**7. Conclusion**

Too often telehealth is seen as a panacea to resolve issues in a failing health service and is applied without consideration of the changes that must be made in order to integrate the telehealth into the existing service in terms of the technology, infrastructure, care pathways, new care services, management, support, training, new and changed roles, patient relationships, and professional relationships.

Telehealth is often promoted as being able to provide cost savings to the health service. Whilst reductions in length of stay, and possibly a reduction in the number of hospital admissions can be shown, resulting in notional savings, it is unlikely that the savings can be realised, as the hospital services will not be reduced. Most likely an organisation will be burdened with the additional costs for the technology and staff and the cost of providing services in the community. Or in cases where services have separate budgets, any saving in one service is not transferred as additional budget to the second. It is therefore essential that a holistic view be taken and all circumstances considered. For example, some organisations reimburse the costs of travel to the patient, and thus this would provide a realisable saving if the patient stays at home. In a single payer system, budget might be transferred, or made available to the organisation providing the telehealth service.

Alternatively a societal view may be taken. Telehealth can be seen as a solution to provide health services to communities and patients where otherwise it would not be available due to remoteness. Telehealth may also be considered to provide cost benefit to society by removing the need for costly travel for patient and relatives, and loss of earnings for time taken to travel and remain with the patient whilst in hospital.

Telehealth often suffers from poor design of the technology. Frequently devices are designed by enthusiastic young engineers to appeal to their imaginings of the needs of a patient; the system is built around the technology with which they are familiar, and does not relate to the needs of the actual user. At worst this means the technology is unusable with real patients (no broadband available, arthritic fingers cannot manipulate a smart phone, technology phobia), or is detested because it must be placed in a prominent position in the home and causes patients to be stigmatised. This problem also applies to procurement, when managers relate to the technology without understanding the needs of the patient; reminders may appear helpful but become irritating after many days of use. Telehealth should be simple and unobtrusive.

Moreover it must be recognised that telehealth is not a treatment, rather it is an approach to elicit relevant information from patients that may be used to support decision support and management. The effectiveness of outcome therefore relies on the services that use and act on that information. This may include telehealth supporting new approaches to deliver care. This may include using primary care and community to manage the patient, and using communication to support joint management and provide continuity of care, or establishing specialist services to manage the patient in the community. The approach adopted requires careful planning for its introduction.

However when implemented effectively, telehealth can confer significant benefit to the patient health, effectiveness of the clinician, and efficiency of the health service.

*Smart and Pervasive Healthcare*
