Today there is good news for thousands of Dutch heart patients. After the largest insurer Zilveren Kruis announced to fully reimburse the e-health service HeartGuard, four other major healthcare insurers (VGZ, DSW, ONVZ, De Friesland) will also follow and reimburse HeartGuard in 2017. Cardiology Centers The Netherlands (CCN), together with Luscii, founding partner of HeartGuard, announced this news today.
HeartGuard enables continuous monitoring of cardiovascular patients suffering from heart failure, hypertension or atrial fibrillation. Patients can measure their vital signs at home with the Vitals App (formerly cVitals), developed by the Dutch healthcare innovation company Luscii.
The vital signs, like blood pressure or weight, are sent in remotely through the Vitals App on the patient’s iPhone or iPad to the cardiology centres and are automatically added to the Electronic Medical Record of the patient. Doctors and nurses will be alerted in case of detection of an increased health risk. Following that alarm, the staff will reach out to the patient and/or general practitioner. Hospital admissions and outpatient clinic visits are reduced by the HeartGuard service.
Fast scale up possible because of reimbursement
”Contracting with any of these four insurances companies makes it possible to offer the service to thousands of patients”, according to Cecile Goldman, VP of Operations at CCN. ”Now we can offer the service to patients insured at these insurers as well. This number can grow even further, when insurers CZ and Menzis will start reimbursing HeartGuard too. ”We are in dialogue with them to offer HeartGuard as well”.
CCN: “Dutch insurers are setting an example”
By reimbursing HeartGuard, Dutch insurers are setting an example. They are showing that they are not only retaining traditional care delivery, but are willing to support innovation. ”HeartGuard is at the forefront of further evolution in healthcare and by opening up the service to these new patients, we can increase our insights into the effects of this innovative healthcare service on an even larger scale”, says Cecile Goldman.
Insurer ONVZ: “enthusiastic about possibilities of eHealth”
Chairman of the Board of insurer ONVZ Jean-Paul van Haarlem is enthusiastic about the possibilities of HeartGuard for its clients: ”This is an innovation that provides patients with personalised care. HeartGuard will have a positive impact on quality of care and on efficient use of resources. Because it monitors the patient’s health remotely, HeartGuard will lead to a reduced number of hospital visits. This is a major improvement for the patient. Reimbursing HeartGuard is an important step for heart patients insured at ONVZ.
Insurer Zilveren Kruis: “good that others are following”
“We are very happy with the fact that we have realised this breakthrough last summer with Luscii and CCN to bring chronic cardiovascular care close to our clients. The fact that others follow this example towards innovative care, making it available to more patients is great”, says Erik-Jan Wilhelm, VP of Strategy and Innovation of Zilveren Kruis.
Dutch Patients Federation: “positive development”
The Dutch Patient Federation is happy that more and more insurers reimburse eHealth. ”We are glad that other insurers are following the example of Zilveren Kruis”, says Director Dianda Veldman. ”I hope more of these eHealth initiatives will be developed so all patients can enjoy this modern form of healthcare.”
Collaboration with hospitals and GPs
At this moment, only patients of Cardiology Centers the Netherlands are eligible to use HeartGuard, but, according to Cecile Goldman, this will change soon: ”We are already having conversations with GPs and hospitals to offer HeartGuard from their own locations to their own patients. We will monitor the patients in that case in commission of their own doctor. Scale is an important factor to eHealth, sharing our resources and expertise reduces the need for every hospital to reinvent the wheel“.
The role of Luscii in HeartGuard:
Luscii provides hardware, software and patient support in HeartGuard. As a spin-out brand of FocusCura, Luscii is co-initiator of the HeartGuard service, together with Cardiologist Center the Netherlands and insurer Zilveren Kruis. These three partners joined in a mutual innovation team to create the HeartGuard service. The Luscii platform is embedded as a button inside the EMR of the cardiologist (CardioPortal). Patients can download the Luscii Vitals and Luscii Contact apps on their iPhone or iPad, send in their measurements and have (video)-communication with the nurses or cardiologists. Also, after enrolment, Luscii is responsible for all logistics (sending the measurement devices), service and (installation) support for patients within HeartGuard.
This press release was published by Cardiology Centers The Netherlands and Luscii (previously FocusCura) on 6th March 2017.
