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Dutch Forum On Telecardiology

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A Dutch Forum, including all relevant parties, has been founded to design and coordinate a process of development from current routines of care with ICD's (implanted cardiac devices) towards telecardiology. Rationale of the construction of the Forum, incl. the description of a frame of references is elaborated.

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Dutch Forum On Telecardiology

  1. 1. Onward with Telemonitoring – The Dutch Forum on Telecardiology. Rob Halkes Van Spaendonck Management Consultants Peter Boogaard - Cygnea Astrid van den Hoek – Van Spaendonck Ref.: RHA/21January, 2010 Presentation to Eucomed, CRM TELEMONITORING GROUP meeting on January 21 st , 2010 in Brussel
  2. 2. Context <ul><li>The technological developments and actual opportunities of cardiac rhythm devices, lie far ahead on their adoption in care regarding the needed financial, organisational, legal and communication arrangements; </li></ul><ul><li>The evolving technology of the cardiac rhythm devices presents great opportunities </li></ul><ul><ul><li>To improve Quality of Care and Quality of Life; </li></ul></ul><ul><ul><li>To develop features that might prevent incidents of acute care and of hospitalisation; </li></ul></ul><ul><ul><li>To efficiently provide for the expected volume growth in numbers of patients. </li></ul></ul><ul><li>The EC sates: “To enhance the creation of favourable conditions and speed up implementation and roll out, at least the thresholds to telemedicine in general need to be overcome” : </li></ul><ul><ul><li>Building confidence in and acceptance of telemedicine services; </li></ul></ul><ul><ul><li>Bringing legal clarity; </li></ul></ul><ul><ul><li>Solving technical issues and facilitating market development . </li></ul></ul>
  3. 3. Advantages of cardiac devices in remote monitoring <ul><li>Diminish the burden of (hospital) face-to-face or on-the-site control or intervention; </li></ul><ul><li>Potentially alert for upcoming or to be expected incidents; </li></ul><ul><li>Enables adaptation schemes to patients’ specific physical profiles; </li></ul><ul><li>Render reassurance to patients and providers; </li></ul><ul><li>Enhance Quality of Life perceptions; </li></ul><ul><li>Potentially diminish growth of needed costs to serve patient volume; </li></ul><ul><li>Besides , the development of telecardiology adheres to the policies of the Dutch Ministry of Health concerning the preference for integrated care and inclusion of costs (“ketenvorming en functionele bekostiging” ). </li></ul>
  4. 4. Problems to create favourable market conditions: <ul><li>Reimbursement is likely to descend into commodity-like arrangements; </li></ul><ul><li>There is the need for health outcome studies beside those for device based effectiveness; </li></ul><ul><li>The need to provide for adequate technological means of remote signal and data communication; </li></ul><ul><li>Organisational arrangements are to be made within the “electronic triangle”: patient device – service centre – electro physiologist / cardiologist; </li></ul><ul><ul><li>Consequent design for responsibilities is needed between professionals in the health care chain, “…in terms of correct analysis, reaction content and reaction time, attempted reassurance and subsequent patient management” *); </li></ul></ul><ul><ul><li>The need for evidence based design of frequency schemes to monitor physiological profiles and the potential of adaptation to individual profiles; </li></ul></ul><ul><li>The need to develop patterns of participation adequate for specific patient’s conditions and contexts, and the need to adapt communication codes and languages to enable efficient interaction between professionals and between professionals and patients; </li></ul><ul><li>The need for cooperation of related institutions to develop from remote control to integrated care and telemedicine; </li></ul><ul><li>To provide for fair and respected preservation of all related professionals’ income. </li></ul>*) N.M. van Hemel. Netherlands Heart Journal, Volume 17, Number 11, November 2009
  5. 5. Towards Integrated Care for Telecardiology <ul><li>Actual Care for Cardiac Rhythm Management evolves from routines in face-to-face services, to telemonitoring and further on to telecardiology; </li></ul><ul><li>In the course of development of the chain of care and treatments, shifts are possible in: </li></ul><ul><ul><li>Tasks over persons involved, </li></ul></ul><ul><ul><li>Thus in responsibilities, and hence, </li></ul></ul><ul><ul><li>in points of costs within the chain. </li></ul></ul><ul><li>It will also lead towards (more) self management of patients; </li></ul><ul><li>Related parties are aware of their shifting interests in this development; </li></ul><ul><li>So cooperation between parties involved is needed to get things done. </li></ul>
  6. 6. Telecardiology shows 2 mutual dependent areas of development 5 Technological Developments Developments in medical care 1 2 3 4 6 Development cubes of telecardiology
  7. 7. Specifically: Technological developments and Medical care Three technological dimensions: 1) Communication – data exchange From external and periodic control To continuous and one-way feed to distant inspections To interactive, two way and real time management; 2) Parameters en detection, From simple and predominantly technical To complex and broad spectrum, and other physiological vital signs; 3) Therapeutic action From simple and in reactive stimuli To personal and adaptive To pattern recognition and preventive. Three dimensions of medical care: 1) Medical conduct From therapeutic and responsive To adaptation to personal profiles To interactive prevention; 2) Organisation and management of medical treatment From cardio clinic, specialist centred to multidisciplinary and third-party support To pluralistic and including patient self management; 3) Patient values From passive, informed and non integrated To empowered, differentiated and integrated.
