Wirtschafts- und sozialwissenschaftliche Fakultät

eHealth

Disease Management

Seminar E-Gov / E-Health

Dusan Vuksanovic

dusan.vuksanovic@unifr.ch

and

Angela Berchtold

angela.berchtold@unifr.ch

Supervision: Prof. Dr. Andreas Meier

Assistant: Nicolas Werro

7. December 2007

I

Contents

1. Introduction ........................................................................................................................................1

2. Definitions ...........................................................................................................................................2

2.1 Disease Management ................................................................................................................2 2.2 Disease management programs (DMP).....................................................................................2 2.3 E-disease management ..............................................................................................................3

3. Goals of disease management ............................................................................................................3

4 First principles of disease management .............................................................................................4

5. Components ........................................................................................................................................5

5.1 Medical dimension..............................................................................................................................6

5.2 Economic dimension...........................................................................................................................8

5.3 Infrastructure......................................................................................................................................8 5.3.1 Databases ...............................................................................................................................8 5.3.2 Patient / physician information systems.................................................................................9 5.3.3 Advanced training of medical practitioners .........................................................................10 5.3.4 Disease management circle ..................................................................................................10 5.3.5 Organizational management.................................................................................................10

5.4 Clients / Patients...............................................................................................................................10 5.4.1 Incentives for patients ..........................................................................................................10 5.4.2 Incentives for medical practitioners .....................................................................................12

5.5 Evaluation dimension .......................................................................................................................12

6 E-disease management and telehealth .............................................................................................13

6.1 E-disease management .....................................................................................................................14

6.2 Telehealth .........................................................................................................................................15

7 Examples of DMP and telehealth service providers .......................................................................16

7.1 Practice Bubenberg AG and Swiss heart and cardiovascular centre (Inselspital Berne) ................16

7.2 Avalis Telemedicine Ltd....................................................................................................................18

7.3 Card Guard PMP4 ...........................................................................................................................19

8 Difficulties of disease management ..................................................................................................20

9 Summary ............................................................................................................................................21

Bibliography......................................................................................................................................... III

II

List of figures

Figure 1: Information and knowledge control circle .....................................................7

Figure 2: Different methods of patient’s recruitment ..................................................12

Figure 3: Architectural model of a mobile alerting system .........................................15

Figure 4: Overview of Avalis integrated mobile patient-monitoring system .............19

Figure 5: Card Guard PMP4 ........................................................................................20

List of abbreviations

CIS: Clinical Information System

COPD: Chronic Obstructive Pulmonary Disease

DMAA: Disease Management Association of America

DMP: Disease Management Program

HER: Electronic Health Record

ICT: Information and Communications Technology

MAS: Mobile Alerting System

PDA: Personal Digital Assistant

1

1. Introduction

The change from the analogue to the digital age also enters the health care market

under the name of eHealth. eHealt or Electonric Health is the integrated assignment of

information and communication technologies to increase quality and efficiency and to

guarantee regional and worldwide health care.1 Advantages of eHealth are an

increased patient safety, quality in care, and efficiency and as a consequence lower

costs for the service provision. To use the huge potential as effective as possible, it is

necessary to build up the essential infrastructure and coordinate the national and

international systems.2

To use these technologies efficient in for example telemedicine or disease

management, all participants need to think in different terms and be open for new

ideas.3 Nowadays people start to realize this. But to chose the right system, to

implement and operate it is a very complex task that needs a lot of preparation. Also

the people who have to use the new information systems need to be motivated and

able to work with them.

In the beginning of the nineties the pharmaceutical industry in the United States

started to develop disease management programs to provide chronic sick more

effectively and efficient and as a result cut some of the costs.4 However, the impulse

for the development of disease management programs (DMP) in Germany came from

an advice of the expert advisory board in 2001. And in 2002 legal framework for

disease management programs were registered in the compulsory health insurance.5 In

Switzerland these programs were also initialized by state government.

In this paper the authors are focusing on disease management and then see how

different technologies can be used to improve traditional disease management. When

devices are well integrated into DMP that includes appropriate physician incentives

and organizational infrastructure, ehealth technology can contribute to program

effectiveness by improving communication with patients and increasing the efficiency

of data collection and nurse case management.6

1 cp. Anwenderforum eHealth (November 2007)

2 cp. Kanton St.Gallen (November 2007)

3 cp. Anwenderforum eHealth (November 2007)

4 cp. Nadolski (2002)

5 cp. Haas, P. (2006), p.201

6 cp. LeGrow, G. / Metzger, J. (2001)

2

2. Definitions

2.1 Disease Management

In the literature there are many different definitions of disease management.

Lauterbach for example defines disease management as an integrated system that

substitutes the episode based and sectoral split care of chronically ill patients with a

systematic, evidence based, cross-sectoral and continuing care process of chronically

ill patients. This approach considers all illness stages over all health care facilities.7

According to the Disease Management Association of America (DMAA) disease

management is “a system of coordinated health care interventions and

communications for populations with conditions in which patient self-care efforts are

significant”.8

„Disease management:

• Supports the physician or practitioner/patient relationship and plan of care;

• Emphasizes prevention of exacerbations and complications utilizing evidence-

based practice guidelines and patient empowerment strategies; and

• Evaluates clinical, humanistic, and economic outcomes on an on-going basis

with the goal of improving overall health“.9

Besides the disease management there is another concept called case management.

