Health Informatics and Surveillance Response Paper

Introduction.

Telehealth is the application of information technology and/or of telecommunication to health-related practices (HRSA, 2021). It involves a variety of communication technologies, user interfaces, and media of transmission (Miller, 2007; Laureate Education Inc, 2011). It can take the form of any of five modalities of delivery, including (CCHP, n.d.): 1) remote communication, 2) live video, 3) mobile health, 4) remote patient-monitoring, and 5) store-and-forward.

As the prefix tele– would suggest (Random House, n.d.), a central motif of telehealth is the enablement of health-related services/activities across a great distance. Health Informatics and Surveillance Response Paper

Telehealth, broadly speaking, can improve public health surveillance.

Telehealth’s more narrow application to medicine (i.e., telemedicine) can improve or enhance medical/clinical performance but likely can never fully replace it. After all, telemedicine does has a few limitations or drawbacks that are unique to it.

Limitations/drawbacks:

Telemedicine shall likely never completely replace collocated clinical interaction, owing to some drawbacks inherent to it. Perhaps most basically, its use or interface is not suitable for certain kinds of patients, who may fundamentally dislike the idea of telehealth, disapprove of its use or interface, or otherwise consciously resist its uptake (Sanders, 2012).

More commonly though, a lack of face-to-face interaction arguably always imposes at least some non-trivial limitation(s) on the medical provider’s ability to thoroughly examine or otherwise assess the patient, creating some heightened concern for patient safety and for provider liability (Cascella, n.d.). This concern manifests most prominently in the online prescribing of medications (Cascella, n.d.; Myers & Turvey, 2013). Controversy surrounding the practice is perhaps most evidenced by the passage of the Ryan Haight Online Pharmacy Consumer Protection Act, under federal law (US Congress, 2008). Even in my own state of Texas, an intriguing court case arose between the Dallas-based Teladoc (the nation’s first and now-largest provider of telemedicine nationwide) and the state’s Texas Medical Board (in which Teladoc majorly prevailed) (TX 3^rd CoA, 2014; Walters, 2016; Goodman, 2016). The practice still remains controversial, though (Myers & Turvey, 2013), and further guidelines or regulations are likely to come.

01. Post a brief description of the two strategies and/or technological tools you selected.

Medical Improvements:

Despite these inherent limitations, telemedicine shows considerable promise in increasing the efficiency and accessibility of medical care and indeed has been surprisingly slow in its uptake and expansion (Miller, 2007). We should continue to expand, evaluate, and ultimately improve it. The most apparent room for improvement can be seen at the technical level and at the administrative/regulatory level.

At the technical level, current guidelines exist to enhance telemedicine in six key areas: 1) network security, 2) confi­den­tiality, 3) quality improve­ment, 4) training, 5) informed consent, 5) record-mainte­nance, and 6) technical support (WSNA, 2018). In addition, improvements to data-sharing and data access could increase it clinical efficiency (Taylor et al., 2015). Finally, continuing to expand broadband internet access would help to maximize telemedicine’s impact by reaching more marginalized, medically underserved populations (HVH, 2017). Health Informatics and Surveillance Response Paper

At the administrative/regulatory level, the governments should include telemedicine in all payment/reimbursement models (including expanding the coverage thereof by MedicAid and especially by MediCare) so as to more closely align the medical care system’s reimbursement model with the exercise of telemedicine and should ease regulations on licensing, malpractice, and on geographic areas (HVH, 2017; Paul, 2006) so as to better facilitate inter-state telemedicine.

Surveillance Improvements:

In addition to telemedicine’s ability to improve clinical practice, telehealth, more broadly, can be used to enhance public health surveillance.

Teletriage is of especial use in syndromic surveillance, for two major reasons. First, it precedes clinic visits and is available to the patient immediately without appointment and so offers especially timely data (Lombardo & Buckeridge, 2007). Second, telephone triage calls are more numerous than clinic visits, even amongst people who have access to both, and so may even be a more sensitive indicator than electronic medical records (Lombardo & Buckeridge, 2007).

