This Insights Article is the first of four international case studies published to support the mHealth Solutions Insights Guide no. 2, Evaluating mHealth adoption barriers: Politics & Economics.
Placing patients at the centre
One of the main attractions of mHealth applications for both patients and healthcare providers is they can offer an alternative to a long stay in hospital followed by a complex discharge process.
This has a positive impact for patients, their carers and medical teams, and a new study in the Spanish region of Catalonia is aiming to assess these benefits on a significant scale.
A total of 300 patients with Chronic Obstructive Pulmonary Diseases (COPD) will take part in the study from two hospitals: the Hospital Clínic, which covers a large area in the regional capital of Barcelona; and the Hospital de Mataró, which serves a rural area around 30km outside the capital.
The study, which is part of the EU Renewing Health project, will assess the effects of mHealth as part of an integrated care programme, comparing it to the conventional care provided by the two participating hospitals using four measures:
- Clinical outcomes such as re-admissions and mortality;
- User satisfaction including quality of life for patients;
- Economic viability such as cost, utility and cost-effectiveness; and
- Organisational impact of implementing the service.
As well as the “people” issues outlined above – the focus on patients, carers and medical teams – the project will also explore technical issues such as how mHealth applications can work within existing systems for managing clinical data used by the hospitals. It is seen as an opportunity to gain valuable knowledge about the challenges of ensuring strong connectivity between the medical devices, smartphones and the hospitals; sending clinical data securely and reliably over these connections; and updating hospital records.
Smart Monitoring for Early Intervention
Care of patients with conditions such as diabetes, Chronic Obstructive Pulmonary Diseases (COPD) and cardiovascular diseases often involves time spent in hospital, followed by discharge, with little regular support from specialists. For patients, the care they subsequently receive often involves travel to a GP surgery or clinic, or in worse cases re-admission to hospital, perhaps requiring an ambulance service.
In many cases care could be improved by closer routine monitoring using mHealth systems, enabling clinicians to intervene earlier with anti-inflammatory drugs or antibiotics, for example. Early intervention could minimise the need for re-admission to hospital, which can be an unsettling and anxious experience for the patient.
Telemedicine offers an opportunity to achieve these benefits, while also empowering the patient, enabling them to take a more active and knowledgeable role in their treatment, and becoming more of a partner in its delivery.
In practice, this could involve providing a patient with an appropriate monitor for capturing their clinical data and a smartphone equipped with software for receiving and transmitting the data to clinicians for analysis.
The smartphone may be used to prompt the patient to perform an action at a specific time, or enable the patient to do so at a time of their own choosing. It may also be used to volunteer feedback for clinicians about their condition and symptoms, and their general well-being.
Because mHealth of this kind requires patients to play a more active role, it is essential to first examine how capable and confident each patient – or their carer – is at using the technology.
The medical devices being used in the Catalonia study include:
- Pulse oximeters, for measuring oxygen levels in the blood
- Spirometers, which indicate lung capacity
- Blood pressure monitors
- Wireless weight scales
Data from these devices will be transmitted wirelessly using the Bluetooth protocol to a mobile phone, and then sent via GPRS or 3G networks to the hospital system.
Supporting Innovation across Devolved Regions
Under the country’s highly devolved system of government – Estado de las Autonomías – the 17 autonomous communities of Spain are responsible for developing and delivering their own online health services.
The strategy for eHealth in Catalonia is the responsibility of the Catalan Ministry of Health, an arm of the region’s governing body, the Generalitat of Catalonia.
Catalan healthcare is based on a mixed model, providing universal coverage free of charge, and the Ministry of Health is the body responsible for setting policy for public and private healthcare providers. This covers a broad range of responsibilities, including the implementation of ICT systems as well as guidance on clinical issues.
The ‘SITIC’ Strategic Plan for eHealth development in Catalonia 2008-2011 was the ministry’s vision for greater use of eHealth in Catalonia, indentifying priority areas of work including telemedicine for remote monitoring of patients. Two agencies were empowered to lead implementation of the plan: the Catalan Agency for Health Information, Assessment and Quality (CAHIAQ), and the TicSalut Foundation.
The TicSalut Foundation has a role similar to a think tank, being tasked with exploring how new and innovative uses of technology can make Catalonia a leader in eHealth. CAHIAQ has a more practical role. In an earlier incarnation it evaluated new clinical tools and technologies, but it now has broader responsibilities, providing leadership and expertise on the digital technologies needed for online health services. CAHIAQ also plays a co-ordinating role, ensuring telemedicine projects are aligned with a programme to digitise images of medical scans, and the roll out of electronic medical records with online access for citizens.
