Issue 17 / 19 May 2014

MOBILE health technologies — mHealth — may be the catalyst that lifts the cost-effective and sustainable implementation of telemedicine, says a telehealth expert.

Professor Sven-Erik Bursell, professor of telehealth at the NHMRC Clinical Trials Centre at the University of Sydney, said mobile technologies and health applications were crucial in overcoming “barriers to implementation” of telemedicine highlighted in an article published in the MJA. (1)

The MJA authors, led by Dr Nigel Armfield from the Centre for Online Health at the University of Queensland, wrote that the evidence base for telemedicine was “very limited”, leading to “slow and patchy” implementation.

“There is little incentive to adopt telemedicine, particularly in the absence of clinical and economic evidence”, they wrote. “Analysis before implementation of telemedicine is sometimes insufficient or omitted entirely.”

Professor Bursell said he agreed with the authors that the evidence for clinical efficacy and cost-effectiveness of telehealth was often “equivocal and hence it is difficult to make a case for policy changes around adoption”.

He said there was some research showing that text messaging to coach patients and provide support for lifestyle decisions seemed to be effective in improving self-management behaviours and clinical outcomes. (2)

“The solution most likely lies in the use of mobile technologies and mHealth applications”, he told MJA InSight.

Meanwhile the Therapeutic Goods Administration is encouraging interested groups to comment on a proposal put forward by the International Medical Device Regulators Forum to recognise software as a medical device. (3)

The proposal is based on international monitoring by regulatory agencies of developments in medical software that might be used in diagnostic tools and other medical devices. Comments close on 31 May.

Professor Bursell said mHealth strategies were still in the pilot stage but had generated considerable enthusiasm “because of the ubiquity of mobile phone usage and the relatively inexpensive start up costs”.

However, hard medical evidence was yet to be delivered and conducting lengthy clinical trials was “problematic as most applications have a lifetime of about 3 months before the user starts looking for something different”.

“The adoption of mobile technologies could even be a health systems catalyst by providing integrated strategies that fit into existing health system functions and complement the health systems goals”, he said.

Professor Bursell said the MJA authors were “absolutely correct” in recommending appropriate pre-implementation analysis of any tool or portfolio of tools as this was critical to the success of any telemedicine project.

Professor John Wilson, head of the Cystic Fibrosis Service (and Telehealth Service) at the Alfred Hospital in Melbourne and chair of the Royal Australasian College of Physicians education committee, said that unlike new drugs and other new interventions, telemedicine had “escaped” the usual trials to assess risks, benefits and cost-effectiveness.

“We are now in the position that we need to be generating evidence and that is not a very happy position to be in”, Professor Wilson told MJA InSight.

“Having implemented telemedicine we now have a great deal of difficulty finding funds to research the strategies [which makes it] difficult to retro-analyse and provide the right level of evidence.”

Research published in JAMA Internal Medicine found no evidence that the implementation of telemedicine, including 21 hour/day remote support and monitoring by an intensivist and two critical care nurses, in eight intensive care units (ICUs) in the US Department of Veterans Affairs health care system significantly reduced mortality rates or lengths of stay. (4)

An accompanying commentary said that ICUs most likely to benefit from telemedicine were those with “comparably less robust infrastructure”. (5)

“Better care requires better matching of ICU organisational weaknesses to ICU [telemedicine] strengths”, the commentary said.

1. MJA 2014; 200: 530-533
2. J Hum Nutr Diet 2014; Online 31 January
3. TGA 2014; Consultation: Software as a medical device (IMDRF working group)
4. JAMA Intern Med 2014; Online 12 May
5. JAMA Intern Med 2014; Online 12 May


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