“Virtual Nurse”, a promotional and educational portal for health at the service of people

15 Jun
Marc Fortes

Stemming from the necessity to be able to access accurate health information, qualified and within reach of everyone, the Official Nurse’s College of Barcelona (COIB), launched the portal, Infermera virtual (virtual Nurse) in 2005 (in Twitter, @infermeria), for the promotion and education of health.

The almost 3000 pages of content that it contains aims to empower people in taking decisions about their own health while at the same time create a healthier society and achieve a more sustainable healthcare.

Citizens can find all this content adapted in formats such as video, infographs and health tutorials which make both the access and understanding of the information easier.

Additionally, Infermera virtual is a global professional project with the view of it becoming a working tool for nurses and other health professionals in the social area or that of education. The contents, which enable nursing knowledge on each of the health contexts to be shared in an enjoyable and rapid way, become links that allow professionals to prescribe or recommend this information directly to the people they attend, via email or sharing it via social networks.

To generate the content, there are structural, educational and scientific revision processes which are updated annually. The most important piece in the whole puzzle is undoubtedly the more than 70 authors and collaborators who generate all this content.

The Infermera virtual project is based on the 8 daily life activities, what we call “requirements that people must satisfy, in a specific time frame, for their own benefit with the aim of maintaining life, a healthy lifestyle, a continuous personal development and the greatest degree of wellbeing and quality of life possible”, and they are: to breathe, move, eliminate, avoid dangers, sleep, communicate with others, work and enjoy oneself, and eat and drink.

On the other hand, the units of content are organised in two large blocks which we call “life situations” and “health problems” which enable the other  files to be organised as “What you need to know”.

Among the health problems, one can find files ranging from an explanation of cancer to that about having a temperature, for example.

The portal is continuously growing and being improved and is also adapted to the circumstances of the changing context. This is why all the certified and personal content has been offered for more than a year via a free mobile application available both for Android and iOs.

A citizen can find all this content adapted in video formats, infographs and health tutorials which facilitate both the access to and the understanding of information. QR Codes can also be scanned using the application and notifications received related to health. On the other hand, health professionals can prescribe this content via a mobile phone or tablet.

One of the highlights of the application’s menu is the access to the more than  110 tutorials via ‘Look after your health’, aimed at clarifying doubts and obtaining more information about health problems, healthy life styles, life situations and aspects related to the different stages of life. Entering in ‘Files’, nurses and all health professionals can access the complete files created by nurses and other expert authors. Professionals also have direct access to consult on the structure and function of the human body.

If you are a user of the Metropolitan Transport of Barcelona, you may have seen the health advice in video format which is offered in collaboration with virtual Infermera in some of the metro stations and some Barcelona city buses.

The health advice comes by way of a friendly family of extra-terrestrials that have come to our planet unintentionally, the Bonsu Family, and this allows such diverse subjects as bullying at school to sun protection to be dealt with in less than 16 seconds.

Post written by Marc Fortes (@marcfortes).

The DECIPHER Project: from the interoperability to the procurement of innovation

8 Jun
Jean Patrick Mathieu

In 2013 when Agència de Qualitat i Avaluació Sanitàries (AQuAS) relaunched the project DECIPHER (@DECIPHERpcpEU), we were pioneering in the field of Procurement of Innovation and little did we know on the journey ahead. The project proved to be a big challenge for the AQuAS, the Catalan Department of Health and the all consortium involved.

The European Commission Officers and the projects evaluators would also be faced with a new type of project and with the projects consortium and stakeholders, we all learned a lot in this exciting adventure.

The journey would end in March 2017 with the Barcelona final event, but the aftermath of the projects will definitely be felt in the years to come.

Rossana Alessandrello at the DECIPHER – FINAL EVENT (Barcelona 2017)

DECIPHER was a project funded by the European Commission under the 7th  Framework Programme (FP7) under a call for project in 2011 whose topic was “Patient Guidance Services (PGS), safety and healthcare record information reuse”.

The objective of the project was to enable secure cross-border mobile access to existing patient healthcare portals which are individually supported by public bodies.