Nationally, the Spanish government has an important role in coordinating progress between all regions, ensuring the benefits of projects such as this one in Catalonia are made available to all Spanish citizens.
It has two main policy instruments for achieving these aims: the ‘Quality Plan for the Spanish National Health System’ and ‘Plan Avanza’. The latter, which runs to 2015, represents a major commitment to digital technologies, including investment in broadband infrastructure, education and e-government as well as in eHealth.
Plan Avanza includes ‘Sanidad en Linéa’, or Health Online, a national strategy for digitising medical records, prescriptions, and the appointment booking system. It is also committed to offering new interactive services between citizens and healthcare professionals using websites, telemedicine and telecare services, including those delivered through mobile devices.
While there are differences between the autonomous regions, they all work according to key shared principles:
- To guarantee the availability of health-related data nationwide;
- To provide a reliable system for identifying individual users;
- To digitise clinical records;
- To support electronic prescription services; and
- To improve communication between patients and clinicians using telemedicine.
Renewing Health: An EU Partnership
The new work on mHealth being carried out in Catalonia is part of a wider EU effort to evaluate telemedicine applications. The Renewing Health project draws together nine leaders in telemedicine from across EU member states, all of which have expertise in remotely monitoring patients suffering from conditions such as diabetes and cardiovascular diseases.
The project, part-funded by the European Commission, aims to bring new rigour to the assessment of the value of telemedicine to patients, clinicians, and health service providers. It covers the potential of mobile technologies such as smartphones to improve healthcare, examining how they can be integrated with clinical tools such as electronic health records; what concerns patients and clinicians may have about mHealth; and the costs of delivering such services.
As part of this effort, the Renewing Health project is testing new evaluation methodologies: the Model for Assessment of Telemedicine (MAST) aims to provide ways of evaluating the medical, economic, social and ethical issues raised by telemedicine in a systematic and unbiased way. In addition to the nine regional participants the work includes input from groups representing patients, healthcare ICT professionals, and industry.
A key objective is to give patients a central role in the management of their diseases; to provide information valuable for fine-tuning choice and dosage of medicines; tracking progress with treatment; and helping healthcare professionals to detect any early signs of a patient’s condition worsening.
Number of patients covered: 7,900
Total cost: €14.11m
EU contribution: €7.00m
Timescale: February 2010 to September 2012
Participant nations: Italy, Denmark, Sweden, Norway, Spain, Finland, Greece, Austria, Germany
Advisors: European Patient's Forum, European Health Telematics Association, Continua Health Alliance
Spain has set down solid foundations in eHealth which are likely to provide a sound base for future progress in mHealth. For example, recent research by Accenture found that 81% of primary care physicians in Spain enter patient notes electronically, and 69% use electronic tools to reduce the administrative burden for their organisation. At a global level, Spanish physicians are among the leading group in terms of sharing clinical data with other public bodies, the research found.
Spain’s devolved structure of government and regional responsibility for healthcare has given the country’s autonomous communities a high degree of freedom in developing their own online services and infrastructure. This has been a significant advantage in terms of fostering innovation and winning broad support for modernisation from healthcare providers, according to some observers.
“In terms of mHealth policy, what Spain has got right is starting small and taking an organic approach to growth”, says Chuck Parker, Executive Director of Continua Health Alliance , a partner in the Renewing Health project. “The national government has funded and supported mHealth, but not forced a specific technology on the autonomous communities.”
This brings risks too, most obviously a lack of cohesion at the national level or a disparity of approaches that might make joining up the regional services difficult, or could allow some regions to fall too far behind the leaders.
The recent economic woes of the Eurozone have added a further funding challenge into the mix. Like most other EU nations, Spain is under pressure to cut government spending on public services, a challenge it seeks to meet through the National Reform Programme of 2011. However this policy does acknowledge that greater use of new technologies in all sectors is a key part of Spain’s future prosperity. Plan Avanza received 12 billion euros investment between 2005 and 2010, for example, although further spending will be needed to maximise the benefits.
It is unclear at present what priority will be assigned to spending on mHealth among Spain’s other health modernisation initiatives, however, and the issue is rapidly approaching a “crunch point”, says Parker. “There tends to be an 18 to 24 month expenditure cost – a slight increase in spending before you start to see cost savings [from mHealth investment]. The crunch point for the Spanish government will be in maintaining spending across multiple regions, instead of just allowing Andalusia, Madrid, and Catalonia to move ahead of the others.”