When I wrote the title for the post, I realized that it sounds like it would be about the screen size of mobile devices, both smart phones and iPads. Alas, the post is not about screen sizes, but about telehealth and connected health applications. I may still write a post about screen size, which is a very important consideration in app design and functionality, just not today.
For today, I wanted to write about a telemonitoring study I referenced in my last post. The attention-getting Mayo study found no differences in rates of readmission or ED visits between patients who received telemonitoring and those wgi received standard care with no telemonitoring. From this data, the authors concluded that telemonitoring did not help in any way. This is not exactly in line with much of the promise many see in telemonitoring.
In response to the publication and attention it generated, The Continua Health Alliance issued a statement to its members that Chris Wasden was kind enough to share in the comments of my last post. The Continua statement presents some of the limitations of the Mayo study from the authors of the study themselves. It then lists a smattering of other studies that support the use of telehealth and other connected health technologies to improve outcomes.
It is important to have a balanced perspective when it comes to evidence. The Continua cites only evidence that supports telehealth, and a recent Cochrane Review of 25 studies found telemonitoring to be effective both in terms of cost and outcomes. The new study, which was designed as a randomized controlled trial (RCT), is not the only RCT to find no difference in outcomes between telemonitoring and standard care (NEJM study).
To add some power to that, RCTs are the gold standard in study design and are considered the highest level of evidence. Also, the two RCTs I’m referencing above were published in Archives of Internal Medicine and the New England Journal of Medicine, both well-respected journals. At least one of the Continua-cited studies was also an RCT, but I’m not sure about the others because they are not linked back to the primary sources in the Continua statement.
The debate over evidence is a good one. It’s a healthy process as we learn about the efficacy of new treatment modalities, technology included. As the body of evidence surrounding telehealth — and really health technology generally — continues to grow, more answers emerge. However, you don’t know what you don’t know, and as we collect more data, we are also coming up with more questions. In the case of this specific study, questions arise about the infrastructure needed to develop an effective connected health intervention and the population that should be targeted.
These are increasingly important considerations, but there are many, many others. When it comes to providing either sick or well care, there is no magic bullet. Also, I was under the impression that the trend in medicine and healthcare was not one-size-fits-all, but solutions tailored and personalized to the specifics of the patient and situation. Connected health technology and telehealth are great tools for improving access to care and quality of care and increasing our focus on preventative care, but they are not standalone solutions and not a standardizable healthcare delivery system.
I don’t think the studies that find no difference in outcomes and cost with telemonitoring care are edge cases that can be ignored or pushed off. If you look at the demographics and length of study for the linked studies above, the patients represent a significant portion of those who need improved care.
Let’s continue our dialogue and critical assessment of the ways that we design and implement remote care interventions. I have no doubt that telemonitoring has a significant role to play in reducing cost and improving outcomes, but I also have no doubt it doesn’t fit for every patient or every type of healthcare encounter. As long as I still get stuck behind people at the grocery store that write checks and don’t use check cards, we need another way to reach certain people. The really hard part is going to be building the flexibility and upfront identification of those people.