  8. 8. Specific aspects of ICD remote care define departures form current routines: <ul><li>The possibility to monitor the patient with or without the device recipient (wirelessly): one needs to create scheme(s) of actually (re)viewing the data of the patient (by content and by process), also in relation with setting the automatic warnings given by the device; </li></ul><ul><li>The opportunity to add monitors to the device so as to follow other physiological variables of the patient: what monitors are needed to what ends: therapeutic treatment or prevention, or which are redundant or just nice to have ; </li></ul><ul><li>The possibility to adapt alerts and signals from the device to the monitoring agent, the cardiologist and/or to the patients individually. What are the options for a variation in signals and in symbols or codes, to represent complex parameters in more simple codes (agreed upon, evidence based) that are more easy to understand. Under what conditions is there an opportunity to develop patient participation and self-management? </li></ul>
  9. 9. Is one specific party capable to initiate such a process on its own and to realise what needs to be done to get telemonitoring of CRM devices accepted, implemented and reimbursed?
  10. 10. How to bring about a collective cooperation with all parties involved and stimulate course of further development?
  11. 11. <ul><li>One needs to construe: </li></ul><ul><li>the consent of all related parties to the course of development </li></ul><ul><li>as formulated and recommended in a frame of references </li></ul><ul><li>which is the product of a collective process by them. </li></ul>
  12. 12. Frame of References <ul><li>State of the art recommendations to the design and conduct of health care with ICD’s, its needed organisational, qualitative, financial, and technical specifications; </li></ul><ul><li>Common ground to all, to make necessary arrangements, dispute relating interests, provide for necessary research and arrange for specific aspects of practical projects; </li></ul><ul><li>Specifying necessary steps to the further development of telecardiology and telemedicine, the necessary areas of experiment and research to be performed; </li></ul><ul><li>To be effective and efficient as a nationwide process of development, needs the consent of all parties concerned: to avoid chaos in terms of technology, quality of care, responsibilities, reimbursement and so forth, and to construe standards of approach; </li></ul><ul><li>By the boundaries set by the frame of references, no effort will be wasted, yet variation in vision and conduct would be welcomed to create better and feasible options. </li></ul>
  13. 13. “ Frame of References” A frame of Reference is a set of recommendations , conditions and criteria that parties concerned agree upon to take as their starting point when embarking on their design, conduct and research of telecardiology.
