Adopting telehealth as a tool of integrated care: what type of research is required to justify the investment?

In the semi-darkness of the evening a professor walks in the wood. He sees a bird. It flies like a duck. It swims like a duck. It quacks like a duck. Back at home he tells his children: " I saw a duck! ". Later that same evening the professor settles down to write a paper on a case study of a telehealth innovation he has been investigating—one that provided a device to patients with chronic obstructive pulmonary disease (COPD) so that professionals could monitor and manage patient care remotely, and one where patients could manage care better by themselves. The results seemed promising: patients and carers were enthusiastic; self-reported health outcomes had improved; professionals supporting the delivery of the innovation were highly satisfied and felt care was provided in a more integrated way; and hospital admissions and lengths of stay per patient enrolled in the study had decreased compared to previous levels. The professor concluded that the innovation was a great success and that the deployment of new technologies had significant promise in delivering more cost-effective care to people with COPD. On publication of the professor's research his critics hit back. To them, it was unclear from the professor's study whether the telehealth intervention reduced overall costs to the local health system. They pointed out that COPD-related admissions to the local hospital continued to rise at the same rate, suggesting that the interventions were targeted at the wrong people. They queried whether it was really the technology that was important since patients received active nurse-led case management alongside it which they had not benefited from previously. They thought the sample size was too small to be meaningful. They concluded the research was flawed, could not be applied to other settings, and should not be included as 'high-level' evidence to influence whether telehealth solutions should be adopted more widely. Lack of robust evidence is often cited in telehealth as a barrier to adoption, as it is with many integrated care innovations more generally. In our hypothetical example , the level of uncertainty in the professor's observations provided the excuse needed to ignore his results, rather than to take on board the positive noises being produced. It is as if his children had said, disbeliev-ingly, " Are you sure what you saw was a duck? It was very dark outside. I think you may have seen that small swan that we …