Telemonitoring in Diabetes Care Management

TABLE OF CONTENTS

TABLE OF FIGURES

CHAPTER 1: Traditional care delivery models and chronic disease management
1.1. Chronic diseases and the challenge to health systems
1.2. The specific case of Diabetes Disease
1.3. Limitations in the care delivery model
1.4. Bottlenecks in the care pathway
1.5. The need for rethinking
1.6. New expectations and requirements
1.7. A new variable in the equation: enabling technology
1.8. The research issue: Clinical value and economical benefits
1.9. Motivation for the research study
1.10. Aims, objectives and outline of the research study

CHAPTER 2: Literature Review
2.1. Focus of the literature review
2.2. The framework for chronic care management in diabetes condition
2.3. The conventional care delivery and care pathway
2.5. Failing to deliver clinical and economical outcomes
2.6. Variables associated to the limitations
2.7. The search for solutions
2.8. The potential of enabling telemedicine equipment
2.9. Telemedicine and Telemonitoring in Diabetes Care
2.9.1. Impacts on the clinical side
2.9.2. Impacts on the economical side
2.10. Bringing together clinical and economical effects
2.11. Extrapolation for the research perspective

3. CHAPTER 3: Methods
3.1. The Research Perspective
3.2. Reasons to choose the case study approach
3.3. System analysis
3.4. The telemedicine equipment and inbuilt functionalities
3.5. Cost-estimation of identified variables in the care pathways
3.6. Cost benefit and microsimulation modeling

4. CHAPTER 4: Results
4.1. The elements of the care delivery model
4.2. Care pathway and conventional care delivery model
4.3. Assessing the telemedicine equipment
4.4. The results produced by the case study
4.5. Telemedicine in the conventional care delivery model
4.6. Costing data on the conventional and telemedicine care pathways
4.7. Extrapolation of costs and transfer on a simulation model
4.8. The findings

5. CHAPTER 5: Conclusions, lessons Learnt, Recommandations
5.1. Summary and conclusions of the research undertaken
5.2. Research work for the future
5.3. Recommendations

6. REFERENCES

7. APPENDICES

APPENDIX A: WHAT IS DIABETES DISEASE TYPE 2?