Disease management targets individuals diagnosed with specific conditions, such as

diabetes, asthma or hypertension and often involves applying standardized techniques

in a systematic way, whereas case management focuses on high-risk patients with

complex combination of medical conditions.10

2.2 Disease management programs (DMP)

The different definitions of disease management show that disease management

programs are reasonable when there is a high number of new patients and a high

occurrence of the disease, a high mortality as well as a chronically course of it. It is

important to know the dynamics and have defined disease phases and also to have

7 cp. Luterbach, (2007)

8 DMAA (November 2007)

9 cp. DMAA (November 2007)

10 cp. Holtz-Eakin, D. (2004), p. 2

3

common strategies to intervene in the disease. Another key factor is the high costs of

care for the chronically ill patients.11

Disease management programs support and coordinate measures and aim to enhance

communication between practitioners and patients. It facilitates feedback necessary

for behavior modification (which may prevent or delay disease progression), and

measures the effectiveness of interventions.12

For example in Germany the different programs are negotiated and defined by

regional health insurances together with the medical practitioner and other service

providers.13

2.3 E-disease management

LeGrow and Metzger define e-disease management as Web-based “information tools

that provide communication and access knowledge, and enable patient self-

management.”14

“E-disease management is a tool for implementing disease

management, not a program in itself.”15

3. Goals of disease management16 For Haas the goals of this approach are high quality and cost-efficiency of the health

care as well as a continuous control and improvement of the quality of the care

through a systematic process with feed back loops. To achieve these goals it is

important to improve continuity, coordination, integration and quality.

Continuity

Disease management wants to provide continuing health care by linking the different

services and sectors during all stages of the illness. The patient is during the whole

course of the disease accompanied. That means the patient has help during the

prevention, treatment, and also during aftercare operations. The different phases are

planned and observed by a person such as the attending doctor who coordinates the

actions that lead to the cure.

11

cp. Haas (2006), p. 200 and Lauterbach (2001), p.187ff. 12

cp. National Pharmaceutical Council (November 2007) 13

cp. Haas, P. (2006), p.201 14

LeGrow, G. / Metzger, J. (2001), p.6 15

LeGrow, G. / Metzger, J. (2001), p.7 16

cp. Haas, P. (2006), p.198 f.

4

Coordination

The coordination of the health care should be improved by having more transparency

of the “is-situation” and the “should-be-perspective”. The goal is to have an

interactive, complementary and supporting care of a patient. This also improves the

effectiveness of the input of resources.

Integration

The goal is to integrate all people and institutions who/which are involved in the care

of a patient. The different organizations that are involved in the cure of a patient

should be optimal linked to each other mainly through intensive exchange of

information and mutual documentation as well as through integrated organizations.

Increase in quality

The goal is to increase quality by using quality control systems for the quality of the

structure, processes and results. The defined actions in a treatment program and the

involved service providers have to be checked on a constant basis to guarantee the

high quality of the care. The quality control helps to improve the programs

continuously and it also tries to repeal the critiques that the cost-savings of the disease

management programs are only because of a decrease in the quality of care.

4 First principles of disease management

To achieve the goals that were previously explained it is important to split them up

and look in detail to identify a therapy that has the best quality and is cost-effective

and brings the right care to the right patients at the right time. The principles of

disease management are:

• To understand the natural course of a disease and its specific causes, its

characteristics and cost factors.

• The acceptance that cost of therapy and quality of therapy affect each other.

• To use the course of disease as orientation for diagnosis and therapy

possibilities instead of established allowance guidelines.

• To give the patients and service providers the possibility of specific and

continuous further education and training.

• To use the resources specifically.

• To use an effective and continuous quality management.

5

• To establish an effective information and know how transfer as well as a

dialogue among participants.17

Core of disease management programs

By using the principles of disease management some core points for disease

management programs can be named. For one the treatment has to be guideline

oriented as well as standardized, however allowing for individual patient

characteristics. Information has to be structured so that the practitioner recognizes

relevant information fast and can use these to influence the decision making process.

The patients also have to be supported and assured in managing themselves with their

disease. They have to be sensitized to see changes in their disease as early as possible.

