Is Telecare Feasible? Lessons from an in-depth case study

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1 Is Telecare Feasible? Lessons from an in-depth case study Johan C. Wortmann, Albert Boonstra, Manda Broekhuis, John van Meurs, Marjolein van Offenbeek, Wim Westerman, Jacob Wijngaard Faculty of Economics & Business, University of Groningen Abstract This paper describes the empirical findings of a large-scale telecare pilot implementation, called KOALA. The pilot is based on video interaction of clients with a medical service centre of a home care provider. The purpose of the project was to gain experience with telecare and to measure the effects in terms of costs and perceived well-being. The expected effects were that clients well-being would be increased and overall costs of health care would be reduced. The results of this study are: the positioning of the medical service centre in the care provider s network and the organization of the centre are crucial for attaining acceptance and cost effectiveness; introduction of a telecare program needs careful preparation with clients and employees, and alignment with existing care; there is substantial difference in the use of telecare and its advantages for different groups of clients; this is especially relevant when using proprietary technology. 1. Introduction Koala is a pilot experiment in telecare, where the client is able to call for contact with a nurse in a medical service centre via video interaction. The video interaction is two-way and uses the client s television screen. It is based on a high-quality camera mounted on the TV, but is on proprietary technology. For clients under treatment of a medical specialist, the video interaction with the medical service centre can be transferred to the medical specialist. Koala was introduced in early 2007 in the northern part of The Netherlands, and the pilot was conducted over a period of roughly one year. Koala is an initiative taken by a health care insurance company, a home care provider, and a telecom company. The pilot was supported financially by the government. The University of Groningen performed a research program to investigate the effects of the pilot. Although the primary goal was to investigate the cost effectiveness of the program, many other features of the pilot implementation were researched. This paper provides an overview of the results, in terms of lessons learned, in addition to more detailed papers on specific elements of this study, which will be published in more specialized outlets. 2. Koala pilot in context There are two main target groups of clients in the Koala pilot, which are labeled as Care and Cure clients. The pilot is free for the clients in the pilot phase. The system offers a 7x24 service. Care context People who received care are clients of the home care organization who joined the Koala initiative. This home care organization is a major supplier of care services in the region. These clients receive care services, such as house cleaning, personal care and nursery. that are mainly hands-on services. Although the indication for receiving care services has a medical nature, the care services provided are partly of a nonmedical nature. The telecare services provided via Koala are positioned as a low-threshold entry to the medical world, including triage, inquiry, first line advice, and nursery advice. Expected advantage in the Care context For the client, the expected advantage of the Koala system lies in increased accessibility to care. There is always a telenurse present to provide immediate telecare. Clients are able to use the system as they need it. Client s appreciation of these advantages is implicitly assumed. Care providers assume that telecare will reduce the number of home visits considerably.

2 Cure context Cure patients in Koala are patients with three types of diseases, COPD 1, CHF 2 and Diabetes. These patients are under treatment of medical specialists of a hospital (in Koala, two hospitals were involved). Cure patients pass several phases in their disease. Usually, there is a moment when the disease becomes acute for the first time, and when the general practitioner hands over the responsibility for these patients to the specialist. The patient will need treatment by the specialist in the hospital. When the patient is released from the hospital, the patient will be monitored, and remain under medical supervision of the specialist. In the classical setting, the specialist will request the patient to return to the hospital periodically for check up. However, these periodic consults are not ideal from a medical point of view, for two reasons. First the patient may have to return to the hospital too often if the patient is recovering according to the medical norms, the patient s visit is waste for both the patient and the specialist. On the other hand, if the patient does not recover as planned, the patient s visit is too late, and the specialist would have liked to change earlier to e.g. a different therapy such as a different scheme of drugs. Expected advantage in the Cure context The advantage of telecare in general and Koala in particular lies in better monitoring. The Koala system collects data on the patient s medical condition and transmits these monitoring data to the specialist. This allows the specialist to monitor the patient, to take action if needed, and to have the patients data available when required in a consultation session. This procedure is expected to reduce the number physical visits of patients to the hospital. Moreover, specialists expect that patients can be released quicker from the hospital, when they can be monitored at home. From a cost point of view, this is even the most promising issue in Koala. Furthermore, the specialist can observe in an earlier stage that a patient does not recover according to the care plan, which can increase the quality of care. 3. Research project The research conducted by the University of Groningen consists of several parts: implementation of the Koala System; 1 Chronic obstructive pulmonary disease 2 Congestive Heart Failure effects of Koala in the Care context; effects of Koala in the Cure context; organisation of the Medical Service Centre; cost-benefit analysis in monetary terms. The research was set up as a study that covered a substantial period of time. The implementation research was performed in the first half of 2007 with only Care clients. In the same period, a pilot analysis was