APPENDIX B: DESCRIPTION OF THE CHC CARE DELIVERY MODEL

APPENDIX C: DEFINITION OF A CARE PATHWAY

APPENDIX D: WORKLOAD ASSESSMENT METHODS AND GUIDING PRINCIPLES

APPENDIX E: ASSIMILATION TO OBJECT-ORIENTED SYSTEM ANALYSIS

APPENDIX F: DIABETES CARE MANAGEMENT: FEATURES AND CHARACTERISTICS

APPENDIX G: THE RATIONALE BEHIND THE CHOICE OF THE CASE STUDY APPROACH

APPENDIX H: DESCRIPTION OF THE SCENARIOS

APPENDIX I: JUSTIFICATION FOR THE MICROSIMULATION METHOD

APPENDIX J: LIST OF INTERVENTIONS IN THE PRIMARY CARE SETTING

APPENDIX K: KEY REFERENCE DATA FOR THE SIMULATION MODEL

APPENDIX L– CAPABILITIES AND FUNCTIONALITIES OF THE AMD CareCompanion

APPENDIX M: HEALTH CARE EPISODE OF AN INSTABLE DIABETES PATIENT

APPENDIX N: THE COST BENEFIT ANALYSIS MODEL

APPENDIX O: TABLES WITH CARE INTERVENTIONS AND TIME COEFFICIENTS

TABLE OF FIGURES

Figure 1: Level 1 of the care setting - the spatial dimension

Figure 2: Objects in an integrated care network

Figure 3: Core process in diabetes care management

Figure 4: Core elements of the pathway and related modules

Figure 5: 28 days of workload assessment - Conventional versus Telemedicine

Figure 6: Identifying the breakeven point – Conventional versus Telemedicine

Figure 7: The evolution of workload over 1 year

Figure 8: Care interventions and time coefficients

CHAPTER 1: Traditional care delivery models and chronic disease management

1.1. Chronic diseases and the challenge to health systems

Health care delivery needs to change There are a number of ominous forebodings to support this assertion. First, the set of prevalent diagnoses in western health systems is changing, with largely chronic cardiovascular disease emerging and pushing ahead (Metzger 2002). Second, the issue of chronic disease care management has reached the public political debate and a call for action is heard. (DoH 2004; Colin-Thomé 2004, Kinsella 2003: page xiii). Third, there is a rapid growth of health care services in the US (Kinsella 2003), and the share of primary care services is reaching new heights in the UK (Gordon & Hadley 1996). Fourth, chronic diseases are rated to contribute in a major way to the costs build-up in health care with a risk of spiralling out of control (Clarke et al 2004; PriceWaterhouseCoopers 1999). All this in addition indicates that today, ‘chronic disease represents a significant and exciting challenge for the NHS’ (Colin-Thomé & Belfied 2004).

While the growth in importance of home care services are attributed to four major reasons, namely (1) an ageing population, (2) advances in technology, (3) economic pressures, and (4) enhanced patient choice (Kinsella 2003), the underlying factors need to be mentioned as well. Both the (yearly) incidence and the (overall) prevalence of chronic disease patterns are disturbingly on the increase and the trends could even intensify (Walker et al 2002). Associated to this epidemiological (clinical) phenomenon is the growing economical burden of health care costs, while health systems are constrained by limited financial resources and self-imposed budgetary discipline (Palmer 2000).

1.2. The specific case of Diabetes Disease

According to Robert Beaglehole (WHO 2004) “diabetes is a growing and massive silent epidemic that has the potential to cripple health services in all parts of the world.” The quality of life reducing as well as cost-driving nature of Diabetes Mellitus disease (Appendix A: What is Diabetes disease type 2) has been shown by many studies and statistics^[1]. (WHO 2002, The Oxford Centre for Diabetes, The DCCT Research Group 1993, CDC 2004 and WrongDiagnosis.com) The Centre for disease control and prevention (2004) has evaluated the yearly average health care costs generated by a diabetic patient at 12500 USD as compared to the 2500 USD for the average US health care patient. These figures show that the complex illness of diabetes is, on the one hand, affecting an overall high number of people and is for that matter a public health issue of extent, while also being related to a high cost service patterns, based on evolving patient needs as complications emerge and progress and multiply. (CDC 2004, Kinsella 2003). For Wagner (2004) Diabetes is ‘the single greatest challenge facing organised medical practice.’ More generally also ‘more and more pressure has been exerted by third party payers to demonstrate the effectiveness of home care services through improvement in patient outcomes’. (Kinsella 2003: page xiii)

1.3. Limitations in the care delivery model

Confronted to this (afore described) situation, the traditional care delivery model appears to have reached its inherent operational limits. This can be found out on the ground of its inability of contain the health care costs in chronic (recurring) disease for which there is no cure, but at best a way of controlling the condition (Johnson & Andrews 1996). In order to reduce costs, health system reforms have over the years shifted chronic care service operations from costly hospital structures towards primary care settings (Gordon & Hadley 1996; Saltman et al 1998). Also integrated case management models were thought to help optimise clinical outcomes and economic benefits (Colin-Thomé & Belfied 2004). For D W Light (1993) however, traditional health delivery approaches are too much ‘medicalised’ and disease oriented, with a strong focus on curative care. According to Light (1993), they can get out of the cost trap only by opting for disease prevention and health promotion that are operated in a community-based primary care setting.

1.4. Bottlenecks in the care pathway

If also the National Services Framework (DoH) and National Institute for Clinical Excellence (2002) guidelines as well as relevant literature (Gordon & Hadley 1996) advocate the clinically safe provision of diabetes care follow-up services in primary care settings, and while the requirements as well as standards today in diabetes care are set by national service frameworks and guidelines, it can be seen that the needed collaborative approaches are hampered by distances found inside the care setting, by lack of appropriate data and information sharing equipment as well as limitative communication opportunities. Wagner (2004) and Leichter (1999) see the reason for the bottleneck in the provision of clinical need based care services in the nature of organisation of diabetes services in primary care itself. The critique is offered by Wagner who blames the way specialised and episodic follow-up care is organised in regular intervals rather than on a continuous basis at the level of the GP practice to assert that the current care pathway is not designed to serve appropriately the real clinical needs of diabetic patients. In the same way, Kinsella (2003) is characterising the care given as ‘reactive’ leading to suboptimal care provision and often to curative care solutions.

