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Esteban Manuel Keenoy
Director Kronikgune
„Basque case story using e-health for tackling the
chronic diseases“
Tallinn
April 23rd, 2015
Index
• Introduction: Basque Country
• A strategy to deal with ageing, chronicity
and dependency
• Two cases:
– Multimorbidity patients
– Telehealth
• Main ICT features
• Lessons learnt and conclusions
Index
• Introduction: Basque Country
• A strategy to deal with ageing, chronicity
and dependency
• Two cases:
– Multimorbidity patients
– Telehealth
• Main ICT features
• Lessons learnt and conclusions
Demographic and epidemiological context
4
Basque Health System
Life expectancy
85,7 years
women
79 years
men Source: Eustat –Basque Institute of Statistics 2012
Population (2011): 2.183.615
≥65 years: 19%39% in 2050
BIZKAIA
GIPUZKOA
ARABA
25%
Private
75% Public
• GNP/per capita: 29.960€ (2013) (Spain 22.280€)
• Public Health Expenditure in 2013= 3.257 M€
• 5% GDP in 2012
• 35% of the Basque Gov. budget total budget
• Health Expenditure: 1.590€ per capita (Spain 1.250€)
6
The Basque Health System (BHS)
PLANNING/FINANCING/REGULATION
SERVICE PROVISION
Department of Health
Basque Public Healthcare Service
FRAMEWORK CONTRACT
PROGRAMME (COMMISSIONING)
AGREEMENTS Private providers75% Public
7
The Basque National Health System
• Universal health system,
• Funded by taxes
• Free access to the system for all residents in the Basque Country
Service organization map of Osakidetza
319 primary care facilities 6 Acute care Hospitals
3 medium and long stay care Hospitals 3 Mental Health networks Emergencies
Staff-Osakidetza
Total: 25.816 (2012)
• 6.305 physicians
• 8.246 nurses
• 4.055 auxiliary nurses
• others (7.210)
8
Health expenditure 3.257 M€ in 2013.
Contract Program, Pharmacy and Agreements expenditure evolution 2005-2012
Economic context
Total
Osakidetza
Pharmacy
Agreements with private sector
Eu
ros
9
Source: Department of Health, Basque Government (2013)
Chronic conditions in the
Basque Country
• Chronic diseases 80% of medical
consultations
• 75% of the Health BudgetIn a system designed:
• To treat acute problems
• Not to deal with chronic patients: episodic care
age
%
% of patients according to the number of chronic diseases per patient (2010-2011)
0
10
20
30
40
50
60
70
80
90
100
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95
5+ 4 3 2 1
Chronic diseases and multimorbidity
11
Source: PREST- Stratification Database in the Basque Country (2010-2011)
Primary
CareHospital
Care
A&E 24X7
8.760 HOURS/YEAR
HEALTHCARE
HOME
1-2% contact with Healthcare System
In a system designed to treat acute problems:
episodic care
• Prevent the occurrence
• Avoid predictable complications through treatment and optimal management.
1. ANTICIPATION
Chronic Diseases approach
• Well-defined Plan of care and follow UP,
• Self-management,
• Monitoring performance and compliance
2. LONGITUDINAL PERSPECTIVE CARE
3. MULTIDIMENSIONAL ACTION
GAP Increased demand for medical care
• increase in chronicdiseases
• complexity of science and technology
Inability of the system to meet demand
• poorly organized caresystem
• economic restrictions
Adapted from Institute of Medicine (IOM)
European healthcare systems remarkable results in health and safety
while maintaining acceptable levels of equity and sustainability
Index
• Introduction: Basque Country
• A strategy to deal with ageing, chronicityand dependency
• Two cases:
– Multimorbidity patients
– Telehealth
• Main ICT features
• Lessons learnt and conclusions
1. People: the backbone of the health system
2. Chronicity, old age dependency
3. Sustainability of the system
4. Professional Health System
5. Research and Innovation
Basque Department of Health Strategic Lines
Health Plan 2013-2020
Osakidetza2013-2016
Social. Healthcare
2013-2016
Pulley
Hoists
Multi lever approach
TOP- DOWN
STANDARIZABLE
INTERVENTIONS
ELECTRONIC
MEDICAL
RECORD
FINANCING AND
JOINT
COMMISSIONING
ELECTRONIC
PRESCRIPTION
NURSES NEW
ROLES
SUBACUTE
CENTRES
BOTTOM UP
LOCAL INNOVATION
POPULATION
STRATIFICATION
CONTINUUM
OF CARE
BOTTOM UP
Combined top-down and bottom-up Technological and Organizational actions
PREVENTION
EMPOWERMENT
SOCIAL CARE AND HEALTH
COLLABORATION
MULTICHANNEL PLATFORM
O-SAREANPUBLIC
HEALTH
Index
• Introduction: Basque Country
• A strategy to deal with ageing, chronicityand dependency
• Two cases:
– Multimorbidity patients
– Telehealth
• Main ICT features
• Lessons learnt and conclusions
Integrated Intervention Plans (IIP)
• Promote integrated care on patients with high complex
conditions
• Boost the coordination of multidisciplinary health care
teams
• Improve Health outcomes, efficiency and patient
satisfaction
1.394.539
636.000
173.000
43.000
• General Population
• Chronic patients
• High Risk Patients
• High complex multimorbidity
Health Promotion and prevention
Self management support
Diseases management
Case management
Risk-based Approach
Organisational model
WHO is involved in caring for and supporting patients, WHAT functions these
actors perform, and HOW different ICT tools facilitate the delivery of these
activities.
