Esteban Manuel Keenoy

Director Kronikgune

„Basque case story using e-health for tackling the

chronic diseases“

Tallinn

April 23rd, 2015

Index

• Introduction: Basque Country

• A strategy to deal with ageing, chronicity

and dependency

• Two cases:

– Multimorbidity patients

– Telehealth

• Main ICT features

• Lessons learnt and conclusions

Index

• Introduction: Basque Country

• A strategy to deal with ageing, chronicity

and dependency

• Two cases:

– Multimorbidity patients

– Telehealth

• Main ICT features

• Lessons learnt and conclusions

Demographic and epidemiological context

4

Basque Health System

Life expectancy

85,7 years

women

79 years

men Source: Eustat –Basque Institute of Statistics 2012

Population (2011): 2.183.615

≥65 years: 19%39% in 2050

BIZKAIA

GIPUZKOA

ARABA

25%

Private

75% Public

• GNP/per capita: 29.960€ (2013) (Spain 22.280€)

• Public Health Expenditure in 2013= 3.257 M€

• 5% GDP in 2012

• 35% of the Basque Gov. budget total budget

• Health Expenditure: 1.590€ per capita (Spain 1.250€)

6

The Basque Health System (BHS)

PLANNING/FINANCING/REGULATION

SERVICE PROVISION

Department of Health

Basque Public Healthcare Service

FRAMEWORK CONTRACT

PROGRAMME (COMMISSIONING)

AGREEMENTS Private providers75% Public

7

The Basque National Health System

• Universal health system,

• Funded by taxes

• Free access to the system for all residents in the Basque Country

Service organization map of Osakidetza

319 primary care facilities 6 Acute care Hospitals

3 medium and long stay care Hospitals 3 Mental Health networks Emergencies

Staff-Osakidetza

Total: 25.816 (2012)

• 6.305 physicians

• 8.246 nurses

• 4.055 auxiliary nurses

• others (7.210)

8

Health expenditure 3.257 M€ in 2013.

Contract Program, Pharmacy and Agreements expenditure evolution 2005-2012

Economic context

Total

Osakidetza

Pharmacy

Agreements with private sector

Eu

ros

9

Source: Department of Health, Basque Government (2013)

Chronic conditions in the

Basque Country

• Chronic diseases 80% of medical

consultations

• 75% of the Health BudgetIn a system designed:

• To treat acute problems

• Not to deal with chronic patients: episodic care

age

%

% of patients according to the number of chronic diseases per patient (2010-2011)

0

10

20

30

40

50

60

70

80

90

100

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95

5+ 4 3 2 1

Chronic diseases and multimorbidity

11

Source: PREST- Stratification Database in the Basque Country (2010-2011)

Primary

CareHospital

Care

A&E 24X7

8.760 HOURS/YEAR

HEALTHCARE

HOME

1-2% contact with Healthcare System

In a system designed to treat acute problems:

episodic care

• Prevent the occurrence

• Avoid predictable complications through treatment and optimal management.

1. ANTICIPATION

Chronic Diseases approach

• Well-defined Plan of care and follow UP,

• Self-management,

• Monitoring performance and compliance

2. LONGITUDINAL PERSPECTIVE CARE

3. MULTIDIMENSIONAL ACTION

GAP Increased demand for medical care

• increase in chronicdiseases

• complexity of science and technology

Inability of the system to meet demand

• poorly organized caresystem

• economic restrictions

Adapted from Institute of Medicine (IOM)

European healthcare systems remarkable results in health and safety

while maintaining acceptable levels of equity and sustainability

Index

• Introduction: Basque Country

• A strategy to deal with ageing, chronicityand dependency

• Two cases:

– Multimorbidity patients

– Telehealth

• Main ICT features

• Lessons learnt and conclusions

1. People: the backbone of the health system

2. Chronicity, old age dependency

3. Sustainability of the system

4. Professional Health System

5. Research and Innovation

Basque Department of Health Strategic Lines

Health Plan 2013-2020

Osakidetza2013-2016

Social. Healthcare

2013-2016

Pulley

Hoists

Multi lever approach

TOP- DOWN

STANDARIZABLE

INTERVENTIONS

ELECTRONIC

MEDICAL

RECORD

FINANCING AND

JOINT

COMMISSIONING

ELECTRONIC

PRESCRIPTION

NURSES NEW

ROLES

SUBACUTE

CENTRES

BOTTOM UP

LOCAL INNOVATION

POPULATION

STRATIFICATION

CONTINUUM

OF CARE

BOTTOM UP

Combined top-down and bottom-up Technological and Organizational actions

PREVENTION

EMPOWERMENT

SOCIAL CARE AND HEALTH

COLLABORATION

MULTICHANNEL PLATFORM

O-SAREANPUBLIC

HEALTH

Index

• Introduction: Basque Country

• A strategy to deal with ageing, chronicityand dependency

• Two cases:

