Event-‐Driven Telecare Monitoring Systems
Paper: MSc Thesis, Technology Management Version: Public version
Event-Driven Telecare Monitoring Systems
By Hein Souman Supervisors at university:
Prof. Dr. Henk Sol Drs. Robert Rozier - Supervisors at De Trans: Drs. Ignaas Folkers Drs. Benny Langenkamp - University of Groningen School of Economics and Business
Preface
This thesis paper describes the final research project to qualify for the degree of Master of Science in Technology Management at the University of Groningen.
The research conducted was intended to determine how De Trans’ event-driven telecare program can be utilized and what the key success factors are. I hope that the results of this thesis can ultimately help create a better quality of care.
I would like to thank all of my supervisors for their guidance during this project. Amersfoort
Management Summary
In 2010, De Trans began preparing for the construction of new buildings (expected to start in 2013) with a budget of 15 million1 euros.
As part of these preparations, it is important for De Trans to be able to make informed decisions about the correct utilization of the technology to be used during the nightshift and its impact on the care process, especially so since several problems occurred after the introduction of the event-driven telecare system in 2008. The telecare system is designed to monitor the status of clients during the night in response to which, based on the different event alerts, the nurse has to take (care-based) action. However, with the introduction of this “triggering function” that generates the alerts, a
number of problems arose: too many (false) alarms are triggered in De Trans. Also, the personnel tend to perceive the technology as too expensive and with many disruptions due to malfunctioning. These problems undermine the trust of personnel and thereby possibly the safety of clients and quality of care.
Considering the recent changes, the perceived problems and possible new implementations of a telecare monitoring system, it is unclear to De Trans whether an optimal configuration has been reached between personnel, care processes during the nightshift and investments made in the telecare monitoring system. In other words, De Trans wants to know what the success factors are in the utilization of an event-driven telecare system.
The aim of this thesis is to describe the required steps to a better design of the current used telecare system also regarding future implementations of telecare.
How can the telecare be redesigned in order to create an even-driven care process with use of a telecare system and what are thereby the key factors for a successful utilization?
An analysis has been made of the current use of the telecare system and the care process during the night, with the following results:
• There is a lack of management information regarding the amount of alerts and unplanned care process during the night.
• De Trans does not have the necessary insight into the future operational costs of the telecare system and is therefore not in financial control.
• The system is not used in an event-driven manner for the delivery of unplanned care. In other words, the trigger for unplanned care is the personnel, not the telecare system, which can be configured individually per client.
• Some of the personnel/stakeholders distrust the system as a “gatekeeper” for triggering the delivery of unplanned care services while maintaining client safety.
De Trans plans to start a pilot project at the end of 2012 in which the telecare system is linked to the contact center (ZCN) located in Meppel. De Trans wants the pilot to be the start of centralized assessments of alarm events that will divide the deployment of employees in the current care process in terms of delivering planned and unplanned care. The pilot is a prelude to event-driven care, 24/7, 365 days a year, with the use of proven technology in careful collaboration and communication with clients and employees. However, when examining the challenges in the current use of telecare technology, the prerequisites for the pilot have not been achieved and the pilot is therefore doomed to fail.
The established success factors make it possible to use a systematic approach regarding a better design and utilization of a telecare system by examining the following domains: Technological context (1), External context (2), User context: innovation-value fit (3), Organizational climate (4) and Implementation strategy (5).
This thesis provides concrete directions for removing the current barriers to the successful utilization of the current telecare system and using the key factors for future implementation with or without the
1 Table of Contents
PREFACE 3
MANAGEMENT SUMMARY 4
1
INTRODUCTION 7
1.1
ESPRIA GROUP 7
1.2
RECENT CHANGES AT DE TRANS 9
1.3
PROBLEM DEFINITION 10
1.4
RESEARCH QUESTION 11
1.5
SUB-‐QUESTIONS 11
1.6
SCOPE 11
1.7
OUTLINE OF THESIS 11
2
RESEARCH APPROACH 12
3
LITERATURE REVIEW 14
3.1
TELECARE MONITORING LITERATURE 14
4
ANALYSIS 20
4.1
PROCESS AND PROBLEM DESCRIPTION 20
4.2
TELECARE MONITORING SYSTEM AT DE TRANS 23
5
TO BE DESIGN AT DE TRANS 29
5.1
PILOT EVENT-‐DRIVEN TELECARE WITH A CONTACT CENTER 29
5.2
DIRECTIONS FOR A SUCCESSFUL DESIGN 30
5.3
SOLUTIONS TO THE PROBLEMS 31
6
CONCLUSIONS 37
6.1
LIMITATIONS 41
7
REFERENCES 42
1
Introduction
This chapter describes the care organization Espria Group and, more specifically, the De Trans organization, located in Drente in the Netherlands. An overview is also given of recent developments in the field of health care for adults with developmental disabilities, the utilization of care technology in general and the telecare technology implemented in recent years at de De Trans.
