building a bridge between clinical pathways and ehealth ... · between clinical pathways and...
TRANSCRIPT
Building a bridge between clinical pathways
and eHealth solutions to manage
chronic diseases and social care
Angelo Rossi Mori
MIE 2011 Workshop WS2
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• Albert ALONSO, Fundació Clínic per a la Recerca Biomèdica, Barcelona, Spain
• Jacob HOFDIJK Integrated Payment for Chronic Diseases, Ministry of Health, The Netherlands
• Michael RIGBY Emeritus Professor of Health Information Strategy, Keele University, United Kingdom
• Angelo ROSSIMORI, Marta MAZZEO eHealth Unit, Institute for Biomedical Technologies, CNR, Rome, Italy ([email protected]) 2
The background
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Improvement potential, as percent of system inefficiency [IBM 2011]
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1. new models of care
Disease Management and Chronic Care Model, with an appropriate Patient Engagement, are being introduced to face the increasing requirements of long-term care. Integration of health and social care requires: • Integrated “vertical” roadmaps; • Integrated governance; • Integrated management of information.
A joint research effort across Europe could build a bridge to connect the existing Evidence-Based Clinical Pathways to a wide spectrum of eHealth functions. 5
2. ehealth solutions
Most countries and regions are entering the “Connected Health” era. The eHealth progresses may enable the introduction of dramatic changes in the organisation of health and social care. eHealth solutions could assist the move towards more sustainable care systems, to effectively transform the care provision towards the territory, supporting home care and reducing improper hospitalisations.
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3. e-gov plans
Significant achievements were made by e-government plans to accelerate the adoption of ICT and in particular of eHealth. These plans usually act on two lines: • The national / regional infrastructures to share
clinical data and documents among care providers (e.g. the longitudinal EHR, Electronic Health Record);
• Specific ehealth initiatives on ancillary services, e.g. on e-booking, e-prescriptions, electronic diagnostic reports, patient summaries. with a “horizontal” approach aimed at the population as a whole. 7
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4. a “vertical” focus
However, the policies on health and social care are mostly based on a “vertical” focus on specific sub-populations, with an holistic view about the individual, e.g. : • integrated management of a long term condition, • risk control for the frail elderly, • support the independent living of those with disabilities, • health promotion and supervision
of the process of the regular children growth
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policies driven by patients’ needs
• multiple conditions, long-term activities ? • proactive role of the citizen and the family ? • shift from hospital to community (and home) – shift from acute to chronic – relevance of social issues
a dramatic change of perspective: implementing and adaptating a care plan more than the diagnostic process and the decision processes
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11 [ Taylor 2007 ]
5. synergies
Many fragmented eHealth solutions do already exist across Europe to support the needs of long-term care provision. There is still a lack of a comprehensive framework to put systematically together • the technology-driven horizontal approach
of e-government • the problem-driven vertical approach
of care policies
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all kinds of technologies
• (apparently) low-tech tools, e.g. glasses and contact lenses
• equipments, e.g. surveillance, home measurement devices
• ICT services – personal productivity – within a facility – in the jurisdiction
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e.g. low-tech tools related to feeding
• Universal-cuff to hold utensils • ADL wrist splint to stabilize wrist • Non-skid bowl • Plate guard • Scoop dish • Adaptive utensils • Long straw • Mobile arm supports
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Management of Information, Communication and Knowledge (MICK) – a comprehensive view
health / social professional
informal actor
operator of contact centre
health / social manager
subject of care
clinical data
administrative data
home devices
procedural instructions
clinical knowledge
practical information
other services
common substrate of data, information and knowledge
social networking
individual data local/universal resources services
issues • wellness • healthy ageing • chronic diseases • independent living • frail elderly
technologies • information systems • mobile devices • home clinical devices • domotics
actors • the citizen • informal caregivers • doctors (care, self-audit) • allied professions – community nurses /
care managers • call centre operators • clinical, organizational
and administrative managers
• policy makers 16
towards a fully integrated ecosystem - 1
care models • chronic care model • medical home • disease management • patient empowerment • predictive,
participative, preventive, personalized medicine
integration • hospital and community
care • social and health care • formal and informal care • vertical and horizontal
eHealth roadmaps • care provision and
governance / policies 17
towards a fully integrated ecosystem - 2
The workshop
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the challenge
• new models of care are being introduced (Disease Management, Chronic Care Model) to face the increasing requirements of long term care.
