
efectively to a majority of chronic care patients?
Further, medical traditionalists are (rightfully) concerned
with how patients will perceive being ofered indirect
telemonitoring care, instead of the traditional direct care
ofered at medical care facilities. Though telemonitoring is
just as, or even more efective than traditional care in many
circumstances, will patients feel like they are receiving sub-
standard care through telemonitoring because of the physical
absence of healthcare professionals?
These concerns about usability and patient reception
have been echoed in telemonitoring literature. As a
-1
0
1
2
3
4
5
6
Estimation Importance
S
c
o
r
e
Change in Adherence to Medication
0
2
4
6
8
Estimation Importance
S
c
o
r
e
Change in Adherence to Fluid Restrictions
-2
0
2
4
6
8
10
12
Estimation Importance
S
c
o
r
e
Change in Adherence to Weighing
Efect of Health Buddy Telemonitoring on Patient Adherence Metrics
Telemonitoring Usual Care
Heart failure patients adhere better to their self-care regimens with the help of Health Buddy. Adherence was measured using the
Heart Failure Compliance Scale, which takes into account the 6 measures of appointment- keeping, medication, sodium restriction, uid
restriction, daily weighing and exercise. Telemonitored patients were found to adhere signicantly better to daily weighing and uid
restrictions, and estimated the importance of medication to be higher after using Health Buddy for 12 months. Data taken from [Boyne et
al., 2013].
13
consequence, they have been repeatedly investigated as
part of numerous telemonitoring trials, both independently
and federally funded, to elucidate the viability of
telemonitoring in the context of its target demographics.
The Medicaid-supported IDEATel study (see Patient
Outcomes) that demonstrated the merits of telemonitoring
in diabetes management also conducted surveys of patient
and physician satisfaction with the system. According to the
authors, all 346 telemonitored patients who responded to the
survey gave uniformly high satisfaction ratings of 4 out of 5
or higher on each of the 26 questions on the survey about
the telemonitoring programme
[Shea, 2007]
. 116 physicians to some
of these patients also indicated a generally high level of
satisfaction
[Shea, 2007]
with the telemonitoring programme.
These high satisfaction ratings from physicians and
patient were not easily won. Of the studys participants,
more than half reported annual household incomes of
USD$20,000, approximately 79% reported that they
did not know how to use a computer prior to the study,
and all participants were elderly, being of age 55 and
above. Despite being the antithesis of the young and
tech-savvy demographic that would take immediately to
telemonitoring technology, these patients were still able to
benet immensely (and contentedly, to boot) from using the
telemonitoring system.
United States Department of Veterans Afairs and
Bosch Health Buddy In a 2010 interview with Ageing
International, Adam Darkins, Chief Consultant for Telehealth
Services at the VA, observed that although shifting
healthcare services to the realm of the digital may make
it seem more impersonal in theory, telehealth actually
supports relationships between the patient and the care
coordinator
[Lindeman, 2010]
in practice.
Far from short-changing the patient by depriving
them of contact with healthcare providers, telehealth
and telemonitoring services actually bring patients and
physicians closer together on a daily basis, facilitating more
frequent bite-sized conversations that can help further ne-
tune and personalise patients treatment regimes.
Darkins also notes that most resistance (when there has
been any) came from clinicians initial reservations about this
relatively new mode of treating patients. On the other hand,
patients were relatively enthusiastic and satised with its
telemonitoring services from the very start. Even when the
VA was just starting to roll out its telemonitoring services in
2006, a survey of 42,460 early adopters already indicated
a mean 86% satisfaction
[Darkins et al ,2008]
with its telemonitoring
services. Of the many patients that the VA telehealth service
has treated, 90%
[Lindeman, 2010]
would be happy to continue
with using the telehealth services that the VA ofers instead
of reverting to in-person care. These telehealth services
were not just usable by the entire demographically diverse
spectrum of patients served by the VA, but also widely
accepted by patients and physicians involved with the
programme.
One of the reasons the telehealth programme
found such a warm reception amongst patients was the
uncomplicated push-button devices that the telehealth
service provided for patients. Such devices are simple in the
extremeone of them has just four big buttons and a LCD
screenthey just work. Patients need only think about their
health when using the device, and not about how to use or
troubleshoot complicated technology.
So the vast majority of patients have neither qualms nor
difculty with receiving healthcare through telemonitoring
servicesthis even includes patients who are not traditionally
known to be particularly technologically inclined. Moreover,
upon having experienced the conveniences of telemonitoring
Patients with the VA health service
welcome the use of telemonitoring in
their healthcare delivery. Data taken from
[Darkins et al., 2008].
90% of patients
want to continue
with telemonitoring
14
care, many patients are loath to part with it
[Darkins et al., 2008]
. Not
only are telemonitored patients living healthier and happier
thanks to telemonitoring technology, they are also gaining
deeper and more productive relationships with their doctors
and caregivers.
Medical Resource Utilisation
One of the major benets of telemonitoring is that the health
information provided to patients through the platform helps
them make wiser health care decisions. These smarter
individual decisions on the micro-level can translate into
considerable improvements to efciency in the healthcare
sector, on the macro-level.
These efciencies have been well-documented in many
large studies of telemonitoring systems. They work both by
encouraging proper use, and reducing unnecessary use of
hospital resources. Patients who are unsure about medical
resources available to them can learn about their options
through daily contact with healthcare professionals on the
telemonitoring system. On the other hand, patients unsure
about the signicance of a particular symptom can check
with healthcare professionals before checking themselves
into a medical facility. This can save patients and payers a
potentially costly and unnecessary trip to the hospital, where
patients may also be exposed to contagions that may further
exacerbate their condition. At the same time, this helps
hospitals free up resources being infringed upon by non-
emergent cases.
For instance, researchers on the Columbia University
IDEAtel project (see Patient Outcomes) observed that the
telemonitored diabetes patients from medically underserved
regions tended to end up having better managed conditions,
and claiming more benets from Medisave than those
who only experienced usual care
[Shea, 2007]
. The authors
hypothesised that these patients had been less aware than
the average patient of the healthcare options available
to them, and that the increased contact with healthcare
professionals through the telemonitoring system allowed
these patients to seek out more appropriate care than they
would have on their own. Previously unsure and uninformed,
these underprivileged patients were able to acquire a higher
level of care more appropriate to their conditions, and stay
healthier in the long-term with the help of telemonitoring.
Inversely, a large integrated healthcare delivery and
nancing system in Pittsburgh, Pennsylvania found that they
could reduce unnecessary hospital service utilisation by
ofering a telemonitoring programme to chronic care patients.
In their pilot study, case managers were assigned to
chronic care patients to support their self-management and
self-care measures, ensure patients adhere to their medical
regimens, and consult on any medical concerns patients may
have.
Telemonitoring
Usual Care
-20
-15
-10
-5
0
5
ER Visits Readmissions Admissions
C
h
a
n
g
e