  14. 14. Two conditions to formulate the Frame of References and to reach at the consent of parties with it. <ul><li>An authority is to be created, respected by all parties involved, that will formulate the frame of references; </li></ul><ul><li>All parties involved must have ample opportunity to participate in the formulation of the final frame of references and express their consent with it, explicitly . </li></ul><ul><li>Such is only possible if parties get ample opportunity to contribute or criticize the process and content of the frame of references! Only by the parties’ perceived experience that their contribution has been heard and weighed in the process, a common consent may emerge. </li></ul><ul><li>The following criteria are conditional to the design of the process: </li></ul>
  15. 15. Criteria to the design of the process of developing the frame of references <ul><li>The coordination by an independent authority, respected by the community; </li></ul><ul><li>Transparency of process and content: by use of a website to inform the respective people and to act as open platform to respond on forthcoming and evolving processes and content; </li></ul><ul><li>All parties and persons involved must have the opportunity and must be facilitated to act to respond to initiate and to get their positions acknowledged; </li></ul><ul><li>A process in which the needed basis for commitment and consent will gradually evolve; </li></ul><ul><li>A process of activities, interactions and research to build a potential consent with the final document. </li></ul>
  16. 16. The Advisory Committee and Editorial Committee of the Dutch Forum on Telecardiology <ul><li>Advisory Committee : </li></ul><ul><li>Prof. Dr. Norbert van Hemel </li></ul><ul><li>Dr. Carel de Cock, Amsterdam VU </li></ul><ul><li>Drs. Jan Elders, Nijmegen </li></ul><ul><li>To support and direct content of discussion and processes of deliberation. </li></ul><ul><li>Rob Halkes Van Spaendonck mc </li></ul><ul><li>Peter Boogaard, Cygnea </li></ul><ul><li>Astrid van den Hoek, Van Spaendonck </li></ul><ul><li>Invited speaker: </li></ul><ul><li>Prof. dr. Hein Heidbuchel, University of Leuven </li></ul><ul><li>Editorial Committee </li></ul><ul><li>Dr. Ype Tuininga, Deventer </li></ul><ul><li>Dr. Dominique Theuns, Rotterdam </li></ul><ul><li>Dr. Liselotte van Erven, Leiden </li></ul><ul><li>Dhr. Thijs Hendriks, Amsterdam, VU </li></ul><ul><li>Dr. Lucas Boersma, Nieuwegein </li></ul><ul><li>Dr. Alexander Maass, Groningen </li></ul><ul><li>Mr. Otto Swens - Legal Expert and financial expert. </li></ul><ul><li>Patient representative: dhr. Marinus Split </li></ul><ul><li>To elaborate and write the consensus document. </li></ul>
  17. 17. Overview of the development of the Frame of References: <ul><li>Meetings </li></ul><ul><li>Initial Invited Conference: State of the art Telecardiology ; </li></ul><ul><ul><li>General orientation on Telecardiology and Cardiac Rhythm Management; </li></ul></ul><ul><ul><li>Invited participants of all parties; </li></ul></ul><ul><li>Interactive invited Symposium (Working Conference): Towards a Frame of Reference for telecardiology in the Netherlands; </li></ul><ul><ul><li>Selected and Invited Conference </li></ul></ul><ul><ul><li>N ≤ 60 participants from all parties concerned </li></ul></ul><ul><ul><li>Presentation and discussion Delphi study first branch </li></ul></ul><ul><li>Concluding Conference: Consensus Meeting for Frame of Reference </li></ul><ul><ul><li>End results and conclusion Delphi Study </li></ul></ul><ul><ul><li>Discussion and Conclusion Fame of Reference </li></ul></ul><ul><ul><li>Implementation how to proceed. </li></ul></ul><ul><li>Delphi Study </li></ul><ul><li>To collect, segment and integrate opinions and choices </li></ul><ul><li>Survey among participants of the invited conference; </li></ul><ul><li>Results to participants selected to the interactive symposium; </li></ul><ul><li>Discussion Results of Interactive Symposium to participants; </li></ul><ul><li>Results to Concluding Conference. </li></ul><ul><li>Website - platform </li></ul><ul><li>Co-Creation of Consensus to Frame of Reference for Telecardiology </li></ul><ul><li>Platform for exchange of information </li></ul><ul><li>Forum discussion on issues concerned </li></ul><ul><li>Information channel on things to know </li></ul><ul><li>Information channel to forthcoming events and organisational need to know. </li></ul><ul><li>The site will be a linked site of NHRA and NVVC as well as linked to related parties </li></ul>
  18. 18.
