More and more hospitals are using telemonitoring to support patients at home. Heart Guide, a digital care concept from the Netherlands’ Cardiology Centra (CCN), is an inspiring example within this field. Patients measure their own blood pressure, weight or heart rhythm at home. An app coaches the patient and alerts the right healthcare professional if necessary. Visits to the emergency care department have fallen dramatically among users.
HartGuide is currently used by people with heart failure, high blood pressure and atrial fibrillation. Amsterdam UMC and CCN are now investigating whether people with congenital heart defects are also better off with telemonitoring. This year, a Randomised Controlled Trial will start under the supervision of cardiologist, Michiel Winter. Luscii talked to him about the setup of the study and the future of telemonitoring.
A congenital heart defect, is that common?
‘Around 50,000 people suffer from the defect across the Netherlands. Thankfully, most disorders are mild. But there are also those born with a complex condition, such as patients with only one functioning heart chamber. Surgical techniques have improved in recent decades. The number of people living with congenital heart disease is therefore increasing. Babies who died shortly after birth in the 1980s now have much greater chances of survival’.
Can you grow old then, as a patient?
‘With a mild defect, your chances these days of growing old are almost equal to those of healthy people. Yet, this isn’t the case for serious problems. Some people undergo multiple operations in their childhood. Things may go well for many years, but at around 40, they inevitably develop heart failure. In any case, a birth defect always has an impact, for example in the form of atrial fibrillation’.
Do you expect telemonitoring to make a difference?
‘Absolutely. Normally, these people go to a hospital with specific expertise. But that is expensive for society and the journey is stressful for the patient. With HartGuide, we can reassure patients remotely when everything is fine. If there is a serious problem, such as heart failure, then we see it arising sooner, as we monitor the patient’s weight, blood pressure and well-being at home. And we can therefore intervene earlier. The research will show whether it works that way in practice, but I am confident it will’.
What are your most important research questions?
‘We will look specifically at people who visit the outpatient clinic at least twice a year with complaints. Is it possible to prevent acute moments by guiding them remotely? We do not immediately expect visit clinics to decrease, as it is all so ingrained, instead we hope to really focus on preventing acute situations’.
And what will the research look like in practice?
‘We will assemble two groups. One group will be supervised at home via HartGuide. The other group will receive regular care. And in two years, we will compare the differences between the two. It is actually a nationwide research study. We are talking to a number of hospitals about including their patients. At least two hundred patients are needed to form a clear picture’.
What did the medical ethics committee think of the setup?
‘The handling of patient data in particular raised questions. Normally, this information remains secure within the hospital’s walls. With the e-health design, the data is sent from home via Luscii’s digital platform to the Medical Service Centre of HartGuide. There it is interpreted by doctors and nurses, and afterwards, I receive a call to discuss the findings. Questions were asked about that. Who exactly does the patient’s data belong to? And where is the information stored? In the end, we worked everything out and developed a clear protocol of how to deal with such concerns’.
How do you see the future of telemonitoring?
‘I actually expected digital development to go faster. Everyone nowadays has Netflix and Google Maps, but we are still a bit behind in the hospital. Collaboration with businesses, such as Luscii, is in my opinion the key to success. I am a cardiologist. I was not made to set up a company or deal with logistics. Moving care from the hospital to the home is such an adjustment. We definitely need the businesses, but with our own ideas, too. If we work well together, I believe that the entire cardio clinic can eventually switch over to remote guidance at home. Provided that an effective system of expert supervision has been built around it. Then patients only have to come to the hospital if something is really wrong’.
Are patients ready for that too?
‘I have eighty-year-old patients who Skype with their grandchildren. That is not the problem. Healthcare professionals are the ones who must make the switch correctly. But don’t underestimate that task. As a doctor, I am used to seeing patients. I trust my clinical view. Letting that go is complicated, although I believe video calling offers plenty of opportunities in that regard’.
