The components of digital health

NHS England uses the term 'technology enabled care services' (TECS), which it defines as including telehealth, telecare, telemedicine, telecoaching and self-care apps.  These terms signify the different ways in which technology is being used to support care.  However, this is an evolving area, and these different terms are often used by different people to mean different things.

Taken from Technology Enabled Care Services: Resource for Commissioners, NHS Commissioning Assembly.

The key components explored on this page are:

Telehealth (also called mHealth or self-monitoring)

Telehealth is the term used for when people monitor and record their own health, rather than needing to visit their GP or other health services. 

Using equipment provided by health services, people can monitor different aspects of their health, such as their temperature, weight, blood pressure, pulse rate and oxygen saturation (depending on what has been agreed with their health professional) and at a frequency determined by consultation between the patient and their key health worker.  Commonly the data they record is automatically shared with their healthcare team (usually with an information system, rather than an individual).  If the readings are ‘outside’ the pre-determined parameters for the individual patient, an alert is raised for the Key Health Worker (such as the person’s diabetes specialist nurse) to take action, such as a change in medication, which could lead to the prevention of an emergency admittance.

As this is an emerging approach, there is currently very little published research, and therefore there is little evidence of its impact on clinical indicators.  However, anecdotal evidence is widely published of patients describing feeling more confident about their condition and more supported in improving their health.

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Independent self-monitoring  and apps

In addition to the technology provided by the NHS, an increasing number of people are using personal devices, such as wearable sensors, mobile phones and tablets, to monitor their own health and fitness independently of health services.  These devices collect, process and display a wealth of personal data to help people monitor and manage all aspects of their personal health. 

Unlike telehealth, the data is not shared directly with health services, but linked to an app, giving people the option to use these self-tracking tools to share results with others, give and receive encouragement, and even compete.  The element of sharing is often highly valued by those using such tools.

At their best self-monitoring and apps can:

  • Inform: Provide information in a variety of formats (text, photo, video)
  • Instruct: Provide instructions to the user
  • Record: Capture data entered by the user
  • Display: Graphically display user-entered data, enabling people to see trends in their behaviour and health over time
  • Guide: Provide guidance based on user entered information (e.g. recommend a consultation or course of treatment)
  • Remind/Alert: Provide reminders to the user
  • Share: Provide communication with healthcare professionals/patients and/or provide links to social networks

There has been some criticism of the number of apps developed without sufficient consultation with health professionals and the people who will eventually use them, and the evidence of their efficacy is mixed.  The most effective technologies are developed in partnership between people who bring clinical expertise, people who bring technical expertise and the people who will ultimately be using them. 

Some NHS services have also developed health apps.  Whether people are using apps developed and supported by the NHS or independently, they form part of how people are choosing to manage their health and wellbeing, and should therefore be included in the conversation between individuals and their healthcare team, and understood as another facet of how health professionals work with their patients. 

NHS Choices highlights a number of free apps people can use to improve their health.

Other examples include:

My Health Tools was designed by health professionals and people living with long-term conditions, to help people make the changes they want by using understandable, easy-to-use tools to achieve their goals and improve their life for the better.  It was developed by a partnership between Kirklees Council, Greater Huddersfield CCG, and North Kirklees CCG.

Diabetes UK Tracker enables users to log and track a number of indicators including their blood glucose, insulin, carbohydrates, calories, weight and ketone levels.  The app won the best use of digital media award at the Third Sector Excellence Awards in 2012.  It was developed by Diabetes UK when the diabetes tracker market was not well served, but there are now over 300 diabetes tracker applications available.

My Asthma Log helps children and young people self-manage their asthma.  It enables asthma patients to construct their own individualised asthma plan and manage their lives according to that plan.  It was developed by North East London, North Central London and Essex Health Innovation and Education Cluster (NECLES HIEC) in partnership of Asthma UK, Queen Mary University London, Solar Software.

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Tele-consultations - also called tele-medicine

The term ‘teleconsultation’ is most commonly used for consultations between a person and their health professional that take place remotely via telephone or video (e.g. Skype). 

As well as being used in place of more traditional face-to-face consultations, the technology is also being used to allow groups of people to virtually ‘meet’, who would otherwise find it difficult.  For example this might include: a number of health professionals being able to be involved in a consultation with a single patient; a single health professional holding a group consultation with multiple patients; and a patient and their family being able to be in the consultation with a health professional.

The term can also be used, although it is less common, to mean consultations between health professionals.

Tele-consultations are often more convenient for patients, as they no longer have to travel to appointments – particularly when this involves long distances, such as appointments with specialists who are regional or national.  They also have the potential benefits of calming anxieties that attending an appointment can often cause, and changing the dynamic in the conversation as people feel more at ease and comfortable sharing information when they’re in their own environment.