STABLE PATIENT OUT OF HOSPITAL CARE UNSTABLE PATIENT OUT OF HOSPITAL CARE
HOSPITAL DISCHARGE PREPARATION IN HOSPITAL CARE
GP
Primary care nurse
Patient/Carer
Social worker
Community Pharmacy
PHARMACY
HOME
COMMUNITY
PRIMARY CARE Primary care nurse
Patient/Carer
GP
Emergency
Specialist
Care ManagerPRIMARY CARE
HOSPITAL
HOME
eHealth centre
Primary care nurse
GP
Council Social worker
Hospital Liaison Nurse
COMMUNITY
PRIMARY CARE
Hospital Social teamHospital nurse
Hospital Pharmacist
Emergency room/Day care hospitalReference internist
Other specialists Sub-acute hospital staff
HOSPITAL LONG-TERM HOSPITAL
Telecare centre
Deputy Health Service
· Therapeutic plan· Diagnosis, follow-up· Pharmacologic plan· Referrals to specialists· Test selection
· Assessments· Tests· Pharmacologic follow-up· Patient training· Coordination with social care
· Self-management· Health habits· Action plans
· Follow-up when needed· Identifies and reports needs
to community nurse
Pharmacologic follow-up
· Tests, follow up-visits· Pharmacologic follow-up· Patient training· Coordination with social care
Contact with Primary Care (8h-20h). If out of
hours contact emergency
· Therapeutic plan· Follow-up visits· Pharmacologic follow-up· Referrals to specialists· Test selection, diagnosis
Transport patient to hospital out of hours
Consultations, diagnosis
· Tests & therapeutic plan· Follow-up· Intravenous medication· Follow-up visits· Referral to specialist
Health advice and coordination of health
resources. Telemonitoring.
· Integrated frailty assessment· Therapeutic plan follow-up· Patient training· Home visits (intensive follow-up)· Coordination with social services
· Diagnosis· Intensive follow-up· Therapeutic plan follow-up
· Coordination with health services (Primary Care)
· Social care services · Coordination with Primary Care· Explains to the patient/carer the
therapeutic plan,health advice, alarm symptoms and action plans
Assessment of needs and if required, patient referral to other settings (home, sub-acute or long-
term hospital)
· Intravenous medication· Patient training· Detection of social problems· Integrated frailty assessment
· Analysis of drug interaction and side-effects
· Avoids drug duplication· Monodosis preparation
Patient stabilization when needed and referral to
specialist
· Tests, diagnosis· Therapeutic plan· Pharmacologic follow-up
· Tests, diagnosis· Therapeutic plan· Diagnosis
Similar activities than in hospital but patients are in long-term hospitalization
· Coordination with health & social care
· Activation of ehealth center
Out of care hoursHome-visits
F2F, Email, Phone
EHRE-prescription
F2F, Phone
TM
F2F, PhoneSocial EHR
F2F, phoneE-prescription
Phone
Phone
Phone
Phone
EHRInterconsult.
EHRPhone
Phone
EmailSocial EHR
Phone
PhoneEHR
EHRE-prescription
CRMPhone
EHRE-prescription
F2F, Phone
EHR
EHR
EHR,F2FE-Presc., Phone
EHR
EHR,F2FE-Presc.Phone
EHR,F2FE-Presc.Phone
EHR
Phone
PhoneCRM
EHRPhone
Interconsult.Email
EHR, PhoneInterconsult.
