Innovative Solutions for Integrating Health and Social Care

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ICT Support for Integrating all Aspects of Care ICT Support for Integrating all Aspects of Care

in Diverse Cultural Settings in Diverse Cultural Settings

Innovative Solutions for Integrating Health and Social Care

Jesper Thestrup, In-JeT ApS (stand 1421)

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Overview of Presentation Overview of Presentation

• Introduction

• The PICASO project - A Personalised, Integrated Care Approach

– Funded by the EU, 8m€, 3 years, 9 partners, 7 countries

– Three major innovations in ICT supported integrated care / continuum of care

• Automated and integrated workflows across sectors

• Secure data exchange between actors

• Handling of care plans for multimorbidity

• Trials and reference implementation

– Two trials in Rheumatic Arthritis and Parkinson’s Disease with CVD as co- morbidity

– Diverse set of formal carers and organisation involved (Co-morbidities) – DIverse cultural backgrounds (Northern and Southern Europe)

– Example: Using the PICASO platform for Remote Cardiac Examination

• Questions, conclusions and outlook

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5th October 2016 WHINN 2016 - Odense, Denmark - Integrating Health and Social Care 3

Introduction: The

Introduction: The Patient Journey Patient Journey

Movement, fall alert, agility Fall sensors, fall alert

Incontinence monitor Leg elevation monitoring, image monitoring

Medication, risks factors Continuous BG, urine and ketone monitoring

Medication monitor Environmental sensors Balancing, exercise, gait Temperature, agility Blood glucose (spot), lifestyle advice

Blood pressure, risk score for complication

Monitoring/Therapy

Age Event PICASO Component

45 Hypertension Telehealth, BPM, data mining

Intelligent personalised feedback

55 Type II Diabetes Telehealth, data mining

Intelligent personalised feedback

65 Rheumatoid Arthritis Personalised rehabilitation service

execution, decision support

67 Hearth Failure Telehealth weight, BPM, Kinetics

70 Early Dementia Reminder services, social well being

Integrated care plan execution

72 Insulin dependent Multimorbidity analysis, goal

optimiser

74 Valve disease Integrated care, decision support

75 Peripheral vascular

(leg ulcer) Telehealth, telecare

Integrated care, decision support

76 Incontinence Telecare, intervention alert

78 Fall Telecare, intervention alert

80 Vision Telecare, intervention alert

82 Death

Source: Russell Jones, MD, Chorleywood Health Clinic, mod. IN-JET

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Prevalence of Multimorbidity in Age Groups (UK n=99,997) Prevalence of Multimorbidity in Age Groups (UK n=99,997)

C Salisbury, L Johnson: Epidemiology and impact of multimorbidity in primary care, Br J Gen Pract 2011; DOI:

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Deficits in Communication and Information Transfer Between Deficits in Communication and Information Transfer Between Hospital

Hospital--Based and Primary Care Physicians in relation to dischargeBased and Primary Care Physicians in relation to discharge

• Overall, direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%).

• The availability of a discharge summary at the first post-discharge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction

• Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital

course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counselling (90%-92%), and follow-up plans (2%-43%)

Source: Sunil Kripalani, MD, AMA. 2007;297(8):831-841. doi:10.1001/jama.297.8.831

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Why is There Such a Lack of Information Flowing Across Why is There Such a Lack of Information Flowing Across

Boundaries?

Materials & Substances Sub-assemblies

Assembly Car

Manufacturing Industry

Hospital Clinics General Practice Municipal and Social Care

Healthcare Industry

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PICASO

PICASO - - A Personalised, Integrated Care Approach A Personalised, Integrated Care Approach

Short overview of the

PICASO project

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PICASO Project Overview PICASO Project Overview

• PHC 25 – 2015: Advanced ICT systems and services for Integrated Care

• Re-design health and care systems by

developing integrated care models that are shifting from a reactive approach to

proactive and patient-centred care

Technology Partners Clinical Partners

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Continuum of Care

Continuum of Care – – Roads Roads to Better and Cheaper Healthcare to Better and Cheaper Healthcare

1. Allow more cost-effective care management through automated and efficient workflows

2. Improve cooperation and exchange of knowledge between professional caregivers in health, rehabilitation and social care domains

3. Actively include patients and their relatives in the integrated care settings thus supporting patient empowerment and self-care;

4. Reinforce medical knowledge and create new care models for

management and treatment of patients with multi-morbidity conditions;

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Decoupling of Information and Care Spaces

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Care Management Through Automated Workflows Care Management Through Automated Workflows

• Moving care plans across organisations - narratives

• Moving patient data across organisations - tokenized

• Moving patients across organisations – Assisted Living support

• Making sure that no one feels stigmatized – ethical issues

• Making sure that no one is left behind – compliance issues

• Making sure that no one is excluded – organisational integrity

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Moving Care Plans Across Organisations

Moving Care Plans Across Organisations – – Narratives Narratives

• The aim of ‘narratology’ can be defined as that of producing an in-depth description of the ‘syntactic/semantic structures’ of the narratives. The narratologist is in charge of dissecting narratives into their component parts in order to establish their functions, their purposes and the

relationships among them.

