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Report EUR 25441 EN
2 0 1 3
Authors: Arjanna Van Der Plas, Marc Van Lieshout
Editors: Fabienne Abadie, Maria Lluch, Francisco Lupiañez Villanueva, Ioannis Maghiros, Elena Villalba Mora, Bernarda Zamora Talaya
Country Study: The Netherlands
Strategic Intelligence Monitor on Personal Health Systems,
Phase 2
European Commission
Joint Research Centre
Institute for Prospective Technological Studies
Contact information
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This publication is a Scientific and Policy Report by the Joint Research Centre of the European Commission.
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JRC71178
EUR 25441 EN
ISBN 978-92-79-25738-4 (pdf)
ISSN 1831-9424 (online)
doi:10.2791/88542
Luxembourg: Publications Office of the European Union, 2013
© European Union, 2013
Reproduction is authorised provided the source is acknowledged.
Printed in Spain
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Table of Contents
LIST OF ACRONYMS ......................................................................................................................................... 5
1 INTRODUCTION .......................................................................................................................................... 7
2 HEALTH SYSTEM CONTEXT .................................................................................................................... 9
2.1 Socio-demographic statistics ........................................................................................................................................... 9
2.2 Prevalence and hospitalisations ..................................................................................................................................... 9
2.3 Social and healthcare costs .............................................................................................................................................. 9
2.4 ICT context ............................................................................................................................................................................... 10
2.5 Disease management ....................................................................................................................................................... 16
3 AXIS 1: HEALTH IMPACT ASSESSMENT (HIA) ............................................................................... 21
3.1 Description of the case studies ................................................................................................................................... 21
3.2 Clinical and economic effects taken into account in the case studies.................................................. 27
3.3 Evaluation studies found in literature ..................................................................................................................... 28
4 AXIS 2 - DIFFUSION OF INNOVATION ............................................................................................. 31
4.1 Survey results diffusion of innovation .................................................................................................................... 32
4.2 Acceptance of the innovation ....................................................................................................................................... 33
5 AXIS 3 – GOVERNANCE ....................................................................................................................... 35
5.1 Health Insurance companies ......................................................................................................................................... 35
5.2 Survey results governance ............................................................................................................................................. 36
6 CONCLUSION ........................................................................................................................................... 39
7 REFERENCES ........................................................................................................................................... 41
ANNEX 1 – STATISTICS ................................................................................................................................ 43
ANNEX 2 – QUANTITATIVE DATA COLLECTION FOR HEALTH IMPACT ASSESSMENT .............. 49
ANNEX 3 – QUALITATIVE DATA COLLECTION - DIFFUSION OF INNOVATION AND
GOVERNANCE ...................................................................................................................................... 54
ANNEX 4 – SOCIETAL COSTS AND EFFECTS OF KOALA .................................................................... 59
ANNEX 5 – LIST OF INTERVIEWEES AND INTERVIEW SUMMARIES .............................................. 60
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List of figures
Figure 1 – Schematic overview of integrated payment in the Netherlands (cash flow, cooperation, control and care standards) .................................................................................................... 12
Figure 2 – The CardioConsult system. ..................................................................................................................................... 22 Figure 3 – Actual number of patients involved. Source: http://intouchtrial.nl/ ................................................. 23 Figure 4 – Health Buddy system. Source: www.sananet.nl ......................................................................................... 24 Figure 5 - The COPDdotCOM system. Source: http://www.copddotcom.nl .......................................................... 25 Figure 6 – Wagner's chronic care model, .............................................................................................................................. 32 Figure 7 – Age structure of the Dutch population ............................................................................................................ 43 Figure 8 – (Un)employment in the Netherlands 2005-2010 (source: CBS.nl) ................................................. 43 Figure 9 – Distribution of income, source: CBS.nl ............................................................................................................. 44 Figure 10 – Level of education of the laborious Dutch population in 2009 (15-65). Source:
CBS.nl ............................................................................................................................................................................... 44 Figure 11 – Prevalence chronic diseases (%), 2001/2008. Source: CBS.nl ........................................................ 45 Figure 12 – Average amount of hospitalizations per 10 000 persons from 1993 to 2008 (blue =
male, pink = female). Source: CBS.nl .............................................................................................................. 45 Figure 13 – Average amount of days per hospitalization from 1993 to 2008 (blue = male, pink
= female). Source: CBS.nl ...................................................................................................................................... 45 Figure 14 – Costs of healthcare compared within Europe in 2006. Source: Eurostat, WHO, OESO .... 47 List of Tables
Table 1 – International standards used in the Netherlands ....................................................................................... 13 Table 2 – ICT projects in healthcare found by Kok et al. (2010) ............................................................................. 28 Table 3 – Use of health care, contacts with care professionals (average amount per person),
2008. Source: CBS.nl ............................................................................................................................................... 46 Table 4 – Expenses and costs of healthcare (in €million). Source: CBS.nl ......................................................... 46 Table 5 – Average costs per hospital day per patient. Source: NVZ ...................................................................... 47 Table 6 – Economic effectiveness measured (folded) .................................................................................................. 49 Table 7 – Economic effectiveness measured (unfolded) ............................................................................................. 50 Table 8 – Clinical effectiveness measured (folded) ........................................................................................................ 52 Table 9 – Clinical effectiveness measured (unfolded) .................................................................................................. 52 Table 10 – Societal costs and effects of Koala, in euro's per patient. “PM” is the value of the
improvement in the quality of health or healthcare that is not quantified. ............................ 59 Table 11 – List of interviewees .................................................................................................................................................. 60 List of Boxes
Box 1 – Learning from the past: the case of Meavita ................................................................................................... 15 Box 2 – Setting up a strategic eHealth agenda ................................................................................................................. 18 Box 3 – In search for regional collaboration: the wavering emergence of telemedicine centres ......... 32 Box 4 – The involvement of the Ministry of Health in eHealthNU .......................................................................... 35 Box 5 – Menzis and eHealth ......................................................................................................................................................... 36 Box 6 – Convincing the insurer: a proactive approach ................................................................................................... 36
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LIST OF ACRONYMS
AAL Ambient Assistant Living
DM Disease Management
DTC Disease Treatment Combination
CVZ College voor zorgverzekeringen / Healthcare Insurance board
EPD Elektronisch Patientendossier / Electronic Patient Record
HIA Health Insurance Act
NVEH Nederlandse Vereniging voor eHealth / Dutch eHealth organisation
NZa Nederlandse Zorgautoriteit / Dutch Healthcare Authority
PHS Personal Health System
RCT Randomized Controlled Trial
RMT Remote Monitoring Technologies
SIMHS Strategic Intelligence Monitor on Personal Health Systems
TEHAF TElebegeleiden HArtFalen / TElecare HeAFailure
VWS Ministerie van Volksgezondheid, welzijn en sport / Ministry of Health, Wellbeing and Sports
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1. INTRODUCTION
This study is a follow-up of the 2009 Strategic Intelligence Monitor on Personal Health Systems (SIMPHS) of the JRC-IPTS.1 The European Commission, by means of JRC-IPTS, has commissioned a study to assess the state of the art in Integrated Personal Health Systems in a number of European countries. The study aims at updating existing knowledge in the profile of the countries related to the health care system, the demographic circumstances and the orientation towards Integrated Personal Health Systems (IPHS), and acquiring in-depth knowledge on specific case-studies within the respective countries. Through this in-depth knowledge the study contributes to building up a data repository which may help in assessing the potential of IPHS within Europe, identifying barriers, and building up strategic intelligence on IPHS.
To understand market and innovation dynamics in IPHS, a study has been performed to the situation regarding IPHS in the Netherlands. The study focuses on remote monitoring and treatment for chronic disease management and in particular on COPD and chronic heart failure. The Netherlands are seen as a front-runner in eHealth within Europe, and is therefore interesting to study.2
The study consists of literature research, interviews and three case studies. The results of the studies will be discussed based on three axes:
Health Impact Assessment; i.e. the cost-effectiveness of healthcare interventions (in this case IPHS);
Innovation; i.e. the stage of innovation of IPHS in the Netherlands (diffusion, dissemination, implementation or sustainability);
Governance; i.e. the governance structure or models that help or prevent healthcare innovation.
The three cases that are studied are:
COPDdotCOM; the design, development and demonstration of a system that supports self management of the patient and communication between the patient and the care professional;
TEHAF study - Health Buddy; a study of the clinical and economical effectiveness of the Health Buddy, an American IPHS that was adjusted to the Dutch context;
In Touch study; a study aimed at measuring the value of ICT guided disease management combined with telemonitoring for heart failure patients.
For information about the context of health innovation approaches and practices in the Netherlands interviews have been conducted with:
Hans Haveman (Department of Health)
Geja Langerveld (ZonMW, Care Research Netherlands Medical Sciences)
Harry Nienhuis (Menzis care insurance company)
Chris Flim (Flim P&C, NVEH (Dutch Organisation for eHealth))
1 This study can be found on http://ftp.jrc.es/EURdoc/JRC62159.pdf 2 Currie et al (2010) A Healthier Europe: applying the tempest model to twelve European countries, Warbick
Business School
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Definition of IPHS3
“For this purpose, SIMPHS phase 2 utilises a broader definition of Personal Health Systems (PHS) namely, Integrated Personal health Systems (IPHS):
“Integrated Personal Health/Care Services address the health and/or social care needs of individuals outside of care institutions and support the work of care providers in an integrated fashion: a) they can integrate assistance, remote monitoring of chronic diseases, wellness and fitness; b) they are produced as a result of integration of different institutional and information systems. They are personal and possibly personalised in the way they gather, process and communicate data (for feed-back/action) and in terms of technological components they can include all of the items illustrated under letters a) through c) of the PHS2020 definition of Personal Health System.
This definition is based on the original definition of PHS provided by the PHS2020 action which specifies:
“Personal Health Systems (PHS) assist in the provision of continuous, quality controlled and personalised health services to empowered individuals regardless of location. They consist of:
a) Ambient and/or body (wearable, portable or implantable) devices, which acquire, monitor and communicate physiological parameters and other health related context of an individual (e.g., vital body signs, biochemical markers, activity, emotional and social state, environment);
b) Intelligent processing of the acquired information and coupling of it with expert biomedical knowledge to derive important new insights about individual’s health status.
c) Active feedback based on such new insights, either from health professionals or directly from the devices to the individuals, assisting in diagnosis, treatment and rehabilitation as well as in disease" prevention and lifestyle management.”
So the SIMPHS phase 2 the extended definition of IPHS solves the problem of overlapping between remote monitoring and Telecare, or between more sophisticated PHS applications and Ambient Assisted Living and/or Independent Living.”
3 Definition of IPHS as provided by IPTS
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2. HEALTH SYSTEM CONTEXT
In this chapter, the context of the Dutch health system is outlined. Socio-demographic and health statistics are discussed in the text, and supporting figures can be found in Annex 2.4 Subsequently the ICT context and disease management in the Netherlands are described.
2.1 Socio-demographic statistics
The Netherlands has a population of 16.6 million (CBS, 2010). The age structure of the Dutch population (see Annex 2) reveals a relatively large group in their forties to sixties. This group will put additional pressure on the Dutch health care system, needing a relatively substantial number of people to look after them when they become aged.
The labour market is slowly recovering from the financial crisis. Unemployment is decreasing, while the amount of jobs and job offerings is increasing. The average income of Dutch households is €33,400. The average level of education of the Dutch population is increasing. Additionally, more and more people have at least a MBO level 2 or HAVO/VWO:5 from 61% in 1999 to 68% in 2009.
2.2 Prevalence and hospitalisations
An overview of the prevalence of chronic diseases in the Netherlands can be found in appendix 1. Migraine was the most common chronic disease in the Netherlands from 2001 to 2008. Over 12% of the population suffered from it. Almost 8% of the Dutch population suffered from COPD, 3,5% from diabetes and almost 2% experienced severe heart diseases.
