E-health networked services: E-health networked services:

empowering elderly and chronic patients, empowering elderly and chronic patients, increasing output of the health and social care increasing output of the health and social care

system and improving productivitysystem and improving productivity

Th. Vontetsianos, MD, PhDTh. Vontetsianos, MD, PhD Consultant Pulmonary PhysicianConsultant Pulmonary Physician

Head, e-health UnitHead, e-health Unit

The care provision changesThe care provision changes• Ageing of the population• Increased demand for continuity of care

and home care• Increased mobility of the population• Wellness pathways• Evidence based medicine• Managed care• Health control from a distance• Emphasis on the existence of an active

continuously updated EHR• Increased role of genomics and bio-

informatics

The problem….The problem….

The costThe cost

The costThe costWHO WHO 19811981

TodayToday

The aged and chronic patients represent the 1% of all the patients who consume

the 30% of the insurance expenses

The aged and chronic patients represent the 1% of all the patients who consume

the 30% of the insurance expenses

Beyond Beyond 20202020

It is estimated that these patients will absorb the 60-

80% of all the insurance expenses

It is estimated that these patients will absorb the 60-

80% of all the insurance expenses

Quality changesQuality changes

• Today’s elderly are more educated and more demanding for better quality of care, more social life, more autonomy, and more protection by the community

• There are no clear boundaries between elderly and disabled

• There are no clear boundaries among personal, informal, formal and social health care

• Shortage of informal care givers • Shortages in health care personnel • Specialization and sub-specialization of personnel

The technologyThe technologyA philosophic point of viewA philosophic point of view

• Technology is the second defense line of the human, after religion, against his existence anxiety Chr. Malevitsis

The technology developmentsThe technology developments

• Smart wearable sensors measuring physiological parameters, personal and safety data

• Wireless telecommunication

• High bandwidth Internet

• Smart and networked homes

E-health status in EuropeE-health status in Europe

• e-Health is still an evolving concept

• Citizen-centric model is not a reality as yet– Limited number of citizen-targeted applications

• Benefits have not been proven– cost-effectiveness, quality improvement

• Security – Privacy – Confidentiality– main concerns

• Organisations towards e-Health era– need for new knowledge and skills

– workflow-compatible applications

E-health status in Europe (II)E-health status in Europe (II)

• Lack of business & reimbursement models– Impact both supply & demand side

• Industry: limited innovation

• e-Health is not yet part of national priorities– Initiative from national policy makers will be limited

(in most countries)

• Standards, cross-country harmonisation need to be promoted

e-Health hindering factorse-Health hindering factors

• Legal and ethical (outdated or variable legislation, different perceptions)

• Cultural (organisational, IT related) • Managerial (strategy, harmonisation) • Financing (funding, reimbursement)• Human attitudes• Established workflows

What we’ve been doingWhat we’ve been doing

Provision of e-health home-based rehabilitation, follow up and home hospitalisation services in patients with advanced stages of chronic diseases

Hospital

The e-health unit was established in 1999, as a horizontal research and therapeutic unit, for the implementation of various telemedicine applications, especially focused in home tele-health

The ‘‘Sotiria’’The ‘‘Sotiria’’ Hospital Hospital home care teamhome care team

• Physicians• Nurses• Physiotherapists• Clinical psychologists• Social workers• Dieticians• Pharmacists• The patients themselves and

their relatives

The patientsThe patients

• Chronic patients suffering mainly of COPD of advanced stages with a history of multiple hospital admissions in the past

Elements of the e-health systemElements of the e-health system

• EElectroniclectronic HHealthealth R Record ecord for for each patient based on each patient based on especially designed multimedia especially designed multimedia

s/w systems/w system (Frontis) (Frontis)

Compilation of medical Compilation of medical devices integrated into each devices integrated into each patients’ s EHRpatients’ s EHR

Digital camera for live, Digital camera for live, interactive communicationinteractive communication

Phases of Home integrated carePhases of Home integrated care

• Initial phase

Home hospitalization

Home base rehabilitation –

regular follow up

Main (chronic) phase:

Outpatient rehabilitation program

Initial phaseInitial phase

• It aims to create patients’ EHR and to train both patients and their relatives for the optimal, holistic rehabilitative treatment of their disease and to prepare them for the innovative services of the program

Main - HomeMain - Home care phasecare phase

It is performed by nurse home visits on a scheduled or on emergency basis

• Regular follow up - home based rehabilitation

• Home hospitalization of the patients

Nurse’s equipmentNurse’s equipment

• Laptop with Frontis system and patient’s EHR

• Peripheral medical devices for patient examination at home

• Digital video-camera

Schematic View of ServicesSchematic View of Services

Patient Site Telemedicine Unit

Ambulance

Doctor

Nurse

Relatives

Tasks of Scheduled Home VisitsTasks of Scheduled Home Visits

• Checking of vital signs and physical condition• Control of pharmaceutical therapy • Consultation for the correct use of medical devices• Checking of exercise training program and

nutrition • Reinforcement of patient’s and relatives training • Detection of primary signs of disease exacerbation• Treatment of other health related special problems

of each patient.

