Telemedicine and Homecare

Ole Hejlesen

Department of Health Science and Technology, Aalborg University, Aalborg, Denmark

Various terms with overlapping meanings

• Self-Care, • Self-Management, • Telemedicine, • Home Monitoring, • Home Care, • Pervasive Healthcare,• ……• “the practice of health care at a distance” – ??

Various actors in various combinations

• Patients, • General practitioners, • District nurses, • Private specialists,• Various hospital clinicians, • ……

Various degrees of online contact

• One end of the scale: A patient who, after being discharged hospital, has no significant communication with the clinician

• The other end of the scale:A patient who, for example, is discharged with a device which, using a mobile telephone, transfers the patient’s ECG to the hospital for continuous monitoring

• The communication can be one-way – or two-way

Various degrees of devolution of responsibility

• One end of the scale:For example, the situation where the patient is monitoring the ECG and where the patient is not supposed to make any decisions regarding the treatment

• The other end of the scale:For example, the trained diabetes patient, who in accordance with varying meals etc. has full responsibility of taking the right insulin doses

• May be aided by a decision support system

Framework for classification

Online contact

Devolution of responsibility

- various actors in various combinations

• Hospital clinician – patient at home• GP – patient at home• Hospital specialist – GP• Hospital specialist – Hospital clinician• ……

Devolution of responsibility

Devolution of responsibility

Devolution of responsibility

Online contact

Online contact

Online contact

Online contact

Devolution of responsibility

Hospital clinician – patient at homean inverse correlation ??

ECGmonitoring

Online contact trained

diabetic

Devolution of responsibility

Example no. 1 – anticoagulation

• In Denmark 50.000 patients are in AC treatment, the number increasing 10-15% per year

• AC treatment is an effective prophylaxis for thromboembolism in high risk patients (e.g. cardiac patients with atrial fibrillation)

Number Needed to Treat (NNT)* in Various Cardiac Conditions

Abs. NNTred.

AF, primary prevention 5% > 2% 3% 33.3

AF, secondary prevention 12% > 4% 8% 12.5

post AMI 2.4% > 1.1% 1.3% 77

* NNT Definition: No. of pt.s to treat to avoid one event of Intracranial Hemorrhage : 1/abs. reduction %

Risk of Intracranial Hemorrhage in Outpatients

Adapted from: Adapted from: HylekHylek EM, Singer DE, Ann Int Med 1994;120:897EM, Singer DE, Ann Int Med 1994;120:897--902902

Lowest Effective Intensity for Warfarin Therapy for Stroke Prevention in AF

Hylek EM, et al. NEJM 1996;335:540-546.HylekHylek EM, et al. NEJM 1996;335:540EM, et al. NEJM 1996;335:540--546.546.

Low degree of online contact – and high degree of devolution of responsibility

• Aahus University Hospital the first place in Denmark to introduce formal training ofpatients in AC treatment -> ’The Skejby Way’

• Patient self-management• A paper based communication structure• Data manually entered into a database

High degree of online contact – and low degree of devolution of responsibility

Hospital clinician – patient at homean inverse correlation ??

SimpleSimon

DSS +training

Online contact The Skejby

Way

Devolution of responsibility

The Hillingdon algorithm• M = 1 + 0,58 * ln (T / A).

– M is dose-ratio – actual / previous– T is target INR– A is actual INR

• Modified by Dalsgaard:• M = 1 + (0,4 + (1 / (D + 5)) * ln (T / A )

– D is number of days between INR values

The INR risk function in a DSS

Risk

INR

1 2 3 4 5 6

Example no. 2 – diabetes home care

DiasNet/MAGNET

Online contact DiasNet

Devolution of responsibility

DiasNet

Blood glucose prediction generated by DiasNet

Effect of changing meals or insulin

The BG risk function in DiasNet

DiasNet /MAGNET

Example no. 3 – diabetic retinopathy Hospital specialist – Hospital clinician

Online contact

TOSCA

Std. ophth.service

Devolution of responsibility

TOSCA communication structure

Example no. 4 – lyme borreliosis diagnosis Hospital specialist – General practitioner

Online contact

Borrelia DSS

Std. microbiol.service

Devolution of responsibility

The most common tick-borne infection

Clinical findings & lab evidence

A web based DSS for the GP

Various terms with overlapping meanings – which one to use?

• Self-Care, • Self-Management, • Telemedicine, • Home Monitoring, • Home Care, • Pervasive Healthcare,• ……• “the practice of health care at a distance” – ??

Various terms with overlapping meanings – which one to use?

‘The Google Way’

• Self-Care / Selfcare – 1 450 000 hits• Self-Management / Selfmanagement – 840 000 hits• Telemedicine / Tele medicine – 3 550 000 hits• Home Monitoring – 157 000 hits• Home Care / Homecare – 5 200 000 hits• Pervasive Healthcare / Health Care – 5 000 hits