Phone
Integrated Intervention Plans Definition
PIIs
TOP-DOWN
BOTTOM- UP
• Bundled payment
• ICT systems
• Intervention groups.
• Patient selection criteria.
• Assessment Framework.
• Weights in the financing framework
• Registration and local patient recruitment.
• Care pathways
• Care plan + telehealth.
• Effective delivery of care (care coordination)
• Monitoring results.
Scientific Evidence
Experiences from other organizations
Compilation of ideas and best practices
Methodological support
Cultural Change
Browse new models of care (most
appropriate and most cost-effective): + home
+ PC and-Hospitals
Governance and coordination elements
Local innovations
Patient identification (at home or healthcare centre):· Assessment· Therapeutic plan· Follow up
Primary Care
Yes No
Additional resources needed?
· Specific empowerment programmes
· Social resources· Ehealth centre· Telemonitoring
Primary CareFollow-up:· Therapeutic plan· Patient training· Assessments· Tests
GP
Primary care nurse
Unstable patient?
Yes
No
Primary Care
GP /Primary Care
nurse
· Clinical assessment· Therapeutic plan
Telecare Centre
Emergency
ehealth Centre
Home care?
Yes No
Stable patient out of hospital care Unstable patient out of hospital care
Stable patient?
Yes No
Scheduled admission
Emergency Day hospital
Secondary Care
· Assessment· Clinincal interventions· Therapeutic plan
In hospital care Hospital discharge preparation
Cardiologist Pulmonogist
Other specialist
Discharge report (electronic)
· Coordination with Primary Care
· Follow-up planning
Integrated social assessment
· Social assessment
· Home hospitalization· Sub-acute hospital
admission
Yes
No
Stable patient, additional resources needed?
Reference internist
Hospital nurse
· Home hospitalization· Reference internist
(interconsultation)· ehealth Centre
Social resources
Social Care
Hospital Social worker
Secondary CareReference internist
Secondary Care
Hospital nurseSecondary Care
Reference internist
Social Care Secondary Care
* * **
***
* Entering into service
*
Integrated Care Pathways
35
Model based on
structures
Model based on
Integrated Systems
Fragmented
Reactive
Paternalist
Continuum of care
Proactive
Patient empowerment
Need to move towards a model focused on “systems” rather than “structures”
Case
manager
Liason
nurse
Community
carenurse
Reference
Internist
Reference
Specialist
Primary
Care
Subacute
hospital
Acute
Hospital
Counseling
services
Model1
Model2
Model3
Model4
Model5
Model6
3
3
2
1
1
1
Improvement areas identified
39
ICT toolsOrganization
/persons
ProcessesChange
management
• New functionalities in EHR
• Optimize information sharing
• Integrate telehealth data in
EHR.
• Correct identification of the
patients included in the IIP.
• Extend new nursing roles
• Deploy the role of the
Reference internist
• Improve job descriptions
• Promote social health care
coordination
• Improve care pathways
• Enhance proactivity of care.
• Ensure continuity of care with
Counseling Services.
• Optimize stratification tool
• Refine the evaluation
framework
• Collaborative space
(benchmark, training
programs, communication,
care pathways).
• Improve patient
communication
Telehealth Pilots
BIZKAIA
GIPUZKOA
ARABA
1
Telbil A
Telbil T FRAIL
2
U4H CHF
3
Telepoc COPD
4
Respirratory
rehabilitation
5
Teki COPD6
Tele diabetes
7
Frail Patients
CHF
COPD
FRAIL MM
DIABETES
SYSTEMS
Weight
Oxigen
saturation
Questio
nnaire
Devices and
services
Hardware
Software
Reception Base
HOME
EHR Osabide
Telecare
Blood
pressure
Manual
EXTERNAL
WEB
PLATFORM
Main findings
• Facilitates clinical decision making.
• Better relationship with professionals
• Sense of security and easeness, patients and
caregivers
• Patients greater role in self-care.
• Greater adherence to treatment.
• Increased satisfaction
• Avoid admissions and increases patients quality of life.
BUT EXTENSION AND SCALING UP?
