Inventory of Telemedicine Applications in the Regions

Inventory of Telemedicine Applications in the Regions January 2006 Working Document 6 P.J.M.M. Epping, O.J.P.S.T.M. Smits, J.A. Cosijn, Eindhoven A.C...
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Inventory of Telemedicine Applications in the Regions January 2006 Working Document 6

P.J.M.M. Epping, O.J.P.S.T.M. Smits, J.A. Cosijn, Eindhoven A.C. Wagener, Den Haag The Netherlands



Table of content


Introduction 4

2 2.1 2.1.1 2.1.2 2.1.3 2.2 2.2.1 2.2.2 2.2.3 2.3 2.3.1 2.4 2.4.1 2.4.2

The Health Care Systems in the Tele Medicine Project Regions 6 Italy (Genoa and Bologna) 6 The National Level 7 The Regional level 8 The Local Level 9 The United Kingdom (Southampton) 11 Primary Care Trusts 12 Strategic Health Authorities 12 Primary Care 13 The Netherlands (Eindhoven and Den Haag) 13 Primary Health Care 13 Spain (Catalonia/Viladecans and Illes Balears) 14 Public Health in Catalonia 15 Balearic Islands 15

3 3.1 3.1.1 3.1.2 3.1.3 3.1.4

Telemedicine and Chronic Illnesses 18 Introduction 18 Italy (Genoa and Bologna) 18 United Kingdom (Southampton) 18 The Netherlands (Eindhoven and The Hague) Spain (Catalonia and Balearic Islands) 20

4 4.1 4.2 4.3

Behavioural Change: the Main Factor 25 Changing Behaviour 25 Self-management 25 A New Model for Disease Management 26

5 5.1 5.1.1 5.1.2 5.1.3 5.1.4 5.1.5 5.1.6 5.1.7 5.1.8

Focus in the Tele Medicine Project 28 Telemedicine Applications in the regions 28 Introduction 28 Telemedicine and rural areas 29 Telemedicine Applications in the Region of Genoa 29 Telemedicine Applications in the Region of Bologna 32 Telemedicine Applications in Southampton 34 Telemedicine Applications in the Netherlands 35 Telemedicine Applications in Catalonia 39 Telemedicine Applications in the Balearic Islands 40



6 6.1 6.2

Success Factors 44 Technological Aspects 44 Organisational Aspects 44


Implementation 46


Conclusions 47


Literature 48 Annex 1 – Model for Implementation 49




Many cities in Europe are confronted with an increasing health care demand because of an ageing population and an increasing number of people with chronic diseases. The pressure of this increasing demand will be put foremost on primary health care and medical services such as general practitioners, home care services, social assistants, hospitals et cetera. These developments will increasingly have consequences on the needs for health and medical services to be provided as well as for the planning of these services, particularly in urban areas. To implement a new model of care in a rather strict and old-fashioned health care system is not an easy task. Especially when these new models of care are technology driven and are being implemented in the field of the chronically ill patients: a group of patients that may represent 20 to 30% of the total patient population in 5 to 10 years. New technological solutions will provide patients with a number of tools that lead to better self-management and a greater awareness of their health condition. Proven modern disease management tools eventually will lead to improved quality of care, a reduction of hospital admissions and therefore a substantial reduction of costs. From the beginning of the year 2000 up until now, many investigations have been undertaken about the actual situation of health care in Europe [see IST e-Health programme]. Most of them are reporting that health care delivery systems do not provide consistent, high-quality medical care to all people. Today’s health care systems remains overly devoted to dealing with acute, episodic care needs, while people with common chronic conditions are in need of long term health care services. To start dealing with these problems, one of the aspects that now has been broadly accepted is the use of IT (Information Technology) in health care. In order to accelerate and co-ordinate telemedicine developments on a small and regional level in Europe, several regions have combined their expertise in the INTERREG IIIC Tele Medicine Project. The most important task of this INTERREG IIIC Tele Medicine Project is to establish a seamless and secure exchange of patient data between authorised health care providers and patients, using technical communication standards. Additionally there will be an international platform for exchanging knowledge. The use of IT in health care is gradually expanding and applications, which support the exchange of patient data in the continuum of care, become more and more available. The overall objective of the INTERREGIIIC Tele Medicine project is to explore the effects and opportunities for the local planning of health and medical services and housing facilities in urban areas via the stimulation of more efficient en innovative ICT


(wireless) based solutions for domestic health and medical care. (INTERREG IIIC Tele Medicine application form, October 2004). The working definition of the Tele Medicine project is as follows: Tele Medicine is the use of information and communication technology in the primary process (first and secondary line care) to improve health services (like cost reduction, shorter waiting lists) and self-management (like better quality of life). Results will effect health and urban planning (policy making). It is the INTERREG IIIC Tele Medicine Project general opinion that health care as a whole and the care of the chronic ill patient in particular need to turn to state of the art technology. Without the use of Information Technology (IT) the number of medical failures may rise, caused by the lack of information in the continuum of care [TNS NIPO, 2004]. New technological solutions will provide patients with a number of tools that lead to better self-management and a greater awareness of their health condition. Proven modern disease management tools eventually will lead to improved quality of care, a reduction of hospital admissions and therefore a substantial reduction of costs. The INTERREG IIIC Tele Medicine Project will provide an opinion on disease management models, especially with telemedicine as an important driver for disease management, and their place in regional health care systems. A first step in this exchange of information was providing information on the following subjects: – The national and regional health care systems; – The amount of patients with COPD (Chronic Obstructive Pulmonary Diseases); CHF (Congestive Heart Failure) and diabetes – Regional experiences with telemedicine applications. This document provides a ‘state of the art’ of the above mentioned issues.



The Health Care Systems in the Tele Medicine Project Regions


Italy (Genoa and Bologna)

In Italy the health care system is a regionally based national health service that provides universal coverage free of charge at the point of service. The system is organised at three levels: national, regional and local.

