By Susan Usher, Sylvie Nolet, Louis-Marie Boivin, Guy Paré
This case study, produced by Health Innovation Forum with contributions from Sylvie Nolet from the CSSS Alphonse-Desjardins, Louis-Marie Boivin from TELUS Health Solutions and Guy Paré from HEC, looks at a health and social services centre in Eastern Québec's use of telemonitoring for chronic obstructive pulmonary disease.— Produced as part of the MUHC-ISAI's 2010 program.
An increasing number of Canadians are living with chronic diseases, which now account for over two thirds of direct healthcare costs. Diabetes, respiratory disease, heart failure and hypertension are among the most common. These patients are often referred to community-based home care services that aim to manage symptoms proactively to improve functional capacity and prevent exacerbations that lead to ER visits and/or hospitalizations.
In Québec, home care is largely the responsibility of the CLSCs (local community health centres), which are grouped administratively under Centres de la Santé et des Services sociaux (CSSS) and receive funding from the ministère de la Santé et des Services sociaux (MSSS). In 2006, the CSSS Grand Littoral in Eastern Québec, which serves a population of over 221,000 spread over close to 5,000 km2, conducted a review of its services and found that poor coordination of care for home-based patients with chronic disease stood out as a significant problem.
Work reorganization has been identified as a priority by the MSSS, which makes funds available for improvements. The CSSS Grand Littoral applied for funding to reorganize home-based care specifically for patients with chronic obstructive pulmonary disease (COPD). “We noted a problem in our territory with continuity of care for this population,” said Sylvie Nolet, Director of Quality Service at Grand Littoral. “Nurses and respiratory therapists in the five CLSCs under the CSSS jurisdiction worked differently and had poor coordination. They were meant to form a team but rarely worked together. We found instances where they would both visit a patient on the same day.”
COPD is a long-term illness characterized by breathing difficulties and a progressive deterioration of functional capacity. Patients use prophylactic medication and follow a personalized treatment plan in their homes to improve quality of life and clinical results. Careful management can prevent symptom escalation and acute attacks that often trigger ER visits and hospitalizations.
“There was a crying need for a case manager to coordinate home care for this group of patients,” says Ms. Nolet. “Telemonitoring was seen as a way to encourage teamwork and introduce the function of case manager, who would make the links with other caregivers and improve collaboration.” It was also seen as a way to increase access to follow-up, involve patients more actively in their own care, and reduce travel time by providers and patients.
Home telemonitoring is in its early days in Canada, but has shown promising results elsewhere. AETMIS, Québec’s former health technology assessment agency, conducted a systematic review of 119 home tele?monitoring studies undertaken between 1997 and 2007 in pulmonary and cardiovascular disease and diabetes. Results were highly encouraging: telemonitoring appeared to be clinically effective, increasing adherence to therapy and reducing demand for care.
Grand Littoral began working with a company called New IT (later bought by TELUS) to implement the program. “The technology was very interesting,” says Ms. Nolet, “primarily because care protocols were already incorporated and could be used to design personalized care plans for each patient. Given that our major problem was the absence of uniform protocols, the provision of a scientifically validated and evidence-based standard of care was a big advantage.” Government funding covered a project manager and the purchase of 20 home monitors.
Louis-Marie Boivin, who is now Director of Sales at TELUS Health Solutions, has been involved in the project from the beginning, providing training and continuing support. “The equipment we delivered to Grand Littoral involved pre-configured terminals that worked on a phone line,” he says. The software application involves a series of questions, information and reinforcement messages based on best practices and the patient’s medication regimen. Patients complete a data entry form with their peak flow rate, symptoms, medications and activities, along with qualitative information. “According to the patient’s responses, the system will push particular education and further questions,” says Mr. Boivin. “This helps motivate patients to manage their health because questions and information are context-sensitive and change according to their condition at any given moment.”
