Interim Audit checklist and Report 3
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Interim Audit checklist and Report 3


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Inventory of Telemedicine Applications in the Regions January 2006 Working Document 6 P.J.M.M. Epping, O.J.P.S.T.M. Smits, J.A. Cosijn, Eindhoven A.C. Wagener, Den Haag The Netherlands p PROJECT PART-FINANCED BY THE EUROPEAN UNION Table of content 1 Introduction 4 2 The Health Care Systems in the Tele Medicine Project Regions 6 2.1 Italy (Genoa and Bologna) 6 2.1.1 The National Level 7 2.1.2 The Regional level 8 2.1.3 The Local Level 9 2.2 The United Kingdom (Southampton) 11 2.2.1 Primary Care Trusts 12 2.2.2 Strategic Health Authorities 12 2.2.3 Primary Care 13 2.3 The Netherlands (Eindhoven and Den Haag) 13 2.3.1 Primary Health Care 13 2.4 Spain (Catalonia/Viladecans and Illes Balears) 14 2.4.1 Public Health in Catalonia 15 2.4.2 Balearic Islands 15 3 Telemedicine and Chronic Illnesses 18 3.1 Introduction 18 3.1.1 Italy (Genoa and Bologna) 18 3.1.2 United Kingdom (Southampton) 18 3.1.3 The Netherlands (Eindhoven and The Hague) 19 3.1.4 Spain (Catalonia and Balearic Islands) 20 4 Behavioural Change: the Main Factor 25 4.1 Changing Behaviour 25 4.2 Self-management 25 4.3 A New Model for Disease Management 26 5 Focus in the Tele Medicine Project 28 5.1 Telemedicine Applications in ...



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                   Inventory of Telemedicine Applications in the Regions  January 2006 Working Document 6   
       P.J.M.M. Epping, O.J.P.S.T.M. Smits, J.A. Cosijn, Eindhoven A.C. Wagener, Den Haag The Netherlands  
Table of content
2 2.1 2.1.1 2.1.2 2.1.3 2.2 2.2.1 2.2.2 2.2.3 2.3 2.3.1 2.4 2.4.1 2.4.2
3 3.1 3.1.1 3.1.2 3.1.3 3.1.4
4 4.1 4.2 4.3
5 5.1 5.1.1 5.1.2 5.1.3 5.1.4 5.1.5 5.1.6 5.1.7 5.1.8
Introduction 4
The Health Care Systems in the Tele Medicine Project Regions 6 Italy (Genoa and Bologna) 6 The National Level 7 The Regional level 8 The Local Level 9 The United Kingdom (Southampton) 11 Primary Care Trusts 12 Strategic Health Authorities 12 Primary Care 13 The Netherlands (Eindhoven and Den Haag) 13 Primary Health Care 13 Spain (Catalonia/Viladecans and Illes Balears) 14 Public Health in Catalonia 15 Balearic Islands 15
Telemedicine and Chronic Illnesses 18 Introduction 18 Italy (Genoa and Bologna) 18 United Kingdom (Southampton) 18 The Netherlands (Eindhoven and The Hague) 19 Spain (Catalonia and Balearic Islands) 20
Behavioural Change: the Main Factor 25 Changing Behaviour 25 Self-management 25 A New Model for Disease Management 26
Focus in the Tele Medicine Project 28 Telemedicine Applications in the regions 28 Introduction 28 Telemedicine and rural areas 29 Telemedicine Applications in the Region of Genoa 29 Telemedicine Applications in the Region of Bologna 32 Telemedicine Applications in Southampton 34 Telemedicine Applications in the Netherlands 35 Telemedicine Applications in Catalonia 39 Telemedicine Applications in the Balearic Islands 40
6 6.1 6.2
Success Factors 44 Technological Aspects 44 Organisational Aspects 44
Implementation 46
Conclusions 47
Literature 48
Annex 1  Model for Implementation 49
1 Introduction
Many cities in Europe are confronted with an increasing health care demand because of an ageing population and an increasing number of people with chronic diseases. The pressure of this increasing demand will be put foremost on primary health care and medical services such as general practitioners, home care services, social assistants, hospitals et cetera. These developments will increasingly have consequences on the needs for health and medical services to be provided as well as for the planning of these services, particularly in urban areas.  To implement a new model of care in a rather strict and old-fashioned health care system is not an easy task. Especially when these new models of care are technology driven and are being implemented in the field of the chronically ill patients: a group of patients that may represent 20 to 30% of the total patient population in 5 to 10 years.  