In the midst of the summer holidays, healthcare insurer Zilveren Kruis introduced a unique financing model for hospitals who want to offer telemonitoring at home for their patients. The news is a breakthrough for thousands of citizens that suffer from heart disease. Together with Menzis – who previously introduced unique funding for COPD monitoring – the insurers show that this innovation is not just a whim for them. Now, what does this mean for hospitals and patients?
Financial paradox for eHealth
Despite all the promises, eHealth is not widely available for every patient. A major cause being the current funding system. Though VBHC (Value Based HealthCare) sounds inspirational, nowadays reimbursements for specialist medical care are based on the number of actions that have been carried out. In short; a hospital gets paid when patients visit the doctor or the outpatient clinic, or are admitted. In contradiction, many eHealth solutions – including home measurement – aim to prevent care. And that’s a catch 22; Costs to the hospital increase when introducing home measurement tools, while turnover decreases because fewer interventions or admittances are needed. From an insurer or payer or citizen perspective this is a win (we all pay taxes and fees for insurance). But this does not work for the hospital and the doctor… What now?
The start of new financial models for home monitoring
In 2016, Zilveren Kruis, Cardiology Centers the Netherlands (CCN) and FocusCura entered into a long-term partnership to bring as much hospital care as possible to the homes of patients. They launched the “HeartGuard” concept, watching over patients with heart failure, hypertension and atrial fibrillation. Part of this concept would also include a completely new way of funding, and that was easier said than done…
Over the course of nine months, an innovation team representing all three parties worked on the concept. They shared the vision that care should be delivered tailor-made to the patient’s needs, and while monitored safely at home with technology, a hospital visit would only be necessary in case of urgency. This approach improved the patients’ service-experience tremendously, while at the same time, the cost of care was reduced: Admissions are prevented and outpatient care is partially substituted. The calculation model of the innovation team was tested at CCN, and after testing the ‘Hartwacht fee’, would be made widely available by Zilveren Kruis. And that moment is now.
The concept is based on the principle of ‘bundled payments’. An insurer pays the hospital a bundled price per care pathway. The price being determined upon the historical price of the mix of healthcare products in the concerned care pathway. Though this seems complicated, basically it comes down to the hospital always receiving a guaranteed rate per pathway. Regardless of whether the patients visit the outpatient clinic, are hospitalised or are monitored remotely through home monitoring and videocare. Caregivers can thus determine, without financial consequences, in consultation with their patients, what is best for them. And if they decide to use the home monitoring, there are no additional costs for the patient, since they are paid for in the bundle price.
Does it work for the patients?
From my own experience, I can tell what this means for patients. Kor: “Someone in my immediate family has heart problems. He had to go to the hospital very regularly. Sometimes for a routine check-up, even though he had no complaints. Another time in panic to the emergency room. Fortunately, he has a modern cardiologist who prescribed ‘HeartGuard’”.
Kor received measuring equipment at home and the Vitals app was installed on his phone. During the first ‘setting week’, a personal measurement protocol was set up. Now he sends in his measurements weekly and he no longer has to visit the clinic. “I remember how ‘happily surprised’ he was after being ‘videocalled’ by the HeartGuard Centre, when it appeared that there were strange values in his measurements. His medication was adjusted and altogether this gave him such peace of mind. Not only for him, but also for us, as his direct family”.
More time for cardiologists
And besides, his own cardiologist was extremely satisfied. He now has insight into all home measurement data in the EMR and remains Kor’s regular point of contact for those moments when something is really off. According to a jointly agreed protocol, home measurements are treated in the HeartGuard Centre in Dokkum. The HeartGuard data shows that less than one in ten measurements have to be forwarded to the cardiologist. The rest of the home measurements are handled by the Vitals app itself or the HeartGuard team in Dokkum.
For Kor’s cardiologist, this means that many urgent questions popping up in his busy schedule, now belong in the past, while patients immediately have clarity about their condition and possible risks. He can thus have more patients under his supervision. And his own work is more pleasant, he said, because he can do his job even better by intervening proactively and by using the data for the benefit of his patients.
