Monthly TQG Feature: November 2015

Dr Malcolm J. Fisk
Senior Research Fellow, Centre for Computing and Responsible Research, De Montfort University, Leicester.
Director, Telehealth Quality Group EEIG.



Prescriptive standards that tell us ‘how to do’ things restrict innovation and reduce flexibility. This is as true for telehealth (and telecare) as it is for other products and services. The discussion in this monthly feature points to the need for standards for telehealth services (ranging from social alarms and PERS to ‘home telehealth’) to evolve in response to the shift in perspective – so that both the impact of new technologies is recognised and there is a clearer and better response to changing needs and choices of service users. The International Code of Practice for Telehealth Services is offered as an exemplar that has responded to the new realities and can ‘fit’ with or be adopted in place of related (and more ‘operational’) codes or standards.    

We can approach telehealth from two different directions – from clinical health or social care. Both of these have histories, traditions and professional dogmas that have been re- enforced by standards (or norms). Those standards have given us some of the certainties that have framed our personal or professional lives – and gave us our ‘comfort zones’.

But telehealth cuts across such certainties. It follows that we must question the role of standards as we know them (and which reflect one or other direction), lest our services become trapped within straight-jackets that we have weaved and stitched for ourselves. In this context, are the standards for telehealth fit for purpose? The answer is for some standards, yes – but much change is needed if the opportunities around telehealth are to be properly harnessed.

What is required is a positive move towards standards that offer flexible frameworks that can, in turn, be supported by ‘operational’ codes, relevant guidelines and good practice principles. This will help us to escape from any notion that telehealth should be ‘done to’ people and enables it to be seen as offering services that individuals can access and use in the ways that they want. This will provide, furthermore, a context for innovation and development that can respond to different needs – from supporting peoples’ fitness and healthy lifestyles to addressing mental health, pregnancy, palliative care, rehabilitation or the management of (other) conditions.

But in thinking about change, one thing we can agree on is that much of the old way of ‘delivering’ medical treatment to deferential and grateful patients is over. Besides, with increasing longevity, many of those kinds of health (or illness) services are becoming unsustainable and unaffordable. It follows that the notion of service ‘delivery’ (such a one-way term!) must be discarded in favour partnership approaches – where people take more responsibility for their health, its management and treatment. Telehealth can play a key part in these partnership approaches, but changes in the nature of standards to support this have some way to go.

From the social care side of things ‘standards thinking’ around telehealth is focused on social alarms (PERS), telecare and emergency responses. Over the last thirty years the United Kingdom has led with regard to such technologies and services. The associated ‘operational’ and somewhat prescriptive standards extend from the early offering of the British Standards Institution in 1987 to the Telecare Services Association’s ‘Integrated Code for Telecare and Telehealth’ in 2012. Similar operational and largely prescriptive approaches were adopted in standards for these technologies and services that were issued in Australia, France, New Zealand and Spain.

From the clinical health side of things ‘standards thinking’ around telehealth is focused on ‘home telehealth’ where operational standards were promulgated from 2002 by the American Telemedicine Association (ATA) and fed into in their 2014 ‘Core Operational Guidelines for Telehealth Services involving Provider-Patient Interactions’. What is significant in these, however, has been the ATA’s consistent and clear awareness of the broader agenda that includes social care. It follows that the ATA’s approach to service operation has been and remains less prescriptive than that which is reflected in most standards around social alarms and telecare.

Of course, the world of telehealth must embrace both health and social care. The technologies, in any case, cross those old boundaries. And it is clear that falls (that particular area of service that social alarms and telecare have well addressed) is a matter for health every bit as much as it is for social care. Social care also has a role to play in clinical health by such activities as supporting people with their medication, facilitating virtual visits and encouraging people with regard to therapies. And we don’t need to stop there. Telehealth technologies and services are beginning to recognise the broader community and environmental contexts – through incorporating or facilitating links to e.g. navigation systems and social networks.

So telehealth has an exciting and crucially important future when it comes to health and social care reform. And with regard to standards we can take the European Commission’s 2011 ‘Strategic Vision for European Standards’ as one of our touchstones. It is, of course, the European context in which the International Code had its origins. And it is this link and this common perspective that has helped to craft the vision and the flexibility that is built into it. And in offering a framework rather than a formula, we believe, this makes the International Code uniquely fit for purpose within what will be a new raft of standards, guidelines and good practice principles that offer a similar approach.

Interestingly, we can note that the International Code is not isolated in so doing. The partial resonance with ATA guidelines has been noted. But clearer is the approach that the International Code has in common with that of Accreditation Canada as set out in their 2014 ‘Telehealth Services Standards’. Both those bodies are in dialogue with the Telehealth Quality Group in order to consider how their offerings ‘fit’ (with the International Code) and respond to the imperatives around changes in the role and form of standards.

With such matters in mind, the International Code is clearly at the head of a curve. That curve points the way forward for telehealth standards more generally – offering a way forward to help services to rethink their approaches in ways that will

  • create new thinking around telehealth and its purpose;
  • enable them to respond more flexibly to peoples’ needs and choices;
  • promote service reforms (including the integration of health and social care);
  • support service innovation; and
  • help individuals and families to be more pro-active in managing their health.

Given the challenges that we face, this makes the International Code relevant to your needs – whether you are a service user, provider or commissioner. But don’t take it from me … please take a look at the International Code on this website.