1. TeleCare
– Supporting the patient-client, what
are the real benefits –
Vision, reality and challenges
Karl A. Stroetmann
empirica Communication & Technology Research, Bonn, Germany
www.empirica.com
Belgian eHealth Congress 2007, Nov. 08, Brussels

2. Contents
Vision: patient-centred health
services
Reality
– Pilots, pilots, pilots ...
– Limited convincing evidence
– Unmet citizen needs and expectations
Challenges
Conclusions
Belgian e-Health Congress 2007, Nov. 08, Brussels © 2

3. “Old” Vision: “New” Model of Healthcare
Characteristics Traditional model of New model of healthcare
healthcare
Health philosophy Disease centred cure Citizen centred and wellness fo-
cused
Data & knowledge Fragmented, proprietary Integrated, distributed, shared, con-
sharing tinuous update
Interactions Episodic, on demand Continuously, autonomous
Care giver Healthcare professional Citizen, informal carers, commu-
nity, healthcare professional
Care receiver Patient All citizens (independent of social,
mental, physical capacities)
Entry into health Disease triggered Choice
system
Consultation de- Linear (cottage industry Ubiquitous, seamless, collaborative
livery process type)
Consultation re- Hospital, GP office Home, community-based
ceiver location
Source: www. www.scenarios4health.eu
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4. Key elements of the “ new“ model of healthcare
Impetus on health, not on sick care
Focusing on the idiosyncrasies of the individual
citizen (personalised)
Support & help at the point of need (home,
mobility, community, abroad, ...)
Meeting new challenges (chronic diseases, ageing
population, ...)
If in need of healthcare, supply of collaborative,
integrated, seamless services across all health
value system actors (including LT and social care)
Support for optimal communication, sharing of
data, access to latest knowledge
Initial vision and policy recommendations date
back at least to the 70’s
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5. Reality check: Pilots, pilots, pilots ...
First pilots in the early 1970’s (satellite-based)
First interactive CATV system (services for 70 to 90 years old ladies) 1990 in
Frankfurt/Germany
Hundreds of (rural) pilots (and hundreds of $m) in the USA and elsewhere
failed
Pilots in 2007:
– Several pilots in the Netherlands: Philips Motiva System in Rijnmond
(Rotterdam) and Twente; Health Buddy in Limburg etc.; KOALA
Foundation in Groningen ...
– “The Canadian Home Care Association (CHCA) has entered into a
partnership with Canada Health Infoway to lead a national project on
technology in home care. The project, ‘Integration through Information
Communication Technology in Home Care in Canada’, will result in a
better understanding for the potential of, and readiness for, information
communication technology (ICT) in the Canadian home care sector.”
(Volume 5 – Fall 2007: Newsletter Canada Health Infoway, p. 4)
– UK Department of Health (Oct. 2007) ‘Shifting Care Closer to Home’: The
report looks at the experiences of 30 chosen demonstration sites in six
specialty sub-groups ...
– Ukrainian Telemedicine and eHealth Development 1st International
Conference quot;Telemedicine: myths and reality”, 8-9 November 2007
A real, sustained market does not yet exist, eHealth industry
is still searching for it
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6. Evidence
Most empirical studies relate to pilots, not
routine services
Most studies are scientifically and
methodologically weak
“Home telemonitoring of chronic diseases seems to be a
promising patient management approach that produces
accurate and reliable data, empowers patients, influences
their attitudes and behaviors, and potentially improves
their medical conditions. Future studies need to build
evidence related to its clinical effects, cost effectiveness,
impacts on services utilization, and acceptance by health
care providers.
(Source: Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base:
J Am Med Inform Assoc. 2007;14:269 –277)
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7. More evidence
“We identified summaries of 8,666 studies ... The review included 68 randomized
controlled trials (69%) and 30 observational studies with 80 or more participants
(31%). Almost two-thirds (64%) of the studies originated in the US; more than half
(55%) had been published within the previous three years. Based on the evidence
reviewed, the most effective telecare interventions appear to be automated vital signs
monitoring (for reducing health service use) and telephone follow-up by nurses (for
improving clinical indicators and reducing health service use). The cost-effectiveness of
these interventions was less certain. There is insufficient evidence about the effects of
home safety and security alert systems. It is important to note that just because there is
insufficient evidence about some interventions, this does not mean that those
interventions have no effect.”
(Source: A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions. J
Telemed Telecare. 2007 ;13 (4):172-179)
Our search initially identified 4,083 citations. ... Following a full-text review, 106 studies
were included. Store-and-forward services have been studied in many specialties, the
most common being dermatology, wound care and ophthalmology. The evidence for
their efficacy is mixed. Several limited studies showed the benefits of home-based
telemedicine interventions in chronic diseases. Studies of office/hospital-based
telemedicine suggest that telemedicine is most effective for verbal interactions, e.g.
videoconferencing for diagnosis and treatment in specialties like neurology and
psychiatry. There are still significant gaps in the evidence base between where
telemedicine is used and where its use is supported by high-quality evidence. Further
well-designed research is necessary to understand how best to deploy telemedicine
services in health care.
(Source: Diagnosis, access and outcomes: Update of a systematic review of Telemedicine services. J. Telemed. Telecare 12 (Suppl.
2):S3-31, 2006)
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8. Benefits: Telemonitoring of Heart Failure Patients - A
Randomised Controlled Trial
Significant reduction in mortality: Survival days follow up
3
* *p < 0,05
2
1
Source: TEN-HMS
study/empirica
Interval 0-240 0-360 0-480
UC 199 263 304
NT 214 307 377
TM 217 303 371
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9. Benefits: Fewer days in hospital
Days in hospital (all patients)
NT TM
2500
2000
1500
Days
1000
500
0
0-240 0-360 0-480
Days of follow-up
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10. Good practice example:
Health Telematic Network S.r.l. , Brescia, Lombardia, Italy
- A sustained long-term service since 1998 -
The Health Telematic Network offers:
• teleconsulting and ECG referrals and multi-specialty second
opinion for general practitioners
• home telenursing for chronic cardiac diseases
• telediagnosis for arrhythmia
• call centre for hospitals
The Service Centre is characterized by:
• an advanced technological platform
• a call centre operating 24/7 all year round
• a highly skilled team
• an intensive use of teleworking
• a network of physicians able to offer effective and efficient
telemedicine services
Source:Health Telematic Network S.r.l. , Brescia, Lombardia, 2007
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11. A profitable, sustained long-term service supported by
Agenda
a reimbursement model:
Health Telematic Network S.r.l. , Brescia, Lombardia, Italy
25
20
Million Euro
15
10
5
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Present value of total costs Present value of benefits
Source: eH IMPACT study/ACCA 2006
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12. Citizen (50+ old) expectations: their interest (in %) in receiving infor-
mation on treatment (Personal Health Record) on their home computer
50
Interest health information: getting info about treatment on computer
48
44
42
40
39
30
31
29
27
27 27
26
25 25
20
20
15
10 11
0
IRL
FIN
NL
UK
DK
EL
A
B
D
L
F
E
S
P
I
COUNTRY Source: www.seniorwatch.de 2000 / empirica
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13. 13
Citizen expectations: e-mail communication
with doctors: high unsatisfied demand
Usage of ICT supporte d consultations
50%
45%
40%
35%
General interest
in email
30%
consultations
25%
Usage of email
consultations
20%
15%
10%
5%
0%
Germ any France Italy Denm ark UK Ireland Poland Hungary Czech Slovenia EU 10
Republic Average
Base: A ll respondents
Source: eUSER, GPS 2005/empirica
13

