Telematics for Health

The Role of Telehealth and Telemedicine in Homes and Communities

Marjorie Gott

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315346021
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Electronic communications are already revolutionizing the delivery of health care in homes and communities. The medium will have increasing impact on the delivery of health care in response to the pressure to use limited resources cost-effectively. To date much of telematics in health care has focused on hospital-based bio-medicine. In this book a case is made for reorientation of telematic activity towards the use of "low tech" (social) technologies supported by "Health for All" philosophies. This book uses several case studies of pilot schemes to illustrate how the models can be applied in a variety of settings. Experience of telematics in America, Canada, Germany, Italy, The Netherlands, Portugal and Wales is shared for an international readership of innovators in health care management.

1 Health and Technology: Making Connections

‘The information society can be a threat to our physical, mental and social well-being and we should learn to recognize it and treat it as a threat. That way, we might at least reduce the health effect somewhat, and learn at the same time how to enhance the potential health benefits.’

(Hancock, 1992)

Much of the ‘health’ work undertaken in this century has in fact been illness work. Illness work is big business; medicine coupled with telematics is even bigger business. The use of telematics in medicine is growing and the scale and scope of this growth need to be challenged.

In order to challenge the unchecked rise in the use of telematics in medical care, it is necessary to revisit and contextualize some key issues that have influenced how health is constructed and understood in society today. These are:

• shifts in meanings of health
• the use of telematics in health care
• health choices.

Shifts in meanings of health

During the latter half of this century, both public and professional views on health and health care have changed. There are a number of reasons for this. The universal adoption of biomedicine as the basis for health care throughout the first three-quarters of this century has meant that, by separating the body out into ‘bits of bits’ (biopathology), we have lost sight of the health and well-being of the whole person.

The twentieth century has been an age of science and, in particular, medical science. Whereas society turned in previous centuries to priests or gods for meaning and leadership, now they turn to doctors. In what Armstrong (1993) refers to as ‘the triumph of truth’, medical scientists can demonstrate the existence of diseases previously hidden within the human body. Ill health was once attributed to evil air (miasmas) or evil eyes (curses); now it is attributed to abnormal physiology (diseases). ‘Normal’ physiology thus becomes equated with health.

Disease protection used to involve the invocation of rituals with charms and prayers. The twentieth century equivalents are low cholesterol diets and running shoes. ‘Look after your heart’ is not a plea for tolerance and understanding in society, but an exhortation (and a responsibility) to individuals to maintain efficient cardiovascular functioning.

Verbraak (1992) describes how the artefacts of this philosophy influence mass consciousness:

‘Healthy behaviour, within certain modish margins, is part of a culturally expected lifestyle ... the weighing scales in railway stations, supermarkets or hotel lobbies are being replaced by instruments to measure your blood pressure or to establish your mental composure. Professional advertising campaigns focus on better lifestyles, newspapers and television have weekly contributions on health and society. Joggers colour the countryside and golf, tennis and surfing clubs prosper.’

Challenges to scientific reductionism

Modern medicine has evolved from the scientific reductionist paradigm that has dominated social life in Western societies throughout this century. The paradigm is characterized by use of the systems theory. This describes everything from the functioning of the human body to the economic functioning of societies (eg free market or communist). Systems theories are intellectually elegant and persuasive, but by stripping away the wealth of detail that is inherent in context, they become merely academic.

Worldwide, dissatisfaction with scientific reductionism as the only explanation for individual and social functioning is growing. Ormerod (1994) argues in The death of economics that economies’ core axioms do not and cannot correspond to any known reality; economists know this but close their eyes to it because their theories have intellectual appeal.

In all areas of social life, the reductionist paradigm is undergoing serious challenge. Not only is it demonstrably lacking in human values and qualities; it simply doesn’t work. This is as true of the medical model on which health care has been based in the twentieth century, as it is of the dominant economics model. The massive financial and human investment that has been made in high technology medicine has, in the main, not paid off. The financial cost of increasingly sophisticated diagnostic and treatment techniques needs to be offset against the moral and social costs often involved for patients and others whose less glamorous needs (eg social support) go underfunded and unmet.

Technological advances in medical care and increased research into health service issues have contributed to a dramatic rise in expenditure on health care in Europe. Despite this, the health of the European people has not improved as much as might have been expected. The problems caused by chronic diseases, disabilities, new epidemics such as AIDS and illicit drug consumption are increasingly worrying, not only to governments, but also to individuals. At the same time, there are serious concerns about the efficacy of sophisticated technology and existing health services that rely heavily on hospital and specialized medicine to confront those problems (Dutton, 1988; Konner, 1993).

Health For All: ideology and targets

Pressures from rising demand for health care in Europe (reflected in increased expenditure) have forced many countries to examine a range of options for changing the system. This is a common problem in spite of differences between individual health care systems. A potential solution is the development of a better system of primary health care with an emphasis on the twin goals of cost efficiency and service effectiveness. A number of strategies are being pursued by European Union (EU) countries to achieve these objectives. The common factor linking such efforts is the Health For All (HFA) ideology propounded by the World Health Organization (WHO, 1978 and subsequent). HFA is based on the use of a social, rather than a medical, model of health.

In 1978, WHO issued the Alma Ata Declaration. This recognized Health For All as a fundamental right and saw reorientation of resources towards primary health care as the way to achieve it. In 1985, 38 targets for HFA were set for countries in the WHO European Region (revised 1992). The European governments that were signatory to the 1985 agreement have in principle accepted the obligation to work on health targets.