A recent publication based on research in primary care shows that 37% of people aged 55 or older have two or more chronic diseases.6 70% of chronic patients older than 55 years have at least one other chronic disease. Heart failure is the disease with the highest rate of co-morbidity, namely 92%! Diabetes and COPD are common comorbidity disease in case of people with cancer (26% and 18% respectively). COPD and diabetes have a prevalence of 2.1%, COPD with heart failure 1.9% and diabetes with heart failure 2.2%.
The average number of hospitalisations is increasing, but the average duration of hospitalisation is decreasing. Whereas in 1993 the average number of hospitalisations per 10,000 persons was approximately 1,400, in 2008 this number had increased to almost 2150. Over the same period the average duration of a hospitalisation decreased from 10 days to 6 days.
The chronic diseases which are of interest for this study (Chronic Heart Failure, Diabetes and COPD) are confronted with steep increases over the coming years. CHF will experience an increase of prevalence with more than 45% up till 2025, while diabetes will double up to 1.2 million persons in 2025.7
2.3 Social and healthcare costs
On average, the Dutch contacted a general practitioner about four times in 2008, a specialist almost twice a year, a dentist more than twice a year and a physiotherapist about three times. Women contact care professionals 1.3 times more often than men.
The total amount of money spent on providers of care in the Netherlands increased from €70,532 million in 2006 to €79,091 million in 2008. 60% of this amount was spent on providers of healthcare in 2008 and 40% on social care. Care insurances financed most of the provided care (40%), government paid for 13%. The average costs per hospital day per patient are €1,200 per
4 Health data in the appendix are based on the CBS publication "Gezondheid en zorg in cijfers 2009”. This
publication provides rich data about health and healthcare in the Netherlands. 5 MBO2 level: advanced vocational training; HAVO/VWO-level: lyceum level or higher in secondary education 6 Sandra H. van Oostrom et al. (2011). Multimorbiditeit en co-morbiditeit in de Nederlandse bevolking –
gegevens van huisartsenpraktijken. Nederlands Tijdschrfit voor Geneeskunde 2011. 155; A3193. 7 See website of eHealthNU http://www.ehealthnu.nl/ehealthnu-plein
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diem. When comparing the Netherlands to Europe, the costs of healthcare in the Netherlands are relatively high, but still slightly lower than the average of the EU27 in 2006.
In this study, the focus is on chronic diseases. The treatment of these diseases is relatively expensive: in 2005 the costs of diabetes care were €814 million (1.2% of the total costs of healthcare in the Netherlands) and are expected to rise.
€2.4 billion (3.4% of the total costs of care) was spend on respiratory diseases.8 In the same year, €5.5 billion was spent on diseases in the cardiovascular system (8% of the total costs of healthcare).
A relatively recent study that compared costs of patients with a chronic disease showed that these costs are on average two and a half times as high as costs made for the treatment of other patients.9 Costs for chronic diseases are on average €5,200, with diabetes type II roughly on this average and diabetes type I and heart failure (combination of all forms) roughly at 7,500. COPD is not mentioned in this study as a separate category.
2.4 ICT context
ICT increasingly becomes a qualifier for health-related processes. In the Netherlands, attention has been focused on the realisation of an ICT backbone architecture that would allow for the collection, storage, dissemination and use of health-related data in order to improve the interaction between health care practitioners. The architecture for the so-called electronic patient record consisted of an overall scheme of regional data repositories which were connected by a so-called nation-wide switching system. A system of checks and balances should guarantee that data would only become available to those persons who had legitimate access to the data. All access related to the nation-wide switching system were logged in order to enable tracing of unauthorised access. Penalties on unauthorised access and use were prohibitively high: people could loose their job when access was illegitimately acquired.
Due to lack of confidence in the operational features of the system – culminating in mistrust in identity management and privacy issues – the Dutch Senate has just recently put the whole development of the architecture to a hold, after €217 million had been invested over a period of fourteen years. The organization that bears responsibility for the national grid, Nictiz, is requested to develop a migration strategy in which regional activities remain supported but nation-wide exchange is not longer an option.10
Next to these architectural developments the Dutch government has invested in health related ICT developments through subsidies and programmes. In an overview by the Dutch Accounting office, dated in 2009 (and already covered in the previous report) a number of initiatives are mentioned which bear direct relationship with telecare activities:11
1. Pilot projects in chronic care (not all ICT-related); period 2005-2013: €340 million. Of these financial means, part is dedicated to ICT-related care. It is not always possible to identify the precise contribution of ICT-related pilots and projects. The measures relate to innovation projects (testing novel concepts; the European Ambient Assisted Living is an important pillar for these projects with a yearly subsidy of €2 million; the programme funds 50% of eligible costs; some of the projects within the AAL programme have a clear link with PHS, many are related to well-being more than healthcare), implementation projects (rolling out novel concepts over larger communities; this programme had €11.3 million subsidy in the period
8 Poos MJJC, Smit JM, Groen J, Kommer GJ, Slobbe LCJ. Kosten van ziekten in Nederland 2005. RIVM-
rapport nr. 270751019. Bilthoven: RIVM,2008. 9 http://www.vektis.nl/index.php/nieuws/1-nieuws/262-zorgkosten-chronisch-zieken-vier-keer-zo-hoog-als-
van-mensen-zonder-chronische-ziekte- 10 http://headlines.nos.nl/forum.php/list_messages/23950; http://www.zorgimpact.nl/ter.pdf 11 Algemene rekenkamer (2009). Zorg op afstand. Een innovatie in de langdurige zorg. Tweede Kamer der
Staten-Generaal, vergaderjaar 2008-2009, 31967, nr. 1.
11
2006-2009; four out 66 implementation projects related to telecare), and transition projects (supporting transition processes in care; this programme supports more radical transitions which need to be realised in the Dutch healthcare system; it has a yearly budget of €13 million for projects; the projects are usually larger projects directed at realising organisational change and are less focused on pilots with ICT).
2. Screen to screen measure (ICT-related care directed at screen communication): to promote the use of telemonitoring in care and well-being a special measure has been released that subsidised the use of distant communication and consultation. The measure, initiated in 2005, has been prolonged into 2012. Use of the subsidy has however been modest. Figures over the first four years indicated that only ten care providers had made use of the measure at a modest €600,000 over those first four years.
One of the problems identified is the lack of insight in costs and benefits. As will be highlighted in this report, this situation is improving, though generic statistics are still lacking.
ICT budget
Just as it is very problematic to distil ICT budget from the innovation budget that is available, it is also very challenging to distil the ICT-budget within care processes. The main reason for this problem is that ICT is generally integrated in total heath care costs. Detailed statistics on care processes, as has been released by the Dutch Office of Statistics, do not highlight ICT-budgets for any separate part of the health care process. ICT-budgets are part of health care budgets, on every management level in care.
Figure 1 provides an overview of the integrated payment system in the Netherlands. The figures illustrate how the integrated nature of the system makes it difficult to find the costs of a specific healthcare aspect (in this case ICT): health insurers purchase integrated care from care groups by negating a fixed price per patient per year: the so-called chain-DTC, that combines costs of multiple professions. The care groups can deliver the requested care themselves, or sub-contract other providers, making the cash flows difficult to trace.
One study, which has been performed twice now, identifies the contribution of ICT in the overall care budget as indicated by the Dutch hospitals. Over the period 1996-2009 the contribution of ICT to the overall health care budget in hospitals has increased 300%, from 1.3% in 1996 to 3.9% in 2009.12 With this figure, care is still far behind other societal sectors, such as transport and logistics: 4%, government and education: 6% and financial services: 15%!), 60% of hospitals indicated that ICT budget was not isolated from other health care activities and that thus it was very problematic to identify the precise contribution of ICT.
The same series identified that the growth of ICT budget within hospitals is five times as high as the overall growth of health budget for hospitals.
12 http://www.zorginstellingen.nl/ict/algemene-ziekenhuizen-investeren-steeds-meer-in-ict-8535
12
Figure 1 – Schematic overview of integrated payment in the Netherlands (cash flow, cooperation,
control and care standards)
Source: Tsiachristas et al, 2010
Key ICT solutions used
Flim (2010) provides an overview of the standards in the Dutch eHealth environment.13 He describes the central role of Nictiz as the national expertise centre that facilitates ICT in healthcare. Nictiz is mandated by the Ministry of Health, but does not develop standards. Another important player is non-profit organization NEN (Normalisation and Standards Development) that recently set up a telemedicine standard. Furthermore, the Dutch Health Level 7 (HL7) foundation is focused on setting interoperability standards in order to improve the care sector.
13 Flim, C. (2010) , eHealth strategies country brief Netherlands:
http://www.ehealth-strategies.eu/database/documents/Netherlands_CountryBrief_eHStrategies.pdf
13
Table 1 provides an overview of international standards that are applied in the Netherlands.
Table 1 – International standards used in the Netherlands
HL7V2 mainly used in regional and local communications, not for the national infrastructure
HL7V3 used as a standard for the communication using the national infrastructure
Snomed CT
licensed by the Netherlands, and its importance in Dutch healthcare is growing
ICD9 Ninth version of the International Statistical Classification of Diseases and Related Health Problems as published by the World Health Organization in 1977, currently used in the Netherlands
ICD10 Internationally used list of diseases classified by the World Health Organization, is to be adopted in the Netherlands. Adoption process started in January 2011.
Integration among ICT solutions, and between them and core delivery processes;
As indicated, the Dutch approach in the introduction of ICT in care processes is a mixed one, in which the realisation of an ICT information architecture has been leading. Innovation processes, which relate to a variety of health care processes (such as telemonitoring) have been part and parcel of the use of this information architecture. As indicated before, some typical features can be discerned in the Dutch approach:
Barriers between health and well-being; pilots have been focused on issues such as Ambient Assisted Living which somehow should bridge both domains, but regulatory issues prevent an unconstrained implementation of solutions in both domains at once.
A focus on innovation solutions that can be mapped on the existing ICT information infrastructure without endangering ore compromising existing relations and approaches (between health care institutes, between health care professionals); only now one can notice that the transition which has been promoted for some time, seems to take off a bit (creation of eHealth.nu platform. change in cost structure – DTCs, higher awareness level, need to cope with emerging socio-demographic challenges); still, ICT solutions are very much fixed to a specific domain or disease, which is quite understandable given the structure and organisation of health but which prohibits a fast scaling up of existing solutions.
Important role by insurers who are risk averse and who will only adopt proven solutions.
Costs of ICT based RMT and Telecare services
No specific information on the costs of ICT based RMT and Telecare services could be found.
The ICT & Ageing European Study14 provides data on the use of telecare and telehealth in Europe. For the Netherlands, the study describes that telecare and telehealth are mainly provided in pilot and trial activities, and that the take-up of these services is estimated to be below 1% of the population aged 65+. As there is no central registration of telemonitoring and tele-consultation trials, exact figures about the number of people participating in telecare and telehealth trials and pilots are not provided in the ICT & Ageing study. However, the report does provide some indication of the scale of activity:
Measurement and transfer of cardiac rhythm disturbances: up to 750 patients per month (according to the main companies providing the service);
Measurement of blood pressure, weight etc.: max. 500 patients all over the country;
Tele-consultation, such tele-dermatology: up to 750–1000 patient cases per year.
14 European Commission (2010) ICT & Ageing European Study on Users, Markets and Technologies
14
The Dutch institute for healthcare and environment publishes a study in which it provides an overview on health related issues.15 When checking the last two editions on this study (‘Zorgbalans’) over the years 2008 and 2010 it shows that the 2008 edition provides a separate chapter on innovation but the 2010 edition does not! The 2008 edition provides very basic information on telecare pilots, indicating that it has identified more than 15 projects on telemedicine applications, serving over 7000 users. Information about costs of these pilots is lacking. The study observes that no central registration on these pilots is at hand, making it difficult to present a precise and reliable overview.
