Telemedicina i pacients crònics. Conferència impartida pel Professor canadenc Denis Protti Health Information Science - Victoria University. Barcelona, 2 de febrer de 2012. Organitzada per la Fundació TicSalut i l’Agència d’Informació, Avaluació i Qualitat en Salut.

1. Telehealth and Chronic Disease Management:
Potential, Promise and Problems
Departament de Salut
Catalunya -Barcelona
February 2, 2012
15-Feb-12 D. Protti - University of Victoria 1

2. Chronic Disease
What do they impact?
The 1/3 Canadians with more than 1 chronic disease use:
Healthcare System 51% of all GP visits, 55% visits to specialists, 67% of all visits by
home care nurses, 72% nights spent in hospitals
Currently: cause 60% of all global deaths & >70% Canadian deaths
Population per year. By 2020: will account for 73% of all deaths
Managing patients with chronic diseases is about half of a family
Physician’s Practice doctor’s routine work
Less workers | premature retirement | more unemployment |
Labour Supply more welfare | increase economic inactivity | absenteeism
Lower average wages for smokers and diabetics | reduced net
Individual Wages worth | lower productivity
Total Cost
Direct and Indirect
Arthritis + COPD + Cancer + Diabetes + Cardiovascular = $191.8 b
Source: Public Health Agency of Canadal Health Council of Canada Population Patterns of Chronic Health Conditions in Canada, December 2007 2

3. 15-Feb-12 D. Protti - University of Victoria 3

4. A plethora of terminologies and
viewpoints
 Telehealthcare
 Telehealth
 Telemedicine
 Telecare
 Telemonitoring
 Telematics
 Tele…. etc.
 eHealth
 mHealth
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5. 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

6. 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
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7. 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.
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8. 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) – smart
phones.
 Currently active mobile health applications include the
use of smart phones 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.
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9. 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.
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10. Assessing
the value of
telehealth?
First the good news
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11.  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.
 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.
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12.  ―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
15-Feb-12 D. Protti - University of Victoria 12

13. 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

14. Pan Canadian Telehealth Survey
Canadian Telehealth
2011
2011
14 COACH: Canada's Health Informatics Association

15. Summary of Current Benefits Access
 Telehealth was used for mental health consults in 51% of the reported
events, by internal medicine and cardiology in 19% of the events reported,
and for 13% for oncology.
 Almost 94,000 consults were done for rural Canadians in 2010.
 Telehealth events saved Canadians living in far-flung places approximately
46,846,500 kilometres of travel representing:
• 54 person years of travel,
• 5.6 million litres of gasoline and
• Almost 13 million kilograms of C02 emissions.
 Telehealth helped patients save approximately $70 million of personal travel
costs.
Estimates from Praxia - Gartner Report

16. Summary of Current Benefits Productivity
 Some providers used Telehealth instead of traveling to see their patients.
• In the three reports of provider time saved, 25 clinicians saved 496 days of provider
travel time that could be reallocated to more productive activities.
• It was estimated that 20 days could be saved by clinicians annually.
 By avoiding the need for individual patients to travel, Telehealth reduced
utilization of medical travel subsidies or grants.
• Savings in provincial and federally subsidized travel through current Telehealth
programs was estimated to be $34 million.
 As a result of the Telehealth programs in Ontario, British Columbia, Quebec and
New Brunswick, hospitals or health regions saved
• An estimated $980,000 in avoided emergency department visit costs
• About $20 million in avoided inpatient costs.
 Telehealth solutions across Canada resulted in cost avoidance of approximately
$56 million.
Estimates from Praxia - Gartner Report

17. ….. And the Patient
Remote patient monitoring technologies
• Best example in Canada is the Ontario Telemedicine Network
• Over 3,000 clinicians at over 925 sites providing 90,000 patient visits
• Are now rapidly expanding into the use of home monitoring devices
 Each day at home, patients use the device to answer
questions about how they feel, their medications, and
their symptoms.
 Patients learn how to better manage their conditions,
and receive health tips and reminders to take their
medication.
 Data are sent to a secure data centre
 Care managers track progress and review alerts that act
as early warning signs and show potentially serious
changes in a patient's health condition.
A vast array of home monitoring devices are coming on the market allowing
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direct connection to providers in Canada via telehealth networks

18. Assessing
the value of
telehealth
The less
good news
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19.  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
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20. Policies: Tele-Health (in South Africa)
“The Allied Health Professions Council of South Africa views
participation in any telemedicine scheme to be in breach of
patients rights in that patients have a right to, amongst other
things, informed consent, patient confidentiality and
patient/practitioner professional relationship. All practitioners
are therefore required to properly and personally asses and/or
consult with each patient prior to making any diagnosis and/or
for the treatment of any person.”
GOVERNMENT GAZETTE, 25 NOVEMBER 2011, No. 34767. BOARD NOTICE
185 OF 2011. The Allied Health Professions Council of South Africa.
20

