The need for home-care is expanding dramatically. People are living longer than ever before in history. Today 18% of the Italian population is over 65 years old and such a percentage will increase to 20% in 2008 (11 million).
They are better educated and are more comfortable with the use of technology. Most people want to remain independent and live in their homes as long as possible, yet a greater number of people are suffering from chronic conditions.
At the same time, the health care industry is facing a critical shortage of public resources, as well as nurses and other health care personnel to care for our population. Health care providers are forced to do more with less resources, with decreasing reimbursements and increased focused on quality and clinical outcomes.
IGEA SAT (Integrated General E-care access for home-care via SATellite) final objectives are:
- To provide added value social services through the most innovative technologies, like Interactive TV and satellite, allowing service utilization by all people, in particular the elderly, in spite of their geographical location. For highly distributed geographical areas including under served and remote areas, the satellite remains the only means to make healthcare services really “universal” and to guarantee the necessary quality standards.
- To support disease management by providing communication and access to knowledge, and by enabling patient self-management. Success with disease management requires delivering the right interventions, at the right time, in the right way, to all the right patients.
- To test the system in the framework of a clinical pilot study aiming to demonstrate the possibility to effectively manage, through telemedicine services, chronic patients at home.
- Existing infrastructure and clinical systems were the basis upon which IGEA SAT has been implemented. The project aimed to supplement existing infrastructure rather than replace infrastructure.
- Rollout of the IGEA SAT services was undertaken at the very beginning of the Project to provide at the later stage learning’s from previous implementation and utilization.
- Compliance of all actors to the tele-monitoring system according to the clinical protocol defined for each disease and the improvement of the QoL (Quality of Life) were the initial targets for the IGEA SAT evaluation.
- The pilot operations were carried out as clinical pilot study managed and monitored by a Scientific Committee.
- IGEA SAT seeks to make significant change and be a catalyst for even more change in the way the healthcare services are delivered.
In a healthcare system the ambition of Telbios is to promote within, to develop for and to make available to the healthcare community, a series of tools and services with a unique and final objective of improving the citizen/patient wellness. This can be achieved through connecting three broadly defined constituents:
- The patient management community: which include physicians, disease management therapy companies, and organization that provide information and knowledge services and standardization of care profiles.
- The patients and their family that would value information about their health and disease management.
- The citizens in order to be better informed about disease prevention and to improve general health status.
IGEA SAT, through the use of the satellite, represents both an accelerator for the deployment of innovative healthcare services, and a major complementary market potential. From the general healthcare perspective, IGEA SAT is the sole way to overcome the digital divide in e-healthcare services within the “old” Union countries and to offer such services in the “new” Union countries, where the broadband infrastructure could be not generally available.
From the point of view of the healthcare system organization, IGEA SAT should allow a clinical improvement that can be also measured through:
- A reduction of the number of visits to the emergency rooms,
- A reduction of unnecessary visits to physician's offices,
- An improvement of the patients education in early symptom management ,
- The monitoring of vital signs on a 24-hour basis, to provides a potential for early intervention and/or prevention of repeat hospitalization,
- The assessment of the mental status, functional status, and overall health status.
IGEA SAT reframes the interaction between patients and professionals, creating easier communication between users and physicians, aiming to engage and help users stay healthy, by organizing and motivating themselves keeping track of their progress.
IGEA SAT offers an array of health related services and makes them available to citizens directly in their "daily environment" shifting the centre of health related actions from the "health institution" to herself/himself and her/his everyday environment.
Success with disease management requires delivering the right interventions, at the right time, in the right way, to all the right patients. Chronically ill consumers who must deal with their disease every day are interested in playing a more active and informed role in managing their health.
IGEA SAT answer to the needs of the patient with the following services:
- The “Agenda” in the form of an “Activity List” of daily actions to be performed and drugs that shall be taken during the day by the patients.
- The Telemonitoring of physiological parameters through the use of portable medical devices.
- The Video Assistance for periodical video-sessions between patients and operators of the Telemedicine Service Centre, or between the patients and the physicians or the physiotherapists.
- The Edutainment, to see on the TV set the video pills on the utilization of the assigned medical devices and on some topics related to their disease (e.g. heart failure, diabetic foot).
Figure 1 – Interactive Application for the services fruition by the patients
This set of services requires a highly reliable system associated with a fully featured, integrated quality of service . This kind of control will be based not only on technical parameters but on the full service chain, including the physicians' and specialists' availability and the reliability of the procedures carried out via the network.
The implemented network is a mix of terrestrial, satellite and wireless solutions. All applications are independent of the network arrangement. The VSAT HN7000S terminals, allowing a full-duplex communication is the adopted satellite technology. It is a mature choice and it represents a cost effective way to achieve the deployment of value-added solutions for medical practice and care management by ensuring interoperability with heterogeneous network environment.