Figure 1: Overview organisational actors and relationships


The national level is responsible for ensuring the general objectives and fundamental principles of the national health care system are set out. Regional governments, through the regional health departments, are responsible for ensuring the delivery of a health benefit package through a network of populationbased health management organisations (local health units) and public and private accredited hospitals. Figure 1 summarises the main organisational actors, as well as the relationships among them. Parliament approves framework legislation, which lays out the general principles for organising, financing and monitoring the NHS. 2.1.1

The National Level

At the national level, health care and the operation of the National Health Service (NHS) are governed primarily by Law No. 833/1978 and following modifications (DPR 502/1992, DPR 517/1993, Legislative Decree 229/1999). The implementation of the national health programme is delegated to the regional and the local regional organisations. The objectives of the national health programme are set out following the approval of the National Health Plan, which is intended to bridge the existing social and health care gap, especially in the southern regions. All the objectives of the national health programme are determined with the help of the regions – within the framework of economic planning and in accordance with the relevant legislation, which stipulates, among other details, the levels of health care services that must be guaranteed for citizens. The government draws up the National Health Plan based on proposals from the Minister of Public Health; the Plan is subject to the approval of parliament at the same time as the legislation on the multi-year funding programme for the National Health Service. The National Health Plan runs for three years. The regions have 150 days from the day of enactment to adopt or amend the regional health plans in accordance with the national health plan. The 2002–2004 National Health Plan differed from previous health plans in its response to the following: – the process of transferring more power to the regions; and – The ageing of the population combined with the increased efficacy of medication is a new crisis, leading to increased frailty in much older age. The National Health Plan offers unitary management of health protection throughout the country through a network of local health enterprises. These local health enterprises operate independently and more in the manner of a business, covering the structures and offices of each municipality. In addition, they are responsible for providing health promotion, health care, and physical therapy, guaranteeing health services to the entire population.


In 2001, the National Health Plan extended the scope of health promotion strategies by defining broad objectives: – promoting healthy lifestyles; – fighting the major causes of death (cardiovascular diseases, cancer, infectious diseases and accidents); – Improving the environment; protecting vulnerable members of society (children, elderly, disabled, destitute, etc.). 2.1.2

The Regional level

Regional governments, through their departments of health, are responsible for pursuing the national objectives laid out in the National Health Plan. In relation to health, the regional health departments deliver these through a network of populationbased health care organisations (local health units), public and private accredited hospitals. They are responsible for legislative and administrative functions, for planning health care activities, for organising supply in relation to population needs and for monitoring the quality, appropriateness and efficiency of the services provided. The regional level has legislative as well as executive functions, technical support and evaluation functions. Legislative functions are shared between the regional council and the regional government. Legislative Decree 229/1999 states that regional legislation should define: – the principles for organising health care providers and for providing health care services; – the criteria for financing all health care organisations (public and private) providing services financed by the regional health departments; and – The technical and management guidelines for providing services in the regional health departments, including assessing the need for building new hospitals, accreditation schemes and accounting systems. This Decree has significantly increased the legislative power devolved to the regions and is being currently implemented at the national and regional levels. The executive functions of the regional governments entail outlining a three-year regional health plan. This plan is based on National Health Plan indicators and on the assessment of regional health care needs and is used to establish strategic objectives and initiatives, together with financial and organisational criteria for managing health care organisations. Other responsibilities of the regional health departments are allocating resources to various health units and hospitals and applying the national framework rules to public and private health care and other activities related to health care. The regional health departments in some regions also provide technical support directly to the local health units and to public and private hospitals. Other regions


have formed an agency for regional health care services, which is responsible for assessing the quality of the local health care and for providing technical and scientific support to the regional health departments and the local health units. Technical support is also provided during the planning process to assess population needs, to define the range of services to address those needs. Emilia-Romagna is one of the regions that have created such an agency for their regional health care services. 2.1.3

The Local Level


The 1978 reform gave an important role to municipalities, which were in charge of governing the local health units. However a series of reforms in the late 1980s shifted municipal powers to the regional level. From 1992, the structures operating at the local level in relation to public and private health care structures and providers were divided into four different categories: – local health units, – public hospital trusts, – national institutes for scientific research, – Private accredited providers. At present the municipalities carry out the functions of programming and controlling the health system as legally designated. Following these measures, municipalities assume a more important role in the political government of the National Health Service. More precisely, they evaluate the results of the health agencies. The metropolitan health system must act in a network between the various provincial bodies and institutions, with the objective of realising a better and more efficient distribution of services, to agree prevention and communication strategies and carry out necessary control and monitoring procedures for these activities. At present in the territory of Bologna there is a Territorial Social and Health Conference (TSHC) set up to carry out these functions at provincial level. The TSHC responds to functions outlined in regional law n°21 of 2003 and n°2 of 2003. The conference is made up of the president of the province of Bologna or his delegate, the mayor of the municipality of Bologna or his delegate and the mayors of the municipalities in the territory of the Bologna Health Authority. At the conference, tasks of active administration, control, direction are delegated. Among the control functions, the territorial social and health conferences express obligatory opinions on the planning budget, on the estimated budgets and the current balance sheet of the health agencies and send their comments to the region for eventual action by the regional administration, they also express a formal opinion on the appointment of the general managers of the health agencies. As for programming, they participate in defining needs, evaluating health service functionality and their distribution in the territory. They promote and co-ordinate


agreements between municipalities and health agencies to improve the integration between social and health services. Local health units are geographically based organisations responsible for assessing needs and providing comprehensive care to a defined population. They provide care directly through facilities or through services provided by public hospital trusts, research hospitals and accredited private providers (acute and longterm hospitals, diagnostic laboratories, nursing homes, outpatient specialists and general practitioners). A general manager appointed by the regional health departments for a period of five years heads them. Services are structured under a divisional model in which each division has financial autonomy over and technical responsibility for the different areas of the health care system, including health promotion. The health promotion department is responsible for health promotion as well as prevention of infectious and other diseases, promoting community care and enhancing people’s quality of life. These divisions also provide services for controlling environmental hazards, preventing infectious and other diseases, promoting community care, enhancing people’s quality of life, preventing occupational injuries and controlling the production, distribution and consumption of food and beverages. Local health units are responsible for delivering a benefit package by directly providing services or by funding hospital trusts and private accredited providers. The activities to be performed are defined in the local implementation plan, which should be consistent with the regional health plan. According to the 1999 reform (Article 3, Legislative Decree 229/1999), local health units have to guarantee equal access to services for all citizens, the efficacy of preventive, curative and rehabilitation interventions and efficiency in the production and distribution of services. They are responsible for maintaining the balance between the funding provided by regions and expenditure on services. Local health units are organised into health districts responsible for ensuring the accessibility, continuity and timeliness of care. Health districts also have the role of encouraging an intersectorial approach to health promotion and ensuring integration between different levels of care and between health services and social services. The health district, therefore, represents both an operational structure for providing services and a vehicle for promoting health projects that integrate various operational structures, in accordance with the strategic plans of the region and the local health unit. A co-ordinating office to achieve these objectives supports the manager of the health district. This office includes general practitioners, paediatricians and specialists to promote the integration of health care and social services, which is also accomplished by developing and disseminating general organisational guidelines. Public hospital trusts provide highly specialised hospital care (or tertiary care).