1.5. The need for rethinking

On the ground of his inspired analysis, Light (1993) admonishes to undertake a fundamental rethinking in the way chronic care is delivered and in which settings it is provided. Says Malcolm Clarke et al (2004: page 115) “if health systems are to cope, novel methods need to be developed”. On the ground of the identified complex challenge affecting the clinical and economical side of the care delivery system, an alternative model needs to offer a solution both at the level of (1) the reduction of costs, and (2) the containment of incidence and prevalence rates, thus excluding serial linear reform approaches that target either cost or the offer / demand of services (Saltman 1998). So in practice, how can follow-up care in chronic patients be organised to shed a substantiated cost-benefit outcome? What can be the model be and look like which components need to be integrated?

1.6. New expectations and requirements

New pressures exerted by various stakeholders complement the basic challenge of containing costs and reducing the prevalence of chronic care. While patients and their families value their health much more today, they also increasingly embrace self-care (Kinsella 2003), and in case of disease / illness they also “prefer to remain in a familiar environment” (Clarke et al 2004) as long as reasonably possible. As a consequence of this changing mindset, patients also perceive a need to get ‘more accurate, evidence-based and effective clinical diagnosis and follow-up”. Departments of health and public instances try hard to abide by the principle of offering ‘equity of access for equal needs’. That is only possible if, on the other hand, there is a sustained drive for cost containment, compliance with national service frameworks (NSFs) and guidelines (NICE). If additionally quality outcomes and patient satisfaction can be reached, support for the shifting of chronic care services to primary care settings (Johnson, 1996) is an option, also because, first ‘primary care is seen as offering much towards a solution’ (Clarke et al 2004) and second, as actual costs are lower than the equivalent service provided from hospital (Clarke et al 2004).

1.7. A new variable in the equation: enabling technology

In the wake of these findings and driven by the symptoms, the search for innovative approaches associating ‘chronic disease care management’ and telemedicine tools is launched. Says Malcolm Clarke (2004: page 115) Specific characteristics and functionalities found in Technology (Hjelm 1999) are thought to be an enabler of new processes and ways of working” overcome some of the limitations identified earlier and thus in this case, “technology is seen to offer a solution”, ‘particularly if it results in methods to manage patients in the community and keep them out of expensive hospitals’. Information and Communication Technologies (ICTs) used in telemonitoring equipment have successfully started to be used for a decade in vital signs telemonitoring programmes (Johnson & Andrews 1996) and ‘the technology has been developing rapidly in recent times’ wile the ‘market, in general, has concentrated on products capable of monitoring chronic disease in the home’. (Clarke et al 2004: page 115). It is accepted that “advanced cost-effective medical devices for diagnosis and (remote patient) monitoring, especially at the level of chronic disease care management (Qinetic 2004) are available. Says Kinsella (2003) ‘there is an innovative solution in the form of ‘remote patient monitoring’ that can be used at the level of chronic disease care management. Prices remain however high and this raises the issue of cost-benefits associated to its use. The First Consulting Group (2003) Research report has mentioned disease management as a field where a wide range of tools can support the management of chronic diseases. According to these authors, the most sophisticated technology integrated with a physician practice’s core clinical system has been shown “to effectively improve the quality of care for those patients and reduce costs for populations of patients across a community.”

1.8. The research issue: Clinical value and economical benefits

The research problem can be characterised as the identification of limitations in the potential of the conventional care delivery model and associated care process to (1) contain costs and (2) produce optimised clinically effective outcomes (Bergmo 1996). While this same model is confronted with new needs, expectations and requirements both at the clinical and economical levels, while also it is rightly understood that a patient-centred, holistic approach, organised on an individualistic day to day care basis (Wagner 2004) is needed, and the use of telemedicine technology in a primary care setting ‘is seen as offering much towards the solution” (Clarke et al 2004: p 115) as it is enabling to combine changes in the care provision while at the same time offering the potential to reduce related costs. A basic condition is however, that “the health care organisation should adapt to make best use of the introduction of technology.” (Clarke et al 2004) ‘in order to give full benefit of use of the new technology’. This all entails that the next step needs to consider how the aforementioned limiting process might be changed.” The central question of this research study is thus to show that a telemonitoring model (‘modality’ Wootton & Craig 1999) applied to diabetes care management is able to overcome the limitations, first, by producing a shift towards optimised clinical follow-up care, and second, is able to reduce costs related to this targeted efficient care provision approach (producing better clinical value, targeted at the real needs) while at the same time complying with the high stake requirements set out above. As changes need to be brought to the care process, subsidiarily the research question is about analysing how the telemedicine driven care pathway needs to be designed to produce the sought after added values.

