Interactive education new standard in patient information
From now on, Indiveo’s information videos and animations can also be found in the Luscii app for telehealth coaching. They are a user-friendly way for patients to learn how to deal with their illness. The partnership between Luscii and Indiveo takes self-management to the next level.
Pulmonologist Ralph Koppers from the Medical Center Leeuwarden was frustrated by patient leaflets full of general information and endless paragraphs of text. To change this, he got together with designer Edwin de Boer to establish Indiveo. Their “Divis”, as they’re known, provide accessible and bespoke patient information, in audio and video form. Already, more than 30,000 patients have used Indiveo as a source of information. “We’re finding that, thanks to the information we provide, people are less unsure about what to expect,” says the pulmonologist.
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Example of a “Divi”
Education via the Luscii app
The Luscii app is now used in nearly half of all Dutch hospitals. The app has three main functions for remote patient coaching: home monitoring, education, and contact. “We wanted to modernize our educational element, but only with the very best user experience,” says Dr. Joris Janssen, Head of Product at Luscii. “Cid Berger, Commercial Director at health insurer De Friesland, put us in touch with Indiveo. Through their foundation, they had funded the creation of several Divis and thought there was great synergy.”
Strength in Synergy
Luscii’s goal is to coach patients towards independence. “Self-management is crucial to this,” stresses Joris. “By integrating Indiveo into Luscii, we can enable this in a very modern way. Bespoke information is instantly available in the app. And together we’re developing Knowledge Biites: short, interactive questionnaires that digitally coach patients in everyday situations. Exercise, nutrition, maintaining your network: All of this is covered in the Knowledge Biites.” Lung specialist Ralph Koppers is also enthusiastic. “This way, we can use our Divis even more widely and add to them.”
One App for all Diseases
The first Divi produced by the Luscii/Indiveo partnership was for people with COPD, but it doesn’t stop there. There are Divis for lots of specialties, and Luscii can already be used in various fields. The partnership is a great example of the strong synergy created when Dutch companies join forces.
Wilhelmina Hospital Assen (WZA) now has more than half a year of experience with the Luscii app, and enthusiasm levels are high. Evaluations show that patients feel safer, the cooperation between professionals is running smoothly and Luscii is easy to use. Therefore, the hospital has decided to expand. Initially, within the heart failure department, but with ambitions to extend even further.
It was back in April 2019 that the first patients at WZA’s heart failure clinic were introduced to the Luscii app. Since then, patients measure their own pulse, blood pressure and weight at home, which means they no longer need to visit the hospital for check-ups. The measurement data is then sent via the Luscii app to the Medical Service Centre NAAST. Is there a rise in weight or blood pressure? If so, NAAST informs the heart failure nurse in the WZA immediately. With a razor-sharp video connection, the nurse can make direct contact with the patient to assess the situation.
Nurse takes the lead
Stoer, a heart failure nurse in training, is one of the initiators. ‘At the outpatient clinic, I often see people returning for check-ups. And yet, agendas are bulging. I asked myself: could we not do something differently? We already had a vision document on remote guidance in the WZA, so I started to look for suitable systems. Then I came across Luscii. Coincidentally, our board was already in contact with Luscii’. A meeting was then arranged between cardiologist Richard de Jong, WZA director Suzanne Kruizinga and Daan Dohmen, the founder of Luscii. And Erica Stoer? She joined too. ‘We are a relatively small hospital with more direct lines. Everybody knows each other. The fact that I was a part of such a conversation as a nurse fits in with that philosophy. Ultimately, I’m the one who has to work with the system’.
About thirty patients with heart failure are now connected to the Luscii app, and enthusiasm levels are high. Evaluations show that patients feel safer. The collaboration between professionals is also going well and the Luscii technology is easy to use. That’s why the decision was made to continue to expand. Initially to fifty patients, but the ambitions of the hospital extend even further.
Step by step
‘The growth from thirty to fifty patients is an intermediate step’, according to cardiologist Richard de Jong. ‘We need to gain experience and adjust the organisation where necessary. Of course, I would prefer to supervise all my heart failure patients remotely. It is still too early for foregone conclusions, but several studies have since shown that remote guidance stimulates a patient’s insight into their own illness and encourages self-management. We even expect that the number of acute admissions will decrease in the long term because we can spot deterioration earlier. Growth in the number of patients does mean a shift in outpatient work. Nurses are now in charge of remote guidance. They are doing a great job, but they must be facilitated in that responsibility. For them, I am merely a supervisor and a back-up’.