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Examples

Examples – – Workflows in Outpatient Clinics Workflows in Outpatient Clinics

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Steps for C

Steps for C onstructing onstructing Care Plans Care Plans

Narrative

Care plan (pathway) described in plain text

Care Plan

Standard care plans to be customised to individual patients by physicians and others authorised

to set up care plans

Template

Standard care plan for various disease management actions specific to organisation/physician with open data

fields for specific service details

Service Library

Standard services to be included in templates and used for automatic service execution including in clouds and

in patient’s homes

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Visualisation of Integrated Care Plans and Work Flows Visualisation of Integrated Care Plans and Work Flows

MAQUET INSIGHT Clinical Logistics IBM Case Management

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Cooperation and Exchange of Knowledge Between Caregivers Cooperation and Exchange of Knowledge Between Caregivers

Distributed Physical Care Spaces

Integration Information Space

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PICASO Integrated Data Exchange Ecosystem PICASO Integrated Data Exchange Ecosystem

Sentinel Agents

PICASO Public Cloud Distributed Physical

Care Spaces

Integration Information Space Meta Data!

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Visualisation of and Search for Data Structures Visualisation of and Search for Data Structures

• Web-based interactive Data Resource Browser

– The user retrieves data by querying the Shared Memory Manager for instances of connectors relevant to a certain patient or a certain carer.

– The query provides a visual image of which data are found and that the user can retrieve.

– The relationship between the kind of data available and the data owner can be presented

• Security and Privacy Management Subset

– Requestor must have patient credentials before anything is shown

– Requestor must be authenticated before

owner will be displayed – request can be send – Patient and owner (and 3rd party) must agree

before data can be send to requestor

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Moving Patient Data Across Organisations

Moving Patient Data Across Organisations – – Tokenized Tokenized

Distributed Physical Care Spaces

Integration Information Space

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Trials and Reference Implementation of the PICASO Components

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Overview of PICASO Trials (Planned for Jan 2017 to Dec 2019) Overview of PICASO Trials (Planned for Jan 2017 to Dec 2019)

Two trials chosen for cultural diversity for organisation of health and social care:

• Trial 1: Rheumatologic Arthritis (RA) and CVD in Düsseldorf

– Northern European Institutional social care

• Focus on transition of workflow and patient data between formal carers

– Bismarck healthcare financing system

• Focus on the involvement of insurance companies

• Trial 2: Parkinson Disease (PD) and CVD in Rome

– The Mediterranean Family Centred Healthcare

• Focus on transition of workflow and patient data between formal and informal carers

– Beveridge healthcare financing system

• Focus on the cost effectiveness of organisations

• Trials performed in two phases of 9 months with initial and updated PICASO platform

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Narrative for Remote Monitoring of CVD Narrative for Remote Monitoring of CVD

1. Assign patient to regular physical trainingsessions

2. Deploy remote ECG equipment in patients’ care spaces 3. Train patient to perform standard exersises

4. Send reminder to the patient the day before 5. Start sessions at the scheduled time

6. Check that patients are on-line 7. If yes, to to 9

8. If not, go back to 6

9. Monitor patients’ exercises and results 10. If OK, continue to 12

11. If not, call patient via video and instruct for changes 12. Session ends

13. Store results in EPR

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LinkWatch

^©^©

MEGA MEGA BioLink BioLink

^©^©

Remote ECG Monitoring in Real- Remote ECG Monitoring in Real -time time

• 1 or 3 channel ECG with Bluetooth

• Real-time transmission of data to command centre

• Simultaneously monitoring of up to 8 patients

• Including 3D activity data and breathing

• Store in HIS in EDF format

• Optional Blood Pressure, Weight, SpO₂ etc.

http://www.linkwatch.se & http://www.megaemg.com/products

PICASO components and reference implementations will be used in the trials Example from Cardiac Remote Monitoring e.g. during physical training.

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ECG Event Viewer (EDF format) ECG Event Viewer (EDF format)

http://www.megaemg.com

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Please see us here: www.picaso-project.eu

Permission is granted to print material published in this presentation for personal use only. Its use for any other purpose, and in particular its commercial use or distribution, is strictly

forbidden in the absence of prior written approval.

PICASO has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 689209.

Possible inaccuracies of information are under the responsibility of the project. This presentation reflects solely the views of its authors. The European Commission is not liable for

any use that may be made of the information contained therein.