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Telehealthcare in EU Regions, IPTS
- 1. June 1, 2012 Telehealthcare in EU Experiences on Integrated Personal Health and Care Services (IPHS): Evidence from eight European countries www.jrc.ec.europa.eu Elena Villalba, Fabienne Abadie, Maria Lluch, Francisco Lupiañez, Ioannis Maghiros,Bernarda Zamora JRC – IPTS, IS Unit Serving society Stimulating innovation Supporting legislation Disclaimer: "The views expressed in this presentation are purely those of the authors and may not in any circumstances be regarded as stating an official position of the European Commission“ 1
- 2. Introduction June 1, 2012 Policy context European health and social care systems: PRESSURES • To contain healthcare expenditure • To further improve the health status of the population in terms of increasing life expectancy and quality of life At EC level, policy-making translated into the EIP target to increase the average healthy lifespan of European citizens by two years by 2020 Strong focus on chronic diseases 2
- 3. Introduction June 1, 2012 Addressing Chronic diseases: from Disease Management Programmes to Integrated care Integrated care from a clinical perspective (or clinical integration), as defined by Suter et al (2007), involves organising functions and activities around patient care and services. The focus is on continuity and coordination of care, disease management, good communication among caregivers, smooth transfer of information, and the elimination of duplicate testing and procedures. Integrated care requires a central system of patient records, service delivery and best practice protocols to deliver care successfully as an integrated system. 1. Health and Social care coordination 2. ICT supported 3
- 4. SIMPHS2 June 1, 2012 Strategic Intelligent Monitor on Personal Health Systems Supply side •Market findings: size, trends, outlook Issues Demand side • Country studies & regional approach – Data collection Health indicators Transparency • Integrated care cross-country comparison Comparability • Citizen survey online panel outcomes Granularity Impact • IPHS deployment and its impact 4
- 5. Demand approach June 1, 2012 1. Analysis of EU 27 Member States through secondary data collection and desk research • Socio-demographic statistics & Prevalence statistics • Healthcare organisation, costs, financing, incentives and DMP & Social care organisation • ICT context – investment, applications, penetration, data exchange • Selection of the countries for field work based on the HC system market mechanisms and eHealth readiness • Regional approach in 8 selected countries • Analysis of ICT for Health deployment and case studies for TC and TH for 3 main chronic conditions • Primary data collection in field work – interviews with: • Policy-makers/government officers incl. HTA agencies • Healthcare managers – project/unit/HC centres & Health and social care professionals • Technology providers • Patients 5
- 6. Countries’ selection June 1, 2012 Denmark The Netherlands Evidence of IPHS, high eHealth deployment Quasi-market HC system UK Estonia eHealth large scale trials High IT investments in Health France Focus on CDM Germany programs Focus on CDM programs Spain Italy Regional approach Regional approach Evidence of IPHS Evidence of IPHS 6
- 7. Data gathering June 1, 2012 Denmark 9 interviews United Kingdom The Netherlands 17 interviews 8 interviews Spain France 21 interviews 1 interview + 20 questionnaires Germany Italy 17 interviews 13 interviews Estonia 10 interviews 7 8 countries – 96 interviews
- 8. Data gathering June 1, 2012 Denmark (all TH, full coverage TC) Patient Briefcase: 800 Anticoagulant: 300 United Kingdom The Netherlands (all TH, Telekat: 132 (towards IC) full coverage TC) WSD: 5721 Koala: 838 Telescot: 256 Health Buddy: 382 Spain (regional & local) France (TC) Basque Country: Domocare: 400 Evidence 1338 Y-DOM: 6500 Consolidation NEXES (Cat): 3600 Germany Italy (regional & local) Heitel: 300 TH Telemaco: 1000 TH Estonia eCare: 3000 (TC/TH) VIRTU: 8 TC DREAMING: 60 TC ELIKO: 40 TH 8 8 countries - 31 initiatives - almost 20,000 patients
- 9. Findings summary June 1, 2012 Denmark England Scotland demand side factors, policy commitment, policy commitment, incentives, funding, incentives, re- high eHealth MAINSTREAMING TREND impact assessment, organisation, towards deployment, DRG, high towards health & social health & social care stakeholders care integration integration, stakeholders involvement, legal involvement, social care framework, tradition?, geographical? geographical? Italy: region-DRG, geographical? , engagement strategies, stakeholders involvement, towards health & social care integration Spain: funding, tradition to cooperate with other tiers, stakeholders involvement, towards health & social care integration France: funding, policy commitment, industry involvement Netherlands: market failure, government intervention needed Germany: market failure, government intervention needed Estonia A trend towards health and social care coordination Bridging the gap gap between policy and implementation But many barriers still to overcome!! 9
- 10. Findings June 1, 2012 Key facilitators towards Integrated Care: 3. Reorganization of services – organisational change 5. Governance and funding mechanisms 7. Incentives and financing 9. Technology in place 11.Professionals as drivers 13.Patients as drivers 10
- 11. Findings June 1, 2012 1. Reorganization of services – organisational change Organisational change needed in order to provide integrated care Cooperation between tiers of care involving the creation of new roles Example in Scotland • Call handlers IPHS and co-located with NHS24 Social care services Ambulance services • Accidents & Emergencies • Community (primary care and matrons) Elderly care wards closing down • Hospital – hospital discharge teams 11 Organisational change as key facilitator
