“Introducing personalized healthcare in daily clinical ... › en › digital-society › ... ·...

“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


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

http://www.google.nl/url?sa=i&rct=j&q=vitality+elderly&source=images&cd=&cad=rja&docid=NR4rR389KEFIJM&tbnid=1eyt0CZtU6YM9M:&ved=0CAUQjRw&url=http://www.123rf.com/photo_15154610_overweight-senior-woman-full-of-zest-and-vitality-exercising-on-a-gym-mat-with-her-leg-raised-in-the.html&ei=sseIUb63LqrM0QX_p4DABQ&bvm=bv.45960087,d.d2k&psig=AFQjCNF37Rye1Mh8GcDqj15NkZMmLwD8Uw&ust=1368004893855506

http://www.google.nl/url?sa=i&rct=j&q=vitality+elderly&source=images&cd=&cad=rja&docid=xTyOgDPudpcPxM&tbnid=C48GThiiESoFSM:&ved=0CAUQjRw&url=http://www.research.leiden.edu/news/staying-fit-while-ageing-is-a-question-of-realistic-planning.html&ei=CciIUbSTJtCn0wW21IHYDw&bvm=bv.45960087,d.d2k&psig=AFQjCNG5DWlOxFxlwHrc0cvPrk-a15DeoQ&ust=1368004988891816

http://www.google.nl/url?sa=i&rct=j&q=vitatily+elderly&source=images&cd=&cad=rja&docid=ibOmqz5hqrC6yM&tbnid=WEnxF3pG8lQgTM:&ved=0CAUQjRw&url=http://news.softpedia.com/newsImage/Beta-Alanine-Restores-Muscle-Vitality-in-the-Elderly-2.jpg/&ei=yseIUaj3O8_Y0QW4toD4Cg&bvm=bv.45960087,d.d2k&psig=AFQjCNEG_1fQMAIuNXdn8dKAeWCFc3VecA&ust=1368004890178742


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


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

5

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


6

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


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

E-mail

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*#


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


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


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


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


13

Target group: Cancer

survivors

Blended care program:

- Activity coaching

- behavioral change

models

- implemented in 9

weeks first line

fysiotherapy

- Weekly coaching by

e-mail

Marije Wolvers

Fieke Everts

Next step: blended care programs

RCT with 330 patients


14

Exercise-based telerehabilitation service

Category 4: Exercise applications

http://www.google.nl/url?sa=i&source=images&cd=&cad=rja&docid=-rTEp8Flv1JBJM&tbnid=7RH4JEyGKPJwQM:&ved=0CAgQjRwwAA&url=http://www.signomotus.it/en/research/clear_en.php&ei=MPKIUY_eD8-X0AWrkoEI&psig=AFQjCNEOjWs6bNF6UftewAbqzJMAb85Eww&ust=1368015792295701


• 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

15

Category 4: Exercise applications



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

http://www.tele-nu.nl/


NL

Chronic pain

COPD/ASTMA

PL

Orthopedic:

Knee / hip replacement

IT

CVA ES

TBI

Dementia

800-1000 patients

(2008-2012)



Netherlands:

(2008-2012)



• 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)



• 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


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)


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

22

(2010-2012)

Region Twente is

candidate

reference site

within EIP-AHA


23

Further development User requirements engineering

- Iterative approach

- Combined framework using State of the art methodologies from

- Computer sciences

- Medical science

(2010-2012)


Multimodal service platform

Selfmanageme

nt

Teleconsultatie Webbased oefenen

Zelfmanagement Activiteiten coaching

(2010-2012)

Further development

https://www.dropbox.com/s/tg5vouv50cbxphf/TelerevalidatieDEF.mp4


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)

http://www.google.nl/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=zTTuB7iLgpsYIM&tbnid=h_dNu2-htlASvM:&ved=0CAUQjRw&url=http://www.dreamstime.com/royalty-free-stock-photos-senior-woman-using-computer-image13909948&ei=XjB1UYffG8G00QXB1IC4DQ&bvm=bv.45512109,d.d2k&psig=AFQjCNFXV69cOZEAguh9B7NIfQ9UcRltwQ&ust=1366720980663616





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%


27

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)


• 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

http://www.tele-nu.nl/


29

(2014-2018)

Next step: Rehabilitation initiative


30

Next step:

(2013-2016)


www.perssilaa.eu

PERsonalised ICT Supported Service for Independent Living

and Active Ageing “ no: 610359

Next step: Preventive personalized services (2013-2016)


Monitoring Screening Training Profesionally

Supported care

Multimodal: physical, cognitive and nutrition aspects

Next step: Preventive personalized services


- Second screening and

Service provision

- together with

municipalities a

- as self management

services

First screening with

general practitioners


Development into self

management programs

with a personal

recommender system,

taking into account

- Expert opinion

- Patients

preferences

- Patient goals

Hossein Nassabi



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


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


http://www.google.nl/url?sa=i&rct=j&q=twente&source=images&cd=&docid=YEPQ3rYetCWzpM&tbnid=XlgckJMbbdy9DM:&ved=0CAUQjRw&url=http://nl.wikipedia.org/wiki/Twente&ei=Mdu5UcveCqrC0QWA_4GoCQ&psig=AFQjCNEWV-ukZnBqjaARZfImxx20dB3rAA&ust=1371221154994488


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



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



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

39


40

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