2019: Extra financial incentive
To make this widely available, Zilveren Kruis goes a step further; they commit to a fixed bundle price for three years. So hospitals will receive the same bundle price over the next three years, regardless of how their operational costs of the outpatient clinic decrease or the number of admissions decreases. Hospitals are allowed to keep the margins themselves and are given the time to adjust to the new way of care. A huge incentive!
Sharing knowledge to better care
It is very cool to be able to contribute to this movement with our team. We are happy to share our knowledge gained through various channels, such as in this blog. Because I hope that other hospitals will now also take the step. Since not only my Kor, but all heart patients, deserve the best care that fits their needs. VBHC then becomes a practice.
Or like my inspiration Florence Nightingale stated:
“Were there none who were discontented with what they had, the world would never reach anything better.”
This blog was published in Dutch on the website of Qruxx about Value Based Healthcare in August 2018.
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.
The role of Luscii in Rode Kruis Hospital:
Luscii provides hardware, software and patient support for the Rode Kruis Hospital. The Luscii platform is used as a web portal. Patients download the Luscii Vitals and Luscii Contact apps on their iPhone or iPad to send in their measurements and have (video)-communication with the nurses or cardiologists. Also, after enrolment, Luscii is responsible for all logistics (sending the measurement devices), service and (installation) support for patients within the service.
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.
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.
The role of Luscii in the Martine Hospital:
Luscii provides hardware, software and patient support for the Martini Hospital. Luscii also helps the Hospital to implement Luscii the right way and to create the business case for insurers. Furthermore, when a patient is enrolled in telemonitoring, he/she will receive the Luscii Vitals and Luscii Contact apps to send in their measurements and have (video)-communication with the nurses or doctors. Also, after enrolment, Luscii is responsible for all logistics (sending the measurement devices), service and (installation) support for patients within the region of the Martini Hospital (Groningen). The PhD of Luscii (Martine Breteler) will be helping with the validation research.
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:
The role of Luscii at Isala Hospital:
Luscii provides hardware, software and patient support for the COPD project at the Isala Hospital. Luscii helped the hospital to introduce telemonitoring into the outpatient clinic visit. Luscii worked together with the pulmonologists and specialised nurses in setting up the project. Furthermore, when a patient is enrolled into telemonitoring, they will receive the Luscii Vitals and Luscii Contact apps to send in their measurements and have (video)-communication with the nurses or pulmonologists. Also, after enrolment, Luscii is responsible for all logistics (sending the measurement devices), service and (installation) support for patients within the service.
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”.
The role of Luscii in Cardio@Home at Haga Hospital:
Luscii provides hardware, software and patient support for the Cardio@Home project at the Haga Hospital. Luscii helped Haga Hospital to introduce telemonitoring into the outpatient clinic visit. Luscii’s implementation specialists guided the cardiologists and specialised cardio nurses in setting up the project. Furthermore, when a patient is enrolled in telemonitoring, he/she willl receive the Luscii Vitals and Luscii Contact apps to send in measurements and have (video)-communication with the nurses or cardiologists. Also, after enrolment, Luscii is responsible for all logistics (sending the measurement devices), service and (installation) support for patients within Cardio@Home.
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
“I can’t do it anymore. My husband has late-stage dementia and my children live far away. I just don’t know what to do anymore. Please help me”. Wow, that hit home. I looked up and saw an older woman sighing with frustration at the health-care counter. The woman at the desk was doing her best, but didn’t really know how to help. I was sitting in the waiting room, watching it all unfold. For some reason, I couldn’t stop thinking about it. Is this vulnerable group of people being left behind? Are we expecting them to be too self-sufficient? Are we doing enough to help them?
Technology back in the day
When I first started working with FocusCura in 2003 (the company which I founded and of which Luscii became a spin-out brand), the world was relatively simple. iPads and iPhones didn’t exist and technology was reserved for cool youngsters and nerds, not for senior citizens. That’s why a lot of people called me crazy when I came up with the idea of using technology to help older people maintain their independence. But I did it anyway. And the senior citizens loved it. You can see how it looked on the picture below (made in 2004).
Things are very different today. Technology plays a dominant role in the lives of young and old alike. We use computers, smartphones, and tablets for everything. In fact, our devices are the first thing we see when we wake up and the last thing we see when we go to bed.
