Telehealth in the Basque Country
Dr. José Asua
Health Technology Assessment (Osteba)
Department of Health, Basque Government
Telemedicine in Spain
Most of the 17 regions have implemented:
Electronic Clinical Records
Key aspects that require further development:
Compatibility among regions
Acceptability of clinicians and other health
Where is the Basque Country?
Where is the Basque Country?
Guide for the evaluation of heath services
based on telemedicine
Structure of the Guide
Important points to consider
prior to the establishment of Design and evaluation of
Introduction of the
telemedicine research telemedicine research
projects and pilot projects projects and pilot projects
Chapters 1 - 2 Chapters 3 - 7 Chapters 8 - 9
Design of telemedicine assessment studies
Identification of the needs, search for Identification of barriers
opportunities and setting up of priorities
Comparison: Effectiveness and safety
Outcome measures to be evaluated health care Economic analysis
Monitoring of the telemedicine activity
Telemedicine Evaluation Framework
3. Health system outcome
2. Changing patterns 5. Implementing
Need for change in Evaluation
of healthcare change
resource use practice
1. Importance of the 4. Quality scientific 6. Factors
disease evidence on affecting
Decision framework for the development of telemedicine applications adapted from Hebert et al. 2006.
Essential Elements for the Evaluation of
Project description and research questions
Project management plan
Level and perspective of analysis
Research design and analysis
Individual structure : Individual outcomes:
*Patient * Patient
- Access to services, adaptability
, - Satisfaction with health
*Provider - Quality of life
- Training with the equipment . - Fuctional status
- Changes in clinical practice
- Satisfaction with health
Healthcare process: - Number of hospitalizations
- Adverse effect rate
- Efectiveness compared to
face to face examination
- Management of the health
- Location of equipment - Efficient use of resources
- Cultural aspects -
- Costs - Healthcare service usage
- Effectiveness of the equipment
Telemedicine Evaluation Framework proposed by Hebert 2001
Design of the new telemedicine service (Design of the organizational model)
Optimization of the initial design (Operative research)
Is it feasible? YES
Assessment of the designed organisational model
Is it more efficient?
Pilot test in real context
Is it effective?
NO Is it safe?
YES ¿Are there any complications not
detected during the pilot project?
Implementation of the telemedicine
Algorithm for the design and evaluation of application in the clinical practice.
a health service based on telemedicine NO
Continuous monitoring of the activity.
• Tele Ophthalmology for diabetic retinopathy
• Tele Dermatology
• Tele Home care in chronic patients
• Tele control of the quality of Spirometries
• Tele Neurology
• Tele Oncology
1.- Telescreening of Diabetic Retinopathy.
1. To conduct a systematic review of existing data on the
effectiveness, diagnostic accuracy and reliability of
teleophthalmology for the diagnosis of diabetic
retinopathy and other eye diseases.
2. To evaluate a store-and-forward teleophthalmology
service linking a primary healthcare region and the
ophthalmology division at Cruces General Hospital.
3. To carry out an economic assessment of two of the
diagnostic tools used for the detection of diabetic
retinopathy: the digital non-mydriatic retinal camera vs
the conventional indirect ophthalmoscopy.
Diabetic Retinopathy Screening using
Non-Mydriatic Retinal Camera
Transmission of encrypted images
to specialist reading centre
Systematic Literature Review: Inclusion Criteria
Studies conducted from 1997-2007, published in
English or Spanish.
Study designs: systematic reviews, meta-analysis,
controlled clinical trials, prospective studies,
retrospective studies, case-series.
Participants: patients examined through telemedicine.
Description of software, photographic techniques,
Studies in which the patient is not physically present
during the telemedicine consultation.
Selection of Studies
923 References retrieved
21 Cochrane Library
25 CRD databases 346 duplicated records
23 PASCAL BIOMED
182 Web of Knowledge
499 References excluded
577 Initial References Did not meet the inclusion criteria
78 Studies selected from the abstract 58 Studies excluded after
complete text review
19 Studies included
Accuracy of Teleophthalmology
Strong evidence showing that telemedicine is a highly
sensitive and specific technique for the detection of DR,
glaucoma and AMD.
Eye disease Sensitivity Specificity
Diabetic retinopathy 85-100% 71-95%
Glaucoma 91% 94%
AMD 89%* 94%*
*For the detection of pigmented epithelial detachment
Store-and-Forward teleophthalmology appears to be
an effective method for the screening of retinopathy in
patients with diabetes Mellitus:
Accuracy: sensitivity and specificity values close to those
specified at the St Vincent Declaration (80 and 95%).
Reliability: good agreement between clinical examination
There were not enough high quality studies to prove
the effectiveness of telemedicine as a screening
method for other eye diseases.
