Denis Protti


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Denis Protti

  1. 1. Assessing and enhancing the public value of telehealthcare Masterclass - Imperial College London September 17, 2009 24-Sep-09 D. Protti - University of Victoria 1
  2. 2. A plethora of terminologies and viewpoints  Telehealthcare  Telehealth  Telemedicine  Telecare  Telemonitoring  Telematics  Tele…. etc.  eHealth  mHealth 24-Sep-09 D. Protti - University of Victoria 2
  3. 3. Cochrane review definition  'Telehealthcare' has the following elements (adapted from Miller 2007):  Information from the patient whether voice, video, other audio, electrocardiography, oxygen saturation or other.  Electronic transfer of such information over a distance.  There is personalised patient feedback from a healthcare professional who exercises their skills and judgement.  Interventions captured within the terms telehealthcare include both synchronous and asynchronous (store and forward) technologies.’ 24-Sep-09 D. Protti - University of Victoria 3
  4. 4. 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 2009 24-Sep-09 D. Protti - University of Victoria 4
  5. 5. Definition of Telemedicine • Telemedicine (or telehealth) - Delivery of healthcare services when the clinician and patient are at different locations - Data, images, audio, video - Excludes tele-education - Excludes CPR, EMR, HIE and phone calls • Telemedicine covers five healthcare processes - Monitoring - Diagnosis - Triage - Consultation - Procedure • Telemedicine is part of telecare: patient safety at home - Fall detectors, bed monitors, panic alarms
  6. 6. 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. 24-Sep-09 D. Protti - University of Victoria 6
  7. 7. 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).  Currently active mobile health applications include the use of PDAs 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. 24-Sep-09 D. Protti - University of Victoria 7
  8. 8. 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. 24-Sep-09 D. Protti - University of Victoria 8
  9. 9. Assessing the value of telehealth? First the good news 24-Sep-09 D. Protti - University of Victoria 9
  10. 10.  Edinburgh City Council has announced it is to spend almost £1m on telecare this year, more than doubling the amount it has spent in previous years.  Edinburgh launched its telecare programme in 2006 and has invested an average of £400,000 over the past three years with more than 700 people on the existing telecare programme.  The latest plans will mean 1500 people will be supported to live in their own homes and 700 carers supported in caring for relatives using telecare systems.  The Council estimated that its cash injection would save an estimated 3,000 hospital bed days and 3,000 care home days per year. Edinburgh to invest £1m in telecare Ehealth Insider, 17 Aug 2009 24-Sep-09 D. Protti - University of Victoria 10
  11. 11.  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.  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. 24-Sep-09 D. Protti - University of Victoria 11
  12. 12. Telemedicine Case Study: U.S. Veterans Administration How 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 incorporated But their total eligible population is 70 million! in existing health services What if they extended this to well patients? • Financially self-sustaining Benefits 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
  13. 13. Assessing the value of telehealth The less good news 24-Sep-09 D. Protti - University of Victoria 13
  14. 14.  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 2008 24-Sep-09 D. Protti - University of Victoria 14
  15. 15.  A recent Manhattan Research survey found that 39% of doctors said they have communicated with patients online, up from 31% in 2007 and 19% in 2003.  However, a survey of Rhode Island physicians and electronic health record software vendors found little use in the state of readily available online tools and a general reluctance among doctors to adopt such tools.  A large percentage of the state's doctors treat older patients, and "people believe that our aging population can't connect with that."  No health insurance companies in the state are paying for online patient communication and that doctors are reluctant to take on work they will not be reimbursed for.  Liability issues also deter doctors in the state from communicating online with patients. Rhode Island Doctors Reluctant To Embrace Online Communication Providence Business News July 27, 2009 24-Sep-09 D. Protti - University of Victoria 15