The monitor is lent to patients for three months and is very easy to use. A team member from the CLSC installs the equipment, teaches the patients how to use it, and sets the number of times a day they should enter their data. The information flows into dedicated workstations at the CSSS and is checked by the case manager, who is either a nurse or respiratory therapist. Readings on the home tests that fall outside given parameters trigger an alert to the case manager and patient. The alert system enables personnel to act quickly if they see that a patient is worsening, and the case manager can link with the patient’s family doctor or pharmacist to plan a response. “We were already providing education to help patients deal with their symptoms,” says Ms. Nolet, “but telemonitoring improved their ability to recognize signs and symptoms of COPD exacerbations before they led to a crisis and hospitalization.”
Implementing the program required rewriting the job descriptions of respiratory therapists and nurses, and harmonizing skill sets and tool kits at the five CLSCs. It also brought together the different sites involved in care: the Info Santé headquarters (the provincial teletriage system); the local hospital from which most patients were referred into the program; the treating physicians, who provide prescriptions and set clinical objectives; and the CLSC-based case managers. A pharmacist was added to the team in 2009 to visit patients in their homes, check for problems with medication schedules, review patient charts to detect potential drug interactions, and work with the physician to adjust prescriptions or dosages.
The telemonitoring care protocols were designed by health professionals from the Anna Laberge Hospital in Chateauguay. Teams at the hospital develop protocols for different chronic diseases, and update them every year. “Each centre using the protocols from Anna Laberge has the same approach and benefits from the expertise of other users,” says Mr. Boivin. Anna Laberge Hospital has managed virtually all clinical content for the almost 1,000 telemonitoring systems that TELUS has in use around Québec, covering about 4,000 patients a year with diabetes, COPD, heart failure, hypertension, sleep apnea, cystic fibrosis and high-risk pregnancies. Current efforts aim to create protocols for more narrowly defined subsections of patients (i.e. they now have a number of different variations for diabetes protocols).
TELUS provides a clinical content editor who can help centres adapt telemonitoring protocols to their own reality. Grand Littoral incorporated a depression/anxiety score into the protocol for COPD patients, as these are common problems in patients who have difficulty breathing.
Grand Littoral undertook an evaluation of the telemonitoring program that went far beyond Ministry requirements, despite receiving no dedicated funding for that purpose. It was fortunate enough to attract two internationally recognized authorities on telemonitoring, Dr. Guy Paré, Canada Research Chair in Information Technology in Health Care at the École des Hautes études commerciales (HEC) and Dr. Claude Sicotte, Professor of Health Administration at the Université de Montréal, to assess the impact of the program.
The researchers undertook a non-randomized study with a matched control group in order to compare the effects of telemonitoring (the experimental group) with traditional home care (the control group). Patients in the two groups (23 in each) were compared on a number of variables: satisfaction with home care services, quality of care, empowerment to self-manage, usage of home care services and usage of other health care services.
Patients in the study group were followed by telemonitoring for an average of four months. More than half had severe COPD and 27% were on home oxygen therapy (vs 13% in the control group). The study group’s patients had greater difficulty following the health team’s recommendations than the control group and were, in fact, selected for telemonitoring for this reason.
The study showed that telemonitoring improved patient knowledge, attitude and behaviour and thus the ability to manage one’s own conditions. Patients reported that telemonitoring facilitated contact with nurses, reduced delays in nursing interventions and helped avoid a worsening of symptoms. Nurses and respiratory therapists noticed a dramatic decrease in required home visits. “Caregivers were saying that instead of going to a person’s house three times a week, they were going once a month,” says Ms. Nolet.
Researchers found an increase in telephone calls among patients in the experimental group, requiring additional staff hours at the surveillance centre. This may indicate a need for further work reorganization, but could also, Ms. Nolet feels, reflect early problems with the alert system that automatically triggers a follow-up call. There was a statistically significant reduction in the number of hospitalizations among patients in the telemonitoring group and a reduction in ER visits that was not statistically significant.
