DITIS: VIRTUAL COLLABORATIVE TEAMS FOR HOME HEALTHCARE

1. DITIS: VIRTUAL COLLABORATIVE TEAMS FOR HOME HEALTHCARE Andreas Pitsillides1, Barbara Pitsillides2, George Samaras1, Eleni Christodoulou1 1University of Cyprus 2PASYKAF http://www.ditis.ucy.ac.cy

2. Agenda • The problem and the need - General Scope • DITIS history and funding • Added value • DITIS Architecture • Qualitative and Quantitative impact • Problems faced • Participation and usage of service • Lessons learned • Accomplishments • Enhancements and Future goals

3. Since 1994 Cancer centre (located in Nicosia) Hospice (located in Nicosia) PASYKAF HOME-CARE Coverage island wide Government Hospitals located in main cities (oncologist once a week)

4. DITIS idea: Support virtual collaborative team through IT Co-operative model of the caring team • patient and • nurse(s) • general • Palliative • family • practitioner • care specialist • social • hospital (records) • worker • oncologist • physiotherapist • psychologist • others that • may join • priest • pain • the team (e.g. • volunteer • consultant • surgeon, radiologist) Short Film

5. DITIS - Goal Improvecitizens’ quality of life for both healthcare provider and patient. • Support the healthcare team for a more effective service in the homecare. • Continuityof care, everywhere the patient’s is with the use of a common electronic health record. • Access of information from anywhere - anytime • Fast and effective decision making from collaborativehealthcare teams that are not in the same physical place (Virtual Teams).

6. Supporting Organizations • UCY • Development of the system software, • UCY has an active policy for spinning • off technology, spin-off company • - System maintenance, operational support, hosting service • PASYKAF • End user, medical know-how provider, • mediator Initiators/Drivers Main Supporters CYTA Telecom infrastructure provider Oncology Centre End user

7. DITIS History • 1996 – The initial idea for cancer patients care is presented in a conference • 1998 – Work initiated, RPF Grant • 2000 – DITIS I deployment starts at PASYKAF • 2002 – Goals set for phase II • 2003– Microsoft Research Labs grant • 2003 –Larnaca fully supported by DITIS operation • 2004–Successful grant application for DITIS continuation • 2004 – All district offices main data entered, users are trained • 2005 – Larnaca team starts testing DITIS as true virtual collaborative team • 2005 – Direct connect with the Bank Of Cyprus Oncology Center • 2006– DITIS connected with cardio patients of polyclinic LITO through 2 EU projects • 2009– Cyprus wide use of DITIS PMS system

8. DITIS - Funding • Overall Budget > 1.5 Million Euro • RPF Grant 1999-2001 • RPF Grant Continuation 2004-05 • The Cyprus Development Bank 2001 • Microsoft Research Labs Cambridge 2003-04 (First funding for research project in the area) • University of Cyprus (from1999 till today) • PASYKAF – Technical knowledgeand pilot run (from1999 till today) • CYTA – infrastructure (from1999 till today) • 2 EU E-Ten projects adopting DITIS technology (2005-2007) • Other support

9. Added Value • A comprehensive solution that brings state-of-the-art mobile technologies in support for emerging healthcare practices focusing on virtual healthcare team collaboration • Rich functionality, highly adaptable user interface, secure communication, open and highly interoperable system • Enables increased efficiencies that can translate in high quality service and lower costs

10. DITIS Architecture Overview

12. Main System Components • A variety of options for system role based access using • Desktop (any PC with Windows OS) • Mobile Devices • Web-based (any phone with a web browser capability) • Standalone (smart phones such as the SonyEricsson P910, the QTec) • System components are built to support these through tailored secure role-based interfaces

13. DITIS Features • Comprehensive and Customizable Patient Management System (PMS) • Collaboration Engine • Communication Engine; includes Messaging and Alert Service • Application-specific Auditing Cancer Cardio

14. A rich user interface for desktop component Screen Shot

15. Extensive Reports Can provide comprehensive reports, including summarisation, but also drill down to detail, e.g. printouts of patient continuations Example printout

16. Mobile Device access Access to patient information, including on the spot entry, plus customised team collaboration software