- 12. Findings June 1, 2012 1. Governance and funding mechanisms Governance • There are policies promoting coordination between health and social care – UK, Italy and Spain National versus regional implementation • Policies promoting interoperability – DALLAS example • Need for legal framework / Liability – i.e.: Denmark • In Germany, although many cases exist, government intervention is needed to deploy IC Funding • Needed for up-front costs, testing and crucial for long-term sustainability to avoid projects dying out UK, Germany, Netherlands, France – national funding sources Denmark, Italy, Spain both EC and own sources Estonia – little funding at national level 12 Policy push & adequate funds as key facilitators
- 13. Findings June 1, 2012 1. Incentives and financing • Differences in financing schemes among tiers as a main barrier: • Payment and incentives to service providers • Payment to Primary care: FeeForService (DE), eCare payment (DK), capitation, Pay-for- Performance / P4P (UK, Andalusia), • Payment to Hospital care: DRG in Italy (Lombardy) and Denmark • BUT hospital staff-nurses-social care? • Incentives alignment across tiers of care as a facilitator • Andalusia – common indicators between primary and secondary care negotiated at District level 13 Adequate incentives as key facilitator
- 14. Findings June 1, 2012 1. Technology in place • Interoperability in place as a driver and as an innovation process • Involvement of Industry, e.g. France • Policy towards nationwide EHR as a driver, e.g. Denmark High eHealth deployment • However, the technology is not enough, e.g Estonia: 1st class nationwide EHR in place, but no IPHS uptake 14 Technology in place as key facilitator
- 15. Findings June 1, 2012 1. Professionals as drivers • Role of champions, also related to evidence consolidation • Services mainly run by nurses or social carers but little direct involvement from physicians (hospital and primary care) • Need for cooperation between different tiers of care Interoperability Care pathways re-design Patient ownership issues • Barriers to overcome: Data overload, data granularity, data structure and interoperability Liability issues Threat to the doctor-patient relationship Lack of incentives Professional resistance as a main barrier 15 Role of champions as a key facilitator
- 16. Findings June 1, 2012 1. Patients as drivers • Integrated care around the patient - empowerment Organising functions and activities around patient care and services Patients willingness to stay within the community • Learning to self-manage their condition Technology rotation is emerging as an option • “Paternalism” of the system reliance on patient or on the service (i.e.: SMS reminders) • Influenced by their family/carers and GPs • Barriers to overcome: Intrusiveness Fears of lack of care 16 Patients readiness and wiliness as key facilitators
- 17. Drivers June 1, 2012 Mainstreaming and deployment at scale in Denmark, In line with England, Scotland and some regions in Spain and Italy; progress whilst relevant initiatives in other Member States are taking towards place (FR,DE,NL) Integrated Care Drivers: Re-organisation of services and towards integration of health and Service delivery social care High eHealth deployment and progress towards interoperability Patient record Involvement of HTA agencies Availability of evidence even if practice-based Best practice Funding for development Reimbursement of services Incentives Incentives and frameworks promoting cooperation Committed & Integrated governance (+ stakeholders) Good Legal framework governance in place Demand (patient) side as a significant driver of change Patient empowerment 17
- 18. Conclusions June 1, 2012 Technology is not the issue, the issue is about re-organisation of care (10% / 90%). However, for this, interoperability is key. More likely to deploy IPHS in countries where policy towards integrated care, incentive frameworks and funding mechanisms are in place. Forget about getting new evidence (e.g. more RCTs). Look at demand (users and patients) and raise awareness. More on SIMPHS2: http://is.jrc.ec.europa.eu/pages/TFS/SIMPHS2.html 18
- 19. Next Steps June 1, 2012 “Amongst the 31 initiatives studied it is clear that there is a need to define a common monitoring and assessment framework. Such a framework could combine different indicators to enable decision makers to assess both the state of maturity and the readiness for scaling up. It would represent a basis for knowledge and evidence as well as enable better international comparisons of performance”. SIMPHS3 aims at developing a common Reference Framework for evaluation of EIP AHA actions. 19
- 20. Telehealthcare in EU Experiences on Integrated Personal Health and Care Services (IPHS): Evidence from eight European countries Elena Villalba, Fabienne Abadie, Maria Lluch, Francisco Lupiañez, Ioannis Maghiros,Bernarda Zamora JRC – IPTS, IS Unit Elena.Villalba-Mora@ec.europa.eu Disclaimer: "The views expressed in this presentation are purely those of the authors and may not in any circumstances be regarded as stating an official position of the European Commission“
Notes de l'éditeur
- IPTS is one of the 7 institutes of the JRC. The JRC is the EC in-house research arm This presentation includes the experiences in IPHS from eight EU countries and the consolidation of evidence extracted from the cross analysis By IPHS we include RMT applications involving telehealth and telecare applications
