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The September 23, 2003 Issue Provided by System Dynamics Inc.
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Home-based Health Services: Telefónica’s Pilot

A Guest Article by Ana Altadill Arregui, Víctor Manuel García Muñoz, Miriam Ibáñez Lequerica, Jose María Montero Cebrián, Ana María Ruiz Blanco and Jesús Felipe Lobo Poyo

Note from the Editors: In our June visit to Spain, we had the opportunity to see Telefónica’s "Hogar Digital" and to hear about some of the Engineering and Development (TID) organization’s projects. Their home-based health services project is in operation today with actual patients. The Telefónica authors kindly agreed to provide an overview of the project’s goals and its conclusions to date.

Also see the "Author Biographies" page.


Introduction

Home-based Health Services are expected to be a key factor in the evolution of health systems. The use of new information technologies can allow end users to obtain health care and social services at any location, erasing many obstacles from current health services and creating a universal service everybody can access.

Home-based Health Services need to bridge the differences between the various health assistance layers in order to introduce health assistance in the patient’s house. The integration of the house and a hospital, or any other health institution, into a coherent health assistance scenario clearly involves big technological and organizational challenges.

In this new scenario, personal communications, remote monitoring and surveillance are going to be the most relevant Home-based Health Services for remotely controlling the patient’s condition. It is important to recognize that a significant portion of the users of such services will be lonely elderly people or patients who live in a location where access to health facilities is limited. These people may also have some handicap or illness which makes it difficult and uncomfortable for them to move from one place to another.

Because the patient is being supervised by the hospital, these services require a new remote vital signs controller system and some integration with the hospital’s information systems. For example, the system should be able to use a remote glucometer to measure the glucose of a diabetic patient, and integrate this data within the hospital database.


Telefónica’s Role

Telefónica, the main Spanish telco operator, in collaboration with the Hospital Clínico San Carlos (HCSC), one of the biggest public hospitals in Madrid, has developed a Home-based Hospitalization Service. It is part of the Hogar.es project, an innovation project partially originated by the Spanish Administration. The project began in September 2000 and will finish at the end of 2003.

The main near-term goal of Hogar.es is to provide the infrastructure for a “Connected House” or “Digital Home” in which multiple advanced services can be easily deployed. Hogar.es has chosen an OSGi architecture Open Services Gateway Initiative which is based on the existence of a Residential Gateway at home as the appropriate platform to enable the provisioning of advanced services from different providers in an integrated way.

Within the project a set of services based on the platform have been developed. These services include home control, surveillance, information services, data services, remote-assistance, e-learning and home hospitalization

The project results are being evaluated by means of field trials with real users in approximately 30 houses/flats. This pilot experience, including three volunteer patients remotely assisted from the HCSC, is currently underway and will last until the end of 2003.


Home Hospitalization Service of the "Hospital Clínico San Carlos"

The former service

The development of the home hospitalization services in Spain has been prompted by two needs. On one hand, the users of the Public Health System are asking for a more responsive and humane service, and on the other hand, the managers of public hospitals are looking for ways to reduce expenses without reducing the quality of care.

Thus, the two main objectives of the home hospitalization are: to treat the patient within his/her own environment with the same quality and doctors as if he/she were at the hospital and to optimize the costs involved in long-term treatment of the patient.

Until now, there have been about 40 available home hospitalization units in hospitals all around Spain, including the HCSC. The medical staff uses portable medical equipment which is carried to every patient home each day for the doctor’s visit. A personal communication channel could be established between the doctors and patients with the support of cellular phones.

In order to participate, the patient and their family must want to participate, have a suitable caregiver and appropriate physical conditions within the home.

Advantages of the new service

HCSC intends to use the new service to improve the attention offered to their patients at home, increase the number of patients that take part in the Home Hospitalization Plan and increase the variety of pathologies that can be treated at home.

In order to suit HCSC’s specific needs, the Home Hospitalization Service was designed with the direct support of their medical staff, satisfying the following criteria:

  • Availability of hospital information for the doctor from the patients home
  • Reduction of medical visits to the patients
  • Remote control of medical devices
  • Profile support for different type of users
  • Security
  • Customization of the application depending on the user


System description

The service is based on the OSGI-compliant architecture developed within the Hogar.es project. This architecture provides platform independence, interoperability with other services, modularity/scalability, ease of administration and remote administration.

See the "System Architecture" page for diagrams and a description of the system architecture and the equipment installed in the users’ homes.

The system was designed to meet the following requirements

  • Mobility: The service should be accessible for any authorized user from any device with an Internet connection.
  • Customized Access with different profiles: It defines several profiles for the application (medical personnel, nursery, patient or relative).
  • Security: Users are authorized by the hospital’s Computer department; system is accessed via a user and password mechanism; all communication between the hospital and the patient’s house is established using IPSec and VPNs;. firewall in the residential gateway at the patient’s home as well as in the hospital.
  • Adaptability: Allows configuration and application visibility on-line.

Trial experience

The trial is being developed in collaboration with the Hospital Clínico San Carlos and their home-based hospitalization department.