1.9. Motivation for the research study

An in-depth understanding of the process and the underlying cost structure elements of the conventional current care pathway, and its changing into a telemedicine driven one is thought to be fundamental to appreciate the potential for optimising clinical outcomes generated by the paradigm shift from reactive to proactive care provision. ‘As policy changes often have to be made without sufficient information about either the current environment or the consequences of change’ (Walker et al 2002), the findings of the research study ‘analyse data and produce models so that decision-makers have the best possible quantitative information on which to base their decision’. This will enable decision-makers to know for which selectively targeted groups / cohorts of diabetic patients, the use of (still) expensive telemonitoring equipment is an alternative to the conventional care delivery model, as it can be both clinically valuable and cost-beneficial, also considering that cost-intensive hazards (exacerbations, hospitalisations, complications) can potentially be avoided. This interest is in line with NICE supported policy approaches (Oliver & Pritchard 2000), it needs to be pointed out however that, while innovative cost estimation / quantification has been applied to ‘start-end’ acute care pathways (MIPP, Hellmann 2002, Rieben 2003) a similar study applied to a recurring / looping chronic care pathway in primary care has not been found so far.

1.10. Aims, objectives and outline of the research study

The first objective is to see whether the current impasse and associated dilemma in the follow-up of instable diabetes type II patients can be potentially overcome through the use of innovative telemedicine tools. The associated aim is to find out about the breakeven point related to specified cost structures, when comparing the conventional and the telemedicine care pathways thus enabling the identification of the most targeted patient profiles that can be selected and subsequently followed up in a positive cost-benefit relationship with telemonitoring. This would help to close a gap between practice and related knowledge that is potentially available.

Aligning on this research perspective, chapter 2 is critically reviewing the relevant telemedicine literature focusing on clinical and economical aspects related to the operation of care pathways in chronic disease management. Chapter 3 relies on the findings of the literature review to devise a research plan made up of research methods and techniques that are applicable to the research perspective outlined earlier. The results of the research study will be presented and analysed in chapter 4, whereas chapter 5 concludes the study by summarizing, and furthermore extrapolating to lessons learnt and making tentative recommendations.

CHAPTER 2: Literature Review

2.1. Focus of the literature review

This chapter on literature review emphasises in the first place on the role that information and communication technologies (ICT) play in the reengineering of traditional patient care pathways operated in primary care based diabetes care. Davenport (1993) is showing that for the reengineering effort of a set of (care) processes to be profitable, the very depths as well as the constituting elements of the organisation need to be explored, starting from top to bottom and involving the functions. (Fischer & Blonde 1999) These same authors point to the importance of “the care process (before telemedicine is implemented), and to the understanding of the pre-telemonitoring workflow.” This entails the need for “dissecting the processes involved in a typical patient encounter (here diabetes follow-up day).

Therefore the in-depth analysis of the organisation of current diabetes care delivery models is undertaken. The literature review attempts to describe and analyse features, structures, and settings of the conventional care delivery model, including care pathways and associated variables. This is thought to work towards clarifying the situation around the identified research problem consisting in a lack of information regarding cost-benefits as they are potentially generated by the use of ICTs in primary care based diabetes care. The focus of the analysis of the care delivery model will be directed on the set of variables that are active in the care processes and which are thought to be influenced by the introduction of ICTs. (Davenport 1993).

The capabilities and functionalities of the new ICTs used in diabetes telemonitoring need to be known as they drive for a reengineering process affecting the care pathway. Therefore literature on a qualitative technology assessment is highlighted. Finally the cost-benefit relationships need to be substantiated, for that matter literature on quantitative evaluation methods are presented. From the literature review, the range of research methods and techniques that can be used in this research study should finally emerge. From a more practical point of view, the literature review needs to find out what the impacts and outcomes have been so far, showing whether the patterns of care delivery have been changing, with an impact on outcomes.