The right care in the right place
Director Suzanne Kruizinga, formerly a doctor in emergency care, thinks it is a wonderful development. ‘We are eager to scale up extensively with Luscii. I would prefer to include all patients who need care for a longer period of time in the home measurement program today. The aging population is increasing the number of patients while specialist nurses are becoming scarcer. The right care in the right place offers a solution and Luscii’s technology helps to implement it safely. In addition, we desperately need to involve patients more in their treatment. Research shows that telemonitoring offers a starting point to achieve this goal’.
Sometimes, Kruizinga experiences some opposition within the organisation. ‘Healthcare professionals have to let go of their patients and that is not always easy. But’, she puts the resistance into perspective, ‘it is, above all, a challenge to steer the enthusiasm about remote guidance in the right direction. Every week, I have a medical specialist at my desk who has big plans for home measurement. And we had to stop recruiting patients because we couldn’t handle the influx. I want to scale up as quickly as possible, but carefully, too. Remote guidance means adjusting processes. I prefer to do that without overhauling the entire organisation. Learn, grow and consolidate, that is the goal. There must be room to try new things and make mistakes. And the revenue model must also be right. But I am confident that, together, we can make the transition a success’.
Health care insurer happy with safe care at home
Many people like being treated at home’, says Rutger de Vries, senior buyer at health care insurer Zilveren Kruis. ‘They feel that this type of care gives them more control over their lives, flexibility and comfort. So, we are happy with the upscaling within the WZA. The hospital puts innovation to the fore. Periodic check-ups for chronically ill seniors have long been the rule, but home measurement offers many benefits. It leads to customisation and prevents patients and their loved ones from having to travel unnecessarily. Hospitals see that. However, it requires a change in organisation and different ways of working. For example, nurses need support in their new role. We continue to actively look for options to organise healthcare in a smarter manner and are subsequently following developments in the WZA with more interest than usual’.
De Vries agrees with Suzanne Kruizinga that the revenue model of the WZA needs attention. ‘When hospitals are successful with telemonitoring, this leads to fewer visits to the outpatient clinic and emergency department. That is good for the patient and healthcare costs, but not for the income of the hospital. We are currently in discussions with the WZA about compensating for such a loss of income. After all, money cannot put the brakes on this great development. We will look together at which type of contract offers the best solution’.
In the meantime, the WZA has not been idle. With the publication of this article, the upscaling to fifty patients has long been achieved and there are concrete plans to use the Luscii app in other specialties, including oncology and surgery.
In the view of many doctors and nurses, remote guidance is still seen as a thing of the future. However, the Dutch Slingeland Hospital, which is a part of Santiz, has been guiding chronically ill patients from a distance for years. Luscii spoke with Malou Peppelman, a program manager of innovation at Santiz. Who is Malou? What is her role? And why has her hospital soared so far forward in terms of experience?
Some children dream of becoming a firefighter. Yet, you thought: ‘When I grow up, I’m going to be an innovation manager’?
‘Ha ha, no. After my pre-university education, I had various interests. Healthcare appealed to me a lot, but I also liked maths and technology. That’s why I opted for technical medicine. After graduating, I obtained my PhD in Nijmegen on non-invasive techniques for skin disorders. As a postdoc, I then worked for a while at the Radboud Hospital. Working closely with healthcare practice, collaborating with companies, and implementing innovative technology; it was useful, fascinating and educational. Afterwards, I wanted to broaden my horizons. I had management ambitions, but I also longed to be involved with innovation in healthcare. I got talking with Santiz hospitals. They were in the process of setting up an innovation structure in Doetinchem (Slingeland Hospital) and Winterswijk (Queen Beatrix Regional Hospital), and saw a great role for me to play in the process. That’s how I became an innovation manager’.
And what exactly are you doing now?