New technological solutions will provide patients with a number of tools that lead to better self-management and a greater awareness of their health condition. Proven modern disease management tools eventually will lead to improved quality of care, a reduction of hospital admissions and therefore a substantial reduction of costs.  From the beginning of the year 2000 up until now, many investigations have been undertaken about the actual situation of health care in Europe [see IST e-Health programme]. Most of them are reporting that health care delivery systems do not provide consistent, high-quality medical care to all people. Todays health care systems remains overly devoted to dealing with acute, episodic care needs, while people with common chronic conditions are in need of long term health care services.  To start dealing with these problems, one of the aspects that now has been broadly accepted is the use of IT (Information Technology) in health care. In order to accelerate and co-ordinate telemedicine developments on a small and regional level in Europe, several regions have combined their expertise in the INTERREG IIIC Tele Medicine Project.  The most important task of this INTERREG IIIC Tele Medicine Project is to establish a seamless and secure exchange of patient data between authorised health care providers and patients, using technical communication standards. Additionally there will be an international platform for exchanging knowledge. The use of IT in health care is gradually expanding and applications, which support the exchange of patient data in the continuum of care, become more and more available.  The overall objective of the INTERREGIIIC Tele Medicine project is to explore the effects and opportunities for the local planning of health and medical services and housing facilities in urban areas via the stimulation of more efficient en innovative ICT
(wireless) based solutions for domestic health and medical care. (INTERREG IIIC Tele Medicine application form, October 2004).  The working definition of the Tele Medicine project is as follows: Tele Medicine is the use of information and communication technology in the primary process (first and secondary line care) to improve health services (like cost reduction, shorter waiting lists) and self-management (like better quality of life). Results will effect health and urban planning (policy making).  It is the INTERREG IIIC Tele Medicine Project general opinion that health care as a whole and the care of the chronic ill patient in particular need to turn to state of the art technology. Without the use of Information Technology (IT) the number of medical failures may rise, caused by the lack of information in the continuum of care [TNS NIPO, 2004].  New technological solutions will provide patients with a number of tools that lead to better self-management and a greater awareness of their health condition. Proven modern disease management tools eventually will lead to improved quality of care, a reduction of hospital admissions and therefore a substantial reduction of costs. The INTERREG IIIC Tele Medicine Project will provide an opinion on disease management models, especially with telemedicine as an important driver for disease management, and their place in regional health care systems.  A first step in this exchange of information was providing information on the following subjects: The national and regional health care systems; The amount of patients with COPD (Chronic Obstructive Pulmonary Diseases); CHF (Congestive Heart Failure) and diabetes Regional experiences with telemedicine applications. This document provides a state of the art of the above mentioned issues.    
2 The Health Care Systems in the Tele Medicine Project Regions
2.1 Italy (Genoa and Bologna)
In Italy the health care system is a regionally based national health service that provides universal coverage free of charge at the point of service. The system is organised at three levels: national, regional and local.  
