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Telemedicina i pacients crònics / Telemedicine in chronic patients
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Telemedicina i pacients crònics / Telemedicine in chronic patients



Telemedicina i pacients crònics. Conferència impartida pel Professor canadenc Denis Protti Health Information Science - Victoria University. Barcelona, 2 de febrer de 2012. Organitzada per la ...

Telemedicina i pacients crònics. Conferència impartida pel Professor canadenc Denis Protti Health Information Science - Victoria University. Barcelona, 2 de febrer de 2012. Organitzada per la Fundació TicSalut i l’Agència d’Informació, Avaluació i Qualitat en Salut.



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Telemedicina i pacients crònics / Telemedicine in chronic patients Presentation Transcript

  • 1. Telehealth and Chronic Disease Management: Potential, Promise and Problems Departament de Salut Catalunya -Barcelona February 2, 201215-Feb-12 D. Protti - University of Victoria 1
  • 2. Chronic DiseaseWhat do they impact? The 1/3 Canadians with more than 1 chronic disease use: Healthcare System 51% of all GP visits, 55% visits to specialists, 67% of all visits by home care nurses, 72% nights spent in hospitals Currently: cause 60% of all global deaths & >70% Canadian deaths Population per year. By 2020: will account for 73% of all deaths Managing patients with chronic diseases is about half of a family Physician’s Practice doctor’s routine work Less workers | premature retirement | more unemployment | Labour Supply more welfare | increase economic inactivity | absenteeism Lower average wages for smokers and diabetics | reduced net Individual Wages worth | lower productivity Total Cost Direct and Indirect Arthritis + COPD + Cancer + Diabetes + Cardiovascular = $191.8 bSource: Public Health Agency of Canadal Health Council of Canada Population Patterns of Chronic Health Conditions in Canada, December 2007 2
  • 3. 15-Feb-12 D. Protti - University of Victoria 3
  • 4. A plethora of terminologies and viewpoints Telehealthcare Telehealth Telemedicine Telecare Telemonitoring Telematics Tele…. etc. eHealth mHealth15-Feb-12 D. Protti - University of Victoria 4
  • 5. The Telemedicine Hype Cycle Off the Hype Cycle: • Teleradiology • Call centers Teledermatology Telepathology Continua Home Health Monitoring (Wired) Kiosks Videoconferencing Mobile Health Telecardiology Monitoring Remote ICU E-visitsTechnology Peak of Trough of Slope of Enlightenment Plateau of Trigger Inflated Disillusionment Productivity Expectations Maturity
  • 6. EUROPEAN COMMISSION WORKING PAPER Telemedicine is the provision of a healthcare service to a patient in situations where the patient and the health professional (or two health professionals cooperating on a specific patient) are not in the same location. It involves secure transmission of medical data and information, such as biological/physiological measurements, alerts, images, audio, video, or any other type of data needed for prevention, diagnosis, treatment and follow-up monitoring of patients. Telemedicine for the benefit of patients, healthcare systems and society EUROPEAN COMMISSION STAFF WORKING PAPER SEC(2009)943 final June 200915-Feb-12 D. Protti - University of Victoria 6
  • 7. e-Health - Definitions  Claudia Pagliari and colleagues e-Health is an emerging field of medical informatics, referring to the organisation and delivery of health services and information using the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a new way of working, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology.15-Feb-12 D. Protti - University of Victoria 7
  • 8. A new term has entered the arena Mobile health (mHealth) is a recently coined term, largely defined as health practice supported by mobile devices.  Mobile health practice includes public health, clinical medicine, and self-monitoring supported by mobile phones and personal digital assistants (PDAs) – smart phones. Currently active mobile health applications include the use of smart phones in collecting community health data; using the mobile phone to deliver health care information to practitioners, patients, and non-patients; and real-time monitoring for citizens, both patients and non-patients.15-Feb-12 D. Protti - University of Victoria 8
  • 9. Health Informatics, eHealth, TeleHealth, etc. It is really all about the use of Information and Communications Technologies (ICT) in health and health care delivery to support the decision making needs of individuals, their supporters, and their clinicians.15-Feb-12 D. Protti - University of Victoria 9