14. 14
Patient experience (%): doctor-patient
communication
Percent reported doctor: AUS CAN GER NETH NZ UK US
Always knows important
69 67 78 71 69 63 62
information about your
medical history
Always explains things so
79 75 71 71 80 71 70
you can understand
Always spends enough
73 59 70 71 69 59 56
time with you
Always tells you about your
treatment options and
66 62 62 60 67 54 61
involves you in decisions
about your treatment
THE
COMMONWEALTH
FUND
Source: 2007 Commonwealth Fund International Health Policy Survey

15. 15
Patient experience (%): care management
and coordination for chronic conditions
Adults with a chronic
AUS CAN GER NETH NZ UK US
condition reported:
Doctor gives you a written
40 33 22 31 35 30 61
plan for managing care at
home
Receive reminder for
44 40 57 58 48 58 70
preventive/follow-up care
Often/sometimes receive
conflicting information
14 16 19 13 19 18 22
from different health
professionals
THE
COMMONWEALTH
FUND
Source: 2007 Commonwealth Fund International Health Policy Survey

16. Challenges
Results (2007) from across several USA Medicare
disease management (DM) demonstration/pilot
programmes:
Changing patient and provider behaviour is HARD:
– Limited use of behaviour change models
– No incentive for physicians to communicate
Some patients too ill, others not at short-run risk
Programmes don’t collect timely hospitalization and Rx info
Usual care providers are minimally engaged
Programmes led by marketers, not clinical experts:
– Ineffective use of available data
– Unfamiliar with unique needs of the elderly
Improvements in quality of care don’t guarantee better
patient outcomes in short run
(Source: Annual Academy Health Research Meeting, June 2007)
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17. More challenges
Where is the (wider European) market???
Providers need a clearly cut business case
Regulators must set the right incentives:
– Equal access to a basic package of health care services
– Competition organised around the integrated care for a
patient’s condition (DRG-like)
– (Published) all-inclusive prices
– Transparency: published data on (relative) quality of
service and outcomes
– Incentivize patients (or third party payers) to search for
high quality, efficient care (e.g. through co-payments
for patients; or outcome-adjusted reimbursement)
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18. More challenges
Strong health policy leadership (not focused on eHealth)
Professional attitudes and cultures
Organisational change, change management
Integration and re-engineering of healthcare and social
care “business” and delivery processes
Legal framework, regulation
Reliability, ease of use, interoperability, certification of
eHealth solutions
Training, education
We have only just started on a very long
journey
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19. Conclusions
Telehealth will slowly expand (less costly; quality of life)
Telehealth concepts are slowly maturing and are expected
to meet new health system and policy needs
It is not sufficient to demonstrate the medical, patient and
economic benefits of new telehealth services
In addition, the interests (benefits & costs) of various
health system actors need to be taken into account
In the longer term, the “new” paradigm of seamless,
patient-centred care will require new, more efficient
service delivery and incentive models
Belgian e-Health Congress 2007, Nov. 08, Brussels © 19