Technical progress, statistical evidence of significant increases in therapeutic success, as well as the participation of an increasing number of ambulatory physicians has made telemedicine successful.
Health is one of the most important human commodities. However, in times of economic shortage, it is not only crucial that a healthcare system is fair and effective, but also that it is efficient. Protagonists and institutions within the German healthcare system are increasingly having to base their actions on the imperative of efficiency. But this necessity for efficiency is not the only thing changing the situation in the care system. The simultaneous occurrence of erroneous care, overcare and undercare, as well as increasing patient contributions to the costs and, especially, medical progress and the resulting increase in chronic diseases are all playing their part. This increase is also due to the demographic development, which is leading to an ever larger morbidity in the field of chronic diseases, in particular as a result of a steadily aging population. The growing shortage of physicians is also taking more and more of an effect, exposing the limitations of medical care and necessitating the creation of new care structures.
The Institute for Applied Telemedicine (IFAT)
The cardiologists at the Heart and Diabetes Center North Rhine-Westphalia (HDZ NRW) in Bad Oeynhausen, University Hospital of the Ruhr-University of Bochum, are among the pioneers of telemedicine and have been working successfully on this project since 1998. The Institute for Applied Telemedicine (IFAT) was founded at the HDZ NRW in late 2003. It plays an integral part in various medical quality studies and also conducts its own. With due respect to data protection and medical secrecy laws, patient data are collected at IFAT and statistically evaluated. The patients, as well as all treating hospitals and physicians, are informed of this procedure in detail. The result is a multitude of services which IFAT is able to provide in the areas of prevention, diagnostics and treatment.
To date, more than 7500 patients with cardiological diseases have been monitored and treated by IFAT. Chronically diseased patients are able to be treated in accordance with the guidelines as a result of their own collaboration in a kind of cross-sector telemonitoring. Its goal is the treatment at home of patients with chronic diseases such as cardiac insufficiency, diabetes mellitus, impaired coagulation, increased risk of heart attack, chronic arterial hypertension or cardiac dysrhythmia. Patients are looked after by the telemonitoring team at IFAT and appropriately trained physicians at the HDZ NRW. The aim of this undertaking is to improve both the quality of life and the safety of patients in the light of cost reductions in the healthcare system. Should IFAT observe any changes in the health of its patients requiring more intensive supervision by a family practitioner or even inpatient treatment, then the institute will initiate this step. IFAT is striving to introduce blanket coverage of telemedicine, primarily through integrated care contracts and in particular with AOK NordWest. This is taking place in close cooperation with family practitioners, ambulatory physicians, other specialists and clinical contact partners. Qualified evaluation of data, supervised by a physician, is guaranteed around the clock, 365 days a year. The medical expertise of the IFAT team is continually being expanded by networking and integrating telemedicine in other fields of medicine. The comprehensively trained physicians and specialists on call rotate after four months of telemedical work to perioperative cardiology or outpatient care, where they gain practical experience in ambulatory and diagnostic medicine. This guarantees a high level of training and further training for IFAT staff, reduces staff fluctuation and increases motivation.
IFAT’s chief cooperation partners are ambulatory physicians and hospitals. IFAT thus functions as complementary support to the conventional treatment of patients. The indication for telemedical supervision by IFAT is pronounced by the cooperating physicians. They also select the diagnostic equipment required, such as a blood pressure measuring device, a set of scales or a portable ECG device, and decide the duration of telemedical monitoring.
From March 2011, patient telemonitoring at IFAT will undergo technical reorganization. A special telemedical software platform is being created using the medPower power solution from IBM premier business partner SVA and IBM technology, with support from EU and regional funding for its development and implementation at IFAT. This new platform will provide a higher quality of treatment, easier access to affiliated physicians and hospitals, lower costs, less complicated processes and higher safety levels.
Models of care for home monitoring
Preparatory work for IFAT began as early as 1994. Clinical studies on anticoagulation self-management following mechanical heart valve replacement were performed at the ESCAT (Early Self-Controlled Anticoagulation Trial) headquarters. Patients in a study group were each given a CoaguChek measuring device from Roche Diagnostics Deutschland GmbH, enabling them to measure their INR values at home. The ESCAT I and subsequent ESCAT II studies were able to show that self-management and an INR adjustment within the low-dose range are significantly able to reduce the complication rate, as well as patient mortality and morbidity, compared to conventional treatment by family practitioners.
The current ESCAT III study has reduced the INR target ranges of 1.8-2.8 for patients with aortic valve replacement and 2.5-3.5 for patients with mitral valve replacement to 1.6-2.1 (aortic valve replacement) and 2.0-2.5 (mitral valve replacement) after seven months in order to examine whether in this study group, with very low adjustments, significantly fewer complications (e.g. hemorrhaging, thrombosis) occur. Such a tendency could already be ascertained in the interim analysis. Patients performing coagulation therapy self-management display a scientifically proven loss of expertise over the course, which reduces the quality of their INR adjustment. For this reason, in 2003, the TELEQIN study (Telemedical quality assurance in INR self-monitoring versus INR self-management after a mechanical heart valve replacement) was initiated. TELEQIN is a prospective study for evaluating INR quality following mechanical heart valve replacement. It aims to register the frequency of under and overadministration of marcumar, as well as to draw up a mid- to longer term quality control evaluation. This study is examining whether the loss of expertise in patients can be compensated by continually monitoring them with telemedicine, in order to guarantee optimum safety in the long term.