National institutes for scientific research are research-oriented hospitals operating at the local level. They are spread throughout Italy and are directly financed by the Ministry of Health. Private accredited providers provide ambulatory, hospital treatment and/or diagnosis services financed by the NHS. Genoa

In Liguria there are five ASL, that divide their territories in 20 Basic Healthcare Districts, that organise primary help services, home care system and outpatient services. These bodies support the families, old and AIDS illness and manage the health care activities that the Municipalities delegate them with the co-ordination between other structures of the hospital assistance. The Basic Healthcare Districts, to perform these functions, make use of these subjects’ help: 1. Basic Doctors (Doctors of General Medicine and Doctor for Children): they weigh the real need of the citizen and regulate the access to the other services of the National Health Care System. 2. Medical Service on duty: it guarantees the non-stop assistance in all the day and for all days in the week 3. Hospitals 4. Not Hospital Health Structures: there are different structures that supply specialised services. National Healthcare Fund in 2003 was 78.403.971.577 and in 2004 Respectively in 2003, 2.454.044.310 were allocated to Liguria, and in 2004, 2544.292.177. Healthcare expenditures are 40% of the whole balance of the Region. The balance of Ligurian Region is composed in this way: 4% prevention, 46% community, 48.5% hospitals (about 80.000.000 for First Aid activities), 1.5% emergency service and other.


The United Kingdom (Southampton)

In the United Kingdom the Department of Health is a government department tasked with improving the health and well being of the population. The Department is responsible for: – Setting overall direction and leading transformation of the NHS and social care – Setting national standards to improve quality of services – Securing resources and making investment decisions to ensure that the NHS and social care are able to deliver services – Working with key partners to ensure quality of services, such as: - Strategic Health Authorities, the local headquarters of the NHS - The Commission for Healthcare Audit and Improvement (CHAI) and the Commission for Social Care Inspection (CSCI), new independent bodies



The NHS Modernisation Agency and the Social Care Institute for Excellence to identify and spread best practice locally The Department of Health has recently started a programme of change, ‘Shifting the balance of power’, designed to make sure they provide leadership to the NHS and social care. The aim is to design a service centred on patients, which puts them first. It is intended to be faster, more convenient and offer them more choice. The main feature of the change has been to give locally based Primary Care Trusts (PCTs) the role of running the NHS and improving health in their areas. This has also meant creating new Strategic Health Authorities, which cover larger areas and have a more strategic role. 2.2.1

Primary Care Trusts

Primary Care Trusts (PCTs) are local health organisations responsible for managing health services in a local area. They work with local authorities and other agencies that provide health and social care locally to make sure the community's needs are being met. PCTs are now at the centre of the NHS and get 75% of the NHS budget. As they are local organisations, they are in the best position to understand the needs of their community, so they can make sure that the organisations providing health and social care services are working effectively. For example, PCTs must make sure there are enough services for people in their area and that they are accessible to patients. They must also make sure that all other health services are provided, including hospitals, dentists, opticians, mental health services, NHS Walk-In Centres, NHS Direct, patient transport (including accident and emergency), population screening, pharmacies and opticians. They are also responsible for getting health and social care systems working together to the benefit of patients. 2.2.2

Strategic Health Authorities

In April 2002, 28 new, larger Strategic Health Authorities (SHAs) were set up to develop strategies for the NHS, and to make sure their local NHS organisations were performing well. The new health authorities are responsible for: – Developing plans for improving health services in their local area – Making sure local health services are of a high quality and are performing well – Increasing the capacity of local health services - so they can provide more services – Making sure national priorities - for example, programs for improving cancer services - are integrated into local health service plans They manage the NHS locally and are a key link between the Department of Health and the NHS.



Primary Care

This is the care provided by people you normally see when you first have a health problem. It might be a visit to a doctor or dentist, an optician for an eye test, or just a trip to a pharmacist to buy cough mixture. NHS Walk-in Centres, and the phone line NHS Direct, are also part of primary care. All the people offering primary care are now managed by new local health organisations called Primary Care Trusts (PCTs).Primary Care Trusts are responsible for planning secondary care. They look at the health needs of the local community and develop plans to improve health and set priorities locally. They then decide which secondary care services to commission to meet people’s needs. Therefore they work closely with the providers of the secondary care services that they commission to agree about the delivery of those services.


The Netherlands (Eindhoven and Den Haag)

Health care in The Netherlands is provided by thousand of institutions, tens of thousands of contracted or self-employed health professionals and hundreds of thousands of other health workers. Most health care facilities are owned and managed by not-for-profit, non-governmental entities of religious and charitable origins. Most general practitioners (GPs) work in small group practices and there are a small number of health centres where they work with other health professionals. Almost all dentists have a solo practice. Physiotherapists outside of institutions usually work in small group practices. Until the late 1980s, the majority of medical specialists worked in small groups as private contractors (maatschappen), basing their activities on contracts with hospitals for the utilisation of the beds, facilities and auxiliary services. Traditionally, medical specialists in teaching hospitals have worked under contract. Hospitals or other health care facilities and organisations employ most other health professionals. In the 1990s, providers of primary care sought collaboration and forms of horizontal and vertical integration with secondary and tertiary care. They extended their activities beyond their traditional borders. Hospitals, nursing homes and home care organisations created formal and informal alliances and regional networks. This also blurred the traditional borderlines between the different ‘echelons’ in health care and related social services. As a consequence, traditional definitions of health care services no longer easily apply. 2.3.1

Primary Health Care

In principle, citizens are responsible for their own health. Where physical and mental symptoms are concerned, a person can decide for him- or herself whether or not to seek primary health care.


