Vision, reality and challenges


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Vision, reality and challenges

  1. 1. TeleCare – Supporting the patient-client, what are the real benefits – Vision, reality and challenges Karl A. Stroetmann empirica Communication & Technology Research, Bonn, Germany Belgian eHealth Congress 2007, Nov. 08, Brussels
  2. 2. Contents Vision: patient-centred health services Reality – Pilots, pilots, pilots ... – Limited convincing evidence – Unmet citizen needs and expectations Challenges Conclusions Belgian e-Health Congress 2007, Nov. 08, Brussels © 2
  3. 3. “Old” Vision: “New” Model of Healthcare Characteristics Traditional model of New model of healthcare healthcare Health philosophy Disease centred cure Citizen centred and wellness fo- cused Data & knowledge Fragmented, proprietary Integrated, distributed, shared, con- sharing 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 Disease triggered Choice system Consultation de- Linear (cottage industry Ubiquitous, seamless, collaborative livery process type) Consultation re- Hospital, GP office Home, community-based ceiver location Source: www. Belgian e-Health Congress 2007, Nov. 08, Brussels © 3
  4. 4. Key elements of the “ new“ model of healthcare Impetus on health, not on sick care Focusing on the idiosyncrasies of the individual citizen (personalised) Support & help at the point of need (home, mobility, community, abroad, ...) Meeting new challenges (chronic diseases, ageing population, ...) If in need of healthcare, supply of collaborative, integrated, seamless services across all health value system actors (including LT and social care) Support for optimal communication, sharing of data, access to latest knowledge Initial vision and policy recommendations date back at least to the 70’s Belgian e-Health Congress 2007, Nov. 08, Brussels © 4
  5. 5. Reality check: Pilots, pilots, pilots ... First pilots in the early 1970’s (satellite-based) First interactive CATV system (services for 70 to 90 years old ladies) 1990 in Frankfurt/Germany Hundreds of (rural) pilots (and hundreds of $m) in the USA and elsewhere failed Pilots in 2007: – Several pilots in the Netherlands: Philips Motiva System in Rijnmond (Rotterdam) and Twente; Health Buddy in Limburg etc.; KOALA Foundation in Groningen ... – “The Canadian Home Care Association (CHCA) has entered into a partnership with Canada Health Infoway to lead a national project on technology in home care. The project, ‘Integration through Information Communication Technology in Home Care in Canada’, will result in a better understanding for the potential of, and readiness for, information communication technology (ICT) in the Canadian home care sector.” (Volume 5 – Fall 2007: Newsletter Canada Health Infoway, p. 4) – UK Department of Health (Oct. 2007) ‘Shifting Care Closer to Home’: The report looks at the experiences of 30 chosen demonstration sites in six specialty sub-groups ... – Ukrainian Telemedicine and eHealth Development 1st International Conference quot;Telemedicine: myths and reality”, 8-9 November 2007 A real, sustained market does not yet exist, eHealth industry is still searching for it Belgian e-Health Congress 2007, Nov. 08, Brussels © 5
  6. 6. 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 improves their 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) Belgian e-Health Congress 2007, Nov. 08, Brussels © 6
  7. 7. 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) Belgian e-Health Congress 2007, Nov. 08, Brussels © 7
  8. 8. Benefits: Telemonitoring of Heart Failure Patients - A Randomised Controlled Trial Significant reduction in mortality: Survival days follow up 3 * *p < 0,05 2 1 Source: TEN-HMS study/empirica Interval 0-240 0-360 0-480 UC 199 263 304 NT 214 307 377 TM 217 303 371 Belgian e-Health Congress 2007, Nov. 08, Brussels © 8 8
  9. 9. Benefits: Fewer days in hospital Days in hospital (all patients) NT TM 2500 2000 1500 Days 1000 500 0 0-240 0-360 0-480 Days of follow-up Belgian e-Health Congress 2007, Nov. 08, Brussels © 9 9
  10. 10. Good practice example: Health Telematic Network S.r.l. , Brescia, Lombardia, Italy - A sustained long-term service since 1998 - 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 Source:Health Telematic Network S.r.l. , Brescia, Lombardia, 2007 Belgian e-Health Congress 2007, Nov. 08, Brussels © 10 10
  11. 11. A profitable, sustained long-term service supported by Agenda a reimbursement model: Health Telematic Network S.r.l. , Brescia, Lombardia, Italy 25 20 Million Euro 15 10 5 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Present value of total costs Present value of benefits Source: eH IMPACT study/ACCA 2006 Belgian e-Health Congress 2007, Nov. 08, Brussels © 11 11
  12. 12. Citizen (50+ old) expectations: their interest (in %) in receiving infor- mation on treatment (Personal Health Record) on their home computer 50 Interest health information: getting info about treatment on computer 48 44 42 40 39 30 31 29 27 27 27 26 25 25 20 20 15 10 11 0 IRL FIN NL UK DK EL A B D L F E S P I COUNTRY Source: 2000 / empirica Belgian e-Health Congress 2007, Nov. 08, Brussels © 12
  13. 13. 13 Citizen expectations: e-mail communication with doctors: high unsatisfied demand Usage of ICT supporte d consultations 50% 45% 40% 35% General interest in email 30% consultations 25% Usage of email consultations 20% 15% 10% 5% 0% Germ any France Italy Denm ark UK Ireland Poland Hungary Czech Slovenia EU 10 Republic Average Base: A ll respondents Source: eUSER, GPS 2005/empirica 13
  14. 14. 14 Patient experience (%): doctor-patient communication Percent reported doctor: AUS CAN GER NETH NZ UK US Always knows important 69 67 78 71 69 63 62 information about your medical history Always explains things so 79 75 71 71 80 71 70 you can understand Always spends enough 73 59 70 71 69 59 56 time with you Always tells you about your treatment options and 66 62 62 60 67 54 61 involves you in decisions about your treatment THE COMMONWEALTH FUND Source: 2007 Commonwealth Fund International Health Policy Survey
  15. 15. 15 Patient experience (%): care management and coordination for chronic conditions Adults with a chronic AUS CAN GER NETH NZ UK US condition reported: Doctor gives you a written 40 33 22 31 35 30 61 plan for managing care at home Receive reminder for 44 40 57 58 48 58 70 preventive/follow-up care Often/sometimes receive conflicting information 14 16 19 13 19 18 22 from different health professionals THE COMMONWEALTH FUND Source: 2007 Commonwealth Fund International Health Policy Survey
  16. 16. 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) Belgian e-Health Congress 2007, Nov. 08, Brussels © 16
  17. 17. 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) Belgian e-Health Congress 2007, Nov. 08, Brussels © 17
  18. 18. 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 Belgian e-Health Congress 2007, Nov. 08, Brussels © 18
  19. 19. 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 Belgian e-Health Congress 2007, Nov. 08, Brussels © 19