Key success drivers and barriers for ICT innovation in healthcare in the Netherlands
Key drivers that were identified in the interviews and in literature are16:
Ageing population ;
Rising health costs and need for cost effectiveness;
Scarcity of care professionals;
Focus of the government on eHealth;
Rising expectations concerning the quality and safety of health;
High IT/eHealth maturity level in the Netherlands;
The self management trend and the citizens’ increasing desire to live independent;
Innovative care professionals start with eHealth projects (bottom-up developments);
Innovative (SME) firms that offer their innovative eHealth solutions to the care sector.
PHS mostly provide the care professionals with parameterized information (i.e. information that is standardized according to a specific protocol), which fits with the EPD standards (electronic patient record) and makes it relatively easy to measure effects. However, although the data is interoperable it should be noted that technological interoperability issues are still a major challenge for integration between PHS and EPD.
However, substantially more barriers for ICT innovation in healthcare were identified in literature and the interviews.17
Governance
The transition from temporary to structural financing is often a problem. Innovations often stop when the project grant stops.
Provision and administration of public health programs (as % of current health expenditure) is low.
The care sector is supply driven rather than demand driven; there are hardly any incentives for innovation and diffusion for innovation.
15 RIVM, Zorgbalans Utrecht.RIVM, http://www.gezondheidszorgbalans.nl/english-editions/ 16 This list of drivers is based on the interviews and the following literature:
OECD e-Government Studies: Netherlands 2007, OECD Publishing Sprengers (M) (2009) National eHealthprogram in the Netherlands–policies and status, Nictiz Currie et al (2010) A Healthier Europe: applying the tempest model to twelve European countries, Warbick Business School.
17 This list of barriers is based on the interviews, the barriers mentioned on eHealth.nu, that is referred to by the interviewees and in literature and Currie et al (2010) A Healthier Europe: applying the tempest model to twelve European countries, Warbick Business School.
15
There is a lack of clinical and economic evidence for eHealth. This lack of evidence withholds insurance companies from reimbursing PHS and policy makers have difficulties formulating policy and regulations.
Additional to the former issue, when evidence is gathered it takes too long before it is available. Insufficient attention is paid to how the evidence is collected and what evidence is truly necessary for the insurance companies.
Legislations and regulations lag behind innovative developments. Rules and regulations are based on existing forms of care, and new forms of care have to be incorporated in the existing system. Quality criteria for new systems are often lacking.
The focus on cost efficiency in the care sector does not stimulate innovation. For example: if less staff is needed due to an innovation, the organization cannot use this staff to create extra profit.
The current technological developments in eHealth are too fragmented and hardly based on standards that can enable wider implementation. The responsibility for a broader dispersion lies with many different organizations, that each have their own interests, making the dispersion difficult and fragmented.
There is a lack of collaboration and communication between primary and secondary care and it is difficult yet very important to integrate medical and social care in the care sector. The interviewees for example speak highly of the benefits of involving general practitioners in PHS developments (e.g. in terms of e-consult), but find it difficult to collaborate with them as the general practitioners do not receive reimbursement for these kind of activities.
This is preventing optimal integration of different types of care in PHS and thus preventing optimal health systems;
The current diagnosis treatment combination requires that the first meeting with a patient should be face to face, and thus takes away an important pro of PHS, which could enable a first meeting through for example teleconference.
Box 1 – Learning from the past: the case of Meavita
In 2008, home care organization Meavita went bankrupt. The main cause of this was a large project, in which elderly received a communication system that allowed them to communicate with their caretakers. Meavita ordered a large amount of systems, without wondering whether their clients wanted them. Cancelling the boxes cost millions of euros.
In the interviews conducted for this project, Meavita is often mentioned as a typical example of technology push and lack of user-centeredness.
Source: www.zorgvisie.nl
Innovation dynamics
Starting with PHS often comes with high costs, especially when traditional care is still offered besides eHealth, which is often the case. As the business case for PHS is not clear yet, investing in PHS is considered to be risky.
The business models of the companies that develop PHS are not in line with the ‘business models’ of healthcare: whereas the companies want to earn money with data, the healthcare organisations focus on curing patients and need to access the data any time for that purpose.
Universities are not sufficiently involved in studying clinical and economic evidence.
16
Developed applications are often disease specific and do not fit with reality: patients often suffer from multiple chronic diseases (e.g. COPD and diabetes) and PHS could be more beneficial if the systems would be suited for multiple diseases.
Care professionals and patients often are involved too little and too late in the strategy for and design and implementation of PHS. Involving care professionals could increase acceptance and usability.
PHS is often not sufficiently personalized, and the same PHS is offered to a wide group of patients. Personalization of the system and its use (e.g. for a short period or long term) could improve its success.
There are some privacy issues in the relation between client and caretaker that are yet unsolved.
Knowledge and culture in care sector
The culture in the care sector can be characterized as traditional: medical specialists and nurses are often resistant to new (ICT) innovations and innovation is not seen as clinically or financially rewarding.
The information systems in hospitals are often very traditional and paper-focused. One of the interviewees describes how introducing PHS in a hospital caused resistance among care professionals, as it doubled their administration (on paper and digital).
Medical professionals are insufficiently aware of the possibilities of innovations in eHealth.
Their education is traditional, so that they are not sufficiently trained to work with ICT.
Medical education is disease specific organised.
Patients are insufficiently aware of the availability, possibilities and benefits of PHS.
There is a lack of technological standards and a multi-enterprise business model in the care sector in which all care providers (e.g. hospitals, GPs and pharmacies) are responsible for their own finance, medical policies, investments and IT, causing large interoperability problems.
Due to unknown liability regulations, care professionals are scared to use PHS.
Overall, although there are great technological challenges to be faced, the organisational changes that are required for ICT innovation are considered to be major barriers in the Netherlands. Organisational challenges such as institutional boundaries between health and home care as such are less tangible than technological challenges, yet in literature they are described as being extremely relevant to tackle and are mentioned by all interviewees. Organisational change relates to institutional change as this has been started in the Netherlands some years ago with a radical change of the healthcare system (see next section and IPTS country-study 2009 on the Netherlands). This change implied that market structures would be more acceptable for health care practices. Insurers got a more prominent role, health care provides should negotiate with insurers about care practices offered and about reimbursement. A major new introduction has been the Diagnose treatment combination (DTC) approach which combines diagnosis, treatment and payment structures, leading to organisational changes as well. While this has led to radical reforms in care with a large impact on organisational components, one should also observe that another boundary – between homecare and health care – has not been abolished yet.
2.5 Disease management
This paragraph consists of an update of the country study already performed by JRC-IPTS in the Netherlands.18 New and relevant (policy) activities are added. Overall, it can be concluded that a
18 In fact, the Dutch country study has been prepared by one of the authors of this study during his stay as
visiting scientist at the JRC-IPTS in 2008/2009,
17
shift in attitude towards eHealth is taking place. Care professionals, insurance companies and Dutch government are more strongly focused on PHS than two years ago. PHS is increasingly seen as a potential solution to the ageing of the population and the pressing decrease of care professionals. Whereas two years ago PHS seemed to be considered more an external opportunity impinging on medical practices by the aforementioned stakeholders, their motivation to develop a vision on PHS and to stimulate innovation seems to be more intrinsic today. According to one of the interviewees PHS processes in the Netherlands are implemented from a healthcare, care and wellbeing perspective, rather than from a technological point of view as is common in EU projects.
The main changes in the care sector are related to the fine-tuning of the DTC (Disease Treatment Combination) and the increased costs of healthcare. In 2006, an important change was introduced to the health care system, as a new Health Insurance Act (HIA) was introduced. The primary goal of the HIA was to introduce competition on various levels in the health care system. It created a regulated market of health care with competition initiated between insurers, clients and health care providers. The distinction between privately and publicly insured clients disappeared. All Dutch citizens were offered a basic package of insurance. Additional insurance packages (for dental care for instance) could be added. Insurers compete on prices of the basic package and quality of services of additional features. Other elements, such as ranking of hospitals on quality criteria19 and constructing hospitals as for-profit organisations, are steadily introduced. Insurance companies obtained a more central role in the health care system. The DTC became the instrument to decide about quality of care and about price. The DTCs are enforced by the NZa (Dutch Healthcare Authority). This position makes this organisation quite influential in terms of the adoption of PHS, as it offers a medium that enables a match with the requirements of the DTCs.
Tsiachristas et al. (2010) describe how the chain-DTC, an integrated payment system, aims to stimulate the development of a well-functioning integrated chronic care system. They emphasize that the implementation of disease management programs is rather complex. For example, care groups have a complex double-role, as they are both purchasers (in the chronic care sub-market) and suppliers (in the insurance market). This might increase bureaucracy within care groups, which is a barrier to the integration of care. Another risk they identify is that delays in the implementation phase of disease management programs might lead to reduced ambitions, for example ambitions for new self-management strategies and effective collaboration between care providers. Furthermore, Tsiachristas et al. warn for the risks in financing the registration of performance scores instead of the actual overall medical performance per se. Instead of providing better quality of care, care providers could focus on increasing the performance indicator scores. In other words: this attempt to rationalise health processes by focusing on certain indicator scores might lead to negligence of the holistic approach which is basic to approaching health. It remains to be seen how the implementation of the DTC will continue.
The ever increasing costs of healthcare demand new healthcare solutions. It is feared that traditional care models can no longer offer healthcare to all the patients in need in the future. ICT, and with that PHS, are seen as possible solutions in bringing healthcare costs down.
Currently, there is no consensus on how to proceed with disease management and the role of eHealth in it.20 There are many visions, but the lack of consensus holds back coherent strategic developments and successful leadership. However, initiatives such as eHealthNU and NVEH (the Dutch organization for eHealth) are working on a shared vision culminating in an eHealth agenda (eHealtNU, which will be discussed in more detail in the following sub paragraph).
Trends
Two trends are substantially influencing the developments of disease management and PHS. The first trend we identified is patient empowerment. Patients are central in their treatment, and bare a
19 For example on Kiesbeter.nl, zorg.independer.nl and Elsevier’s yearly hospital ranking 20 Interview with Geja Langerveld of ZonMW
18
greater responsibility for their own health than before. At the same time, care professionals should treat the patient more equally and should educate the patient in how to deal with his condition. PHS can support patients in living independent. They provide safety, as the patients are monitored and can contact care professionals easily when something is wrong. Furthermore, they can educate the patients about their diseases, increasing their independence even more.
Another trend is the convergence of prevention, cure, care and wellbeing. Health is seen as more than healthcare and medicine: a healthy person should be in a healthy mental state, and diseases should not just be cured, but preferably be prevented beforehand by living a healthy life. This requires a substantially different approach to healthcare, taking away responsibility (and income) from healthcare specialists and bringing responsibility to people who have to monitor their health while still being healthy. This trend translates to the portfolio of insurance companies who recently started reimbursing wellness and wellbeing - such as sports activities – alongside explicit healthcare treatments.
On the innovators’ side, precompetitive cooperation in eHealth is a relevant trend. Commercial parties noticed that the only way to make eHealth an integral part of disease management is to cooperate in defining a vision, setting standards, gathering evidence and allowing for interoperability. This trend most visibly shows in the formation of eHealthNU, the platform that is initiated by six market parties: Philips, Menzis, Achmea, Rabobank, KPN en TNO. As eHealthNU unites different stakeholders, they are expected to be a powerful source of innovation.
Box 2 – Setting up a strategic eHealth agenda
eHealthNU recently started with setting up a strategic eHealth agenda. The starting point of this agenda was a meeting on March 9, 2011 in Zeist, during which representatives of the care sector, insurance companies and innovative eHealth focused companies jointly set the starting point of the agenda.