A focus will therefore be put on the highlighting of the structures that are established around the patient and the families in the primary care settings to provide the necessary care. More specifically then, the literature review is focusing on selected and specific publications that relate to the care provision schemes proposed to instable Diabetes II patients, staying at home and followed up in the conventional or telemedicine driven care delivery model attempting to comply with the objectives and principles fixed in the NSFs, NICE guidelines, as well as local protocols (Lakasing & Francis 2004). Beside the identification of elements, the analysis of both clinical and economical effects and impacts need to undertaken.

While it is understood that the issue of compliance with the guidelines and protocols established for directing and providing the care delivery in diabetic patients is important for enabling the benchmarking of results, the literature review is however not highlighting the question as it would extend the scope.

This study will not look at or analyse the problems encountered in implementing / running telemonitoring projects, benefits and drawbacks (advantages and disadvantages) of the use of telemonitoring in chronic disease management (in terms of project management), but rather identify the impacts and effects of diabetes disease care management operated in the two different care delivery models. The focus will be on both care delivery modalities as they have been described in relevant literature. It endeavours to find out how the outputs can be quantified through a model.

2.2. The framework for chronic care management in diabetes condition

While the overall and general challenge posed to care provision is to offer effective, comprehensive patient care, and subsequently improve patients’ lives, there are a number of instances that articulate specific expectations on various aspects of home care based chronic disease care management.

The first requirement is set by governing instances in the health system itself through the definition of National Service Frameworks (DoH) containing a range of validated aims and objectives. They are complemented by evidence-based standards and guidelines as they are issued b the National Institute for Clinical Excellence (NICE 2002). As a consequence, baseline quality that needs to be achieved is thus uniformly fixed by national standards. It is understood from the practical review of these (NHS based) guidelines that generally speaking, “diabetes (type II) care management needs to work towards achieving objectives, and this is independent of both the setting where the care is provided and the care delivery model that is used. First, it needs to ‘maintain glucose levels within a safe range’ (applying to the management of blood glucose levels) with the expected outcome of avoiding complications, second, it needs to help prevent complications (blood pressure, blood lipids management, management of renal disease and retinopathy, management of foot care) and, third it should endeavour to educate the patient, (and the families) regarding follow-up care, adding to the empowered self-care approach in diabetes disease. This entails that diabetic patients will receive regular surveillance and check-ups to monitor the evolution of the disease and in the advent of complications timely, appropriate and effective investigation and treatment is scheduled with an objective to reduce the risk of disability and premature death. (NSF Standard 11). The NSFs also propose to all people with diabetes requiring multi-agency support to receive integrated health and social care services. (DoH 2004). It goes without mentioning that all these requirements need in the same way be applied to a telemedicine driven care pathway. External pressures are exerted first of all by the patient (and family) in the form of expectations in terms of quality, satisfaction, involvement and clinical outcomes (Kinsella 2003). All these clinical requirements go together with financial and economical pressures. Thus, in the US health system third party payers are mounting the pressure exerted on care providers to handle in a more efficient way the costs related to the human resources factors, the latter are indeed amounting to 90% of the costs generated in homecare. (Kinsella 2003). But also in the UK, institutions such as NICE are gathering information on cost-effective interventions that are making use of a low level of resources (Oliver & and Pritchard, 2000) with an objective to popularise the most cost-beneficial ones.

2.3. The conventional care delivery and care pathway

From a historical point of view, chronic disease care management (involving diabetic conditions) has over the last decades shifted from an acute care based hospital system to the primary care setting (Gordon & Hadley 1996; DoH 2001), with according to Kinsella (2003: page xvi) home health care now clearly emerging as the next frontier in the continuing evolution of the health care continuum”. But according to Fischer and Blonde (1999 ) this shifting of services across settings (from acute to primary care in the case of diabetes care) is not without an impact on the care delivery model and associated workflows. Davenport (1993) is showing in the same line how a need for reengineering work processes emerges when IT is introduced.

