ICT AND THE PROVISION OF SMART HEALTH CARE AT HOME
The current care offer is often criticized for its overly hospital-centered nature, and the importance given to the curative in relation to prevention. The desired orientation is that it gradually gives way to an outpatient approach, open to smart home healthcare provision, preventive and tending to personalization of care. However, this necessary mutation due to epidemiological, economic and societal changes, is increasingly made possible by technology.
Electronic and computer technologies are already present in many areas related to the health system. The uses of ICT in medicine reveal three main practices developed in the following paragraphs: practices between professionals, practices of health professionals with regard to the patient, and the more integrated organization of the supply of care reasoned in the part of the patient’s health journey.
Professional to Professional
The purpose of tele smart health
The purpose of tele-expertise is to enable a medical professional to seek the opinion of one or more medical professionals remotely, because of their training or their specific skills, on the basis of medical information related to the patient management.
The purpose of tele-consultation is to allow a medical professional to give a remote consultation to a patient. It can be practiced between a health professional and a patient at a distance, but it seems today more commonly practiced between several health professionals at a distance in the presence of the patient.
The purpose of remote medical assistance is to enable a medical professional to assist another health professional from a distance during the course of an act.
Collaboration between professionals: uses supporting a reticular approach
Collaboration between professionals is supported and encouraged by ICT. These have made it possible to exercise already existing practices via new tools, but also the emergence of new expertise and remote assistance practices.
The use of medical expertise or assistance has always been common practice. But that supposed a proximity of the actors with each other. ICT today enables distance-changing collaboration. One can imagine the regrouping of specialists in centers of expertise providing expertise and assistance to other professionals via the possibilities offered by ICT without being limited by the accessibility of the places of dispensation.
In terms of tele-expertise, we can cite the example of CREBEN, the Breton experience of radiological tele-expertise. To help their colleagues working in less specialized centers, the Rennes and Brest teaching hospitals have created for Brittany, the Breton Regional Center for Neuroradiological Expertise (CREBEN). By scanning images and creating an image-sending interface with written notification, radiologists across the region can transfer files of problem patients. A duty neuroradiologist analyzes the imagery during the day and, in urgent cases, within 30 minutes. It recommends the most appropriate radiological procedure for the clinical situation, helps with interpretation and offers an explanation for the interpretation, as well as the course of action to be taken in terms of possible radiological management, particularly in interventional neuroradiology.
Regarding remote assistance, the example of robots allowing remote operation of a patient is one of the most well-known and spectacular.
Telesurgery is practiced in France in some large French university centers. This is computer or robot-assisted surgery performing the surgeon’s gestures, with the aim of optimizing the results of certain risky invasive surgical procedures. Telesurgery is also used for the training of young surgeons. Telesurgery will ultimately promote minimally invasive surgery, carried out completely endoscopically by a telemanipulated surgical robot, with, as a corollary, more and more ambulatory care.
For its part, radiological remote assistance is already carried out in certain tele-imaging centers where the teleradiologist doctor assists remotely in carrying out certain imaging procedures, in particular scanners requested by the emergency services with a guard on site of radiology. Robot-assisted “teleechography” is being tested. If this new technology is confirmed, it will join teleconsultation acts since it incorporates videophone during the patient’s examination. Applications in the obstetrics field are already conceivable, to limit the movements of expectant mothers, long and costly, and thus compensate for the lack of maternity in certain regions.
There are also similar experiences on fundus production for diabetics, aiming to screen for retinopathies. In the case of the Ophdiat network, an orthoptist takes the fundus image which is analyzed remotely by an ophthalmologist. The network spans 33 screening centers in France, performs 15,000 examinations per year with an interpretability rate of the transmitted image of 90%, in less than 72 hours. This case belongs to the rare situations for which reimbursement of Health Insurance is currently envisaged.
Finally, there are other, simpler assistance practices with lower investments.
The example of DOMOPLAIES, which is a remote aid in the specific management of chronic wounds in Languedoc-Roussillon in France, is an illustration. Travel by nurses specializing in wound care has been reduced by the installation of a digital tablet system. These allow these specialized nurses to intervene in support of doctors and nurses at home and to provide practitioners with expert assistance from a distance.
These new medical practices are based on ICTs which facilitate the exchange of information between actors. However, the possibility of having complete and shared information remains a major issue which brings us back to the concept of shared medical records.
