The Martini Hospital starts, in collaboration with Luscii (previously ‘FocusCura’), two innovative projects to monitor patients with a chronic disease remotely and thereby prevent hospitalisation. Patients with COPD or heart failure receive a tablet at home, on which they transmit medical information about their condition to the hospital on a daily or weekly basis. If a patient exceeds their specific threshold value, the hospital will contact the patient via video calling. For example, medication can be adjusted at an early stage to ultimately prevent hospitalisation. In addition, it increases the degree of self-management, the feeling of safety and the quality of life of patients.
Hans Feenstra, the Martini Hospital’s chairman of the board: “These projects are a good example of ‘The right care in the right place’. We believe that, in principle, care should be organised as close to the patient as possible and we are therefore actively engaged in this”.
Patients who are already being treated by the hospital can participate in these projects. It is not the aim to relocate care to the general practitioner (substitution). This effective care is not only adding value for patients, it also reduces the costs of healthcare. Emergency admissions can be prevented and fewer outpatient visits are necessary. Feenstra: “The projects give substance to the long-term agreements that we have with healthcare insurers Menzis and Zilveren Kruis. We have committed to develop initiatives for care close to the patient.” Both projects start with a small group of patients in order to gain experience with this new way of working. Also, in collaboration with Luscii, scientific research into the results of telemonitoring is being conducted.
Prevent an exacerbation
COPD is a lung disease in which the lungs are damaged. The lungs fail to provide adequate breathing and the patient has less energy. COPD is characterised by lung attacks, in which the patient experiences more stuffiness, coughing and production of mucus, which often results in hospitalisation. We want to prevent these exacerbations by means of more frequent monitoring. Patients suffering from severe COPD fill in a validated questionnaire every week, containing questions about how the patient feels. A specialised nurse monitors the outcomes in the hospital. If these outcomes exceed certain threshold values, the nurse will contact the patient via a video consult. This way she can literally see how the patient is doing and can, for example, adjust the medication. This may possibly prevent an exacerbation. For patients with COPD, the trip to the hospital is very exhausting, as it often requires a great physical effort. Therefore this type of remote care is very suitable for them.
Titration of medication
Heart failure is a condition in which the pumping function of the heart decreases slowly or abruptly. As a result, patients get tired faster, develop fluid retention and experience shortness of breath in daily activities. Patients with heart failure transmit measurements of their weight, blood pressure and heart rate to the hospital daily, using the iPad. Therefore, these patients do not only receive an iPad, but also a weighing scale and a blood pressure meter at their disposal. Telemonitoring for heart failure is highly suitable for patients who have just been diagnosed with heart failure and for patients who are in an unstable phase of their condition. In both groups, the medication must be properly set or reset. And where that normally happens over a period of eight weeks through a series of visits to the outpatient clinic, it is expected that this can now be done in just a few visits and in just a few weeks. Adjusting the medication and explaining the condition and lifestyle will now take place via video contact, so that the patient does not have to visit the hospital. It is also expected that emergency admissions will be prevented. In addition, the patient is actively involved in his or her care process through this form of telemonitoring. Research shows that more control and self-management increases the patient’s quality of life.
This article was published in Dutch on the website of Martini Hospital in July 2018.
The Department of Pulmonary Diseases at the Isala Hospital started with digital homemonitoring for COPD patients via Luscii Apps in 2017. Patients in the project don’t have to come to the hospital as often and have a lower risk of hospital admissions as well. The check-ups of the patients are completed remotely, with home measurements taken twice a week using the Luscii Apps. If Luscii detects deterioration, the nurses at Isala will be informed and will reach out immediately. The project is accompanied by research carried out by Martine Breteler MSc, working together with different people at the Isala Hospital, including pulmonologist Jan Willen van den Berg MD, PhD.