Primary health care stimulates this (re)taking of the patients’ personal responsibility, the prevention of disease, the recuperation, revalidation and adapting to a chronic disease or handicap. Primary health care must be offered according to demand, must be accessible (close by), must be organised efficiently and must provide care of high quality. A strong primary health care provided by general practitioners (GPs), physiotherapists, home care, et cetera, is an essential pillar of efficient health care. Primary health care professionals are the gatekeepers to specialist (hospital) care and it is intended that they prevent unnecessary (and costly) medical care. Primary health care has a large number of tasks: providing information, giving advice about self-care and prevention, nursing and caring, diagnosing and treatment. Additionally, primary health care is responsible for the management of medical records and referrals to medical specialists. In the past few years, the organisation of GPs has undergone some changes. The trend for more GPs to work together in a practice has been evident for a long time. Additionally, the employment of supporting staff has increased. They now often employ nurse practitioners or practice assistants (of Higher Vocational Education level). These supporting staff often perform check-ups on the chronically ill. There have also been changes in health care outside of office-hours. The demand for this kind of care has increased dramatically over the last few years. Most regions offer primary health care after office hours at so-called General Practitioners Post. The nature of the demand for care is changing. The needs for primary health care of chronically ill patients, of young parents with children, or of older people are very different. Some patients feel that a long-lasting relationship of trust with their GP or health care provider is important. Other patients do not feel the same way and would rather decide which carer they want to help them on an ad hoc basis. There is no standard patient anymore and a traditional supply of health care is no longer sufficient. It is necessary to diversify and become more flexible. Primary health care is also changing. As co-operation between primary and secondary health care improves, the importance of primary health care will increase further. An example of this is consultation between professionals in primary health care and in secondary health care that has already been implemented successfully in mental health care. Possibilities for consultation will increase due to telemedicine, (the electronic assessment of medical questions.) As health professionals and organisations integrate their services and change their organisations and contractual relations, it has become difficult to provide an exact overview of ‘primary’ and ‘secondary’ care.


Spain (Catalonia/Viladecans and Illes Balears)

Health care in Spain is public, free of charge and universal. It is a totally decentralised system: “comunidades autonomas” (autonomous regions) which are fully responsible for health. Next to the public health sector there is a co-existence of a private health sector.



Public Health in Catalonia

Catalan “Department of Health- DH” is responsible for health policies and budget. CatSalut (Catalan Health Service) is responsible for planning, purchase and assessment of health services. Besides that there is a “mixed” health care model. In this case it means that there is an integration of: – publicly owned (state run) infrastructure – Subcontracted organisations historically devoted to health (such as: health care funds, foundations, centre supported by the Church, cities owned centres, etc). Complementary to the public insurance there is private insurance (las mutuas). They have their own health infrastructure networks (hospitals, laboratories, etc) + specific agreements with private centres of GP and specialists. A private insurance subscriber gets free access to health services of his private insurance. Owners of the public health card do have 100% free access to general and specialised health services, (except dentists and opticians). Besides that there is 60% reimbursement of medicaments cost and 40 % of medicaments co-payment. Access to primary health care is through the “reference GP + nurse” of the “reference primary health care centre” (CAP), which primary is the one in the district of the patient. CAP is the usual entry to the health care system as a whole (triage). Access to specialist care. Each “primary health care centre” re-directs patients to a specific network of reference specialist care organisations. Which are: – Hospitals (3 levels) – Social health care (elderly, chronic patient and terminal phase patients) – Psychiatric and mental care – Drug dependency – Other specialised resource care (including rehabilitation, health transport, respiratory therapy for instance) – Pharmaceutical assistance In case of emergency there is access to emergency services of the primary health centre or directly to the hospital according to the cases and patient’s choice. 2.4.2

Balearic Islands

The Administration of the Balearic Islands is responsible for the “competencies” in health and hygiene, healthcare, hospital co-ordination and pharmaceutical planning of the islands. These “competencies” were transferred from the Spanish Central Government on the first of January of 2002. After the transfer of abilities, the Regional Ministry of Health of the Balearic Islands was restructured as follows: – Planning and Financing Directorate-General: the areas of competence of this body are those related to the planning and financing of the healthcare system, as well as the definition of its quality policy.


– Accreditation and Assessment Directorate-General: it was created with the aim to assess and inspect health services, to authorise health centres, professionals and services, and to define the policies concerning training and research on health issues. – Chemistry Directorate-General: the monitoring and improvement of the quality of pharmaceutical products is under the jurisdiction of this body. – Consumers Directorate-General: it is competent for consumers defence and market monitoring. – Public Health Directorate-General: it is responsible for the promotion, prevention and protection of health and food safety. While the Regional Ministry of Health plays a political and administrative role, the Health Service of the Balearic Islands (Ib-Salut) is the organisation that puts into practice the guidelines defined by the ministry. It is an autonomous public entity provided with legal responsibility and its own estate portfolio. Its main goal is to manage the public healthcare services of the islands. It contributes to: – defining the priority areas dependant on the citizen’s requirements; – distribute and manage accurately and efficiently the economic resources assigned to finance the services; – guarantee, assess and improve the quality of healthcare; – Encourage health professionals to involve themselves in the management of the sector, as well as to promote training and research. The Balearic Islands boasts 8 public hospitals (3 more under construction), 48 PACs (29 more under construction) and 15 private clinics. Those centres offer the following services: – Social healthcare - Provision of additional support to assist informal carers (relatives) - Daily personal care - Solving basic financial difficulties – Primary care - Solving basic financial difficulties - Healthcare at doctor’s office and at home - Basic diagnostic tests - Health promotion actions - Illness prevention and rehabilitation - Emergencies (24 h) management - Parental treatments - Minor surgery – Specialised care It will be provided after trying all the options in the Primary Care through PACs and hospitals. - Diagnostic tests - Surgical treatments and interventions - Rehabilitation - Prosthesis implantation and rehabilitation