‘I have a connecting and a facilitating role. Whenever doctors or nurses are faced with obstacles, I put them in contact with the right person to arrange a solution. That can be internal, but also external. For example, the medical service centre NAAST undertakes the first triage of the patients we guide remotely. And Luscii provides the digital technology. In the region, we are working with a pilot for a personal health environment (PHE). That is a website or an app, through which you can actively get started with your health and well-being. You can manage medical data, but can also share the information with, for example, the doctor or district nurse. As far as that is concerned, it is important for me to have a good network. In addition, I have a more strategic role. I initiate and lead various projects and am chairwoman of the innovation steering committee within Santiz’.
You are quite far ahead when it comes to digital innovations. Is it difficult to keep healthcare professionals connected?
‘A technical innovation is never implemented just like that. There is an idea behind it. It has to be the solution to a bottleneck. For example, we don’t use telemonitoring for the fun of it: it is there to benefit the well-being of the patient. The complications do not lie in the technology, but in the alteration of work processes. That is often the biggest challenge. It begins with explaining effectively why change is needed and then facilitating in helping others take the first step. Initially, we try to get the enthusiasts involved. They are then in the best position to get their colleagues on board. Here, a vast network is important, too. After all, I have to know who the enthusiasts are’.
How do we keep healthcare future-proof?
‘We are struggling with an aging population in the Achterhoek. This causes pressure on the system from two sides. Together with our partners, we are looking for local solutions. But for that, decompartmentalisation is necessary. Administration wise, we are now on the right track with the PHE. But at a financial level, every organisation still has to stand on its own two feet. Here too, solutions are sought based on solid regional cooperation. Steps are also needed at capacity level. If an alarm from a patient arrives at the service centre, the nearest district nurse must be able to get there. Whether he or she is from organisation A or organisation B should not really matter. After all, together we have to organise healthcare in the region as efficiently as possible’.
That pressure on the region, with the aging population: does that explain your head start when it comes to innovation?
‘Santiz has anticipated the challenges of the future at an early stage. And the fact that the pressure has rapidly increased has certainly helped. We have the ambition to make healthcare more sustainable and bring it closer to home. We achieve this by making healthcare proactive instead of reactive, and we use various digital and technological solutions in order to fulfil our goal. The right care, in the right place, from the right caregiver is subsequently an important principle. Those who really need to be in the hospital are very welcome. If it is not a necessity, then we organise care outside the hospital, for example, with telemonitoring. We invest in self-control for patients and look closely at the qualities of our employees. The direction for remote guidance, for example, lies with nursing specialists. They are well equipped for this and thus create space for cardiologists and pulmonologists to dive deeper into their own medical specialisms. Everyone should be able to be at their very best’.
Since working at Luscii, I often think about the World Exhibition in Paris in 1900. Electric street lamps, escalators, moving images on a screen. The people couldn’t believe what they were seeing. Was this really possible? All those new inventions brought enormous energy into society. What progress! The beauty is that this wonder and energy was captured in various works of art. The painting Bal Tabarin by Jan Sluijters (1907) is one such striking example. People dancing euphorically under ultramodern artificial lighting.
That wonder of new possibilities that Parisians felt during the fin de siècle; I experience that almost daily at Luscii. As a nurse, I am confronted with developments in healthcare that I had never thought possible. The future, I am learning quickly, is now.
People with heart failure measure their own blood pressure and weight at home. The easy-to-use measuring equipment is connected wirelessly to the Luscii app. Values are immediately available in the EPD of the correct healthcare provider. And if there is a risk that things are heading in the wrong direction, nurses make direct contact via a razor-sharp video connection to assess the situation, long before a crisis situation arises. How wonderful and safe would it be for patients if they no longer have to go to the hospital with wailing sirens?
I have seen with my own eyes that new possibilities are transforming healthcare. Nurses have more control. Patients feel more involved in their own treatment. The collaboration between doctors and nurses is improving. New energy is being nurtured in organisations to meet the future challenges of the sector.
Because, let’s face it: those challenges are great. With fewer professionals, we will have to provide more care in the coming years. At the same time, I realise that many doctors and nurses are not even aware of the new possibilities. Until recently I was the same, even though I am naturally quite curious and read a lot about the developments in my field.
That’s why I am making a series of interviews for Luscii. Nurses, doctors, physician assistants, innovation managers, researchers and administrators. I let them all have their say. They can talk about their daily work, how they view the challenges of the sector from their position, and what it is like in practice to monitor and guide patients remotely.
