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


“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


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


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


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)


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)


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


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


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


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


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


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)


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)


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


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

Vision, reality and challenges

Health & Medicine

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