performed for Koala in the Care context. The main research was performed from mid 2007 till March In this period, the main research in the effects of Koala in Cure and Care was performed, and the organization of the Medical Service Centre was studied. This investigation was also the basis for the cost benefit analysis. The research was performed by interdisciplinary team of researchers, in close collaboration with the Koala partners. Methodology of research The methodology of the research differed substantially among various parts. The implementation research was largely based on interviews with home Care clients who were connected by Koala with the Medical Service Centre, with care coordinators, and with project members in the first half a year of the project. Despite of the rather critical findings (see below), the Koala team did not change its approach substantially, and accordingly, further investigation into the implementation approach was abstained from. The effects of Koala in the Care context were measured in various ways, to be discussed in detail below. It should be born in minds that the pilot group was not very stable, because many clients moved from independent living to another phase in life (or passed away). In order to compare the consumption of Care services to a situation without Koala, the client s care consumption was compared to a control group of clients. Both groups had in statistical terms the same care consumption in the 6 month period before the start of Koala. The effects of Koala in the Cure context were also measured in various ways. Again, the pilot group was not very stable, mainly because of mortality. Due to their precise protocols, the specialists could estimate very precisely what the consumption of medical services is for the patients who do not use Koala. Therefore, a control group is not included in the research design. The research directed to the Medical Service Centre focused on the relationship between the input of calls and organizational design variables.

3 The cost benefit analysis was based on the above field research and calculated break-even points for the investments made. 4. Koala project as it evolved The Koala project started early About 600 clients taking regular Care services were sought to join the experiment. These clients were by no means selected as a random sample. Rather, the responsible nurses in particular neighbourhoods selected clients considered suitable for Koala. The influence of the responsible nurse should not be underestimated: some nurses hardly selected any clients other nurses (probably with a more positive attitude towards Koala) selected dozens of clients. After having given their consent, the selected clients were informed that an installer would install the required equipment in their homes. However, considerable time elapsed before this actually happened (up to 11 weeks). The project moved more slowly than expected by Koala project management. As a consequence, an active marketing campaign was started in spring 2007, to sell Koala telecare to nurses and clients. In this first half year, many features of the Koala project were still unclear, e.g. protocols had to be developed, nurses in the medical service centre had to be trained, and software needed to be debugged. Meanwhile, the research team started to prepare measurements related to the Koala Care clients and prepared for a longitudinal study of the medical service centre. In the early summer of 2007, the research for implementation took place. After August 2007 the number of Koala Care clients increased to 375 and the project remained stable, allowing proper investigation by the research team. Koala Cure was prepared in the summer 2007, but it took until the end of the year before substantial numbers of patients actually were connected to Koala. In contrast with the situation with Care clients, the protocols for Cure patients were made explicit before the start of the project. The patients were selected by the medical specialists. As specialists would advice Koala to all new patients in a given period of time, bias is unlikely. An important disadvantage was the fact that the installer of the Koala equipment needed three weeks (!) to install the equipment. Therefore, the medical specialists could not gain experience with the most important factor for cost reduction with videobased telecare, viz. the reduction of the number of days which the patient stays in the hospital. The Koala project ended formally in March However, clients with Koala equipment continue to receive telecare services in the remainder of Research results Implementation research It is well known that implementation of new technologies seldom leads to spontaneous adoption [1]. Users and other stakeholders have to be consulted, informed, trained, involved. It should be expected that the technology is not merely adopted as foreseen by the systems designers. The research team concluded that the Koala project management had followed a technology push approach for implementation of the Koala system, where clients and their relevant social network actors were hardly involved. Consequently, the buy-in from clients for the Koala system varied greatly, from extremely positive via neutral to many rather negative attitudes. See [2] for more details. Starting a marketing campaign for KOALA Care to meet the required numbers could have been an opportunity to change this approach. However, with hindsight, the top down push approach was balanced too late by more bottom up interventions. Effects of Koala in the Care context The research team (investigating Koala in the Care context) performed an extensive investigation as to the number of Koala calls, the time distribution of the length of the calls, the nature of the calls (and especially whether these substituted other care services) and so on. These results were compared with the consumption of care by the control group in order to avoid conclusions that might not be attributable to Koala. For a detailed account of these findings, see [3]. Some of the findings with respect to the call pattern by clients in the Care context are: By far most of the calls took place during normal 9 to 5 working hours Much less calls occurred during the weekends or in the evenings Hardly any calls were at night Calls would normally take less than 5 minutes, with moderate variation Regarding clients appreciation of the Koala system, the majority of the clients was positive, but there is also a minority with neutral or even negative feelings. (This issue is discussed below.) The quality of the care given via Koala is considered appropriate or even good. This opinion is