In addition, I offer people a platform that contributes to future-proofing healthcare in other ways. As that is what we need now in the healthcare sector: energy and inspiration. Are you, as a doctor or nurse, working on something special at the moment that is helping to keep healthcare accessible? Then please contact me!
Hugo van der Wedden is a nurse and medical sociologist. He visited bedsides across different hospitals in the most diverse specialisms. He has written a regular column in a Dutch Nursing Magazine for years and published in several news papers. As the “voice of Luscii”, it is his job to make the voice of people within the field resonate in everything that Luscii does.
Hans van den Heuvel is about to begin his gynaecology training and is set to conduct doctoral research into the impact of remote guidance on high-risk pregnancies. Luscii spoke to him about the challenges of his field, the influence of home measurement on his patients, and the mutual cooperation between doctors and nurses.
Your current focus is obstetrics. What sort of things do your patients encounter in daily life?
‘For many of my patients, pregnancy is something they are experiencing for the first time. That in itself is exciting, yet can also be somewhat daunting. If complications are present too, this makes the situation considerably more complex. Inadequate growth, diabetes, blood pressure problems. We also assist women in Utrecht with a congenital heart defect. All these people suffer from uncertainties and have to visit the hospital regularly for check-ups and treatment. That causes stress to daily life. The biggest problems with high-risk pregnancies are therefore usually social in nature. You not only have to offer guidance to the pregnant woman, but also to her loved ones. Emotions must be addressed and dealt with correctly and, as a result, expectation management is very important. As a doctor, you want to offer guidance, but the difficult thing with a complicated pregnancy is that you cannot say much with certainty. The bottom line is that I always strive to outline and explain different scenarios with great patience’.
You are using home measurement with Luscii for pregnancy hypertension. How’s that going?
‘We are all really happy with it. And by we, I also mean my patients. Pregnant women measure their blood pressure at home on a daily basis, and send the results to us via the Luscii app. They also fill in a questionnaire about their general well-being via the app. Home measuring promotes insight into illness. Patients learn what good blood pressure is and recognise the physical signals. That leads to involvement and cooperation. For example, when my patients develop a headache, they measure their blood pressure levels more often by themselves. And when their levels are too high, they call the hospital to discuss. They understand the connection. On top of that, they find it reassuring that someone is always watching. After all, a nurse will make immediate contact if blood pressure levels show an upward trend. In the past, you may not have seen someone for two weeks and were then suddenly confronted with sky-high blood pressure at the outpatient clinic. With the use of Luscii, that hardly happens anymore’.
Does home measurement have an impact on treatment?
‘If you catch it early enough, you can stabilise high blood pressure with tablets, for example with a beta-blocker. But you don’t want the blood pressure to drop too much for the well-being of the baby. In the past, women sometimes had to go to the outpatient clinic several times a week for a check-up. Some were even admitted to monitor their blood pressure. That has become less frequent now women are able to measure blood pressure at home and we can identify hypertension earlier. We are still investigating whether it has a positive effect in large groups too, but I regularly experience a promising impact in practice’.
What are the biggest challenges in gynaecology?
‘The thing that worries me the most is the lack of nurses. You see it everywhere: in the delivery rooms, in the clinical department, the children’s ward. It would help if we appreciated the nursing field more. A higher salary, making the training programme more appealing. I work fairly intensively with specialised nurses and hold them in very high regard. Strangely enough, it is actually through the use of Luscii that I can see how the range of their duties is changing and how they are gaining more control. Nurses used to explain the delivery at the outpatient clinic, but now they are also an important link in the remote monitoring of pregnant women. Nurses are the first point of contact; they respond when blood pressure steps out of line. I think it’s great that gynaecologists share the responsibility of home monitoring with nurses. It strengthens mutual cooperation, and that can only be a good thing’.
CCU nurse Bep Sonneveld has been working within cardiology for 35 years. She experienced the emergence of thrombolysis and the first catheterisation and angioplasty treatments. She has recently began assisting patients remotely through the Luscii app. Bep was initially sceptical, but that soon gave way to enthusiasm.
Why so much love for cardiology?