Assessment of a Teleophthalmology
Service from Biscay: Evaluation of the
Satisfaction and Impact on Waiting Lists
Diabetic Retinopathy Screening
PRIMARY PC PRIMARY
CARE OPHTHALMOLOGIST CARE
SC Intervention Presence of Absence of
OPHTHALMOLOGIST / Treatment DR DR
PRIMARY RETINAL PRIMARY
CARE CAMERA Results CARE
PC Presence of Absence of
OPHTHALMOLOGIST DR DR
/ Treatment OPHTHALMOLOGIST
Usage of the Non-Mydriatic Retinal Camera
Total Number of Tests = 5,654
No of photographs taken / month .
Impact of Telemedicine on Primary Care
Ophthalmology Waiting Lists
Number of Patients in Waiting List Number of Days in Waiting List
300 60 49,6
No of patients in waiting list .
No of days in waiting list .
Mean before establishment of Mean after establishment of Mean before establishment of Mean after establishment of
telemedicine telemedicine telemedicine telemedicine
The number of patients in waiting list decreased significantly after the
establishment of telemedicine in the region
There was no significant alteration on the average number of days per
patient in waiting list
GP Satisfaction with Teleophthalmology
100% 100% 100%
90% 86% 87%
Percentage of Positive Answers.
60% 57% 57%
Reliability Information Management DR follow up Patient Usefulness Speed GP
quality of patients satisfaction satisfaction
Questionnaire sent to 102 GPs of the Uribe region
Response rate = 29%
Patient Satisfaction with Teleophthalmology
180 patients were given the questionnaire after a
pilot test was run.
Response rate = 50%.
95% of the patients had type II diabetes.
47% of the patients were diagnosed with diabetes 6-
10 years ago.
All patients showed a high degree of satisfaction
with the telemedicine procedure.
Patient Satisfaction with Teleophthalmology
80% 35% 37%
30% 65% 63%
Duration of the visit Access Information Overall satisfaction
The establishment of the teleophthalmology system in the
region has had an impact on the ophthalmology waiting lists.
Despite the significant reduction in the number of patients in
waiting list, the average waiting days per patient did not
This may be due to organisational issues that need to be
It could imply that ophthalmologists have more time for other
Both patients and GPs showed a high degree of satisfaction
with the teleophthalmology procedure.
Teleophthalmology appears to facilitate referral of patients
with DR to ophthalmologist for appropriate care.
Economic Analysis of the Use of a
Digital Non-Mydriatic Retinal Camera
Methodology Used for the Economic Analysis
Direct costs which differ for both techniques were
calculated, including time spent by medical
personnel, equipment, consumables, maintenance
of equipment and internet connexion.
A one-way sensitivity analysis was carried out
considering two different scenarios (an optimistic
and a pessimistic one) depending on the dexterity of
the person in charge of the digital camera.
Results of the Economic Analysis
Cost assessment results:
The average total cost per patient was 8.33 € and
7.67 € for ophthalmoscopy and the digital camera,
One-way sensitivity analysis results:
Optimistic scenario: savings of 1.57 € per patient for
the digital camera compared to the ophthalmoscope.
Pessimistic scenario: the ophthalmoscope is 0.70 €
cheaper per patient than the non-mydriatic camera.
Total Costs of the Screening Alternatives
(80% ophthalmoscope, 20% retinal camera)
HS1: exclusive use of the ophthalmoscope 158,919 €
HS2: exclusive use of the retinal camera 146,314 €
HS3: 90% retinal camera, 10% ophthalmoscope 147,574 €
HS: Hypothetic Scenario N = 19,076 patients
Our results coincide with the findings of other published
studies indicating that the use of the digital non-
mydriatic camera is cheaper than the conventional eye
examination through ophthalmoscopy.
For the current scenario, in which 19,076 patients are
examined for diabetic retinopathy each year, the digital
camera is 0.66 € cheaper per patient and has shorter
waiting lists that the traditional eye examination using
The payback period of the cost of acquiring a digital
fundus camera is 2.92 years and 3.35 years for the
hypothetic scenarios with high usage of the retinal
camera HS2 and HS3, respectively.
2.-Telemonitoring of Patients with
Heart Failure or COPD
Heart failure (HF) and Chronic Obstructive Pulmonary
Disease (COPD) are among the leading causes of
mortality and morbididy.
Information and Communication Technologies (ICT)
could allow distance follow-up of these patients at
This study aims to assess the utilisation of tele-
homecare in HF and COPD patients.
Patients’ and carers’ satisfaction, technology
accepance by heathcare professionals, and impact on
health services utilisation will be assessed.
Telemonitoring of Patients with
Heart Failure and COPD
Orruño E, Asua J, Gagnon M-P
Telemonitoring system used in the study
Telemonitoring of Patients with Heart Failure
Randomised clinical trial with a 1year follow up comparing:
Control group: received a previously tested multiple strategy of individualised care (MSIC)
Intervention group: daily transmission of blood pressure, weight, temperature and O2
saturation using a home telemonitoring system in addition to the MSIC.
Degree of satisfaction of patients and carers validated questionnaires.
Estimation of the quality of life of the patients EuroQoL EQ-5D questionnaire.
Evaluation of telemedicine adoption by physicians Technology Acceptance Model (TAM).
Pictures of skin lessions
….. questions, comments?
Dr. José Asua