4 shared both by clients and by the care providing employees (nurses). The usage of the system by clients is highly skewed. Very few clients will call more than once per day, some clients will call weekly, most clients will call monthly or not at all (calls are counted here only if they are genuinely calls for the purpose of getting Regarding clients appreciation of the Koala system, the vast majority of the clients is positive, and there is also a small minority with neutral feelings. Hardly any client s reaction is negative. The quality of the care given via Koala is considered good. This opinion is shared both by clients and by the care providing employees (specialists and nurses). The usage of the system by clients is rather predictable and orchestrated by the specialists. Most clients will call weekly, according to a predetermined scheme. Figure 1. Care providing without and with Koala service). Last but not least, the embedding of Koala in the Care organization was not appropriate. This point is illustrated below. Figure 1 shows the collaboration pattern within the Home Care provider in the original situation as well as the pattern, when Koala was added. There is clearly an increase of complexity and there is confusion about the division of work and (despite of the fact that the responsibilities remained with the coordinating nurse). Effects of Koala in the Cure context The research team also investigated Koala in the Cure context. However, the protocols agreed with the various specialists in the case of Cure patients were much more strict than in the Care context. Moreover, it should be borne in mind that the patients in the Cure context were selected for Koala by the medical specialists. Some of the findings with respect to the call pattern by patients in the Cure context are: Nearly all calls took place under normal working hours Calls with Cure patients are shorter and have less variation than calls with Care clients. This can be explained by the fact that most calls are planned calls for a periodic review of progress monitoring Organization of the Medical Service Centre Within Koala, the Medical Service Centre plays a key role. This center is 7x24 hours per week available. When clients call for assistance, this center is the first point of contact. However, Koala did deliberately not specify or restrict the services to be requested by clients. The rationale behind this approach was to allow clients to ask for services with a low threshold in order to allow the demand for services to be experienced. In particular, clients were not discouraged to call in case of loneliness or small inconveniences. This approach is also reflected in figure 1. Basically, Koala was prepared to provide comprehensive care consults by experienced nurses, who should even be trained in nursing for each of the three types of medical specialists involved in the Cure services. However, these well-trained nurses are seldom addressed to fully use their competence. Despite of the fact that the nurses were not always working at their competence level, the work was perceived as interesting. The nurses considered the Koala system to contribute to the client s well being, and (as mentioned earlier) the quality of services delivered was considered as good. The requirement to be available 7 x 24 hours a week, combined with the high level of skills required for the nurses on duty, implies a considerable cost level. Consequently, the Medical Service Centre is the major fixed cost component of the Koala pilot. Cost-benefit analysis One of the obvious issues in making a cost-benefit analysis for telecare is the fact that the benefits are not

5 gained at the same place as where the costs have to be made. In the particular case of Koala, the costs are made in the Medical Service Center and in the clients homes, and the benefits lie with the clients as well as with the providers of care and cure services. For this reason, the cost-benefit analysis has been done for the society as a whole. Contrary to a popular belief, video-based telecare does not easily pay off. In the analysis for Koala, given below, it is doubtful whether the investment in monetary terms is justified. However, in terms of labor hours saved and in terms of clients well being there is reason to continue with video-based telecare. In the case of Koala Care, a first analysis is required for the investment of equipment in an individual client s home. Moreover, monthly costs of communications should be balanced by monthly savings in home care costs. In order to estimate these savings, the care providers had been asked to log each call of a client, and determine whether this call would have given rise to a call or visit if Koala would not have been present. Such a service might e.g, be a consultation of the client s GP or a visit of a nurse to the client s home. In the first case, Koala saves the doctor s time, whereas in the last case the savings consist of reduction of time spent by care providers due to the fact that they do not have to travel. These data were cross-checked with the medical consumption of a control group of the care clients. It turns out that about 40% of the client s calls are leading to a reduction of medical services. However, because the vast majority of clients only used Koala infrequently, for these clients the investment could not be justified. Only for clients who use Koala several times per week it is worthwhile the effort. An exception can be made for clients who live in remote areas, where time of transportation becomes a dominant cost factor. In case of Care clients, in order to establish the break-even point for the investment in the medical service center the number of clients were calculated which is needed to reach break even. Of course, the workload associated with this number of clients should still be within the limits of the staff of the center. It turns out that telecare in the Koala setting can be made economically feasible, but that a substantial region of clients has to be covered in the order of magnitude of ten thousands. As for the Cure patients, an economic analysis is dependent on the nature of the disease and on the exact way in which the protocol of a specialist in a hospital proceeds. However, the savings in economic terms are limited. The real economic business case should be based on reduction of the time that the patient resides in the hospital, and a reduction in medical consults. The first aspect requires that video interaction can be installed in 24 hours. Further information and in particularly quantative data are available in the Koala report [3]. 