The Dutch Ministry of Health made a video of this great project and showcased it as an example of the eHealth movement in the Netherlands during the eHealth Week:
Mr. Foederer suffers from heart failure, a serious condition in which the heart’s pumping function continues to decrease. As one of the first patients of the Haga Hospital’s Heart Centre and in the region in general, he is now under supervision at home via ‘Cardio@Home’. The doctor or nurse sees all measurement results and can intervene quickly if a situation changes.
In the Netherlands, about 150,000 patients are suffering from heart failure. There are many disorders that can cause heart failure: a heart attack, high blood pressure, cardiac arrhythmias, cardiomyopathy, valvular heart disease, inflammation of the heart muscle or a congenital heart defect. “Although the medication continues to improve, the condition is unfortunately as yet incurable”, explains cardiologist Ivo van der Bilt. “Half of these patients have a life expectancy of 5 years after the diagnosis, so it is a serious condition that calls for proper support of the patient and family. The Haga Heart Centre has an outpatient clinic with specialised nurses for heart failure. Here, we recently started the project Cardio@Home”.
More measurements, less hospital visits
“The patients that participate in the project Cardio@Home are now monitored more often, while they have to visit the hospital less often”, says heart failure nurse Arjan te Hoonte. “They receive an iPad, a wireless blood pressure monitor and a weighing scale for 6 months. The equipment is delivered and installed at the patient’s home by the supplier Luscii (previously ‘FocusCura’). At home, the patient measures his or her weight and blood pressure 2x a week. The results are sent to us via an app and we assess them immediately. We also ask the patient to fill in a questionnaire regularly, which contains questions about shortness of breath and fatigue during the measurements. This helps us in evaluating the measured values. In addition to the regular check-ups in the hospital, now we can also monitor and check on the patient remotely, adjust medication or give other advice, and if necessary, we can video call the patient via the iPad”.
Arjan is very enthusiastic about this development. It helps the patient to feel safer and to reduce the the hospital visits. “We also ask about the level of satisfaction, to make the quality of life visible. It provides us with a lot of information for scientific research, which helps us to adjust policies and to continue the use effectively”.
Safe and secure
Mr. Foederer feels comfortable with monitoring at home. “I do not have to go to the hospital as often, and if there is something strange, I can take action immediately. I can have a call with the nurse through the iPad. The nurse also called me once when my weight suddenly went up. He wanted to know if I was also developing fluid retention around my ankles. Now I’m being watched closely, but remotely”.
E-health has become an integral part of healthcare
Ivo van der Bilt considers this form of e-health a valuable addition to healthcare. “Innovative e-health facilities are used increasingly as part of the care process in healthcare.Thanks to Cardio@Home, these vulnerable patients can live independently at home for as long as possible. We can reassure the patient remotely, but also intervene faster if the situation worsens. With medication adjustment, for example, we can prevent a visit to the Emergency Department and maybe even a hospital admission, which is a reassuring thought for the patient”.
This article was published in Dutch on the website of Haga Hospital in December 2017.
People often question the proof of innovation in healthcare, for example, in projects such as COPD InSight or HeartGuard. Which is no small thing, considering so many innovations are implemented ‘on top of’ current healthcare, making it unnecessarily expensive. Just what do we mean by ‘proven’? What evidence already exists?
In this blog, Martine Breteler and Daan Dohmen will guide you through these questions. We can define the success of digital care as consisting of three categories of ‘evidence’, otherwise referred to as the Triple Aim principle. While it may be a slightly informal term, it actually just means ‘a healthy population’, ‘a better qualitative experience of healthcare’ for ‘relatively lower costs’. What evidence already exists?
Telemonitoring makes people healthier
For the first type of evidence, we will look at the effects of digital care, specifically that of telemonitoring in the population. In short, do patients experience fewer symptoms? Has there been a reduction in patients with worsening symptoms? Has there been an improvement in patients’ blood pressure?