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22.  Although few instances of routine application have yet
emerged in Europe or elsewhere – in contrast with an
enormous breadth of research activities – an increasingly solid
evidence base is emerging indicating that telehealth can be
used effectively to help support better integrated care, in
particular for those with long-term chronic conditions.
 Telehealth, the provision of care at a distance, is a key
component in future integrated care. Today's segregated
telehealth applications still require linking into more
comprehensive eHealth strategies, in which clinical pathways
and service delivery processes are fully coordinated and
patient data safely shared. Mainstreaming remains a
challenge; market forces alone are likely to remain
insufficient.‖
Stroetmann, K et al
How can telehealth help in the provision of integrated care?
WHO. 2010

23. WSD Action Network 2011
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24. Key lessons
 Undertaking fundamental service redesign. The logic of telehealth
rests on the principle that enrolled patients can be monitored
remotely and visits can be intelligently targeted. It will not be
possible to scale up telehealth services without increasing individual
caseloads, and individual caseloads cannot increase unless
professionals are prepared to work differently.
 Reshaping professional development and staff training. There is a
clear need to embed new ways of working in order to take
advantage of the benefits that telecare and telehealth can offer.
This cannot happen unless staff development and guidance aim to
build core competences – for example, in how to interpret data,
how to make decisions based on those data, setting parameters for
individual patients, and how to apply (and enforce) standard
protocols, both on site and in the field.
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25. Key lessons (cont’d)
 Ensuring that technology meets service needs. Some sites procured
equipment from vendors (or were given equipment) before
undertaking any structured analysis about how they wished to
redesign care services. Neglecting the analysis and design phases
often leads to a costly waste of resources, with equipment procured
being either underused or not used at all. Interoperability and
connectivity problems (both technical and service aspects) severely
restrict the potential to provide seamless integrated care to patients
and users.
 Applying and developing quality standards. Applying standards to
data and information that are generated, and the procurement and
interoperability of technologies, should be a key feature of future
telecare and telehealth programmes.
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26. Key lessons (cont’d)
 Encouraging decision-making based on available data and evidence.
Given the limitations of the evidence, health and social care teams
need to learn from experience when developing new services
through continuous monitoring and quality improvement processes.
Using data and evidence collected from sites currently deploying
new technologies can help to open up a variety of solutions and
approaches that might otherwise remain hidden.
 Developing an integrated governance structure. As telecare and
telehealth services grow in the future – and as more people benefit
from them – there needs to be a governance structure that ensures
that each programme’s goals are achieved. This needs to be
integrated, involving all stakeholders, with a clear remit to meet the
needs of users and patients.
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27. Continuing Challenges to Adoption in Canada
 Clinician Reimbursement — a transparent reimbursement model for
institutions, physicians and other healthcare providers who provide
Telehealth services.
 Technology Integration — implementation of complex underlying
infrastructure, but especially integration with hospital information systems,
jurisdictional interoperable electronic health records, and physician
electronic medical records.
 Licensure and Other Regulatory Issues Professional Development — design
and development of new roles, and training, education and in-service
support to develop new skills and insights.
 — support for clinicians to provide care within and across jurisdictional
boundaries, and policies and processes for authorization, authentication,
privacy, security and consent.
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28. Continuing Challenges to Adoption (cont’d)
 Governance and Policy — clear and transparent structures for deciding on
Telehealth investment priorities, determining service scheduling and service
delivery protocols, and for facilitating the alignment of demand and supply.
 Change Management and Adoption — carefully designed workflows and
processes which are effectively and widely transitioned into mainstream
practice.
 Benefits Realization and Measurement — clear articulation of benefits and
the value proposition to each stakeholder group, measurement against
those benefits, and activities to optimize over time.
 Support for Implementation and Transition to the Mainstream —
operationalization of the many existing projects, and extension of the
existing technical and physical infrastructure, as well as change
management to support the continued move of Telehealth into the
mainstream of care delivery.
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29. Conclusion
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30. 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.
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31. 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.
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32. 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.
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33. ICT Strategic projects in Catalonia
Electronic
Telemedicine Prescribing
Care at a distance Electronic prescribing and
performance dispensation services
Interoperability among
stakeholders of the health
sector
Medical image Personal Health
digitization Record
Digitized medical images Online site with health personal i
backup nformation

34. Finite
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