Last year, 86% of Dutch people used a smartphone (source: Dutch Smartphone Users report by Telecompaper). The majority of this growth was found among older people, given that most young people already used smartphones. In fact, smartphone use among people in the 65-80 age bracket increased from 9% to 63% in 2016.
Self-sufficiency and technology
Technology is playing an increasingly important role in our lives and is therefore becoming a determining factor in our ability to remain self-sufficient. However, there are a lot of vulnerable people who don’t understand these advancements – like the woman in the story above – and are afraid to ask for help. They are limited in their ability to take care of themselves and manage their lives. In many cases, the children live far away or have no interest in caring for their parents. It’s important that we don’t forget these people. And we aren’t: ten thousand nurses, caregivers, and volunteers are committed to helping this vulnerable group every day.
At home with dementia
I recently had the opportunity to shadow a dementia nurse at a healthcare organisation we work with. Dementia nurses help old people with dementia and their relatives, such as husbands, wives, and close family members, the entire time that person lives at home. During my work, I try to have this kind of ‘days in the life of’ with the users of our products once in a while (see also our way of working in the keynote below).
Together, we biked around visiting several clients. One of those clients was a couple and the wife had severe dementia. The husband was faced with a tough decision: put her in a nursing home or keep her at home. Their daughter was there too and I had so much respect for how they handled the situation. They explored all of the possibilities and thought long and hard about ways to avoid this difficult decision. “The last thing you want is to have your own wife committed”, he explained to me. The case manager and community care services were extremely supportive.
We visited another older gentleman that day who lived alone. He was vulnerable but very happy. He was eager to share his stories with us, with no real connection between them. He didn’t know a thing about technology. He was still coming to terms with the passing of his wife. As we were walking out the door, he explained that his children were worried about him. They all live far away and don’t really know how to help.
Technology to alleviate concerns
I was very impressed that morning and it really got me thinking. All of these people have their own challenges and problems, but were extremely happy with the support of the community care services and the case managers. To them, self-sufficiency was about as abstract a concept as technology. Although, that’s not entirely true with respect to the latter. Lots of people asked me to explain what FocusCura does. So I told them about partnering with healthcare institutions to help vulnerable people live at home safely and independently.
These people in particular, who didn’t really understand technology at all, were the ones who encouraged me to continue. While the sensors may be too late for them, they would have certainly made life easier. It also would have been nice to stay in the comfort of their own home for dementia check-ups, instead of having to take their partner with them to the hospital.
Plenty of work to do
This day made me realise all the more how important technology is. While it may not help dementia patients directly, it does give them the opportunity to enjoy the personal attention of their own warm, loving, and dedicated caregivers.
I don’t want to be a doomsayer, but the statistics don’t lie. With the number of healthcare users on the rise and a shortage of healthcare workers, our problem won’t be a lack of budget in the future. The real problem is a lack of qualified nurses, caregivers, and case managers.
The clever use of technology can provide support to these caregivers in helping their clients. In this way, we can help them maximise their limited time so they can also focus on offering personal and warm care. After all, they’re the ones who know the type of care someone needs and when they need it.
How great would it be if they could use wearables to check on their clients and take immediate action when something goes wrong? And how comforting would it be for the client’s children to be able to hop by using Luscii videocare, to join a visit of the nurse?
We still have a long way to go and there’s still plenty to do and develop in terms of healthcare technology. As great as the commercials are, it’s extremely challenging to develop technologies that perfectly address the needs of users, be they healthcare providers or clients.
We also have to reform our healthcare budget system if we want to achieve this. We don’t even have to replace the current rules and regulations with new ones; in fact, I believe that almost everything we want is possible in our current healthcare system. We just have to do it, which requires courage on all sides: healthcare providers, insurance companies, and businesses. If they create the room for healthcare providers to determine their own care methods, we can make good on our promise!
It all comes down to one thing: the people.
Of course, the gadgets, robots, and new technologies are super exciting, but they really play a minor role. It’s all about the people who use these technologies: the case managers who trust that these devices will be their eyes and ears; the caregivers who know that the smart sensors will alert them if something goes wrong.