A brief look at scientific articles indicates that there is a growing body of evidence worldwide showing this to be the case. Cardiologist Dr. Milani convincingly proved that virtual care for hypertension using connected devices has delivered a huge improvement (Milani et al. Am. J. Med. 2016). No less than 71% of patients diagnosed with high blood pressure achieved their goal to manage their blood pressure (with an average improvement of 14/5 mmHg) after three months, compared to 31% of patients who received regular care.
In addition to the hypertension patient group, other patient groups saw significant improvements to their health. One of the largest telemonitoring experiments in the world, the famed ‘Whole System Demonstrator’ programme, showed promising results based on its test group of 3,230 patients who had been diagnosed with either diabetes, COPD, or heart failure. This cluster randomised controlled trial showed a significant reduction in the number of fatalities and the number of visits to the emergency room among patients who used telemonitoring, compared to the control group.
Our own project reviews also show promising results. One review of 77 patients suffering from heart failure or COPD showed that among patients suffering from heart failure, 42% experienced fewer symptoms, and 69% felt more independent. Among COPD patients, this was 28% and 52% respectively. However, it is important to remember that these results were reported in specific patient groups whose doctor or healthcare specialist had ‘prescribed’ for measurements to be performed at home. So the question remains, in spite of these great results, whether this change is only temporary in nature. To achieve this result in the long term, it is even more important that patients themselves actually want to keep using telemonitoring.
Patients want it!
The second type of evidence is possibly the most important – improvements to a patient’s perception or experience. This may seem like a ‘softer’ type of evidence compared to the efficacy of studies of effectiveness. Then again, Uber and booking.com didn’t need to scientifically verify that their way of doing things was better than the way it used to be, did they? It’s the consumers who appreciate their services more, and therefore choose to keep using them.
In the healthcare industry, the number of options to choose from is limited. Patients are dependent on the suppliers, yet there are hardly any major differences between those suppliers. Meanwhile, we have already deployed telemonitoring in hospitals and are seeing impressive results among patients. A review among 23 patients of the St. Anna Hospital, Zuidzorg, and SGE show that 92% have experienced improved healthcare. Our test group of patients suffering from COPD and heart failure showed that 81% of patients with heart failure and 68% of patients with COPD experienced better healthcare.
Looking at HeartGuard, the first effect measurement among patients with resistant hypertension, who had been referred to second-line care and now receive remote support, improved these patients’ quality of life (measured using EQ-5D-5L) and increased their level of self-management (measured using PAM-13).
We shouldn’t really suggest that there is a link between the results shown in our test groups, which are still limited, and the existing body of scientific literature, yet we see similar results among patients who use telemonitoring as well. A large study was conducted among 851 vulnerable elderly patients suffering from COPD, heart failure, diabetes, or hypertension who had just been discharged from the hospital to investigate the effects of telemonitoring (Cardozo and Steinberg, Telemed J E Health 2010). This study showed that telemonitoring, defined as the daily measurement of vital signs combined with regular nurse visits, increased beneficial outcomes for elderly patients as well. 66% of patients thought that the quality of healthcare provided had improved, with customer satisfaction easily reaching 90%.
Again, the way in which measurements at home are performed – which specific patient group, which technology, and which type of intervention – is clearly a determining factor in the results. Behavioural scientists still have a lot to explore in this area. There is also a great deal left to research about the long-term effects, as many studies run over a limited time frame. Whatever happens, it’s going to be interesting!
Of course, although there’s no doubting the huge role played by scientific research in this area, we think it’s just as important to simply talk to patients and keep listening to their experiences. It really gives you a boost when patients themselves tell you what this service means to them.
Lower cost of care when using telemonitoring
It’s no simple matter to measure whether the cost of care provided decreases when using telemonitoring, mainly due to the way that care is ‘calculated’. However, scientific research concluded that the use of telemonitoring led to a reduction in the number of COPD patients with worsening symptoms, a reduction in hospital admissions, and a reduction in overall costs.