– –

- Emergency services - Laboratory services - Renal lithotripsy - Radiotherapy - Transplants – Pharmaceutical care - Pharmaceutical specialities - Specialised vaccines - Provision of products and accessories accepted by the Health Ministry The pharmaceutical services can be obtained at the hospitals and at the PACs. Complementary care - Orthoprosthesis - Oxigentherapy at home Healthcare services are obliged to provide healthcare users all the necessary information on their rights and duties, what services are available, as well as the information related to the reports regarding the healthcare processes they are subjected to and their clinical history. Women’s care - Medical indication and following up of the different contraceptive methods, including education and health controls. - Actions for diagnosing early breast and gynaecological cancer, and for detecting vulnerable women. - Actions to treat the menopause and its complications. Children care - Health information and education for parents, teachers, caregivers, etc. - Application of vaccines according to the official schedule. - Regular check-ups Adults and care of older people - Home care for immobilised and terminally ill patients. Dental care - Information and education on dental health - Preventive and healthcare actions: – application of fluorine for external use – fissure sealing – teeth cleaning – molar caries filling at 6 years of age Others - Infertility treatment - Prenatal diagnosis in vulnerable groups - Mental healthcare



Telemedicine and Chronic Illnesses



In the participating regions we see a lot of chronic diseases. With the ageing population also the amount of chronic ill patients will increase. In this section we will provide an overview of the chronic diseases of the regions. 3.1.1

Italy (Genoa and Bologna)

In Liguria the old people touches the 26% of the population: it is the oldest region in Italy and the ageing index is one of the most high in Europe. The 28.7% of women are older 65 years, the 20.9% of men older 65 years. Moreover, in Liguria, the age structure is peculiar: there is the highest dead rate 13.6 (national average 9.8) and the lowest birth rates 7.3 (national average 9.3). The Ligurian population ageing, more than in other countries of Italy, is a great problem for the regional health care policy owing to the high number of requests for healthcare services. Generally 2/3 of the total healthcare expenditure is used for the old people, the main users of the regional health system. The epidemiology in Liguria region in year 2003 is distributed this way: 29% cancer, 42% heart, 6% COPD, 4% trauma, 5% G.I. diseases, 4% neuropathologies, 3% diabetes, endocr., immunity. Diseases, 1% infective pathologies. In Liguria, more than 60% of the total cases of cancer concerns people older than 65 years. Bologna reported that there are about 5200 diabetes patients in the region. Besides that there are about 2100 patients suffering from senile dementia or Parkinson disease. 3.1.2

United Kingdom (Southampton)

Southampton On a national level the next overview provides information about the situation of chronic sickness. On a local level the next figures regarding chronic illnesses were found: in the North and Central locality COPD is the number one admission in 2004 for elective admissions. Heart disease features in the top 10 admissions for elective, day and emergency admissions. In the North and Central the average number of admissions for CHD is 934 and at any one time there are 2311 people with CHD and 2283 with diabetes.


Chronic sickness: rate per 1000 reporting selected longstanding condition groups, by age and sex Great Persons aged 16 and over Britain : 2003 Condition group 75 and All 16-44 45-64 65-74 over ages XIII Musculoskeletal system Men 65 175 223 229 128 Women 58 195 355 338 160 Heart and circulatory VII system Men 17 147 345 317 113 Women 22 118 297 303 109 VIII Respiratory system Men 49 45 91 101 56 Women 55 61 101 56 62 III Endocrine and metabolic Men 10 55 111 77 39 Women 24 69 100 107 54 IX Digestive system Men 14 36 49 41 27 Women 17 34 60 60 31 VI Nervous system Men 19 27 32 34 24 Women 25 40 36 31 31 Table 1: Overview chronic Iillnesses UK


The Netherlands (Eindhoven and The Hague)

Eindhoven has an ageing population: there is an increase in the total group of elderly people and the average age of this group is also increasing. This implies that in the coming years there will also be an increase in the amount of inhabitants that suffer from chronic illnesses. In 2000 the prevalence of people with COPD was 17.000, the expected increase in 2020 is 1.700 new patients. In 2000 the prevalence of people with coronary heart disease was 32.000, the expected increase in 2020 is 3.550 new patients. In 2000 the prevalence of people with diabetes was 28.000, the expected increase in 2020 is 2.200 new patients. The Hague’s focus is on COPD. Information gathered for that showed that this region has about 17.000 patients suffering from COPD. Hospitals, GP’s and home health organisations developed a collaborative program for treatment. The next step is the use of telemedicine applications.



Spain (Catalonia and Balearic Islands)

In Catalonia, figures from 2000 show that 1338 deaths caused by diabetes. 10% of population > 30 years suffers from diabetes and diabetes mellitus 2 patients account for 80% of the persons with substitutive kidney treatment. Annually the costs of diabetes are 1.200,- (2002 study). Regarding heart failure the figures from 2000 show 5399 death (9,8% of total mortality) due to cardiovascular disease. In Spain in general 9% of the adults between 40 and 70 years old suffer from COPD (study of 2000). Average costs for a patient are 1.876 per year ( 2.911,- year for patients at critical stage and 1.484,- per year for patient at non-critical stage) For Catalonia specifically hospital admissions of persons older than 65 years increased 28% due to COPD (1997 and 2000). Making new improvements in primary health care, considering it not only the entry to the health care system but also the guarantee of ongoing health care services. With regard to hospitals, highlight the relationship with other health care levels, in a model that is more open to the community and gives increasing importance to alternatives to hospital admissions (home care). (Clear references to WHO promoted models such as involvement of local communities, non-formal carers, etc). Special programs have been started especially efforts in prevention and early detection of diseases. Balearic Islands Composition of the population The impact of immigration in the structure of the population caused an increase in adult population. In general terms, a 53% of the registered foreigners were between 30 and 64 years old, while the group aged from 15 to 29 represents a 26,4%. Only a 6.7% of the immigrants were over 65 years. As a consequence, the population of the Balearic Islands is younger than the rest of populations in Spain and in other European countries as the population over 65 years is under the Spanish average (16,9%) and under the rates registered, for instance, in Germany (17,7%), France (16,3%), Italy (19,1%) or Belgium (17,1%). The situation of dependent population – which compares children and people over 65 years with people aged between 15 and 65 – also shows the immigration impact. The global dependence rate in the Balearic Islands (40,8%) was below the national average (45,1%), being higher the dependence rate for youngsters (21,3%) than for elder (19,5%). The ageing rate registered in the Balearic Islands -that rate calculates the proportion of people over 64 years in comparison with the people under 20 years- fell last year to 67,5 years, which is below the 85,7% registered at a national scale.