A key reason for these programs is to save costs. Therefore it is important that the

programs use an optimal input of resources. Another point is that the documentation

should be centralized to have the possibility to make epidemiological analyses as well

as have an overview to ensure the high quality of these programs.18

5. Components

Disease management programs vary widely in specific techniques and tools that they

use, but they share several common components that are designed to address those

shortcomings.19

One component of disease management is to educate patient about their disease and

how they can manage it. The goal is to encourage patients to use medications

properly, to understand and monitor their symptoms more effectively and as a result

change their behavior. A second component is to actively monitor patients’ symptoms

and treatments following evidence based guidelines. Coordination of the disease care

among all providers (physicians, hospital, laboratories and pharmacies) is another

component of disease management.20

According to DMAA full-service disease management programs must include the

following six components:

17

cp. Haas, P (2006), p.199 18

cp. Haas, P. (2006), p.199 and Lauterbach, (2001), p.187ff, 19

cp. Holtz-Eakin, D. (2004), p.2 20

cp. Holtz-Eakin, D. (2004), p.2

6

• Population identification processes;

• Evidence-based practice guidelines;

• Collaborative practice models to include physician and support-service providers;

• Patient self-management education (may include primary prevention, behavior

modification programs, and compliance/surveillance);

• Process and outcomes measurement, evaluation, and management;

• Routine reporting/feedback loop (may include communication with patient,

physician, health plan and ancillary providers, and practice profiling). 21

DMPs consisting of fewer components are defined as disease management support

services.22

In terms of components of disease management, Lauterbach makes distinction

between five different dimensions: medical dimension, economic dimension,

infrastructure, clients and evaluation dimension.

5.1 Medical dimension

Medical dimension of disease management includes different components. Essential

component of the disease management are evidence-based guidelines. Evidence based

guideline is a statement that is based on “good” research evidence on clinical

effectiveness.23

It represents systematically developed decision support for physicians

and patients.24

A critical success factor of disease management is the availability of a knowledge

base. To keep this knowledge base accurate there is a need for an appropriate medical

information system that analyses essential treatment parameter and sends these to a

data basis that integrates standardized DMP-documents, guidelines etc. This is ideally

done in a information and knowledge control circle.25

This important aspect of disease management programs, knowledge accumulation,

can be enhanced by adoption of so called DMP-knowledge portals. The DMP-

knowledge portal includes informations such as cost structure of the disease,

evaluation studies and results, indicator statistics, patient segmentation, treatment

21

DMAA homepage (November 2007) 22

cp. DMAA homepage (November 2007) 23

cp. The Royal College of Radiologists (November 2007) 24

cp. Lauterbach (2001), p. 99 25

Cp. Haas (2006), p.202f.

7

flows, and guidelines. It creates descriptive and explorative statistic analyses, which

are being used as tool for gaining knowledge and as a benchmark of the institutions

and so make quality management possible. The portal reports the changes of the

indicators, documentation and operation standards to the institutional information

systems.26

Figure 1 shows the information and knowledge control circle for disease

management.

Looking at this figure, it can be seen that the DMP approach is a complex system.

Without a corresponding support through information technological and telematic

process isn’t it possible to implement disease management.27

Figure 1: Information and knowledge control circle.28

Another component of disease management is the individual patient care plan. Patient

plans have to be tailored for each patient individually to have a higher impact on

patient’s health condition. It is also important to define patient inscription criteria

which allow avoiding inscription of unqualified patients and so providing the

prevention of the manipulations (see 5.4.1).29

Patient training as a next component of

26

cp. Haas, P. (2006), p.203 27

cp. Haas (2006), p.203 28

cp. Haas, P. (2006), p.203 29

cp. Lauterbach (2001), p.25

Cost structure of the disease Evaluation studies and results Indicator statistics Treatment flows Guidelines

DMP-knowledge portal

Plan

Documentation of treatments Appliance of clinical guidelines Documentation of indicators

Institutional information system

(clinical practice, hospital…)

Do

Current standards

Check

Indicators

Analysis

Results

Act

Epidemiologisches

Krankenregister

Outcome measurement Analysis of the Process-Output-relation Development of care delivery standards

8

medical dimension is a “supporting pillar” of DMP. It should provide encouragement

for patient self-management. Experiences in the past showed that not all patient-

training-programs are effective and that standardized, fixed schooling methods do not

lead to long term success.30

5.2 Economic dimension

The component that reflects economic dimension is the cost-benefit-analysis.31

Cost

saving is one of the aspects that disease management is expected to have influence on.

The proposition for DMPs is that people will be healthier if they receive better care

and this will cause lower costs in the future.32

Medical benefits of disease management programs are unquestioned because one

patient integrated in such a program receives better care then another one that is not.

Medical benefits alone are not enough to make statements about total utility of disease

management programs from social and health insurance point of view. For this reason

it is necessary to make a cost-benefit-analysis.33

5.3 Infrastructure

Databases, patient-physicians-information systems, advanced training for medical

staff and organizational management are the infrastructural components that are

necessary to enable disease management.

5.3.1 Databases

Disease management is an information and data driven approach for systematic

enhancement of medical care for patients with chronic diseases. For the success of the