– Multimorbidity patients

– Telehealth

• Main ICT features

• Lessons learnt and conclusions

Integrated Intervention Plans (IIP)

• Promote integrated care on patients with high complex

conditions

• Boost the coordination of multidisciplinary health care

teams

• Improve Health outcomes, efficiency and patient

satisfaction

1.394.539

636.000

173.000

43.000

• General Population

• Chronic patients

• High Risk Patients

• High complex multimorbidity

Health Promotion and prevention

Self management support

Diseases management

Case management

Risk-based Approach

Organisational model

WHO is involved in caring for and supporting patients, WHAT functions these

actors perform, and HOW different ICT tools facilitate the delivery of these

activities.

STABLE PATIENT OUT OF HOSPITAL CARE UNSTABLE PATIENT OUT OF HOSPITAL CARE

HOSPITAL DISCHARGE PREPARATION IN HOSPITAL CARE

GP

Primary care nurse

Patient/Carer

Social worker

Community Pharmacy

PHARMACY

HOME

COMMUNITY

PRIMARY CARE Primary care nurse

Patient/Carer

GP

Emergency

Specialist

Care ManagerPRIMARY CARE

HOSPITAL

HOME

eHealth centre

Primary care nurse

GP

Council Social worker

Hospital Liaison Nurse

COMMUNITY

PRIMARY CARE

Hospital Social teamHospital nurse

Hospital Pharmacist

Emergency room/Day care hospitalReference internist

Other specialists Sub-acute hospital staff

HOSPITAL LONG-TERM HOSPITAL

Telecare centre

Deputy Health Service

· Therapeutic plan· Diagnosis, follow-up· Pharmacologic plan· Referrals to specialists· Test selection

· Assessments· Tests· Pharmacologic follow-up· Patient training· Coordination with social care

· Self-management· Health habits· Action plans

· Follow-up when needed· Identifies and reports needs

to community nurse

Pharmacologic follow-up

· Tests, follow up-visits· Pharmacologic follow-up· Patient training· Coordination with social care

Contact with Primary Care (8h-20h). If out of

hours contact emergency

· Therapeutic plan· Follow-up visits· Pharmacologic follow-up· Referrals to specialists· Test selection, diagnosis

Transport patient to hospital out of hours

Consultations, diagnosis

· Tests & therapeutic plan· Follow-up· Intravenous medication· Follow-up visits· Referral to specialist

Health advice and coordination of health

resources. Telemonitoring.

· Integrated frailty assessment· Therapeutic plan follow-up· Patient training· Home visits (intensive follow-up)· Coordination with social services

· Diagnosis· Intensive follow-up· Therapeutic plan follow-up

· Coordination with health services (Primary Care)

· Social care services · Coordination with Primary Care· Explains to the patient/carer the

therapeutic plan,health advice, alarm symptoms and action plans

Assessment of needs and if required, patient referral to other settings (home, sub-acute or long-

term hospital)

· Intravenous medication· Patient training· Detection of social problems· Integrated frailty assessment

· Analysis of drug interaction and side-effects

· Avoids drug duplication· Monodosis preparation

Patient stabilization when needed and referral to

specialist

· Tests, diagnosis· Therapeutic plan· Pharmacologic follow-up

· Tests, diagnosis· Therapeutic plan· Diagnosis

Similar activities than in hospital but patients are in long-term hospitalization

· Coordination with health & social care

· Activation of ehealth center

Out of care hoursHome-visits

F2F, Email, Phone

EHRE-prescription

F2F, Phone

TM

F2F, PhoneSocial EHR

F2F, phoneE-prescription

Phone

Email

Phone

Phone

Phone

EHRInterconsult.

EHRPhone

Phone

EmailSocial EHR

Phone

PhoneEHR

EHRE-prescription

CRMPhone

EHRE-prescription

F2F, Phone

EHR

EHR

EHR,F2FE-Presc., Phone

EHR

EHR,F2FE-Presc.Phone

EHR,F2FE-Presc.Phone

EHR

Phone

PhoneCRM

EHRPhone

Interconsult.Email

EHR, PhoneInterconsult.