Figure: Age, sex and origin pyramid in the Balearic Islands, 2004 85 i més 80-84 75-79



70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39

Nascuts Espanya Born inaSpain

30-34 25-29 20-24

Nascuts a l'estranger Born abroad

15-19 10-14 05-09 0-4

Chronic illnesses: COPD and Diabetes COPD IBERPOC is a population-based epidemiological study conducted in seven different geographic areas in Spain to ascertain the prevalence of COPD. 4035 interviews and 3.978 spirometries were performed. The prevalence is 9,1%. Functionally, the majority of COPD diagnoses were based on the presence of chronic irreversible airflow limitation (74,1%) of cases. That prevalence was structured as follows: 15% in smokers, 12,8% in ex-smokers, and 4,1% in non-smokers. COPD prevalence in Spain 15,00% 12,80% 9,10% 4,10%

Global prevalence





Women presented a prevalence of 3,9% and men were 14,3%. The prevalence of COPD rose significantly in the male group as age and tobacco consumption increased. The prevalence of COPD regarding smoking habit is presented in the following table. In smokers of > 30 pack-years and subjects > 60 years old, COPD prevalence was 40,3%.m.


*Packages-year/ Source: IBERPOC

Very marked differences existed regarding tobacco consumption between sexes: 76,3% of women did not smoke vs. 23% of men. Differences were also significant when ex-smokers (8,8% vs. 40,8%) and active smokers (14,8% vs. 36,2%) were compared Of the cases of COPD found, 78,2% cases had not been diagnosed previously; 19,3% of the cases detected were being treated. Treatment had been indicated in 49,3% of severe cases, 11,8% of moderate cases and 10% of mild cases. The results of logistic regression analysis that show the variables related to the previous diagnosis of COPD are detailed as follows: tobacco consumption > 15 packyears, age > 60, living in the city, male gender, having a higher educational level (>12 years vs. < 12 years of schooling), and existence of chronic bronchitis and other thoracic diseases had a significant association with the previous diagnosis of COPD, chronic bronchitis or emphysema. Social class, history of sinusitis, hay fever, lung infection and industrial occupation did not enter the logistic final model. Diabetes Mellitus The relationship between known diabetes and unknown diabetes is 1/1 and 2,2/1 depending on the age groups. That means that a half of the people suffering from diabetes doesn’t know they are ill. In Spain, there are more less 1,5 million diabetes cases diagnosed, although that figure could be 2,5 millions if all the cases were diagnosed. Diabetes mellitus II is the most common type of diabetes – In adults and elderly people (a 12% of the Spanish population over 30 years suffer from diabetes and this figure stands at 25% for the population over 65 years! Only the 0,2% of people with diabetes are under 15 years.) – in people having a history of diabetes


– and in people with overweight or obesity (Only a 15% of people with diabetes mellitus II are normal weight: the 30% have overweight, more than the 40% are obese and a 5% have morbid obesity.) The average prevalence of diabetes in Spain is 6%. We do not have data on diabetes type II prevalence in the Balearic Islands, but for general diabetes. Total DM Detected Known Untreated Treated Uncontrolled Controlled

TOTAL 11.7 30.3 69.7 36.2 63.8 73.9 27.1

MEN 15.3 32 68 36.2 61.2 73.1 26.9

WOMEN 8.4 23.3 75.3 30.9 69.1 76.3 23.7

Source: Health Plan of the Balearic Islands 2003-2007

Current scientific studies allow foreseeing the scenario of diabetes for this century: Estimated evolution of diabetes in Spain 3500000 3000000 2500000 2000000 1500000 1000000 500000 0 1996







Source: Fundación Diabetes

Diabetes in Euros Annual average cost per person with diabetes: 1.300 Annual average cost per general population: 1.130 Percentage on global healthcare cost: 4,4,% Taking into account that there are 1,5 million people with diabetes mellitus II all over the country, the estimated annual costs are about 2 billion Euro The costs are distributed as follows:


Costs of diabetes

4,60% 33,20%

Insulin 32,00%

Hospitalisation Oral antidiabetics Healthcare in medical centres


Source: Diabetes Foundation



Other drugs


Behavioural Change: the Main Factor


Changing Behaviour

Unhealthy behaviour is one of the most important causes for health problems worldwide (poor diet, insufficient exercise, alcohol consumption and smoking). Methods for health promotion and behavioural change are often being applied in the area of public health trying to motivate people to pursue a healthier lifestyle. Changing health behaviour is a main part of disease management. However to change long term behaviour is a challenge that requires a lot of discipline. For many patients this is very difficult and changing behaviour is very stressful. Failing may lead to frustration, feelings of guilt etc. Because of that some people give up and spiral down into poorer health. Some of the most successful telemedicine applications are focusing on behavioural change. An application in itself is not able to change behaviour. There must be a willingness to change. This readiness to change usually goes through several stages (Prochaska en di Clemente, 1985): - Precontemplation: the patient is not motivated and doesn’t even want to think about change. - Contemplation: the patient starts to think about change. - preparation for action: the patient starts to prepare to change - action: patient shows healthy behaviour and executes certain activities accordingly - maintenance: patient tries to follow the health rules and tries to avoid pitfalls Some e-health solutions are anticipating these stages and support the patient during these stages by giving them positive feedback. This aspect of “tele-coaching” mainly focuses on providing information about the current situation of the patient in relationship with the disease. Sometimes informing a patient about the consequences of the disease is helpful if the behaviour is changing.