These results earned the CSSS Grand Littoral a ‘mention as a leading practice’ from Accreditation Canada and earned TELUS the designation of 2009 Health Transformation Company of the Year by the Information Technology Association of Canada (ITAC).
Potential for expansion
The CSSS Grand Littoral is now looking to expand its telemonitoring program to patients with other chronic diseases. The administration has internal support despite the extensive work reorganization required. Ms. Nolet feels that external evaluation was tremendously helpful in achieving staff support. “It gives a project credibility,” she asserts. “We can say that external experts evaluated the project and found these results. It speaks much louder than an internal assessment and supports us in taking the measures required to reorganize work.”
Ms. Nolet has presented the project at various forums in Québec and across Canada, and a number of other organizations are moving ahead with projects of their own. However, widespread funding to implement these programs is not yet available and the lack of solid economic impact data is one of the hindrances to wider roll-out of telemonitoring. Dr. Paré recognizes this as a general shortcoming in health IT programs. “Organizations invest in technology without being sure of the results that will be produced once it is deployed,” he states. “This is dramatic. We really need tighter project management and a strong business case for the investment.”
A few developments are likely to help. The Ministry is currently funding a rigourous economic analysis of telemonitoring in COPD at Maisonneuve-Rosemont Hospital in Montreal and the CSSS Jardins-Roussillon in Montérégie, which will be the most in-depth economic study to date in Canada. Dr. Paré and Dr. Sicotte are taking on this project and face the challenge of capturing patient contacts at a wide range of care sites. “If we had an electronic health record,” says Dr. Paré, “this type of study would be much easier to complete.”
Evaluation may become easier as improvements are made to the application’s ability to generate reports based on the original data capture. “Researchers will no longer need to return to the paper output to find out how many calls were made, how many alerts were generated, and all the other items of interest in studying the effectiveness of the system,” says Mr. Boivin.
As well, equipment costs will fall as Web-based platforms enable patients to enter their data on a home computer, thereby reducing the need for investment in the self-contained units. “The system is much more software than hardware,” says Mr. Boivin. “Increasingly, patients will access the system on their mobile phone or home computer and we will adapt the application to the medical devices they use (thermometer, scale, glucometer and blood pressure cuff are the most popular).”
Another challenge is assuring GP participation. In Grand Littoral, very few patients were referred into the program by GPs. The vast majority came from two local hospitals. Doctors were notified when one of their patients was enrolled in the program and were asked to ensure that patients had a prescription for corticosteroids and antibiotics in advance to eliminate the need for a doctor visit in case an exacerbation occurred. About 50% participated, according to Ms. Nolet.
GPs did not have access to the data collected through home monitoring in the Grand Littoral project, but may in future. “Doctors with electronic health records want access to these reports,” says Mr. Boivin, “and we are now trying to create interfaces between the two systems so doctors have access.” Ms. Nolet anticipates that doctors will become more directly involved when telemonitoring becomes available to a broader group of patients. However, compensation for physician telemonitoring activities remains an issue.
Across the border
The Veteran’s Health Administration (VHA) in the U.S. has integrated home telehealth thoroughly into its care program since 2003. Between 2003 and 2007, the number of VHA home telehealth patients increased from 2,000 to 31,570 and is expected to increase to 50,000 by 2011, representing 50% of the VHA’s non-institutional care. The VHA’s Care Coordination/Home Telehealth program has resulted in a 19% reduction in hospital admissions and a 25% reduction in bed days of care. Eighty-six % of patients expressed satisfaction with the program.
• Cost of home telemonitoring/year: $1,600
• Cost of VHA home-based primary care service/year: $13,121
• Cost of nursing home care/year: $77,745
Ref: Darkins, A., Ryan P. et al. The Systematic Implementation of Health Informatics, Home Telehealth and Disease Management to Support the Care of Veteran Patients with Chronic Conditions. Telemedicine and e-Health, December 2008.