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Sustaining innovation in remote care –four lessons

James Barlow, Jane Hendy, Theti Chrysanthaki

International Congress on Telehealth and Telecare

King’s Fund

London

2 March 2011

So finally I can reveal the solution to mainstreaming telecare

Lesson 1 How ‘mainstream’ is remote care? Counting the numbers

Remote care market hype

▬ Many projections of actual and potential remote care market size

▬ Not necessarily comparing like-with-like

▬ Lots of market boosterism

▬ Market projections are an inexact a science when a sector is rapidly changing

▬ There’s clearly a lot of remote care around, so given the research effort it’s time to ask how ‘mainstream’ is it?

So what does the picture in the UK look like?

▬ Remote care is entering the public awareness

Which? (Feb. 2009)

Remote care adoption curve in the UK ... and elsewhere?

Adoption Spread Mainstreaming

Time

Remote care adoption

Growth in remote care users in England ... with many assumptions Source: Based on CQC returns, JIT

(Scotland) data, and authors’ research for WAG.

Includes LA and other agency services.Assumes 30% drop-out rate each year

With Scotland & Wales

0

50000

100000

150000

200000

250000

300000

350000

Assumes 15,000 remote care users (2005) and 5000 users (2000)

Geographical spread

2006-07

2009-10

Source: Based on CQC returns.Per 10,000 population. Includes LA and other agency services.

Another approach – how big is the potential market?

Potential remote care market 2010

1,400,000

Actual remote care market 2010

350,000

Potential telehealth

market 2010450,000

Actual telehealth market 2010

22,500

Source: based on CQC returns, JIT (Scotland) data, and authors’ research for WAG. Telehealth figures from Minutes of the Strategic Intelligence Monitor on Personal Health Systems [SIMPHS] meeting, Brussels, 17-18 November 2009.

Assumptions: • UK population aged

75+ rises from 4.9m (2010) today to 11.4m by 2050

• c85% of older people wish to remain at home as long as possible

• 1/3 needs remote care at any given time

Lesson 2 We know what needs to be done to plan and implement remote care projects

Implementation is a ‘dynamic’ process –organisational roles need to evolve to reflect the needs of each stage

Planning & initial implementation Mainstreaming

Leader(s)

Champions:Characteristics: personal interest, personal perseverance, ability to take ownership / responsibility Role: infuse enthusiasm, increase engagement, ensure commitment to / identification with the project

Change agents:Characteristics: ‘boundary spanner’Role: strategic position, interest in innovation but priority is whether innovation fits strategic objectives of whole organisation

Project managers

STAGE

Implementation is a ‘dynamic’ process –roles need to evolve to reflect the needs of each stage

Planning & initial implementation Mainstreaming

Leader(s)

Champions:Characteristics: personal interest, personal perseverance, ability to take ownership / responsibility Role: infuse enthusiasm, increase engagement, ensure commitment to / identification with the project

Change agents:Characteristics: ‘boundary spanner’Role: strategic position, interest in innovation but priority is whether innovation fits strategic objectives of whole organisation

Project managers

STAGE

Implementation is a ‘dynamic’ process –roles need to evolve to reflect the needs of each stage

Planning & initial implementation Mainstreaming

Leader(s)

Champions:Characteristics: personal interest, personal perseverance, ability to take ownership / responsibility Role: infuse enthusiasm, increase engagement, ensure commitment to / identification with the project

Change agents:Characteristics: ‘boundary spanner’Role: strategic position, interest in innovation but priority is whether innovation fits strategic objectives of whole organisation

Project managers

STAGE

Implementation is a ‘dynamic’ process –roles need to evolve to reflect the needs of each stage

Planning & initial implementation Mainstreaming

Leader(s)

Champions:Characteristics: personal interest, personal perseverance, ability to take ownership / responsibility Role: infuse enthusiasm, increase engagement, ensure commitment to / identification with the project

Change agents:Characteristics: ‘boundary spanner’Role: strategic position, interest in innovation but priority is whether innovation fits strategic objectives of whole organisation

Project managers

STAGE

Dangers

▬ Conventional belief is that professional clinical/care groups block innovation spread but ...

▬ ... harder to engage group is top management

▬ Dependency on champions:

• can cause dysfunctional rigidities to settle within sub-groups

• helps to sustain a culture of remote care ‘pilot necessity’

“telecare is not an issue that is discussed at the board level ... that’s the group that’s most difficult to penetrate”

“Now the senior management has got involved, ... things have changed and I don’t want to lose that new autonomy.”