DMP it is crucial that relevant data, which is being used for effective and efficient

resource use, is provided in real-time. For this reason, data has a strategic importance

for disease management. High quality and cost-efficiency of DMP can be reached

only by systematic and standardized data documentation.34

Lauterbach suggests that collected data should be centrally collected and stored by

health insurance companies. The main arguments are: time and place independent

data access possibility, more efficient information flow, immediate matching of

30

cp. Haas, P. (2006), p.200f 31

cp. Haas, P. (2006), p.200f 32

cp. Holtz-Eaklin (2004), p.4 33

cp. Lauterbach (2001), p.279 34

cp. Lauterbach (2001), p.154

9

historical and new data, the possibility of control of reminder systems (see 5.3.2) and

quick data transfer.35

5.3.2 Patient / physician information systems

“The effective use of information systems and telecommunication technologies will

be a major success factor in the nation’s ability to manage an ever-growing population

long-term chronic health conditions”.36

Such systems are essential to improve

information flow and communication between disease management patients and their

caregivers (physicians) and will be a major factor in the success of the disease

management industry in treating chronically ill patients.37

A commonly used information system in disease management is the reminder

system. It is kind of a feedback mechanism that allows patients and physicians to

communicate changes of health indicators. This system also informs and reminds

patients and physicians about measurements that have to be done, or alarms them if

the examinations results have reached critical values.38

The disease management association of America identified four types of patient

information systems: 39

Patient Call Center: it is very often a deployed communication system by

organizations; Most of the organizations operate their own call centers, but some of

them also outsource call center services.

On-line Access: organizations use e-mail, instant messaging, and websites to

communicate with their patients and/or providers.

Home Monitoring Device: organizations use home monitoring devices for patients to

report data on their weight, glucose levels, blood sugar levels, lung functions etc. The

majority of the providers use live call-center agents, and some of them also offer non-

call center options, including e-mail, web access, Interactive Voice Response (IVR),

or other forms of automated data transfer such as mobile alerting systems.

Patient Data Exchange: practitioners use e-mail, web access, fax, or IVR devices for

exchanging data with their patients. Some of them use one or more of these

35

cp. Lauterbach (2001), p.160f 36

Fiddleman, R. H. / Bernett, H. / Montrose, G. (2002), p.5 37

cp. Fiddleman, R. H. / Bernett, H. / Montrose, G. (2002), p.5 38

cp. Lauterbach (2001), p.120f 39

cp. Fiddleman, R. H. / Bernett, H. / Montrose, G. (2002), p.7

10

technologies for clinical data exchange (for prescription refills, test result reporting, or

medication management). Direct data exchange is used for care management activities

such as behavior change reminders, decision support, and reporting health risk

information.

5.3.3 Advanced training of medical practitioners

The goal of the training is to support the physicians by the implementation of the

evidence-based and cost-effective therapies. The subject of this training is not only

medical knowledge, but also the development of the medical profession.40

5.3.4 Disease management circle

The disease management circle is an intervention in disease management that

contributes to the training of medical practitioners and it suites the purpose of decision

support, quality assurance and implementation of guidelines.41

5.3.5 Organizational management

Organizational management ought to ensure alignment of the organizational

operations on the requirements and needs of chronically ill patients by restructuring

the organizational operations und praxis routines. In the broader sense, organizational

management includes also the use of decision support systems. Decision support

system ought to provide therapy relevant information in structured and prepared form

to the medical practitioners, in order to ensure rapid integration of all important and

relevant informations in the decision making process.42

5.4 Clients / Patients

5.4.1 Incentives for patients

One example for an incentive for patients is that the participating patients could get a

bonus from their insurance companies. This bonus could be a decrease in fees, an

additional contribution for the patient or a guarantee of a decrease in the over-all

contribution.43

40

cp. Lauterbach, K. W. (2001), p.174 41

cp. Lauterbach, K. W. (2001), p.183f 42

cp. Lauterbach, K. W. (2001), p.166 43

Cp. Haas (2006), p.202

11

Example Recruitment of patients for a DMP (cardiac insufficiency)44

The potential of disease management can only evolve if a significant number of

patients are recruited for a certain program. There are three different recruitment

methods:

• Recruitment via attending doctor

• Recruitment via health insurance

• Recruitment via media

These recruiting processes were tested while searching for patients with a cardiac

insufficiency. For all three recruitment methods a prospect with information

concerning the specific DMP was prepared to give out to the patients who were

interested in participating. Also a health adviser was available for patients who were

interested in participating. They could register for a noncommittal talk with the health

adviser and then decide if they still wanted to attend the program.

In the first recruitment method the participating doctors were asked to recommend the

program to all their patients with cardiac insufficiency. For the second method the

health insurances selected some of their insured people who were treated for cardiac

insufficiency and had used certain combinations of medication the previous year.

They mailed them a prospect with a questionnaire which helped to figure out if a

person was a candidate for the program. The third method used the media and there

the DMP was introduced in the “Tagesanzeiger” as well as in the telecast “Pulstipp”.

Patients who were interested could write or call to get more information.

Looking at figure 2 it is obvious that the recruitment quality of the attending doctor is

the best, while the quality of the recruitment via the media is very poor. Most of the

attending doctors said that they have trouble identifying all the right patients for a

DMP (in this case for cardiac insufficiency). The identification of patients by their use

of medication also doesn’t find all patients (only around 70%). Even though, through

the media it’s possible to reach most people, unfortunately many who were interested

in the program didn’t fit the patient requirements. This is because there is no pre-

selection of the patients.

44

cp. Weber, / Götschi, / Kühne, / Meier (2004), p.2581ff.