/

%
Change in Hospital Service Usage, 2009-10
The UPMC, a large integrated healthcare
delivery and nancing system in
Pittsburgh, Pennsylvania, was able to
reduce hospital service usage and improve
patient adherence to self-care measures
through a telemonitoring programme. Data
taken from [Rosenberg et al., 2012].
This yielded benets for patients and the healthcare
system alike. Diabetes patients who were being
telemonitored were tracking their disease metrics (e.g.
HBA1c levels, eye exam, etc.) more closely than their usual
care counterparts. The health system, in turn, was seeing
signicantly fewer ER visits and readmissions from the
telemonitored patients in the second year of the trial (p <
0.05)
[Rosenberg et al., 2012]
. By all counts, medical resources were
being employed more appropriately, as case managers
worked to actively close the gaps in patients pre-
existing care and ensure that patients did not need to be
unnecessarily hospitalised.
15
United States Department of Veterans Afairs In their
landmark 2008 study, Care Coordination/Home Telehealth:
The Systematic Implementation of Health Informatics, Home
Telehealth, and Disease Management to Support the Care of
Veteran Patients with Chronic Conditions, the VA published
4 years worth of telehealth service performance data
collected across 43,432 patients.
One of their main ndings was the drastic reduction
in the frequency and length of hospital stays amongst
telemonitored patients. Comparing data from the year
preceding and following 17,025 patients recruitment into the
telemonitoring programme in 2006-07, the authors found
that the telemonitoring programme signicantly cut hospital
service utilisation
[Darkins et al, 2008]
regardless of the condition
the patient was being monitored for.
These results are due to the fact that home
telemonitoring systems allow care coordinators to maintain
low level surveillance on the conditions of many patients at
once. This helps them keep track of patient self-care and
any warning symptoms of rapidly deteriorating conditions
that may arise.
Darkins, head of the VA telehealth service, describes
this as just-in-time
[Lindeman, 2010]
carenot unlike a tsunami
warning system. Just like how tsunami warnings can
save thousands of lives by getting people to evacuate
early, telemonitoring systems can warn of impending
deteriorations, enabling healthcare professionals to stage
life-saving interventions before the big wave hits, and
patients decline to such a state where they have no choice
but to be hospitalised.
Telemonitoring signicantly reduced utilisation of hospital services for all conditions monitored. Most of the patients being
telemonitored for the more common chronic conditions saw the inside of a hospital 20-30% less times than when they were not being
telemonitored. Patients being telemonitored for mental health conditions saw more drastic reductions of 40-60%. Data taken from
[Darkins et al., 2008].
2,800
patients
Change in Utilisation by Condition due to Telemonitoring, 2006-07
-60
-50
-40
-30
-20
-10
0
O
t
h
e
r