  19. 19. Results of the initial Conference <ul><li>Ref.: Article by Jan Elders et al.., based upon first Round of Delphi published on the website </li></ul>Examples of questions asked, using a personal voting system at the conference
  20. 20. Summary of results of the initial round of the Delphi study <ul><li>Participants at the Conference (n=76, 100%) (N=100 including organisation, advisory board, speakers not using the voting system) </li></ul><ul><li>Pacemaker technicians 46%, Device industry 18% Cardiologists 17% Patients(organisation) 4% Health Care Insurance 3% Health Care authority 3% Rest 9% During the day we had missing data of 10 participants. </li></ul><ul><li>Age of population: born between1956 en 1965 (± 47/8). </li></ul><ul><li>Experience: 41% > 25 years of experience with.. 35% between15 and 25 year. </li></ul><ul><li>Location: 58% from Noord-Holland/ Zuid-Holland/ Utrecht Rest equally divided over North, East, South </li></ul><ul><li>Reasonable to well known on telecardiology: 76%. </li></ul><ul><li>59% participants claim to have experience with telecardiology; 82% participants claim to have an adequate vision of telecardiology. </li></ul>
  21. 21. General Results <ul><li>Participants have a much more and clear understanding of telecardiology: There has been a clear positive shift from before to after the forum discussion; Telecardiology is now seen as a self evident development and doubts have strongly been diminished; </li></ul><ul><li>81% (n=57) is convinced of the intention that developments must lead to patients’ self management in response to automatically generated signals! Before the forum, this attitude was only shared by 60% (n=46). </li></ul><ul><li>Concerns about legal aspects and patient directedness have been diminished, (although 62% (n=46) is not yet satisfied about this), whereas concerns about financial arrangements and data logistics have increased. </li></ul><ul><li>Nearly all participants are positive about the development of telecardiology and do appreciate a Frame of References as an absolute condition to the well functioning of telecardiology. </li></ul><ul><li>Everyone is convinced that a Frame of References is to function well, if all parties involved cooperate in its realisation. </li></ul>
  22. 22. Actual state of the art of the NFT <ul><li>The first conference has been held at November 30, 2009 and was attended by nearly 100 participants; Thanks to FHI, the Dutch association of cardiac device industry! </li></ul><ul><li>We have launched the website; </li></ul><ul><li>At the conference: the Delphi study’s first research round among the participants; </li></ul><ul><li>Further probing for large participation of representatives from all parties; </li></ul><ul><li>Preparing working conferences to formulate the frame of references. This is also done by communication and publication; </li></ul><ul><li>Moreover, much energy is invested in acquiring funds for continuation. </li></ul><ul><li>Preparing for an EU conference on the issue and approach, for feedback and supporting. </li></ul>
  23. 23. Invitation to actively monitor and support Register at www.NHRA-NFT.nl
  24. 24. Join us in Autumn at the EU Conference How to forward the development of telecardiology
  25. 25. <ul><li>Content of the presentation is supported by the advisory committee of the Dutch Forum on Telecardiology (ref. sheet 16 ) </li></ul><ul><li>This presentation and the initiation of the Forum has been made possible by a fund rendered by the Dutch affiliates of: </li></ul><ul><ul><li>Biotronik </li></ul></ul><ul><ul><li>Boston Scientific </li></ul></ul><ul><ul><li>Medtronic </li></ul></ul><ul><ul><li>Sorin Group </li></ul></ul><ul><ul><li>St. Jude Medical Associated in the Dutch Federation of medical technology branches. (FHI). </li></ul></ul>
  26. 26. Rob Halkes BU Van Spaendonck – Value innovation in Medical and Life Sciences T +31 418 578000 F +31 418 578010 M+31 653 420722 G.E.H . Tutein Noltheniuslaan 7 E r.halkes@VanSpaendonck.nl 4181 AS Waardenburg W www.medicalandpharmamarketing.com; the Netherlands Van Spaendonck’s BU “Value Innovation in Medical and life Sciences” is a focused consultancy firm. Van Spaendonck management consultancy supports and directs parties and professionals involved to their choices and processes to create and develop their USP , a better market position and performance. In the dynamics of health care systems, pharmaceutical and the medical devices industry, health care insurers, social parties, and health care professionals will be challenged more and more to their added value. The business unit “Value innovation for Medical and Life Sciences,” has the needed expertise and experience to initiate and develop processes and clinics for health care, marketing, sales and management systems, professional development, and strategic organisational change. 20 years of consultancy expertise to pharmaceutical and medical industry, life sciences and health care. Actual research and publications in health care and marketing developments.

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