17. Benefits - Qualitative Impact • For the patient – quality of life • Opportunity to stay at home – Resting assured that should a change in condition occurs, the entire team is virtually there • For the healthcare professional – continuity of care • improved communication and collaboration • 24/7 access to patient information • tools for decision making • For the home care provider organization – evaluation • audit and statistics to help with planning, training and research • can support lobby for more support • For the healthcare system at large – directions for better healthcare • Opportunity to gather vital statistics that help with policy making

18. Benefits – Quantitative Impact Regarding Cancer patients is Cyprus: Paper case study of potential homecare savings • Indicative yearly cost without homecare (hospital based): 1.344.747 Euro • Number of patients: 210 • Cost per month per patient in the hospital: 1067 Euro • Reasons • Indicative yearly cost with home care (for similar level of care): 124.882 Euro • Number of patients: 210 • Number of visits: 4000 • Cost per visit: 31.22 Euro Above estimates exclude medicine expenses

19. Quantitative Impact of DITIS • Indicative yearly running cost estimates without DITIS: • Total cost per nurse (excluding overhead): 53,570 Euro • Indicative yearly running cost estimates with DITIS (approx. savings: 40%): • Total cost per nurse: 35,141 Euro • Cost per nurse (excluding overhead): 32,141 Euro • Yearly maintenance, operational support, hosting, Telecom and Internet access cost: 90,000 Euro. For PASYKAF considering 30 professionals the cost per nurse is estimated at 3000 Euro per year

20. Quantitative Impact of DITIS Cost savings are due to reduction of: • healthcare staff unnecessary visits to the head office • preparation work prior and after the visit in the head office • Access and updating patient data • communication/collaboration time among healthcare staff

21. Level of system adoption • Patient Management System (PMS) – considered essential • adopted by PASYKAF Cyprus wide 6 years after development and 3 years of paperless operation in Larnaca office • achieves paperless operation • full functionality is yet to be realised • Mobile access – considered beneficial • has been used in many instances when access on the spot was necessary • only then has it been considered an essential component by the end-users • BUT trust on availability not present at the moment to allow full reliance • Collaboration aspect – has potential • potential confirmed by small scale pilot • but, to be used organisation-wide • need to have PMS and Mobile access fully adopted and used (by the whole team)

22. Participation and usage of the service Patient Management System (PMS) aspect • PMS system in full use (Larnaca): 2004 • PMS system in full use (Cyprus wide): 2009 104 villages Paperless status achieved Cyprus wide now

23. Usage of collaborative aspect of DITIS Currently, has not reached its full potential (despite pilot shown potential benefits): • Inhibiting factors in adopting full collaborative model include: • Technology • Telecommunication infrastructure; lack of island wide, predictable connectivity, whenever needed • Mobile device technology still immature • Mobile device display (perhaps) too small, especially for admission -- new NetPC devices appealing • Constant need for device (and sometimes program) upgrade - costly

24. Usage of collaborative aspect of DITIS • Human factors • Training took longer than anticipated • Management and staff commitment for uptake was initially slow • Cost • Lack of funding (relied on external research grants) • Can be prohibitive. Need to divert hard earned money to a system whose benefits cannot be fully quantified upfront, with also some risk with regard to its uptake

25. Problems faced By Health Professionals • Clinical working process reorganization • High user expectation and ‘lack’ of understanding of complexity of implementation • Healthcare team high workload • Nofunding for a dedicated healthprofessional to be involved fully in its development • Health professionals phobia of technology (easing off)

26. Problems faced By Health Professionals • Constant upgrade requiring technology change and re-training • Healthcare team often not able tomanage IT problems • Time taken in developing TRUST between the (virtual) team members as well as team members and technology • Missing Legal framework for ePrescription • Missing link to other healthcare systems, e.g. Oncology centre and government hospitals

27. Problems faced By Management • Management commitment slow -- essential in adopting policy and ‘enforcing’ its use • Never had ‘luxury’ to set up a proper deployment strategy • Patience (!?) --- it took 6 years to adopt PMS by all -- this figure, however, could had been much less • Perseverance (especially during the trial phase) Recall Electronic Health Record example from UK – it turns out to be extremely complex

