Thank you for the opportunity to present today and tell you a bit about some of the work we're doing in improving the care for patients with chronic disease, primarily in the area of cardiac disease.
I'll be specifically speaking about programs that operate in the Ottawa region, but many of its parts have been implemented in other regions and provinces in Canada.
In today's environment, we're seeing a growth in the number of patients who have chronic diseases. We've already talked about how people often have more than one chronic disease. In cardiac we find that it's a disease of the elderly, that individuals living in rural communities tend to have a greater preponderance of the disease, and they often have less access to services and specialists than their urban Canadian counterparts. The health care challenges for these people are: making sure they receive care that is based on best practices; helping them learn to live and cope with their chronic disease; providing support to the family, and this most often is an elderly spouse who may also have a chronic disease; preventing adverse events, particularly around medications; keeping them out of hospital, unless they need to be there; and improving their quality of life.
In our region we've developed an innovative e-health strategy that actually allows us to deliver different care by connecting patients to us virtually, without actually requiring them to come to the facility. This is an integrated model with three layers, and each layer provides an e-health strategy that works for the specific needs of the patient as they move through the course of their disease. This is chronic, and many of them will come to an end stage in this disease.
The first layer is telemedicine. This is a high bandwidth video conferencing capability. It allows us to add diagnostic capability. For example, we connect an electronic stethoscope to the system. We can hear the heart sounds of people who live in Nunavut and we can actually make a diagnosis. We can also send electrocardiograms and X-rays. It allows a cardiologist at the institute to conduct a full cardiac exam without ever having the patient leave their home community. This is a huge benefit to the family and patients. They don't have to travel. In addition, we can have the local health care provider—who's usually a family physician—with them so that the plan of care is well understood and discussed all at one time.
In a large study done in 2001, the institute found there were significant cost savings to patients and families, as well as improved access to services, using this technology. This led to the creation of the provincial system in Ontario called OTN, which now connects all of our hospitals. Today we can connect with hospitals across Canada and internationally to discuss patients.
We've expanded these initial services now to provide patients access to services that are not available unless you live in an urban city. For example, our rehab program broadcasts its classes on exercise, diet, and healthy lifestyles to the telemedicine stations in our partner hospitals that may not have these kinds of services. We also use it for follow-up visits for patients who prefer not to travel to a larger city. As a final service, we can see complex, admitted patients in hospitals where the local providers may be struggling with the diagnosis. They take a mobile telemedicine station to the bedside of the patient and we assist them with the diagnosis.
As a final use, we actually help to link families and patients when patients have to stay in Ottawa, for example, for long periods of time. This is particularly helpful for our patients from Nunavut. They become quite socially isolated while they're here, so we connect them to their families for a visit by using these stations.
The benefits of this system are reduced travel costs to patients and families, improved access, people can stay in their home communities, we have an ability to support local family physicians in complex care, and they reduce readmissions to hospital.
Of the strategies I'm going to talk to you about, this is our most expensive, and it has to be done centrally. You have to come to a site that has a telemedicine station, but it has the highest bandwidth and we can do the most detailed work with it.
The second layer is our home monitoring program. This program uses portable home monitors about the size of two pounds of butter. We give them to the patients to take home. These devices are plugged into their telephone jack and they're able to transmit their actual vital signs in the same way we would take them in a hospital. So we can assess blood pressure, pulse, weight, electrocardiogram, oxygen levels, and blood sugar levels. The data comes into a central station. We have a nurse there who can assess the results, based on a pre-set parameter. If the patient is outside of range, the nurse may call them back and adjust their medications or they may offer them some advice around diet or other compliance issues.
The system also allows us to pre-program questions—in eight different languages—that we would normally ask a patient. It speaks to the patient and the patient simply presses a button responding yes or no. This adds additional symptomatic screening capability that we don't have because we can't see the patients.
In addition, once a week we do a regular medication update to make sure they're still on the right medications and that no one has inadvertently changed them off their best practices. I can say that on every call we usually find a problem.
There's a considerable amount of medication management that has to be monitored. The typical monitoring period lasts three months, and during this time, in addition to seeing how they're doing, we actually have a predefined teaching program to help them learn to deal with their disease. In the Ottawa region, we have 150 of these monitors; 90 are located at the Heart Institute. The remaining 60 have been sent out to the local hospitals so that they can actually provide them locally to patients. Again, they don't have to come in to the city to receive the service.
Because these transmissions use a regular telephone system, we've sent monitors with patients all across Canada. We do see patients from across the country, and we've been able to use this because it plugs into the telephone system. The patients just simply ship it back on the bus when they're done.
We've started these systems for many years, and we've found the following. Patients are statistically more likely to be on best practices. They have a lower rate of readmission. The old, elderly, or people over the age of 85 do not require any more interventions and they're very capable of using the system. There's a high degree of satisfaction with patients and family physicians. By way of comparison, an average nurse in a centre like ours can look after three or four patients and sometimes up to six. These nurses who manage these systems look at 30 patients at a time. The cost of a monitor is $5,000. The cost of an average readmission is $7,000. In the first year, we saved $340,000 in one year looking after patients with this technology.
The third layer is automated calling, and the strategy was developed for the longer to medium term. We run five services under this program, but I'm going to restrict my comments to one related to heart attacks. We work with a local company, and we just use a simple automated calling platform. We have clinicians who develop a series of questions in the same way they would ask questions of a patient during a follow-up visit. The patient is called at regular intervals and responds to the questions, and the voice is captured in the system as a text response. A nurse can see what the patient has actually said, yes or no, to the question, and in the event that they see a wrong response—a patient may have stopped taking a medication—they'll call them and see what the issue is.
Each of these five systems are separate and they deal with different diseases and conditions that patients may face. This is the least expensive of all of the strategies, and it has the largest and easiest reach. If you have a phone, you can get a call. For example, patients with heart attacks often stop taking their medications once they're feeling better. This is a huge problem, since those medications will prevent them from having future heart attacks. The calling system for heart attacks calls people at day four, after they get home, and at months one, three, six, nine, and twelve. Their individual medications have been loaded into the system, and it simply asks them if they're continuing to take each of those medications. If they answer that they've stopped taking them, a nurse will call them and work with their family physician and/or the patient to get them back on the desired medications.
Again, these systems have been tested for effectiveness. We've just finished a large randomized control trial, with 600 patients receiving the call and 600 not. The patients who received automated calling are statistically more likely to be on best practice medications at the end of a year, and they are also statistically less likely to have a readmission during the course of that year.
The benefits to patients are that they have a smoother transition from hospital to home. We can give them additional support and reassurance as they learn to live with their disease. We're able to identify problems that are happening and intervene in a more timely way, and it removes geography as a barrier to care. This system has also been used by patients across Canada, and it is being implemented in other facilities in Ontario and across other provinces.
In conclusion, the e-health technology, when implemented properly, can be used to better clinically manage patients and to better support their families. It removes the barriers of geography, resource inequities, age, and regional disparities. It's inexpensive compared to hospital care, and it keeps the patients closer to home. There's a high degree of satisfaction with these systems from patients, and there does not appear to be any specific difficulties in using them with the elderly.
As a final comment, the clinical needs of the patients have to drive the type of technology you choose. That's why we have three layers. Some of the least expensive technology, when implemented in an innovative way, brings the best outcomes.
Thank you.