12

0

10

20

30

40

50

60

Registration after getting

some information

Registration after having

the talk with a health

adivser

Participating in the

program

Nu

mb

er

of

pati

en

ts

Attending doctor

Health insurances

Media

Figure 2: Different methods of patient’s recruitment45

5.4.2 Incentives for medical practitioners

Practitioners that are involved in DMPs get support and also an advanced training in

how to deal with chronically ill patients with a certain disease. They don’t have to

concentrate to be up to date with all the diseases anymore because this is done by

someone else. For example in the study for a DMP for patients with a cardiac

insufficiency (see 8.1) a nurse is specialized in the care of such patients and is up to

date with the newest medications and the adverse effects of these.46

5.5 Evaluation dimension

After disease management programs are being applied, it is important to measure their

impact. Only a few evaluation designs for assessing the impact of DMP interventions

are being applied. Here we briefly present three of them.

The total population approach is currently the most widely applied evaluative

model in the disease management industry. It is typically used to evaluate DMP on

medical utilization and costs. This model uses pretest-posttest design, which is a

relatively weak evaluative technique. Basic weakness of this method is that here is no

control group for which comparisons of outcomes can be made. The validity of the

design can be improved by adding a control group receiving no disease management

45

Weber/ Götschi / Kühne / Meier (2004), p.2581 46

cp. Schnetzler (2002), p. 15ff. and Weber/ Götschi / Kühne / Meier (2004), p.2581

13

intervention or instead of costs, utilization or quality indicators should be used as

outcome measures.47

Survival analysis is the second method that can be used to evaluate the impact of

disease management programs. It offers insights into the effect of disease process

progression over time while providing the ability to measure the impact of secondary

prevention techniques on these processes. Survival analysis can be used to determine

how long it takes for disease management interventions to improve patients

physiologic markers and also how long after that reduction in utilization and costs

become evident.48

The time series analysis model uses previous observations as the basis for predicting

future behavior. Time series analyses are used to characterize a pattern of behavior

over the measurement period by analyzing fluctuation of the variable along the

continuum, inferring the impact of an intervention introduced during measurement

period, and also forecasting future direction of the time series variable.49

Several evaluative methods can be used for assessing DMP effectiveness. However,

before an evaluation is lunched, it must be ensured that the chosen design best fits the

data and softens the effects of biases that may raise concerns about the validity of the

outcomes.50

6 E-disease management and telehealth

Both, e-disease management and telehealth include using information and

communication technologies to improve communication between patients and

medical practitioners. However, there is a difference in these two approaches. Starting

point for e-disease management is DMP and the accent is on enabling patient self-

management by using informations tools that provide communication and access to

knowledge. On the other hand, telehealth focuses on home health care delivery to

chronically ill patients.51

47

cp. Linden, A. / Adams, J. L. /Roberts, N. (2003), S.7f 48

cp. Linden, A. / Adams, J. L. /Roberts, N. (2003), S.8f 49

cp. Linden, A. / Adams, J. L. /Roberts, N. (2003), p. 11 50

cp. Linden, A. / Adams, J. L. /Roberts, N. (2003), p. 17f 51

cp. LeGrow, G. / Metzger, J. (2001), p.7ff and TeleHealth, Inc. (November 2007)

14

6.1 E-disease management

E-disease management covers the broad range of applications. Some of the

applications focus exclusively on patients, some aiding primarily clinicians and others

supporting collaboration between clinicians and patients. The advent of these

electronic applications in disease management has resulted in improvement in few

areas such as improved patient communication with caregivers, 24-hour patient access

to disease-specific information and improved access to patient tracking and decision

support tools. 52

According to LeGrow and Metzger e-disease management applications connect

participants in four different ways:

• Patient self-directed (no other participants are electronically linked to the

application),

• Patient focused with case manager (nurse case) linkage,

• Patient focused with physician linkage,

• Clinician focused. 53

One example of the patient focused applications with physician linkage is “a mobile

alerting system for the support of patients with chronic conditions.” Mobile alerting

system (MAS) for the support of patients with chronic conditions is a push-based and

patient-centred support system. The patient-centred approach strongly promotes the

cooperation between patients and medical staff . The whole support system has been

composed of a MAS and a clinical information system (CIS). MAS includes an event

filter and a light database and CIS consists of an event filter and an electronic health

record (EHR). Figure 3 shows the architectural model of a mobile alerting system.

MAS is a system aiming to support patients themselves in the management of their

own treatment. It helps patients to have in check the organisation of their medication

regime and doctor appointments, to lead a health lifestyle and to keep condition-

relevant parameters under control. 54

52

cp. LeGrow, G. / Metzger, J. (2001), p.7f 53

cp. LeGrow, G. / Metzger, J. (2001), p.10ff 54

cp. Jung, D. / Hinze, A. (2005), p.2

15

Figure 3: Architectural model of a mobile alerting system.55

6.2 Telehealth

Telehealth (telemedicine) technologies can be used to improve disease management

programs. Usual components of a telehealth system are electronic patient card, mobile

measurement device, decision support system and communication technology.56

These tools allow patients with chronic conditions to stay at home and still be

involved in the care delivery process.57

Since disease management occurs at the beginning of the continuum of care, all of the

costs associated with the rest of the continuum of care are avoided, which is the goal

of successful disease management. Care can be delivered by physicians, nurses,

nutritionists and psychiatric specialists and others, to patient’s true point of care, their

home. The disease management process operationally relies on the medical staff that

works in partnership with and as an extension of the patient's physician. The medical

staff is guided by physician-approved therapeutic protocols and uses a telemedicine

delivery platform to deliver and coordinate care to patients. The medical staff uses a

computer and can access protocols over the Internet via an information system that

can initiate and deliver patient outcomes and store them into a database for analysis.