The overall targets of eHealthNU are removing the barriers for eHealth services and creating optimal conditions for providing eHealth services on a large scale in order to support patients and elderly in managing their own care process, and support care professionals with providing more effective care. In order to reach those targets, eHealthNU regularly organizes meetings with relevant market parties, government and care professionals. Furthermore, eHealthNU conducts studies on eHealth in the Netherlands, such as the Chronic Heartfailure report and the Diabetes report.21
A concrete example of precompetitive cooperation within eHealthNU is the strategic eHealth agenda that is currently being developed in collaboration with NVEH, KNMG en NPCF.22
Integration Disease Management with Social Care and IPHS
In this study, little evidence for the integration of disease management with both social care and IPHS was found. For the integration of disease management and social care, institutional boundaries are experienced. In contrast to the UK, where primary care integrates both social care and healthcare, in the Netherlands these two domains are strictly separated, both in institutional terms (different regulatory framework and supervisory authorities) and in workplace features (different educational practices, different organisations, different reward and reimbursement systems).
Within PHS pilots, attempts are made to integrate social and healthcare despite the institutional boundaries. For example: in the Health Buddy study, when a patient reported mental discomfort, the caretakers would advise him to contact a psychologist or ask whether the patient had a home
21 Both reports can be ordered for free through [email protected] 22 More information can be found on www.ehealth.nu
19
caretaker that could assist him. Nevertheless, PHS pilots are often initiated by a hospital, causing the hospital’s medical protocols to be leading and leaving little room for social aspects.
Overall approach to and objectives of eHealth
The Netherlands is characterized by a market oriented care system. Care insurance companies compete on the insurance packages they offer, stimulated by the government. The department of health has a vision on eHealth, but the market is responsible for what is offered. The objectives of eHealth and with that for PHS are largely defined by the stakeholders (care professionals, insurance companies, developers of eHealth systems). The government is working from a middle-out approach (as is explained in more detail in chapter 5), stimulating innovation without guiding the actions. As indicated in the 2009 report, the shift of the Netherlands towards a more market oriented approach had its consequences for the playing field between government, market parties and health carers. This leads to a more complicated playing field in which top-down is not the dominant mode of action anymore. The objectives of eHealth are therefore still somewhat unclear, but the creation of a strategic implementation agenda for eHealth is expected to lead to clear objectives, defined from a shared vision.
Overall objectives that can be mentioned are:
Bringing down costs of healthcare;
Raising quality of healthcare;
Dealing with the decrease in care staff;
Stimulating collaboration and communication between primary care, secondary care and patients;
Increasing independency of patients.
Currently ActiZ, NZa, CVZ and the Ministry of VWS are discussing how telecare should become part of the regular funding within the NZa rules and regulations.23
23 See:
http://www.kcwz.nl/dossiers/zorg_en_technologie/bekostiging_zorg_op_afstand_na_2012_nog_niet_duidelijk
21
3. AXIS 1: HEALTH IMPACT ASSESSMENT (HIA)
Evaluation of PHS is complex24 and scarce, especially on a societal level (see for example Kok et al. (2010), Alpay et al. (2010) and the eHealthNu platform, who call for a more systematic approach to the evaluation of eHealth). If assessment of clinical and economic aspects of eHealth takes place, it often is local and incidental, as is also recognized by the interviewees. We did not identify long-term in-depth evaluations, probably due to the fact that most eHealth projects until now were pilots. A difficult issue for clinical evaluation is described by eHealth.nu: due to privacy regulations, it is difficult to monitor medical interventions (eHealth.nu (2010)). However, there are examples of care providers that structurally gather data to investigate the effects of specific interventions. This chapter is based on a more extensive study of three cases in which data of introduction of Personal Health Systems in specific disease settings have been gathered (or are being gathered). Within these cases, researchers focus on finding clinical and economic evidence for specific interventions. Although the results of the studies are not available yet, the interviewees were very willing to share the indicators they used in studying the PHS-cases. We also asked the researchers to being engaged in dialogue with JRC-IPTS in order to enable the gathering of systematic data by JRC-IPTS in due time. In all three cases researchers indicated their willingness maintaining contact and contributing to a European scale monitoring system that JRC-IPTS is intended to develop. In 0 we provide an overview of the indicators which are yet under study in the three cases as a starting point for future collaboration with the representatives from the three cases. Additionally, we provide the results of economic and clinical assessments that were available from other Dutch cases and that we found through desk research.
3.1 Description of the case studies
Three cases were selected for this study, based on geographical dispersion,25 fit with the definition of PHS that is used for this study, and whether clinical and/or economical effects are studied in the cases. Based on these criteria, the following three cases were selected:
24 The presentation “Telemedicine: a vital service for the multidisciplinary management of elderly patient
with chronic disease” of Simonetta Scalvini (2009) for example provides a striking example. 25 It should be noted however, that regional dimension not necessarily is a relevant indicator in the Dutch
context, the Netherlands being a relatively small country in which the region fulfils a different role than for instance in countries as Spain or Germany.
22
In Touch study – CardioConsult26
The In Touch study aims to measure the value of ICT guided disease management combined with telemonitoring for heart failure patients. The study is conducted in ten hospitals: Martini hospital, UMCG, MCL, Rijnland, CWZ, Haga, Diakhuis, Antonius, CZE and DZ. Initially, the aim was to compare disease management and telemedicine with conventional care. However, no hospitals wanted to be in the control group. Therefore, all patients received care with an ICT guided disease management system (CardioConsult, shown in Figure 2), as well as tailored information on life style changes, complying with the pharmacological and non pharmacological regimen, including symptom management. One group of patients received additional telemedicine devices (measuring weight, ECG, health monitor and blood pressure meter). Collected data are transferred automatically by the GPRS network into the disease management system CardioConsult. Based on what the telemedicine devices measure, the system provides the patient with interactive dialogues in order to obtain health state measurements from the patient to evaluate and assess the progress of the patient’s disease, to review and adjust therapy to optimal levels and to give the patient medical advice for administering treatment. The health professional is automatically informed via SMS or email when the data of the measurements are out of range and indicate that medical care is necessary.
Figure 2 – The CardioConsult system.
Source: Presentation Arjen de Vries (2010) The value of ICT guided disease management combined with telemonitoring in heart failure patients, International Congress on Telehealth and Telecare, March 1-3 2011
Outcomes of the study are clinical as well as economic indicators. The focus is on a composite end point (aggregated indicator which tries to capture a number of indicators in one final indicator) for death, readmission for heart failure, change in quality of life, death from any cause, treatment according to guidelines, optimal dosage of medication, number of visits to the heart failure clinic, HF knowledge and self-care behaviour and cost-benefit ratio.
Additional to this project, the Martini hospital in Groningen is offering telecare systems to pregnant diabetes patients.27
26 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1898 27 Contact person: René van Dijk,
http://www.martiniziekenhuis.nl/default.cfm?itemid=96&reffererString=Persberichten%20archief&pid=210&contentitemid=184
Region: Groningen
Duration: Sept 2009- Sept 2011
Focus: CHF
Aimed & current nr. of patients involved: 220/105
Recruitment: 12/2009-9/2011 or 1/2012
Experiment: 1/2010-6/2012
Analysis: 6/2012-12/2012
23
Figure 3 – Actual number of patients involved. Source: http://intouchtrial.nl/
TEHAF study - Health buddy28
The TEHAF study is aimed to measure the effects of a tailor made telemedicine application for CHF patients. The development of the system is based on former experience with the Health Buddy. One of the important lessons learned from the first studies was to personalize the system. Therefore four programs, differentiated based on symptoms, level of disease specific knowledge and behaviour, were designed for the current study. A randomised controlled trial is conducted in the same centres, i.e. Heerlen (Atrium Medical Centre), Maastricht (University Medical Centre) and Sittard (Orbis Medical and Care Concern). The patients were randomly divided over a group that receives the Health Buddy and a control group that receives usual care according to European guidelines.
The Health Buddy29 is a telemedicine device that provides the patients with a set of questions on a daily basis. The responses to the dialogues are sent through a protected server to the caretakers. Patients’ responses to the dialogues are transferred into risk profiles (low, medium or high) and
28 See : http://www.unimaas.nl/hcns/websiteVW/publications/Publication%20scans/Boyne.%20Telemonitoring%20in%20patients%20with%20heart%20failure,%20the%20TEHAF%20study.pdf 29http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7T-50GC63D-1&_user=603085&_coverDate=01%2F31%2F2011&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1636858346&_rerunOrigin=google&_acct=C000031079&_version=1&_urlVersion=0&_userid=603085&md5=50339f2b1e324b5eb6216bb6ac259278&searchtype=a
29 http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7T-50GC63D-1&_user=603085&_coverDate=01%2F31%2F2011&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1636858346&_rerunOrigin=google&_acct=C000031079&_version=1&_urlVersion=0&_userid=603085&md5=50339f2b1e324b5eb6216bb6ac259278&searchtype=a
Region: Limburg
Duration: Sept 2007 –
Dec 2010
Focus: CHF
Nr. of patients involved : 382
Recruitment: 15 months
Experiment: 12 months
Analysis: Ongoing (from January 2010)
Blue: Total inclusion
White: expected inclusion until April 2011 Development of inclusion
24
ordered according to risk level. Consequently, care providers are able to quickly select high-risk patients and anticipate to their problem. The involved care providers consist of specialized heart failure nurse specialists, a nurse assistant and a supervising cardiologist. The nurse specialists are educated in chronic heart failure at the level of an advanced medical student. The nurse assistant is a caregiver at a lower educational nursing level being instructed before and coached by a nurse specialist during the study.
Figure 4 – Health Buddy system. Source: www.sananet.nl
Outcomes of the study are clinical as well as economic indicators in terms of hospital admissions, quality of care and cost-effectiveness. Furthermore, therapy adherence, the level of disease specific knowledge and quality of life is studied.
COPDdotCOM30
COPDdotCOM is part of the program ICT and Disease Management of ZonMW. It is aimed to deal with two issues in the treatment of COPD patients, i.e. the lack of insight in the daily activities and with that the lack of insight in the impact of physical training on the patient’s health and wellbeing and the lack if inter-professional communication in chronic care settings. The study is initiated by Roessingh Research and Development. The study is conducted at the Medical Spectrum Twente hospital. The University of Twente is also involved in the study.
30 See : http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2440 for trial information 31 Results of the first nine patients are presented at
https://www.ersnetsecure.org/public/prg_congres.entree?ww_i_congres=121
Region: Twente
Duration: 2009 - Oct 2011
Focus: COPD
Nr. of patients involved: 32
Recruitment: 10/2010-4/2011
Experiment: 11/2010-5/2011
Analysis:5/2011-9/201131
25
Figure 5 - The COPDdotCOM system. Source: http://www.copddotcom.nl
Figure 5 provides an overview of the COPDdotCOM system. For the study, a demonstrator is
developed. Quantitative monitoring of the daily activity patterns and physical condition of the patient is an essential part of COPDdotCOM. The patient wears a sensor and a PDA, that measures his daily activity levels and compares it to the optimal activity level. Additionally, through a web based portal, the patient answers questions about his current condition, allowing for remotely supervised training and monitoring of the disease status.
Outcomes of the study are clinical indicators and usability aspects. A follow-up study, CoCo (condition coach) recently started and focuses on economical effects and setting up a business case in order to come to structural financing and moving from the pilot phase to structural implementation. Splitting up the research project in two phases, one focused on clinical outcomes (COPDdotCOM) and economic outcomes and setting up a business case (CoCo) is an explicit choice the researchers made, as they believe that the clinical effectiveness is most important, and economic effectiveness is only relevant if the system proves to be useful for patients and care professionals. Therefore, COPDdotCOM is conducted on a relatively small scale, and the CoCo project will be on a larger scale than COPDdotCOM, and has to be integrated in the hospital.
Within both CoCo and COPDdotCOM, implementation and effect study go hand in hand in an iterative process.
Current studies not subject to our case studies
For this study, three cases were selected. However, more eHealth-related studies are conducted in the Netherlands. Since there is no central database of eHealth studies, the list below is non-extensive and should be seen as an indication of the situation in the Netherlands.
