Few Touch Application Services extending a diabetes diary application. Tromsø, North Norway

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1 Scaling up ehealth facilitated personalised health services. WP 2: Personalised health services and patient-centred healthcare for an ageing population Case studies of Personalised Health Solutions and Projects Case Study #3 Few Touch Application Services extending a diabetes diary application Tromsø, North Norway 1 Summary ehealth application, product or project Application area (Service domain) and objectives Target population Target care setting and care organisations Financial model Overview of the application; service functionality and scaling Overview of the deployment / Networking of the Service with other Health-IT services Evaluations and benefits... 9 Version 06 of 5 March 2012 Case Study compiled by: Dr Stephan H Schug, MD - EHTEL

2 Context of the case study: The ehealth Innovation project, supported by the European Commission, develops a European roadmap for large scale co-operating ehealth services that support patients in managing their health and health care. An important aspect of this work is to discover and learn from successful commercial solutions and projects that have already established good practice in ways to involve and empower patients and healthy citizens in illness management and illness prevention. In a second phase the ehealth Innovation consortium focuses on projects that support personalised health services and patient-centred healthcare. The project partners will use this information to draw out common themes that help inform good practice in the design and adoption of personalised health systems, success criteria and lessons learned. 1 Summary This case study is based on a personal ehealth service offered in North Norway. Diabetic individuals use a mobile phone with a diabetes diary application ("Few Touch Application ), a self-help tool that allows e.g. food habits registration, blood glucose data management and physical activity registration. Users may monitor themselves at their discretion and at intervals that they feel beneficial and manageable. So far, using the application and its support service does not necessarily imply that the data is shared with health professionals. Now within the RENEWING HeALTH project the effects of using the service in combination with supervision by health professionals (with or without additional health counselling) are studied. 2 ehealth application, product or project Name of this initiative/service, the lead organisation(s) responsible for it and its role? The service is referenced as The Few Touch Application (FTA). The Few Touch Application (FTA) service has been developed and provided by the Norwegian Centre for Integrated Care and Telemedicine at University Hospital of North Norway (NST). Large scale test in the RENEWING HEALTH Norwegian pilot together with a health counselling module delivered by the University College of Oslo and Akershus (HiOA) The Northern Norway Health Authorities have a strategic focus on diabetes and represent the authorities commitment to find better solutions for diabetes treatment. As part of the project RENEWING HeALTH ( new options have been added to the service, it is extended on a large scale and is currently under evaluation (300 patients/diabetic users will be involved in the trial). RENEWING HeALTH includes 18 services in 9 Regions and aims to consolidate evidence on personal health services and telemedicine for the chronically ill. The methodology applied to build evidence is MAST ( and will cover will cover not only the clinical domain and e.g. health related quality of life for patients, but also the economic and organisational dimensions. 3 Application area (Service domain) and objectives What aspect of health care or wellness management is this application targeting? Does it aim to meet any specific health improvement objectives? 2

3 The aims for the patient are: Better metabolic control, self-monitoring and quality of life by using mobile monitoring tools. Empowerment As opposed to many other telemedicine solutions, the Few Touch Application as such is a self-help tool, the purpose is primarily to support the individual user in his/hers management of his condition - thereby leaving it to the user to decide whether he shares his diary information with health professionals. The basic functions are given in figure 1: Figure 1: diabetes diary functionality The five main elements of the mobile diabetes diary application (the "Few Touch Application ) are: food habits registration, blood glucose data management system, physical activity registration, personal goals setting and general information. Patients have the possibility to self-monitor their blood glucose levels, eating behaviour and physical activities, at a phase and at intervals that they feel are beneficial and manageable. While blood glucose data is automatically transferred to the phone from the blood glucose meter, activity data and food habits have to be entered manually by the user. As part of the Norwegian RENEWING HeALTH pilot, a link to the healthcare providers is added and it is investigated what effect this will have on the perseverance of the patient in use of the tool. This software has been tried out for smaller groups and through several projects with the Norwegian Centre of Integrated Care and Telemedicine. The challenge for the RENEWING HeALTH Norwegian trial is to see how this kind of self-help tool for diabetes self-monitoring can be implemented for new and larger groups, and what kind of support mechanisms a successful implementation may require. Such mechanisms can be automated, like software for technical support and monitoring, or it may be follow-up activities and routines from health care personnel or organisations. 3