  • 10. Assessing the value of telehealth?First the good news 15-Feb-12 D. Protti - University of Victoria 10
  • 11.  Since the late 1980’s, Norway has had experience in a wide range of areas including: teleradiology, telecare, telepsychiatry, and the electronic delivery of laboratory results. In August 1996, Norway became the first country to implement an official telemedicine fee schedule making telemedicine services reimbursable by the national health insurer.  Telemedicine is widely used in Northern Norway which is characterized by a scattered population and a scarcity of health service specialists, most of whom are in Tromsø.15-Feb-12 D. Protti - University of Victoria 11
  • 12.  ―There is evidence that, when combined with proper organisation, leadership and skills, telemedicine and innovative Information and Communication Technologies (ICT) can help to address some of the societal challenges to Europe’s healthcare systems. Its benefits range over different levels, from individual patients, through healthcare systems as a whole and to the wider European economy.‖ Telemedicine for the benefit of patients, healthcare systems and society EUROPEAN COMMISSION STAFF WORKING PAPER SEC(2009)943 final June 200915-Feb-12 D. Protti - University of Victoria 12
  • 13. Telemedicine Case Study:U.S. Veterans AdministrationHow Many Patients? How Did They Do It?• Home Telehealth (monitoring): 21,000 patients • Care coordination program General Telehealth (VTC): 17,000 patients • Enterprisewide CPR system• Store and Forward (diagnosis): 7,600 patients • Telemedicine incorporatedBut their total eligible population is 70 million! in existing health servicesWhat if they extended this to well patients? • Financially self-sustainingBenefits Reported? in each local network• Fewer bed days • Standard processes for implementation and treatment• Fewer outpatient visits • National contracts for devices• Better access to care in remote areas and applications• Lower travel costs • Federal Supremacy allows• Better sharing of expertise clinicians to practice across state lines
  • 14. Pan Canadian Telehealth Survey Canadian Telehealth 2011 201114 COACH: Canadas Health Informatics Association
  • 15. Summary of Current Benefits Access  Telehealth was used for mental health consults in 51% of the reported events, by internal medicine and cardiology in 19% of the events reported, and for 13% for oncology.  Almost 94,000 consults were done for rural Canadians in 2010.  Telehealth events saved Canadians living in far-flung places approximately 46,846,500 kilometres of travel representing: • 54 person years of travel, • 5.6 million litres of gasoline and • Almost 13 million kilograms of C02 emissions.  Telehealth helped patients save approximately $70 million of personal travel costs. Estimates from Praxia - Gartner Report
  • 16. Summary of Current Benefits Productivity Some providers used Telehealth instead of traveling to see their patients. • In the three reports of provider time saved, 25 clinicians saved 496 days of provider travel time that could be reallocated to more productive activities. • It was estimated that 20 days could be saved by clinicians annually. By avoiding the need for individual patients to travel, Telehealth reduced utilization of medical travel subsidies or grants. • Savings in provincial and federally subsidized travel through current Telehealth programs was estimated to be $34 million. As a result of the Telehealth programs in Ontario, British Columbia, Quebec and New Brunswick, hospitals or health regions saved • An estimated $980,000 in avoided emergency department visit costs • About $20 million in avoided inpatient costs. Telehealth solutions across Canada resulted in cost avoidance of approximately $56 million.Estimates from Praxia - Gartner Report
  • 17. ….. And the PatientRemote patient monitoring technologies • Best example in Canada is the Ontario Telemedicine Network • Over 3,000 clinicians at over 925 sites providing 90,000 patient visits • Are now rapidly expanding into the use of home monitoring devices  Each day at home, patients use the device to answer questions about how they feel, their medications, and their symptoms.  Patients learn how to better manage their conditions, and receive health tips and reminders to take their medication.  Data are sent to a secure data centre  Care managers track progress and review alerts that act as early warning signs and show potentially serious changes in a patients health condition.A vast array of home monitoring devices are coming on the market allowing 17direct connection to providers in Canada via telehealth networks