26
AAL studies
(Partly) Dutch studies in the first AAL call (ICT-based solutions for prevention and management of chronic conditions)
A2E2: Adaptive Ambient Empowerment for the Elderly (VU Amsterdam)
CCE: Connected Care for Elderly persons suffering from dementia
HAPPY AGEING: a Home based APProach to the Years of AGEING
IS-ACTIVE: Inertial Sensing Systems for Advanced Chronic Condition Monitoring and Risk Prevention (Universiteit Twente)
ROSETTA: Guidance and Awareness Services for Indepent Living (TNO)
(Partly) Dutch studies in the second AAL call (ICT based solutions for advancement of social interaction)
ALICE: Advanced Lifestyle Improvement system & new Communication Experience
Co-LIVING: Virtual Collaborative Social Living Community for Elderly (Orbis)
CVN: Connected Vitality, the personal telepresence Network (Presence Displays)
E2C: Express to Connect
HOMEdotOLD: HOME services aDvancing the sOcial inTeractiOn of eLDerly people
TAO: Third Age Online Community & Collaboration
WeCare 2.0 (TNO)
V2Me: Virtual Coach reaches out “to me”
(Partly) Dutch studies in the third AAL call (ICT-based services for advancement of older persons’ independence and participation in the ‘self-serve’ society’
Yet unknown.32
Example: regional studies in the north
Many studies are conducted on a regional level. For the eHealth agenda 2010-2015 for the northern part of the Netherlands, Flim et al. summarized the eHealth projects that were running in the area in 2010:33
Survivalkid.nl en SurvivalkidXL.nl. by GGZ Drenthe
Dementia and telecommunication by Gemeente Aa en Hunze
Telecare Masterprogramme by Stichting Koala
Healthy Ageing through serious games by NHL hogeschool,
Care group Noorderbreedte by Oosterlengte
Patient portal by Universitair Medisch Centrum Groningen
Screen watch by alant
32
http://www.aal-europe.eu/calls/aal-call-3-2010 33
Flim, C. Kalverboer, K. and Holterman, S. (2010) eHealth agenda Noord-Nederland 2010-2015, Groningen: Zorginnovatie forum
27
Demand driven innovation by Talant
Mammapoli at home by Wilhelmina Ziekenhuis Assen
Webdoctor by Huisartsen Zorgcentrum Leeuwarden
HemoBase by Stichting Hematologie Friesland
Tele/videoconsult for depressed patients by Lentis/Dignis
Medalert by GGZ Friesland
Electronic Care-life plan by Zorggroep Noorderbreedte
Digital elastoplast protects patients by Ommelander Ziekenhuis Groep
Videoconferencing/Teleconsultation by Ziekenhuizen Friesland
Talking about health by DIPEx, UMCG and patient organisations
Serious Game Laparoscopy by Grendel Games, UMCG, LIMIS
3.2 Clinical and economic effects taken into account in the case studies
The results of the three projects that were subject to our case studies are not available yet. However, an overview of all the effects that are measured in the cases can be found in 0.
Economic effects that are measured within the three cases
For the In Touch study, the economic effects that were taken into account mainly focus on the changes in use of health care resources (e.g. hospitalizations and use of primary and tertiary care) due to the application of CardioConsult. Furthermore, investments in equipment and use of staff are measured. Although formally analysing the business case is not part of the study, it does provide insight in how the business case could be. For example, if PHS enables discharging a patient a day earlier, 600-700 euro’s are saved. Furthermore, hospitals are penalised when a patient comes back within 28 days after first treatment, since the first DTC still serves then and no additional funding is available. Lastly, telecare could decrease the time for finding the optimal medicine combination.
Another interesting economic effect mentioned in the interviews is the re-orientation of task differentiation and specialisation between medical and paramedical personnel. As (relatively cheap) paramedical staff can work with PHS, medical staff can focus on other tasks for which medical specialism is necessary.
For the TEHAF study, similar aspects as for In Touch were taken into account. Additionally, equipment and maintenance cost and time investment of patients and care professionals are included in the TEHAF study.
For the COPDdotCOM study, no economic effects are taken into account. The follow up study (CoCo) that recently started will focus on economic aspects.
Clinical effects that are measured within the three cases
For the In Touch study, the effects on mortality, physical and mental health, quality of life, behavioural outcomes and utilization of health services are included in the study. Additionally, a substantial list of CHF specific checks are included, as can be found in 0.
For the TEHAF study, clinical effects that are included are effects on mortality, physical and mental health, quality of life and utilization of health services. Furthermore, a list of CHF specific checks are included in the study, i.e. the heart failure self efficacy scale and the Kansas city cardiomyopathy questionnaire.
28
In the interview, increasing disease specific knowledge of the patients (especially for those that only recently started to experience heart failure) was mentioned as an important effect: the Health Buddy taught them how to deal with their disease and thus led to patient empowerment.
For the COPDdotCOM study, the effects on mortality, physical and mental health, quality of life and behavioural outcomes are studied. The utilization of health services will be studied in detail in the follow-up study. The patients fill out the COPD questionnaire of health related quality of life, and the number of (re)hospitalisations and emergency department, primary clinic and specialist visits are registered.
Transferability and methods for data collection
All studies are conducted through a randomized controlled trial. All personal health systems are also tried for other patient groups (i.e. the Health Buddy is used for diabetes patients).
3.3 Evaluation studies found in literature
Desk study provided us with a couple of recent evaluation studies that are summarized below. It should be noted that there are still not many Dutch studies available that provide insight in clinical and/or economical effects of personal health systems.
Kok et al. (2010) studied the effects of investments in ICT in healthcare. Through desk research and interviews they identified 195 projects in the Netherlands in healthcare in which ICT plays a key role (Table 2) and found that most of these projects were aimed at communication outside of the care institutions (between care providers or between patients and care providers).34
Table 2 – ICT projects in healthcare found by Kok et al. (2010)
ICT supporting the care process 34
ICT within care institutions 4
ICT supporting communication between care institutions 95
ICT supporting communication with patients 106
ICT focused on the market 13
Kok et al. conclude that there are hardly any studies on the clinical or economic effect of these projects and consequently illustrate their report with international effect studies rather than Dutch studies. Although projects in the Netherlands often are evaluated when they end, the effects of ICT applications are hardly measured. They especially identify a lack of effect studies that include a control group. The fact that the case studies that we conducted for SIMPHS 2 do include a control group shows that the care sector also noted that this was a necessary next step in the innovation process.
Kok et al. conducted an in-depth study of four cases,35 of which only the Koala study is relevant for SIMPHS 2. The Koala project was launched in 2006 by KPN, Menzis and Sensire/Thuiszorg Groningen. The Koala system provides patients with a 24/7 service to contact nurses in a medical service centre through their television. Koala was aimed to provide more effective care, without losing quality. The economic effects of service were compared to a situation in which the patients did not have the Koala system. For COPD patients, the effects could not be measured, since they used Koala as an extra, not as a substitute. The effects for the CHF and diabetes patients are
34 Note that the 195 projects are not defined in the report of Kok et al. 35 The implementation of an electronic information transfer system (IZIT zorginnovatie), telecare for elderly
and chronically ill (Koala), internet treatment for alcoholics (Toegankelijke Internetbehandeling) and the care auction (Beste zorg beloond). Of these projects only Koala deals with telecare as is of interest for this study.
29
shown in Table 10 in Appendix 4. As can be seen, the total of the societal costs and benefits of Koala is negative: €18,800 per patient for the project. The quality of health of the patient and the quality of healthcare with Koala were similar to the quality level experienced with conventional treatment according to the researchers. The clinical and economic effects of Koala could become positive if the Koala system would be implemented in a substantially larger group of CHF patients, because in their case Koala could prevent hospitalization.
The expert group CHF of eHealthNu mapped the eHealth innovations for CHF patients. They mention Hartmotief, a pilot study in which CHF patients were provided with telemonitoring devices (Motiva). The study showed that patients that used the telemonitoring device knew more about their disease. However, in terms of days of hospitalisation, no difference could be found between the control group and the intervention group. Cleland et al. (2005) compared home telemonitoring with Motiva with nurse telephone support and usual care for high risk patients with heart failure in a RCT in the Netherlands, Germany and the United Kingdom. The number of admissions and mortality turned out to be similar for patients assigned to nurse telephone support or telemonitoring. However, the patients that received usual care had higher one-year mortality than the other two groups. Similar effects were found by Balk et al (2008).
It should be noted that a medical service centre was involved in Hartmotief as well as in Koala, which lead to more work for the care professionals and made the communication more complex. This, together with the time it took to install the telemonitoring devices, discouraged the care professionals. Furthermore, the systems were not interoperable with the electronic patient record, causing even more work for the care professionals. From a patients’ perspective, however, patients showed a great acceptance and use of the Motiva system, even though they were elderly and therefore less familiar to modern technology.
31
4. AXIS 2 - DIFFUSION OF INNOVATION
To describe in which stage of innovation the organisations that were studied in the case studies can be found, we distinguish among four stages of innovation: diffusion (passive spread), dissemination (active and planned efforts to persuade target groups to adopt an innovation), implementation (active and planned efforts to mainstream an innovation within an organization), and sustainability
(making an innovation routine until it reaches obsolescence).
For the Netherlands, the PHS innovation is in the dissemination stage. Market parties, such as care insurance companies and eHealth focused SMEs, the government and the care sector are collaborating on a national strategic eHealth agenda, but the innovation is most visible on a local level. In the regions that were studied local hospitals (Limburg, Groningen), research institutes (Twente) and companies (Limburg, Groningen) started up innovative initiatives. Although these initiatives often started as pilot studies, the stakeholders that are involved in the initiatives aim for broader implementation, albeit first in regional setting, and only then potentially later on a national level. They are working on clinical and economic evidence and a business model, improve the user friendliness of the system and look for structural financing of the systems. Within these processes, involving all stakeholders that are relevant for making the innovation work is explicitly mentioned as a vital success factor by the interviewees.
In Groningen as well as in Limburg, a commercial party (resp. Cavari and Sananet) are the suppliers of the personal health system (resp. CardioConsult and Health Buddy). These parties naturally focus on the commercial aspects (i.e. the business case) of the telemedicine application. In Twente, the personal health system (COPDdotCOM) is developed by a research institute (RRD) and therefore, the business case is not yet the focus of the study.
During the interviews with the stakeholders in Twente as well as in Limburg, several of the interviewees emphasize that there is a specific order in terms of the aspects that need to be taken into account when working on an innovation, as it is not possible to address all issues at once. One of the interviewees refers to Wagner’s chronic care model (Figure 6) that shows what elements need to be taken into account in health innovations. He describes that for the Health Buddy, the focus is mainly on patient and societal aspects, and the system is not yet an organic part of the health care process. Although this is seen as an important step for the implementation of the Health Buddy, now is not the time to address this yet.
32
Figure 6 – Wagner's chronic care model,
Source: derived from http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
Moreover, the interviewees describe the challenging quest to implement personal health systems in care guidelines in order to sustain their application in the healthcare system. Currently, these aspects are more and more in the centre of attention (e.g. in the national strategic eHealth agenda), showing that the Netherlands is taking the first cautious steps towards implementation.
In making the step from dissemination to implementation, the care insurance companies play a vital role. They have to be fully committed to eHealth, as they are the ones that have to make personal health systems part of their reimbursement programs and with that enable care professionals to make personal health systems part of regular healthcare and patients to ask for personal health systems.
Box 3 – In search for regional collaboration: the wavering emergence of telemedicine centres
An acute issue for eHealth in the Dutch healthcare system is the barrier between primary and secondary care. Innovative care professionals have been trying for years to overcome this barrier. A new trend in this light is the wavering emergence of plans for telemedicine centres. For example, the people that are involved in the TEHAF study are planning to start a telemedicine centre. Sananet, the supplier of the Health Buddy, is the main driver, though the care institutions are sponsors of the plan, as they find that they can use their experience with implementing eHealth for a broader community and decrease the costs per individual patient.
4.1 Survey results diffusion of innovation
The survey that was filled out by the representatives of the three cases (Annex 5) incorporated a couple of questions about the diffusion of the innovation.