Kate Lorig describes the differences between old a new care models using a metaphor of someone who falls into a river (a river of diseases). The unfortunate person can be helped in three ways. Firstly the person can be pulled out of the water (a traditional care model), secondly we can prevent the person from falling into the water (public health) and thirdly we can teach the person to swim so that he can save him self if he falls into the water (disease management) [Lorig, 2001]


Optimal self-care means that a patient (and his environment) has to deal with more than one disease on a daily basis. If this is insufficiently or not done, there will be problems. Our health care systems are more or less ‘crisis driven’ models. If there is a problem the system ‘wakes up’ and comes into action. But, especially in the area of chronic diseases this model doesn’t work well. With respect to patients this is an unwanted situation. Not only because of being admitted to hospital, but also that the situation will worsen and cause of a greater risk of complications further down the road. Because care providers due to a lack of resources often can not care for chronically ill patients they are only ’picked up’ if there are problems. This mechanism is a driver for higher costs in health care. It has been investigated that a higher level of self-management of people with chronic illnesses has positive effects such as a higher quality of life and a better health for patients [Niesink, 2005]. An important success factor for good self-management to patients who have been diagnosed with a chronic illness is sufficient information and instructions about the illness and its processes [Dimmick, 2003].


A New Model for Disease Management

Recent studies have shown that a disease management process involving frequent in-home patient monitoring and management has a vast potential to improve quality of care and reduce costs by preventing crises and improving patient education and treatment adherence [Ryan et at 2003; Cherry et all 2002; Pontin 2002; Meyers at al 2002] With daily in-home patient monitoring and communication, combined with a care coordination process assisted by telemedicine, health care providers can reduce hospital admissions and costs by detecting and responding to problems before they lead to a crisis. The information that patients provide to health care providers on a daily basis is obtained by answering a set of questions about the actual health situation of the patient related to the specific disease. The questions themselves are derived from, or related to the operative national guidelines for chronic diseases. Applications of a provider-driven model of care enable remote monitoring of patient symptoms, education of patients regarding their condition and coaching of patients for improved self-management behaviour. When (specialist) nurses use this model they can intervene and/or escalate selective information to the patients’ physicians for additional intervention. This approach empowers patients to be more comfortable in understanding and managing their condition. Such patient-understandings and timely provider-intervention avoids unnecessary hospitalisations. This approach brings the care into the patient’s home through remote patient monitoring will help patients to remain living independently in their homes for as long as possible. This disease


management model will lead to optimal medical management, efficient and effective utilisation of health care services and improved quality of life for patients. The goal of this disease management model is to provide better care to people who need to maintain, restore health or learn to live with chronic health conditions. The model of care includes daily scripted communication with patients in order to empower providers with information to be more efficient and effective, and educate chronically ill patients to change health behaviours for better health outcomes and a higher quality of life. In this model of care the daily information obtained through telemedicine is personal, relevant, and actionable so that the providers can focus on the needs of the patients without being deluged with unwanted or unnecessary information. The information is presented to the provider in a format that it is quick and easy to analyse, prioritise and act on. It supports self-care and behavioural changes by providing patients with the education and support they need in order to self-manage their chronic condition. Through the use of telemedicine technology this model provides a patient-provider communication that ultimately improves the quality of care. The technology uses an interactive in-home survey, messaging and data collection device designed for ease of use by patients, and an Internet web service for data management and care co-ordination by care providers. The system collects information daily regarding signs and symptoms, patient health behaviours and assesses a patient’s knowledge of self-management behaviours for chronic illness. The technology is used to instruct, reinforce, remind and encourage patients to comply with their medical treatment plans. The model facilitates risk stratification to ensure care interventions are targeted to those patients most in need. By answering personalised daily questions about disease symptoms, medication regimes, and disease knowledge, patients become educated in their condition and apply that knowledge toward improving their self-care behaviours. In this model, the care providers access patient information on a secure website that includes an integrated set of patient enrolment, scheduling and monitoring tools that enables them to stay abreast of their patients’ day-to-day conditions and prevent critical situations by providing early intervention. With the above described model for disease management, including new guidelines for COPD, diabetes, and health failure and models for disease management, it should be possible to serve at least 20-40% of the chronic population within the next 5 years. Based on investigations in the United States it is roughly estimated that cost savings up to 2 billion annually are achievable [Krumholz et al 2002; Waratah Corporation 2001].



Focus in the Tele Medicine Project

It is agreed that the Tele Medicine INTERREGIIIC Project will focus on chronically ill patients. The three important diseases in all the involved regions are: – COPD (Chronic Obstructive Pulmonary Diseases), – CHF (Congestive Heart Failure), and – Diabetes. Two regions (Southampton and Eindhoven) will execute a pilot focusing on the above mentioned illnesses. Results of this test phase can be expanded to other chronic illnesses. E.g. in Italy one of the target groups is the treatment of patients with (chronic) pain. Tele-consultation is one of the aspects of telemedicine that can be developed as a separated functionality in the area of telemedicine. In a later stage this functionality should be connected to telemedicine in a broader way. In Italy (Genoa) a big project in the area of tele-consultation, using a call centre, is very successful. In this way signals can be captured by other remote activities e.g. a central call centre can monitor telemonitoring.


Telemedicine Applications in the regions



Within the countries, mostly on a national level, several telemedicine applications and best practices are described. Focusing on Hospital Son Llàtzer (Palma de Mallorca), it has a very deep and welldeveloped ICT support system across all the hospital. Moreover the hospital communicates electronically with all the health care centres spread over the Las Palmas region. Perfect examples of how a modern hospital uses ICT as the basis for further developments regarding health care provision in the continuum of care. In order to develop telemedicine in a proper way a good ICT infrastructure is a basic requirement. According to general developments in several countries we see that hospitals seem to become the central basis of ICT and health care on a regional level. In all the countries there are examples available of telemedicine applications. (Genoa: call centre related; Catalonia: COPD; the Netherlands: CHF, COPD and diabetes; Southampton: heart diseases). In projects in the Netherlands and Catalonia some positive results have been reported, such as a reduction of costs. In general it is assumed that telemedicine solutions have the possibility to decrease the costs in health care. Also one of the effects is the increase of self-care and selfmanagment activities that lead to less health care consumption (less consultations).


