Connected Health

Connected Health is a term used to describe a model for healthcare delivery that uses technology to provide healthcare remotely. Connected health aims to maximize healthcare resources and provide increased, flexible opportunities for consumers to engage with clinicians and better self-manage their care. It uses technology – often leveraging readily available consumer technologies – to deliver patient care outside of the hospital or doctor’s office. Connected health encompasses programs in telehealth, remote care (such as home care) and disease and lifestyle management, often leverages existing technologies such as connected devices using existing cellular networks and is associated with efforts to improve chronic care.

The United States and European Union are two dominant markets for the use of connected health in home care service, in part due to the high availability of telephone and Internet service as compared to other parts of the world. Within the United States, over 260 million people have a land line connected, over 190 million are cell phone users, and approximately 200 million are Internet users. The European Union has roughly an equivalent number of people connected to land lines, but prevails over the U.S. with more than 300 million cell phone users and 230 million Internet users. More recent data collected by Pew Internet: Americans and their Gadgets suggest that 86% of US residents own a mobile phone and this number is as high as 96% among Americans aged 18 to 29 years. According to the International Communications Union, it is predicted that there will be 4 billion mobile phone users worldwide by the end of 2008¹.

The vision of the connected health model can be implicitly understood by contemplating the significant impact of technology on other industries, such as in banking, shopping, logistics and personal communications. Proponents of connected health believe that technology can transform healthcare delivery and address many inefficiencies especially in the area of work flow management, chronic disease management and patient compliance of the US and global healthcare systems.

History

Connected health has its roots in telemedicine, and its more recent relative, telehealth. The first telemedicine programs were primarily undertaken to address healthcare access and/or provider shortages. Connected health is distinguished from telemedicine by:

• A broader concern for healthcare cost, quality and efficiency, particularly as related to the chronically ill
• Concomitant interests in making healthcare more patient centric by promoting healthcare consumerism through education, and patient feedback
• Efforts in the direction of integrating of data generated outside of traditional healthcare settings such as the home with centralised, often electronic patient record

One of the first telemedicine clinics was founded by Dr. Kenneth Bird at Massachusetts General Hospital in 1967. The clinic addressed the fundamental problems of delivering occupational and emergency health services to employees and travellers at Boston’s Logan International Airport, located three congested miles from the hospital. Over 1,000 patients are documented as having received remote treatment from doctors at MGH using the clinic’s two-way audiovisual microwave circuit². The timing of Dr. Bird’s clinic more or less coincided with NASA’s foray into telemedicine through the use of physiologic monitors for astronauts³. Other pioneering programs in telemedicine were designed to deliver healthcare services to people in rural settings.

Connected Health in Operation

Two “core platforms” are emphasized in connected health, self-care and remote care, with programs primarily focused on monitoring and feedback for the chronically ill, elderly, and those patients located at an untenable distance from primary or specialty providers. Programs designed to improve patient-provider communication within an individual medical practice (for example, the use of email to communicate with patients between office visits) also fall within the purview of connected health. There are also “lifestyle coaching” programs, in which an individual receives healthcare information to facilitate behavior change to improve their fitness and/or general well being, (see wellness) or to reduce or eliminate the impact of a particular behavior that presents a risk to their health status. Some of the most common types of connected health programs in operation today include:

• Home care via remote monitoring of chronically ill patients including surveillance connected devices or patient controlled monitoring of health parameters
• Traditional telehealth programs, where care is provided in remote areas by teams of local clinicians or community healthcare workers teamed up with specialists in medical centers
• Monitoring programs whose aim is to ensure the safety and quality of life of elderly parents living at a distance from their relatives
• Web-based second opinion services for patients in need of medical care
• Lifestyle and fitness coaching for wellness or health risk reduction

The Center for Connected Health is implementing a range of programs in high-risk, chronic and remotely located populations.

