Collaborative Point-of-Care Services Agder: Follow-up of COPD patients as part of the United 4 Health EU Project

U4H is part of a large EU-financed study: UNIversal solutions in TElemedicine Deplyment FOR European HEALTH care = United4Health, with 33 partners in 15 countries. The European study seeks to implement telemedical followup on a broad scale for 3 different patient groups (COPD, diabetes mellitus and heart failure) and includes close to 12 000 patients, of whom 2000 patients woth COPD in 6 centres. The Norwegian VERDIKT- project seeks to demonstrate that COPD (Chronic Obstructive Pulmonary Disease) patients can be closely monitored and followed up in their homes, using telemedical solutions, where decentralized care teams are responsible for the daily patient communication and care. The project aims to: 1. Improve the patient's telemedical communication with support network of relatives, informal caregivers and healthcare professionals. 2. Establish triage procedures for remote evaluation of clinical condition by a combination of questionnaire and measured indicators of lung functions by telemedical technology. 3. Establish well defined thresholds for different forms of treatment and hospital admission, based on a scale of indicators in an algorithm for COPD. 4. Improve the quality of life for COPD patients and empower them to stay longer at home. 5. Developing new ICT-services, establish a flexible and general platform for an international market. An approach with home-monitoring and video-conferences in the treatment and follow-up of patients creates a number of principal, economic, judicial and scientific questions. These demand exploration of new organizational structures on close dialog with users, health care workers, researchers and technological suppliers. The Norwegian part of the EU-project needs to relate to the Collaboration Reform, integrating primary- and secondary care. The project aims to describe a future model for collaborative telemedical care for all 30 counties in Agder, which gradually aims at more patients groups with chronic diseases. The project itself aims at development of a technological solution for homebased care for COPD-patients using a web-tablet. In the first phase a model for Agder is established with a telemedical center for Kristiansand county and another for the Lister area, and procedures and routines for followup of patients are developed. Personnel are trained and equipment are tested at the Centre for E-health at UiA and in real-life connected to patients. A consortium agreement for the VERDIKT-project has been signed between the partners: SSHF, UiA, DIPS ASA, Devoteam solutions AS, Sintef ICT dept Trondheim and Applica consulting AS.

Chronically ill patients needs close follow-up at home-based Point-of-care, where different health care organizations needs to have close collaboration with coordinated services. The present project seeks to develop telemedical solutions for communication between the patient, caregivers, primary health care and the hospital. The project is closely related to the EU-project "United4Health", where Sørlandet Hospital HF is supposed to follow up COPD patients for a period of time after hospital treatment. Bas ed on the Collaboration reform in Norway, such remote home care should be carried out in close collaboration between the primary health care service, the local doctor (GP), and the Specialist service. This requires establishing new organization of care te ams, with suitable technological solutions. Medical indicators should be developed, in order to evaluate the patients' actual condition based on a standardized triage, where the need for follow-up and escalations in treatment when needed are defined. Deci sions will be decentralized to local health care services, and supervised by the GP and/or specialist. This is assumed to give cost-effective treatment plans for large groups of chronically ill patients like CHF, COPD, and Diabetes etc. line with the prin ciples of Best Effective Care Level (in Norwegian: BEON). During the project period, important aspects of organizational, juridical and technology obstacles will be taken care of and new solutions and procedures will be evaluated in a clinical trial. Inte rnational aspects are incorporated, and the main results will be disseminated within EU-projects. The project will collect research data on benefits for patients, relatives, informal caregivers and healthcare professionals and also some data for cost-effe ctiveness analyses. This includes time used in daily follow-up with remote monitoring, changes in the patient's condition, number of acute interventions and measure of Quality of Life.