The term, “health information technology” (HIT), is a broad concept encompassing a range of widely used technologies for storing, sharing and analyzing health information.
The electronic medical record (EMR) is a file kept by a single health practitioner (such as a general practitioner). He replaces the doctor’s paper file.
The electronic health record (EHR) contains the records of numerous health practitioners shared throughout the patient’s health journey; for example, demographics, allergies, medical history, laboratory reports, immunization or radiology records, drug prescriptions, etc. This tool is the most complicated to implement mainly because of interoperability issues. In France, we can draw a parallel between the DMP (personal medical record) and the EHR.
The personal health record (PHR) is up to the patient. It is a document created and updated by the patient, for example, information about diet or exercise programs. Note that Google and Microsoft have tried to set up PHR (Google and Microsoft Healthvault), without success to date.
Data convergence: electronic medical records (EHR)
According to a study carried out in 2019 on more than 3,000 American hospitals, only 1.5% of them were fully equipped with EHR (electronic health record) and HIT (Health Information Technology), this small minority being mainly in the big cities. And only 4% of clinics and doctors’ offices used EMR (electronic medical records). Faced with this finding, the USA administration launched the HITECH (Health Information Technology for Economic and Clinical Health Act) project. This project represented an investment of $ 100,000 per physician and between $ 2 million and $ 10 million for each hospital to become a significant user of EHR.
Other countries are significantly more advanced than the United States in the sector. Denmark, for example, has fully integrated HITs into hospitals and clinics. Even in India, Apollo Hospital is a leader in the adoption and democratization of EHR. The leading HIT countries are New Zealand, Australia, the United Kingdom, Italy, the Netherlands, Sweden, Germany and finally the United States.
One of the difficulties observed in all these approaches concerns the ramp-up towards full automation of the EHR. During the intermediate phases, many establishments are faced with a series of unconnected proprietary software (comparable to intranets). When we try to put them together, we see a kind of chaos linked to the lack of interoperability of these systems with each other. This type of technical problem further hampers the adoption of these tools by healthcare professionals, who are already reluctant to dematerialize and share patient information.
The use of EHR is not limited to recording past information in order to better monitor the patient. They have many other uses: alerting doctors to allergies to certain drugs, preventing them from the next necessary vaccinations, allowing them to find relevant information in the most recent scientific publications, or even serving as evidence in case litigation thanks to the traceability of certain information.
New tools, new practices with their share of questions. One of the fears commonly put forward by healthcare professionals is, for example, that the doctor spends more time typing on his keyboard than listening to or examining the patient in front of him. In addition, the rise of data automation can be paradoxically inflationary in terms of additional requests for information to report. For example, requests for “reporting” from partial or complete EHRs, notably supplying medical and administrative systems concerning finance or quality, have increased so much in the United States that a new profession has recently appeared: doctors scribes who come to help the medical practitioners in this reporting exercise.
Beyond technical questions and financial investment, there is the issue of data confidentiality for patients. Many of them are afraid of commercial or ill-intentioned use of them. Can we consider that information relating, for example, to diabetes should be given automatically and other information, relating, for example, to cancer, should be suppressed? If the patient requests a second medical opinion, does he want the first opinion to be known (via the EHR)?
The Blue Button is the symbol of the user’s access to their medical data. It represents the single button making it possible to download the entire personal medical file. Originally developed in 2010 for veterans by the US government, Blue Button facilitate the sharing of information between healthcare providers, caregivers and other potential stakeholders (insurers, etc.). In theory, 100 million Americans today have access to the Blue Button system. This gives the individual, family members or doctor, information on the previous three years containing the list of the patient’s problems and pathologies, medicines and treatments, list of doctors and their contacts, tests for laboratory, imaging studies, procedures, hospitalizations, and outpatient visits. To date, many companies such as Humetrix are working to convert data files into an interoperable format with iBlueButton applications, allowing information to be displayed on a smartphone or tablet.
If ICT influences practices between professionals through their way of collaborating and exchanging information, they also intervene in the relationship between these same professionals and the patient in the provision of care.
Professional to Patient
ICT plays various roles in the therapeutic relationship between the professional and the patient: communication interface (access to information and care, translation), coordination and collection / monitoring.
Remote health services / access to care
The communication interfaces are already used to practice telemedicine with patients. The three regulated uses are teleconsultation, remote monitoring and response to urgent situations (for example the regulation of vital emergencies by the SAMU).
The purpose of teleconsultation is to allow a medical professional to give a remote consultation to a patient.
For example, oral and dental teleconsultations in medico-social establishments have been tested by the e-DENT project in Languedoc-Roussillon. A specially trained nurse passes a specific camera, using fluorescent light which makes it easier to detect carious lesions and gum inflammation in the patient’s mouth. The images (videos and photos) will then be sent to the Montpellier CHRU for analysis. A diagnosis will be made, a treatment plan proposed and an adapted care plan considered.
An Aix-based company, Health for development (H4D), manufactures and markets teleconsultation booths to break the isolation of patients in medical deserts. This new type of remote consultation offers advice through a small screen. The patient is seated in a small cabin, equipped with several medical tools. A few dozen kilometers away, it is therefore possible to conduct a battery of exams without ever going to your doctor. Using videoconferencing tools, the doctor can examine the patient remotely by guiding the patient in handling the devices. The instruments in the cabin make it possible to take many measurements. They house, among other things, an electrocardiogram, a stethoscope, a camera for a dermatological examination, a camera for an ENT examination as well as measuring devices for weight and height. It has received the approval of several regional health agencies (ARS) and of the Order of Physicians.
This practice remains limited in certain medical fields such as psychiatry due to the need for the presence of the doctor for communication and clinical analysis thanks to non-verbal communication. The development of teleconsultation may thus be condemned to be limited to minor clinical symptoms, unless there is a remote discussion between healthcare professionals, one of whom is in the patient’s physical presence.
The purpose of medical telemonitoring is to allow a medical professional to remotely interpret the data necessary for the medical follow-up of a patient. The recording and transmission of data can be automated or carried out by the patient himself or by a healthcare professional. They can allow, in particular, continuous and objective monitoring of certain data such as physiological variables or behavioral data (medication compliance for example).
DISDEO, or Intelligent Monitoring and Assistance Device, is a health solution based on an intelligent connected pill box, allowing better organization of treatments as well as compliance monitoring. It secures the preparation of weekly treatments, schedules alerts and reminders in case of forgetfulness and records all events.
Numerous applications are also emerging on smartphones to capture health data and pass it on to medical teams.
Among them are applications that allow you to control vital signs. Thus Airstrip technology is a bracelet allowing to measure and transmit data related to uterine contractions and to the fetal heart rate. In another area, Asthmapolis uses sensors in the inhalers of asthma patients to send frequency and location data over the phone or the Internet and can be transmitted to the doctor.
Continuous, permanent and non-invasive monitoring of blood sugar becomes possible thanks to transcutaneous sensors (patch from the Dutch company Abbott Diabetes Care). I-rhythm adhesive patches send heart condition information by email. There is also an application validated by the FDA (Food and Drug Administration), Alive Cor, which traces an ECG using a shell with sensors / electrodes.
The e-Celsius® is an ingestible capsule which, by telemetry, continuously communicates the precise measurement of the central temperature. The same company is also developing a dermal patch that communicates the heart rate.
In the logic of portability and permanent activity control, data capture technologies are now tending towards maximum miniaturization and measurement instruments equipped with nanosensors are now developed.
Remote monitoring is also used to refine the monitoring and early detection of complications at home.
The OSICAT project thus aims to demonstrate that taking care of patients with chronic heart failure associating global care, therapeutic education, daily collection of physiological data by remote monitoring and telephone follow-up by specialized nurses improves the quality of care, and in particular a significant improvement in the functional capacities of patients.
Within the general framework of remote monitoring is the concept of domomedicine.
This new form of care requires the implementation of technologies both to ensure global monitoring of the patient from a distance and to allow good coordination between all the stakeholders who must intervene to care for the patient (staff hospital, attending physician, city nurses, pharmacist, possibly paramedical professions, and the patient’s entourage).
PICADO (Innovative Project for the Change in the Scope of Domomedicine) aims to design, develop, test and evaluate the first Domomedicine platform for personalized care of multi-pathology patients at home (chrono-chemotherapy, diabetes, etc.). Supported by the French Academy of Technologies, this project brings together health, academic and research stakeholders (INSERM, University of Reims, University of Technology of Troyes) and companies (Axon, Bluelinea, FSI, Voluntis and Altran).
• Serious games for smart health
On the sidelines, new practices known as “serious games” which do not fall within the framework of the law framing telemedicine allow collaboration between the patient and the caregiver via ICT. “Serious games” are fun software (related to video games) with a purpose other than simply recreational. In medicine, we can pursue educational or physical rehabilitation goals.
Voracy Fish, developed by Applied Genious Healthcare, is one of the first “serious games” in the service of health. This playful upper limb rehabilitation for stroke victims uses classic functional rehabilitation exercise movements (extension of the shoulder and elbow, pronation / supination of the wrist and grip of the hand) to guide a fish in a universe. colorful sailor. This allows the therapist to quantitatively monitor the motor recovery of his patient: all movements, speed spikes and other reaction times are recorded in order to analyze each session.
Other ICT applications in the patient / doctor interface are being developed with patients with autism. For several years, researchers have observed that people with autism have a “positive” relationship with computers. Since the rise of touchscreen terminals, numerous testimonies from professionals and parents of autistic children have confirmed that their intuitive interface favors their use. These tablets provide an activity support on which autistic children can focus their attention. While there is still a lack of scientific perspective to assess the relevance of using tablets, the testimonies of parents and educators evoke the fact that these applications help these children to communicate with their parents, to learn and also to become more independent. Many applications dedicated to autistic children (more than 300) are available today. These tools have in common to allow information flows between the patient and the caregiver for the purpose of a remote exchange.
In addition to allowing accessibility of care thanks to the transmission of information at a distance or thanks to miniaturization improving the mobility of caregivers, ICTs also support support activities allowing the management of the disease in response to the whole of the data collected.
From patient accompaniment to the coordination of stakeholders in the health journey
The support of the patient in the management of his pathology which is one of the main roles of the doctor can indeed be optimized thanks to the intervention of ICT. In a constrained socio-economic context, the moments of discussion between the patient and his caregiver are currently reduced to the time necessary for the caregiver to perform the technical gesture for which he is paid (diagnosis, injection, dressing, etc.). To improve these times of exchange between professionals and patients, ICT (patient internet portals, applications, tablets) have added value.
The first use is to improve patient support from a distance
Support can be targeted. The miniaturization of diagnostic devices facilitates, for example, the mobility of examination techniques complementary to the clinical examination of caregivers towards patients and their home.
More broadly, the use is part of coordinated systems of intervention and communication between the health system, doctors and patients.
A Canadian company has developed the TAVIE® system, which is a support portal like the SOPHIA project, but which uses a virtual nurse interacting with the patient thanks to pre-recorded videos according to predefined and validated algorithms to better understand the need of the patient and respond appropriately.
The second use aims to develop patient portals
A second use aims to develop patient portals to make them access interfaces to professional coordination platforms allowing to organize the patient’s health journey. The path thus created allows us to act on the relevance of the responses provided (medical consultation, therapeutic emergency, etc.), optimizing logistics (grouping of trips and exams, limiting duplication and inconsistencies, appointments medical) and the exchange of information between stakeholders.
We can cite the CAPRI platform (Cancer Care Pathway in the Île-de-France Region) which coordinates care and supports patients treated for cancer at Gustave Roussy when they return home. It aims to assess the added value of a coordinated course on the quality of care and efficiency in coming to Gustave Roussy. The CAPRI coordinated course is based on the establishment of a system composed of two coordinating nurses (IDEC) and two Internet portals; one for professionals and one for patients. The IDECs are in contact with the patient and the health professionals involved in the care of the patient (in particular, general practitioner, liberal IDE, city pharmacist).
The patient has access to a portal allowing:
o Contact a Gustave Roussy coordinating nurse via secure messaging
o Record monitoring data such as temperature, weight, pain and adherence to treatments
o View and record all medical appointments on a calendar
o To have a directory with the contact details of professionals involved in care as well as useful numbers
o Access directly to selected websites giving certified information on the disease, treatments and side effects
o To have a storage space to download, archive and classify the documents relating to the treatment (results of examinations, biological assessment, report, etc.).
These examples illustrate the capacity offered by ICT to monitor and support patients remotely, and to organize the sharing of medical information. An additional step is to consider the entire journey of a patient within a single integrated system, linking health facilities and professionals.
Integrated care networks
Integrated care networks correspond to the connection of different organizations and health professionals within the same organization to which the patient has access, and to the provision between these different organizations of patient medical information.
Traditionally, health networks have mainly developed from relational networks of health professionals, the medical records of patients in these health networks being most often in paper format.
The development of health ICTs now makes it possible to support and develop these networks. By consolidating the exchange of information between professionals, and by constituting a coordinated organization from which the patient benefits. These networks guarantee a so-called integrated care offer. They allow a better follow-up of the patient whatever his professional contact, and this at all stages of his illness.
These integrated care networks respond particularly well to the management of chronic diseases. The treatment of these requires the involvement of multiple health professionals, and therefore, cooperation between them. The examples of an integrated care network for understanding the role played by ICTs are essentially North American. In these cases, as illustrated below, the promoters are both providers and insurers.
Kaiser Permanente, the success of an integrated healthcare network
Kaiser Permanente, flagship of the American HIT, is probably the most extensive and well-known integrated care network system to date, comprising 9 million individuals, 14,000 doctors, 431 medical offices, and 36 hospitals in 9 different states. . In 2003, Kaiser Permanente invested $ 4 billion in the development of the largest EHR facility. On Kaiser, 3 million people have access to their data and can communicate with doctors via a secure email. This system would have led to a decrease in visits to the city doctor by 26%.
Historically, the Kaiser network was developed in California in the 1950s. He then represented an association between a health insurance company, a hospital foundation (both non-profit) and a large group of independent “permanent” doctors.
The organizational model of Kaiser Permanente is based on better quality monitoring of the patient suffering from chronic diseases based on clinical evidence (evidence-based medicine), and a search for efficiency. A priority axis is that of preventive medicine. A patient education program “to reduce smoking” has reduced health care costs caused by myocardial infarction and reduced the prevalence of smoking in California (among their insured) greater than that observed in the rest the United States.
Kaiser also encourages patients to develop their autonomy and self-management skills when faced with the disease. Booklets are distributed to learn how to live better with a chronic illness. Similarly, access to information is highly favored, with in particular the possibility of having access to pre-recorded information (bilingual English-Spanish), to reach a nurse in order to be referred to a doctor or an emergency service. , or to contact the doctor by email. Time is also devoted to online consultations.
Lastly, Kaiser Permanente more recently launched its mobile application enabling access to information from the mobile health network. The main tabs are the medical record, the (virtual) pharmaceutical center, the (virtual) medical center, the mailbox, and the location search tab.
In the context of chronic diseases, one of its specialties as we have seen, the group has developed standardized care protocols (based on recommendations of good practice) established for all associated doctors. These protocols allow in particular to reduce unnecessary visits to specialists. Patients identified as having a high level of risk are subject to specific monitoring by a specific team in collaboration with their doctor.
The organization of the Kaiser care network is also based on the transfer of skills from doctors to nurses with the creation of a new profession “specialized clinical nurses” which allows them to delegate to the latter a number of tasks traditionally performed by the doctor (prevention, therapeutic education, etc.).
Other examples of integrated healthcare networks based on the same organizational model as Kaiser Permanente have developed in other regions of the world such as the Maccabi Healthcare System in Israel which covers nearly 2 million insured persons.
The development and maintenance of health networks through information systems and ICT shared between health organizations would allow the emergence of practices, called “new medicine”, closer to a patient made more autonomous . Health networks would also correspond to a certain form of “extra-territoriality” for traditional health actors: the network “links around a sick person all the necessary resources” and it is “neither in city, neither in the hospital, neither medical, nor social, but all this at the same time.
This new form of proximity with patients comes in two dimensions: physical proximity enabled by the use of forms of ambulatory medicine, and virtual proximity enabled by the patient’s permanent connectivity to the network. In this regard, the involvement of patients and the territorialisation of health practices are identified as essential elements to avoid the risk of confining health networks “in a closed circuit of professionals”.
THE NEW PATIENT AND CITIZEN FIGURE
ICT has made it possible to increase the medical information delivered to the patient or to the citizen in good health. It is sometimes difficult to draw a line in the use made of this information: between the help provided to patients during this care by this available information, and support for preventive measures before the disease. In both cases, a common point remains the autonomy of the patient or the citizen who remains in control of accessing this information. Two major developments can be distinguished: information websites for the general public, and that of so-called “self quantified” ICT tools. These two movements lead to placing the patient in a role of “self manager”.