Telecare

Telemedicine as support for chronic disease management

Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory conditions in adults in the developed world and poses an enormous burden to society, both in terms of direct cost to healthcare services and indirect costs to society through loss of productivity.

Nearly 1 million people in England and Wales are diagnosed with COPD every year, with the NHS spending around £818 million a year on it.

COPD is thought of as the ‘Cinderella disease’ in medicine and it has received scant attention in comparison to heart disease, asthma and lung cancer. Attitudes are, however, beginning to change and there will be a national service framework for COPD in 2008-9 which will recognise that chronic ill health and death due to COPD are preventable in most cases.

But despite this backdrop of difficulties and barriers, the COPD Community Service at Central Surrey Health, which covers a catchment area of 50 square miles with a caseload of 300 terminal COPD patients, is now witnessing significant improvements in patient care, including the reduction in the severity of exacerbations, hospitalisation, maintained lung function and subsequent quality of life for those with COPD.

COPD services – goals and objectives

In 2001, I was employed as a community respiratory nurse specialist, primarily to see patients who were unable to attend hospital appointments, and to act as a liaison between primary and secondary care. As the caseload increased to 150 patients and with over 70 requiring home visits on a regular basis, it was becoming increasingly problematic to monitor patients effectively and, subsequently, to keep them out of hospital — simply because of the difficulty in searching for up-to-date information in the patients’ paper notes.

A change of approach was required and in 2004 the COPD community service was initiated by East Elmbridge & Mid Surrey PCT to address these issues.

The aim of the service was to provide high quality personalised care to patients at home, therefore reducing the over-reliance on secondary care. There was also a desire to change the emphasis from a reactive, crisis management service to a more proactive preventative partnership approach and to promote multidisciplinary collaboration.

With limited resources, the following objectives were set:

• people with severe disease were to be seen at home;
• patients and their carers were to be fully informed about their disease by the nurse and given advice on self-management for exacerbations and educated about the use of oxygen and safety precautions;
• patients and carers were to be taught to recognise changes in condition and encouraged to contact the respiratory nurse or GP directly;
• we pledged to improve ‘patient empowerment’, to encourage patients to take an interest in their own disease and day-to-day care; and to
• reduce patient admissions to hospital.

To achieve these objectives we had to find a more-effective way to monitor patients by finding suitable technology that could be set up in the patient’s home while enabling the development of an electronic patient record.

In 2004, I heard about a system called Excelicare Direct, a software programme developed by AxSys Technology. The system was being used at Glasgow Royal Infirmary for the home monitoring of patients with rheumatoid arthritis. Through the use of this computerised telephone monitoring system staff could detect any deterioration in the patient’s condition without having to physically see them. This fulfilled the criteria required for the COPD patient group.

How the system works

Excelicare went live in September 2004 and now provides a patient-focused telemedicine solution for the remote assessment and monitoring of 250 registered COPD patients. It has been set up to ensure that the correct treatment protocols are followed while documenting the clinical care pathway for each patient.

The system works by patients placing a call to the system whenever their symptoms change. The patient dials a dedicated number and enters their secure PIN number and date of birth, which identifies them to Excelicare and opens their individual patient record. The system welcomes the patient by name and delivers a personalised questionnaire over the phone, relating to their signs and symptoms.

The patient responds by pressing the appropriate touch tone keys and all responses are recorded into forms in the patient record as Excelicare has the power to interpret a patient’s responses. After the call, a report is created which generates an alert if it has detected deterioration in the patient’s condition.

This alert is automatically sent to the respiratory nurse via a text message. The nurse then calls the patient to give appropriate advice or, if necessary, to make a home visit. After an incident, the nurse will enter her clinical notes directly into the system and clear the alert.

Today’s model of care for COPD patients dictates that there is a change of emphasis from crisis management to preventative partnership; that the patients find the system acceptable, although nothing can take the place of a personal visit; frequency of home visits is decreased, allowing more patients to be managed by the same number of nurses and the use of electronic monitoring is an adjunct to home visiting.

Also that embedded rules and alerts in the electronic patient record ensure that manual intervention occurs when required; type and extent of data capture at home is not restricted; patients become more actively involved in their own treatment; they are given speedy access to their nurse for advice and care; the inconvenience, cost and time incurred in travelling to clinics for investigations or to see the consultant is minimised.

Results and benefits

Results published demonstrate that considerable improvements have been made since the establishment of COPD Services and to date those benefits include:

• the maximum response time for answering an alert is now 15 minutes;
• the severity of exacerbations has been reduced, which is helping to maintain lung function and subsequent quality of life;
• since starting the Respiratory Service in 2001, hospital admission for patients seen at home has fallen by 40% and the average length of stay in hospital; has been reduced to 5.9 days, representing a 26% reduction in bed days;
• the target of saving 10% of admissions every year from 2007 is now achievable;
• considerable cost savings have been made through the outpatient nurse-led clinics. In the first eight months of the Service starting £28,620 was saved for the PCT by moving the clinics to community hospitals from the acute trust;
• consultations made by phone or email have increased;
• the system supports integrated care and enables establishment of clinical networks;
• quality data can be entered from any site and care can be delivered from anywhere; and
• more patients can be managed without having to increase the number of staff.