Momentum telemedicine service descriptions

HOME MONITORING DOPI IL TRAPIANTO / HOME MONITORING AFTER TRANSPLANTATION (IT)

Objectives, expected outcomes, main beneficiaries

Seventy-four adult patients who underwent liver transplantation at ISMETT and were discharged between 15 July 2011 and 30 April 2013 were included in the study. Sixty-six of these patients completed the follow-up period (3 months). Because the entire liver transplanted population for our study period was included in the study, we used the liver transplanted patients discharged home in an equivalent period between July, 2009 and June, 2011 as a control group. The average length-of stay after transplantation in the home-monitoring was 19.8 days, considerably lower when compared with the control group (25.4 days). No urgent re-admission was observed in the study group, compared with four urgent admissions (for an overall length of stay of 25 days) in the control group.

We can affirm that the introduction of this new monitoring system increased ISMETT physicians’ confidence in discharging patients and sending them home because of an improved ability to monitor their progress without requiring any travel.

The questionnaires administered to the patients showed that the system was well accepted, and it improved the patient experience in such a critical period as the first days after a liver transplant.

In terms of economic benefits, the saving related to the reduction of the length of stay in hospital was €396,000, about nine times higher than the annual cost of home-monitoring (€44,550 for 66 patients followed for 3 months). The project is still ongoing for 2014 and on.

Targeted population, number of patients

Patients after receiving transplantation at ISMETT, about 75/85 patients per year. The number can gradually increase over the next few years.

Type of telemedicine service

To implement this new service, the ISMETT team had to find a partner able to provide the necessary technology, with a significant presence in the region, and able to support patients in their homes. This partner had to provide complete service, including:

Telemedicine equipment, including all the interfaced devices.
Equipment installation at the patient’s home.
Equipment configuration to connect to the patient’s Internet connection, or installation of a new Internet connection at the patient’s home.
Training for the patient and family members.
Helpdesk service for technical issues.
Removal of equipment after the monitoring period.
Cleaning of equipment before the next installation.

Moreover, the technology partner had to provide a secure server that would allow the physician to see the patient parameters and the videoconferencing sessions with the patient. The required system would combine a home patient device with an online interface that is accessible on the Internet and accessible to properly authorized physicians. The Web interface allows physicians to monitor patients’ health status and remotely manage care progress. The device installed at the patient’s home had to be easy to use, even by people with no computer experience. Patient interaction with the system had to be supported by a touch screen.

Among the functions of the home monitoring system the ones considered essential by the project team were:

The possibility of delivering to the patient questionnaires prepared by the physicians, to better evaluate the patient’s progress.
The possibility of displaying multimedia material concerning the patient state of health, prepared by the physician remotely and upgradeable via the Web interface.
The possibility of displaying a calendar of activities prepared by the physician.
The possibility of displaying reminders via audio /visual aids to encourage the patient to follow treatment protocols.
The possibility of having teleconferencing sessions between the patient and the referring physicians.
The possibility of performing periodic measurements of the patient’s vital signs, with automatic registration in the system.

Using the home monitoring device, patients have to be able to measure vital signs, answer the questions of health assessment, and receive educational and motivational information. Once the session is completed, the results have to be made available to authorized health care professionals, who can use the latest recorded information to assess the state of the patient’s health and, if necessary, to modify the patient’s care plan.

The selected system is able to connect to a variety of devices, both wired and wireless, and allows for monitoring and acquisition of measurements of the patient’s parameters. The parameters that can be measured are blood pressure, blood glucose, pulse oximetry, spirometric data, and weight.

All parameters can be part of a routine defined for the particular patient. In this case the system will alert the patient of the measure to be performed.

Set-up that was being replaced

Hospital re-admission of patients after transplantation.

Outcomes and results expected after introduction

It is believed that this increased intensity of disease monitoring and management will create improved patient health, with resulting reduction in acute and chronic complications, and that these will translate directly into decreased consumption of expensive emergency health care resources (emergency room visits and re-hospitalizations), and decreased long-term disease complications. This, in turn, should translate directly into decreased consumption of expensive medications, personnel, equipment and hospitalization days required to manage those long-term complications. This pilot study demonstrates that the introduction of a home monitoring system to support the patient during the first three months after discharge can produce all these benefits.

The home monitoring system is an important solution, not only for early discharge from the hospital, but also for better day-to-day monitoring of transplant patients, which can be carried out more frequently, and without patients having to travel to the hospital for routine check-ups. This is particularly true in the first three months after a transplant, an extremely delicate moment from the clinical point of view, when patients need to be constantly connected with their health care team.

Tele-health monitoring is not only useful in reducing health care costs, but actually enables a two-way dialogue between patients and the health care staff (medical practitioners, transplant coordinators, therapists and psychologists), making patients feel better monitored and allowing them to ask for immediate support.

The results obtained in this study can be considered a “proof of concept”: home-monitoring is a safe and effective solution not only in stable chronic patients, but also in unstable patients facing difficult issues in clinical and therapeutic management.

Detailed description

As defined by the American Telemedicine Association’s, “Home Telehealth is a service that gives the clinician the ability to monitor and measure patient health data and information over geographical, social and cultural distances.” The objective is to improve disease management and undertake “earlier and proactive interventions for positive outcomes.”

The technology to be used is usually determined by clinical needs, health objectives, and available resources. Home monitoring and remote monitoring systems are usually used for patients who have the following clinical conditions: asthma, diabetes, chronic obstructive pulmonary disease, chronic heart failure, or mental health problems (anxiety and depression).