Tasks of Emergency Home VisitsTasks of Emergency Home Visits

Monitoring of patient’s vital signsLive communication with the Telemedicine Unit Patients’ s home treatment (in cases of mild exacerbations) or instruction for patients’ s admission to the hospital

A home VisitA home Visit

• Application of the therapeutic plan

• Performance of medical examinations

•Optionally, real time connection with e-health Unit

Home Visit FunctionsHome Visit Functions

Home Visit FunctionsHome Visit Functions

• Use of patient’s TV set, via an ISDN line (128kbps)

ResultsResults

Significant decrease of patients’ Significant decrease of patients’ hospitalizationhospitalization

376

315

64

156

86

0

50

100

150

200

250

300

350

2 years before theintervention

2 years after theintervention

Number of hospitalizations (per year)

Number of inhospital days (per year)

Number of Emergency andScenduled visits (per year)

Patient’s disease knowledge and Patient’s disease knowledge and self managementself management

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Initial assessment After the initial phase(3 weeks)

After 12 months

+++

++

+

Significant cost savingsSignificant cost savings

0,00 €

1.000,00 €

2.000,00 €

3.000,00 €

4.000,00 €

5.000,00 €

6.000,00 €

7.000,00 €

Hospital days Emergency room andother visits

12 months before

12 months after

What we have learnedWhat we have learned• Significance of the team work• Skills of health care professionals in team

and net-working• Service personalization (from medical and

technological point of view –flexibility)

• Accessibility “a single point of entry and access to continued and coordinated care among care levels”

• Greater emphasis on prevention (at all levels)

•Training health-care professionals

What we have learned IIWhat we have learned II

• Patients’ acceptance• Sustainability and affordability of the services• Significance of political, social, ethical,

organizational, managerial, civil values “e-health services provision is more an organization reform than a simple issue of technology adoption”

• Cost savings

The next stepThe next step

• The development of a home and community based care delivery network of sustainable connections among all levels of care providers, patients, insurance organizations and community for integrated,patient-centered services

UN Ageing ConferenceUN Ageing Conference International Plan of Action

• Promote strong partnerships between all levels of government, civil society, private sector, the elderly themselves and their care givers

WHO guide linesWHO guide lines

Diagram, modified from Caro's Model, showing Future Health Systems under the co-influence of major

transformational forces.

The Spanish The Spanish predictionprediction

The Home Telehealth Delivery Network

The Canadian The Canadian proposalproposal

Insurance organization

Tertiary Hospitals

Primary careResearch / University

Telecom organizations

Local authoritiesPrivate sector

Ministry of Health / RNHS

Home and community based Home and community based health care delivery Networkhealth care delivery Network

Patients and

relatives

Expected improvementsExpected improvements• Co-ordination and optimization of the personal health

management and care provided by the informal givers, formal providers and community structures

• Elimination of multiple overlapping activities• Reduction of the management burden• Transfer of expertise from academic centers to the

point of care (empowerment of care providers and patients)

• Optimal surveillance within the system • Clinical information sharing between care providers

regardless of geographic or organizational boundaries

Expected resultsExpected results• Delivery of the right patient care, at the

right place by the right care provider• Provision of more timely, accessible and

convenient care• Increased focus towards health promotion

and prevention• Reductions in emergency room visits, re-

admission rates, length-of-stay and the use of other community services

•  Increased productivity• Significant direct and social cost savings

Current technologiesCurrent technologies

SensorsSensors 3G GSM and high 3G GSM and high bandwidth bandwidth InternetInternet

WEB

”Sotiria” Hospitale-health services

WEB

Emerging home and community based care Emerging home and community based care NetworkNetwork in Greece in Greece

Athens Medical schoolDept. of intensive care

Municipality of Athens

Public employees insurance organization

Primary care doctors’ association

Hellenic MobileTelecom Organization

’’NGO child’s smile’’ for children with cancer

Hellenic

Telecom Organization

• Medical Exams include:

Lab results, Video, Image.

• Schedule Organizer for professionals

• Patients’ Medical Records include:

History, allergies & lifestyle.

• Internet links and Services included

• Communication Tools include:

Video-Conference, Chat, File Transfer, Forum and E-mail utilities

The Agenda for the Decade

Ministry of Health and Social Solidarity, Executive Secretariat

INFRASTUCTURES FOR SERVICE QUALITY AND PATIENT SAFETY

THE NATION’S HEALTH INFORMATION SYSTEM (NHIS)

THE NHS OBSERVATORY

OPEN HEALTH FORUM

NATIONAL CENTER FOR QUALITY OF HEALTH SERVICES

CENTER FOR INFORMATION MANAGEMENT AND TECHNICAL SUPPORT

INSTITUTE FOR HUMAN RESOURCE DEVELOPMENT

Ministry of Health and Social Solidarity, Executive Secretariat

Europe elderly care Europe elderly care provisionprovision

Europe elderly e-care Europe elderly e-care provisionprovision

Strategic partnerships

Technology and care providers

Organizational-cultural changes

Traditional infrastructures

Standardization-Interoperability

Heterogeneity

Non coordinated services

Networked services

towards

ConclusionsConclusions

I am 74 years old and for a long time I’ve been suffering from bronchitis, heart failure, diabetes and arthritis. I used to visit a lot of specialists and sub-specialists, take a lot of medication and worst of all I was taken to the ER very often and admitted to the hospital when my diseases got worse.   For the past two years though, ever since entering the home care program, instead of my searching through the system for good care and specialists … the specialist and good health care came to me. This significantly improved my personal quality of life and that of my family. I am very grateful that we don’t spend our time running around from hospital to hospital any more. St. Papaioanou

A patient’s opinionA patient’s opinion