  16. 16. The Business Case for Telemedicine • The evidence base for telemedicine is weak - AHRQ study • Store-and-forward services: "the evidence for their efficacy is mixed" • Home monitoring: "required additional resources and dedicated staff" • VTC: "most effective for verbal interactions" - JAMIA study • Effects on patients' conditions: inconclusive • Patient compliance is high • Effect on resource utilization is mixed • Minimal evidence of economic benefit • The current evidence emphasizes • soft benefits (quality, patient satisfaction, access) • indirect economic benefits
  17. 17. 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-visits Technology Peak of Trough of Slope of Enlightenment Plateau of Trigger Inflated Disillusionment Productivity Expectations Maturity
  18. 18. Enhancing the value of telehealth 24-Sep-09 D. Protti - University of Victoria 18
  19. 19. How Gartner Evaluates Telemedicine Applications • Adoption and Readiness • Potential Impact for Adoption - Potential financial impact - Market penetration • How much money will it save for • What percentage of care delivery patients, providers and payers? organizations in North America - Potential clinical impact and Western Europe are using • Will the application help clinicians this application? provide better quality care? - Patient readiness • Will patients want to use the application? • Time to Value - Clinician readiness - How soon is the application likely • Will clinicians want to use it? to provide a return on investment? - Market readiness • Will payers want to pay for it? - Technological readiness • Is the application experimental or mature? - Vendor maturity • Is it sold by start-up companies or well-established vendors?
  20. 20. Remote Monitoring: Great Potential but Minimal Usage Market Potential Potential Patient Market Technological Vendor penetration financial clinical readiness readiness readiness maturity impact impact Home health monitoring <1% Very high Very high Very high Low Moderate Low Remote ICU <1% High High High Moderate Moderate Moderate
  21. 21. Remote Diagnosis and Triage: Early Commercialization Market Potential Potential Patient Market Technological Vendor penetration financial clinical readiness readiness readiness maturity impact impact Telepathology (static) <1% High Low NA Moderate High Very high Teleradiology/remote 30-50% High Moderate NA Very high Very high Very high PACS Call centers for remote 10-20% High High High Low Very high Very high triage
  22. 22. Remote Consultation and Procedure: Beware the Hype! Market Potential Potential Patient Market Technological Vendor penetration financial clinical readiness readiness readiness maturity impact impact E-visits <1% High Moderate Very high Moderate Moderate Moderate Videoconferencing 1-5% High Moderate High Moderate Moderate Moderate Telesurgery 0% Low Low Very low Very low Low Very low
  23. 23. Adoption, Impact and Time to Value High Teleradiology Call Centers Standard Essential Current Adoption Time to Value Short Telecard. Services Video teleconferencing Medium E-visits Long Telepath. (static) Telederma- tology Transformational Nice to Have Home Health Monitoring (wired) Remote ICU Low Clinical Kiosks Mobile Health Monitoring Low High Potential Impact
  24. 24. Conclusion 24-Sep-09 D. Protti - University of Victoria 24
  25. 25. Telemedicine Drivers and Inhibitors Drivers Inhibitors Patients: Financial: • Keep patients at home, avoid • Reimbursement admission to nursing homes • Financial justification • Easier access to specialist care • Perverse incentives Staff: Staff: • Use scarce resources more • Clinician resistance effectively • Staffing • Skills transfer • Legal and licensing Organization: Technical: • Reduce travel costs • Integrating data with EMRs • Make money by offering new services/reaching more patients • Cost and availability of infrastructure and connectivity
  26. 26. EUROPEAN COMMISSION WORKING PAPER Barriers to the wider deployment of telemedicine 1. 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. 24-Sep-09 D. Protti - University of Victoria 26
  27. 27. EUROPEAN COMMISSION STAFF WORKING PAPER 2. 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. 24-Sep-09 D. Protti - University of Victoria 27
  28. 28. EUROPEAN COMMISSION STAFF WORKING PAPER 3. 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. 24-Sep-09 D. Protti - University of Victoria 28
  29. 29.  “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 2009 24-Sep-09 D. Protti - University of Victoria 29
  30. 30. Finite 24-Sep-09 D. Protti - University of Victoria 30