Remote monitoring technologies have the potential to improve clinical management of chronic diseases. There are currently several clinical conditions for which home monitoring is being used, and this approach has been found to produce benefits in a number of research trial.
There is little in the literature on the use of remote monitoring for non-chronic patients, and no experience has been reported on the monitoring of post-transplant patients.

Even if tele-home-care and remote monitoring are usually viewed as supplements to normal in-person care and not as substitutes, patients involved in this pilot used remote monitoring as the primary contact option between the patient and the ISMETT specialists. The patient was contacted daily by the transplant hepatologist, but the entire multidisciplinary physician team of ISMETT was involved in the project and, using the system, the patient could receive indications for care from all the specialists.

In order to implement this new service, the ISMETT team had to find a partner able to provide the necessary technology, with a significant presence in the region, and able to support patients in their homes.

This partner had to provide complete service, including:

Telemedicine equipment, including all the interfaced devices.
Equipment installation at the patient’s home.
Equipment configuration to connect to the patient’s Internet connection, or installation of a new Internet connection at the patient’s home.
Training for the patient and family members.
Helpdesk service for technical issues.
Removal of equipment after the monitoring period.
Cleaning of equipment before the next installation.

Moreover, the technology partner had to provide a secure server that would allow the physician to visualize the patient parameters and the videoconferencing sessions with the patient. The required system would combine a home patient device with an online interface that is accessible on the Internet and accessible to properly authorized physicians. The Web interface allows physicians to monitor patients’ health status and remotely manage care progress. The device installed at the patient’s home had to be easy to use, even by people with no computer experience. Patient interaction with the system had to be supported by a touch screen.

Among the functions of the home monitoring system the ones considered essential by the project team were:

The possibility of delivering to the patient questionnaires prepared by the physicians, to better evaluate the patient’s progress.
The possibility of displaying multimedia material concerning the patient state of health, prepared by the physician remotely and upgradeable via the Web interface.
The possibility of displaying a calendar of activities prepared by the physician.
The possibility of displaying reminders via audio /visual aids to encourage the patient to follow treatment protocols.
The possibility of having teleconferencing sessions between the patient and the referring physicians.
The possibility of performing periodic measurements of the patient’s vital signs, with automatic registration in the system.

All parameters can be part of a routine defined for the particular patient. In this case the system will alert the patient of the measure to be performed.

The home monitoring system installed at the patient’s home is connected to a Web-based service, with restricted access through encrypted connections. This Web-based service allows physicians to configure the calendar of the patient, and to define a series of questions to be transmitted to the terminal of the patient, or plan the “measurement sections” during which the patient data are collected. All the patient’s responses and data collected are stored in a central database and can be reviewed by the physician using a standard computer connected to the Internet.

One of the typical concerns in the home monitoring project is the possibility of having a good Internet connection at the patient’s home. The possibility of connecting the equipment to the Internet was critical for the success of the project. In order to allow the smooth flow of images during the video conferencing sessions, the Internet connection must have enough bandwidth and reduced latency. This meant that the service required of the commercial partner included a preliminary on-site visit to the patient’s home in order to verify whether the patient had an Internet connection or whether it was possible to install an ADSL line. If these two options were not possible the vendor had to provide a 3G modem for data transmission and support the connectivity costs.

In order to maintain data privacy all the data transferred by the system had to be encrypted, and the connection between the telemedicine equipment and the server had to use encrypted VPN connections.

After a rigorous analysis of the available solution on the Italian market, ISMETT decided to use the “Guide” developed by Care Innovation. Care Innovations is joint venture, formed in January, 2011, between Intel Corporation and GE. Its mission is to create technology-based solutions that give people confidence to live independently, wherever they are. With the combined expertise of its parent companies – GE’s in health care and Intel’s in technology – Care Innovations developed a user friendly tool that meets patient and physician needs. For health care professionals involved primarily in remote monitoring, Care Innovations offers the FDA-cleared and CE-cleared Intel-GE Care Innovations™ Guide, which allows seamless interaction with health care providers and home-based patients monitoring their health.

The system was delivered to the patient’s home by Vivisol, the Italian distributor of The Care Innovations™ Guide, and a leading European company in the field of home care services, with a significant presence in Sicily in terms of nursing and technical personnel available.
The system allows direct and visual contact between patients and physicians through a reliable system of video conferencing. It creates conditions similar to those of a hospital medical examination, with the advantage that the patient does not need to leave home, and with all the resulting benefits in terms of comfort. Through a special kit, the device allows for the periodic assessment of vital parameters, such as blood pressure, heart rate, and blood oxygen concentration, and the automatic entering of the results into the system. The system includes an integrated camera, microphone and speakers for interactive video-conferences, offering face-to-face support to the patient-physician interaction. Clinicians and patients can take advantage of videoconferencing to discuss and evaluate the patient’s condition, and patients have the opportunity to express their thoughts and voice any current concerns.

Using the this telemedicine system, patients have access to a variety of multimedia educational content, including text, audio, and video. Health care professionals can add content as part of a health session, and patients can access that content to help them gain a deeper understanding of their disease state, health status, and care protocol.

Moreover, the physicians can design for each patient a personalized care path that defines which measurements have to be performed and how frequently, which assessment questionnaires have to be filled out, and what educational and motivational sections the patient has to study.
The system empowers patients by giving them the means to actively manage their conditions, live as independently as possible, and engage them in their care path.

Operational status

The service is included in ISMETT’s routine activity. After the Italian Ministry of Health has released the Italian telemedicine guidelines, now the Region of Sicily – as well as other Regions – will have to include the service, and similar ones, into the regional reimbursement system.

Further information

Website: www.ismett.edu

email: tpiazza@upmc.it