Chief Physician Odense University Hospital Hospital of Svendborg, Denmark
Even though IT communication systems like mobile phones and Internet are well established in most parts of the world, their usage by the medical profession is fare from optimal. The doctors just do not seem to care! How come? Why do we not take these tools, right at hand, into our world? The obvious reasons ought to be well known: lack of specialists, lack of services to patients living at a distance from hospital, growing number of elderly people in need of chronic care and lack of money. But other factors seem to be the bigger challenge: the urgent, evident need of change of culture and the need to share competence among the staff of a hospital. Furthermore, it has been argued that the patients are not ready to cope with the IT-solutions. This is far from the truth. The fact is that if handled properly these problems can be overcome.
The patients and the population are ready! They already have, or will soon get access to sophisticated communication systems and will expect the medical world to go along and offer professional support whenever and wherever they need it. In other words we have to deal with the growing demands of accessibility. Organisations, who will not adapt to these demands, will sooner or later get into serious problems.
Care providers need to realise that the medical world is changing from a market of supply to a market of demand. In other words, we have to accept a set of guidelines that can be referred to as the patient principles:
Sharing competence is a very important issue in adapting to IT solutions. It is obvious that doctors must focus on patient matters, wherever their knowledge is needed. However, many specialists perform consultations that could be performed by trained nurses just as well.
In my medical department, we have worked seriously on this issue for many years and today about 50 per cent of all outpatients are consulting the nurses. For 5 years, we have been running out patient clinics at a distance on a small island, 3 hours travel from our hospital.
A good example of this is patients suffering from type 2 diabetes on a near by island: a specialist nurse travels to the island twice a month and takes consultations. Whenever she requires the consultation of an endocrinologist, she connects via the Internet to the hospital and gets the doctor online for support. The doctor then takes over the consultation, talks to the patient and provides the necessary treatment. A simple solution and yet the treatment of patients with type 2 diabetes has improved considerably. The HbA1C has fallen from 8.7 to 7.2 per cent in the population. This is astonishing!
Another such example deals with patients suffering from suspected heart failure. A specialised trained nurse goes to the same island, equipped with a portable echocardiograph. She makes the ultrasonic investigation and concludes whether the condition is normal or abnormal. Whenever an abnormal investigation occurs, she connects to the cardiologist on duty and shows him the result of the ultrasonic investigation. The cardiologist then makes a decision on the issues and takes over the consultation. All the normal investigations are afterwards shown to the cardiologist. In the last five years, 75 per cent of the referred patients had a normal echocardiography and could be discharged instantly. In addition, the amount of medication for heart failure rose to the expected level for patients suffering from the disease. All this is well documented in our regional prescriptions database.
Let us turn to another issue: sharing competence and assisted IT solution have proved to be of great value in minimising the amount of 'in days' in the medical ward for the severely ill chronic patients.
Several studies have proved that Assisted Home Care (AHC) is as good as continuing hospitalisation for about one-third of the patients admitted because of exacerbation of Chronic Obstructive Pulmonary Disease (COPD).
The goal is to seek solutions that are safe for the patients, save time for the specialists and bring down the costs.
Our medical department, together with MedCom International is conducting a project, which brings ICT tools into healthcare and thus, in a cost-efficient manner, facilitates high-quality care for chronic patients by offering hospitalisation at home.
The objective is to compare AHC with hospitalisation at home under the surveillance of a newly developed briefcase that enables the hospital to be in contact with the patient through ICT. The project focusses on COPD (often referred to as smokers' lung disease) patients and the overall goal is to reduce the length of hospital stays for a patient group, to reduce cost and, more importantly, to improve the quality of life for the patients. During the summer of 2006, our medical department and GITS, a Danish IT company, developed a patient briefcase, which makes it possible to take care of COPD patients in their own homes. The ICT equipment allows live images / sound as well as data measurements from medical equipment (e.g. Spiro meter and devices to measure oxygen saturation) to be quickly transferred to the hospital either via the Internet or a satellite connection. At the hospital, the doctor can evaluate and guide the patient as if the patient was present at the hospital. The data transmitted from the patient's home enables the hospital to perform a systematic monitoring and control the quality of the treatment.