For the In Touch study, the innovation process is evaluated as very positive. The innovation has a great relative advantage that is compatible with the needs of care professionals and patients. Care professionals and patients participated in the design of the innovation, and the innovation is not too complex for them to assimilate. The adoption process was relatively easy, as patients, care professionals were well aware of the innovation and carefully educated. The innovation is seen as sustainable. Opinion leaders are important and champions within the organization were identified. The influence of adopters outside the organization was not considered and formal dissemination did not take place. The organizational context for innovation was positive, meaning that the
Informed active patients Prepared proactive practice team
Community Health
systems Resources and policies
Self management
support
Organization of health care
Delivery
system
design
Decision
support
Clinical
information
systems
Improved outcomes
Productive
interactions
33
organization facilitated the innovation and that ICT is seen as a means for to tackle the challenges of health systems.
For TEHAF, the innovation is perceived as positive, holding great relative advantages and fitting quite well with the motivation and intellectual abilities of patients and health professionals. However, in terms of values, goals and specific skills, patients and health professionals are not fully ready to use the innovation. Health professionals did participate in the design of the innovation, patients did not.
Concerning the adoption process, health professionals and patients were part of the adoption decision process, but did not play a large role. Similarly, the health professionals and patients were quite aware of the innovation and had sufficient information about the innovation and its effect. Support and training were offered to health professionals as well as patients. The innovation is seen as very sustainable, the organization is aware of it and evaluation is taking place. Extensive and planned communication to the heterogeneous stakeholders is taking place. Within the organization, innovation is facilitated, although the score for change orientation is just above average. ICT is seen as a major means to tackle challenges of health systems, and the innovation fits with existing organizational values.
For COPDdotCOM the innovation itself is perceived as very positive: it fits with the context, and is not too complex. Care professionals as well as patients were involved in the design. However, the innovation is not yet fully embedded in the work routines of the professionals.
The adoption process is evaluated quite positively, with strong support for patients and care professionals, but a relatively low awareness of the intended adopters (patients) concerning the innovation’s existence and its advantages for the patients. The innovation is seen as very sustainable and the organization is aware of the innovation. Communication among the actors involved in the adoption of the innovation is considered important, though opinion leaders are not strongly influenced. It should be noted that the system antecedents for innovation are not evaluated very positive: the organizational structure is not facilitating the innovation process and the organization is not very change oriented. ICT is seen as a means to tackle challenges of health systems, but the innovation clashes with the existing values, strategies and goals.
4.2 Acceptance of the innovation
An important aspect in the innovation process is the acceptance of the innovation by relevant stakeholders on an individual as well as on an organizational level.
In the interviews that were conducted for this research, the interviewees unanimously describe a high acceptance among patients and care professionals. Interestingly, some of them describe how care professionals initially were somewhat hesitating, but that working with the respective personal health systems convinced them of their usability. Initially, they were afraid of loosing personal contact with patients when they have less face to face meetings. And in the perspective of an ever changing world, some of the care professionals were afraid their job will change substantially due to the increase of ICT in their work environment. Nevertheless, the experience with working with personal health systems in the end is positive, as the care professionals receive much more data about the patient and are able to make better diagnoses. Moreover, some of the care professionals report that they have a more personal relationship with the patient, as they talk to them on the phone on a very personal level, as was explained by one of the caretakers in Groningen. Vital in the acceptance of personal health systems is that the system should work properly at all times: care professionals feel very responsible for their patients, and have to be able to trust the technology. According to the interviewees, an important factor in the acceptance is the involvement of care professionals (and patients) in the design process of an eHealth innovation.
It should be noted that the positive attitude of the care professionals involved in these projects is not expected to be representative for the attitude of all care professionals. Innovative projects are often adopted by innovation minded people, and in the interviews the care sector was often described as a conservative sector.
34
From a patients' perspective, user-friendliness is vital for the acceptance. In line with the patient empowerment trend, patients want to live independent of doctors and a personal health system that can help them with that is often warmly welcomed. The interviewees reported that as long as the systems are easy to use, and patients are well instructed to work with them, the acceptance is high. This was even the case for the COPD patients in COPDdotCOM, that are relatively low educated and less used to ICT than other patient groups.36 Although the interviewees report that the COPDdotCOM participants were on average positive about the system, there is an interesting contradiction in how the interviewees perceived using the system: one interviewee states that the patients did not mind wearing the PHS, while another mentions that some patients complained about carrying the sensor and PDA all day, as it was discomforting for them.
Although privacy is often mentioned as an issue in the context of PHS innovation, the interviewees report that the patients value safety and independence over the decrease of privacy.
36 COPD patients are not used to work with computer, but it is expected that the patients in the COPDdotCOM
were more computer-minded than average COPD patients.
35
5. AXIS 3 – GOVERNANCE
Based on the interviews that were conducted for this study, the governance in the Netherlands can be characterized as following a middle-out approach, where historically it used to follow a top-down approach. The interviewees depict the attitude of the Dutch government towards eHealth as supportive and market oriented. The Ministry of Health aims to stimulate innovation and wants to create optimal conditions for market parties to offer high quality care at low costs. It does not impose an eHealth vision, but instead tries to stimulate market parties to cooperate (e.g. through funding) and come to agreements on a regional, national and European level. The Ministry sees regional platforms as key players in the provision of care, and the national eHealthNu platform, in which the Ministry takes part, tries to take away barriers that are experienced by the market parties. Furthermore, the Ministry tries to facilitate standardisation and interoperability, and subsidises new approaches. An example of the role of the government in the development of the innovation is the electronic patient record, for which the Ministry was responsible for setting technological standards.
However, some interviewees state that they would prefer the government to have a stronger eHealth vision and provide more (technological) standards and regulations that enable eHealth. Interoperability is seen as a major challenge. Similar to the situation in the United States, PHS providers try to interconnect their systems to existing health information exchange systems, or aim to do so in a later stage. This leads to a fragmented innovation landscape. Some of the interviewees state that the government should commission interoperability standards. It was also mentioned that having a national approach is very difficult, that the government could stimulate innovation by providing guidelines for regional development.
Furthermore, it was suggested that the government should stimulate hospitals to modernize, and sanction old fashioned hospitals.
Box 4 – The involvement of the Ministry of Health in eHealthNU
On June 14 2011, the Minister of Health, Welfare and Sport will meet with eHealthNU to discuss the national implementation agenda for eHealth, that is aimed to make eHealth an integral part of the Dutch care system.
The Minister stated earlier that she aims to increase cost effectiveness in healthcare. Furthermore she thinks that if telemonitoring becomes part of the basic insurance, it should replace conventional care.
Other aspects that will be discussed in June are the reimbursement of telemonitoring for diabetes and CHF through the basic insurance, and the quest for economic and clinical evidence for telemonitoring.
5.1 Health Insurance companies
Health insurance companies play a vital role in the implementation of personal health systems, as they decide whether the systems are reimbursed. The interviewees often characterise health insurance companies as hesitant towards health innovations such as personal health systems. The insurers do sometimes participate in eHealth pilots, but usually shrank from investing in such projects. They require strong economical evidence before they are willing to reimburse personal health systems, and currently the mindset among insurance companies is that the current pilots are too slow with gathering clinical and economical evidence, and do not fully take the business case into account. A concrete example of a business case aspect that could be taken into account in pilot studies is provided by one of the interviewees, who emphasizes the importance of scalability in terms of removing the PHS from a patient’s home when the patient does not need it anymore, so that the insurance company only has to reimburse what is truly necessary. Similarly, setting up distinct programmes for patients that need the system for a short or a long period could decrease the price insurance companies have to pay. Nevertheless, the large insurance companies, such as
36
Menzis, are actively participating in the eHealth debate and are taking part in the eHealthNU platform.
Box 5 – Menzis and eHealth
During his presentation at the eHealthNu conference of March 9 2011, Mr Nienhuis stated the ambition to make eHealth services for diabetes and CHF available nationwide in 2012. This is a quite strong statement, as currently there is no proof that this is possible and insurance companies do not offer any personal health systems to their clients. Mr Nienhuis explains that by making such a statement, the health insurers want to encourage the market parties to make these systems available nationwide
A risk that is identified by multiple interviewees is that insurers will be afraid to choose between eHealth and conventional care, and will therefore make unnecessary costs by reimbursing both, so that both systems will be kept intact. A solution that is raised in the interviews is to sanction offering conventional care, or to differentiate between care providers that offer either conventional care or eHealth.
However, as one of the interviewees states, as the costs of chronic diseases rise, and competition between insurance companies increases, the insurers might become more open towards reimbursing PHS.
Box 6 – Convincing the insurer: a proactive approach
The hesitant attitude of insurers was also noticed by the management of the Martini hospital, that decided to act proactively: Insurers were offered a guarantee that the hospital would bear the risk in case telecare proves to be more cost intensive than regular practices, especially regarding recidivist behaviour of patients. When the clinical pathway of the approach through the heart failure centre would be more cost intensive than the regular practice, the Martini hospital would bear the additional costs. The hospital considers telecare to offer a better quality of care to the patient, in a more cost effective manner. It wants to show these benefits to insurers.
Hospitals
Most of the interviewees, although not all of them, think that hospital management on average is open to personal health systems , as they are aware that it can offer a solution to the problems with the ageing of the population and the growing lack of care staff. However, hospitals are not considered to be innovative organizations, in which ICT innovation naturally finds its way. The Martini Hospital is a positive exception, as it has an ICT strategy and has a long tradition in working with ICT.
Innovation-mindedness on a lower management level can be of vital importance for eHealth innovations. For example, in the interviews with the representatives of the TEHAF study, the enthusiasm of the department manager was marked as an important success factor for the implementation of the Health Buddy.
However, multiple interviewees said that not only the management of the hospitals have to be convinced of PHS to make it a success. A positive attitude of care professionals is also seen as vital. One of the interviewees therefore proposes to provide incentives to them to stimulate the adoption of PHS.
5.2 Survey results governance
The survey that was filled out by the representatives of the three cases (Annex 5) incorporated a couple of questions about governance.
For the In Touch study, the survey results show that the organizational structure in terms of decision processes was a stimulating factor for the innovation. Both top and middle management were involved in the innovation process. Intra- and inter-organizational networks facilitated the
37
implementation process. Political directives pushed the innovation process. Funding is seen as very relevant for the implementation.
For TEHAF, the organizational structure in terms of decision processes was a stimulating factor for the innovation. Both top and middle management are involved in the implementation and routinization. Funding and political directives are considered to be extremely important for the innovation process. Intra- and inter-organizational networks facilitated the implementation process.
For COPDdotCOM, the organizational structure related to decision processes and intra-organizational communication did not play an important role in the implementation of the innovation according to the interviewees. Nevertheless, both top and middle management were involved in the process. Political directives did push the innovation process (7 out of 10). Informal inter-organizational networks were included, but hardly facilitated the implementation (5 out of 10). Funding is seen as very relevant for the implementation.
39
6. CONCLUSION
The ageing population, the rising healthcare costs, the need for cost effectiveness and the growing scarcity of care professionals in the Netherlands require new healthcare concepts. PHS is one of the means that can offer solutions to the current problems and PHS project are popping up like daisies in this innovation minded country.
Currently, the main question is how to come from a multitude of pilots to a structural nationwide implementation of interoperable eHealth solutions. The Dutch government aims to stimulate eHealth innovation and its implementation, but does not take a leading role. Other parties, such as eHealthNu and NVEH (the Dutch organisation for eHealth) are taking a leading position in boosting the eHealth developments, among other things by setting up a national eHealth agenda in cooperation with the government, large insurance companies and care professionals.
This increased attention for alternative approaches to today’s healthcare practices is part of the radical transformation of Dutch healthcare system, started in 2006 with a market orientation of health care. This market orientation implies that insurers are key in agreeing on health care arrangements with health care practitioners. Part of these negotiations are done in the form of setting up Diagnose treatment combinations which form the kernel of disease management practices in the Netherlands, based upon protocols for treatment and reimbursement. These DTCs form part of an innovative stimulus for introducing PHS in health care practices.
