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“Introducing personalized healthcare
in daily clinical practice”
Miriam Vollenbroek-Hutten
Roessingh Research and Development, Enschede, the Netherlands
• Chronic diseases are the leading cause
of mortality and morbidity in Europe
• Traditionally chronic diseases concern,
cardiovascular disease, diabetes and
asthma or chronic obstructive
pulmonary disease (COPD) chronic
pain.
• As survival rates and durations have
improved, nowadays chronic diseases
also concern many varieties of cancer,
HIV/AIDS, mental disorders and
disabilities such as sight impairment
and arthroses
2
Introduction
Roessingh Research and Development, Enschede, the Netherlands
Commonalities of chronic diseases
• they need a long-term and complex response, coordinated by
different health professionals
• They need access to the necessary drugs and equipment, treatments
like physiotherapy, cognitive behavioral treatment and extending into
social care.
• Improving vitality and functional status is key
3
Introduction
Roessingh Research and Development, Enschede, the Netherlands
However
Most health care today, however,
is still structured around acute
episodes
Main Challenges
• Prevention and early detection
• Coordinating care for individual
chronic diseases: DMPs
• Managing care across chronic
diseases: integrated care
models
4
Introduction
Chronic Care Model,
Wagner 2001
Roessingh Research and Development, Enschede, the Netherlands
Marco Rogante1, Mauro Grigioni1, Daniele Cordella2, Claudia Giacomozzi1
1Technologies and Health Department, Italian National Institute of Health, Rome, Italy 2SIDBAE Informatic Sector, Italian National Institute of Health, Rome, Italy
This paper aims at delivering a structured overview of telerehabilitation literature by analysing the entire set
of articles under the search terms "telerehabilitation" or "tele-rehabilitation" to portray "state of the art" ten
years after the publication of the first scientific article on the topic. A structured study has been conducted
by considering all those articles containing the word "telerehabilitation" or "tele-rehabilitation". Medline,
Embase, Cochrane, UK Centre for Reviews and Dissemination, Canadian Agency for Drugs and
Technologies in Health databases have been interrogated for articles between 1998 and 2008. 146
scientific articles were found. 56 articles focus on patient treatment, 23 are reviews, 3 are to be considered
as both patient treatment papers and reviews, 53 are either technical reports, system descriptions or
analyses of new approaches; 8 are general discussion on telerehabilitation. The present paper draw the
scenario of the first ten years of telerehabilitation, focussing on clinical applications and technologies.
Basically, it confirms the lack of comprehensive studies providing evidence for supporting decision and
policy-makers in adopting telerehabilitation technologies in the clinical practice. An overall lack of
standardisation in the used terminology also results from the analysis of keywords, which is typical of quite
recent fields of application.
Category 1 – synchronous communication technologies
Category 2 – asynchronous communication technologies
Category 3 – sensor-based technologies
Category 4 – exercise-applications
Category 5 - virtual reality and gaming
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Rogante, M., et al., Ten years of telerehabilitation: A literature
overview of technologies and clinical applications.
NeuroRehabilitation, 2010. 27(4): p. 287-304.
Current status
Roessingh Research and Development, Enschede, the Netherlands
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Professional-professional
Patient-professional
Current status
Currently finding it way in
clinical practice are
Category 1 and Category 2
- Video consultation
between professionals
- Videoconsultation
between patients and
professionals
- E-mail consultation
Roessingh Research and Development, Enschede, the Netherlands
7
Category Number of
paper
Technology Clinical purposes
Synchronous
communication
24 papers
1 paper
1 paper
Videoconferencing
Telephone
Telephone +webcam
To enable contact
between patient and
professionals
A-synchronous
communication
technology
4 papers
2 papers
Asychronous messaging
technology
To enable contact
between patient and
professionals
Sensor based
technology
26 papers 8 papers ECG, O2
7 papers HR, BP
9 papers motion detection
3 papers EMG
Secure exercising
To monitor progression
Quality/Quantity
motion
Treatment/Coaching
Exercise
applications
18 papers 10 papers web application
6 papers PC workstation
3 papers phone application
Providing treatment
plans
Virtual
community/games
4 papers
Why telemedicine does not find its way towards sustainable implementation?