• shift towards social care • proactive role of the citizens
(Patient Engagement) • close coordination of all the actors
as an ad hoc, “virtual” care team 19
goal of the workshop
• To add a “vertical” perspective to the current eHealth Roadmaps, to deploy and monitor effective eHealth initiatives embedded into the policies on health and social care.
• The initial focus could be on chronic diseases, long-term care and ageing well, i.e. a relevant health problem for citizens and the most resource-consuming sector in health and social care.
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schedule of the workshop
• Rigby – Introduction to holistic health, social care informatics (10’)
• Rossimori, Mazzeo – Background concepts (20’) • 3 short presentations (10’ each) – Rossimori: Integrated vertical roadmaps – Hofdijk: Integrated governance – Alonso: Integrated management of information
• Rigby – guided discussion and conclusions (30’)
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1. Rossimori – Integrated vertical roadmaps
• formalize actors, objectives, roles, tasks, interaction points and information needs in the clinical pathways
• as the context for the clinical, organizational, managerial, educational, administrative, practical eHealth functions
• to produce the “vertical” components of the eHealth roadmaps compatible with health and social policies, funding models, demographic changes and needs for care
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2. Hofdijk – Integrated governance
• Integrated care asks for indicators on quality and appropriateness, and for specific economic agreements between payers and providers
• Most eHealth initiatives focus on data and infrastructures, but a systemic sharing of data requires a proper regulatory/economic context, or the individual providers have no stimulus to collaborate or to engage the citizens.
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3. Alonso: Integrated management of information
The “engaged” patients and their informal carers, supported by a new generation of home devices and telemedicine services, should manage most routine care at home or in long-term facilities, and the related information, in an integrated way.
Proactive citizens and their related professionals make up a particular “functional care team”, an ad hoc “virtual facility” different for each patient, because it depends on the (multiple) health issues and the social situation within the specific ecosystem of that patient.
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Integrated vertical roadmaps
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issue - need to stratify recipients and caregivers
• extending the “Kaiser pyramid” (for chronic conditions) to elderly, frail people, social care
• different phenomena for different stages of the chronic condition (diabetes, obesity, dementia)
• support to caregivers ?
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27 [ Taylor 2007 ]
intrinsic difficulty to measure a context-dependent adaptation
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area of intervention: self, carers, technologies
ideal functional level
impaired function
“age”, disease, accident
partial functional recovery, satisfactory for adaptation to work or social life of a particular individual
WP4 of the ANCIEN Project
• to set up a framework to foresee the impact of technologies on the LTC milieu
• to apply it to 3 case studies, respectively: dementia, diabetes and obesity
• to envisage the qualitative effects on the distribution of activities among formal and informal carers
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ANCIEN: building qualitative scenarios
• organizational models to be adopted • regulatory changes, “aware” of the technologies,
likely to intervene in the medium-long term • role of the family as consumers
(buying complementary services and devices, provided by public system or insurances),
• impact of the innovative care models (assisted by the technologies) on labour productivity and costs in LTC.
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ANCIEN: the case studies
• identify the possible stages for each case study 1. prevention / onset, 2. stable phase, 3. complex consequences
• impact on the autonomy of the recipient, on the need of professional activities, on the distribution between residential and home care, and on the burden of care helpers
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ISSUE% TOPIC% TOOL% ACTOR%
pain%rest% medications,%electric%profiling%bed,%electric%height4
adjustable%couch,%pressure%reduction%mattresses% GP%(to%prescribe)%nocturne%
walking% aids%and%appliances%as%walking%stick%or%walking%aid%
ADL%
elimination% bedside%commode%chair,%bedpans,%bedbaths%
nurse,%care%giver%(to%make)%
dressing%underdressing%shoes% special%shoes%and%clothes%personal%hygiene%and%grooming% mobile%bariatric%shower,%commode%chair%functional%transfers%(bed↔chair)%
sliding%sheet,%mobile%sling%lifter,%bariatric%slings,%bariatrc%wheelchair%%
ambulation% walking%aid,%walker%with%castors%
IADL%shopping%for%groceries,%clothing,%medications% e4commerce,%care%giver%
care%giver,%social%services%mobility%/%transport% coordination%services%
health%mainte4nance%
taking%medications% eletronic%diary,%dispenser%
specialist,%self%nutrition/diet% food%journal,%sensors%in%the%fridge%self4monitoring% contacalorie%remote%monitoring% weight,%pression,%blood%glucose%
education%remote%training% portals,%community,%% contact%
centre%(counselling)%supervision%technology% portals,%community%
preven4tion%%
follow4up%nutrition% ICT%application%for%communication%and%reminders%GP%follow4up%related%pathologies%% ICT%application%for%communication%and%reminders%
follow4up%psychological%state%% ICT%application%for%communication%and%reminders%safety% home%enviroment% alert%systems,%sensory% ?%leisure% communication% telephone,%pc,%tv% self%physical%activity%
rehabilitation% tele4therapy,%wii% therapist,%self%trainer%% tele4therapy,%wii%
© ANCIEN 2011
potential impact of technologies, 1
33 © ANCIEN 2011
34 © ANCIEN 2011
potential impact, 2
Discussion
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The specific role of ICT
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predict the information needs
Ideally a "contract" should clarify the role, the goal and the activities by each professional and by the patient, to "enroll" them into an explicit (stable) personalized plan of care for a suitable period. The Clinical Pathways allow to predict information needs and interactions among all the actors: which data should be available to whom, when, where, captured by whom, to address the co-operability – ability to cooperate among actors – in addition to the inter-operability among systems.