4 The Norwegian Centre for Integrated Care and Telemedicine (NST) has run several projects involving mobile technology in designing and testing self-help tools for people with diabetes. Expected benefits therefore are: The patient / user: Better self-control and motivation Better health The health service /society: Less short- and long term complications Lower cost level Better patient service individually adapted The introduction of personalised and technology supported self-management, telemonitoring and health coaching interventions is expected to improve diabetes self-management through increased disease control, and should result also in improvement in terms of health related quality of life. 4 Target population What kinds of patients or citizens are, or will be, included in this service/initiative, in terms of age range, gender, kinds of health or social situation for which individuals will become invited to participate? What is the actual or intended geographical coverage of this application? North Norway is a sparsely populated area with sometimes extremely difficult transportation routes separating patients and health care facilities (see for example the map of the Finnmark region). Honningsvåg Hammerfest 180 km Båtsfjord 248 km 142 km 174 km Vadsø Alta Kirkenes Figure 2: Finnmark, example of sparse health infrastructure in North Norway The Few Touch Application service will be offered to chronically ill patients suffering from Diabetes mellitus Type II. For the RENEWING HeALTH study phase, patients have to fulfil the agreed inclusion 4

5 criteria, i.e. for Diabetes mellitus: DM 2 diagnosed > 3 months prior to enrolment, HbA1c (glycolysed hemoglobin) > 7,0%; capability of filling in questionnaires in Norwegian language, capability to use the devices provided and being cognitively able to participate. 5 Target care setting and care organisations Health care organisations that are, or will be, involved in sharing or supporting care within this initiative. If this application is targeted directly for autonomous citizen use, will any other organisation (e.g. insurer, health charity) be supporting the individual participants? Health care in Tromsø, Norway is provided by a public health system and accessible to all users without charge. Thus financial benefits have to be achieved and accessed on the system level. The service combines a mobile tool (the Few Touch Application) with technical and cognitive support. After the various testing periods it is expected that the service will regularly used by patients as well as by healthcare services. The trial will be carried out together with a partner for the Norwegian pilot, the Oslo University College, who will be responsible for the cognitive support element, while the Norwegian Centre of Integrated Care and Telemedicine will be responsible for the FTA tool. Figure 3: Comparison of one control and two FTA service options The additional health counselling intervention is based on principles from cognitive behavioural therapy, and the diabetes nurse is using Motivational Interviewing 1, and the Transtheoretical Model (Stages of Change model) 2 when counselling the patients by telephone. In the practical development of this low-intensity treatment intervention, we are using problem-solving models with, for example, identification of the patients the problems, identifying possible solutions, analysing strengths and 1 Miller WR & Rollnick S. Motivational interviewing: preparing people for change. 2002, New York, Guilford 2 Prochaska JO, DiClemente CC & Norcross JC. In search of how people change. Applications to addictive behaviours. The American Psychologist, (9): p

6 weaknesses, selecting a solution, planning implementation, implementing, and reviewing all together with the patients 3 4. Technically, for the health counselling, the SMS based secure dialog ( HelseDialog ), which is a standard tool delivered by a Norwegian software supplier, is integrated along with the FTA tool. 6 Financial model How is this service/initiative funded? For example this might be supported completely by a public health system and be accessible to all users without charge, established through a grant (e.g. research, ministry, charity), sponsored by industry or insurers, purchased or subscribed by individuals or healthcare organisations, or a mixed model. If possible please indicate the size of any grants or budgets or costs, and indicate if these figures are for a start up or the intended sustainable model. Health care in North Norway is provided by a public health system and accessible to all residents without charge. Thus financial benefits have to be achieved and accessed on the system level. While the service is in the testing phase, all elements are funded by the Norwegian Centre for integrated Care and Telemedicine and its project partners with the support of European project funding. For a large scale deployment, a commercial model is under consideration. That means that the diabetic individuals would rent the equipment and will have to pay service charges for using advice and counselling. 7 Overview of the application; service functionality and scaling Overview of the functionality of the service/application: What specific health or healthcare scenarios it is used for, who are its main users, what kind of data does it collect and provide, what services does it offer its users. If possible, please paste some screen shots at the end of this document, and/or include a web site reference for us to look at [include any documentation you have about the application as an attachment] The Few Touch Application has as one primary objective to enable better insight and disease control for diabetic subject. Besides the monitoring functionalities also health counselling is offered to the users of the service. The Health counselling module is technically based on HelseDialog a module for secured SMS communication between diabetes nurse and patient. Standard User support - as support system for technical issues - is on the other hand delivered by the telephone provider. 3 Peyrot M & Rubin RR. Behavioural and psychosocial interventions in diabetes: a conceptual review. Diabetes care, (10): p Richards D & Whyte M. Reach Out. National Programme Educator Materials to Support the Delivery of Training for Psychological Well being. Practitioners Delivering Low Intensity Interventions. N.I. Programme, Editor

7 Figure 4: Components of the Few Touch Application All collected and processed data, including data about the use of the components of the Diabetes Diary application, is sent from the phone to a central storage and presentation system the Zope 3 web application server. These data will be made available for researchers through reports with pseudonymised user data that can be ordered by persons who are authorised by the research administrators. The reports will then be distributed to the relevant researchers. The mobile phone is connected to one of the telecommunication providers available for personal mobile services. Communication with the server is partly by wireless technologies, i.e. 3G/GPRS/EDGE, and partly on the Internet, between GSM service provider and the server. 7