M
e
n
t
a
l

H
e
a
l
t
h

C
o
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o
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s
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p
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e
s
s
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P
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o
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c

O
b
s
t
r
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t
i
v
e
P
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l
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o
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a
r
y

D
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U
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i
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a
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i
o
n

/

%
16
United Kingdom Whole System Demonstrator (WSD)
Besides experiencing signicantly lower mortality rates (see
Patient Outcomes), telemonitored chronic care patients in
the British WSD telemonitoring trial were also in hospital
signicantly less frequently (p < 0.05), and for shorter stays
each time than their usual care counterparts
[Steventon et al., 2012]
.
Telemonitored patients experienced 10.8% fewer
hospital admissions, 20.6% fewer emergency admissions,
14.7% fewer ER visits, and 14.3% shorter hospital stays than
those under usual care regimens, on par with the statistics
published by the VA.
Paired with the nding of reduced mortality rates, these
results show that telemonitoring lets us have our cake, and
eat it too. Not only will patients stay healthy and alive for
longer, hospitals can also devote less of their already limited
resources towards treating deteriorations that were entirely
preventable in the rst place.
Cost
Given the relatively novel place telemonitoring occupies in
the public imagination, it is not unreasonable for patients,
payers, and healthcare professionals to be questioning
whether this newly-fangled technology is truly worth it.
But as telemonitoring emerges from its infancy, it has
become increasingly clear that its return-on-investment
(ROI), both nancial and medical, is attractive enough that
pre-eminent healthcare providers, like the Cleveland Clinic
and the VA (Department of Veterans Afairs), are extending
their telehealth services immediately following their own
successful prior trials of the technology.
In 2008, Emily Seto, a researcher at the Centre for
Global eHealth Innovation in the University Health Network
of Toronto, Canada identied and reviewed 10 published
trials that investigated the economic viability of home
telemonitoring for heart failure patients. Studies varied in
how they conducted cost analyses, but most considered
costs from hospital admissions, nurse telemonitoring and
intervention, telemonitoring equipment and upkeep costs,
etc. All 10 trials had found cost reductions, of up to 68.3%
from using telemonitoring over usual care
[Seto, 2008]
.
Four years later in 2012, researchers in neighbouring
Montral followed this up in a 21-month trial with 95 chronic
care patients, citing the prior review as inspiration. Their
implementation of telemonitoring resulted in cost savings of
CAD$1,557 per patient per year, shaving of 41% of annual
usual care costs
[Par et al., 2013]
. Included in these calculations
were the costs for nurse home visits, hospitalisations and ER
visits, telemonitoring equipment purchase and maintenance,
nurse salaries, and staf training costs.
The bulk of cost savings came from the shorter, and
less frequent hospital stays that the telemonitored patients
experienced. Because telemonitoring systems alert
40
42
44
46
48
50
Usual Care Telemonitoring
Patient Admittance Proportions
P
r
o
p
o
r
t
i
o
n

/

%
0.0
0.2
0.4
0.6
0.8
Usual Care Telemonitoring
ER Visits Emergency Admissions
Change in Hospital Service Utilisation
I
n
s
t
a
n
c
e
s

p
e
r

H
e
a
d
4.0
4.5
5.0
5.5
6.0
Usual Care Telemonitoring
Bed Days
D
a
y
s

p
e
r

H
e
a
d
Medical resource utilisation by chronic care patients can be reduced with the help of telemonitoring technologies. Participating
researchers in the WSD found signicant reductions (p < 0.05) in patient admittance proportions and instances of emergency admissions
and ER visits for telemonitored patients. They also tended to have shorter hospital stays once admitted. Data taken from [Steventon et al.,
2012].
17
programme for their chronic care patients
[Rosenberg et al., 2012]
.
The authors reported that following the success of their
telemonitoring trial in 2010, the UPMC planned an 8-fold
expansion of the telemonitoring programme to 240 practice
sites owned by the UPMC by 2012.
United Kingdom Whole System Demonstrator (WSD)
Other trials of telemonitoring systems did not report such
positive ndings. In the UK WSD telemonitoring trial, a
component study undertaken by researchers from the
London School of Economics and the University of Oxford
found that while telemonitoring yielded benets for patients,
the calculated probability of it being cost-efective was low.
Instead of conducting the straight-forward cost-benet
analysis used by other researchers, this WSD component
study used an indirect measure of cost-efectiveness known
as the incremental cost per quality adjusted life year (QALY).
A QALY is rated on a scale of 1 to 0, with 1 representing
perfect health, and 0 representing death. By combining
scores for a patients mobility, discomfort, self-care abilities,
anxiety and depression, and day-to-day activities, one can
theoretically determine how a year in the life of the patient
0
100000
200000
300000
400000
Usual Care Telemonitoring
Cost Calculation Breakdown
T
o
t
a
l