  • 18. Assessing the value of telehealth The less good news15-Feb-12 D. Protti - University of Victoria 18
  • 19.  Telehealth has great potential to improve access to care but its adoption in routine health care has been slow. The lack of clarity about the value of telehealth implementations has been one reason cited for this slow adoption. Cusack CM et al. The value proposition in the widespread use of telehealth Journal of Telemedicine and Telecare 200815-Feb-12 D. Protti - University of Victoria 19
  • 20. Policies: Tele-Health (in South Africa)“The Allied Health Professions Council of South Africa viewsparticipation in any telemedicine scheme to be in breach ofpatients rights in that patients have a right to, amongst otherthings, informed consent, patient confidentiality andpatient/practitioner professional relationship. All practitionersare therefore required to properly and personally asses and/orconsult with each patient prior to making any diagnosis and/orfor the treatment of any person.”GOVERNMENT GAZETTE, 25 NOVEMBER 2011, No. 34767. BOARD NOTICE185 OF 2011. The Allied Health Professions Council of South Africa. 20
  • 21. 15-Feb-12 D. Protti - University of Victoria 21
  • 22.  Although few instances of routine application have yet emerged in Europe or elsewhere – in contrast with an enormous breadth of research activities – an increasingly solid evidence base is emerging indicating that telehealth can be used effectively to help support better integrated care, in particular for those with long-term chronic conditions. Telehealth, the provision of care at a distance, is a key component in future integrated care. Todays segregated telehealth applications still require linking into more comprehensive eHealth strategies, in which clinical pathways and service delivery processes are fully coordinated and patient data safely shared. Mainstreaming remains a challenge; market forces alone are likely to remain insufficient.‖ Stroetmann, K et al How can telehealth help in the provision of integrated care? WHO. 2010
  • 23. WSD Action Network 201115-Feb-12 D. Protti - University of Victoria 23
  • 24. Key lessons Undertaking fundamental service redesign. The logic of telehealth rests on the principle that enrolled patients can be monitored remotely and visits can be intelligently targeted. It will not be possible to scale up telehealth services without increasing individual caseloads, and individual caseloads cannot increase unless professionals are prepared to work differently. Reshaping professional development and staff training. There is a clear need to embed new ways of working in order to take advantage of the benefits that telecare and telehealth can offer. This cannot happen unless staff development and guidance aim to build core competences – for example, in how to interpret data, how to make decisions based on those data, setting parameters for individual patients, and how to apply (and enforce) standard protocols, both on site and in the field.15-Feb-12 D. Protti - University of Victoria 24
  • 25. Key lessons (cont’d) Ensuring that technology meets service needs. Some sites procured equipment from vendors (or were given equipment) before undertaking any structured analysis about how they wished to redesign care services. Neglecting the analysis and design phases often leads to a costly waste of resources, with equipment procured being either underused or not used at all. Interoperability and connectivity problems (both technical and service aspects) severely restrict the potential to provide seamless integrated care to patients and users. Applying and developing quality standards. Applying standards to data and information that are generated, and the procurement and interoperability of technologies, should be a key feature of future telecare and telehealth programmes.15-Feb-12 D. Protti - University of Victoria 25
  • 26. Key lessons (cont’d) Encouraging decision-making based on available data and evidence. Given the limitations of the evidence, health and social care teams need to learn from experience when developing new services through continuous monitoring and quality improvement processes. Using data and evidence collected from sites currently deploying new technologies can help to open up a variety of solutions and approaches that might otherwise remain hidden. Developing an integrated governance structure. As telecare and telehealth services grow in the future – and as more people benefit from them – there needs to be a governance structure that ensures that each programme’s goals are achieved. This needs to be integrated, involving all stakeholders, with a clear remit to meet the needs of users and patients.15-Feb-12 D. Protti - University of Victoria 26