- The emphasis on chronic diseases is mainly due to the fact these patients are the ones whose quality of life is deteriorating and because these conditions are responsible for a high part of healthcare expenditure (i.e.: 70% of healthcare expenditure in the UK and along the same lines across EU Member States
- This is why challenges to ICT & IPHS deployment have become of paramount relevance at EC level. As a result the ICT for Health unit at DG INFSO has been funding research in this area and and the SIMPHS2 represents one of these projects
- All of them have clinical champions
- Also similar to the eCare case in Italy. NEXES is aiming at this. Telekat in Denmark is rolling out involving all tiers of care
- Also similar to the eCare case in Italy. NEXES is aiming at this. Telekat in Denmark is rolling out involving all tiers of care Hospital Clinic – NEXES - RCT on 3,600 patients testing multi-intervention deployment at scale involving primary care and social services Legal framework - Denmark represents a case where this issue has been addressed to a certain extent. The National Board of Health (SST) published the so-called “Guidance concerning responsibilities in doctors’ use of telemedicine” (c.f. VEJ nr. 9719 of 09.11.2005). According to these guidelines, " a GP must perform an autonomous assessment of whether the information about the patient, which the GP in question has received, is relevant and sufficient". In contrast, the same guidelines conclude: "for the use of telemedicine, specific local instructions and procedures must be developed to ensure a safe and sound course of treatment for the patients". Thus, although progress has been made, some of the issues are still blurred and further action may be required.
- The funding source will define the type of development. In scotland, TDP the funding has covered for the reorganisation For instance, since 2007 a specific fund for non self-sufficient people (fondo regionale per la non autosufficienza- DGR 509 / April 2007) was established. the Emilia Romagna region has established a specific taxation for this fund that covers all the expenditures for classic health and social services for non self sufficient people for all ASLs, municipalities and since 2006/ 2007 and also for the development of ICT enabling services. Thus, aiming to bridge to the gap between policy and implementation through defined financing mechanisms. This mechanism has represented a catalyser for the eCare project to widespread.
- Role of the industry = England is a good example interoperability – DALLAS programme
- Healthcare professionals Data granularity and work overload Doctor-patient relationship Fears to lose their jobs, Big brother syndrome, Liability Incentives stimulating ICT use in general and IPHS deployment in particular Outcomes based incentives seem to promote ICT use (as opposed to FFS) stimulating cooperation with other tiers of care - Andalucia provides an example of incentives aligned across primary and hospital care when it comes to healthcare professionals but not institutionally Other strategies associated to fears to lose their jobs, doctor-patient relationship and big brother syndrome: Role of Champions and the role of nurses Trainings as engagement Dissemination and communication strategies to set the right expectations = Italy prominent very good examples Introducing the use of these technologies at educational (school) stage
- Role of patients in: Learning to self-manage their condition and life independently in the community (and die in the community) Intention to use the technology highly influenced by their relatives/carers and by care professionals, in particular GPs Digital divides and IT savvy - The case of Denmark where patients exercise a relevant demand side pressure for healthcare professionals to use ICT Using patients to engage other patients should be further explores
- Those that involve integrated care delivery in terms of involving all tiers of care are: Denmark – Telekat and ICHM (integrated clinical home monitoring project) Spain: Catalonia - NEXES in hospital clinic Basque country – Evidence based medicine clinical unit (with geriatric centres) Finland - South Karelia (not covered under SIMPHS2) The drivers All of them have clinical champions. Drivers i dentified are very much in line with the definition and features of integrated care that we used: Integrated care requires a central system of patient records ( High eHealth deployment and progress towards interop.) , service delivery (= re-organisation of services integration of health and socical care) , and best practice protocols (= Involvement of HTA agencies, Availability of evidence even if practice-based, funding available to develop best practice), to deliver care successfully as an integrated system. The need for Incentives ( Reimbursement of services; Incentives and frameworks promoting cooperation) and good governance in place ( Committed & Integrated governance involving stakeholders; Legal framework; Demand (patient) side represent a relevant driver of change ) “ Amongst the 31 initiatives studied it is clear that there is a need to define a common monitoring and assessment framework. Such a framework could combine tangible (cost) and intangible (care) factors to enable decision makers to assess both the state of maturity and the readiness of scaling. It would represent a basis for knowledge and evidence as well as enable better international comparisons of performance”
- IPTS is one of the 7 institutes of the JRC. The JRC is the EC in-house research arm Main Gist of this presentation: present examples of IPHS related initiatives in EU and draw conclusions as to lessons learnt from mainstreaming By IPHS we include RMT applications involving telehealth and telecare applications