1. Telemedicine an distans care in Västerbotten
E-health business models for chronic conditions
Thomas Molén, Strategist
Strategic Development Office
County Council of Västerbotten, Sweden
thomas.molen@vll.se

2. Northern care region in Sweden (SE)...
• ... occupies 10 % of the population
• ... located on half the Swedish area (total area 449 964 km²)
• Sweden is the 5:th biggest country in Europe
• 9,5 milion citiziens

3. Distribution of the
Swedish population?

4. Västerbotten county
• Sweden is sparcely populated in a
European perspective: 22
inh/km2
• Västerbotten:
• - 4.7 inh/km2
• - 260.000 inh

5. An important infrastructure component: One
of the fastest networks in the world
- owned by public sector
1000 Mbit/sek

6. Objectives from the National Government
1) By the year of 2020, 90% of all households and companies
in Sweden will have access to broadband at a minimum
capacity of 100 Mbit/s.
2) Already 2015, 40% should have access to that capacity

7. Telemedicine - Västerbotten
• Long distances between hospitals and primary
care centers
• Ensure good access to healthcare for the
inhabitants
• Reduce travel, work more efficiently, saving the
environment, reducing costs
• Projects started back in 1995 – 18 years of
experience of telemedicine

8. Telemedicine - Västerbotten
Status 2013
• All hospitals and primary care centers have
videoconference systems (H.323)
– 180 systems, 800 web camera users
• Very good infrastructure
– Network, video
• Increased use of videoconferencing for administrative use
• Many clinical telemedicine applications

9. Videoconference - Västerbotten
Phone/ISDN
Sjunet
Internet

10. Timmar
500
1000
1500
2000
2500
0
355
818
1112
jan
1358
1904
482
900
1376
feb
1723
2290
682
818
1456
mar
1897
2151
827
791
1317
apr
1496
1551
719
878
1249
maj
1957
1974
411
945
979
jun
1118
Videoconference VLL (hours)
972
66
Månad
99
116
jul
136
138
302
H.323 2008 - 2012
524
602
aug
900
372
1060
1244
32% increase 2008=>2009
1364
sep
1940
2068
1172
1228
1605
okt
1970
2340
36% increase 2009=>2010
1095
1357
1807
nov
2226
2186
781
913
1275
dec
1457
27% increase 2010=>2011
2012
2011
2010
2009
2008

11. Telemedicine – examples
Consultations
– Dermathology
– Bacteriology
– Ultrasound (heart and gynecological)
Clinical rounds (local, regional, national)
– Radiotheraphy
– Upper gastro
– Hemathology
– Pathology
– Neurology
Treatment / rehabilitation
– Speach pathology
– Hand rehabilitation

12. Northern care region - examples
– Children with cleft palate
• First meeting with specialist and speech therapis
via video
– Newborn with suspected heart disease
• Cardiologist in Umeå diagnoses the ultrasound
examination via video
– Rehabilitation after hand surgery
• Patient get treatment and rehabilitation in their
home or at the nearest primary care center

13. 16
Telemedicine in rehabilitation
Routine since 2009
Hand surgery clinic in Umeå - video sessions with colleagues and
patients in the northern region
Telemedicine is used for:
• Clinical consultation to colleagues at health care centres
• Evaluation and control of goal achievement for patients at health
care centres
• Distance intervention in the client’s home

14. 18
Telemedicine in rehabilitation
Distance intervention in the patients home
Technical solution
• Patients own computer and broadband or Ipad with Wifi or 3G
• Cisco Jabber software
• The quality is ”good enough”

15. 19
Telemedicine in rehabilitation
Evaluation and control of goal achievement of
patient at health care centres
Technical solution
• Videoconference system at the health care centers
•Therapist at the hospital - web cam or videoconferencing system

16. 20
Telemedicine in rehabilitation
• In 2012 - 238 telemedicine sessions
• 164 journeys to hospital avoided – 82 000 km
• 17 000 euro in reduced travel costs
and
- patients reported the same level of satisfaction
- most patients described less travelling as the greatest benefit

17. Speech and language therapy by video
• To offer patients treatment close to home or in their home
• Equal access to healthcare and rehabilitation
Patient
Speech therapist

18. Speach therapy
Routine since 2007
Experience from 2-year project
• 779 telemedicine sessions with 194 patients
• Reduced travel with 154 000 km for patients
• 130 000 euro in reduced travel costs
and
- more alert patients
- less travelling for patients and therapists
- fewer cancellations
- patients completes their treatments – better treatment results!