Email

Phone

Integrated Intervention Plans Definition

PIIs

TOP-DOWN

BOTTOM- UP

• Bundled payment

• ICT systems

• Intervention groups.

• Patient selection criteria.

• Assessment Framework.

• Weights in the financing framework

• Registration and local patient recruitment.

• Care pathways

• Care plan + telehealth.

• Effective delivery of care (care coordination)

• Monitoring results.

Scientific Evidence

Experiences from other organizations

Compilation of ideas and best practices

Methodological support

Cultural Change

Browse new models of care (most

appropriate and most cost-effective): + home

+ PC and-Hospitals

Governance and coordination elements

Local innovations

Patient identification (at home or healthcare centre):· Assessment· Therapeutic plan· Follow up

Primary Care

Yes No

Additional resources needed?

· Specific empowerment programmes

· Social resources· Ehealth centre· Telemonitoring

Primary CareFollow-up:· Therapeutic plan· Patient training· Assessments· Tests

GP

Primary care nurse

Unstable patient?

Yes

No

Primary Care

GP /Primary Care

nurse

· Clinical assessment· Therapeutic plan

Telecare Centre

Emergency

ehealth Centre

Home care?

Yes No

Stable patient out of hospital care Unstable patient out of hospital care

Stable patient?

Yes No

Scheduled admission

Emergency Day hospital

Secondary Care

· Assessment· Clinincal interventions· Therapeutic plan

In hospital care Hospital discharge preparation

Cardiologist Pulmonogist

Other specialist

Discharge report (electronic)

· Coordination with Primary Care

· Follow-up planning

Integrated social assessment

· Social assessment

· Home hospitalization· Sub-acute hospital

admission

Yes

No

Stable patient, additional resources needed?

Reference internist

Hospital nurse

· Home hospitalization· Reference internist

(interconsultation)· ehealth Centre

Social resources

Social Care

Hospital Social worker

Secondary CareReference internist

Secondary Care

Hospital nurseSecondary Care

Reference internist

Social Care Secondary Care

* * **

***

* Entering into service

*

Integrated Care Pathways

35

Model based on

structures

Model based on

Integrated Systems

Fragmented

Reactive

Paternalist

Continuum of care

Proactive

Patient empowerment

Need to move towards a model focused on “systems” rather than “structures”

Case

manager

Liason

nurse

Community

carenurse

Reference

Internist

Reference

Specialist

Primary

Care

Subacute

hospital

Acute

Hospital

Counseling

services

Model1

Model2

Model3

Model4

Model5

Model6

3

3

2

1

1

1

Improvement areas identified

39

ICT toolsOrganization

/persons

ProcessesChange

management

• New functionalities in EHR

• Optimize information sharing

• Integrate telehealth data in

EHR.

• Correct identification of the

patients included in the IIP.

• Extend new nursing roles

• Deploy the role of the

Reference internist

• Improve job descriptions

• Promote social health care

coordination

• Improve care pathways

• Enhance proactivity of care.

• Ensure continuity of care with

Counseling Services.

• Optimize stratification tool

• Refine the evaluation

framework

• Collaborative space

(benchmark, training

programs, communication,

care pathways).

• Improve patient

communication

Telehealth Pilots

BIZKAIA

GIPUZKOA

ARABA

1

Telbil A

Telbil T FRAIL

2

U4H CHF

3

Telepoc COPD

4

Respirratory

rehabilitation

5

Teki COPD6

Tele diabetes

7

Frail Patients

CHF

COPD

FRAIL MM

DIABETES

SYSTEMS

Weight

Oxigen

saturation

Questio

nnaire

Devices and

services

Hardware

Software

Reception Base

HOME

EHR Osabide

Telecare

Blood

pressure

Manual

EXTERNAL

WEB

PLATFORM

Main findings

• Facilitates clinical decision making.

• Better relationship with professionals

• Sense of security and easeness, patients and

caregivers

• Patients greater role in self-care.

• Greater adherence to treatment.

• Increased satisfaction

• Avoid admissions and increases patients quality of life.

BUT EXTENSION AND SCALING UP?