Since IFAT was founded, more than 3000 marcumar patients have joined the network and received telemedical care. On the basis of more than ten years’ experience with anticoagulation following heart valve replacement, a system has been developed for the telemedical quality assurance of INR management. The telemedical thrombosis service reliably helps patients to ascertain their INR values and promptly recognizes any fluctuations in coagulation status. Patients with the appropriate indication are equipped by their health insurance companies with a CoaguChek XS coagulation measuring device for autonomous ascertainment of INR values. In addition, IFAT provides patients with an electronic data transfer module. Patients are instructed in INR self-management or INR self-control 7-10 days after the heart valve operation. How to use the devices, the anticoagulation treatment, how to use the test strips and the telemedical data transfer are all explained to the patients. Immediately after an INR value has been measured, patients use the module to transmit it to IFAT automatically. There the new data are added to the corresponding patient file and looked at by physicians and trained staff. If the values are outside the therapeutic range, a physician contacts the patient to discuss what action is to be taken.
(NOPT / AUTARK)
Inpatient rehabilitation measures after surgery are conducive to the healing process, but contribute to financial pressure on the healthcare system. Politicians are therefore now concentrating on establishing a care system which prioritizes ambulatory over inpatient care. With this in mind, ambulatory rehabilitation with telemedical support for patients after a heart attack or cardiac surgery was tested as a pilot project in the NOPT study – New OWL Postoperative Therapeutic concept – from 1998 to 2002.
In 2005, following positive experience with the NOPT study regarding physical performance and quality of life in patients undergoing ambulatory rehabilitation with telemedical support, the AUTARK program was developed – ambulatory follow-up rehabilitation following coronary or valvular surgery on the basis of telemedicine. With AUTARK, patients are spared tiring journeys to outpatient clinics, while their autonomy at home improves their quality of life. Participation in the program does require the continual support at home of next-of-kin or other carers, however.
Patients are supervised over a period of three months. They are equipped with a portable ECG device and a bicycle ergometer. Following a thorough postoperative cardiological examination, patients are prepared for ambulatory rehabilitation, including individually adapted instruction and consultation on their particular cardiovascular risk factors (arterial hypertension, nicotine abuse, hypercholesterolemia, diabetes mellitus, lack of exercise, diet). Training also includes practical instruction on operating the portable ECG device, which can be used in an emergency to record and send an ECG by telephone to the medical team at IFAT. On the basis of their postoperative ergometric values, patients are given an exercise plan for closely supervised implementation at home using the bicycle ergometer provided. The exercising program should be completed daily, but can be adjusted to suit the individual routine of the patient in question and is thus very flexible. Every three weeks, the treating family practitioner and cardiologist perform ambulatory check-ups. After each check-up, the exercising program is adjusted to suit the updated condition of the patient. The portable ECG device also helps patients to estimate their physical tolerance levels more accurately, providing a high degree of safety. The treatment plan for the rehabilitation period has an interdisciplinary framework and includes different levels of patient care, but the overall coordination of everybody involved is managed by IFAT.
SMART – Slim with Applied Telemedicine
Over the past few decades, the number of overweight and obese people has increased dramatically. Obesity is one of the most significant risk factors for cardiovascular diseases. There are many programs which target weight loss, all with different aims, and yet participant compliance in such measures is often insufficient. Since October 2006, patients have been able to participate in the SMART program. Based on experience gained in the initial SMART study, IFAT offers overweight patients who would like to be slimmer, as well as patients who would like to keep their weight down after successful slimming, the chance to participate in the telemedically supervised SMART program for 12 months. The aim of this weight management program is to achieve a long-term adjustment of diet and lifestyle in participants, while reducing body weight and improving cardiovascular risk factors. Following an initial examination, participants are individually supervised and counselled by specialists at IFAT. Here, too, patients are equipped with a special set of scales and a Bluetooth mobile phone for transmitting their values. Instruction in the program takes place at the HDZ NRW. Following an interim examination after six months, the second half of the program is then continued autonomously by patients at home (telemedical supervision and transmission of recorded weight). At the end of the twelve-month period, a final examination is performed.