6. Discussion Implementation The difference in acceptance of Koala between Care clients and Cure patients is remarkable. Although no formal implementation research was performed in the context of Cure, the influence of the medical specialist is obvious. This corroborates the finding that introduction of new technology should be based on a stakeholder analysis and that important other parties may contribute to acceptance. Koala on the Care context The ambition of the Koala pilot was high. Probably, the initiators did not expect that it would be difficult to find interested clients and that clients would not have a favorite attitude. This leads to a situation where Koala has to be actively promoted and sold. The fact that the Koala service was not clearly specified in advance has quite a few drawbacks. First of all, clients and care providers may easily be confused about what is offered by Koala and what is not offered. Second, the Koala offering was not well embedded in the offering of the home care provider, which increased confusion amongst different care providers and increased coordination costs. (as illustrated in figure 1). Third, it is not easy to measure savings via substitution, because the target service to be substituted is not specified. Koala in the Cure context In the cure context, Koala was a success from the point of view of medical care and patient s well-being. However, the economics hardly worked out positively. Again, this point may become different if the Koala service can be installed within a day. Medical Service Center A medical service center is a substantial investment. The services provided by the organization, the protocols followed, the competence and skills required should be carefully designed. A decision such as to provide 7x24 hours is a major design choice. The center can be conceived in a range of options between: A light-weight first point of communication with no other task than to connect a client to the right care and medical service provider

6 A full service provider of all nursing and medical care and even domestic services for which personal vicinity is not required. 7. Lessons learned It should be borne in mind that these findings are all based on the specific situation in The Netherlands. Whether these results can be generalized, is still to be investigated. Implementation The implementation research performed in the context of care clients and care service provided has a clear message: when implementing new technologies, such as video-based telecare, an active strategy for adoption of the technology should be followed. Technology push is not the way towards success. In the case of Koala, the difference between Care clients and Cure patients is remarkable: the medical specialists created a positive attitude in the case of cure patients. The difference is attributed to the active and persuasive role of the medical specialists in the cure context. Video-based interaction in the Care context Video-based interaction in the Care context is only economically viable for clients with a high demand for services (i.e. several calls per week), or clients living in remote areas. However, if the costs of the equipment and connections become lower, the economics would allow more and more clients to be connected. Moreover, there is all reason to include other first-line healthcare service providers also in the telecare system. Video-based interaction in the Cure context Video-based interaction in the Cure context may lead to better medical service: continuous monitoring is possible, and contact between specialist and patient occurs only when necessary. However, the added value of video as compared with telephone is not always obvious. Video-based interaction is not immediately economically viable, unless intramural cure in the hospital can be reduced. This requires technology that can be delivered within 24 hours. The role of the Medical Service Ccenter The medical service center should have a clear mission, with associated a clear set of services offered. If these services require medical competence, it should be clear which services are substituted, and then these services can be paid for by e.g. insurance companies. Moreover, the mission and services portfolio determine whether all services should be available during 7x24 hours, and which skills the nurses should have. Moreover, the work of Medical Service Center should be seamlessly integrated in the processes and protocols of the services provided to the clients and patients. 8. Conclusion Telecare is likely to become a widespread phenomenon in future health care. It has the potential to save time of clients and of health care providers. In addition, it may create the possibility to deliver health care services precisely when needed. This contributes to social welfare. Nevertheless, video-based telecare is not immediately viable from an economic point of view. Video-based telecare also leads to a change in the responsibilities of parties involved in providing care. For example, it may bring the medical specialist into the living rooms of clients, which was the domain of home care services and first-line medical workers in earlier days. Therefore, telecare is an interesting subject from a business research perspective in health care. Video-based telecare is also interesting from a technology perspective. It interferes with home entertainment technologies and with domestic developments. It is part of a development in society where social life becomes partly virtual. It will remain an element in a portfolio of technologies to be considered in the context of enhanced independent living. For these reasons, video-based telecare remains a subject to be researched. A living lab approach is a useful research setting as a follow-up of insights gained from Koala. 9. References [1] Barlow, J., Bayer, S. & Curry, R. (2006) Implementing complex innovations in fluid multi-stakeholder environments: Experiences of telecare. Technovation, 26, [2] Boonstra, A., Offenbeek, M.A.G. van (2009) Towards consistent modes for e-health implementation, Analysis of a telecare programme s limited success. Under review. [3] Actual Koala report see In Dutch.