Patients with a severe form of the pulmonary disease COPD have been using home monitoring since February. By completing a questionnaire twice a week via the Luscii app, they are monitored remotely and are immediately assisted in the event of deterioration. Pulmonary nurse Iris Huisman explains the benefits.
Fewer trips to the hospital
More and more people are suffering from Chronic Obstructive Pulmonary Disease (COPD), a chronic lung disease, in which the damaged lungs lead to shortness of breath, coughing and fatigue. In patients with a severe form of COPD, the symptoms are often so bad that they become less mobile or may need extra oxygen. For them, a mild cold can lead to a dramatic increase in symptoms. We call this a lung attack, resulting in hospitalisation and further damage to the lungs. Iris: “Now that we are monitoring this group of patients remotely, we are able to guide them more effectively and hope to prevent such attacks and hospital admissions. In addition, patients no longer need to come to the hospital for standard checks, which they often find tiring because of their limited mobility”.
Contact at the right time
For the home monitoring of patients, Tergooi is working together with the medical service centre, NAAST. The nurses at NAAST already have experience with this method of monitoring at Slingeland Hospital and know the procedure at Tergooi. They keep an eye on everything 24/7 and if they see a deterioration, they immediately contact the patient via a video consultation, calling through the Luscii video connection. “If NAAST are unable to respond, we become involved. Coincidentally, this afternoon I had a video consultation with a patient whose symptoms we had noticed had suddenly worsened. He admitted that he did not realise that things were going so badly and would not have called himself, but he was very pleased that there was direct contact and that action had been taken”.
Telemonitoring can also be a solution for COPD patients who need more intensive support. Iris: “Because NAAST is available 24 hours a day, a patient who is very anxious and scared at night can make contact very easily. A video consultation at such a moment is exceptionally reassuring and supportive. Patients’ voices are therefore heard if necessary and they can ask for care at any time. At the same time, they also gain more insight into their illness by completing the questionnaires twice a week”.
Since the introduction of telemonitoring for patients with chronic heart problems (in 2016), more than 500 Zilveren Kruis policyholders have been using HartWacht (translated HeartGuard, a remote monitoring service powered by Luscii, red.). 128 patients (25% of the participants) have been using HartWacht for more than a year. Comparisons have been made between their healthcare usage for the 12 months prior to telemonitoring and the 12 months following use. The results are impressive.
The first research results show a large decrease in the use of care. Olivier Gerrits, Director of Zilveren Kruis Healthcare Purchasing: “We were already convinced that telemonitoring contributes to more control and better quality of life. Now it appears that for our policyholders, there are also fewer admissions, emergency visits and ambulance trips”.
Major decrease in emergency first aid visits on A&E
Patients guided by HartWacht for a year have experienced a decrease in the number of nursing days, the number of emergency trips and the number of emergency room visits. This reduction has been compared to the year prior to the supervision of HartWacht. The number of nursing days has dropped by more than 40% and the number of emergency trips with the ambulance has been reduced by 30% in one year. The largest decrease occurred in the number of emergency room visits: In the group of patients that began with HartWacht, the number of emergency room visits (A&E) fell by 70%, compared to the year before.
VBHC Prize 2019
HartWacht is a joint initiative of Zilveren Kruis, the Netherlands’ Cardiology Centre (CCN) and the Dutch healthcare innovation company Luscii. The number of participants is growing steadily. This breakthrough in eHealth was an international first for the Netherlands in 2016. Last month, HartWacht received the VBHC Prize for its collaboration. Igor Tulevski, cardiologist and co-founder of CCN: “A wonderful reward for increasing the quality of life for patients and reducing healthcare costs on a daily basis”.
HartWacht, the innovative healthcare concept that was set up through a collaboration of Cardiology Centers the Netherlands, Luscii and insurer Zilveren Kruis, was awarded by the Professor Porter Value Based Healthcare Collaboration Award 2019. For Luscii, this means that one of its projects wins this prestigious award the second year in a row. Last year the COPDInSight-service of NAAST, insurer Menzis and Luscii was the winner of the Professor Porter Value Based Primary Care Award 2018.