‘Thirty-five years ago, I began my training as an in-service nurse. I had to do an internship at every department in the hospital and simply lost my heart to cardiology. This was partly due to the technical aspect, but especially to the focus on guidance. I see anxious people regularly. Giving them reassurance and advice is a great thing to be able to do. It continues to amaze me that such a small organ as the heart has so much impact’.
What exactly do you do now in the hospital?
‘I have a combi-role. Within coronary care, I nurse people who have been catheterized a few hours earlier. Others suffer from acute heart failure or have trouble with arrhythmia. I delve into their backgrounds and monitor them throughout the day. Setting medication, observing, reassuring, doing the rounds with the doctor. The turnover is high. When I transfer a patient to a regular ward, the next one is already waiting for me. At the outpatient clinic, I see the same category of patients, but then in a different phase. The relationship there is also very different. I monitor some of them for years and then you really do build a bond’.
A combi-role; does that give added value?
‘Absolutely! Sometimes, I nurse people at the CCU who know me from the outpatient clinic. They are always so happy to see a familiar face. That can happen the other way around, too. And even if I receive people at the outpatient clinic that I haven’t seen before, I know what they went through at the CCU. That all contributes to the continuity of care’.
You recently started assisting people with chronic heart failure remotely. How does that feel?
‘Very good actually. We receive the weight, blood pressure and heart rate through the app from patients at home. And we can see people through a video connection. That gives so much added value. We can now detect deterioration much earlier. For example, you see weight increase before serious complaints arise. We have already prevented an acute admission three times. Eventually, they did become admissions, but not those delivered with wailing sirens. If patients are still well enough to provide notifications themselves, it really makes a world of difference’.
But you weren’t immediately enthusiastic about remote supervision?
‘I thought, now we are only going to offer “computer treatment”. But that is not the case at all. With video calling, you not only get to speak to your patients, but also see them sitting in their own homes. Therefore, you can observe everything: how they talk, how they sit, the colour of their skin. Basically, everything you would normally make note of when someone is sitting opposite you. It just feels very natural’.
And are patients happy with it, too?
‘For patients, it is an accessible system. They all pick it up quickly. As they measure their own blood pressure and weight, they also learn what their normal values are. Insight into their illness increases as a result. I have noticed that remote monitoring is particularly reassuring for those who are still getting used to their heart failure. The fear diminishes. They feel they are under close supervision’.
Do you see room for expansion?
‘The length of stay in hospitals is getting shorter and shorter. Sometimes, I think it’s best to keep people in a day longer, just to be sure. I would prefer to keep an eye over people with heart failure who, for example, have not been away from the furosemide pump for very long. At the moment, we call them after three days. It would give me more peace of mind if we could monitor them instantly at home, as soon as they are discharged’.
Hospitals are full, emergency services are overrun and the ageing population has not yet reached its peak. How can we keep healthcare future-proof? Luscii lets the healthcare professionals who are part of the solution have their say. Today, we spoke to Rudolf Tolsma, a nurse specialist in emergency care. He is currently investigating whether the triage of people with chest pain can be moved from the emergency room to the home.
What is triage and why is it so important?
‘Chest pain is a very common reason for calling an ambulance. They are afraid of having a heart attack, but there is often another explanation, such as stress or muscle pain. On a yearly basis, thousands of people end up in the emergency room, when a visit to the doctor is more appropriate. This is frightening and stressful for patients. But emergency doctors and nurses are investing their precious time in those who don’t actually need their help. Triage means making distinctions, in this case between pain caused by heart damage and pain arising from a less serious origin. That is important for everyone involved’.
Is the triage complicated?
‘Not really. Many years ago, doctors in the Utrecht region developed an instrument, the HEART score, with which you can easily and reliably predict the likelihood that chest pain is caused by a heart condition. This involves listening to the complaints, assessing the heart recording, and we also take into account the patient’s age and risk factors, such as diabetes, obesity or a previous attack. Finally, we take blood samples and assess Troponin levels. Troponin is an enzyme that is released into the blood if there is oxygen damage to the heart’.
Then what is the problem?