C
o
s
t

/

C
A
D
$
Technology Costs
Home Telemonitoring Costs
Hospitalisations
ER Visits
Home Visits by Nurses
healthcare professionals to the early signs of a patients
deterioration, resultant just-in-time interventions help prevent
costly, repeated hospitalisations from happening over the
long term. Other cost savings also come from the patient
becoming more engaged with their own self-care, adhering
better to medication regimens, and keeping healthier with a
lessened need for serious interventions in the long-term.
Encouraged by these ndings, payers and healthcare
providers have started trying to nd ways of integrating
telemonitoring into their pre-existing local health systems.
One example is the patient-centred medical home, a
telemonitoring trial set up by the UPMC, an integrated
healthcare delivery and nancing system serving 1.8 million
insurance plan members in Pittsburg, Pennsylvania.
In their trial implementation of telemonitoring for 23,900
chronic care patients covered by their health plan, the
payof from the reduced utilisation of medical and pharmacy
services (reported earlier) more than ofset the cost of hiring
telemonitoring case managers and setting up and maintaining
the telemonitoring infrastructureso much so that they were
able to gain a 160% ROI from investing in the telemonitoring
With telemonitoring, the Canadian
health system saved CAD$1,557 per
patient, per year (p < 0.025). Patients
paid CAD$2,641 less in hospital fees (p <
0.0005) when telemonitored, but these
savings were ofset somewhat by the cost
of implementing the telemonitoring system,
which came to CAD$870 per patient per
year. Data taken from [Par et al., 2013].
0
10
20
30
40
50
60
70
80
S
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m
m
i
c
k
B
e
n
e
t
a
r
M
y
e
r
s
J
o
h
n
s
t
o
n
Time / Months
C
o
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t

S
a
v
i
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g
s

/

%
Cost Savings from Telemonitoring Heart Failure Patients
All 10 studies reviewed in Setos 2008
paper reported cost savings from
telemonitoring heart failure patients. On
average, these studies found cost savings
of 26.4% from using telemonitoring over
usual care methods. Data taken from [Seto,
2008].
18
measures up against a year of perfect health.
To nd the incremental cost per QALY, researchers
then divided the additional cost from telemonitoring a
patient (~1,110) by the additional QALYs experienced by
telemonitored patient (~0.012), working out to an incremental
cost per QALY of 92,000. According to recommendations
from previous studies, payers are likely to be willing to pay
up to 30,000 per additional QALY, making the 92,000
gure only 11%
[Henderson et al., 2013]
likely to be cost-efective.
But despite the advanced methods of analysis
used in their study, authors acknowledge that there are
methodological aws present in their study design that
could have led to inaccurate results.
For example, the gure used to calculate diferences in
medical service usage costs between the 2 groups was less
of a precise measurement, and more of a rough estimate.
Unlike other studies, service use in this study was calculated
based on patients own estimates of service use, rather
than logged by the researchers themselves. It is likely that
the cost benets of telemonitoring could have been grossly
underestimated because of this uncertainty, since other
studies that meticulously logged these service utilisations
found that the greatest savings from telemonitoring came in
the form of reduced service use.
Moreover, unlike most other large-scale studies on
telemonitoring, the WSD left it up to local sites to decide
on their own design of telemonitoring systems instead of
implementing a uniform system across the entire study
population. This is little diferent from aggregating data
from small studies, a complaint common of telemonitoring
studieseach site was unlikely to have achieved the true
economies of scale the study of 3,230 patients was actually
capable of. This is hinted at by the abnormally high cost of
telemonitoring per patient per annum (1,847 = USD$2,751
in this study, vs. the VAs counterpart of USD$1,600
[Darkins
et al., 2008]
), as well as the extremely high variation in
telemonitoring costs across the study population.
These high uncertainty margins call into question the
0
100000
200000
300000
400000
500000
600000
Computer
Hardware
and
Peripherals
Computer
Software
Installation
Contractor
Costs
WSD Telemonitoring Component Cost Ranges
C
o
s
t