HartWacht telecardiology service
HartWacht is a revolutionary telecardiology service offered by the Cardiology Centers The Netherlands to their patients in 15 centers across the Netherlands. Patients with heart failure, hypertension and atrial fibrillation don’t need to go to the clinic anymore, unless it is needed. The eHealth service was announced in 2016 and is currently available all across the Netherlands with full reimbursement from five of the biggest Dutch insurers.
HartWacht telecardiology service
Globally, the demand for cardiovascular care is rising due to the ageing populations, increased cardiovascular risk and the quest for personalized care. However, resources are limited.
The “classic” healthcare system cannot meet these requirements. Therefore, an affordable and scalable solution is needed. The aim of HartWacht is to increase population health, improve the quality of care and lower the per capita costs by making use of new health technologies such as Luscii vitals.
Heart failure, hypertension and atrial fibrillation
Patients are selected for HartWacht by their cardiologist based on their diagnosis and protocolized inclusion and exclusion criteria. Patients can then share their data with their healthcare provider using the app and the results will be integrated in their electronic patient file. By making both the home measurements and the other relevant medical data online available to the patients, they are encouraged to participate actively in their healthcare processes. In addition, therapy and policy are focused around patient data and adapted continuously if needed. Interventions include lifestyle advice if appropriate, change in medication, education about disease and/or additional diagnostics, thereby forming an IPU.
Patients with severe hypertension and heart failure are guided by the Luscii app to do home measurements with connected measurement devices for blood pressure, heart rate and weight. Also patients with atrial fibrillation are enrolled using Kardia with EKG-monitor. All the data of patients is analyzed and securely transmitted to the the electronic patient file and is interpreted by a dedicated team supported by smart algorithms and a nationwide network of outpatient clinics which can be visited by the patients if needed. The concept is financed through bundled payment schemes. Patient value is measured through standardized questionnaires.
To continuously monitor quality and safety and patient outcome, research projects have been initiated. First results are published in scientific peer reviewed journals and demonstrate a positive effect on safety of the program and patient experience and outcome. Research shows that HartWacht results in less visits to outpatient clinics and emergency departments, thereby adding value to our healthcare system by improved health outcome with less costs. Also patients and treating physicians are satisfied: with less effort they experience faster results of success of their therapy.
In the coming six months, the Reinier de Graaf hospital, together with the e-health company Luscii, will conduct a pilot of home measurement for patients with the chronic lung disease COPD. With the help of these measurements, caregivers can provide medical advice remotely. Therefore, COPD patients will need to visit the hospital less often.
Prevent hospitalisations due to lung attacks
COPD is a disease in which the lungs are damaged. This makes it more difficult for patients to breathe and reduces their energy levels. Patients with COPD often suffer from lung attacks, in which they experience shortness of breath, coughing or excess mucus production. As a result, they often need to be hospitalised.
25 COPD patients are taking part in the pilot. The participants will receive a tablet, through which they use an app to complete a weekly questionnaire concerning their quality of life. They will also measure the oxygen content of their blood through a device known as a saturation meter, which is connected to the tablet.
A specialist lung nurse then examines the results in the hospital. If these exceed certain threshold values, the nurse will contact the patient via videocall. In this way, the nurse can literally see how the patient is doing and he or she can, for example, adjust the medication in consultation with the treating specialist. Therefore, the patient doesn’t need to come to the hospital as often for a check-up or treatment. This journey is a major undertaking, especially for patients with COPD. Remote care is subsequently perfectly suited for this group of patients.
Bring healthcare close to the patient
“With this pilot, we want to bring healthcare as close to the patient as possible”, says project leader René de Brouwer. “In addition, we can ensure that COPD patients gain more control over their own health. This project is a great example of how we, at Reinier de Graaf, want to provide the right care in the right place”.
Evaluation will take place during and after the pilot. The experiences of patients and caregivers are the central concern. Scientific research into the results of remote monitoring is also being carried out in collaboration with Luscii. If the pilot is successful, the Lung Diseases department wish to monitor more COPD patients remotely.