To even further improve Telehealth’s contribution to public health syndromic surveillance efforts, I have two suggestions (the first pertaining mostly to the United States). Health Informatics and Surveillance Response Paper

1. Create a nationwide, general-purpose telephone triage (TT) system.

Despite TT’s exceptional timeliness and sensitivity, for syndromic surveillance in the United States, TT data seems to me underutilized, owing indeed to being curiously underdeveloped in the first place. To date, the United States government has no nationwide, universally available, general-purpose TT hotline (Lombardo & Buckeridge, 2007). Of course, TT hotlines does exist, but only in a patchwork way, amongst separate private entities (e.g., medical care-provider organizations, HMOs, etc.) or in a subject-specific way (e.g., for domestic violence, etc.) (FYSB, n.d.). This poses a problem for surveillance, because each institution shall inevitably have some selection bias in who is included amongst the data. For example, the Department of Veterans Affairs (VA) medical system has a TT system and even uses it for biosurveillance, but its patient population is only 9% female (Lucero-Obusan et al., 2017).

By contrast, the United Kingdom (UK) has a nationwide, general-purpose TT system, called NHS 111 (Harcourt et al., 2016) (which has replaced the NHS Direct system described in our textbook) (Lombardo & Buckeridge, 2007). NHS 111 is proving tremendously useful in the UK, both for triaging patients and for syndromic surveillance in the UK (Harcourt et al., 2016).

So, the United States should first implement a nationwide, general-purpose TT system, analogous to NHS 111 but, of course, larger in scope. The system could, first and foremost, help direct many confused, symptom-experiencing Americans to appropriate medical care, but, beyond that, would serve as a useful data stream for syndromic surveillance nationwide. In order to maximize surveillance performance, the TT system should have a few characteristics, however. First, the TT system should be in operation always – 24 hours per day, 365 days per year. This insulates the system against signal-distortions caused by time-of-day effects, day-of-week effects, holiday effects, inclement weather, etc. (Lombardo & Buckeridge, 2007). Also, the system should collect demographic data and geographic data (Lombardo & Buckeridge, 2007), since the population size and geographic range of the United States are both exceptionally large. Finally, like the Ontario Telehealth System (Rolland et al, 2006), the United States TT system should ensure that decision-making rules are uniform amongst all of the call centers and should use a central database structure (Rolland et al, 2006). This would ensure that the triage algorithms are the same nationwide and therefore that the data is compatible and comparable across the country (Rolland et al, 2006). Health Informatics and Surveillance Response Paper

2. Have historic/baseline data available.

If the surveillance goal is not merely to quantify some health indicator but, quite beyond that, to detect an outbreak (i.e., a sudden increase above the norm) afoot, then the surveillance practice is very much an exercise in detecting a signal within noise. To do this, knowing the normal/baseline levels for the indicator is sine qua non, because knowing the number of syndromes at any given time is unhelpful in identifying an outbreak if the surveillants have no established basis for comparison. Health Informatics and Surveillance Response Paper

For that reason, any surveillance system needs background data. In deciding to launch some new surveillance system, surveillants should consider this need seriously.

For example, when the UK chose to replace NHS Direct (NHS-D) with NHS 111, two changes gave rise to some uncertainty regarding data validity. First, NHS 111 uses different Clinical Decision Support Software (CDSS) algorithms that did NHS-D, possibly resulting in significant levels of differing, non-comparable diagnosis data between the two systems (Harcourt et al., 2016). Second, NHS 111, at launch, did not have any baseline data. Instead, NHS’s surveillants chose to have NHS 111 rely on NHS-D’s baseline data. Although I can understand the convenience or practicality underlying this choice, the possibility for significant difference in baseline data between the two systems would, for me, have been too great a cause for concern. Instead, I would have recommended a baseline/training period for NHS 111 to generate its own, internally consistent baseline data. This would have made longer the process of developing and then rolling out NHS 111, but, to my mind, confidence in the data and its ability to offer credible assurance is more important than swiftness in the starting up of a new surveillance system. Health Informatics and Surveillance Response Paper