  • 27. Continuing Challenges to Adoption in Canada Clinician Reimbursement — a transparent reimbursement model for institutions, physicians and other healthcare providers who provide Telehealth services. Technology Integration — implementation of complex underlying infrastructure, but especially integration with hospital information systems, jurisdictional interoperable electronic health records, and physician electronic medical records. Licensure and Other Regulatory Issues Professional Development — design and development of new roles, and training, education and in-service support to develop new skills and insights. — support for clinicians to provide care within and across jurisdictional boundaries, and policies and processes for authorization, authentication, privacy, security and consent.15-Feb-12 D. Protti - University of Victoria 27
  • 28. Continuing Challenges to Adoption (cont’d) Governance and Policy — clear and transparent structures for deciding on Telehealth investment priorities, determining service scheduling and service delivery protocols, and for facilitating the alignment of demand and supply. Change Management and Adoption — carefully designed workflows and processes which are effectively and widely transitioned into mainstream practice. Benefits Realization and Measurement — clear articulation of benefits and the value proposition to each stakeholder group, measurement against those benefits, and activities to optimize over time. Support for Implementation and Transition to the Mainstream — operationalization of the many existing projects, and extension of the existing technical and physical infrastructure, as well as change management to support the continued move of Telehealth into the mainstream of care delivery.15-Feb-12 D. Protti - University of Victoria 28
  • 29. Conclusion15-Feb-12 D. Protti - University of Victoria 29
  • 30. EUROPEAN COMMISSION WORKING PAPERBarriers to the wider deployment of telemedicine1. Confidence in and acceptance of telemedicine services  Telemedicine changes traditional working methods and brings new ways of practising medicine and delivering care.  New roles for health professionals, new skills and new actors (e.g. telemedicine call centres) appear in the process of healthcare delivery.  Understanding and implementing these changes in an acceptable and coherent manner is essential to enable wider deployment.15-Feb-12 D. Protti - University of Victoria 30
  • 31. EUROPEAN COMMISSION STAFF WORKING PAPER2. Legal clarity  Typical examples of the legal obstacles that wider deployment of telemedicine is facing are the need for physicians to be registered in all EU countries where they are providing services via telemedicine (e.g. interpretation of radiographs received via teleradiology), or the legal requirement for all medical acts to be carried out in the physical and simultaneous presence of the health professional and patient.  By not recognising telemedicine services specifically (the definition of healthcare services often does not include the concept of ―at a distance‖), most Member States discourage its wider use.15-Feb-12 D. Protti - University of Victoria 31
  • 32. EUROPEAN COMMISSION STAFF WORKING PAPER3. Technical issues and facilitating market deployment  Issues linked to infrastructure, such as access to broadband and the ability for the provider to enable full connectivity across the European territory from urban, highly-populated areas to remote, rural, scarcely-populated areas, still represent a major challenge.  The security of the network, the reliability and accuracy of certain types of telemedicine applications (for instance, using GSM lines to measure certain vital signs) are additional challenges.  On the other hand, for other types of telemedicine solutions, for instance the remote monitoring of cardiovascular implantable electronic devices, reliability and accuracy of the measurements are considered to be sufficient.15-Feb-12 D. Protti - University of Victoria 32
  • 33. ICT Strategic projects in Catalonia Electronic Telemedicine Prescribing Care at a distance Electronic prescribing and performance dispensation services Interoperability among stakeholders of the health sector Medical image Personal Health digitization Record Digitized medical images Online site with health personal i backup nformation
  • 34. Finite15-Feb-12 D. Protti - University of Victoria 34