There are three groups of targets. The first is aimed at reducing inequalities between countries and social groups. The inequalities identified are concerned with traditional preventive care (eg reducing maternal and infant mortality) and new public health issues, such as reducing traffic accidents and deaths by suicide.

The second set of targets addresses changes in lifestyle, the environment and provision of health care. The scope of this group is vast, covering policy and structural changes necessary for the adoption of healthy lifestyles, promotion of positive health behaviour, and action on air pollution, hazardous waste, water pollution and food contamination. Also advocated are healthy homes, schools and workplaces and a redistribution of resources from secondary to primary care.

The third set of targets identifies the necessary support frameworks as research, information systems, policy and planning frameworks and the education and training of health and other public service workers.

A major vehicle for putting these targets into operation is the Healthy Cities movement, in which the principles of partnership, team-work and collaboration are employed in planning for health (see Ashton, 1992). Healthy Cities philosophy is underpinned by principles contained in the 1986 Ottawa Charter. In this, the need for reorientation of health services to primary health care is addressed, as are the needs to strengthen community action, create supportive environments, develop personal skills and build a healthy public policy.

The HFA philosophy places more emphasis on health promotion than on treatment and care. Key features are:

• community responsiveness and representation
• collaboration and partnership in service planning, delivery and evaluation
• multidisciplinary teamworking (professional, voluntary and lay)
• equity in service distribution
• measures to redress health inequalities (ie social justice in care access and provision)
• individual and community development.

Health promotion: medical and social models

The social model of health is concerned with the conditions and contexts that shape health opportunities and illness experiences. Recognition of the value of the social model of health has been responsible for the development of a new health paradigm: health promotion. The emerging discipline of health promotion encompasses three strands:

• preventive care
• health education
• health protection.

Preventive care involves screening and diagnostic activities (medical model), and also social interventions such as immunization against specific diseases. A sensitive community diagnosis indicates appropriate interventions (social model). Health education may be individualistic and disease focused (medical model), or collective and health oriented (social model). Health protection is concerned with both remedial and rehabilitative care (medical model), and promotion of full health potential (social model).

Generally, medical models are reactive whilst social models are proactive. There is a need for both types of model and both sets of action. The social model is longer term, visionary and encompasses all citizens, whilst the medical model is more immediate, more narrowly focused and relates to significantly fewer individuals. The medical model can quite comfortably be accommodated within a social model of health; indeed this is the case made in The New Public Health (Ashton and Seymour, 1988). Too frequently, however, the medical model is chosen as the sole vehicle for policy making. The New Public Health has its origins in the WHO HFA movement. It recognizes the need for a range of strategies to be employed in health care delivery and health promotion and acknowledges that society needs to care for those already ill, as well as promote the health and interests of those who are not ill, but may be vulnerable.

Conflicting models of health operate in society and produce inequalities in health experiences and opportunities. Medical reductionism causes fragmentation of social policy and champions particular policy approaches over others. The social backdrop of scientific reductionism that has influenced policy making in this century has led policy makers to base decisions on medical models. However, health practitioners who have adopted HFA values are not comfortable when forced to act exclusively within the confines of the medical model; doing so provokes extreme role conflict.

Gott and O’Brien (1990) have explored the role of the nurse in health promotion. They identified how nurses are required to work to a medical model of health to carry out their nursing tasks (giving health advice), yet their personal and professional values are rooted in a social model:

Today it’s the “in thing” to go jogging, to be “green”, to be “ozone friendly” and I don’t think that’s such an issue for someone lower down the social scale. I think they’re more interested in scraping a living together and their day to day existence ... I think we don’t give a very good deal to those who most need the services because they end up with the middle-class body governing their lives.’ (health visitor)

Jonkers-Kuiper (1992) describes the conflicting health models and agendas surrounding implementation of the Collective Prevention Health Care Act in The Netherlands and notes similar problems to those described above. Other authors (Siler-Wells, 1988; Jacobson et al., 1991) challenge the Western policy focus on individualistic (medical model) ‘risk reducing’ interventions (eg screening) at the expense of health promoting (community-wide) interventions. They comment that lifestyle (and victims) are socially constructed.

A ‘risk reduction’ approach is appropriate for disease prevention. However health and well-being demand a broader approach encompassing the promotion of quality of everyday life in homes and communities. With regard to sustained behaviour change, a community development approach offers the greatest chance of success (Beattie, 1988; Lefebvre, 1991). Moreover, interventions alone are insufficient to protect and promote health. There needs to be a supportive framework of healthy public policies and an understanding and commitment by health professionals (service providers) to work together.

Several authors (Jones, 1990; Gott and O’Brien, 1990; Godinho etal, 1992) have noted the imperative for health professionals to change from paternalistic to co-operative practices. There are marked differences, however, in views of how this should be done. Some see the changed role for health professionals as simply giving more and ‘better’ information:

‘The professionals will need better ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• Acknowledgements
• 1 Health and Technology: Making Connections
• 2 Telehealth and Telemedicine: A Case Study Approach
• 3 Telehealth and Pregnant Women
• 4 Telehealth and Adolescents
• 5 Telehealth and Disability
• 6 Telehealth and the Elderly
• 7 Telehealth and Social Support
• 8 Telehealth and Public Policy
• 9 Promoting Good Practice in Telehealth
• 10 Telehealth For All
• 11 Concluding Recommendations
• Appendix: Contact Person by Case Study
• Glossary of Abbreviations
• References
• Index