p
e
r

Y
e
a
r

/

Telemonitoring component costs varied

wildly across diferent sites in the UK WSD
trial, likely causing low precision in the nal
cost-efectiveness estimate. Only ranges
were reported; other important statistical
information on these costs, such as their
means and standard deviations, were
not reported in the 2013 paper, making
it difcult to discern the true statistical
signicance of nal cost-efectiveness
estimates. Data taken from [Henderson et
al., 2013].
The UPMC, an integrated healthcare
delivery and nancing system serving
1.8 million insurance plan members in
Pittsburgh, Pennsylvania reports a 160%
ROI from telemonitoring. Researchers
found that they were able to save $9.75
per patient per month by ofering a
telemonitoring service to chronic care
patients on their health plan. Savings from
reduced medical and pharmacy utilisation
amounted to a signicant $15.84 per patient
per month (p < 0.01). Data taken from
[Rosenberg et al., 2012].
Reduced
Medical
Service
Utilisation
Reduced
Pharmacy
Service
Utilisation
Net
Cost
Avoidance
Telemonitoring
Costs
-$4.73
-$11.11
-$9.75
+$6.09
160%
ROI
19
statistical signicance of the calculated cost efectiveness
value. This is an acknowledged weakness of the study,
and after using lowered telemonitoring cost estimates
and taking into account some extent of the economies of
scale that telemonitoring systems are capable of, the study
hypothesised that it was 61% likely
[Henderson et al., 2013]
that a
generalised telemonitoring system would be cost-efective.
Bosch Health Buddy A study in the US Northwest that
showed that the Health Buddy could lower mortality rates
in chronic care patients (see Patient Outcomes for study
details) also found that healthcare costs for these patients
were also signicantly reduced compared to those who
were not telemonitored.
In this particular study, cost estimates were derived from
patients Medicare claims data, but the cost of the Health
Buddy device and other monthly telemonitoring costs were
not accounted for in the nal analysis. After a 2 year study
period, researchers determined that quarterly healthcare
spending had declined on average by $511 (p < 0.01)
[Baker et
al., 2011]
for telemonitored patients, or 7.7%-13.3%. The Centers
for Medicare and Medicaid Services (CMS), which oversees
Medicare claims, evaluated this same telemonitoring
programme independently, and found slightly more
conservative cost reductions of 6.0%-8.1%.
Analysing the data by condition, the studys authors
found that patients with congestive heart failure
experienced the greatest amount of cost savings per
quarter, of USD$1,009 (p < 0.01), followed by those with
COPD, of USD$726 (p < 0.05), and nally those with
diabetes, of USD$519 (p < 0.05)
[Baker et al., 2011]
. These results are
consistent with the ndings of the VA on the reductions in
medical service usage by condition (see Medical Resource
Utilisation). Since cost savings come primarily from service
use reductions, results from these two studies corroborate
in showing that telemonitoring can result in better outcomes
despite decreased spending on healthcare.
United States Department of Veterans Afairs According
to internal data from the VAs Telehealth Service, the
average cost to provide telemonitoring services for each
patient was USD$1,600 per annum in 2008
[Darkins et al., 2008]
.
As VA researchers emphasise, the rates for traditional care
that performs similar functions is USD$13,121 per annum
within the VA, and USD$77,145 per annum for market-rate
nursing home care. In comparison, telemonitoring looks to
be an extremely attractive option for the VA in providing
healthcare for all their veterans.
Going forward, as telemonitoring technologies mature,
the cost savings that this innovative healthcare delivery
solution will bring to healthcare systems around the world
can only get more attractiveand while it is not a panacea for
the worlds ageing problems, telemonitoring could take much
of the heat of of governments and payers in being able to
pay for adequate healthcare for each ageing citizen.
Many more lives will be at stake in the near future, in
view of the projected increase in chronic disease loads.
Healthcare providers cannot aford to lag behind in adopting
life-saving technology that has been proven, over and
over, to keep patients healthier in the long-term without
putting additional loads on the healthcare system. As Adam
Darkins of the VA opined in an interview, telemonitoring has
advanced far enough today to make the cost worthwhile for
-1200
-1000
-800
-600
-400
-200
0
Congestive
Heart
Failure
Chronic
Obstructive
Pulmonary
Disorder
Diabetes
Mellitus
Cost Savings via Health Buddy Telemonitoring, by Condition
C
h
a
n
g
e