The patient briefcase (MediSat®) is a specially developed, portable communicating item that includes video-conference equipment, three buttons (on / off, call me and sound adjustment) and medico technical equipment, connections to the specialist via ADSL / LAN or satellite, A mobile phone with the specialist on duty to receive calls from the patients and a computer with electronic medical health record at hand and videoconference equipment.
The population of the Svendborg Hospital consists of five municipalities. Two of these, (A) have made agreements with the medical department to participate in the project, and the other three municipals (B) have been given the part as controls. Every patient, admitted to the department because of exacerbation in COPD, is evaluated through a validated test to part them into one of three groups:
Patients from group 3 are offered an early dismissal within 48 hours supported by the portable IT solution which enables the patient to ask for urgent assistance and provide for hospitalisation at home with regular rounds by a specialist at fixed times.
During the first 24 hours of admission, the patients are instructed in how to use the briefcase. The aim was to include 50 patients with the briefcase at home and 50 patients with assisted home care solution with the controls of the patients from the B municipals. The evaluations focussed on 1) safety of the technology 2) patient experience 3) savings on in-time in the medical ward 4) savings on economy compared with continuous admittance / assisted home care-solutions 5) experiences from the hospital staff 6) number of patient readmitted within the first 30 days.
1. Patient's satisfaction is evaluated by an interview, conducted by a third party (a department of quality) and finally a control-visit in the outpatient clinic four weeks after the briefcase has been withdrawn
2. System effectiveness is evaluated by the number of re-admittances within the first four weeks, compared to a control group
3. The different technologies of the briefcase are continuously evaluated by surveillance of reliability
4. The costs of the different solutions
Results (47 patients with the briefcase)
1. The patients feel safe and comfortable at home
2. Everyone asked will participate
3. Reduction in number of patients who were readmitted within the first month by more than 50 per cent
4. Reduction in 'in-days' by 5 days on an average
5. Improved staff-patient relations
6. Reductions in expenses
The study is still in progress.
Chronic patients have to be offered services of surveillance, either by education or by offers from the specialists.or both! I believe that educational programmes can improve the competence of these patients and evolve them to be alert of their own symptoms and react properly to hard-core medical measurements. The last part can be supported by surveyed IT systems that makes early intervention possible and thereby either improve the everyday status or even avoid admission into hospital units. Furthermore, the specialists can considerably improve care by using their skills wherever needed and not on problems which could be handled by nurses.
All over the world, healthcare providers have to deal with the growing demands for medical services. We can do this by developing solutions, which are cheaper and seek solutions where the population gets more value for money (the average in-bed time for patients in medical departments vary an astonishing 9-7 to 4-2 days even in Europe!).
Many options are right at hand and well documented yet they are not used. We could, for instance, start by adapting to the growing access to IT-solutions used in other parts of the society.
Many IT-systems are already there for medical purposes, but the use is limited to hard-core fanatics within the healthcare sector and to very local initiatives. That is just not good enough! The doctors also have to learn, that sharing competence with nurses does not mean loss of prestige but helps reaching the overall goal: improving healthcare to the population that we are meant to serve. We are in urgent need of support from the government and from the medical profession.
Michael Hansen-Nord has been chief physician at one of Denmark's largest medical departments, leading a team of 84 doctors, for the last 7 years. Since 2003, he and his team have been working with the Danish Center of Health Telematics (MedCom). The first e-health programme, they took part in was the Health Optimum, the e-health project of 2005 in the EU. The present focus of his team is the chronic patient with more than 2 admittances a year with the aim of reduction of in-bed-time and re-admittances.