The analysis yields the effect of the protocols, the effect of disease management, and

ultimately predicts changes in patient status.58

A challenge today is to exploit the technology to achieve fundamental change, not just

automate or facilitate current healthcare delivery processes. There are many questions

55

cp. Santa Cruz, A. / Vuksanovic, D. (2006), p.7 56

cp. Tschanz, A. / Dyson, A. / Reichlin, S. (2004), p.6 57

cp. Tan (2005), p.275 58

cp. TeleHealth, Inc. (November 2007)

Patient Medic

16

to be answered and challenges of technical, professional and interpersonal nature to

deal with.59

Telehealth technologies have great potential as disease management tools, but they

must be user-friendly, technically and economically scalable and deliver an improved

level of patient care at reduced cost. The biggest problem today is still that especially

the mobile devices are not as user-friendly as they should be.60

7 Examples of DMP and telehealth service providers

Miscellaneous manufacturers such as Philips, Nonin, Card Guard or Siemens already

produce devices and tools as well as provide the services for products used in disease

management. The services of the devices are for example that they record

automatically all data, transmit these to the according location and save as well as

evaluate the data.61

7.1 Practice Bubenberg AG and Swiss heart and

cardiovascular centre (Inselspital Berne)

This project was started in 2002 and can be called a pioneer project since before it

there was barely any disease management tested. The practice Bubenberg AG and the

Swiss heart and cardiovascular centre of the Inselspital in Berne made together a

study for “ambulatory disease management of cardiac insufficiency”. The initiative

came from the cardiologist and cardiac insufficiency specialist Thomas Suter. He had

worked in the United States in a cross-institutional disease management program for

patients with cardiac insufficiency and learned that through these programs the life

quality of the patients could be improved as well as costs saved.62

According to Suter about 2 percent of the population suffers of cardiac insufficiency.

Using the population at the end of 2006 (7’508’700)63

that means that more than

150’000 people suffer from this disease. The forecast even predicts that the number of

59

cp. TeleHealth, Inc. (November 2007) 60

cp. Murray, B.J. / Rinde, H. (2004), p.20 61

cp. Berger Kurzen (2004), p.36 62

cp. Schnetzler (2002), p.15 63

Neue Ch-Daten (November 2007)

17

patients will double in the next 10 to 20 years because people are getting older and

also survive more often heart attacks or other heart diseases because of better

therapies and medication. Moreover, this disease costs more than half a milliard Swiss

Francs per year of which the cost for hospitalization is the highest.64

Even though this program tries to shift the supervision of the patients from the

hospital to an ambulatory division, the Inselspital is still involved. This is because the

hospital only gets a case-based lump sum for each patient which only pays for about

four days of hospitalization.65

Therefore is it in the concern of the Inselspital to

decrease the days of hospitalization of each patient.66

Leading character in this program is a nurse who is specialized in the care of patients

with cardiac insufficiency. The therapy for this disease enhances continuously and

therefore a key function of the nurse is to keep up to date with the newest medications

and the adverse effects of these. The nurse only has to concentrate on this specific

field as compared to a general practitioner who has to have a broad knowledge of all

diseases and therefore the whole process is optimized. The nurse consults, controls,

and attends to the patients under medical supervision. A cardiologist is in charge of

the supervision of the medications and optimization as well as arranging the

echocardiography.67

Usually the average age of the patients is seventy-five years and since they are treated

with a number of different medications they need an intensive supervision. Therefore,

the nurse has to control the patients regularly and needs to figure out if there are any

symptoms for an incipient decompensation as well as remind them to keep up with

their dietary measures. The nurse also stays in contact with the patients, especially if

there was a change of medication and tries to intervene before there is a need for a

decompensation or hospitalization.68

The goals of this study are to improve the medicinal therapy, reduce the pathology,

improve the cardiac function, minimize the time in hospital, and reduce the costs.

64

cp. Schnetzler (2002), p.15f. 65

For a cardiac patient the lum sum is only 3'100 Swiss Franc and the patient costs the hospital 800

Swiss Francs per day. 66

cp. Schnetzler (2002), p.17f. 67

cp. Schnetzler (2002), p.15ff. 68

cp. Schnetzler (2002), p.17f.

18

7.2 Avalis Telemedicine Ltd

Avalis Telemedicine Ltd is a provider of disease management products. The company

is based in Zurich, Switzerland and their products include complete, disease specific

solutions that work on commercial mobile devices.69

To assure efficient disease management their products have to meet following criteria:

• operator convenience

• interactive patient self-management

• reminders and warnings

• clinical telemonitoring

• real-time communication (notification, reports)

• Hardware-independent connection and communication of medical devices

• Web-based data collection und management

The application area of Avalis products is chronic diseases such as asthma, diabetes,

hypertension, chronic obstructive pulmonary disease (COPD).

