Description of the collaboration
TeleCare Nord was initiated in January 2012 by the Region of Northern Jutland in Denmark. The collaboration focused on telemedicine for patients suffering from Chronic Obstructive Pulmonary Disease (COPD). The project ran to June 2015 and was the first full scale project with telemedicine in Denmark (TeleCare Nord, 2015).
The collaboration involved an executive project secretariat, a steering group, a business committee and four working groups, and included the Region of Northern Jutland, the 11 municipalities, General Practice and the COPD patients Association. The aim was to have all actors related to COPD patient care represented. The organization of the project did not rely on contractual agreement. Instead, it was based partly on a business case that explicated the expectation that all municipalities and the hospitals were committed to make the new telemedical service work. Patients with COPD were included during the development of the solution and the IT.
Impact of ICT on collaboration
ICT play an important role in this collaboration on telemedicine. TeleCare Nord involves a TeleKit hardware, which consists of a tablet, a body measuring weight, a saturation meter and a blood-pressure meter, and a software solution accumulating and transferring patient data. All the three main actors have access to the health measurements registered by the patients. The TeleKit’s software is mobile and inspired by an earlier project from the Central Denmark Region, which was centered on telemedicine for heart patients. TeleCare Nord provides a platform for both the citizens and for the clinicians.
The local patient database KIH (clinical integrated home monitoring) ensured that the hospitals, municipalities, and the general practitioner all had access to the same data (in the KIH database). This joint access allowed actors to easily notify each other and recommend courses of actions with regard to individual patients when they (the hospital staff, municipal nurses and the GPs) notice a change in the patient’s data. The ICT system has also contributed with a greater professional respect between the actors and more consultations (TeleCare Nord, 2015). Furthermore, the TeleKit has made it easier for the health professionals to communicate with the citizens and check-up on their health measures without having to meet in person, which has improved the citizen’s knowledge and participation (Ibid.).
Impact of collaboration on efficiency
When the project finished in June 2015, 1,225 COPD patients had participated and many have examined TeleCare Nord in order to recommend whether the project should be translated onto other areas of the health sector or other regions (TeleCare Nord, 2015). The project proved successful in establishing a strong collaboration and trustful relationship between the health sector actors and substantially improved intersectoral working procedures. The project also resulted in fewer hospitalizations.
In spite of this, the project did not convincingly reduce costs. In the initial business plan the municipalities envisaged substantial savings due to the expected reduction of COPD patients admitted to hospital for acute treatment (Region Nordjylland 2012). This saving has to do with the general rule that all municipalities co-pay 25% of the costs (held by the Region) when their citizens are admitted to hospital. The project organization itself estimated that savings for the most severe cases of COPD amounted to 7.000 DKK per patient per year. These savings were mainly the result of a reduced number of hospital admissions and a reduction in the time that patients were admitted (TeleCare Nord 2015, p. 5). However, the hitherto most thorough randomized controlled trial of the TeleCare Nord project, comparing costs and increased QALY for randomly selected COPD patients receiving telemedicine compared to a control group receiving the usual care revealed that costs was higher for the telemedicine service group and that improvement in QALY were negligible (Udsen et al 2017). It added that telemedicine is only likely to be cost-effective for the most severely ill COPD patients.
In terms of health outcomes, a user survey conducted among the participating COPD patients showed that 72% felt safer and better capable of managing their illness and 50% reported that they were now better able to recognize and react to detritions in their health (TeleCare Nord, 2015). This is also reported by the nurses connected to the project. Lastly, TeleCare Nord proved beneficial enough for a national roll out to be agreed upon.
Impact of collaboration on red tape
The TeleCare Nord has functioned quite well and has so far been able to overcome / work around administrative and legal obstacles. However, not all of these issues have been permanently settled. The obstacles include data sharing between the three main authorities in the collaboration, half-hearted support and engagement from the general practitioners, the use of the national electronic identity key when accessing patient data (NemID), and conflicts with mandatory professional guidelines. The project showed that there was a decreasing need for controls and check-ups from the hospitals. However, the clinical rules and guidelines dictated a minimum frequency and therefore limited the success and results of the project. Furthermore, in the beginning there was an uncertainty about who was responsible for delivering and financing the services. This is not yet solved, at least no formalized agreement has been reached. The solution was a common set-up with a collaborative secretariat who has the responsibility for orchestrating the services.
Implications and lessons learned
The TeleKit has made it easier for the health professionals to communicate with the citizens and check-up on their health measures without having to meet in person, which has improved the citizen’s knowledge and participation (TeleCare Nord, 2015). Telecare Nord was proven especially beneficial for patients with severe COPD, and the criteria of inclusion has therefore been changed accordingly. Based on the experiences of TeleCare Nord, a business case was made in 2017 for the national roll out of telemedicine for COPD patients (PA Consulting Group, 2017). The business case estimated annual net saving to be 202 million DKK, on the condition that only COPD patients with severe symptoms are targeted (PA Consulting Group, 2017). For groups, with less severe symptoms the net gains are likely to be much smaller. The main driver for these savings is the reduction in the number and duration of hospital admissions. Finally, having three authorities running the service meant that accountability was not clear, in particular who would be responsible if mistakes occur during patient treatment. This was also mentioned as a possible issue in the business case from 2012 (Region Nordjylland, 2012).
You can read the full case study here.
To read more about this research, see D9.1 – A Review of Efficiency and Red Tape in Public Sector Collaborations report.
PA Consulting Group (2017). Business Case for the nationwide rollout of telemedicial home monitoring for citizens with COPD. Retrived from: https://en.digst.dk/media/14147/3103bda-business-case-del-1-final-version-english-formatted-2.pdf
TeleCare Nord (2015). Afslutningsrapport – telemedicinsk storskalaforsøg i Nordjylland. Retrieved from: https://rn.dk/-/media/Rn_dk/Sundhed/Til-sundhedsfaglige-og-samarbejdspartnere/TelecareNord/Telemedicin-til-borgere-med-KOL/KOL-projekt/Evaluering-og-forskning/Fra-tro-til-viden---afrapportering/TeleCare-Nord-afslutningsrapport-18-11-2015-final.ashx?la=da
Region Nordjylland (2012). Business Case TeleCare Nord. Retrieved from: https://rn.dk/sundhed/til-sundhedsfaglige-og-samarbejdspartnere/telecare-nord/telemedicin-kol/nordjyske-erfaringer-med-telemedicin-kol/-/media/Rn_dk/Sundhed/Til-sundhedsfaglige-og-samarbejdspartnere/TelecareNord/Telemedicin-til-borgere-med-KOL/KOL-projekt/Mere-information-om-projektet/TeleCare-Nord-Business-Case.ashx
Flemming Witt Udsen, Pernille Heyckendorff Lilholt, Ole Hejlesen, Lars Ehlers (2017) Cost-effectiveness of telehealthcare to patients with chronic obstructive pulmonary disease: results from the Danish ‘TeleCare North’ cluster-randomised trial, British Medical Journal Open, 7 (5). URL: https://bmjopen.bmj.com/content/7/5/e014616.abstract
About the authors
Peter Triantafillou, Roskilde University
Signe Elmer Christensen, Roskilde University