Cloud Computing / Tele- Health in a Novel Integrated CHF Disease Management Program: The Israeli Experience

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1 Cloud Computing / Tele- Health in a Novel Integrated CHF Disease Management Program: The Israeli Experience Haim Silber MD Programs Initiator Maccabi Health Care services and Gertner Institute, ISRAEL

2 Background CHF affects up to 20% of the rapidly increasing population of persons aged 65 years and over Heart failure is a chronic, progressive disease that is characterized by frequent hospital admissions and ultimately high mortality rates

3 CHF in Maccabi Health MHS is the second largest HMO serving 1,700,000 members (23% of the population) throughout Israel There are 6,000 CHF patients. Half of them are hospitalized once a year On average there are 22 Patient Primary Care Encounters a year Maccabi Healthcare Services, Sheba Medical Center, and the Gertner Institute created a

4 Study Objective To evaluate the feasibility, efficacy and cost-utility ratio of a comprehensive, community disease management (DM) program in moderate to severe *-NYHA stage III or IV

5 Study Design An open-labeled clinical trial with random allocation of patients to either usual care arm or to DM arm

6 Components of 1. Regional Heart Failure Centers Baseline evaluation and delineation of treatment plan by cardiologists DM by nurses for patients with unstable disease* 2. National Call Center Operated by trained HF nurses, functioning as Disease Managers for patients with stable disease* 3. Tele-monitoring of heart rate, body weight and blood pressure at patients

7 Study Outcome Measures Major All-cause mortality or readmissions for exacerbation of HF Minor Quality of Life (SF-36) Depression (PHQ9) Functional Capacity (6-minutes walk test)

8 Intervention arm Disease Management Tele-Monitoring HF call center operated by HF specialist nurses Patient Consultant cardiologist Management of unstable patients Case manager Regional HF Center multidisciplinary team Primary care physician (PCP) 8

9 Tele-monitoring 1000 Primary care physician 10 Regional centers Phone Lines HUB Information Systems RF Hospital (partial) Call center Devices: BP Pulse Weight Patients home

10 Tele-monitoring

11 Video Conference (100)

12 Tele-monitoring Results are Integrated to the EHR

13 Daily Report of Abnormal Measurements

14 Integrated Data Patient Database Management Sophisticated storage and manipulation of all patient data. Automatic Real-Time recording and reception of patient-transmitted indices. Automatic Comparison to Medical Protocol

15 One Week s Activity Abnormal Results Patients Phone Calls EHR managemen 28 0 Sun Mon Tue Wend Thu Fri

16 Results of 215 Nurses Worsened Non Compliant Weight above 2 Weight kg loss 2 kgweight loss 1 kg

17 Follow-up All patients are evaluated every 6 months Mean follow-up period: 24 months Study duration: 36 months

18 Current Status Treatment Protocols were established Qualified nurses were recruited and trained Designated HF patient electronic record was designed and implemented 10 Regional HF Centers were opened 1350 patients have been recruited and randomized

19 What are the innovations? A new system of management of chronic diseases with proactive approach Provision of multiple, integrated services DM with comprehensive care by a variety of health care professionals, as a support for the primary practitioner Healthcare according to designated protocols/ guidelines Use of innovative technology to effectively assess

20 Lessons To Be Learned The Primary Care Physician Has the main responsibility treating the stable patient The call center should recognize the first signs of decompositions Personal contact is strengthened using video Conference One lead ECG monitoring should be

21 When Will the Results be Published? Recruitment of patients has ended To our knowledge this is the largest DM randomized trial applying telemedicine in CHF ever done An average follow up of 24 month due in 2012

22 Thank You

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