02. Justify your selections and explain how they would improve telehealth systems.
(see previous).

03. Briefly describe any potential difficulty in adopting the strategy or tool.

1. Creating a nationwide TT system.

Although I am sincere in my recommendation of the development of a nationwide, general-purpose TT hotline in the United States, the idea, practically speaking, is fanciful. The United States has a much larger population than Ontario or the UK, and so the hotline would be much more expensive to operate than either the Ontario Telehealth System or NHS 111. Although I do think that the idea is probably feasible, the nevertheless steep cost involved would likely be insufficiently politically palatable to win acceptance.

There is another difficulty in applying the TT system. Although exceptionally timely and sensitive, TT data suffer from poor specificity. Because the nurse is triaging (rather than diagnosing) and is classifying by syndrome and severity (rather than by disease), the data’s specificity suffers (Lombardo & Buckeridge, 2007). However, in some cases, the individual call data can be linked to any subsequent, individual clinical data on a patient-by-patient basis, including to ICD-9 codes (Lombardo & Buckeridge, 2007). This would ameliorate the poor specificity, but, again, would likely require additional cost, making the prospect seem even less initially inviting.

2. Having historic/baseline data available.

As mentioned previously, the most obvious challenge in generating background/baseline data for a surveillance system is the inclusion of a baseline/training period. This makes the system take longer to become operational, but, in my judgment, is generally still the preferable choice.

I do note that, in chapter 10, the textbook discusses the various ways of generating background data (e.g., authentic vs. simulated, various models, etc.) and their respective strengths and weaknesses (Lombardo & Buckeridge, 2007), but that discussion seems a bit too complex and much too far ahead in the coursework to elaborate on here

References

Cascella, L. M. (n.d.). Risk perspectives in telehealth: Online prescribing. MedPro Group. https://www.medpro.com/telehealth-onlineprescribing-risks.

Center for Connected Health Policy [CCHP]. (n.d.). About telehealth. CCHPca.org. https://www.cchpca.org/about/about-telehealth.

Goodman, M. (2016, November). How the north Texas telemedicine revolution began. D Magazine. https://www.dmagazine.com/publications/d-ceo/2016/november/how-the-north-texas-telemedicine-revolution-began/.

Harcourt, S. E., Morbey, R. A., Loveridge, P., Carrilho, L., Baynham, D., Povey, E., … Elliot, A. J. (2016). Developing and validating a new national remote health advice syndromic surveillance system in England. Journal of Public Health, 39(1), 184–192. 

Healthcare Value Hub [HVH]. (2017, November). Telemedicine: Decreasing barriers and increasing access to healthcare. Healthcare Value Hub. https://www.healthcarevaluehub.org/advocate-resources/publications/telemedicine-decreasing-barriers-and-increasing-access-healthcare.

Laureate Education, Inc. (Executive Producer). (2011). Introduction to health informatics and surveillance: Telehealth.

Lombardo, J. S., & Buckeridge, D. L. (2007). Disease surveillance: A public health informatics approach. John Wiley & Sons.

Lucero-Obusan, C., Winston, C. A., Schirmer, P. L., Oda, G., & Holodniy, M. (2017). Enhanced influenza surveillance using telephone triage and electronic syndromic surveillance in the department of veterans affairs – 2011-2015. Public Health Reports, 132(1_suppl), 16S–22S. 

Miller, E. A. (2007). Solving the disjuncture between research and practice: Telehealth trends in the 21st century. Health Policy, 82(2), 133–141. 

Myers, K., & Turvey, C. (2013). Telemental health: clinical, technical, and administrative foundations for evidence-based practice (1st ed.). Elsevier.

2 days ago

Nyoka Rogers

RE: Discussion – Week 8