The intended pilots in regions, Eindhoven and Southampton are anticipating cost reduction and an improvement of patient’s quality of life. The pilots are focusing on the axis of patient, home health care and GP. At particular places in the care process (continuum of care) telemedicine can be implemented in order to support the care process. In the flow chart above a general information flow picture is presented for the care process of diabetes. All the red lines indicate communication- or information flow. At some places in the Netherlands the information is electronically supported according to the above-presented model. To some extent there are also telemedicine solutions already available. The yellow part of the picture can be conceived as typically the area of telemedicine. On an international level it is of interest to visit: This site provides information about current vendors on the market. 5.1.2

Telemedicine and rural areas

Telemedicine may have a great impact to improving a better quality of health care for people living outside the urban centres and in the rural areas. since it can provides the way to link the rural areas with the best specialist operating in a region. Given to the strong urbanisation process of the 50thies, people now living in rural areas are mainly aged and old people and may have limited access to basic and specialised health care due to geographic isolation, scarcity of rural physicians, poor public transportation to larger cities and even – during winter season – vagaries of weather that impede travels. Telemedicine holds great promise to enhance health care delivery in rural areas by allowing physicians or other health professional to examine a patient while linked by video or other means to an expert consultant at a distant medical centre. Radiologists and other specialists can review medical images transmitted over telephone lines. And university-based pathologists can review biopsies done in a rural hospital while the patient is still under anaesthesia. Without telemedicine, these services would require travel on the part of either the patient or the consultant, or would simply not be available at all. Rural health professionals who use telemedicine may also likely feel less isolated from medical colleagues and resources, and a wider use of telemedicine could improve recruitment and retention of health professionals in rural areas, many of which would otherwise be more attracted to work in large urban hospitals. 5.1.3

Telemedicine Applications in the Region of Genoa

CUP LIGURIA – tele-assistance project

In the Liguria region the CUP-system is a good example of using IT in combination with a call centre to centrally organise all the reservations in hospitals and the exchange of information between hospitals, GP’s and pharmacies. At the call centre it


is known where patients can be directed with their health problem. As well as the local people, the millions of tourists are being supported by this system. The overall satisfaction with the system can be ranked as high. TESEO – tele-consultation project

The project is based on the technology Bliss Virtual Microscopy and allows digitalising the microscopic image of a slide with common glass optical systems, producing a digital image with diagnostic quality. Each Institute has a Microscope Image Workstation, and the system is able to digitise the slides, store the images on the central server. The moving operations of the images can be done in an asynchronous way, reducing the band requisites. The images can be used either for diagnostic aims (first diagnosis, further consultation, agreement meetings, and interactive discussion of clinical cases) or for formative aims (medical formation in the distance). OMERO – tele-consultation project

The project consists in a study of the mammary carcinoma HER2 positive and defines a diagnostic therapeutic path specific for this kind of tumour. In the sphere of the realisation of this project, was suggested the use of the technology applied to the project TESEO to spread and obtain a quality control, either in diagnostic terms or regarding the execution of the immuno-histochemistry procedure, on a considerable number of cases (over 110) of which were preventively digitised the images and captured on the central server. Constitution of a virtual Network for the National Oncology Bio-Banks - tele-consultation project

It’s a project financed by the Department of Health for the development of specific software to manage a Biologic Virtual Bank that should be connected to the international Network named TuBaFrost (European Human Frozen Tumour Tissue Bank). The aims of the network are: create a database with information, regarding biologic samples, to be managed in an electronic e-size including adoption of a management tool. This tool should be interoperable with the management software of the various centres. IPOCM (Integration and Promotion of the Hospitals and of the Health Centres in the World) tele-consultation project

The project intends to promote, through the use in a continuative way, of a service of medical tele-consultation and of distance formation, the growth of the quality of the health services distributed by the Health Centres in the world to the populations who ask for it. Italian Health Centres in the world (CSMI) in 20 countries agree to the project and National Health Reference Centres too (CSNR), they are in Italy and represented by Hospitalisation and Scientific Treatment Institutes and big public and private hospitals. The project expects the installation of a dedicated position, with the application of special software to do the tele-consultation, connected with the Secretariat of Technical Assistance.


Tele-consultation for the hemorrhagic diseases

The telecom system of consultation 24/24h pursues the object to assure written specialist advice to the patient who suffers from haemophilia even if he’s in a peripheral hospital (if the pathology of the patient permits) reducing the trouble to the patients and to their families for the moving from one place to another, assuring the control of the therapy by the qualified medical staff. The system is based on the use of 4 “palmari” computers of Windows Pocket PC 2003 and of an apposite software developed in Visual Studio Net. All the dates of the patients of the haemophilia centre are on a database SQL Server on a PC with static IP equipped with MS, SQL Server CE. A special routine manages the data with regular cadence pre-established by the user. The “Palmari” can enter the data through GPRS and the various screen readings allow to plan the advice showing synthetically the important data of the diagnosis of the patient, the product that has to be infused, the timing and the number of the infusions and other information. The advice can be sent by fax or by e-mail digitally signed. Every advice includes a page of recommendations for the treatment of the pathology object of the advice. On the server at the Centre the advice is automatically annotated. The possibility to send written and signed advices reduces the risk of failures including complete traceability of the services. IPOCM – Integration and Promotion of the Hospitals and of the Italian Health Centres in the World – tele-consultation, tele-assistance, tele-monitoring project

The project promotes the quality improvement of health care delivery through the supply of tele-consultation and e-learning services to doctors, health personnel and, eventually, to the local population. The Italian Hospitals in the World (CSIM), located in 22 countries, and the excellence Hospitals in Italy (CSNR), which are Health Care and Research Institutes and important public and private hospitals in Italy, do participate in the project to create a telematic network via Internet. Tele-assistance to the paedriatic patients in peritoneal dialysis domiciliary

The project has the purpose to optimise the quality of the assistance given by the Dialysis Centres to the paediatric patients (

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