Ambulatory rhythm diagnosis/ ischemia detection
In addition to the abovementioned programs and telemedical studies, IFAT also attempts to reach all cardiovascular risk groups by offering programs for patients who suffer from cardiac dysrhythmia or have problems breathing. In clinical practice it is often difficult to record cardiac dysrhythmia because it occurs so irregularly. It is often the case that during an outpatients consultation or a 24-hour, even a 72-hour Holter ECG no dysrhythmia is recorded. Patients with difficulties breathing often do not know the cause. This is the basis for telemedical rhythm diagnosis and ischemia detection. For their telemedical supervision, patients are given a portable ECG device which guarantees transmission of an ECG in the highest quality with maximum safety. Two device types are available to patients. The Cardiophon with twelve leads is for patients with apnea (breathing difficulties) and an unclear cause (ischemia detection). The Holterphon with one lead controls heart rate in conjunction with dysrhythmia, atrial fibrillation or tachycardia (palpitations). This portable ECG device can be used by patients after a very short instruction period. Transmission of an ECG recording is possible with immediate effect. When the symptoms in question are experienced, a recording can be made at the press of a button. The recorded ECGs are transmitted to IFAT as an acoustic signal via an open telephone line, where they are evaluated by IFAT experts. The results are then sent straight to the treating cardiologists. In an emergency, the physicians at IFAT can give patients immediate advice or, if necessary, send for an ambulance.
Telemedical blood pressure management
Telemedical supervision is also suitable for patients with hypertension or hypotension. The telemedical controls give chronically sick and high-risk patients an elevated degree of safety and a better quality of life. Dangerous fluctuations in blood pressure can be detected early on, enabling physicians to intervene straightaway. Patients receive blood pressure management instruction in a special training session which includes operation of the telemedical device. They then transmit their blood pressure and pulse values to IFAT at regular intervals. This regular transmission of data by patients means that all values can be precisely monitored. In an emergency, necessary measures can be taken immediately.
IFAT links patients, ambulatory physicians and hospitals. An electronic patient file means faster and better access to information for all physicians involved in the treatment of a patient under telemedical supervision. In addition, the physicians themselves pronounce the indication for telemedical supervision. For each of the diseases mentioned, a modular concept is in place so that the clinical picture can be monitored telemedically. All care programs were developed with the additional goal of investigating the medical and economic benefits of telemedicine. The success of telemedicine is now scientifically proven. This success is based on technical progress, statistical evidence of significant increases in therapeutic success, as well as the participation of an increasing number of ambulatory physicians. In addition, savings of 30-40% have been realized for the cost bearers. By closely linking clinical research and scientific practice, and through the variety of programs available, the comprehensive range of preventive, diagnostic and therapeutic services is continually improving. Patient satisfaction with the system, which has also been scientifically proven, plays a particularly important role alongside the medical aspects. The greatest problem which still needs to be solved is how to increase acceptance of this new type of care in the medical colleagues working in inpatient and outpatient care.
HerzAs Telemedical care of patients with a structural cardiac disease including symptoms of cardiac insufficiency
Chronic cardiac insufficiency is one of the most common internal diseases and can lead to cardiac decompensation on the basis of different mechanisms.
A new concept for treating chronic cardiac insufficiency within the framework of integrated care has been in place at IFAT since January 2008. Patients with chronic cardiac insufficiency of degree NYHA II or higher are cared for jointly and in accordance with § 140a SGB V by IFAT, AOK NordWest, the German association of ambulatory cardiologists in the SHI region Westphalia-Lippe, the regional association of medical practice networks Westphalia-Lippe, the association of SHI physicians Westphalia-Lippe, as well as KVWL-Consult. Patients join the program on the basis of an assessment by their local cardiologist. The latter then also instructs them in the telemedical procedure.
Home monitoring, with its combined modular structure, facilitates early detection of signs of cardiac decompensation and thus immediate therapeutic intervention. Patients are equipped with a set of scales and, if appropriate, a blood pressure measuring device and an ECG device (Holterphon/ Cardiophon). Regular back-up examinations are performed by the treating cardiologist after three, six and twelve months, and by the family practitioner after three, six, nine and twelve months. During the IFAT program, initially spanning twelve months, patients are supervised in telephone consultations. They are instructed in how to deal with their disease in prevention talks which take place in the first six weeks. In these talks, patients receive comprehensive information about their disease, use of medication, diet and lifestyle.
The vital parameters recorded using the scales and blood pressure measuring device are transmitted to IFAT by text message automatically, where they are collected in a database. Recorded ECGs are transmitted to IFAT as an acoustic signal via an open telephone line. Patients can thus ascertain their values with these devices independently and autonomously, sending them to the telemedical service center at any time they choose around the clock. At IFAT the data are checked by experts and compared with previous values logged in an electronic patient file. If the new values indicate any deterioration (cardiac decompensation), the physician then telephones the patient in order to take early measures and prevent repeat inpatient treatment. Four times a year, a complete set of pathological data is sent to the physicians working within the program. In an emergency this happens immediately.
Heinrich Körtke is the Medical Director of the Institute of Applied Telemedicine (IFAT). He is a member of the working group “INR Self-Management“ of the German Society of Cardiology; member of the Association of German internists; and Member of the Medical Board of the German patients’ magazine “Die Gerinnung”.