28. Problems faced By IT Team • Unreliability of Telecommunications infrastructure (GSM/GPRS) • Constant technology change requiring upgrade of system, re- education of Health Care Professionals, financial input of new hardware • Substantial IT support to medical personnel in different districts • Research funding limitations (small local govt. grants / sponsors) • Research associates high resource investment and constant staff turnover • Commercialization of system

29. Concluding remarks • DITIS has changed clinical work processes at PASYKAF • more efficient and effective • Improved Quality of life for both patient/family as well as health professional allowing a more flexible workload • Availability of audit not previously available • The implementation would have been easier and more efficient had their been • Continuity and adequate level of funding • Dedicated health professional to advice IT team • Healthcare team had their own IT support within the organisation • User involvement from the very first development stage

30. Accomplishments • Adoption by PASYKAF. Paperless operation in Larnaca since 2005 and now Cyprus wide • Used in 2 EU funded e-TEN market validation projects (HealthService24, LinkCare) for cardiac patients • Proposed as the software to be used by Ministry Of Health homecare pilot program • Proposed as the software to be used for homecare of patients with acute respiratory failure (Nicosia hospital) Finalist at the 2003 eHealth Ministerial Conference 7th at the WSA competition The only non-IST funded project participating in the cluster project MEMO Cambridge Microsoft Research Labs grant Publications, book chapters, conference presentations

31. ENHANCEMENTS and FUTURE GOALSIntegrated Homecare Monitoring PlatformMultiple types of Homecare services

32. Promising solution This is the reason we continue to work so hard to keep people at home We KNOW DITIS can make the work more efficient while offering continuity of care to people at home.

33. Questions

34. Sponsors Other Sponsors www.research.org.cy

35. NetPC example Model Features: 8" display with XBRITE-ECO™ LCD technology, 2GB RAM, 60GB HDD, 1.5 lbs., GPS, integrated mobile broadband (3G) Price from a few hundred Euro fits right in your purse.

36. Electronic Health Record UK example ‘Just a few weeks ago, Martin Bellamy, head of the National Health Service (NHS) National Programme for IT (NPfIT), the UK's national electronic health record implementation program, was promising that by this time next year, EHR systems will be routinely delivered to NHS hospitals.’ Posted by Robert Charette on May 6, 2009 10:30 AM UK Electronic Health Record Roll-out Causes Pain "Heartache and hard work." That is how Andrew Way, chief executive of London's Royal Free Hospital, described the hospital staff's experiences with the electronic health record (EHR) system that it received under the UK's £12 billion plus National Health System's (NHS) National Programme for IT. Posted by Robert Charette on February 15, 2009

37. Supplementary slides

38. DITIS Modularity Mobile Module Desktop Module Web Module Database DITIS

39. DITIS Modules • Desktop Module • Full functionality • Multi-modal user-friendly interface • User customizability • Web-Mobile Module (any browser enabled device) • Customized functionality (for organization’s needs) • Light interface (capable to load on mobile devices) • Standalone Mobile/Smartphone Module • Customized functionality (for organization’s needs) • User-friendly interface • Offline local database

40. A rich user interface for desktop component Screen Shot

41. Desktop Module

42. Web Module Sessions Sessions Nurse Interface Doctor Interface Nurse Doctor Login Page Oncologist Oncologist Interface Patient Interface Secure Connection Internet … Patient

43. Web Module

44. Standalone Mobile/Smartphone Module

45. Mobile Device access Alert Service (SMS) Medication management

46. Web Module Sessions Sessions Nurse Interface Doctor Interface Nurse Doctor Login Page Oncologist Oncologist Interface Patient Interface Secure Connection Internet … Patient

47. DITIS Collaboration • Collaboration is achieved using the following components • Virtual team management • Workflow engine • Collaboration engine • Messaging service management • Alert service

48. Workflow Engine • Incorporates organization specific actions into DITIS • Actions are recorded in DITIS through an organization administrator • Automatically executed in some scenarios

49. Alert Service Alerts are sent to both patient and personnel according to the needs of the organization Three types of alerts so far: • Appointment alerts • Notify the personnel and patient for an upcoming appointment • Medication alerts • Notify the patient that he must take his medication • Diary alerts • Notify professional if a symptom exceeds a predefined threshold Options for turning the alerts on and off