“(they) have gone off and done their own little thing and no one else really knows about it. To be honest they like to hold on to their own little kingdoms.”

Lesson 3 We know what the barriers to mainstreaming remote care are

Mainstreaming challenges

▬ Scaling up is not the same as ‘becoming large’ – it’s about:

• normalising practices

• embedding them into, and changing, existing models

• expanding impact

▬Constructing a shared vision is important for creating the right kinds of institutional arrangements with legitimacy amongst stakeholders

What’s needed for mainstreaming

▬ Benefits evidence (of the right kind) to increase stakeholder receptiveness

▬ More robust evidence helps to build business cases for all stakeholders

▬ Understanding of the distribution of costs and benefits across the system

▬ Mechanisms for addressing the lack of integration within and between care providers

▬These are all related issues

“you need the evidence, … when you get the evidence you get true buy-in”

Moving to the next stage

Adoption Spread Mainstreaming

Time

Remote care adoption

Source: Barlow, Hendy, Chrysanthaki

Enthusiasts

Grants

Pump priming

Champions

LeadershipProject mgt

AwarenessEvaluation

Evidence

Business case

Lesson 4There is a lot of emphasis on ‘business models’ for remote care ...... but what is a business model for remote care?

What is a business model?

▬ Business models articulate the underlying logic that explains how to deliver value to customers at appropriate cost:

• market segment, i.e. users to whom the offering is useful and for what purpose

• value chain required to create and distribute the offering

• cost structure and profit potential

• position of the supplier(s) within the value network

• competitive strategy to gain and hold advantage over rivals

Source: Chesbrough (2002)

Business model tests

▬ A good business model passes:

• the narrative test (does the story make sense)

• the numbers test (do the economics add up)?

▬So does remote care meet these tests?

The narrative test – what’s the story?

▬ We all think we know what ‘remote care’ is ...

▬ ... but there are many narratives, all used interchangeably

▬ This makes the ‘story’ hard to clearly articulate –we need to be able to clearly describe:

• Who are the ‘customers’?

• What does they value?

• How is money made?

• ‘Telecare’,• ‘Telehealth’• ‘Telemonitoring’’• ‘Telemedicine’• ‘Assistive technology’• ‘Smart homes’• ‘Prevention’• ‘Managing risk’• ‘Supporting independence’

• etc .......

The numbers test – do the economics add up?

▬ Many case studies from technology suppliers and small trials

▬ Formal knowledge of remote care economics is poor

▬ WSD should help but we need to be careful about translating research between different contexts

▬ We can infer some of the potential system impact from existing clinical studies and modelling

total hospital days100,000

90,000

80,000

70,000

60,000

5 5 5 5 5 5 5 54 4 4 4 4 4 4 43 3 3 3 3 3 3 3 3

2 22

2 2 2 2 2 21 1 1 1 1 1 1 1 1

0 25 50 75 100Time (Month)

total hospital days : base hospital days/Month1 1 1 1 1total hospital days : TC 3M hospital days/Month2 2 2 2 2total hospital days : Prevention 3M hospital days/Month3 3 3 3total hospital days : Screening 3M hospital days/Month4 4 4 4total hospital days : TSP 1M hospital days/Month5 5 5 5 5

One business model or many?

Service customisationLow High

Low

High

Different remote care business models for different market segments

‘High dependency’

•Safety monitoring•Vital signs monitoring•Information•Advice•Support

‘Healthy majority’•Information•Advice•Support C

ost

Low

High

So what can be done now to improve uptake and make sure it's sustainable?

For sustainability ...

▬ “Instead of creating another new structure, the introduction of telecare should become a focus for better integration of existing services and teams” (Barlow, Bayer, Curry 2003)

▬ Place remote care in a broader preventative agenda to increase professional and organisational engagement

▬ So involve established teams from the outset to allow for scaling-up projects – creating dedicated new teams make future integration harder

▬ Include mainstreaming phase in the initial strategic plan – and avoid overly focusing on quick return on investment

Funded by EPSRC and Dept of Health

With thanks to Anna Ramsay, Sarah Jasim, Charitini Stavropoulou

James Barlow

j.barlow@imperial.ac.uk

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