Download - Vision, reality and challenges
TeleCare– Supporting the patient-client, what
are the real benefits –
Vision, reality and challenges
Karl A. Stroetmann
empirica Communication & Technology Research, Bonn, Germany
www.empirica.com
Belgian eHealth Congress 2007, Nov. 08, Brussels
Belgian e-Health Congress 2007, Nov. 08, Brussels © 2
Contents
� Vision: patient-centred health services
� Reality
– Pilots, pilots, pilots ...
– Limited convincing evidence
– Unmet citizen needs and expectations
� Challenges
� Conclusions
Belgian e-Health Congress 2007, Nov. 08, Brussels © 3
“Old” Vision: “New” Model of Healthcare
Characteristics Traditional model of healthcare
New model of healthcare
Health philosophy Disease centred cure Citizen centred and wellness fo-cused
Data & knowledge sharing
Fragmented, proprietary Integrated, distributed, shared, con-tinuous update
Interactions Episodic, on demand Continuously, autonomous
Care giver Healthcare professional Citizen, informal carers, commu-nity, healthcare professional
Care receiver Patient All citizens (independent of social, mental, physical capacities)
Entry into health system
Disease triggered Choice
Consultation de-livery process
Linear (cottage industry type)
Ubiquitous, seamless, collaborative
Consultation re-ceiver location
Hospital, GP office Home, community-based
Source: www. www.scenarios4health.eu
Belgian e-Health Congress 2007, Nov. 08, Brussels © 4
Key elements of the “ new“ model of healthcare
� Impetus on health, not on sick care� Focusing on the idiosyncrasies of the individualcitizen (personalised)
� Support & help at the point of need (home, mobility, community, abroad, ...)
� Meeting new challenges (chronic diseases, ageing population, ...)
� If in need of healthcare, supply of collaborative, integrated, seamless services across all health value system actors (including LT and social care)
� Support for optimal communication, sharing of data, access to latest knowledge
Initial vision and policy recommendations date back at least to the 70’s
Belgian e-Health Congress 2007, Nov. 08, Brussels © 5
Reality check: Pilots, pilots, pilots ...
� First pilots in the early 1970’s (satellite-based)� First interactive CATV system (services for 70 to 90 years old ladies) 1990 in
Frankfurt/Germany� Hundreds of (rural) pilots (and hundreds of $m) in the USA and elsewhere
failed� Pilots in 2007:
– Several pilots in the Netherlands: Philips Motiva System in Rijnmond(Rotterdam) and Twente; Health Buddy in Limburg etc.; KOALA Foundation in Groningen ...
– “The Canadian Home Care Association (CHCA) has entered into a partnership with Canada Health Infoway to lead a national project on technology in home care. The project, ‘Integration through Information Communication Technology in Home Care in Canada’, will result in a better understanding for the potential of, and readiness for, information communication technology (ICT) in the Canadian home care sector.”
(Volume 5 – Fall 2007: Newsletter Canada Health Infoway, p. 4)
– UK Department of Health (Oct. 2007) ‘Shifting Care Closer to Home’: The report looks at the experiences of 30 chosen demonstration sites in six specialty sub-groups ...
– Ukrainian Telemedicine and eHealth Development 1st InternationalConference "Telemedicine: myths and reality”, 8-9 November 2007
A real, sustained market does not yet exist, eHealth industry is still searching for it
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Evidence
� Most empirical studies relate to pilots, not routine services
� Most studies are scientifically and methodologically weak
� “Home telemonitoring of chronic diseases seems to be a promising patient management approach that produces accurate and reliable data, empowers patients, influences their attitudes and behaviors, and potentially improvestheir medical conditions. Future studies need to build evidence related to its clinical effects, cost effectiveness, impacts on services utilization, and acceptance by health care providers.
(Source: Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base: J Am Med Inform Assoc. 2007;14:269 –277)
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More evidence
� “We identified summaries of 8,666 studies ... The review included 68 randomized controlled trials (69%) and 30 observational studies with 80 or more participants (31%). Almost two-thirds (64%) of the studies originated in the US; more than half(55%) had been published within the previous three years. Based on the evidence reviewed, the most effective telecare interventions appear to be automated vital signs monitoring (for reducing health service use) and telephone follow-up by nurses (for improving clinical indicators and reducing health service use). The cost-effectiveness of these interventions was less certain. There is insufficient evidence about the effects of home safety and security alert systems. It is important to note that just because there is insufficient evidence about some interventions, this does not mean that those interventions have no effect.”
(Source: A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions. J Telemed Telecare. 2007 ;13 (4):172-179)
� Our search initially identified 4,083 citations. ... Following a full-text review, 106 studies were included. Store-and-forward services have been studied in many specialties, the most common being dermatology, wound care and ophthalmology. The evidence for their efficacy is mixed. Several limited studies showed the benefits of home-based telemedicine interventions in chronic diseases. Studies of office/hospital-based telemedicine suggest that telemedicine is most effective for verbal interactions, e.g. videoconferencing for diagnosis and treatment in specialties like neurology and psychiatry. There are still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence. Further well-designed research is necessary to understand how best to deploy telemedicine services in health care.
(Source: Diagnosis, access and outcomes: Update of a systematic review of Telemedicine services. J. Telemed. Telecare 12 (Suppl.