‘The HEART score works great in practice as a triage instrument. Only now, it happens at the emergency room because of the blood test. If there is a low risk, people can go home without a follow-up appointment. With a high risk, patients are admitted. In either case, everyone is taken to the emergency department. These days, the technology is so advanced that the blood test can be performed in the ambulance. Therefore, we are investigating whether ambulance paramedics can safely perform the triage at home with the help of the HEART score. Which would mean that a large group of people with a low risk would no longer need to go to the hospital’.
How are patients reacting?
‘You have to be able to explain everything well as a paramedic. And I believe it is actually quite easy to do so. Remember that we used to leave people at home, but we did so based on clinical insight or feeling. The blood test is an additional means of proof. People are often terrified by the pain in their chest, but breathe a sigh of relief when the heart recording shows no abnormalities and the blood test is clear. Incidentally, during the study, we return three hours later to repeat the blood test for every patient. We are investigating whether there is a possibility that the troponin continues to increase after the first visit’.
What happens if the score indicates a low risk, but the paramedic does not trust it?
‘The HEART score helps, but it is certainly not definitive. If you have a feeling that something is not quite right, then you should take the patient to the hospital to be sure. But paramedics are wise enough to make those decisions’.
What are your plans after the study is completed?
‘After having worked for a while at the emergency department at Isala Hospital, I plan to return to the ambulance service. I have realised that my heart leans more towards pre-hospital care. The sector is changing enormously and I am involved in interesting research studies and projects. Although the challenges are great, I see beautiful things happening. In the control room, for example, previous choices were restricted to police, fire brigade or ambulance. Now there are projects where more is being done to improve care coordination. For example, there is also a doctor and someone from home care present within the control room. We are looking much more specifically at what is actually needed: an ambulance? A doctor? A district nurse? This is how we can hope to achieve the right care in the right place. The patient is always the main focus, and that is ultimately why we do what we do!’
Do you think that you, as a healthcare professional, are part of the solution, too? Then contact us and share your story on Luscii.com!
More and more doctors and nurses are using the Luscii app to monitor their patients remotely. Today, we talked to Monique van de Kragt, a physician assistant in the pulmonary department of Zuyderland Hospital.
Have you been involved in healthcare for a long time?
“I started training to become a lung function analyst in Maastricht in 1998. A great profession. Using all kinds of examinations, you can help the pulmonologist make a sound diagnosis. What is the patient’s lung capacity? And their strength of exhalation? Do they have an allergy? In 2001, I joined Zuyderland Hospital in Sittard. When the chance came up to become a physician assistant there, I grabbed it with both hands”.
What does a physician assistant’s day look like?
“Very varied. I mainly work with people who suffer from COPD. I see some of them at the outpatient clinic in the afternoon. I spend a lot of time explaining the influence of lifestyle choices. In the morning, I visit patients who have been admitted with an acute lung attack. I try to take the time and delve deeper into nutrition, exercise and anxiety”
Are people with COPD often anxious?
“During a lung attack, people are really terrified, which is very unpleasant. That is why I always try to visit on the second day of admission. Then the treatment has often already had some effect. I try to make everything open for discussion, even the end of life. About future wishes; what patients still want and don’t want. Sometimes, they are shocked by this, but afterwards almost everyone is happy that I started talking about it. One patient still wanted to visit Indonesia. I said; if that’s what you really want, then you have to do it now. He went right away and had a great time”.
It’s great that you take the time for that.
“Taking the time is so important. I hear that from patients and I also notice that I am achieving more. That people, for example, stop smoking or take up exercise again. Sometimes, it’s a struggle to find enough time for a conversation, but I really believe it pays off. Doctors only have ten minutes per patient. What can you do in such a short period of time? They are far too busy in my opinion, and the real wave of the aging population is yet to come”.
Do these lung attacks always occur so suddenly?
“We are constantly preaching that patients have to exercise more, but before an admission, we often find that people do less and less. For example, they have already stopped physiotherapy for a while and their condition has slowly deteriorated. Then it would only take a virus or urine infection for the COPD to start playing up again”.
Does remote monitoring help to prevent a lung attack?
“We have not been working with Luscii for very long, but I think it does help to see decline earlier. I had a patient who was in the hospital six times in six months. Now that he uses telemonitoring from Luscii, he has become more stable. Once, when his condition began to deteriorate, we saw it early and could treat him with prednisone at home. He was really happy with that. In a way, it provided confirmation that he is being closely monitored from a distance”.