We are very happy to announce that this week a new Research Assistant started at Luscii! Fenna Jonker, who’s currently finishing her Bachelor’s degree in Health Policy and Management at the Erasmus University, will assist Luscii’s team with conducting different research projects.
A number of hospitals in the Netherlands have started with the Experience phase of Luscii telemonitoring. To gain insight in the feasibility of telemonitoring of patients with Heart Failure or COPD, different research projects with care professionals are being conducted. This will make it possible to learn and see whether adaptations are necessary to the current care pathway of the hospitals to prepare and scale remote patient monitoring. Fenna will help us with gathering, structuring and analyzing these data.
Fenna considers continuing a master’s degree in Healthcare management. In the meantime, she hopes to learn here more how eHealth solutions can be implemented successfully for different hospitals. “I am also very curious to learn more from a business perspective, since I don’t have any experience as a student yet”.
Good luck Fenna!
ASSEN – In February, the Wilhelmina Hospital Assen will begin home telemonitoring for patients with chronic heart failure. They will initially start with a group of twenty-five people. At the moment, these patients have to go regularly to the hospital to have their blood pressure and weight measured. With the help of a blood pressure monitor, a weighing scale, and a tablet or computer, this is now possible at home.
“We do not want patients to have to come to the hospital if it is not really necessary”, says project manager Tineke Ottens. “Most people can easily measure their blood pressure and weight, and fill out a questionnaire. This data is sent to a department with specially trained employees. If there are any uncertainties or questions, they then contact the patient via videocall. Subsequently, the heart failure nurses of the WZA have a central role to play.” In order to make telemonitoring a possibility, the WZA has teamed up with Luscii, the Dutch market leader in the field of home measurement. Luscii patient apps work on Apple, Android and Windows, and the company offers a helpdesk for the predominantly older patients, and even provides installation and explanation at home if necessary.
The benefits are great: the patient does not have to go repeatedly to the hospital and can organise his or her own agenda with much more freedom. The patient also has more insight into his or her own data: they can see their blood pressure level or weight for themselves. The fact that direct contact is available also gives a feeling of safety.
The patients taking part will first receive extensive instructions on how to use the equipment. “Even someone without experience of using a tablet or a computer can get started. Older people also often discover that they can do a lot more with the iPad. Sometimes a world opens up for them”, says Tineke Ottens.
Telemonitoring is a fantastic step in the development of eHealth: care via the internet. “We show that people can stay at home more safely and with total self-control through the use of remote expert care. Ultimately, that is what everyone prefers.” In addition to chronic heart failure, this form of telemonitoring can also be offered to people with COPD or sleep apnea in the future.
Imagine no longer having to go to the hospital, but simply having a conversation at home with your lung nurse about how you feel. From February 2019, this will become a reality for 25 Treant patients with the chronic disorder COPD (lung disease). During this month, the healthcare group will begin a trial in which patients receive a tablet, on loan, through which they can transfer their medical information to the hospital. If this information requires further discussion, the lung nurse will contact the patient via ‘video calling’.
Treant, in collaboration with the healthcare innovation company Luscii, is starting this pilot to gain experience in monitoring COPD patients from a distance. Lung specialist, Steven Rutgers, is pleased with the new scheme: “For patients who already have less energy because of their illness, it is of course fantastic that they will no longer have to come to the clinic every time. This pilot also strengthens our vision to concentrate care as close to the patient as possible. It is great that we can experiment with this possibility.”
How does it work?
Every week, patients use the tablet to fill in their information, such as blood pressure, weight and physical activity. They also report how they are feeling. They then send this information to the hospital. A specialist nurse will take a look at the data and, if necessary, will contact the patient. Through the use of ‘video calling’, healthcare professionals can see how the patient is doing and, in consultation with the pulmonologist, can adjust the medication if necessary.