i
n

S
p
e
n
d
i
n
g

p
e
r

Q
u
a
r
t
e
r

/

$
Telemonitoring with Health Buddy can
result in reductions in healthcare spending
for chronic care patients. Patients with
congestive heart failure stand to experience
the greatest amount of cost savings per
quarter, of USD$1,009 (p < 0.01), followed
by those with COPD, of USD$726 (p < 0.05),
and nally those with diabetes, of USD$519
(p < 0.05). Data taken from [Baker et al.,
2011].
20
both public and private healthcare systems. Said Darkins,
The federal government has the ability to make strategic
investments that are not necessarily dependent on the next
quarters nancial returns, as can be the case in the private
sector. I believe that telehealth has now proved itself in the
home care environment, and the systems and technologies
that are available are robust enough that they can be used
more widely in non-governmental sectors.
Electronic Health Records
Operating in the digital realm ofers the healthcare industry
another boon to the conveniences of telemonitoring and
teleconsultation. By moving doctor-patient interactions to the
virtual world, information exchanged during these interactions
can be held for future reference, collated over time in the
cloud to form a complete electronic health record (EHR) of
each individual that can then be shared with all healthcare
providers with an internet connection.
Integrated well, an EHR will give doctors access to
relevant and complete medical information on each patient.
A doctor seeing a new patient for the rst time can make
a more informed diagnosis of a patients condition based
on not just their new symptoms, but also their medical past.
If the patient does not have the capacity to communicate
with healthcare providers (for example, right after a serious
accident), timely access to the allergy information and
medical history documented on an EHR can prove invaluable
in helping doctors quickly prescribe appropriate medications
and course of treatment.
Switching to EHRs also minimises errors in medical
documentation. For one, turning to EHRs means that
mistakes in interpreting doctors written advice could be
eliminated, preventing inaccurate record keeping and the
mis-prescription of medications. A 2006 report from the
US National Academy of Sciences Institute of Medicine
estimates that avoidable medication mistakes (such as
messy handwritings) kill 7,000 people and injure more than
1.5 million people annually in the US alone. These mistakes
crop up mainly during the prescription and administration
stages, but can easily be avoided by switching to legible,
unambiguous electronic prescriptions.
For another, the presence of an EHR could allow
patients access to their own health records. This could be
instrumental in keeping medical records accurate and up to
dateas Dave deBronkart (or e-Patient Dave, as he is known
to his blog readers) discovered after his brush with cancer,
the records that hospitals keep of patients can be wildly
unreliable.
When deBronkart had decided to start a personal health
record after his recovery, he obtained his records from
his hospitals computer system as a starting point. He was
shocked to discover that those records contained conditions
I never had, an allergy I never had, and did not contain an
allergy I do have.
Worse, missing from those records were important
information such as lab and radiology data from his stays
at the hospital. In an interview with HealthIT.gov, a US
government website set up to educate medical professionals
and the public about EHR use under Obamacare regulations,
deBronkart stressed the importance of patients being able
to access and update their own medical records whilst they
are healthy. Otherwise, were a medical crisis to hit, patients
run the risk of being treated with unsuitable medication, and
healthcare professionals run the risk of facing a malpractice
suit.
Another HealthIT.gov interviewee, Regina Holliday, holds
inaccessible medical records responsible for her husbands
end-of-life sufering. After her husband was diagnosed
with end-stage kidney cancer, Ms. Holliday had to ght the
hospital for access to his medical records, so that she could
take better care of him in his last days. It took 21 days to
get to them, at a time when his life span was measured on
a timescale of mere weeks. When she nally read it, [she]
was astounded because it was lled with actionable data
that would have impacted his care and created a better
living condition for him, and for [them]. Had there been a
centralised EHR system accessible to both doctors and
patients, Ms. Holliday and her husband could have been
engaged, active participants in his end-of-life care, instead of
feeling unempowered in the face of the unknown.
In the long term, the data that centralised EHRs collect
from patients could help make healthcare more holistic
21
than it is today. Its biggest strength is personalisation, made
possible by the colossal amount of data collated from
individuals that could aid big-data researchers in devising
individualised treatment regimens.
In his interview with Ageing International, Darkins of the
Veterans Afairs Telehealth Service stated that in order for
a telemonitoring system to achieve success of a kind of the
VAs, a vital prerequisite is to have an electronic patient
record. Physicians can tweak patients medications if the
EHR shows that the medication has not been efective.
Longitudinal trends in a chronic care patients condition can
allow for just-in-time interventions to be staged, and for costly
hospitalisations to be prevented.
Michael Seid, a professor of paediatrics at the Cincinnati
Childrens Hospital Medical Center, describes this as the
bodys check-engine light. His research suggests that
patients tend to withdraw from society and avoid leaving the
house in the days before are ups. Tracking these warning
signs has helped his team reach out to patients with chronic
gastrointestinal troubles before they crash.
Beyond just personalising treatments for those who
are already sick, EHRs can also be a big help for healthy
peopleor those who think they are healthy. Chronic
diseases are more prevalent in certain subsets of the
population, especially those with genetic or environmental
pre-dispositions. If these factors can be identied early from
patients EHRs, then they can be automatically advised to go
in for the relevant health screenings more regularly than the
general population.