Inherent in the concept of connected health is flexibility in terms of technological approaches to care delivery and specific program objectives. For instance, remote monitoring programs might use a combination of cell phone and smart phone technology, online communications or biosensors and may aim to increase patient-provider communication, involve patients in their care through regular feedback, or improve upon a health outcome measure in a defined patient population or individual. Digital pen technology, global positioning, videoconferencing and environmental sensors are all playing a role in connected health today.

Goals of Connected Health

Connected health is viewed by its proponents as a critical component of change in human healthcare. They envision:

• Reductions in the cost of providing quality care to the chronically ill, estimated by the Center for Health Care Economics at the Milken Institute to be over $1 trillion per year
• Improved global and local public health surveillance, with a resultant reduction in epidemics, increased control over infectious disease and improved drug safety
• Diminished rate of medical errors
• Better “customer service” in healthcare
• Ongoing preventive health, with attendant reductions in: morbidity, mortality and the cost of care
• Consumer engagement in health and self-management
• Safer and more effective clinical trials

The Evolution of Connected Health

Healthcare is consistently cited in political polls and in surveys as a chief concern for consumers, administrators, employers and clinicians alike.⁴

The formal establishment of quality improvement organizations in 2002 and rise of independent organizations such as The National Committee for Quality Assurance, The Leapfrog Group and Bridges to Excellence - all of which are dedicated to promoting and monitoring healthcare quality - illustrate intense concern over inefficiency, safety, and customer service in healthcare.

In addition, skyrocketing costs, increases in chronic diseases, geographic dispersion of families, growing provider shortages, troubling ethnic disparities in care, better survival rates among patients fighting serious diseases, an aging U.S. population and longer lifespan are all factors pointing to a need for better ways of delivering healthcare.^5,6,7

Consumer demand for better service and quality in healthcare is the latest source of pressure to improve the healthcare system. Experts speculate that, having acclimated to greater speed, efficiency and cost transparency - as well as vastly improved access to information about products and services - in other industries, consumers are calling for the same responsiveness from the healthcare system. Direct-to-consumer advertising is a demonstrated contributor to the rise in consumer demand, as is the mass availability of inexpensive technology and ubiquity of the Internet, cell phones and PDAs.^8,9 Connected health experts such as Joseph C. Kvedar, M.D., believe that consumer engagement in healthcare is on its way to becoming a major force for change.

In summary, connected health has arisen from: 1) a desire on the part of individual physicians and healthcare organizations to provide better access, quality and efficiency of care 2) dynamics of the healthcare economy (such as rising costs and changing demographics) 3) consumerism in health care and a drive towards patient centric healthcare. Together, these factors are providing impetus for connected healthcare in the United States and many other industrialised nations and forcing innovation both from within and outside the system.

Evidence

While connected health is yet emerging, there is evidence of its benefit. For example, in a program being implemented by the Center for Connected Health and Partners Home Care, over 500 heart failure patients have now been monitored remotely through the collection of vital signs, including heart rate, blood pressure and weight, using simple devices in the patient’s home. The information is sent daily to a home health nurse, who can identify early warning signs, notify the patient’s primary care physician, and intervene to avert potential health crises. A pilot of this program demonstrated reduced hospitalizations¹⁰. Another initiative at the Center for Connected Health uses cellular telephone technology and a “smart” pill bottle to detect when a patient has not taken their scheduled medication. A signal is then sent that lights up an ambient orb device in the patient’s home to remind them to take their medication.

Funding and Implementation

Today, it appears that connected health programs are operated and funded primarily by home care agencies and large healthcare systems. However, insurers and employers, who bear enormous cost to insure their employees, are increasingly interested in connected health for its potential to reduce direct and indirect healthcare costs. For example, EMC Corporation recently launched the first employer-sponsored connected health program, currently in the beta phase of implementation, which is aimed at improving outcomes and cost of care for patients with high blood pressure.¹¹

US Government and Connected Health

Government agencies involved in connected health include:

• The Office for the Advancement of Telehealth
• The Centers for Medicare & Medicaid Services (CMS), to the extent that Medicaid reimburses for telemedicine programs, at the state’s option. According to the CMS Web site, at least 18 states are allowing reimbursement for services provided via telemedicine for reasons that include improved access to specialists for rural communities and reduced transportation costs.
• The Office of the National Coordinator for Health Information Technology (ONC) is charged with creating an interoperable health information technology infrastructure for the nation. That infrastructure has been primarily defined as an electronic health records system, however, former National Coordinator David Brailer indicated his support for personal health records that are portable and controlled by consumers. It remains to be seen how his successor, Robert Kolodner, will interpret this charge.¹²

Personal Health Records

Personal health records, or PHRS, (see personal health record) – are essentially medical records controlled and maintained by the healthcare consumer. PHRs intersect with connected health in that they attempt to increase the involvement of healthcare consumers in their care. By contrast, electronic medical records (EMRs) (see electronic medical record) are digital medical records or medical records systems maintained by hospitals or medical practices and are not part of connected health delivery.

Resources

• American Telemedicine Association, http://www.americantelemed.org/i4a/pages/index.cfm?pageid=1
• Association of Telehealth Service Providers, http://www.atsp.org/business/telehealth_books.asp
• Center for Connected Health, http://www.connected-health.org/
• Center for Studying Health System Change, http://www.hschange.com/
• Center for Telehealth & Ehealth Law, http://www.ctel.org/
• Home Telehealth, Connecting Care Within the Community, Edited by Richard Wootton, Susan L. Dimmick, Joseph C. Kvedar, MD, Director, Center for Connected Health, Partners

HealthCare. http://www.connected-health.org/media-center/home-telehealth-connecting-care-within-the-community.aspx

• Office of the National Coordinator for Health Information Technology, http://www.hhs.gov/healthit/onc/mission/
• Telemedicine Information Exchange, http://tie.telemed.org/default.asp

References

¹International Telecommunications Union website (Accessed December 10, 2008), http://www.itu.int/ITU-D/ict/newslog/Worldwide+Mobile+Cellular+Subscribers+To+Reach+4+Billion+Mark+Late+2008.aspx

²Medscape website, “Highlights from the Eighth Annual Meeting of the American Telemedicine Association” (Accessed December 10, 2008), http://www.medscape.com/viewarticle/457684

³Telemedicine Information Exchange website, “A Brief History of Telemedicine” (Accessed December 10, 2008), http://tie.telemed.org/articles/article.asp?path=articles&article=tmhistory_nb_tie95.xml

⁴Gallup website, “Gallup’s Pulse of Democracy” (Accessed December 10, 2008), http://www.gallup.com/poll/17785/Election-2008.aspx

⁵The New York Review of Books website, "The Health Care Crisis and What to Do About It” (Accessed December 10, 2008) http://www.nybooks.com/articles/18802

⁶Americans for Healthcare website (Accessed December 10, 2008), http://www.americansforhealthcare.org/facts/

⁷Agency for Healthcare Research and Quality website, “Health Care Costs: Why Do They Increase? What Can We Do?” (Accessed December 10, 2008), http://www.ahrq.gov/news/ulp/costs/ulpcosts1.htm

⁸PriceWaterhouseCoopers. 2006. The Factors Fueling Rising Healthcare Costs 2006, Prepared for America’s Health Insurance Plans, 2006

⁹Kaiser Family Foundation website, “How Changes in Medical Technology Affect Health Care Costs” , March 2007 (Accessed December 10, 2008), http://www.kff.org/insurance/snapshot/chcm030807oth.cfm

¹⁰BMJ 2007; 334: 942 (5 May); http://www.bmj.com/cgi/content/full/334/7600/942

¹¹Kowalczyk, L. Employees to get an online checkup: Care provider, EMC will test a program to cut health costs, The Boston Globe, March 3, 2007; http://www.boston.com/yourlife/health/diseases/articles/2007/03/03/employees_to_get_an_online_checkup/?page=1

¹²Brailer, David J. Your Medical History, To Go. The New York Times. September 19, 2006.