COPD is a lung disease in which the lungs are damaged. The lungs cannot absorb sufficient oxygen, leaving the patient with shortness of breath and less energy. COPD is characterised by lung attacks that often lead to hospitalisation. Rutgers: “As we receive information about the condition of the patient more often during this pilot, we hope to prevent such lung attacks and subsequent hospital admissions”.
The pilot was made possible by healthcare insurer Zilveren Kruis and will last for six months. The pilot reinforces the agreement that Treant holds with the healthcare insurer to develop initiatives that bring care closer to the patient. A good example of the right care in the right place. In collaboration with the healthcare innovation company Luscii, scientific research will also be conducted into the results of remote monitoring. To start with, remote monitoring will be available to just 25 COPD patients treated at Scheper in Emmen. If the pilot proves successful, in the future, more patients will be able to pass on information to the hospital via video calling.
This press release was published by Treant ziekenhuis on 4 December 2018 (https://bit.ly/2RhyywZ)
Even our deputy prime minister, Hugo de Jonge, is calling for more speed when it comes to e-health, for example, with home measuring. But where do you start? In this article, we provide an action plan to help you make the right choices with the current healthcare purchases for 2019.
This action plan is based on a combination of practice and science. I learned by trial and error during projects with both FocusCura and Luscii. I studied ICT implementations during my PhD at the University of Twente. This is how I discovered that successful implementations almost always follow a fixed pattern.
My most important lesson: a successful implementation is determined by the execution. The transformation of a dream into the reality of new daily care. Thomas Edison already said it best: “Vision without execution is hallucination”. So, let’s get started!
Preparation: define your dream and be specific
Start by making your dream concrete. Do you wish to give your clients more independence by staying at home with technology as an alternative to the care home? Do you, as a hospital, want to prevent unnecessary admittance for chronic patients?
You don’t have to come up with everything yourself, there are many good examples inside and outside the sector that can inspire you. Make your dream tangible for your organisation or department. Who are you doing it for and at what point will you consider it a success?
There is a big pitfall that I have often fallen into on this point. If you share your dream with care recipients and caregivers, you will notice that organisational limitations or financial restrictions will become the guiding principle. So, turn this around. Discuss your dream and find out whether they share it, but also show leadership to align the preconditions with your preferences.
Step 1: choose your partners and gain experienceNow it is time to involve others. Like the insurer. And partners that can offer competencies that you do not have. And no, in the year 2018 this is not the domain of the purchasing or IT department. It is a strategic choice. Does your partner already have agreements with insurers that you can take advantage of? Which partners can bring practical experience so you don’t have to reinvent the wheel? Choose a partner that suits your culture, as you are about to embark on a journey with one another.
Together, you begin with a proof of concept. As a first step to learn how your vision works in practice. At Luscii, we call this the experience phase. We approach the care process differently with around 25 care recipients by using our technology. That number is small enough to not have to disturb things too much. Yet it is still large enough for users to experience whether this will give them what they need. The dream comes to life and the caregivers involved become frontrunners, or idea champions, as I labelled them in my thesis.
After around four months, you can evaluate whether your idea works and create a follow-up plan to mix up the care path, which will involve financial agreements and technical integrations. If it appears in the evaluation that it does not work, then make alterations or stop. The latter sounds hard but I see many projects that remain dormant and that makes no sense. Show leadership in these cases and keep going, or stop and start again. If you continue, this also means that you choose not to keep the innovation free of obligation.
Step 2: continue and eliminate thresholds
Now that you are continuing, progress to around 150 users. This intermediate step is conscious. At this scale, it is impossible to do everything ‘on the side’, so your care path now changes completely. But with this intermediate step, you can keep the change manageable.
In this phase, you will invest more, for example, in a project leader or time for caregivers to work on new protocols, ICT integrations and/or training. Don’t be afraid to stick your neck out here, but also continue to measure whether you are achieving your goals.
At Luscii, we do this by measuring three-monthly parameters, such as satisfaction of patients and caregivers, reduction of clinic visits and admissions, and the amount of time Luscii saves for nurses. With the help of a ‘data dashboard’, you can monitor continuously and compare outcomes with data from other healthcare organisations. So that you can learn from one another.