CHF Management Protocol
HOME Telecare call centre
BetiOn
24X7 Health Counseling
call centre HACC
Emergencies
Specialist Consultant
Primary Care
Technical
Social alarm
Validated
Health related alarm
HACC Resolution
Referral to
Primary Care
(apppointment)
PC Resolution Resolution
With Specialist consultant
(teleconsultation)
Referral to Specialist Consultant
Activation alarm
215
43
4
5
Weight
Oxigen
saturation
Question
naire
Devices and
services
Hardware
Software
Reception Base
HOME+ BETI ON
HEALTH SERVICE
CRM
Process
management
Platform
Telecare
Blood
pressure
Manual Server EHR Osabide
Scaling up telehealth projects
Index
• Introduction: Basque Country
• A strategy to deal with ageing, chronicity
and dependency
• Two cases:
– Multimorbidity patients
– Telehealth
• Main ICT features
• Lessons learnt and conclusions
Some levers of action for a more efficient provision of healthcare services :
• The incorporation of ICT tools and ICT-based processes
• The deployment of services through remote channels
• Patient empowerment and the home as a place for effectively controlling the disease
ICT innovation: part of the solution
Electronic prescription
Electronic clinical record
Shared information systems
Public tele-care services
Multichannel service platformLocal remote monitoring pilots
(tele-COPD, tele-HF, control of oral coagulotherapy, etc.)
Technological infrastructure
One unique
portalNew
Appointme
nt Model
Medical
Counseling
Patients
remote
monitoring
Prevention
campaigns
Healthy
habits
promotion
Active
Patient
Personal
information
access
Service Portfolio
Service Portfolio
Strategic projects: Multi-channel Health Service Center
50
• Web 2.0
• CRM
• IVR
• BI
Patient-
professional
collaboration
51
One unique
portalNew
Appointme
nt Model
Medical
Counseling
Patients
remote
monitoring
Prevention
campaigns
Healthy
habits
promotion
Active
Patient
Personal
information
access
Service Portfolio
Service Portfolio
Health advice over the phone and
on the net, managed by
Osakidetza nurses.
Personal Health Record for every
citizen, which will
access to information
contained in the EHR
Support for the strategic projects
related to chronicity
Technical support for non face
to face consultations and
telecare.
Leadership and management
of the New Portal 2.0.
Administrative procedures
online
Create a tele-medicine
solution for chronic patients through
mobile platforms
Public Health Campaigns through different channels.
Surveys for citizens to improve knowledge of Health
System
Health School for patients:
validated information by
Osakidetza’s Doctors
Nurses and specialists
and Patient Forums
Extend for the whole population,
the new appointment model to GP,
Paediatricians, nurses and
midwives, through the telephone
channel (IVR and call center).
Healthy Lifestyles promotion
application implementation in
primary care
CRMBI
Patient-
professional
collaboration
Multi-channel Health Service Center customer relationship management
Patient empowerment & home-support pathway
Two points of view:
Pre- start:
• Solve most problems
• Matches Health System needs
• Promises a short development & deployment process
Pre- start:
• Single Payer Healthcare systemspredicts Economies of scale.
• Historic Business Models based onindividual projects
• Fidelization gives market advantage
Health System View Provider’s View
In the long term…
• It requires larger funding and time foradapting and updating
• Significant Transactional costsdevelopment and deployment
In the long term:
• Each Health system has differentstrategies, systems and processes
• Higher Transactional costs
• Budget shortages reduced margins
Index
• Introduction: Basque Country
• A strategy to deal with ageing, chronicity
and dependency
• Two cases:
– Multimorbidity patients
– Telehealth
• Main ICT features
• Lessons learnt and conclusions
Lessons learnt
• Fragmented care delivery inertia protected by laws, norms
and interest groups
• Health care practices highly stable: network of influences
and constraints (knowledge, beliefs, attitudes, habits,
systems, incentives, …)
• Clinicians need evidences: risk free and clear benefits!
• Backlash of unrealistic expectations!
• Difficult integration in clinical practice and information
systems
• High risk no substitution effect: new models require extra
resources and the former practice remains!
• Commitment and active role of politicians
• Involve managers and clinicians… AND NURSES!!!
• Promote local experimentation and scale up successful ones
• Patient and informal caregiver empowerment is essential.
• Technology is crucial to facilitate coordinated management of
all processes and communication between professionals.
• Accept that there is not a single model to move forward:
learning process !
• Identify trends, reallocate funding, align incentives and
objectives
• Process needs time: continuity and resilience!
Lessons learnt
• Crisis is an opportunity
• Provide a narrative which provides a vision and structure
• Co-create products and services
• Large-scale rollouts require a prior multi lever strategy of
organizational change: MATURING ECOSYSTEM
• Need to reallocate funding and redefine targets and
timelines
• It is not easy, ¡Keep going!
Conclusions
If you want to go fast, go alone,
if you want to go far, go together
African proverb
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