The department’s medical staff is composed of doctors, nurses and an administrative assistant of varying ages. All doctors are currently moderate users of the Internet (about 12 hours a week), however only one nurse uses the Internet occasionally.

The department has chosen three patients of different ages with chronic pathologies. The eldest is not in contact with the new technologies at all; the youngest is quite interactive, has a PC and is usually connected to Internet

All users in the trial have an ADSL connection which is appropriate because it is “always on” and is suitable for videoconferencing. All measurements done at the patient's home (usually with the help of a caregiver) are sent automatically to the hospital and immediately integrated with the existing patient data, so the entire medical staff has them available for queries.


Home-based Hospitalization Service description

This system includes the hardware infrastructure and all the services needed to assure the surveillance and control of the patients at home. In addition, it offers an integrated view of the medical data of the patient for any authorized user, inside and outside the hospital. Each user of the system has a customized application that suits his or her own needs.

The patient can access the information that doctors and other medical staff make available for him (e.g: diet, medications…). For the medical staff this service is a query tool, integrated with many information systems of the hospital so that they are able to have all the information from a patient accessible from a single tool.

Main screen of the service --> Click for larger picture
Main screen of the service

The main modules of this system are the following:

Remote monitoring

This is one of the key features of the service. It uses medical devices located at the patient's home. These devices send their measurements in a secure way to the hospital, where they are integrated within the data of the patient. The patient’s glucose level, blood oxidation level, blood pressure, heart rate and gas components of the breathing can be measured with different devices remotely.

One of the advantages of using OSGi is the ability to extend the remote measurement capabilities by integrating new medical devices, whose main requirement is to have a communication port (like USB).

Remote device control interface --> Click for larger picture
Interface for remotely controlling the home devices

The end user’s access to the devices is accomplished through a map which represents the home. In Hogar.es the device control service is the same for any device, such as the medical devices, surveillance cameras and motion detectors.

Integration with other applications of the hospital

One important requirement of the Home-based Hospitalization Service is its integration with existing applications, so that the home hospitalization staff can access various applications in an integrated way. These applications include: Patient data; Pharmacy; Appointment management; Radiology; and Diet.

Patient diary

This is an electronic agenda which contains all relevant information about the patient. It can be checked by the patient or the medical staff, although the patient has read-only access to the data whereas the medical staff can modify the contents. It contains Personal data; Medical tests; Treatments: Emergency Contacts; Appointments and Medication Reminders and Warnings (which uses a flashing light installed at the patient's home).


Attitude towards the system

In order to determine the reactions of all trial participants, both structured interviews and questionnaires were employed with doctors, nurses and patients. The responses to these surveys are summarized below; more information is contained in the "Attitude Surveys" page.

Doctors and Nurses

The medical staff felt the Home Hospitalization Service will save time and travel to the patients homes, making their tasks easier and more effective.

Remote monitoring and videoconferencing were considered a great improvement. Previously, the only available way to communicate with the patients was a cellular phone. The medical staff thought the service both improves patient monitoring and reduces the number of patient visits. Some visits are still necessary, however, since physical presence cannot be completely replaced by videoconferencing, particularly for some emotional aspects.

The surveys showed significant differences in perceptions of usefulness between doctors and nurses, which seems related to the work they have to accomplish. For example, radiology– used almost exclusively by doctors—is scored very high by doctors and very low by nurses. Doctors also found the services much more user friendly—likely due to their greater familiarity with PCs.

Both groups found information services very useful because patient information is centralized; quickly accessed; clearly structured; and accessible for all staff.

The general conclusion is that these services improve the quality of home-based assistance.

Patients and Caregivers

Patients and caregivers think that this system improves their care. There were some complaints about the multiplicity of equipment and difficulties in the installation. Videoconferencing obtained the highest marks, and the impression of users was very similar to the opinion of the medical staff.

Users liked the remote monitoring services. Patients considered the warning service to be very useful as a reminder (e.g. , for when they should take a pill).


Preliminary conclusions

Although the trial is still in a preliminary phase, we have reached some conclusions that can be useful for further experiences.

  • Management and provisioning systems: It is important to integrate the broadband provisioning within the OSGi services provisioning. This is vital in case of failure so the service can be restored faster.
  • Operational costs: At least two days are needed to complete the installation in every house.
  • Specific equipment is needed in order to offer these services. This equipment should be transparent to the user, operate continuously without failure and be managed remotely. OSGi compliant residential gateways fit all these needs.
  • Cameras are not always welcome at home. The patients, as well other users, would like to turn the cameras on and off whenever they want to. The existing cameras did not allow this.
  • User friendly systems: In the pilot we are using a videoconference service based on Netmeeting and web-cams. However, we observed this is not very friendly for our users. Thus we are testing other systems based on the use of the TV to show the images and the phone as dialer and as voice interface.

We are encouraged by the reactions of all the trial users and look forward to reaching decisions on further work in this important application of home broadband.

( www.telefonica.es ) ( www.tid.es ) ( www.msc.es/insalud/hospitales/hcsc/home.htm ) ( www.hogardigital.net )