1.1 Espria Group
Espria is a large Dutch health care organization that provides a wide range of care, welfare, housing and social services. The care services provided are maternity care, childcare, elderly care, mental health care and care for the mentally disabled. The Espria care group serves over 224,000 clients and has more than 38,000 employees (2010).
De Trans
De Trans, a member of the Espria Group, has two locations, one in Rolde (North Division) and one in Emmen (South Division), both located in the Province of Drenthe in the Netherlands.
De Trans provides care and services to around 500 clients (Table 1.1) with: • Autistic disorders with intellectual disabilities
• Auditory and visual impairment combined with other disabilities • Severe multiple disabilities
• Severe mental retardation • Geriatric issues
• Mild intellectual disability
• Strong behavioral problems and severe mental retardation • Strong behavioral problems and mild intellectual disabilities • Mental retardation
Characteristic for these 500 clients is their challenging behavior caused by a number of factors. According to TACSEI (Research Center, U.S. Department of Education), this includes:
• Biological (pain, medication, need for sensory stimulation)
• Lack of knowledge of community norms, insensitivity of staff and services to the person's wishes and needs)
• Environmental (physical aspects such as noise and lighting, or gaining access to preferred objects or activities)
• Psychological (feeling excluded, lonely, devalued, labeled, disempowered, living up to people's negative expectations) or simply a means of communication.2
Looking at De Trans, the above-mentioned characteristics of the clients and their challenging
behavior has resulted in care services with the use of healthcare technology which has the objective to support these clients, with a focus on their talents and abilities. De Trans considers event driven telecare monitoring a means/tool to support every client in his or her specific needs. Furthermore the role of telecare systems is to help De Trans to improve their efficiency by providing health and community care professionals with remote patient monitoring tools. These tools cannot replace human care providers, but, rather, provide care providers with the means to address the increasing demand for services, along with more patient-focused care.
Core data Number/ amount
Clients Number
Number of clients with care and stay, end 2010 493 ZZP (care intensity package) clients with care and stay, end of year 493 Total clients with day activities, end of year 278
Capacity Number
Number of available beds 512
Production Number
Days with care and stay, end of year 180,252 ZZP (care intensity package) days with care and stay, end of year 178,951 Number of part-time daytime activities 51,719 Number of hours of extramural production 84,979
Personal Number
Number of personal 1,041
Paid employment (FTEs) 723
Business revenues Amount (euros)
Total revenues, broken down into: 56,426,687 - Legally accepted cost budget 51,796,334
- Other income 4,630,353
Ratios
Ratio of full-time personnel to clients 0.94 FTE per client Legally accepted cost budget per client 67,181 euros per client
Table
Table 1.1 - De Trans data (Dec. 31, 2010)
1.2 Recent changes at De Trans
For reasons of the above-mentioned general healthcare problems and outdated facilities, De Trans began demolishing and redeveloping their site in Rolde three years ago. The clients were relocated from the central institution to decentralized group homes of 4 to 12 people.
During the old nightshift and delivery of care services, De Trans personnel were supported by a telecare monitoring system for unplanned care. The technology used in the old situation entailed caregivers listening to clients from a distance to check whether they were sleeping well. Due to the limited possibilities to set acoustic thresholds, almost every client had to be monitored manually. The personal knowledge and experience of the caregiver in the control centre determined whether or not and, if so, how quickly care was provided to a client. This meant that whether or not a client was in need of help (and, if so, action had to be taken) depended entirely on the personal assessment of present care personnel. The same held true for the interpretation of camera images. As for the planned care at night, the personnel on duty walked two rounds in which all clients were visited. The clients who didn’t need planned care were also monitored, and therefore frequently disturbed in their sleep. The old situation can be summarized as follows:
• Private site, buildings and infrastructure • Large centralized client groups
• Central monitoring system
• Two rounds along all clients, with planned care • Written transfer of knowledge and client reports
The goal of the development of new facilities can be summarized as follows:
• Clients should live in houses in a “normal” neighborhood (integration in residential areas) • The use of public technological infrastructures
• Telecare configuration based on client-specific demand – Incident-driven
• The use of electronic patient dossiers and reports
• Alarms and incidents are communicated to an external contact center with skilled personal – Mobile care teams
–
Efficiency and increased quality of care1.3 Problem definition
In 2010, De Trans began preparing for the construction of new buildings (expected to start in 2013) with a budget of 15 million3 euros. As part of these preparations, it is important for De Trans to be able to make informed decisions about the correct utilization of the technology to be used during the nightshift and its impact on the care process, especially so since several problems occurred after the introduction of the event-driven telecare system in 2008. The telecare system is designed to monitor the status of clients during the night in response to which, based on the different event alerts, the nurse has to take (care-based) action. Actions are for example: helping clients use the bathroom, guiding wandering clients back to bed or nursing clients with a seizure. However, with the introduction of this “triggering function” that generates the alerts, a number of problems arose: too many (false) alarms are triggered in De Trans. False alarms are the case when there is not a emergency situation for a client and no actions of personnel are required. