ehealth applications to cardiovascular disease management: Phase 1 of the British Columbia Alliance

1
e-health applications to cardiovascular disease
management Phase 1 of the British Columbia
Alliance on Telehealth Policy and Research
(BCATPR)

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• Presentation for the BCNET 7th
• Annual Conference, April 18, 2007
• By
• Dr. Joanna Bates (Chair), Dr. Richard Scott
• Annemarie Kaan Yuriko Araki

2
Agenda

• Overview of the BCATPR
• Current Focus Internet-based Cardiovascular
  Disease Management
• Overview of the Phase 1 and Phase 2 research
  activities
• Internet Access Survey (Phase 1 project)
• e-Health Policy Study Readiness assessment
  (Phase 1-2 project)
• Virtual Heart Failure Clinic Study (Phase 1-2
  project)

3
Background

• BCs population (2006)- 4.1million
• 60 resides in the Lower Mainland
• 70 of the provinces population resides on 1.3
  of the land
• Example Northern Health Authority provides
  health services to 300,000 people over an area of
  600,000 square kilometers ( size of France)
• This population distribution creates challenges
  for ensuring access to primary and secondary care
• Source
• Natural Resources Canada (2001). Population
  Density 2001.The Atlas of Canada.
• Statistics Canada (2001). Population Density
  2001.
• Watson et al. (2005). Planning for Renewal
  Mapping Primary Health Care in BC. Centre for
  Health Services and Policy Research, Vancouver,
  BC.

4
Who are we?

• Team of health researchers and policy-makers
  throughout BC.
• Diverse in geography and expertise.

5
Goals

• To build capacity in health services and policy
  research related to telehealth services,
  education and training.
• To improve patient outcomes in high-impact
  chronic disease through the use of innovative
  telehealth strategies to deliver patient-focused
  care.
• To enhance the continuum of patient care through
  the use of innovative telehealth strategies to
  facilitate shared care between primary and
  secondary care providers.
• To increase the scope of telehealth services by
  using technology that is accessible to a large
  proportion of BC residents and minimizes barriers
  of cost and geographic accessibility.

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BCATPR Themes

• The Patient Self-Managed Care, Technology Uptake
  and Behaviour Change
• The Provider Integration of Clinical Care
• Policy Telehealth Policy and Health Human
  Resources

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Team Phases

• Quick wins
• Literature reviews
• Surveys
• Qualitative interviews
• Short-term prospective studies
• Pilot studies
• Virtual cardiac rehab, online CHF management
• Longitudinal studies
• Randomized controlled trials

8
Current Focuse-Applications to cardiovascular
disease management
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Cardiovascular Disease

• Leading cause of death in Canada
• With improved acute care and ageing population,
  number of CVD survivors increasing
• Primary and secondary prevention effective in
  management
• Inequity of care and access to services along
  geographical boundaries

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Deaths from Heart Disease
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Hospitalizations from Heart Disease
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Internet Use in 2003

• 64 of Canadian homes have 1 Internet user in the
  household
• 7.9 million/12.3 million
• Higher income more prevalent
• Lower income catching up 50 with income between
  24K and 44K
• Source
• Statistics Canada. (2004). Household Internet Use
  Survey, 2003.

Statistics Canada 2004
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Home Internet Use
Percent Access ()
Household Internet Use Survey. Statistics Canada
14
Internet Use by Activity in 2003(regular user
households)
Percent ()
Household Internet Use Survey. Statistics Canada
15
Research activities

• Phase 1 (2006)
• Internet Access Survey (Theme 1) completion
• Telehealth Policy Baseline Study (Theme 3)
• Virtual Heart Function Clinic (vHFC Study) (Theme
  1)
• Phase 2 (2007)
• Telehealth Policy Baseline Study (Theme 3)
• Virtual Heart Function Clinic (vHFC Study) (Theme
  1)
• Qualitative investigation of the Internet-based
  technology in rural and remote communities
  (Themes 1 2)
• Virtual Cardiac rehabilitation program for
  patients in rural and remote communities (Theme 1
  2)

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Internet use in cardiovascular patients (Internet
Access Survey) - Phase 1 project

• Principal Investigator Dr. Scott Lear, Assistant
  Professor, School of Kinesiology, Simon Fraser
  University
• Co-investigators Dr. Dan Horvat (Medical
  Director, Northern Interior, Northern Health
  Authority), Annemarie Kaan (Adjunct Professor,
  UBC School of Nursing, Heart Centre, St. Pauls
  Hospital), and Martha McKay (Heart Centre, St.
  Pauls Hospital)
• Project Coordinator Yuriko Araki (BCATPR)

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Purpose

• To find out how many cardiac patients have
  Internet access and the main ways they use it
• To provide a simple, yet concise,
  characterization of the intended target
  population for future BCATPR studies and indicate
  feasibility for future study recruitment.

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Internet Access Survey

• Consecutive cardiac inpatients at St. Pauls
  Hospital and Prince George Regional Hospital
• Inclusion criteria (a) those who understand
  English, (b) those who are NOT cognitive
  impaired, and (c)19 years or older
• Data collection July 2006 Feb 2007
• Total 284 (71 men), Patients from the Northern
  Health Authority (NHA) catchments 94 (66 men)

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Computer at Home
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Internet Access at Home
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High Speed Internet Access (Internet users)
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Internet Use at Home- Reasons
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Internet Use at Home-Frequency
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e-Health Policy Study Readiness Assessment

• Dr. Richard E. Scott
• Associate Professor, Global e-Health Research and
  Training Program, Centre for Innovation in Health
  Technology
• Harkness Associate Fulbright New Century
  Scholar
• Immediate Past-President, Canadian Society of
  Telehealth
• Co-Investigators
• David Babiuk, Lillian Bayne, Robert Halpenny,
  Heather Manson, Cathy Ulrich, Scott Lear

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e-Health Policy Why?

• Clinician in Fraser
• Clinician in Calgary, Alberta
• Clinician in Cuernavaca, Mexico

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e-Health Policy Why?

• Certification and Training
• Licensure
• Remuneration
• Professional Conduct CMPA
• Clinical Standards
• Accountability for Clinical Decisions
• Scope of Practice
• Protection of Personal Health Information
• Data Stewardship
• Data Quality
• Data Collection
• Data Management

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e-Health Policy Why?

• e-Health a globally networked activity
• Can cross all socio-geo-political boundaries
• But you cant do that!
• Already happening
• Why not!!
• So - How do we facilitate, but also manage, this
  new paradigm?
• e-Health Policy

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e-Health Policy The Problems - The Solution

• Currently
• Ad hoc, local, as needed approach
• Poor policy in any single jurisdiction may
  hamper or even cripple the ability of telehealth
  (e-health) to fulfill its potential Scott
  RE, Chowdhury MFU, Varghese S. (2002)
• e.g. Could restrict access and reduce equity of
  healthcare
• e-Health policy
• Component of health policy
• We need to
• Understand what we have
• Support development of evidence-informed policy

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BCATPR - Policy Study

• Now
• Understand what we have
• Policy Baseline Study
• Future
• Support development of evidence-informed policy
• Other collaborative studies
• Design
• Participants - Health Authorities PHSA
• Methodology - Literature review Survey Key
  Informant Interviews (KIIs) and policy document
  analysis

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Policy Study- Literature Review (Meso Level)

• 2005
• e-Health Strategic Framework
• Tactical Plan for Health Information Management
  in British Columbia Key Projects 2004/05
• 2003
• Framework for an Electronic Health Record for
  British Columbians
• Tactical Plan for Health Information Management
  in British Columbia Nine Key Projects in Six
  Months
• 2002
• Information for Health - A Strategic Plan for
  Health Information Management in British Columbia
  - 2002/03 2006/07

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Policy Study- Survey - HA/PHSA (Micro Level)

• Current or planned e-Health related policy
  documents or reports (1996-2006)

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Policy Study- Survey - HA/PHSA Policy Relevance

• Importance / Impact of Policy Material

A
Key Component
Limited Role
0
2
4
6
8
10
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Policy Study- Survey - HA/PHSA Policy Issues

• Other e-health policy issues
• 6 identified by HA A
• Top 5 e-health policy issues
• Data stewardship

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Policy Study- Survey Other data

• Size of e-Health enterprise
• Available applications or services (CARES)
• Maturity of e-Health adoption
• e-Health impact

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Policy Study- KII and Policy Document Review

• KII Status
• Some participants for Key Informant Interviews
  identified.
• Interviews of CIO, e-health clinician, and
  telehealth coordinator to commence shortly
• Policy Review Status
• To await receipt of soft copies
• N7 software for analysis

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e-Health Readiness- Assessment

• Rationale
• e-Health readiness is recognised as a critical
  parameter for successful implementation of
  e-health (telehealth) solutions
• Purpose
• To understand and compare the e-health readiness
  of Health Authorities
• To provide an baseline data
• To assist in design of planned and future BCATPR
  studies
• Method
• Use of a published e-health readiness tool
• References
• Jennett et al. The essence of telehealth
  readiness in rural communities an organizational
  perspective. Telemed J E Health. 2005
  Apr11(2)137-45.
• Jennett et al. Organizational readiness for
  telemedicine implications for success and
  failure. J Telemed Telecare. 20039 Suppl
  2S27-30.

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BCATPR- Next Steps for Policy

• Now
• Understand what we have
• Collate and analyse data
• Complete final reports
• Broadly disseminate the findings to inform the
  process
• Future
• Provide the evidence-base
• Inform and support future policy and readiness
  debate in BC
• Focus on key issues identified from the study and
  assessment
• Other collaborative studies

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Virtual Heart Function Clinic (vHFC) Phase 1/2
project

• Investigators
• Annemarie Kaan (St. Pauls Hospital), Scott Lear
  (SFU), Andy Ignaszewski (St. Pauls Hospital),
  Cindy Paton (SFU), and Biljana Maric (SFU)

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What is Heart Failure?

• A chronic, terminal disease
• Inability of the heart to pump blood adequately
  around the body
• Result of heart attack or long-term high blood
  pressure
• Expect a huge burden on health care system as the
  baby boomers age

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Heart Failure in BC

• gt40,000 pts with HF
• 12,651 admissions
• gt50 of re-admissions due to non-compliance with
• medications
• diet
• fluid
• reporting of symptoms
• 100,459 pt days
• 90 million

The Failing Heart, British Columbia Ministry of
Health Services, 2002
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CHF via Internet

• Evidence favourable for telephone management and
  other forms of telemanagement
• BMJ. 331(7514)425, 2005 (DIAL)
• Circulation. 110(11)1450-5, 2004 (SPAN CHF)
• Interactive Internet use and CHF seems to be
  effective but not fully studied
• Can J Card. 19(12)1381-5, 2003 (Delgado et al.)
• Internet may provide a simple and low cost
  intervention coupled with HFC support

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Goal

• To develop, test and evaluate a simple
  Internet-based CHF self-management support tool
  that will be time efficient and help transfer
  care of stable patients back to primary care with
  specialist support

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virtual Heart Function ClinicOverview
Weight/symptoms out of desired range
Patient enters daily weight and reports symptoms
Alert sent to nurses inbox
Weight/symptoms within desired range
Continues daily monitoring
Nurse contacts patient implements treatment
algorithm
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Virtual Heart Function Clinic Layout
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Next steps for virtual HFC

• Develop primary care physician interface
• Conduct large-scale randomized trial of vHFC in
  remote regions supporting primary care
• Study impact of vHFC on health care utilization

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Interactive Discussion

• Moderated by
• Dr. Joanna Bates, MD, Associate Professor,
  Medicine/Family Practice, Senior Associate Dean,
  Undergraduate Education, University of British
  Columbia

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Acknowledgements

• Michael Smith Foundation for Health Research
• BC Medical Services Foundation
• Northern Health Authority
• Vancouver Coastal Health Authority
• Heart and Stroke Foundation of British Columbia
  and Yukon

BC Medical Services Foundation
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Contact

• Yuriko Araki,
• Research CoordinatorBritish Columbia Alliance on
  Telehealth Policy and Research (BCATPR)yurikoa_at_sf
  u.ca(604)268-7737