Figure 1: Overview organisational actors and relationships
The national level is responsible for ensuring the general objectives and fundamental principles of the national health care system are set out. Regional governments, through the regional health departments, are responsible for ensuring the delivery of a health benefit package through a network of population-based health management organisations (local health units) and public and private accredited hospitals. Figure 1 summarises the main organisational actors, as well as the relationships among them. Parliament approves framework legislation, which lays out the general principles for organising, financing and monitoring the NHS.   2.1.1 The National Level
At the national level, health care and the operation of the National Health Service (NHS) are governed primarily by Law No. 833/1978 and following modifications (DPR 502/1992, DPR 517/1993, Legislative Decree 229/1999). The implementation of the national health programme is delegated to the regional and the local regional organisations.  The objectives of the national health programme are set out following the approval of the National Health Plan, which is intended to bridge the existing social and health care gap, especially in the southern regions. All the objectives of the national health programme are determined with the help of the regions  within the framework of economic planning and in accordance with the relevant legislation, which stipulates, among other details, the levels of health care services that must be guaranteed for citizens.  The government draws up the National Health Plan based on proposals from the Minister of Public Health; the Plan is subject to the approval of parliament at the same time as the legislation on the multi-year funding programme for the National Health Service. The National Health Plan runs for three years. The regions have 150 days from the day of enactment to adopt or amend the regional health plans in accordance with the national health plan.  The 20022004 National Health Plan differed from previous health plans in its response to the following: the process of transferring more power to the regions; and The ageing of the population combined with the increased efficacy of medication is a new crisis, leading to increased frailty in much older age.  The National Health Plan offers unitary management of health protection throughout the country through a network of local health enterprises. These local health enterprises operate independently and more in the manner of a business, covering the structures and offices of each municipality. In addition, they are responsible for providing health promotion, health care, and physical therapy, guaranteeing health services to the entire population.
In 2001, the National Health Plan extended the scope of health promotion strategies by defining broad objectives: promoting healthy lifestyles; fighting the major causes of death (cardiovascular diseases, cancer, infectious diseases and accidents); Improving the environment; protecting vulnerable members of society (children, elderly, disabled, destitute, etc.).  2.1.2 The Regional level
Regional governments, through their departments of health, are responsible for pursuing the national objectives laid out in the National Health Plan. In relation to health, the regional health departments deliver these through a network of population-based health care organisations (local health units), public and private accredited hospitals. They are responsible for legislative and administrative functions, for planning health care activities, for organising supply in relation to population needs and for monitoring the quality, appropriateness and efficiency of the services provided.  The regional level has legislative as well as executive functions, technical support and evaluation functions. Legislative functions are shared between the regional council and the regional government.  Legislative Decree 229/1999 states that regional legislation should define: the principles for organising health care providers and for providing health care services; the criteria for financing all health care organisations (public and private) providing services financed by the regional health departments; and The technical and management guidelines for providing services in the regional health departments, including assessing the need for building new hospitals, accreditation schemes and accounting systems.  This Decree has significantly increased the legislative power devolved to the regions and is being currently implemented at the national and regional levels.  The executive functions of the regional governments entail outlining a three-year regional health plan. This plan is based on National Health Plan indicators and on the assessment of regional health care needs and is used to establish strategic objectives and initiatives, together with financial and organisational criteria for managing health care organisations. Other responsibilities of the regional health departments are allocating resources to various health units and hospitals and applying the national framework rules to public and private health care and other activities related to health care.  The regional health departments in some regions also provide technical support directly to the local health units and to public and private hospitals. Other regions
have formed an agency for regional health care services, which is responsible for assessing the quality of the local health care and for providing technical and scientific support to the regional health departments and the local health units. Technical support is also provided during the planning process to assess population needs, to define the range of services to address those needs. Emilia-Romagna is one of the regions that have created such an agency for their regional health care services.  2.1.3 The Local Level