19. Chronical diseases
Chronic obstructive pulmonary disease (COPD)
• Self assessment
• Spirometry measurements
Cognitive disorders
• Video consultations
Cardiovascular diseases
• Ultrasound robot

20. COPD project
Goal
• detect and prevent serious exacerbations and subsequent hospital admissions
• encourage the patient to 'behavior change' - mainly physical activity
Methods:
• Sampling of physiological parameters and patient-reported symptoms in the
patients home
• Development of new web-based methods based on theories of health behavior
change, motivational interviewing and self-reporting of physical activity

21. Equipment

22. Specialist support in dementia care
Video consultations with specialists
• Vilhelmina municipality - focus on BPSD problems
• Health care centers in Norsjö, Backen, Malå, Sorsele - focus on diagnostics
for early cognitive impairment
• 3-5 patients present at the monthly consultations
• 1 hour allocated for each consultation
• Web camera based videoconference for the specialist – Cisco Jabber

23. Experiences from Västerbotten - dementia
• Limited access to doctors in rural areas
• Limited knowledge in both diagnosis and treatment of both
cognitive impairment and BPSD
• Distance consultations saves time and resources for patients
and care providers
• Reduced number of referrals and transports over long
distances
• Important with locally engaged staff

24. Ultrasound robot
[… Movie Ultrasound robot - 2:14 minutes]

25. Business model – ”work to do”
– Make business models for all running and new telemedicine
applications
– Establish models for health economic analyzes
– Find incentives for all parties - patients, primary care centers
and hospitals
– Investigate whether a telemedicine visit should cost the
same for the patient as a traditional visit
– Establish clear procedures for investment and support costs
for technical equipment

26. Business model - Nothern care region
– University hospital of Umeå provides highly specialized care
(thorax, neurosurgery, neonatel care etc) to all inhabitants in the
Northern care region
– The three other countys pays a fixed fee (2,50 EUR/inh/year) to
Västerbotten
– The fee includes examination of x-ray images, telephone and
telemedicine conultations
(+) Limits the administration
(-) Free use - number of consultations are increasing – resource issue
(especially for the radiologists)

27. Business model - between hospitals in Västerbotten
– Many clinics in Västerbotten are county clinics
• The county clinics are responsible for the budget, the patients
and the resources on all three hospitals… which simplifies the
incentive structure

28. Business model - between hospitals and primary care
– The travel budget is the key!
• From 2013 the budget for the patient travels are
transferred to the health care centers
• (until today it have been a central budget for the hole
county – a black hole…)

29. Thanks for your attention!
Thomas Molén, Strategist
Strategic Development Office
County Council of Västerbotten, Sweden
thomas.molen@vll.se

30. National eHealth collaboration

31. National eHealth collaboration
CeHis – Centre for eHealth in Sweden
– Create the long-term conditions necessary for developing and introducing
nationwide use of IT in health
– www.cehis.se
– The work comprises new citizens' services and support for health and social
care provision, a national technical infrastructure and common regulatory
frameworks and standards.
– Collaboration between all 21 countys and 290 municipalities

32. Secure access
HSA – catalogue of all health workers in Sweden with details of access rights
SITHS – secure access with 2-step control (SITHS cards and PIN-code) based on
HSA
– Used for determining what information health personnel can see from the
EHR.

33. NPÖ
NPÖ – National Patient Overview – access to all EHR from all county councils in
Sweden
The patient has the right to limit access to EHR for medical staff

34. ”My health care contacts”
A safe way for the patient to communicate with the health
– Obtain an extract from a patient record
– Obtain medical advice from nurses and psychologists/psychiatrists.
– Change a family doctor
– Make a doctor's appointment
– Change or cancel an appointment
– Renew a prescription
– Renew a certificate of illness

35. National goals
– In 2014; 50 % of the population is using ”My health care contacts” and accessing
this via secure solutions.
– In 2015; 100 % of the population can access parts of their own health record.
– In 2017 they should be able to access all data.

36. Situation in Västerbotten County Council

37. Eletronic health records - national
5 EHR-systems are used in Sweden, 12 county councils of 21 use the
same in primary care and hospitals

38. Eletronic health records - Västerbotten
The County Concil uses one basic system for all units (SYSTeam Cross)
All private health centers working with the county council have to use the same system
Introduction started 1993 and finished 2006; it took us 13 years!

39. EHR
Radiology
– All images from the county can be viewed anywhere
– All images taken in the four Northern County Councils can be viewed by all
radiologists
Biochemistry
– All examinations in one system and can be accessed from the patients
record

40. Costs; computerization
Approximately 2,25% of the County Council`s expenditure is on IT
1.01 employee /PC
Cost/PC 27.000 SEK/year (~300EUR/year)