Of course, this extends beyond the technology used in dementia care. The same applies to telemonitoring for COPD and heart failure, whereby patients send their measurements to their healthcare providers. Technology plays an important and welcome role for this group as well. It does, however, have to be extremely user-friendly and often also requires a detailed explanation from our technicians. But when I hear how happy patients and caregivers are and how much calmer they feel, I know we’re on the right path.
Extra help for an extremely vulnerable group
Is eHealth only suitable for independent, trendy, and healthy people? Or for people with a strong social network? Absolutely not! We can’t forget the extremely vulnerable group of people, like the older woman at the healthcare counter. They deserve special attention and help. After all, they’re the ones who will benefit most from the support of modern technology.
Not necessarily from the technology itself, but from the warm and personal attention of caregivers who are always at hand. This personal care can continue to exist for all those who need it in the future!
*The situations were modified slightly for privacy reasons, without sacrificing the essence of the story.
THE HAGUE – Collaboration in the healthcare sector is becoming increasingly important. It is therefore vital that patient data can be shared easily between healthcare providers and with patients themselves. Unfortunately, the multitude of different systems in the healthcare sector has always complicated matters. But that’s about to change. The Reinier Haga Group is the first organisation to put Zorgplatform (the Care Platform) into use, which enables simple, structured and secure exchange of patient data.
The Reinier Haga Group (consisting of Reinier de Graaf Hospital in Delft, Haga Hospital in The Hague and LangeLand Hospital in Zoetermeer) has become the first to put Zorgplatform into action. Using this platform, patient data in the electronic patient file can be shared in a simple, secure and structured manner between healthcare institutions and eHealth solutions, such as the Luscii Vitals (formerly cVitals) app. The introduction of Zorgplatform is a welcome boost to the cabinet’s ambition to promote collaboration in the healthcare sector by actively developing ICT standards and making them compulsory. Today, Secretary General Erik Gerritsen talked about this development during a working visit.
“The Reinier Haga Group strives to offer its patients the right care in the right place at the right time. To achieve this ambition, it is essential that healthcare is tailored to suit individual patients as much as possible, increasingly making patients the directors of their own care processes. The introduction of a home-measurement app to measure vital statistics, such as blood pressure, weight and pulse rate, will facilitate this greatly. In addition, the availability of a patient file to our doctors and nurses is vitally important”, explains ICT manager Marcel Slingerland. “An increasing amount of the patient data we use is now obtained from other healthcare organisations and innovative apps used by patients at home. Zorgplatform has allowed us to tap in to these rich wells of data”.
Standard data exchange
A long-held desire among doctors and nurses is to have a total picture of each individual patient’s health. This is often impossible as the data required is locked away in a maze of separate systems. “We specially developed Zorgplatform to solve this problem simply and securely”, explains ChipSoft’s Remko Nienhuis. “Zorgplatform allows data to be shared with the hospital’s electronic patient file in a standard manner with the aid of the Healthcare Information Building Blocks (Zorg Informatie Bouwstenen or ZIBs) developed by the government. In this way, hospital EPFs can connect to other patient files and even to other innovative healthcare technologies”.
Luscii is the first to have its Vitals app (formerly cVitals) connected to Zorgplatform. This allows medical specialists to prescribe ‘Vitals home measurements’ directly via the electronic medical record (EMR), to access these home measurements and to receive alerts if any deviations are identified. They can then respond to these alerts, for example, via a video call using Luscii Contact (formerly cContact). Cardiologist Jan Willem Borleffs, who works at the Haga Heart Centre at Haga Hospital, is very impressed with the new possibilities. “Last year, we saw exactly how Luscii’s home measurements and video calls can provide vital assistance to patients with heart problems. Patients feel safer and we can take action earlier, which means hospital admission is often prevented”.
The right care in the right place
Mr. van der Hoeven, a heart patient, agrees. “This new form of care means better check-ups for me and that works really well”.
To connect more patients to this system, it is vital that these home measurements are integrated into ChipSoft’s EMR HiX, as this will prevent a whole separate system from being required simultaneously. “I am very happy that Zorgplatform has made all data available in our EMR”, says Borleffs. “This is a key step in gaining acceptance of eHealth”.
The connection of the home-measurement functionality in Zorgplatform means other healthcare institutions who connect to Zorgplatform can also access this data. The Netherlands has therefore made an important medical breakthrough in the field of sharing patient data.