As things stand, evidence on current models of health
screening show that they may not be cost-efective in the
long-term
[Cohen et al, 2008]
, or even benecial for most
[Joelving, 2012]
.
Prevention may not necessarily be better than cure.
Encouraging health screenings for the general population
is just not cost-efective, since the incidence of most chronic
diseases is too low to be worth the screening costs when
averaged over the entire population. Worse, with some
chronic diseases such as slow-growing prostate cancer,
diagnosing and treating the patient is likely to cause more
monetary and medical harm than good. Because the cancer
progresses so slowly, the tumour may not have troubled
the patient in their lifetime. But once it gets diagnosed, the
combination of invasive tests and toxic chemotherapy may
just kill the patient before their time has come.
To increase the efcacy and cost-efectiveness of
preventive health screenings, a more targeted approach
must be taken. This is where an EHR comes in useful. With
an accurate EHR in place, people that exhibit risk factors for
certain diseases, such as age or family history of the disease,
can be identied automatically by the system. Paired with
an efective telehealth system, these people can be called
in automatically for health screenings more frequently than
the general population, making the most of available medical
resources and preventing over-diagnoses.
To achieve these ends, EHRs need to accrue
comprehensive patient information from institutional
and personal sources. The push for such open-access,
comprehensive EHRs has already started online. US
legislators explicitly recognised the value of EHRs when
enacting their latest rounds of healthcare reform, and have
set up an integrated EHR access website known as the Blue
Button Connector. This website provides Medicare patients
with complete access to their health records from their
healthcare and insurance providers. Patients can get access
to their own medical records with just a few clicks of the
mouse.
These open-access electronic health records will
contribute to fullling the meaningful use clause of
Obamacare regulations, in which physicians are required to
make use of patient-provided data in treating them. Patients
empowered with access to their own EHRs are likely to
get engaged, and stay engaged with keeping themselves
healthy in partnership with their healthcare providers.
Coupled with data-driven technologies, the predictive
power of EHRs gets better the more people use it. With
the growing amounts of data coming in from physicians,
patients and telehealth platforms, algorithms become ever
more accurate in pin-pointing aggregate trends to provide
personalised and afordable healthcare for each individual.
22
Indeed, this weak link in the healthcare system has
been acknowledged by MOH Holdings, which owns all
of Singapores public healthcare assets. MOH Holdings
highlighted in the 2012 HIMSS conference that Singapores
primary care services are not well integrated with those
for intermediate and long-term care (ILTC), resulting in
frequent readmissions and disproportionate pressures on
the acute and tertiary care sector. After chronic care patients
are discharged following hospitalisations, no efective
coordinating system currently exists to make sure they stay
healthy, and out of the hospital. Also highlighted by the
local Agency for Integrated Care (AIC), a subsidiary of MOH
Holdings, was the lack of patient condence in the care
capabiilties of the ILTC system when being transferred after
discharge.
The disconnect between primary, acute, and ILTC
services constitutes a serious gap in the existing healthcare
system. In light of research that suggests that half of all
healthcare spending for chronic care patients originate
from hospital service use costs
[Henderson et al., 2013]
, the increasing
prevalence of chronic disease threaten to strain not just
the nances, but also the resources of the system. Already,
Given Singapores position as an ageing and
technologically-advanced city, telehealth applications will
become vital over the next few decades in ensuring that
healthcare costs remain under control for the island-state.
Here, the percentage of those aged 65 and above is set to
nearly double to 23.1% in just 6 years
[BMI, 2014]
. The government
has pledged to expand state expenditure on healthcare to
cover 40% of the national aggregate.
Though globally touted as a shining beacon of medical
efciency, the view from the inside is not as rosy. While public
healthcare spending currently constitutes just 4% of national
GDP, it is on the rise. The ageing population is putting
nancial pressure on patients, payers, and the public sector
to nance the resultant increase in chronic disease case
loads. Recent reports from both PriceWaterhouseCoopers
(PWC) and Business Monitor International (BMI) warn that the
current focus on acute care in the local healthcare system
will quickly become deleterious in the face of the growing
number of chronic care patients. The BMI, in particular,
recommended shifts towards sustainable community
and home-based care methods in its Q3 2014 Singapore
pharmaceuticals and healthcare report.
Translations for Singapore
5% 5% 4% 4% 3% 3% 2% 2% 1% 1% 0%
The proportion of those aged 65 and above is projected to double to 23.1% in 2020 in just 6 years. Data from the UN.
0 - 4
5 - 9
10 - 14
15 - 19
20 - 24
25 - 29
30 - 34
35 - 39
40 - 44
45 - 49
50 - 54
55 - 59
60 - 64
65 - 69
70 - 74
75 - 79
80 - 84
85 - 89
90 - 94
95 - 99
100+
Female Male
Projected Population Pyramid, 2014 -2020
by 5-year Age Group
2020
2014
23
local hospitals and nursing homes are facing issues such as
severe bed shortages and a shortfall of qualied medical
professionals in the intermediate and long-term care
sectors
[BMI, 2014]
.
To close this gap, MOH Holdings is already looking
towards harnessing telehealth services from the agile private
sector
[Muttitt et al., 2012]
as a means of mitigating costs. In view of
the technologys proven track record in streamlining costs,
the healthcare system will be able to signicantly reduce
hospital readmissions and ER visits for chronic care patients
without compromising on care standards.
What makes telehealth services even more promising
for the nation is the preponderance of telecommunications
technology ownership by individuals, which could result in
even greater cost-savings than currently documented. 2013