Stephanie Jansen-Kosterink*, Rianne Huis in ’t Veld*,Karlijn Cranen* ,Hermie Hermens*# ,Miriam
Vollenbroek-Hutten*#
Roessingh Research and Development, Enschede, the Netherlands
8
0
200
400
600
800
1000
1200
1400
1600
8 9 10 11 12 13 14 15 16 17 18 19
Controles
Uur van de dag
Ge
mid
de
lde
ac
tivit
eit
0
200
400
600
800
1000
1200
1400
1600
8 9 10 11 12 13 14 15 16 17 18 19
Controles
CLBP
0
200
400
600
800
1000
1200
1400
1600
8 9 10 11 12 13 14 15 16 17 18 19
Controles
CLBP
COPD
0
200
400
600
800
1000
1200
1400
1600
8 9 10 11 12 13 14 15 16 17 18 19
Controls
CLBP
COPD
CVS
M. Van Weering , R. Evering , M. Tabak
Example: Activity Coaching
Towards a balanced and active life
Category 3: Sensor based technology
Sensor for measuring daily
activities
Smartphone wireless connected with
sensor and coaching engine to provide
tips
Roessingh Research and Development, Enschede, the Netherlands 9
Green:
reference
Blue:
measured
activity
Category 3: Sensor based technology
Roessingh Research and Development, Enschede, the Netherlands
10
0
5
10
15
20
25
30
35
week 1 week 2 week 3 week 4
Nu
mer
of
pati
en
ts
Duration of use
Compliance to activity coaching system
started
completed
Roessingh Research and Development, Enschede, the Netherlands
11
Reinoud Achterkamp
Self – efficacy
People with low levels
of self efficacy do not
change their activity
pattern
ΔSelf-efficacy
Success experience
Vicarious feedback
Verbal persuasion
Physiological states
Next step: Personalized feedback
Roessingh Research and Development, Enschede, the Netherlands
12
Reinoud Achterkamp
Stage of change
People in different stages
of change show different
problems in their activity
behavior
- Level of activity
- Balancing activity
patterns
Next step: Personalized feedback
Roessingh Research and Development, Enschede, the Netherlands
13
Target group: Cancer
survivors
Blended care program:
- Activity coaching
- behavioral change
models
- implemented in 9
weeks first line
fysiotherapy
- Weekly coaching by
Marije Wolvers
Fieke Everts
Next step: blended care programs
RCT with 330 patients
Roessingh Research and Development, Enschede, the Netherlands
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Exercise-based telerehabilitation service
Category 4: Exercise applications
Roessingh Research and Development, Enschede, the Netherlands
• Exercise scheme
• Program made by therapist for each
individual patient
• Patient logs in at home with password to own
exercise scheme (video, sproken word, text)
• Communication via chat
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Category 4: Exercise applications
Roessingh Research and Development, Enschede, the Netherlands
Experience gained in clinical practice
• Evidence gained
– European project Clear (ICT-PSP)
– Dutch Project Telerevalidatie.nl
• Implementation performed sofar
– Regional project CoCo
– Dutch Project Tele-Nu
Roessingh Research and Development, Enschede, the Netherlands
NL
Chronic pain
COPD/ASTMA
PL
Orthopedic:
Knee / hip replacement
IT
CVA ES
TBI
Dementia
800-1000 patients
(2008-2012)
Roessingh Research and Development, Enschede, the Netherlands
Netherlands:
(2008-2012)
Roessingh Research and Development, Enschede, the Netherlands
• User satisfaction is good
• CLEAR as partial replacement:
– As effective as conventional care
• CLEAR as addition
– Not more effective than conventional care
CLEAR as replacement CLEAR as addition
COPD CRQ
CLBP RDQ
COPD CRQ
WAD PDI
CLEAR group 62%
(n=26)
63%
(n=32)
77%
(n=13)
42%
(n=12)
Control group 76%
(n=21)
41%
(n=34)
74%
(n=23)
47%
(n=19)
p=0.389 p=0.053 p=0.951 p=0.638
(2008-2012)
Roessingh Research and Development, Enschede, the Netherlands
• Implementation and evaluation in 3 different rehabilitation
centres across the Netherlands in 5 different patient groups
- Artrosis
- Parkinsons
- COPD
- Astma
- Chronic pain
- About 100 patients are treated
- Business models and cases are calculated to investigate
sustainable implementation using the framework developed