Figure 2 – Network scenario
The technological challenge of the proposed system is also in the main system components:
- Satellite Multimedia Service Centre (SMSC) where all service technical infrastructure is located (web servers, Telemonitoring Application servers, security and access control servers etc.), and where the video-assistance service is managed from both the technical and the operational point of view. The operators at SMSC will be available 24/7.
- In Home Terminal (IHT) that covers the functional area related to Device Gateway and Communication Gateway. It has been produced in two versions: IHT1 (Personal Computer based) and IHT2 (Set Top Box based).
- Interactive Application (iApplication ) on the television providing the end users with an interface very close to the familiar TV environment (TV set and remote control).
The project has had a 2 year duration broadly consisting of three phases of activity:
- Design Phase (4 months)
- Build Phase (10 months)
- Deployment and Operations Phase (10 months)
From the utilization point of view, IGEA SAT has foreseen a pre-validation and a validation phase. During the pre-validation phase occurring at the very early stage of the project, a prototyping network has been set-up and used by a small user group (15 patients) to provide feedbacks on the system “usability” and on the workflows and operations procedures. The validation phase, corresponding at the pilot operations, has involved about 105 patients representing all types of identified users.
IGEA SAT demonstrated that an adequate mix of pervasive technology, education and training is a powerful tool in a new system of delivery of care.
Best Practice data have shown that chronic patients that are included into well planned and well managed disease management programs (DMP) are complying well to prescriptions with only one quarter “behaving” fairly and almost a quarter behaving “very good” while approx 50% of patients have a good compliance. These programs, where implemented, are an asset for the public health but they are only seldom conducted due to the extensive need of human resources (health professionals) and dedicated clinic space.
The performance of patients in IGEA SAT exceeds the data reported from best practices in Disease Management Programs (DMP) with good and very good compliance (being 30% and 58% respectively) with a satisfactory performance of 88% (IGEA-SAT) vs. 76% (DMP). Moreover, the most important result is the improvement in compliance not only as the total of “good” and “very good” but the shift of patients towards the best performance.
These data support the concept that IGEA-SAT (and IT based health programs) can fulfil the needs for better care and self-care and could well be an alternative to standard clinic based DMPs and, in most cases, the only applicable means of implementation of current health policies.
Patient satisfaction has been good with respect to the provided services: 60% of the participants in the pilot gave the maximum score (5) to the overall service; 88% considered the services useful for the management of their disease; 79% considered the service usability easy enough; 83% considered the service fruition through the television very comfortable; 62% considered the monitoring data representation in a table format simpler to read than in a graphical format (38%); the electrocardiograph is the device most difficult to use (57%) as compared to the other devices. These latter were considered very easy to use in complete autonomy (100%).
76% of the sample were declared to be serene, 17,5% declared to be moderately anxious and only 6% declared to be depressed. In evaluating their own healthcare status, 53% of people reported a stability in their healthcare status, 35% an improvement and only the 12% a worsening of their healthcare status in the last 12 months. Despite the low number of patients included in the study, citizens and healthcare professionals involved in the pilot operations very much appreciated the services and their potential: the possibility to have a Service Centre support 24 hours was promoting a peace of mind for the patients that, eventually, gained a central role in the whole process of the service provision.
Physicians, nurses and physiotherapists well accepted their involvement in a new organizational context even if the implementation of these types of services requires a change of both the hospital and the territorial healthcare services organization that not always has been well accepted by the parties in place.
In IGEA SAT, for example, two clinical centres in Lombardia, initially committed to participate to the project, withdrew their adhesion when they faced this problem; in the Elba island only after several months from the start of the operations, the USL (local health administrative authority) that administers the territorial services through the GPs formalised the availability of a territorial nurse for IGEA SAT, and most importantly, the inclusion of the IGEA SAT services among the ADI (Assistenza Domiciliare Integrata-Iintegrated Home-care Assistance) services. This is an important result of the project that opens a new pattern of opportunities for the adoption of telemedicine to support the delivery of primary care.
In general, an organizational change is a long term process that needs time for the initial roll-out and its complete implementation. The IGEA SAT success stands on both the used technological platform and on the cooperation among healthcare professionals made possible thanks to the sharing of protocols, procedures and methods. In any case the impact of technology on this type of services needs to be reconsidered by proposing solutions that shall be simple to use by patients and that, when this component (technological) is relevant, can be proposed to patients with a critical pattern profile for which a cost-benefits return can be relevant.
The project wasn't able to perform an economical analysis of the services aiming to define possible remuneration proposals. Nevertheless, Lombardia Region health administration defined a fixed rate reimbursement for the hospitals participating to the project for the actuation of the CPOD rehabilitation pathway through IGEA SAT.