denis protti
TRANSCRIPT
24-Sep-09 D. Protti - University of Victoria 1
Assessing and enhancing the public value of telehealthcare
Masterclass - Imperial College London
September 17, 2009
D. Protti - University of Victoria 224-Sep-09
A plethora of terminologies and viewpoints
Telehealthcare
Telehealth
Telemedicine
Telecare
Telemonitoring
Telematics
Tele…. etc.
eHealth
mHealth
D. Protti - University of Victoria 324-Sep-09
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 telehealthcareinclude both synchronous and asynchronous (store and forward) technologies.’
D. Protti - University of Victoria 424-Sep-09
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 societyEUROPEAN COMMISSION STAFF WORKING PAPER
SEC(2009)943 finalJune 2009
Definition of Telemedicine
• Telemedicine (or telehealth)
- Delivery of healthcare services when the clinician and patientare 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
D. Protti - University of Victoria 624-Sep-09
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.
D. Protti - University of Victoria 724-Sep-09
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.
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.
D. Protti - University of Victoria 824-Sep-09
24-Sep-09 D. Protti - University of Victoria 9
Assessing the value of telehealth?
First the good news
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 telecareprogramme.
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
D. Protti - University of Victoria 1024-Sep-09
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.
D. Protti - University of Victoria 1124-Sep-09
Telemedicine Case Study:
U.S. Veterans Administration
How Many Patients?
• Home Telehealth (monitoring): 21,000 patientsGeneral Telehealth (VTC): 17,000 patients
• Store and Forward (diagnosis): 7,600 patients
Benefits Reported?
• Fewer bed days
• Fewer outpatient visits
• Better access to care in remote areas
• Lower travel costs
• Better sharing of expertise
How Did They Do It?
• Care coordination program
• Enterprisewide CPR system
• Telemedicine incorporatedin existing health services
• Financially self-sustainingin each local network
• Standard processes for implementation and treatment
• National contracts for devices and applications
• Federal Supremacy allows clinicians to practice across state lines
But their total eligible population is 70 million!
What if they extended this to well patients?
24-Sep-09 D. Protti - University of Victoria 13
Assessing the value of telehealth
The less
good news
D. Protti - University of Victoria 1424-Sep-09
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
D. Protti - University of Victoria 1524-Sep-09
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 CommunicationProvidence Business News
July 27, 2009
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
The Telemedicine Hype Cycle
Technology Trigger
Peak ofInflated
Expectations
Trough of Disillusionment
Slope of Enlightenment Plateau of Productivity
Maturity
Telepathology
Videoconferencing
Remote ICU
Home Health Monitoring (Wired)
Telecardiology
Continua
Kiosks
E-visits
Teledermatology
Mobile Health
Monitoring
Off the Hype Cycle:
• Teleradiology
• Call centers
24-Sep-09 D. Protti - University of Victoria 18
Enhancing the value
of telehealth
How Gartner Evaluates
Telemedicine Applications
• Adoption and Readiness for Adoption
- Market penetration
• What percentage of care delivery organizations in North Americaand Western Europe are using this application?
- Patient readiness
• Will patients want to usethe application?
- Clinician readiness
• Will clinicians want to use it?
- Market readiness
• Will payers want to pay for it?
- Technological readiness
• Is the application experimentalor mature?
- Vendor maturity
• Is it sold by start-up companiesor well-established vendors?
• Potential Impact
- Potential financial impact
• How much money will it save for patients, providers and payers?
- Potential clinical impact
• Will the application help clinicians provide better quality care?
• Time to Value
- How soon is the application likelyto provide a return on investment?
Remote Monitoring:
Great Potential but Minimal Usage
Market
penetration
Potential
financial
impact
Potential
clinical
impact
Patient
readiness
Market
readiness
Technological
readiness
Vendor
maturity
Home health monitoring <1% Very high Very high Very high Low Moderate Low
Remote ICU <1% High High High Moderate Moderate Moderate
Remote Diagnosis and Triage:
Early Commercialization
Market
penetration
Potential
financial
impact
Potential
clinical
impact
Patient
readiness
Market
readiness
Technological
readiness
Vendor
maturity
Telepathology (static) <1% High Low NA Moderate High Very high
Teleradiology/remote
PACS
30-50% High Moderate NA Very high Very high Very high
Call centers for remote
triage
10-20% High High High Low Very high Very high
Remote Consultation and Procedure:
Beware the Hype!
Market
penetration
Potential
financial
impact
Potential
clinical
impact
Patient
readiness
Market
readiness
Technological
readiness
Vendor
maturity
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
Standard Essential
Nice to HaveTransformational
Adoption, Impact and Time to ValueC
urr
en
t A
do
pti
on
Potential Impact
TeleradiologyCall Centers
Video teleconferencingTelecard. Services
E-visits
Telederma-tology
Telepath. (static)
Clinical Kiosks
Remote ICU
Home Health Monitoring (wired)
Mobile Health MonitoringLow
Low
High
High
Time to Value
Short
Medium
Long
24-Sep-09 D. Protti - University of Victoria 24
Conclusion
Telemedicine Drivers and Inhibitors
DriversPatients:
• Keep patients at home, avoid admission to nursing homes
• Easier access to specialist care
Staff:
• Use scarce resources more effectively
• Skills transfer
Organization:
• Reduce travel costs
• Make money by offering new services/reaching more patients
InhibitorsFinancial:
• Reimbursement
• Financial justification
• Perverse incentives
Staff:
• Clinician resistance
• Staffing
• Legal and licensing
Technical:
• Integrating data with EMRs
• Cost and availability of infrastructure and connectivity
D. Protti - University of Victoria 2624-Sep-09
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.
D. Protti - University of Victoria 2724-Sep-09
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.
D. Protti - University of Victoria 2824-Sep-09
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.
D. Protti - University of Victoria 2924-Sep-09
“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 30
Finite