earlier
(2011-2013)
20
Roessingh Research and Development, Enschede, the Netherlands 21
0102030405060708090
100
Chronische pijn GK
voormeting (n=12)
1ste nameting (n=12)
2e nameting (n=7)
0102030405060708090
100
Chronische pijn Reade
voormeting (n=4)
nameting (n=4)
0102030405060708090
100
COPD Merem
voormeting (n=11)
nameting (n=11)0
102030405060708090
100
Merem astma
voormeting (n=4)
nameting (n=4)
Clinical results on quality of life are positive for all diagnosis groups
Webbased exercising and teleconsultation are used most
83% of the users would advise the service to other patients
User acceptance is high (7.7 out of 10)
(2011-2013)
Roessingh Research and Development, Enschede, the Netherlands
12 health care institutes in region Twente
• Rehabilitation centre
• Hospitals
• Home care sector
• 1st line physiotherapists
4 different diagnosis groups
1. Cancer rehabilitation
2. Acute hip
3. COPD
4. Chronic hip and knee problems
More than 100 patients are treated using this technology and research
into sustainable implementation has been done
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(2010-2012)
Region Twente is
candidate
reference site
within EIP-AHA
Roessingh Research and Development, Enschede, the Netherlands
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Further development User requirements engineering
- Iterative approach
- Combined framework using State of the art methodologies from
- Computer sciences
- Medical science
(2010-2012)
Roessingh Research and Development, Enschede, the Netherlands 24
Multimodal service platform
Selfmanageme
nt
Teleconsultatie Webbased oefenen
Zelfmanagement Activiteiten coaching
(2010-2012)
Further development
Roessingh Research and Development, Enschede, the Netherlands 25
Different ways of implementation
Kiosk/ At HOME/ Individual setting in health care institute
Individual protocol in terms of modules used, intensity and
duration versus fixed protocol
As follow up treatment, as partial replacement or as addition to
current treatment
In the health care chain or from a single health care institution
(2010-2012)
Roessingh Research and Development, Enschede, the Netherlands
TELEMEDICINE FOR PATIENTS WITH COPD
New treatment approaches
to improve daily activity behaviour
Monique Tabak
7 februari 2014
(2010-2012)
Diagnosis Client Satisf.
Questionnaire
max 32, Mean (sd)
Webbased
exercising range
(0-10), Mean (sd)
Selfmanageme
nt range (0-10)
Mean (sd)
Activity coach
range (0-10)
Mean (sd)
% that advises
positive
Acute hip,
Hospital
28.8 (4.4), (n=4) 8.6 (0.6), (n=3) 9 (n=2) 10 (n=1) 100% (n=4)
Acute hip,
nursing home
Missing 7.8 (1.7), (n=12) Not relevant 92% (n=12)
Arthritis
22.4 (4.4), (n=7)
6.3 (1.6), (n=6) 5.1 (1.1), (n=7) 5.4 (2.6), (n=7) 28.6% (n=7)
Cancer 28.4 (3.6), (n=16) 6.1 (1.5), (n=17) 6.3 (1.5), (n=17) 5.9 (1.5), (n=17) 44% (n=9)
COPD 26.3(1.3 SE), (n=12) 7.5(1.5), (n=11) 7.9 (1.3), (n=11) 6.8 (2.6), (n=12) 90% (n=10)
Average 27 7.0 6.7 6.2 71%
Roessingh Research and Development, Enschede, the Netherlands
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Diagnosis Treatment
duration
(average)
Patients use
(average %
of treatment
days)
Professionals
use (average %
of treatment
days)
Acute hip,
hospital
60 days
70%
18%
Arthritis Missing Missing Missing
Cancer 231 days 87% 9%
COPD 256 days 79,8% 32%
Use of the portal expressed in general logins
by the patient and professional
(2010-2012)
Roessingh Research and Development, Enschede, the Netherlands
• Implementation of the telerehabilitation modules to 10
rehabilitaton centers in the Netherlands
• 92 health care professionals and 105 patients sofar
(2013-2014)
Teleconsultation Webbased exercising
Self-management Activity Coach
Roessingh Research and Development, Enschede, the Netherlands
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(2014-2018)
Next step: Rehabilitation initiative
Roessingh Research and Development, Enschede, the Netherlands
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Next step:
(2013-2016)
Roessingh Research and Development, Enschede, the Netherlands
www.perssilaa.eu
PERsonalised ICT Supported Service for Independent Living
and Active Ageing “ no: 610359
Next step: Preventive personalized services (2013-2016)
Roessingh Research and Development, Enschede, the Netherlands 32
Monitoring Screening Training Profesionally
Supported care
Multimodal: physical, cognitive and nutrition aspects
Next step: Preventive personalized services
Roessingh Research and Development, Enschede, the Netherlands
- Second screening and
Service provision
- together with
municipalities a
- as self management
services
First screening with
general practitioners
Roessingh Research and Development, Enschede, the Netherlands
Development into self
management programs
with a personal
recommender system,
taking into account
- Expert opinion
- Patients
preferences
- Patient goals
Hossein Nassabi
Next step: Preventive personalized services
Roessingh Research and Development, Enschede, the Netherlands
Physical active
Cognitive stimulation
Healthy nutrition
Adherence to
services provided
Game
layer
Feedback and
rewarding
Positive influence
on mediators
Actual Daily
functioning
Performance while using the services
Performance
Content
Timing
Presentatio
n
Comparison
in relation to
individual
goal and
Decision
Support
Game
layer
Content
Timing
Presentatio
n
- Gamification layer will
be developed to
improve motivation
and adherence to the
service
- Gamification can be
used to involve others
into the services
Frederieke de Vette
Next step: Preventive personalized services
Roessingh Research and Development, Enschede, the Netherlands 36 - Negotiation meeting -
• Moves out of the health care sector
into the community
• In Twente, sport associations,
neighborhood houses etc will be
used as physical place to put the
services in place.
• The region starts with enrollment of
the physical service modules at
district level and will via an iterative
approach broaden the
implementation and validation with
other services modules. Health care
sector
Next step: Preventive personalized services
Roessingh Research and Development, Enschede, the Netherlands
37
Fysio/sportscentres Home care institutions Neigbourhood
houses
Health care Municipalities
Home
Example Enschede, same strategy in Hengelo en
Tubbergen, ……….
Screening
>65 year
(around 3000
older adults
Further
Screening of
pre-frail
and training
locations
Teaching environment for students
Location for
screening and
training
Next step: Preventive personalized services
Roessingh Research and Development, Enschede, the Netherlands 38
Service validation starts in september • 350 Elderly will enroll the study and use the perssillaa services
• First elderly will be enrolled within the first year already
• Outcome assessment will be the same in Italy and the Netherlands and
will be performed every 3 months
• Outcome assessment focuses on parameters like:
• Health status
• Every day functioning
• Awareness
• Satisfaction with the service
• Risk on frailty
• Costs
• Sustainable business models will be developed for implementation after
the project
Next step: Preventive personalized services
Roessingh Research and Development, Enschede, the Netherlands
Take home messages
There is an increasing need for care for those with chronic
diseases
Telemedicine services are about to come and seem to have
potential in various health care sectors in terms of acceptance
and clinical benefits
Implementation of telemedicine in clinical practice is not naturally
Future directions
More personalized care taking integrating behavioural state of individuals
Offered as blended care programs
Prevention / self management services with intelligent personal
recommenders
More motivational strategies for coaching/feedback
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Roessingh Research and Development, Enschede, the Netherlands
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