One of the Avails products is mobile patient monitoring system that is described in

the following paragraph.

Avalis has developed an electronic system for the remote collection of patient’s data

via linked medical devices. The components of the system are eDiary PDAs,

Webbased applications and medical devices. eDiary is a generic mobile platform that

can be used by patients or healthcare workers to collect and store physiological data

through medical devices. It is linked to a data processing server via an internet

connection. The webbased application (WebEDC) is running on the server hardware.

It allows entries of additional patient informations by health care providers and allows

to viewing a patient’s status and his story via any computer with a web-browser.

Figure 4 shows the overview of an integrated mobile patient-monitoring system.70

69

cp. Avalis (November 2007) 70

cp. Murray, B.J. / Rinde, H. (2004), p.16

19

Figure 4: Overview of Avalis integrated mobile patient-monitoring system.71

7.3 Card Guard PMP4

Card Guard produced PMP4 (see figure 5), a wireless healthcare system. The wireless

medical accessories can be used with every Bluetooth enabled Pocket PC running the

client software for the acquisition and transmission of data from the patient to the

PMP4 web-based platform. Physicians and patients alike can access this web access

point using any or all PMP4 medical accessories.72

Card Guard’s PMP4 Web-based Medical Center and suite of vital sign monitors allow

any home healthcare giver to quickly and accurately capture patient data on a PDA for

on-the-spot review. The medical data is easily uploaded to a dedicated web-based

medical center for immediate analysis and follow-up action by a healthcare

professional in a remote location.73

71

Murray, B.J. / Rinde, H. (2004), p.16 72

cp. Hohl, L. (2005), P.113 73

Card Guard (November 2007)

Smartphone

GSM Wireless

MedicalDevices

Modem or WLAN

Web based patient monitoring

Data Center (e.g. of Avalis)

Palm

Syndication (data sharing)

20

Figure 5: Card Guard PMP4.74

8 Difficulties of disease management

Some of the limitations we already briefly discussed in this paper. It is for example

very important to have as many patients participating in the disease management

programs as possible to reach the full potential of these programs. But as we saw in

the example “Recruitment of patients for a DMP”, it is not easy to recruit patients.

One important point is to find appropriate ways to bring the available DMPs to the

patients’ attention. However, it is necessary to have a good data base available to

identify the patients that would be right for the certain DMPs. These data base must

continuously be updated and integrated with all participating institutions (physicians,

hospital, laboratories and pharmacies).75

As we already saw, disease management concentrates on the care of chronically ill

patients. These patients are often older people. For example is the average age of the

patients seventy-five years in the study of the DMP for cardiac insufficiency. The

question is if these people are able to deal with the technological devices and if they

74

Hohl, L. (2005), p.114 75

cp. Weber / Götschi / Kühne / Meier (2004), p.2581ff.

21

are motivated to learn new things. An important point is therefore that the telehealth

technologies are as user-friendly as possible to allow also older people to use them.76

Another problem is that the evaluation of DMP is very difficult. There are only a few

evaluation designs that are applied to evaluate the impact of DMP. Some of these

evaluation designs also have weaknesses (see 5.5). Moreover, it is important to use

the right design that fits the data best.77

A survey showed that a big issue for the users of electronic devices is the confidence

about data security and confidentiality.78

9 Summary

The goals of disease management are high quality and cost-efficiency of the health

care as well as a continuous control and improvement of the quality of the care

through a systematic process with feed back loops. Disease management programs

ought to educate patients about their disease, actively monitor patients’ symptoms and

coordinate the disease care.79

„Disease management programs have generally been found to improve the quality of

care when compared with standard practice. They do so in a number of ways, for the

most part by working with patients and healthcare providers to increase patient

adherence to accepted medical management and lifestyle strategies.“80

Medical benefits of DMP are unquestioned. DMPs don’t necessary decrease costs.

Disease management programs can only be cost saving if the service they encourage

is cost saving. Unfortunately, cost-saving health services are rare. Thus, the key factor

to avert an adverse and costly clinical event is the number of patients needed to treat

in DMPs.81

Employment of information and communication technologies (e.g. telehealth

divecises) could fundamentally change the way of health care delivery to the patients.

There are still some unsolved problems and limitations as usability of mobile devices

or integration of the information and communication services (many small players

with stand alone solutions) that still doesn’t allow massive adoption of telehealth

technologies.

76

cp. Murray, B.J. / Rinde, H. (2004), p.20 77

cp. Linden / Adams / Roberts (2003), p. 7f. 78

cp. Jung, D. / Hinze, A. (2005), S. 8 79

cp. Haas, P. (2006), p.198f 80

Fendrick, A. M. / Chernew, M. E. (2006), p.2 81

cp. Fendrick, A. M. / Chernew, M. E. (2006), p.2

III

Bibliography

Avalis: Fortschrittliche Produkte für gross angelegtes, mobiles Disease Management,

http://www.avalis.ch/products_00_d.html, last access November 2007.