More even, a number of authors have found a limited and intrinsic capacity in the conventional care delivery model to provide the necessary changes and alignments, while attempting to apply the range of new requirements found so far, to the specific structures and the care processes of the patient pathway (care process), (Appendix C: Definition of a care pathway followed by the diabetic patient) of the diabetic patient monitored at home.

These limitations can be identified at various levels. For Wagner (2001) and Leichter (2001) the root of the bottleneck can be identified in the fact that the primary care delivery system looking after the diabetic patient is still imitating the acute care mode of service provision. In the same way (Young 2003) estimates that ‘rather than bringing about ‘lean’ management there is a perceived situation of bottlenecks in the current system.

2.4. Limitations, bottlenecks and fractures

These are limiting features at the structural level. The first is located at the level of the care delivery system: and is affecting collaboration, integration, networking, specialisations and boundaries. Another is given by operational limitations in the way it is possible to work. Limitations and bottlenecks have been identified at the level of ‘data and information exchange’. While it may be accepted that the various operations and flows found in the primary care system are complex inside a bipolar structure (BetterDiabetesCare 2004), there is a perceived need to find solutions to overcome the unsatisfactory situation.

The question today is whether alignment can produce the solution or whether a new model needs to be designed. It needs to be recognised however that the situation is alarming. According to Wagner (2002) “today sizeable proportions of chronically ill patients are not receiving effective therapy (and) have poor disease control.” This is largely attributed to the fact that (according to Edward Wagner) “primary Care practice was largely designed to provide ready access and care to patients with acute, varied problems, with an emphasis on triage and patient flow; short appointments; diagnosis and treatment of symptoms and signs; reliance on laboratory investigations and prescriptions; brief, didactic patient education; and patient-initiated follow-up. In summary, Edward Wagner (1998) is stating that “usual care is not doing the job; dozens of surveys and audits have revealed that sizeable proportions of chronically ill patients are not receiving effective therapy, have poor disease control, and are unhappy with their care.” On the other hand results of randomised trials show that effective disease management programs can achieve substantially better outcomes than usual care, the control intervention. But the question remains of how it can be implemented.

More specifically the limitations of the current care delivery model are found at various levels. The non-satisfying elements in the current care pathway are given by a restricted access to the most comprehensive and useful compilation of patient data from past encounters and recordings in the logbook, limited decision-making opportunities, the potential for errors as a by product when important information about the patient are not available or can not be recalled. All these elements were thought to have ‘effects on daily operational workflows in the diabetes clinic’.

So what is going wrong in the conventional care delivery model and how can telehealth support services improve on this? Kinsella (2003:page xv) wonders “how regular the measurement of the blood glucose level [is]”? “The number of patients with diabetes, asthma and hypertension who receive comprehensive information about important self-care techniques and ongoing support for effective behavior change is estimated to be less than 15%.” (Kinsella 2003) “Medication non-compliance is considered to be responsible for as many as 25% of all nursing home admissions in the US, and many of these patients come from home care.” (Kinsella 2003:page xv). “Patients with chronic care conditions (...) often require support services far in excess of what may be approved (Kinsella 2003:page xv).

2.5. Failing to deliver clinical and economical outcomes

The consequence is that more specifically the conventional care delivery model is not able to delivery both at the clinical and the economical levels.

At the level of clinical outcomes, the evaluation of a key indicator in the form of HbAc1 levels in the diabetic patient provides information on the quality of the follow-up undertaken by the patient at home. Out-of-norm values inform the monitoring clinician that the follow-up over a period of time has been of low quality. A number of reasons can be invoked. The patient is not checking the blood glucose levels regularly and living with hyperglycaemic levels without intervention, (2) the data are collected but not shared in time to take pre-emptive measures, (3) and the data are not used to support decisions in line with guidelines and evidence-based medicine.

From an economic point of view the figures related to outcomes show an ineffectiveness to contain costs. This fact is associated to the current, traditional, conventional model’s inflexibility and inability to overcome inherent operational and structural limitations. There is apparently no scope left to become more cost-effective. Also the present medical and nursing care delivery model (applied to chronic care management) can be characterised to be overall reactive in approach and will for that matter need to focus largely on curative care provision actions and interventions (in case of deviations, relapses). The literature that has been reviewed reveals a picture of the current approach in chronic disease care management that could be described as being linear-serial.