Notwithstanding this support for PHS, PHS still is not common practice in the Netherlands, and the border between pilot and accepted health practice still has not been crossed. In contrast to the situation two years ago, one can notice that awareness for the role of PHS in changing health care practices in order to cope with future challenges has clearly increased. Many organisations pay attention to the opportunities offered by PHS. Projects have matured up to the level that evaluation and provision of clinical evidence have become more common practice than two years ago. This creates an evidence base, which should convince insurers that PHS is the better option. Given that this evidence is not available yet, insurers are reluctant in adopting PHS as the health care practice which is both cost efficient and increases quality of care and well-being. Resistance by medical professionals is diminishing with pilots showing good results but wide spread adoption still is a far cry.
The three pilots studied show the overall positive results that can be realised by adopting PHS as part of regular medical practice. They also show the relevance of organisational change and organisational implementation of new practices with severe consequences for tasks,. roles and responsibilities under medial professionals.
Notwithstanding these positive signs, which are indeed more positive than a similar study of two years ago was able to demonstrate, severe hindrances still need to be overcome for real widespread introduction and adoption. One of these is the primary mono-disease orientation of medical professionals and of DTCs. Medical professionals are trained in a mono-disciplinary mode and require excellence in a specific disease domain, which leads to less awareness for and medical experience with co-morbidity patterns and treatment. Integrated DTCs which combine specific diseases are still rare. This will have to be changed given the very high degree of co-morbidity especially in chronic diseases. The other major barrier is the rigid division between health care practices and home care practices. This is typical for the Dutch situation (though other countries show similar divisions) and has severe consequences for the widespread introduction and adoption of PHS. Again, this is an organisational and socio-cultural barrier rather than a technological one, and one which does not show easy solutions yet.
Another element which is still lacking in the Dutch situation and which has not really improved over the past two years is the lack of a centralised registration system that maps PHS pilots on a number of variables and that enables pursuit of PHS in the Dutch healthcare system. One main reason for this lack of attention is the fact that the Dutch health care system is hardly interested in specific ICT-related developments and approaches healthcare from a health care perspective rather
40
than from a technological innovation perspective. Dutch healthcare related ICT has had a strong focus on the realisation of an ICT architecture that enabled the provision of electronic patient records. PHS pilots were part of innovation programmes of various organisations that either were innovation oriented (such as the Brainport initiative in the southern part of the Netherlands) and were usually more oriented to home care than to healthcare, or were part of healthcare oriented programmes in which ICT was only of secondary interest (such as the Ambient Assisted Living programme).
The realisation of eHealthNU, a Dutch platform that tries to put together market parties and healthcare organisations in order to speed up innovation of Dutch health care practices and that has a focus on chronic diseases is a sign that the continuous provision of clinical evidence on PHS-pilots, and the on-going restructuring of the Dutch healthcare system in order to create a cost efficient and high quality healthcare system chances for widespread introduction of PHS are still clearly present.
41
7. REFERENCES
Algemene rekenkamer (2009). Zorg op afstand. Een innovatie in de langdurige zorg. Tweede Kamer der Staten-Generaal, vergaderjaar 2008-2009, 31967, nr. 1.
Alpay, L., Henkemans O., Otten W., Rövekamp T., Dumay, A. (2010). E-health applications and
services for patient empowerment: directions for best practices in The Netherlands. Journal of Telemedicine and Telecare 16(7):787-791.
Balk, A.H., Davidse W., Dommelen P., Klaassen E., Caliskan K, van der BP, et al. (2008). Teleguidance of chronic heart failure patients enhances knowledge about the disease. A multi-centre, randomised controlled study. European Journal Heart Failure.
CBS (2009). Gezondheid en zorg in cijfers, Den Haag: CBS.
Currie, W. & Finnigan, D. (2010). A Healthier Europe: applying The TEMPEST Model to twelve EU countries, Coventry: Warwick Business School.
eHealthNu (2010). Inventarisatie diabeteszorg, www.ehealth.nu
eHealthNu (2010). Inventarisatie Expertgroep Hartfalen, www.ehealth.nu
Flim, C. Kalverboer, K. and Holterman, S. (2010). eHealth agenda Noord-Nederland 2010-2015, Groningen: Zorginnovatie forum.
Kok, L., Tempelman, C., van der Werff, S., Koopmans, C. (2010). ICT in zorg en onderwijs. Amsterdam: SEO Economisch Onderzoek.
Nijland, N. (2011). Grounding eHealth: towards a holistic framework for sustainable eHealth
technologies. Enschede: University of Twente.
OECD (2007). e-Government Studies: Netherlands 2007, OECD Publishing.
Oostrom Sandra H. van, et al. (2011). Multimorbiditeit en co-morbiditeit in de Nederlandse
bevolking – gegevens van huisartsenpraktijken. Nederlands Tijdschrfit voor Geneeskunde 2011. 155; A3193.
Poos MJJC, Smit JM, Groen J, Kommer GJ, Slobbe LCJ. (2005). Kosten van ziekten in Nederland. RIVM-rapport nr. 270751019. Bilthoven: RIVM, 2008.
Sprengers (M) (2009). National eHealth program in the Netherlands– policies and statutes, Nictiz
Tsiachristas, A., Hipple-Walters, B., Lemmens, K., Nieboer, A., Rutten-van Mölken, M. (2010). Towards integrated care for chronic conditions – Dutch policy developments to overcome the (financial) barriers, Health policy
43
Annex 1 – Statistics
Figure 7 – Age structure of the Dutch population
Figure 8 – (Un)employment in the Netherlands 2005-2010 (source: CBS.nl)
Jobs (right axis) Unemployment (left axis)
Age
Men x 1000 Women x 1000
44
Figure 9 – Distribution of income, source: CBS.nl
Figure 10 – Level of education of the laborious Dutch population in 2009 (15-65). Source: CBS.nl
Primary education
VMBO, MBO-1
AVO
MBO 2-3
MBO-4
HAVO/VWO
Bachelor
Master, doctor
Unknown
Average income: €33.400,-
Income x €1000
x 1
00
0 h
ouse
hold
s
45
Figure 11 – Prevalence chronic diseases (%), 2001/2008. Source: CBS.nl
Figure 12 – Average amount of hospitalizations per 10 000 persons from 1993 to 2008 (blue =
male, pink = female). Source: CBS.nl
Figure 13 – Average amount of days per hospitalization from 1993 to 2008 (blue = male, pink =
female). Source: CBS.nl
Heart attack
Stroke
Cancer
Severe heart disease
Psoriasis
Vascular constriction
Dizziness
Indigestion
Diabetes
Incontinence
Chr. Arthritis
Chr. Eczema
Elbow, wrist hand
COPD
Other
Neck condition
Back condition
Joint degeneration
High blood pressure
Migraine
46
Table 3 – Use of health care, contacts with care professionals (average amount per person), 2008.
Source: CBS.nl
GP Specialist Dentist physiotherapist
Total 4,1 1,8 2,2 3,1
Male 3,5 1,6 2,0 2,6
Female 4,7 2,0 2,4 3,6
Table 4 – Expenses and costs of healthcare (in €million). Source: CBS.nl
2006 2007 2008*
Total expenditure on providers of care € million 70532 74447 79091
Total providers of health care € million 40683 43390 46382
Hospitals and medical specialists € million 17593 19012 20371
Providers of mental health care € million 4208 4385 4895
Practices of general practitioners € million 2296 2435 2471
Practices of dentists € million 1886 2021 2215
Paramedics and midwife practices € million 1471 1580 1649
Total other providers of health care € million 13228 13958 14780
Total providers of social care € million 27523 28562 30204
Administration & management institutions
€ million 2327 2494 2505
Total financing € million 70532 74447 79091
Government € million 7862 10102 10589
Care Insurance € million 26226 27436 32149
Exceptional Medical Expenses Act € million 23104 22679 21260
Private insurance € million 2904 3146 3262
Out-of-pocket payments € million 6678 6994 7567
Other sources of financing € million 3758 4090 4264
Care expenditure per capita € 4315 4545 4809
Costs as a percentage of the GDP % 13,1 13,1 13,3
47
Figure 14 – Costs of healthcare compared within Europe in 2006. Source: Eurostat, WHO, OESO
Table 5 – Average costs per hospital day per patient. Source: NVZ37
<200 beds 200-<300 beds
300-<400 beds
400-<600 beds
>600 beds Total
Costs €1108,23 €1092,06 €1127,95 €1199,31 €1267,04 €1200,39
37 http://www.nvz-ziekenhuizen.nl/Feiten_en_cijfers/Ziekenhuisstatistieken
Romania
Lithuania
Estonia
Poland
Cyprus
Latvia
EU-12
Czech Republic
Ireland
Slovakia
Bulgaria
Luxemburg
Finland
Slovenia
Hungary
Spain
UK
Malta
Italy
Sweden
Netherlands
EU-27
Greece
Denmark
EU-15
Portugal
Belgium
Austria
Germany
France
49
Annex 2 – Quantitative data collection for Health Impact Assessment
This appendix provides an overview of the HIA-aspects that are taken into account in the three cases. The indicators described below are based on the indicators as described in the SIMPHS 2 -Field work Research Protocol.