DECIPHER would deploy Pre-commercial Procurement (PCP) to create step-change innovations in mobile patient ICTs. Using electronic patient records as the key enabling technology, this joint PCP would create technology-led service transformation in cross-border mobile healthcare, delivering qualitative and significant benefits to patients and healthcare organisations.

The Consortium consisted of ESTAR Centro (Tuscany), TicSalut (Catalonia) and CMFT (Manchester).  Suppliers will be challenged to build on outputs from epSOS, CALLIOPE, and LOD2, and advances in mobile technology. Moreover, experts from Greece, France, Finland, UK, Sweden and Ireland will provide support.

DECIPHER will generate a portfolio of interoperable applications, deployed on a pan-European platform. This resource will improve existing healthcare services by supporting mobility of patients and healthcare providers.

As a use-case scenario, the solutions were to focus on patients with a chronic health condition and Diabetes type II was selected.

From anywhere in the European Union, a patient will be able to use a secure mobile device safely to gain 24/7 access to their prescription data, emergency data, examination results and other health information.

By the end of the project, 6 prototypes solutions were funded of which 3 finalists received full funding to develop a full final version. Although the respective national Personal Health Records (PHRs) systems of the three procuring authorities are not able to implement those solutions in their current state, the achievements are important for DECIPHER:

  1. Invaluable experiences were gathered by all stakeholders involved in the project
  2. SMEs from all over Europe came under the radar of potential clients, the public procuring authorities in the consortium and those who were interested on the project
  3. AQuAS acquired an expertise in procurement of innovation that is now well-renowned in Europe and beyond.
  4. The lessons learned will be applied in the new PCP project coordinated by AQuAs, Antisuperbugs.

DECIPHER project was initially designed to address the interoperability issue in the healthcare sector. But, this project has been fundamental in the development of a model of procurement of innovation useful for the set-up of this kind of project. With this objective in Catalonia, we consider DECIPHER as a case use where AQuAS lead the path with a set of toolkit, methodology and expertise.

Post written by Jean Patrick Mathieu.

We take shared decisions here

1 Jun
Víctor Montori

I was recently in Barcelona talking to a group of people interested in the taking of shared decisions (#decisionescompartidas) at a seminar organised by the Catalan Society for Health Management (SCGS) and the Agency for Health Quality and Assessment of Catalonia (AQuAS). My visit was the third stop on a trip which first took me to Poland and later The Netherlands. There is a very strong interest in the subject of shared decisions in all three countries and in all three there are efforts at different levels to promote this practice.

What motivates this interest is also something shared: the feeling that the involvement of patients in important decisions must inevitably reduce costs and improve clinical outcomes. It is also a general phenomenon that doctors feel cornered by this new expectation adding to their already existing agendas that compete for the meagre 7 minutes per patient.

In light of this reality, the promises to take shared decisions that better reflect the situation of a patient and how to deal with it, based on the informed participation of the patient, end up putting the onus on the patient of taking decisions by means of tools in web pages or on printed forms. But what about sharing the process of taking decisions? Corporate poetry, an academic dream.

Taking shared decisions requires patients and clinicians to work together so as to mutually agree on the best way to proceed in order to improve the patient’s situation. The outcome of this effort is a plan of care. To establish this plan it is important to understand what the situation of the patient is and what action is needed, as well as the options available to respond to the demands that the situation dictates in the best way.

The conclusion reached must make sense, intellectually, emotionally and practically. That is, the plan must reflect the best medical science, it has to be agreeable within the biological and biographical circumstances of the patient and be able to be implemented with the least possible inconvenience in the life of the patient. This work is not for the patient to do, nor the clinician, but for both. It is challenging and is based on a clinician-patient relationship, and it takes time.

Many clinicians tell me that they already take decisions together with their patients. This is not evident when we watch videos of clinical encounters in North America (15-30 minutes in length). In these, we see clinicians interrupting patients after less than 11 seconds from the time a patient begins talking, using humour to avoid emotional situations and offering recommendations before listening to the patient’s point of view.