2.6. Variables associated to the limitations

Fischer and Blonde (1999) report that out of a range of components that were identified to inhibit the flow of patient care the most disruptive (time-consuming) one for optimal workflow were (a) documentation, (b) retrieval of medical record information using paper charts, presenting the bottleneck in our efforts to provide efficient and cost-effective medical care.

The first variable that is affected is represented by patient data; it is a fact that data are produced and kept in different places of the setting. The patient is recording measurement data in the logbook. The GP is keeping patient data in paper-based patient records.

But sharing of data is limited. Problems include ‘limited access to the most comprehensive and useful compilation of patient data from past encounters and recordings in the logbook, with implications for limited decision-making opportunities, errors as a by-product when important information about the patient are not available or can not be recalled. The situation is made possible by a lack of formalised links between data generating fields and instances, with the impossibility of meeting guideline requirements (as a networked collaboration was not formalised) due to the fact that the data of the patient are not accessible at any single point of care. There is also the risk that redundancy of data occurs, and the less than optimal use of the patient record as the major source of information and clinical data entry tool (Fischer & Blonde 1999). Another variable is given by the patterns of information and communication, lack of formalised networks. Lastly variables education and knowledge support, as they impact change of behaviour, lifestyle are also affected by the limiations.

Telemonitoring is rated to enable new ways of delivering care; in the same these variables will be touched by the use of new ICTs..

2.7. The search for solutions

In the search for appropriate and adapted solutions with wanted and improved outcomes, Wagner (1998) advocates the structural reconfiguration of clinical systems to address the needs and concerns of chronically ill patients.

At the level of care approaches, care management (Colin Thomé & Belfield 2004) and Integrated Care Pathways have both attempted to overcome the problem of ‘fractures’ observed in the care setting by integration of the care provided, and networking the increasingly specialised health professionals and providing a common collaborative platform for use of resources, implementing interventions and common reporting structures. Even though the patient based information system (IS) [logbook] (Berg 1997) and the GP held patient record are the starting elements of a tentative IS network and enable to some extent the sharing of measurement data, information and ultimately the knowledge” the tools at hand are however restricted in functionality, and especially decision-making in the conventional (paper-based record system), supposed to bring together data, information, guidelines and human experience, is hampered as interoperability is not given and tools are too much spread out in the care setting. According to Fischer and Blonde (1999) the focus for solutions should be directed on (1) improving workflow and (2) access to information. This basically technological / technical hurdle established by the traditional logbook and the POTS can be overcome today by the use of more sophisticated equipment in the form of the promising telemonitoring technology. More specifically now, Wagner (2001) is showing that patients struggling with chronic diseases require “planned, regular interactions with their caregivers, with a focus on function and prevention of exacerbations and complications. This interaction includes systematic assessments, attention to treatment guidelines, and behaviourally sophisticated support for the patient’s role as self-manager. These interactions must be linked through time by clinically relevant information systems and continuing follow-up initiated by the medical practice”. If however it is understood that there is today a felt need to ‘simplify and streamline many of the processes in the care delivery approach’. (Fischer & Blonde1999), it needs to be seen whether ICTs are able to deliver.

2.8. The potential of enabling telemedicine equipment

The introduction and use of telemedicine tools is designed to change the old pattern of communication, the availability of information (here the measurement values of the blood glucose tests) (Hjelm 1999) and induce new ‘collaborations between unfamiliar sectors of healthcare’ (Clarke 2004) Says M Clarke (2004) “Communication technology invites collaborative working between separate parties through the new medium” with the prospect of radically new ways of working (Davenport, 1993). Telemedicine is rated to be able to overcome the limitations in the conventional model (Wootton & Craig 1999) of care delivery. The National Institute of Health (BetterDiabetesCare.nih.gov 2004) has published a list of nine essential functions of information systems that are designed ‘support and improve the performance of clinical care’ as applied to optimal diabetes care. Thus IS ‘enhances patient-provider interaction’, ‘enables patient-centred care’, ‘facilitates communication between all team members and team access to important information’, ‘provides patients with information and support’ and finally provides health care providers with an up-to-date summary of patient requirements to meet current guidelines for quality care.” The emergence of ‘virtual safety nets’ (proactive) for co-morbid and aged chronic disease patients who want to stay comfortably at home.” (Kinsella 2003). The NEHI (2004) report is taking up the issue of ‘remote physiological monitoring (RPM) applied to Congestive Heart Failure patients. It has identified a number of substantial benefits to the health care system: (1) reduction in the number of hospital visits, (2) reduction in the length of stay, (3) reduction in health care costs. Subsidiarily, it has also found that RPM is ‘improving quality of life’.