Bologna The 1978 reform gave an important role to municipalities, which were in charge of governing the local health units. However a series of reforms in the late 1980s shifted municipal powers to the regional level. From 1992, the structures operating at the local level in relation to public and private health care structures and providers were divided into four different categories: local health units, public hospital trusts, national institutes for scientific research, Private accredited providers.  At present the  municipalities carry out the functions of programming and controlling the health system as legally designated. Following these measures, municipalities assume a more important role in the political government of the National Health Service. More precisely, they evaluate the results of the health agencies.   The metropolitan health system must act in a network between the various provincial bodies and institutions, with the objective of realising a better and more efficient distribution of services, to agree prevention and communication strategies and carry out necessary control and monitoring procedures for these activities.  At present in the territory of Bologna there is a Territorial Social and Health Conference (TSHC) set up to carry out these functions at provincial level. The TSHC responds to functions outlined in regional law n°21 of 2003 and n°2 of 2003. The conference is made up of the president of the province of Bologna or his delegate, the mayor of the municipality of Bologna or his delegate and the mayors of the municipalities in the territory of the Bologna Health Authority. At the conference, tasks of active administration, control, direction are delegated. Among the control functions, the territorial social and health conferences express obligatory opinions on the planning budget, on the estimated budgets and the current balance sheet of the health agencies and send their comments to the region for eventual action by the regional administration, they also express a formal opinion on the appointment of the general managers of the health agencies.  As for programming, they participate in defining needs, evaluating health service functionality and their distribution in the territory. They promote and co-ordinate
agreements between municipalities and health agencies to improve the integration between social and health services.  Local health units are geographically based organisations responsible for assessing needs and providing comprehensive care to a defined population. They provide care directly through facilities or through services provided by public hospital trusts, research hospitals and accredited private providers (acute and long-term hospitals, diagnostic laboratories, nursing homes, outpatient specialists and general practitioners). A general manager appointed by the regional health departments for a period of five years heads them. Services are structured under a divisional model in which each division has financial autonomy over and technical responsibility for the different areas of the health care system, including health promotion. The health promotion department is responsible for health promotion as well as prevention of infectious and other diseases, promoting community care and enhancing peoples quality of life. These divisions also provide services for controlling environmental hazards, preventing infectious and other diseases, promoting community care, enhancing peoples quality of life, preventing occupational injuries and controlling the production, distribution and consumption of food and beverages. Local health units are responsible for delivering a benefit package by directly providing services or by funding hospital trusts and private accredited providers. The activities to be performed are defined in the local implementation plan, which should be consistent with the regional health plan. According to the 1999 reform (Article 3, Legislative Decree 229/1999), local health units have to guarantee equal access to services for all citizens, the efficacy of preventive, curative and rehabilitation interventions and efficiency in the production and distribution of services. They are responsible for maintaining the balance between the funding provided by regions and expenditure on services. Local health units are organised into health districts responsible for ensuring the accessibility, continuity and timeliness of care. Health districts also have the role of encouraging an intersectorial approach to health promotion and ensuring integration between different levels of care and between health services and social services. The health district, therefore, represents both an operational structure for providing services and a vehicle for promoting health projects that integrate various operational structures, in accordance with the strategic plans of the region and the local health unit. A co-ordinating office to achieve these objectives supports the manager of the health district. This office includes general practitioners, paediatricians and specialists to promote the integration of health care and social services, which is also accomplished by developing and disseminating general organisational guidelines.  Public hospital trusts provide highly specialised hospital care (or tertiary care).  
National institutes for scientific research are research-oriented hospitals operating at the local level. They are spread throughout Italy and are directly financed by the Ministry of Health.  Private accredited providers provide ambulatory, hospital treatment and/or diagnosis services financed by the NHS.  Genoa In Liguria there are five ASL, that divide their territories in 20 Basic Healthcare Districts, that organise primary help services, home care system and outpatient services. These bodies support the families, old and AIDS illness and manage the health care activities that the Municipalities delegate them with the co-ordination between other structures of the hospital assistance. The Basic Healthcare Districts, to perform these functions, make use of these subjects help: 1. Basic Doctors (Doctors of General Medicine and Doctor for Children): they weigh the real need of the citizen and regulate the access to the other services of the National Health Care System. 2. Medical Service on duty : it guarantees the non-stop assistance in all the day and for all days in the week 3. Hospitals  4. Not Hospital Health Structures : there are different structures that supply specialised services.  National Healthcare Fund in 2003 was   78.403.971.577 and in 2004 Respectively in 2003,   2.454.044.310 were allocated to Liguria, and in 2004,   2544.292.177. Healthcare expenditures are 40% of the whole balance of the Region. The balance of Ligurian Region is composed in this way: 4% prevention, 46% community, 48.5% hospitals (about 80.000.000 for First Aid activities), 1.5% emergency service and other.  2.2 The United Kingdom (Southampton) In the United Kingdom the Department of Health is a government department tasked with improving the health and well being of the population. The Department is responsible for: Setting overall direction and leading transformation of the NHS and social care Setting national standards to improve quality of services Securing resources and making investment decisions to ensure that the NHS and social care are able to deliver services Working with key partners to ensure quality of services, such as: -Strategic Health Authorities, the local headquarters of the NHS -The Commission for Healthcare Audit and Improvement (CHAI) and the Commission for Social Care Inspection (CSCI), new independent bodies
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