Anwenderforum eHealth 2007: 19. Juni 2007, Zurich Marriott Hotel; A. Meier:

http://www.swissict.ch/fgehealth.html, last access November 2007.

Berger Kurzen, Brigitte (2004): E-Health und Datenschutz, Schulthess.

Bethke, Mascha / von Overbeck, Jan (2007): Disease Management in der Schweiz,

Managed Care 6, 2007, p. 52 - 53.

DMAA homepage: http://www.dmaa.org/dm_definition.asp, last access November 2007.

Fendrick, A. M. / Chernew, M. E. (2006): Value-based Insurance Design: Aligning

Incentives to Bridge the Divide Between Quality Improvement and Cost Containment,

The American Journal of of Managed Care, Vol. 12, Special Issue, Dezember 2006.

Fiddleman, R. H. / Bernett, H. / Montrose, G. (2002): A Survey of Patient Call Centres

and Communication Strategies: Enhancing Disease Management Services Delivery,

Disease Management Association of America (www.dmaa.org), last access November

2007.

Guard Guard: Integrated Solutions, http://www.cardguard.com/newsite/

inner.asp?cat=24&lang=1&type=2, last access on November 2007.

Haas, Peter (2006): Gesundheitstelematik, Springer Verlag.

Haas, Peter (2005): Medizinische Informationssysteme und Elektronische Krankenakten,

Springer Verlag.

Hohl, L. (2005): Mobile Health Application, Diploma Internship Swisscom Innovations,

École Polytechnique Fédérale de Lausanne, January 2005.

IV

Holtz-Eakin, D. (2004): An Analysis on the Literature on Disease Management

Programs, from www.cbo.gov, October 2004.

Jung, D. / Hinze, A. (2005): Patient-based Mobile Alerting Systems – Requirements and

Expectations, In Proceedings of the Health Informatics in New Zealand Conference

(HINZ 2005), Auckland, New Zealand, August 2–5 2005.

Kanton St.Gallen: eHealth: http://www.sg.ch/home/gesundheit/organisation_gd/

informatik_vig/ehealth.html, last access November 2007.

Lauterbach, K. W. (2001): Disease Management in Deutschland - Voraussetzungen,

Rahmenbedingungen, Faktoren zur Entwicklung, Implementierung und Evaluation,

Gutachten im Auftrag des Verbandes Angestellten-Krankenkassen und des Arbeiter-

Ersatzkassen-Verbandes, from www.isesuisse.ch/fr/conferences/conf_0711pcs-

lauterbach.pdf, last access November 2007.

Lauterbach, K. W.: Reform des Risikostrukturausgleichs: Disease Management wird

aktiviert, http://www.aerzteblatt.de/v4/archiv/artikel.asp?id=28092, last access November

2007.

LeGrow, G. / Metzger, J. (2001): E-Disease Management, California Health Care

Foundation, from http://www.chcf.org/documents/ihealth/EDiseaseManagement.pdf, last

access on November 2007.

Linden, A. / Adams, J. L. /Roberts, N. (2003): Evaluation Methods in Disease

Management Determining Program Effectiveness, Disease Management Association of

America (www.dmaa.org), last access on November 2007.

Nadolski, H. (2002): Disease Management in den USA, GGW 1/2002 (Januar), 2.Jg.,

http://wido.de/fileadmin/wido/downloads/pdf_ggw/GGW_1-02_16-23.pdf, last access

November 2007.

National Pharmaceutical Council: Definition of Disease Management,

http://www.npcnow.org/diseasemanagement/definition.asp, last access on November

2007.

V

Neue Ch-Daten: http://www.ecopop.ch/A4BEVOELKSCHWEIZ/neuechdaten.htm, last

access November 2007.

Murray, B.J. / Rinde, H. (2004): Developement of a Flexible Mobile System fort he

Remote Management of Chronic Diseases, Swiss Medical Informatics, N.53, 2004.

Santa Cruz, A. / Vuksanovic, D. (2006) : A Mobile Alerting Systems for the Support of

Patients with Chronic Conditions, Seminar paper, on the university of Fribourg, January

2007.

Schnetzler, Rita (2002): Disease Management als Prozessinnovation – zukunfsfähig

auch in der Schweiz?, Managed Care 4/5, 2002, 15 – 18.

Tan, Joseph (2005): E-Health Care Information Systems – An Introduction for Students

and Professionals, Jossey-Bass.

TeleHealth, Inc.: iTeleHealth Publications, http://www.itelehealthinc.com/

diseasemanage.asp, last access November 2007.

The Royal College of Radiologists: Evidence Based Guidelines; http://www.rcr.ac.uk/

index.asp?PageID=667, last access November 2007.

Tschanz, A. / Dyson, A. / Reichlin, S. (2004): Telemedizinisches Disease Management:

Welche Technologien sind vorhanden, um Patienten mobil zu Betreuen? Swiss Medical

Informatics, N.53, 2004.

Weber, A. / Götschi, A.S. / Kühne, R. / Meier, D. (2004): Patientenrekrutierung für

Disease Management, SAEZ 2004 (85); Nr. 48: 2581-2584.