Table 6 – Economic effectiveness measured (folded)
In Touch TEHAF COPDdotCOM38
Investments in equipment X X
Investments in training of staff X
Investments in maintenance X
Investments in use of staff X X
Investments in medication X
Investments in utensils
Investments in patients’ use of time X
Investments in relatives’ use of time
Investments in transportation
Unit costs or prices for each resource used X
Changes in use of primary care X x
Changes in use of emergency unit X X
Changes in use of outpatient visits X X
Changes in use of hospitalization X X
Changes in use of bed days X X
Changes in use of tertiary care X X
Changes in use of primary care
Business case (Expenditures/year)
Business case (revenue/year)
Business case (number of patients/ervices)
Business case (reimbursement per patient/service)
Risk analysis
38 Economic effects are part of the follow-up study of COPDdotCOM (CoCo)
50
Table 7 – Economic effectiveness measured (unfolded)
In Touch TEHAF COPDdotCOM
Airfare (travel)
Travel costs (travel)
Consultant transportation costs (travel)
Costs of travelling by different modes of transportation considered (travel)
Changes in transportation costs (travel)
Costs of travelling to hospitals (travel)
Patient non-emergency transportation costs (travel)
Equipment lease costs (equipment)
Equipment costs (equipment) X X
Maintenance costs (equipment) X
Maintenance provider (equipment) X
Initial purchase of hardware (equipment) X
Installation and maintenance (equipment) X
Hardware (equipment) X
Software (equipment) X
Costs of implementation of home telecare system (equipment) X
System costs (equipment) X
Operational expenses (equipment) X
Costs of each workstation (equipment) X
Telecommunication costs (communication) X
Line rental and call charges (communication)
Long-distance telecommunication charges (communication)
Telecommunications and utilization charges (communication)
Consultant’s time (time)
Midwife’s time (time)
Time devoted by doctor/nurse team (time) X
Patient time (time) X
Physician time (time)
Time for work stoppage for patients (time)
Time spent on project for personnel (time)
Average cost of consultant time for telemedicine (time)
Average cost of GP time at a telemedicine consultation (time)
Number of referrals (care costs) X X
Treatment costs (care costs) X
Standard ancillary care costs (e.g. laboratory services, ambulance) (care costs)
X
Standard hospital costs (e.g. inpatient costs) (care costs) X X
Antenatal clinic visits (care costs per patient) X X
Antenatal inpatient days (care costs per patient) X X
Total cost of domiciliary care (care costs per patient) X X
Changes in the productivity of health-care professionals (care costs)
X
Costs per patient visit (care costs) X
Costs of face-to-face depend on length of clinic sessions, number of investigations and number of reviews (care costs)
X
Prescription costs considered (care costs) X
Overhead costs (administration)
Facility charges (administration)
51
Monthly communication line charges (administration)
Running costs, e.g. telephone line (administration)
Line charges (administration)
Phone calls (administration)
Modem costs (administration)
Costs of telecommunication using ISDN lines (administration)
Installation costs for digital telephone lines (administration)
Personnel for start-up and maintenance of the system (staffing) X
Employment costs of a consultant (staffing) X
Staffing costs (staffing) X
Consultant and support staff fees/wages (staffing) X
Nursing costs, e.g. labour and benefits (staffing) X
Personnel costs (staffing) X
Hourly rate of consultant dermatologist and neurologist (staffing) X
Hourly rate of GP (staffing) X
Supplies (staffing)
Administration charges (staffing)
Other project-specific costs (staffing)
Administrative overhead (staffing)
Accommodation (subsistence costs)
Meals (subsistence costs)
Emerging and evolving reliability of technology (other)
Skill level of users (other)
Uncertainty regarding the most efficient and effective applications (other)
Preparation of submissions (project establishment costs)
Recruitment of staff (project establishment costs)
Selection process to decide which projects are to proceed (project establishment costs)
Preparation of tenders for equipment (project establishment costs)
52
Table 8 – Clinical effectiveness measured (folded)
In Touch TEHAF COPDdotCOM
Effects on mortality X X
Effects on morbidity
Physical health X X
Mental health X X
Effects on health related quality of life (HRQL) X X X
Behavioural outcomes (e.g. exercise) X X
Utilization of health services X X 39
Transferability issues X X X
Methods for data collection RCT RCT RCT
Table 9 – Clinical effectiveness measured (unfolded)
In Touch TEHAF COPDdotCOM
Heart failure
All-cause deaths X
Heart failure related deaths X X
Revised Heart Failure Self-Care Behaviour Scale, X X
MLHFQ: The 21-item Minnesota Living with Heart Failure Questionnaire
X
6 minute walk test
NYHA FC (New York Heart Association functional class) X
Health Failure Self-Efficacy; X
Hospital Anxiety and Depression Score X X
SF-12
SF-36 v. 2
EQ 5D x X
Health distress scores
VAS
PHQ-9 (is the nine item depression scale of the Patient Health Questionnaire)
CES-D (short self-report scale designed to measure depressive symptomatology in the general population)
CSQ: Reliability and Validity of Communication Skills Questionnaire (Client Satisfaction Questionnaire)
Number of hospitalizations X X
Number of heart failure related re-hospitalisations X X
Number of bed days for hospitalised patients X X
Number of primary clinic visits X
Number of specialist visits X X
Number of heart failure related visits at emergency department
X
Added: living with heart failure questionnaire X
Added: Is the patient on the type of medication described according to ESC guidelines and is the patient on the
X
39 Will be part of the follow-up study of COPDdotCOM (CoCo)
53
optimal medicine dose
Added: Quality-adjusted life years (QALYs) X
Added: MTA questionnaire X
Added: Kansas City Cardiomyopathy Questionnaire X
COPD
All caused deaths
The SGRQ (ST GEORGE'S RESPIRATORY QUESTIONNAIRE)
The Chronic Respiratory Questionnaire (for QoL)
The Clinical COPD Questionnaire for health related quality of life
X
SF-36
The Minnesota Living with Heart Failure Questionnaire
Number of hospitalizations X
Number of rehospitalisations X
Number of bed days for hospitalised patients X
Number of primary clinic visits X
Number of specialist visits X
Number of visits at emergency department X
Number of office visits
Number of home visits
54
Annex 3 – Qualitative Data Collection - Diffusion of Innovation and
Governance
In Touch – Groningen
Name of the person interviewed René van Dijk
Position Cardiologist at the Martini hospital / director of Cavari clinics / medical advisor of CURIT Disease Management Systems.
Name of the institution Martini Hospital
Region Groningen
Name of the person interviewed Wendy de Valk
Position Nurse practitioner in cardiology at the Martini Hospital
Name of the institution Martini Hospital
Region Groningen
Name of the person interviewed Reitze Sybesma
Position Manager Health care at the Martini Hospital
Name of the institution Martini Hospital
Region Groningen
Region Groningen
Country Netherlands
Name of the project IN TOUCH
Website of the project http://www.curit.com/nl/index/index
http://www.curit.com/nl/In Touch/
Organizations involved Martini Hospital, Cavari Clinics, Curit
Contact details of the person in charge of the project
Rene van Dijk (see above)
Medical Specialty CHF
Typology of patients Chronic
Number of patients involved 105
Health professionals involved Clinicians
Nurses
Other professionals involved Social workers
IT
Typology of innovation Organizational
Services
55
Technological
Product
Type of organization Hospital
Location Mainly intramural (of course with extension outside the hospital); medical centre is accommodated from the hospital as well. Links with extra-mural organisations (general practitioners).
Time Asynchronous
Financing / Funding VWS
TEHAF study – Limburg
Name of the person interviewed Josiane Boyne
Position Coordinating heart failure nurse and investigator in telemedicine
Name of the institution Maastricht University Medical Centre
Region Limburg
Name of the person interviewed Bert Vrijhoef
Position Director of research of the department of transmural care
Name of the institution Maastricht University Medical Centre
Region Limburg
Region Limburg
Country Netherlands
Name of the project TEHAF study (Health Buddy)
Website of the project http://www.azm.nl/zorgcentra/zorgcentra/hartenvaat/12119/healthbuddy
http://www.sananet.nl/index.php?url=/het_health_buddy_systeem/health_buddy/
Organizations involved Atrium Medical Centre - Heerlen
University Medical Centre - Maastricht
Orbis Medical and Care Concern - Sittard
Medical Specialty CHF
Typology of patients Chronic
Number of patients involved 382 patients involved in the study, of which 197 had a health buddy at home
Health professionals involved Clinicians
56
Nurses
Other professionals involved Social workers
IT
Typology of innovation Organizational
Services
Technological
Product
Type of organization Hospital
Location Mainly intramural (with extensions of equipment in patient environment). Cooperation with general practitioners and company supplying the Health Buddy. Main initiative and organisation of care process is hospital oriented.
Time Asynchronous
Financing / Funding Unrestricted grants from the Government of the Province Limburg, Rescar Foundation, Annadal Foundation, pharmaceutical industry Astra Zeneca, Department of Integrated Care of the Maastricht University Medical Centre, the administration of the University Maastricht and of the Maastricht University Medical Centre.
COPDdotCOM – Twente
Name of the person interviewed Hermie Hermens
Position Professor at University of Twente and clustermanager at Roessingh Research and Development
Name of the institution RRD
Region Twente
Name of the person interviewed Monique Tabak
Position Researcher at RRD
Name of the institution RRD
Region Twente
Name of the person interviewed Job van der Palen
Position Research coordinator at Medical Spectrum Twente
Name of the institution RRD
Region Twente
Region Twente
57
Country Netherlands
Name of the project COPDdotCOM
Website of the project http://www.copddotcom.nl
Organizations involved University of Twente (Biomedical Research Institute (BMTI), Centre for Telematics and Information Technology (CTIT)), Roessingh Research and Development (RRD), Telemetics institute (TELIN)), Medisch Spectrum Twente (MST), Rehabilitation centre Roessingh (RRC)
Medical Specialty COPD
Typology of patients Acute
Chronic
Social assistance
Number of patients involved 32
Health professionals involved Clinicians
Nurses
Other professionals involved Social workers
IT
Typology of innovation Organizational
Services
Technological
Product
Type of organization Hospital
Location Mainly intramural (with extensions of equipment in patient environment). Cooperation with physiotherapists. Main initiative and organisation of care process is hospital oriented.
Time Asynchronous
Financing / Funding Subsidized by ZonMW
59
Annex 4 – Societal costs and effects of Koala
Table 10 – Societal costs and effects of Koala, in euro's per patient. “PM” is the value of the
improvement in the quality of health or healthcare that is not quantified.
Pat
ien
t
Info
rmal
ca
re
Car
e p
rod
uce
r
ICT
su
pp
lier
Ko
ala
Fo
un
dat
ion
Hea
lth
in
sura
nce
co
mp
any
Pat
ien
t’s
emp
loye
r
So
ciet
al
Tot
al
Costs
Expendable costs -2500 -2500
Expendable ICT costs -3300 -3300
ICT costs allowance 3300 -3300 0
Structural costs MSC -6500
-6500
Allowance MSC first year 1400 -1400 0
Structural ICT costs -7500 -7500
Allowance 1900 -1900 0
Subtotal costs 0 0 -5100
-12800
0 0 0 -1900 -19800
Direct effects
Decrease in care costs elderly
33 207 240
Extra costs monitoring -8 -8
Decrease in care costs chronically ill
747 747
Decrease in travel expenses patients
22 +PM 22 +PM
Saving of patients’ time ± PM
± PM
Health gain + PM
+ PM
+ PM
Improvement of quality of care
+ PM
+ PM
Subtotal direct effects 22
± PM
+ PM
0 0 0 772 0 207 1001
± PM
Total 22
± PM
+ PM -5100
0 -12800
772 0 -1693
+PM
-18800
± PM
Pat
ien
t
Info
rmal
ca
re
Car
e p
rod
uce
r
ICT
su
pp
lier
Ko
ala
Fo
un
dat
io
n
Hea
lth
in
sura
nce
cm
pan
y P
atie
nt’
s em
plo
yer
So
ciet
al
Tot
al
Source: Kok et al. (2010)
60
Annex 5 – List of interviewees
Table 11 – List of interviewees
Overview of Dutch healthcare system
Geja Langerveld Programme manager at the Dutch organisation ZonMW (Zorgonderzoek Nederland Medische Wetenschappen – Care Research Netherlands Medical Sciences)
Hans Haveman Senior policy maker at the department of Health
Harry Nienhuis Advisor Strategy & Policy to the Board of Directors of Menzis
Chris Flim Owner of Flim P&C
In Touch
René van Dijk Cardiologist at the Martini hospital / director of Cavari clinics / medical advisor of CURIT Disease Management Systems.
Wendy de Valk Nurse practitioner in cardiology at the Martini Hospital
Reitze Sybesma Manager Health care at the Martini Hospital
TEHAF
Josiane Boyne Coordinating heart failure nurse and investigator in telemedicine
Bert Vrijhoef Director of research of the department of transmural care
COPDdotCOM
Hermie Hermens Professor at University of Twente and clustermanager at Roessingh Research and Development
Job van der Palen
Research coordinator at Medical Spectrum Twente
Monique Tabak Researcher at RRD
European Commission
EUR 25441 – Joint Research Centre – Institute for Prospective Technological Studies
Title: Strategic Intelligence Monitor on Personal Health Systems, Phase 2. Country Study: The Netherlands
Authors: Arjanna Van Der Plas, Marc Van Lieshout
Luxembourg: Publications Office of the European Union
2013 – 60 pp. – 21.0 x 29.7 cm
EUR – Scientific and Technical Research series –ISSN 1831-9424 (online)
ISBN 978-92-79-25738-4(pdf)
doi:10.2791/88542
Abstract
This study presents and discusses the status for integrated personal health systems (IPHS) in the Netherlands. It aims to
illustrate through case studies the patient and health monitoring systems that are available, the level of implementation of
these systems, the impact they have on the general socio-economic context, as well as their cost-effectiveness where
applicable. The analysis presented in this report is based on interviews with key experts and stakeholders from the
Netherlands and a substantial secondary data collection.
z
As the Commission’s in-house science service, the Joint Research Centre’s mission is to provide EU policies with independent, evidence-based scientific and technical support throughout the whole policy cycle. Working in close cooperation with policy Directorates-General, the JRC addresses key societal challenges while stimulating innovation through developing new standards, methods and tools, and sharing and transferring its know-how to the Member States and international community. Key policy areas include: environment and climate change; energy and transport; agriculture and food security; health and consumer protection; information society and digital agenda; safety and security including nuclear; all supported through a cross-cutting and multi-disciplinary approach.
LF
-NA
-25
44
1-E
N-N