Victor M.Montori in the Shared Decisions Conference (SCGS and AQuAS). Barcelona, 19 May 2017

The fact that patients want to participate or that they do in fact participate actively in the taking of decisions is not evident either and yet, patients report high levels of satisfaction in the way that decisions are taken. However, a critical look reveals that many decisions are taken without patients realising it, given that these decisions are disguised as the logical steps to follow in managing a problem rather than being opportunities for the patient to contribute in the process with their opinion, point of view, experience and knowledge.

The effort of converting the taking of shared decisions from what it is (a unicorn) to what it should be (something routine in the care of patients) is enormous and full of uncertainty. There is no country, in my opinion, nor any health system which is at the forefront on this subject. At the tail end, there are of course countless systems that are still hugely in debt with their populations for not yet having been able to guarantee universal access to health with minimum levels of quality and safety.

What those at the forefront need to do, in my opinion, has more to do with attitude and opportunity than with tools or incentive and training programmes. The latter must be there when attitude and opportunity appear.

In my visit to Barcelona I saw great willingness, but with noticeable limitations in attitude and opportunity. In attitude, as health professionals we need to value what patients know about their context, about their biology and biography and about the way in which they want to lead their lives.

We must acknowledge how essential it is that treatment plans make sense and that it is possible to implement them in the lives of patients, especially in the case of chronic patients. And we must be aware that practical guides and other management tools for management are useful to guide our treatment of “patients like these” but are not enough to determine the treatment for “this patient”.

But attitude is not enough. In addition, we need to work at creating opportunities for conversation between clinicians and patients and that these become therapeutic relationships. I believe that our intellect has evolved in the taking of decisions with others. In the same way that I believe in deliberative democracy for social problems, I believe in taking shared decisions for clinical problems.

Clinical problems are not simple (such as in the problem of baking biscuits, with a known recipe and ingredients and an expected result), they are not complicated problems (like flying a 747, with algorithms and feedback that lets one be confident of achieving the desired result) but they are complex problems (like raising a child, with known ingredients, without a recipe or algorithms and with sometimes unexpected results).

Complex problems cannot be solved by technical investments only. These are solved within human relations. Specific results cannot be expected, but one can respond to adverse situations with resilience. Without the fuel of opportunity for this, the flame of a favourable attitude in the taking of shared decisions will be extinguished in the end.

The taking of shared decisions needs human relations between clinician and patient to resolve the human problems of the patient with resilience. In turn, the solution of these problems requires decisions to be shared for the solution to make intellectual, emotional and practical sense in the life of the patient.

Besides attitude and opportunity, it is important to have interpersonal skills (or train up to acquire whatever is possible) so as to communicate with a patient with empathy, to understand their situation and to assess each reasonable option in the context of a conversation.

In this context, tools based on evidence designed specifically to support these conversations can be useful and can facilitate the efficient taking of shared decisions in any context, from emergencies to specialised care.

I am aware that many have found the motivation to participate in taking shared decisions thanks to training or the use of tools for taking shared decisions. This makes it important to understand what is necessary and where so that taking shared decisions becomes routine practice in the care of patients.

But what does all this effort achieve? Many colleagues say that the taking of shared decisions can improve clinical outcomes, the adherence to treatments, the use of services and the costs of care. Taking shared decisions might also help in preventing global warming.

My critical appraisal of the evidence available does not allow me to discern any of these benefits with a sufficient level of certainty. This forces us to consider why we must thus make the effort to create the conditions to be able to take shared decisions and to implement this as routine practice.

For me, as a clinician, the answer comes by means of understanding the aim of a treatment, of clinical care as well as by allowing each patient to fulfil their dreams with the least pathological interruption and the least therapeutic inconvenience possible. To achieve this, we need to design treatments that respond to a patient’s situation – seen in high definition – treatments that make sense for the patient, and a clinician cannot do this without the patient.

Post written by Victor M. Montori (@vmontori), Professor of Medicine at the Clínica Mayo (United States), KER Unit, http://shareddecisions.mayoclinic.org