8 Figure 5: Diabetes Diary Communication Infrastructure The server s access point is located on the open Internet for the mobile phone data transmission. The server is physically located at the NST facilities in a secure server room. This server room is only accessible with a key card and a PIN code. All the equipment and network leases are owned by NST. The blood glucose meters are however given to the users. 8 Overview of the deployment / Networking of the Service with other Health-IT services How is the application deployed and accessed? E.g., is it hosted by a single provider and accessed by all users via the web, is it integrated within the information system at a hospital or GP practice? Is a copy installed at each healthcare setting or can these all share an integrated (multi-organisation) health record for each patient. Is it operational or in development, a pilot or a wide scale service? If this application is able to interface with other health systems and services, e.g. for demographic information, clinical information, security services, please could you outline this capability and indicate which directions of flow are supported (e.g. this application can be populated from a laboratory system, e.g. this application feeds data into a hospital EHR). The service also relies on HelseDialog a module for secure SMS communication. This service is in use in other parts of the health services in Norway and has an approved level of security. Support software for user monitoring and application support: This is standard software, MOZO, that will be delivered with the telephone and hardware provider. This kind of software is in use for different kind of areas, but for the Norwegian pilot trying out the FTA software, it will be necessary software in order to support so many users. Therefore it is also an important element in the experience of how a tool like this can be implemented for regular use. Data management: When moving from small scale trials into large scale implementation and trials, a few more facilities needed to be in place. The user will always have their own data available on the phone, and are free to use this when they consult their GP; but in order to achieve information about the effect of the FTA tool for the individual, the data needs to be available to the researchers. 8

9 In previous implementations, the data were collected directly from the mobile phone, as there were not too many users and this could be done manually. With 200 mobile phone users in this large scale trial, the data needs to be transferred to a server where they can be assessed. In addition to data capture, it is also needed to provide the users with help and manuals on the telephone, so tutorials have been developed for the mobile platform. For the further deployment of the service important questions have still to be solved, i.e. how should the service be organised? As an app to be loaded on to the mobile phone Supported by professional IT-vendor Payment by the user when loading the application to the phone As a pre-installation on a mobile unit Given to the user by their GP Delivered and paid for by the health care service /society Supported by professional IT-vendor, regulated by contract As a mix of the two, sold at the chemists? These questions are yet to be answered but the results from RENEWING HEALTH will contribute to finding these answers 9 Evaluations and benefits Have any formal or informal evaluations been performed. If so, please can you outline how these evaluations were undertaken as well as their main findings? If not a formal evaluation, are there other success criteria that have been used to determine if this initiative is working well and should be continued. Alternatively if there have been some disappointing findings, please provide these too. Are there any lessons learned, things that you would recommend be handled differently if this project was to be taken up by another country.. The thorough evaluation of the service - based largely on the MAST model for the assessment of telemedicine services is carried out in the framework of the European RENEWING HeALTH project. The effect of the service is tested by a randomised trial with a multidimensional evaluation: It will be tested whether the introduction of the FTA tool and support from a diabetes nurse (health coaching interventions) will improve clinical outcome parameters like HbA1c (glycolysed hemoglobin) and disease self-management and result in improved health related quality of life (HRQoL). The evaluation will also cover impact on the organisation(s), effectiveness and cost-efficiency and acceptability by patients and health professionals. The study will implement 300 users in total, where 100 will be in a control group, 100 will get the FTA tool alone and 100 will get the FTA tool and support from a diabetes nurse in addition. The diabetes nurse will communicate with the patients on mobile phone, but also via SMS messages. This needs to be carried out in a secure environment. The application provided for this purpose is in use in other healthcare services and fulfils the national requirements for security. The evaluation also comprises: Automatic logging (continual via mobile application) Questionnaire (3 times: baseline, 4 months, 1 year) 9

10 Study journal from GP/patient (baseline, after 4 months and after 1 year) Qualitative interviews with participants (20) and health personnel / selected GPs. Outcomes analysed: Primary outcome: HbA1c in combination with changes in medication and hypo-/hyperglycaemic events Health-related quality of life (SF-36) Secondary Outcome Measures: CES-D depression scale, patient-empowerment (heiq and DES-SF), nutrition- and physical activity measures Economical effect measures (quantitative and qualitative data) Usability/patients satisfaction (SUS) Organisational data (interviews) Meta-analyses on Cluster level Lessons learned and feedback: Cooperation with GPs: challenging Technical feedback: Touch telephones not yet very user friendly to un-experienced mobile phone users. Health counselling from diabetes nurse: Works but challenging to establish close contact From participants: Overall very positive feedback The telephone is motivating It is impressing how we can measure and store blood glucose results and nutrition How to set goals in FTA: It suits me perfect... On blood glucose graph: Green values are motivating I am positively surprised I do more right than I thought 10

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