2.9. Telemedicine and Telemonitoring in Diabetes Care

Kinsella (2003 chapter 4) affirms that telemedicine is applicable to the follow-up in diabetes care and for this target group of diabetic patients demonstrably improved outcomes have been achieved through telehealth. This target group could benefit from telehealth support services such as simple phone calls or more sophisticated telemonitoring systems, depending on clinical need and economical ratio. Beyond this, diabetes is one of the neediest chronic disease populations in home care today (lending the justification for the selection of the diabetes subject for this research study). While basically from an operational point of view, the procedure for undertaking measurements remains the same, with traditional glucometers, telemedicine equipment is however adding what is rated to be the capability to transmit patient data, from the home to the central receiving station. This high tech telemedicine tools are contributing to some extend to the establishing of a real network, in which the patient occupies a prominent place. (Kinsella 2003).

2.9.1. Impacts on the clinical side

Telemonitoring projects are not new in the field of chronic disease care management. Back in 1996, Johnson and Andrew have shown in a project evaluation (Oxford Telemonitoring System) that the technical feasibility of telemonitoring projects is acquired, and the benefits to clinical outcomes can be substantiated. The study has not included an economical evaluation however, but seen that the clinical and economical views need to be brought together. From this article it can also be drawn that telemonitoring is having impacts on the way care is delivered. Focal points are real-time mode, overcoming of distances, the bringing together of expertise, know how evidence and knowledge.. It is assumed that telemedicine, on the ground of the essential functions enumerated above, is furthermore able to implement NSF standards and obtain guideline based outcome standards. An expected outcome is the gradual shifting from reactive care to proactive and enabled preventative approaches.

More generally speaking, commonly accepted benefits of the use of telehealth equipment in chronic care management are reported to be the (a) improving of the patient monitoring, (b) education, (c) treatment and support [Kinsella 2003 pp xiv and xv] The American Telemedicine Association website is reporting that telemedicine can generally bring about (1) the improving of patient outcomes while decreasing the number of skilled home nursing visits – all without compromising the same level of quality care. It can stabilise chronic conditions and reduce the primary reason for re-hospitalisations and associated loss of revenue. Thus the implementation of telemedice should serve the goals of decreasing recidivism, ER visits, decrease home visits and improve patient satisfaction. More specifcially the benefits of nursing home telemedicine to manage CHF are reported to be “improve patient outcomes, decrease skilled nurse visits without sacrificing quality care’, ‘avoid or reduce unplanned hospitalisations’, and ‘describe cost savings per episode’: (ATA website) It can also be shown that a common denominator is found in the provision of more attention and education via telecommunications delivered to these patients. (Kinsella 2003: page x).

The needs of the patients are known much earlier, almost in real time (through timely calls for positive reinforcement, increased contact). But also the real patient-based, individual need is better assessed on the ground of data that are made available (an electronic care plan can be established, accessible to every stakeholder). The interventions (education, reminder for medication) that are proposed, are definitely depending on the patient need and are part of a care plan. It is here where the paradigm shift of ‘reactive becomes proactive’ comes alive. As a result of these factors, a trend toward encouraging patient self management has accelerated, as also more patient safety can be built in. The assistive technologies are rated to help the patients age in place safely and comfortably, and achieve significant results with minimal costs (needs to be assessed) (Kinsella page xv). Says Kinsella (2003: page x): ‘increased contact can be the key to more successful patient management and improved patient health outcomes’.

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^[1] The figures that have been published by the WHO exemplify this horror vision. Thus the prevalence of diabetes in the UK and Northern Ireland according to the WHO in 2000 is 1.765.000 in the year 2000 and is estimated to reach the figure of 2.668.000 in 2030. Source Internet: http://www.who.int/diabetes/facts/world_figures/en/index4.html