The Development and Evaluation of Evolving Telecare and Telehealth Technologies: Theoretical and Methodological Challeng

1. The Development and Evaluation of Evolving Telecare and Telehealth Technologies: Theoretical and Methodological Challenges Debbie Cooke

2. Structure • Whole System Demonstrators project [evaluation of telecare and telehealth] • Methodological, conceptual, theoretical and practical challenges

3. The Research Team • UCL (PI: Stan Newman, Shashi Hirani, Martin Persson) • Imperial (James Barlow and Jane Hendy) • Oxford (Ray Fitzpatrick and Helen Doll) • Manchester (Anne Rogers, Peter Bower, Caroline Sanders) • LSE (Martin Knapp) • Nuffield Institute (Jennifer Dixon) Funder:Policy Research Programme, DH

4. Whole System Demonstrator Sites • Aims • To improve care coordination of those with complex health and social care needs through integrated health and social care system (including joint teams) • Emphasis on patient education and empowerment • To involve the use of advanced assistive technology (telehealth and telecare) in order to improve the health and efficiency • Serve a population of at least 1 million, run for a minimum of two years and be subject to a rigorous evaluation process

5. Telecare • Remote and automatic (passive) monitoring of lifestyle changes (including emergencies) to manage the risks of independent living. • Target group: people with social care needs. • Movement sensors • Falls sensors • Bed/chair occupancy sensors

6. Telehealth

7. Existing Evidence Base • Cochrane Review: Interactive Health Communication Applications [IHCAs] significant positive effect on knowledge, social support, behavioural outcomes e.g. exercise, calorific intake, and clinical outcomes e.g. weight, HbA1c (Murray et al 2006) • Systematic review of telecare/telehealth interventions: emerging evidence base for clinical effectiveness of telehealth technologies. Insufficient evidence for effectiveness of telecare (Barlow et al 2007)

8. Existing Evidence Base • Several reviews of clinical efficacy of telemedicine, encompassing TC and TH • Criticisms of this literature: - pilot projects - short-term outcomes, do not assess long-term or routine use of technologies - studies do not meet robust evaluation criteria (Bensink et al 2006; Barlow et al 2007; Whitten et al 2007) - uncertain impact on cost savings and benefits (Reardon 2005)

9. Design Practice Group A Practice Group B Telecare for social care needs Usual care for LTCs Usual care for social care needs Telehealth for LTCs Long-term conditions: Type 2 diabetes, COPD and Congestive Heart Failure

10. Design • Advantages • All practices receive some intervention • No usual care practices, even though there are usual care patients • Practices a useful administrative unit • Stable • Patient lists

11. Design • Disadvantages • No assessment of the combination of technologies • Significant proportion of patients will have both social care needs and long term conditions • These patients may benefit from the combination of telecare and telehealth

12. Factorial Design?

13. Factorial Design • Problems with factorial design • Two populations involved • Combination of technology only of use in those with both • - LTC: telehealth only • - Social care: telecare only • - LTC+social care needs: TC, TH or TC+TH

14. Factorial Cluster Design Population B Population A Population C Long-term Conditions alone Social care needs alone Social care needs and LTC

15. Revised Factorial Cluster Design Includes standard component Practice Group A Practice Group B Practice Group C Practice Group D • Social care • Usual care • Social care • Telecare • Social care • Telecare • Social care • Usual care • LTCs • Telehealth • LTCs • Telehealth • LTCs • Usual care • LTCs • Usual care

16. Revised Factorial Cluster Design Includes standard component Practice Group A Practice Group B Practice Group C Practice Group D • Social care • Usual care • Social care • Telecare • Social care • Telecare • Social care • Usual care • LTCs • Telehealth • LTCs • Telehealth • LTCs • Usual care • LTCs • Usual care • Social/LTCs • Telehealth • Social/LTCs • Both • Social/LTCs • Usual care • Social/LTCs • Telecare

17. Revised Factorial Cluster Design • Research Questions that can be Answered • What is the effect of TC in social care needs (with or without LTCs)? [n=1,000] • What is the effect of TH in people with LTCs (with or without social care needs)? [n=1,000] • What is the effect of TC and TH (individually and together) in those with social care needs and LTCs? [n=4,000]

18. Theoretical Approaches • Models from Information Systems Research • Theory of Planned Behaviour • Technology Acceptance Model (Davis 1989): perceptions of value and ease of use of a new technology explain intentions to use it • Sociological Perspectives • Normalization Process Model (May 2006, 2007) • Whole System Informing Self-Management Engagement (WISE Model; Kennedy & Rogers 2001) • Applying Individual Behaviour Change Domains • Knowledge, motivation, goal setting (Michie et al 2005)

19. Challenges in Implementation

20. Points for Discussion 1. Are these technologies promoting autonomy or dependence?

21. Points for Discussion • How can health psychological theories and theories of behaviour change help us to evaluate and develop telecare and telehealth technologies?

22. Points for Discussion • How can health psychology contribute to understanding and narrowing the digital divide?

23. Thank you Email: debbie.cooke@ucl.ac.uk