The integration of Luscii into EMR Chipsoft:
A team of Luscii and Chipsoft HiX (the biggest EMR vendor in the Netherlands) integrated Luscii deeply into Chipsoft using ‘Zorgplatform.’ The integration has three features: 1) sign up of patients for telemonitoring directly from the EMR, 2) alarm handling of Luscii alarms in the EMR workflow and 3) all data measured with Luscii delivered directly into the EMR. The first hospital system to use the integration is Haga Group (three hospitals in The Hague, Delft and Zoetermeer).
This press release was published by Luscii and Chipsoft at the beginning of 2018.
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.
The role of Luscii in HeartGuard:
Luscii provides hardware, software and patient support in HeartGuard. As a spin-out brand of FocusCura, Luscii is co-initiator of the HeartGuard service, together with the Netherlands’ Cardiologist Centre and insurer Zilveren Kruis. These three partners joined in a mutual innovation team to create the HeartGuard service. The Luscii platform is embedded as a button inside the EMR of the cardiologist. Patients can download the Luscii Vitals and Luscii Contact apps on their iPhone or iPad, send in their measurements, and have (video)-communication with the nurses or cardiologists. Also, after enrolment, Luscii is responsible for all logistics (sending the measurement devices), service and (installation) support for patients within HeartGuard.
This press release was published by our partner Zilveren Kruis.
Good news for more than 600,000 COPD patients in the Netherlands: more hospitals across the country are introducing the measurement of vital COPD values at home. This means that COPD patients no longer have to go to the hospital to get these values measured. “It also prevents hospitalisations, which is a great development”, says Emiel Rolink, director of Long Alliantie Nederland (LAN, the Dutch Lung Alliance).
Fewer hospital visits, with continuous supervision
A visit to the hospital is not only taxing on COPD patients who already have reduced energy because of their disease, but because the nature of the disease also causes stress. Patients can feel insecure and worry about ‘lung attacks’. Mr. Bremer, a COPD patient, explains: “I no longer have to go to the hospital as often as I used to, which really was an intense exertion for me. Now I have my values measured twice a week, which really gives me and my family peace of mind”.
Health measurements at home
Measuring the values of COPD patients at home is made possible by Luscii Vitals (formerly cVitals), an eHealth solution designed by the Dutch health care innovation company Luscii, a spin-out brand of FocusCura. Patients submit their measurements twice a week, which are then monitored at a distance. If the system detects an increased risk or if the patient has questions of their own regarding certain measurements, they can contact a healthcare professional immediately by video chat. In doing so, the care provider can give instant medical attention and prevent hospitalisations.
“We need to reduce hospitalisations by 25%”
In the Netherlands, COPD attacks equate to 30,000 hospitalisations every year, half of which are re-admissions. Rolink notes that, “The LAN wants to reduce the number of hospitalisations by 25% across the Netherlands in the context of the Nationaal Actieprogramma Chronische Longziekten (National action programme for chronic lung disease patients), while maintaining or improving the quality of life of patients. Finland and pilot areas in the Netherlands have shown that it is possible, provided you use a systematic approach that monitors the patient closely”.
Hospitals across the Netherlands
“We are working with Luscii to make this kind of modern COPD care available to patients across the Netherlands”, states Joris van Eijck, director of Health Care for Menzis. “This follows multiple successful projects in Slingeland Hospital, Isala, and MC Slotervaart”. To help hospitals achieve this ambition, they will be receiving a book from Erik Gerritsen, the Secretary-General of the Ministry of Health, Welfare and Sport, during the national e-health week. This book contains lessons learned, experiences, and a plan of action to make digital COPD care available.
Luscii provides hardware, software and patient support for a growing number of hospital systems using Luscii for their COPD monitoring programmes. The Luscii platform is embedded as a button inside the EMR of the pulmonologist. Patients can download the Luscii Vitals and Luscii Contact apps on their iPhone or iPad, send in their measurements, and have (video)-communication with the nurses or pulmonologists. Also, after enrolment, Luscii is responsible for all logistics (sending the measurement devices), service and (installation) support for patients within the monitoring programmes of the hospitals.
This press release was published by Menzis during the Dutch eHealth week in 2018.