Seto’s systematic review of nine studies (Telemed J E Health. 2008) shows when comparing the cost of use of telemonitoring to the costs of regular healthcare, the total costs decreased in all studies as a result of telemonitoring, varying between 1.6% and 68.3%. This can be primarily attributed to the decrease in re-admissions. The figures may vary slightly due to differences in the telemonitoring system used, the variety of protocols, and the number of hospitals studied. However, this is still a promising piece of evidence that telemonitoring has a positive financial impact.
The aforementioned decrease in the use of healthcare has an even more significant effect. If we can treat the same number of patients with less labour but for equal or reduced costs, this will give a boost to the ever increasing shortage of staff in the healthcare sector.
So far, the initial results of research on these three types of ‘evidence’ reveal very promising outcomes as far as the use of telemonitoring is concerned. We realise that the body of scientific evidence is still scarce, so there’s still lots of work to be done!
Dilemmas when researching eHealth
For quite some time now, we’ve been trying to establish a generic experiment, intended to test the effectiveness of telemonitoring for COPD patients on a large scale, bridging multiple healthcare organisations. Establishing the correct research design has already proven to be problematic. Although the ‘randomised controlled trial’ (RCT) provides the most credible evidence available, there are various reasons why it’s an unsuitable method for researching the effects of telemonitoring.
A telemonitoring app is in a constant state of development, for example. Our developers regularly publish an updated version of the Luscii Vitals telemonitoring app with improvements for the patient or care provider. This makes a reliable comparison between the test and control group on the impacts of it impossible.
We consider it to be bordering on unethical to exclude patients who wish to participate because we know what it can mean for them (even though we probably shouldn’t be saying this out loud as scientists). Randomising who does and who does not receive telemonitoring is therefore not an option.
No “one size fits all”
How should we do it, then? To avoid reinventing the wheel, we have to take a really close look at scientific literature when establishing a research design.
In concrete terms, this means that telemonitoring is a medical intervention that needs to be implemented in a targeted way – it’s not suitable for every patient. We absolutely must listen to doctors who have ‘prescribed’ telemonitoring and assess how telemonitoring has been embedded in the healthcare process.
Literature increasingly supports this line of thinking. For instance, this month’s edition of Nature featured a meta-analysis of sixteen reliable randomised controlled trials. This showed that telemonitoring as a generic tool for ‘every patient’ has almost no significant benefit, while the proper use of telemonitoring for specific patient groups is very promising (Noah et. al, 2018).
How should we design our multi-centre research?
Unfortunately, there is no such thing as a “one size fits all” research design. After consulting different healthcare professionals, we have come to the conclusion that we need a control group if we want to report useable results. We have chosen a research design, together with Dr. Joris Jansen and in collaboration with professor of Data Science & Health Maurits Kaptein, that uses a matched control group consisting of patients who do not use telemonitoring.
Learning, doing, and researching at the same time
A single experiment won’t be enough to address all the research questions that require more ‘evidence’. Besides, we’re not aiming to conduct only one big experiment, live in a bunker, and await the results before continuing our work. Far from it. You really can’t put a price on the valuable information we obtain from studying continuous results. This targeted approach helps us provide practical applications of the ‘lessons learned’ about implementing an eHealth service. It’s all about learning, doing, and researching at the same time.
Meaning even more to patients
Of course, we want telemonitoring to be part of regular healthcare for patients who could benefit from it, including the funding that comes with it. Because, however complex it is to perform research, simply listening to patients’ experiences in our projects has shown us how we can mean so much more to these people. Given the expected rise in the number of patients, this will be more crucial than ever!
- Milani, R. V., Lavie, C. J., Bober, R. et al. (2017). Improving Hypertension Control and Patient Engagement Using Digital Tools. The American Journal of Medicine, 130(1), 14-20.
- Dransfield, M., Wells, M., & Bhatt, S. (2013). Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial.
- Cardozo, L., & Steinberg, J. (2010). Telemedicine for Recently Discharged Older Patients. Telemedicine and e- Health, 16(1), 49-55.