2):S3-31, 2006)
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Benefits: Telemonitoring of Heart Failure Patients - A Randomised Controlled Trial
Significant reduction in mortality: Survival days follow up
8
371303217TM
377307214NT
304263199UC
0-4800-3600-240Interval
1
2
3
*p < 0,05*
Source: TEN-HMS
study/empirica
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Benefits: Fewer days in hospital
9
Days in hospital (all patients)
0
500
1000
1500
2000
2500
0-240 0-360 0-480
NT TM
Days
Days of follow-up
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The Health Telematic Network offers:
• teleconsulting and ECG referrals and multi-specialty second opinion for general practitioners
• home telenursing for chronic cardiac diseases
• telediagnosis for arrhythmia
• call centre for hospitals
The Service Centre is characterized by:
• an advanced technological platform
• a call centre operating 24/7 all year round
• a highly skilled team
• an intensive use of teleworking
• a network of physicians able to offer effective and efficient telemedicine services
Good practice example:Health Telematic Network S.r.l. , Brescia, Lombardia, Italy
- A sustained long-term service since 1998 -
Source:Health Telematic Network S.r.l. , Brescia, Lombardia, 2007
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Agenda
11
0
5
10
15
20
25
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Mil
lio
n E
uro
Present value of total costs Present value of benefits
A profitable, sustained long-term service supported by a reimbursement model:
Health Telematic Network S.r.l. , Brescia, Lombardia, Italy
Source: eH IMPACT study/ACCA 2006
Belgian e-Health Congress 2007, Nov. 08, Brussels © 12
COUNTRY
UKS
FINPANLLI
IRLFEELD
DKBIn
tere
st
hea
lth
info
rma
tio
n:
ge
ttin
gin
foa
bo
ut
tre
atm
en
to
n c
om
pu
ter 50
40
30
20
10
0
27
4442
20
2729
2627
11
31
15
48
39
2525
Citizen (50+ old) expectations: their interest (in %) in receiving infor-mation on treatment (Personal Health Record) on their home computer
Source: www.seniorwatch.de 2000 / empirica
13
13
Citizen expectations: e-mail communication
with doctors: high unsatisfied demand
Source: eUSER, GPS 2005/empirica
Usage of ICT supported consultations
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Germ any France Italy Denm ark UK Ireland Poland Hungary Czech
Republic
Slovenia EU 10
Average
General interest
in email
consultations
Usage of email
consultations
Base: A ll respondents
14
THE COMMONWEALTH
FUND
Patient experience (%): doctor-patient
communication
61546760626266
Always tells you about your
treatment options and
involves you in decisions
about your treatment
70
71
78
GER
71
71
71
NETH
7071807579Always explains things so
you can understand
5659695973Always spends enough
time with you
6263696769
Always knows important
information about your
medical history
USUKNZCANAUSPercent reported doctor:
Source: 2007 Commonwealth Fund International Health Policy Survey
15
THE COMMONWEALTH
FUND
Patient experience (%): care management
and coordination for chronic conditions
19
57
22
GER
13
58
31
NETH
7058484044Receive reminder for
preventive/follow-up care
2218191614
Often/sometimes receive
conflicting information
from different health
professionals
6130353340
Doctor gives you a written
plan for managing care at
home
USUKNZCANAUSAdults with a chronic
condition reported:
Source: 2007 Commonwealth Fund International Health Policy Survey
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Challenges
Results (2007) from across several USA Medicare disease management (DM) demonstration/pilot programmes:
� Changing patient and provider behaviour is HARD:– Limited use of behaviour change models– No incentive for physicians to communicate
� Some patients too ill, others not at short-run risk� Programmes don’t collect timely hospitalization and Rx info� Usual care providers are minimally engaged� Programmes led by marketers, not clinical experts:
– Ineffective use of available data – Unfamiliar with unique needs of the elderly
� Improvements in quality of care don’t guarantee better patient outcomes in short run
(Source: Annual Academy Health Research Meeting, June 2007)
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More challenges
� Where is the (wider European) market???
� Providers need a clearly cut business case
� Regulators must set the right incentives: – Equal access to a basic package of health care services
– Competition organised around the integrated care for a patient’s condition (DRG-like)
– (Published) all-inclusive prices
– Transparency: published data on (relative) quality of service and outcomes
– Incentivize patients (or third party payers) to search for high quality, efficient care (e.g. through co-payments for patients; or outcome-adjusted reimbursement)
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More challenges
� Strong health policy leadership (not focused on eHealth)
� Professional attitudes and cultures
� Organisational change, change management
� Integration and re-engineering of healthcare and social care “business” and delivery processes
� Legal framework, regulation
� Reliability, ease of use, interoperability, certification of eHealth solutions
� Training, education
We have only just started on a very long journey
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Conclusions
� Telehealth will slowly expand (less costly; quality of life)
� Telehealth concepts are slowly maturing and are expected to meet new health system and policy needs
� It is not sufficient to demonstrate the medical, patient and economic benefits of new telehealth services
� In addition, the interests (benefits & costs) of various health system actors need to be taken into account
� In the longer term, the “new” paradigm of seamless, patient-centred care will require new, more efficient service delivery and incentive models