Step 3: new service is a reality
Now you are ready to change the direction completely. If all has gone according to plan, you have now reached a critical number of care recipients and caregivers involved in shaping the new working method.
By making small interim steps, you have shifted from ‘innovator’ to ‘early majority’ in the innovation model. The ‘project’ is over and your new service has become a reality. Your idea champions, the caregivers of the first hour, are probably already eager for the next stage. In current times, innovation never stops. You will start step 1 again after step 3 is complete: constant innovation is the future for continually meeting the wishes of clients, employees and everyday reality.
The future is now
If you want more tools to make e-health a success, take a look at the Playbook that we made with Menzis or download my thesis. Do you have suggestions for improving the approach yourself? If so, I am very curious to hear your thoughts.
This blog was published earlier in Dutch on Qruxx tech: https://tech.qruxx.com/drie-stappen-voor-succesvolle-introductie-van-e-health/?_ga=2.15733042.529853116.1543238273-1213197350.1530525548
Patients with COPD of the Medisch Spectrum Twente Hospital will now have the opportunity to receive Luscii telemonitoring to support their at-home care and reduce the risk of hospital readmissions. I was at the kick-off meeting with patients and talked to them and their doctors and nurses.
Last week, on Tuesday 11th September, the official Kick Off with COPD patients, their relatives and care professionals took place in Enschede. Patients were shown how to use the iPad with Luscii monitoring and Luscii videocare at home and are now familiar with the term ‘telemonitoring’.
MST – one of the biggest hospitals in the eastern part of the Netherlands – starts with an Experience phase first, where patients with a history of frequent hospitalisations will be monitored at home. To gain insight into the feasibility of telemonitoring for these patients, I will lead a study together with the care professionals in the hospital. Since this new way of providing care to patients is quite exciting to both patients and care providers, we expect to retrieve some initial answers on the added value of telemonitoring from this research.
Chantal van der Linde, pulmonary care nurse, explains that she “hopes to be able to intervene in case of deterioration much earlier”. And to “offer a better safety net to patients”.
Patients are looking forward to starting with home monitoring. When asked what they expect from telemonitoring, one patient explained that they hope for “less hospital admissions, I already had two in a row recently”. Another patient added: “I believe that this makes contact with the nurse much easier and quicker, now I often call when it’s already too late”.
“It is difficult to address the effect of telemonitoring within the first 25 patients we start with”, explains Dr. Hekelaar, pulmonologist. “But I’m curious to see to what extent we can keep patients out of the hospital”.
We are all very excited to start and are looking forward to experiencing the use of telemonitoring in practice!
The innovative project ‘COPD InSight’ won theVBHC Primary Care Award 2018 on April 26th. COPD InSight is an initiative of…
At the start of the Dutch e-Health Week, RKZ-patients will receive their tablets with the Luscii Vitals (formerly cVitals) and Luscii Contact (formerly cContact) applications. They will use them to monitor their vital signs directly from home.
The Luscii Vitals app on the tablet will provide the patients with information about their disease, self-management tips and support when having health problems related to their COPD. Over the following months, they will fill out a questionnaire weekly and whenever Luscii detects deterioration of their health situation, Luscii will inform the pulmonary nurse of VIVA Homecare directly. The nurse will then visit the patients at home or use Luscii videocare for a virtual consultation. If needed, they can refer to the pulmonologist or pulmonary nurse directly at the Rode Kruis Hospital.
Pulmonologist Erik Kapteijns: “We are going to treat these patients much more intensively without them needing to visit the outpatient clinic. By acting earlier, patients will have less exacerbations and a more stable development of their disease”.
Luscii will provide its digital health platform with apps for the patients and hospital users. Through this digital health platform, data will be managed and sent securely. The first step is to test and optimise the care pathway with a smaller group of patients. When successful, it will be scaled further.
Part of this article was published in Dutch on the website of RKZ in January 2017. A follow up article was published in print in May 2018.