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work out the ICT needs
The clinical pathways allow to define the potential eHealth functions and to work out the detailed requirements for structured information: • the appropriate clinical data
to be captured and exchanged, • the level of coding actually needed
for further processing, • the timely indicators
for governance and other secondary uses
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genuine and artificial PHRs
Personal Helath Record systems of providers with a high organizational cohesion (e.g. Kaiser, Veterans, Maccabi) are build on high-quality, care-related integrated information systems.
Several other PHRs are artifacts that do not correspond to an integrated care ecosystem; the citizen seems not to be able or willing to "unify" in that PHR his/her disparate care experiences.
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Supporting health and social care
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Comprehensive solutions will involve a broad ecosystem of participants, including payers, healthcare providers, governments and NGOs. [IBM - The future of connected health devices, 2011]
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[Lamura et al. IPTS study on ICT and migrants in LTC, 2011]
types of care helpers
The role of the technologies
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the direct impact
LTC-related technology should support daily life activities and enrich resident quality of life, addressing – safety (e.g., falls, wandering), – self-care activities (e.g., bathing, taking
medication, eating, mobility, sleeping), – communication
(e.g., social interaction and connection), – entertainment (e.g., recreation, leisure).
[Tak 2010] 44
the mechanisms
• adaptation / reduction of the effects of the existing impairments
• prevent, delay or reduce the impairments as effects of diseases / complications
• prevent risks of accidents; timely interventions afterwards (e.g. emergency button)
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potentialities
• partially restored abilities • more authonomy, less dependency • more people able to remain at home • less burden for care helpers • less need for care helpers for the same people
(but increasing number of people with needs) • less workload for formal carers
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systemic effect
• several isolated tools, equipments, ICT solutions (e.g. directly acquired by the consumer or provided by the care providers) cannot change the context
• innovative organizational models are required to face sustainability and equity e.g. chronic disease management, chronic care model
• according to new rules of the game (regulations, incentives)
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technology as enabler or facilitator
• a systemic, pervasive effect, managed / provoked by authorities, payers, care organizations
• need to shift attention from technology (tool) to organization
• new professions (care manager, a nurse) • new forms of payment
(e.g. Accountable Care Organizatons in US) which provoke an aggregation of care providers 48
technology as catalyser ?
• the (systemic) technologies aren’t the main driver of change, but just a factor or maybe a catalyser
• they offer in fact the opportunities to enable, amplify or support relevant organizational changes
• perhaps endorsed and made possible by new approaches to regulations
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order of magnitude of the cumulated effects
we could perhaps figure out the order of magnitude of the cumulated effects – when new regulations will be in place – how fast the organisational change
will take place – amount of the effect / impact
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obesity – the Bariatric Gallery [Arjo 2011]
CARL • Sits in wheelchair • Is able to partially bear weight
on at least one leg • Has some trunk stability • Dependent on carer in most
situations • Very physically demanding for carer • Stimulation of remaining abilities
is very important DORIS • Sits in wheelchair • No capacity to support herself • Cannot stand unsupported and
unable to bear weight, even partially
• Dependent on carer in most situations
• Extremely physically demanding for carer
• Stimulation of remaining abilities is very important
EMMA • Passive • Might be almost completely
bedridden • Often stiff, contracted joints • Totally dependent • Extremely physically demanding
for carer • Stimulation and activation
is not a primary goal 51