- Seto, E. (2008). Cost Comparison Between Telemonitoring and Usual Care of Heart Failure: A Systematic Review. Telemedicine and e- Health,14(7), 679-686
- Noah, B., Keller, M.S., Mosadeghi, S., et al. (2018). Impact of remote patient monitoring on clinical outcomes: an updated meta-analysis of randomized controlled trials. Nature partner journals Digital Medicine 1, Article number:2
The initial results of the eHealth service HeartGuard are impressive, with 64% of resistant hypertension patients able to manage their high blood pressure more effectively. Zilveren Kruis began paying for its clients’ use of this modern version of heart care in 2016. Patients take their measurements themselves at home, while their cardiologist monitors remotely. “HeartGuard helps us bring care into the home safely, which is a major consideration in our view”, says Olivier Gerrits, director of care procurement at Zilveren Kruis.
HeartGuard is available to patients suffering from heart failure, cardiac arrhythmias, or resistant hypertension. Cardiologie Centra Nederland (CCN, Cardiology centres of the Netherlands) systematically monitor patients who are insured by Zilveren Kruis and are using HeartGuard, to determine the clinical effects, as well as the effects on quality of life. The initial results are very promising.
Patients who used HeartGuard showed an average decrease in blood pressure from 157/89 mmHg to 132/84 mmHg. 64% of patients with resistant hypertension have even been able to control their blood pressure. These are patients who have been referred by their family physician after various medicines failed to lower their blood pressure.
From Waiting Room to Living Room
Since the introduction of HeartGuard in 2016, hundreds of Zilveren Kruis policyholders have used the technology. “The number of applicants is shooting up. This offers good prospects for the future of telemonitoring and eHealth in general”, Gerrits explains. “By bringing healthcare into our clients’ homes in a safe manner, we improve their quality of life, prevent symptoms from getting worse, and avoid unnecessary visits to the hospital”.
The data collected over the past year also shows that patients have an increasing sense of self-management. “In the long run, this means fewer trips to the emergency room or family physician, as well as shorter waiting times in the hospital. eHealth is going to take on an ever more prominent role in Zilveren Kruis’s procurement policy”, says Gerrits.
Dr. Igor Tulevski, cardiologist and co-founder of CCN adds, “The first results show that eHealth is no longer a promise, but a practical solution that really works”. Tulevski continues, “The patients feel a greater sense of freedom and experience an improved quality of life. They also feel safer because they can be in touch with a cardiologist 24 hours a day, seven days a week. It enables them to exercise more control”.
Viable, Scalable, and Affordable
By using Luscii’s Vitals app (formerly cVitals), patients can monitor and send measurements, such as blood pressure and heart rate, to their cardiologist. “For normal treatment, we often only see the patient once a year and have to define our policy based on that. Thanks to HeartGuard, patients can send us many more measurements and vitals from the comfort of their home. This gives a very in-depth understanding of our patient’s situation”, Tulevski explains.
“If any of the patient’s measurements deviate from the norm, we can provide remote care by tweaking the prescription, so as to prevent the situation from worsening. Last year’s data shows that we can prevent sudden changes in the patient’s health status, which leads to a reduction in emergency consultations”.
The Future of Care
Gerrits explains, “By offering eHealth, we are providing the healthcare of the future, today, for our clients. With other insurers also following our example, we’re pleased to see how this kind of telemonitoring is becoming more accessible”. HeartGuard is only available for CCN patients at the moment. “All that’s left now is for other insurance companies to embrace eHealth in the coming years, so that everyone who wishes to use it is able to do so”.
HeartGuard is a joint initiative by Zilveren Kruis, Cardiologie Centra Nederland, and the Dutch healthcare innovation company Luscii (a brand of FocusCura). Since last year, Zilveren Kruis has covered the cost of HeartGuard for its policyholders, if medically prescribed. This eHealth breakthrough in the Netherlands made international headlines in 2016.
This press release was published by our partner Zilveren Kruis.