CHF Management Protocol

HOME Telecare call centre

BetiOn

24X7 Health Counseling

call centre HACC

Emergencies

Specialist Consultant

Primary Care

Technical

Social alarm

Validated

Health related alarm

HACC Resolution

Referral to

Primary Care

(apppointment)

PC Resolution Resolution

With Specialist consultant

(teleconsultation)

Referral to Specialist Consultant

Activation alarm

215

43

4

5

Weight

Oxigen

saturation

Question

naire

Devices and

services

Hardware

Software

Reception Base

HOME+ BETI ON

HEALTH SERVICE

CRM

Process

management

Platform

Telecare

Blood

pressure

Manual Server EHR Osabide

Scaling up telehealth projects

Index

• Introduction: Basque Country

• A strategy to deal with ageing, chronicity

and dependency

• Two cases:

– Multimorbidity patients

– Telehealth

• Main ICT features

• Lessons learnt and conclusions

Some levers of action for a more efficient provision of healthcare services :

• The incorporation of ICT tools and ICT-based processes

• The deployment of services through remote channels

• Patient empowerment and the home as a place for effectively controlling the disease

ICT innovation: part of the solution

Electronic prescription

Electronic clinical record

Shared information systems

Public tele-care services

Multichannel service platformLocal remote monitoring pilots

(tele-COPD, tele-HF, control of oral coagulotherapy, etc.)

Technological infrastructure

One unique

portalNew

Appointme

nt Model

Medical

Counseling

Patients

remote

monitoring

Prevention

campaigns

Healthy

habits

promotion

Active

Patient

Personal

information

access

Service Portfolio

Service Portfolio

Strategic projects: Multi-channel Health Service Center

50

• Web 2.0

• CRM

• IVR

• BI

Patient-

professional

collaboration

51

One unique

portalNew

Appointme

nt Model

Medical

Counseling

Patients

remote

monitoring

Prevention

campaigns

Healthy

habits

promotion

Active

Patient

Personal

information

access

Service Portfolio

Service Portfolio

Health advice over the phone and

on the net, managed by

Osakidetza nurses.

Personal Health Record for every

citizen, which will

access to information

contained in the EHR

Support for the strategic projects

related to chronicity

Technical support for non face

to face consultations and

telecare.

Leadership and management

of the New Portal 2.0.

Administrative procedures

online

Create a tele-medicine

solution for chronic patients through

mobile platforms

Public Health Campaigns through different channels.

Surveys for citizens to improve knowledge of Health

System

Health School for patients:

validated information by

Osakidetza’s Doctors

Nurses and specialists

and Patient Forums

Extend for the whole population,

the new appointment model to GP,

Paediatricians, nurses and

midwives, through the telephone

channel (IVR and call center).

Healthy Lifestyles promotion

application implementation in

primary care

CRMBI

Patient-

professional

collaboration

Multi-channel Health Service Center customer relationship management

Patient empowerment & home-support pathway

Two points of view:

Pre- start:

• Solve most problems

• Matches Health System needs

• Promises a short development & deployment process

Pre- start:

• Single Payer Healthcare systemspredicts Economies of scale.

• Historic Business Models based onindividual projects

• Fidelization gives market advantage

Health System View Provider’s View

In the long term…

• It requires larger funding and time foradapting and updating

• Significant Transactional costsdevelopment and deployment

In the long term:

• Each Health system has differentstrategies, systems and processes

• Higher Transactional costs

• Budget shortages reduced margins

Index

• Introduction: Basque Country

• A strategy to deal with ageing, chronicity

and dependency

• Two cases:

– Multimorbidity patients

– Telehealth

• Main ICT features

• Lessons learnt and conclusions

Lessons learnt

• Fragmented care delivery inertia protected by laws, norms

and interest groups

• Health care practices highly stable: network of influences

and constraints (knowledge, beliefs, attitudes, habits,

systems, incentives, …)

• Clinicians need evidences: risk free and clear benefits!

• Backlash of unrealistic expectations!

• Difficult integration in clinical practice and information

systems

• High risk no substitution effect: new models require extra

resources and the former practice remains!

• Commitment and active role of politicians

• Involve managers and clinicians… AND NURSES!!!

• Promote local experimentation and scale up successful ones

• Patient and informal caregiver empowerment is essential.

• Technology is crucial to facilitate coordinated management of

all processes and communication between professionals.

• Accept that there is not a single model to move forward:

learning process !

• Identify trends, reallocate funding, align incentives and

objectives

• Process needs time: continuity and resilience!

Lessons learnt

• Crisis is an opportunity

• Provide a narrative which provides a vision and structure

• Co-create products and services

• Large-scale rollouts require a prior multi lever strategy of

organizational change: MATURING ECOSYSTEM

• Need to reallocate funding and redefine targets and

timelines

• It is not easy, ¡Keep going!

Conclusions

If you want to go fast, go alone,

if you want to go far, go together

African proverb