data from the Infocomm Development Authority suggests that
87% of Singaporeans have access to the Internet at home,
meaning that online telehealth services will result in little to
no additional infrastructure costs to patients and payers. Even
more encouraging is the fact that a majority of Singaporeans
have an expressed interest in using digital health services
the 2014 McKinsey Digital Patient survey indicated that more
than 75% of respondents in Singapore want access to quality
digital healthcare services.
One of the few required infrastructure investments for
telehealth services in Singapore has already been pioneered
in the public sector. Forming the backbone of all future
telehealth services will be the National Electronic Health
Record (NEHR), accessible to all healthcare providers in
Singapore. This lays the foundation for future private sector
solutions that can cater then specically to the diverse needs
of each healthcare provider.
Further developments in local telehealth services will
have to come from the bottom-up, rather going from the top-
down as in the case of the NEHR. While the public sector is
able to establish consistent and portable standards important
for data-intensive telehealth solutions such as the NEHR, the
private sector, with its natural adaptability, is better at nding
exact ts for the needs of individual healthcare providers.
The resulting smorgasbord of compatible telehealth
applications, such as teleconsultation, telemonitoring, and
personal electronic health records, will allow healthcare
providers to collaborate with patients in their ongoing
treatment using patient-provided health data. MOH Holdings
hopes to be able to collect such data via its web portal,
healthy.sg. It is currently in a limited beta, and caters to
all individuals, regardless of whether they have known
conditions. Most of the metrics it currently tracks focus on
diet and exercise data for healthy people. Whether the
government portal will be able to sustain engagement with
healthy patients in getting them to consistently input health
data over the long-term remains to be seen.
Other eforts towards implementing telehealth systems
for Singaporean patients are promising, though fragmented.
Most healthcare providers have already recognised the
potential of such programmes in the local context, and are
looking to expand on existing initiatives in the near future.
For instance, hospitals such as Changi General are already
ofering their own small scale telemonitoring services for
their chronic care patients, while Tan Tock Sengs NHG Eye
Institute ofers a programme for patients to be referred to eye
specialists via teleconsultation from Hougang Polyclinic. Pilots
have also been started at Khoo Teck Puat Hospital for using
teleconsultations for stroke and geriatric patients. Meanwhile,
local organisations such as the Agency for Integrated Care
and TOUCH Diabetes Support have expressed interest in
being able to provide telehealth services to the chronic care
patients that they serve.
Integrated properly into the health system, these
telehealth services will provide accessibility and convenience
to patients and healthcare providers at each step of the
way. For minor ailments that do not require in-person
examinations, patients could book virtual appointments to
consult with their GP face-to-face without ever stepping out
of their house. In-person appointments could also be made
in advance at the click of a button, helping patients avoid
long waiting times in the doctors ofce with other contagious
patients. In the long run, small practices and medical groups
stand to gain increased patient retention and loyalty through
the convenience of telehealth services.
24
Using the health data collected through frequent
encounters with GPs, people can be recommended to
attend health screenings for specic diseases based on
their personal medical backgrounds and risk factors. If
diagnosed, patients can be easily referred to specialists, who
will have immediate access to therelevant medical history of
the patient. Furthermore, properly implemented telehealth
platforms will allow healthcare professionals to securely
message their colleagues and patients without worrying
about having their patients valuable medical data stolen
by hackers. As opposed to normal, unsecured messaging
platforms such as SMS and email, platforms compliant with
standards such as HIPAA and PDPA protect sensitive medical
data with all the ease of the former.
Should a patient require urgent hospitalisation, acute
care professionals will have the complete records of patient
allergies and pre-existing conditions, collated over a lifetime.
The time and costs of handling administrative paperwork in
hospitals can also be reduced with the help of the integrated
electronic record, since many patient details for admission
can automatically be retrieved from the centralised record.
Home telemonitoring may become the norm for chronic
care patients, who require low levels of care over long
stretches of time, and the occasional just-in-time intervention
to prevent deteriorations from escalating into costly hospital
stays. Hospital stays themselves can be shortened for
patients with the appropriate care-support system for home
telemonitoring care, making acute care more afordable for
patients while alleviating bed shortages in local hospitals.
Only by putting in place these integrated helper
technologies can Singapores healthcare system begin to
cater for the burgeoning healthcare needs of tomorrow.
Large trials in other developed countries have made it clear
telehealth is the way to go for efective, afordable healthcare
for everyone.
25
coordination/home telehealth: the systematic implementation of
health informatics, home telehealth, and disease management
to support the care of veteran patients with chronic conditions.
Telemedicine and e-Health, 14(10), 1118-1126.
[Darkins, 2012] Darkins, A. (2012). Telehealth Services in
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[deBronkart, 2014] deBronkart, D. (2014). Dave Debronkart
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healthit.gov/proles/stage4-kidney-cancer-survivor
[DH, 2011] Whole System Demonstrator Programme: Headline
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[Edwards, 2014] Edwards, E. (2014). Patients see doctors through
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