As with most of the technologies relating to digital health, the research evidence for its impact and efficacy is limited and still developing, although anecdotal evidence that has been published shows that the approach is well received by patients.

Whilst some health services use systems developed or bought off the shelf specifically for this purpose, the use of freely available software such as Skype is increasingly popular.

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Tele-coaching 

Tele-coaching is telephone-based support for people with long-term conditions, designed to support them to better manage their own health.  Coaches provide practical support, motivational coaching, health information, guided self-help and care navigation to other appropriate services and local community resources. 

As with general coaching, tele-coaching has tended to be used for people whose condition requires management and general support but who have not progressed to a level of severity where they are experiencing crises and need intensive support.

Typically tele-coaching has been provided by a trained practitioner (commonly a nurse),  who has expertise in long term conditions, along with specialist training in health coaching. Now it is increasingly being commissioned from specialist providers in the voluntary and community sector who are not health professionals, but who understand long term conditions and the impact they have on people’s lives.  In whatever way it is provided, the approach remains the same: to help individuals to identify goals and build a plan of action that aims to keep them at home and well for as long as possible.

Evidence around the impact of health coaching in general is still emerging, and there is little evidence specifically relating to tele-coaching.  Some studies have shown that tele-coaching has led to changes in lifestyle and self-care capabilities, health improvements, changes in service utilisation, and savings in health care costs.

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Social networks and online communities

Social networks and on-line communities provide a way for people with similar health issues to share information and experiences in order to develop a better understanding of their health condition(s) and how to manage them.  They can also provide peer support by connecting with others who truly understand the disease and its impact.

These sites and networks can be particularly helpful for people with rare medical conditions, who may not be able to access peer support within their local community.  Although they are also popular amongst people with conditions which have a high prevalence, such as diabetes.  They can also provide opportunities for peer support for people where meeting in person might create risks around cross infection e.g. cystic fibrosis and during some cancer treatments.  They also offer different ways of connecting with peer groups according to people’s personal preferences.

Such sites have in fact grown so much in popularity that many health care providers are forming groups for their patients, even providing areas where questions may be directed to doctors.  Charity Sue Ryder has developed an online community for people who are dying and those who are close to them, which includes access to some of their expert nurses able to share their support and advice.

Recent studies have looked into development of health related communities and their impact on those already experiencing health issues, although evidence is still emerging. As with other forms of digital health, anecdotal evidence from people using these forms of network are favourable.

Examples include:

  • Patientslikeme is an example of an effective and well utilised community.  It has 380,000 members who between them have over 2,500 conditions.  It is free to join and allows users of the site to track their symptoms and medication, and compare their experiences with those of other people with the same condition.
  • Our-Diabetes is a community led platform that aims to give people within the diabetes online community a boice by hosting their own tweet chates on a diabetes topic of their choice.
  • My Stroke Guide ·         is a digital self-management tool developed by the Stroke Association in partnership with stroke survivors and carers to support people in their recovery following a stroke.  It includes information tailored to the individual’s needs and local area, peer to peer support, goal setting tools and graphs reflecting the individual’s progress and advice and signposting.
  • Big White Wall s a safe online community of people who are anxious down or not coping who support and healp each other by sharing what’s troubling them, guided by trained professionals.  It is available as a website and via an app.

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Online access to records

People can use their health records in a number of ways, from checking test results to reminding themselves about what was discussed during an appointment. Patients already have a right to see their records and since April 2015 all GPs should offer their patients online access to summary information of their GP records.

There is already evidence that people feel more confident and are better able to manage their own health when they have access to their own records, and records access forms an important foundation for the shared power and responsibility that is at the core of person-centred care.

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Telecare

Telecare is the term normally used to describe different alarm systems that people can have in their home which can let a family member, friend, neighbour, nurse or warden (if people are living in sheltered housing) know when something is wrong.

Telecare is one of the best known and well-established approaches, with reasonable equity of access.  It commonly straddles the divide between health and social care.

Examples of these include:

  • a personal alarm, where the person can raise the alert by pressing a button that they keep on them at all times; it's usually on a small wristband or a pendant worn around the neck
  • motion sensors, which make accidents and falls less likely by automatically switching on bathroom or hallway lights at night when people get out of bed
  • sensors that can raise the alarm that something is wrong – such as a pressure mat on the mattress that can tell if a person hasn’t made it back into bed, or a sensor on a door that can tell if it's open or closed. 

There are some excellent examples of integrated and multi-disciplinary working:

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All resources on digital health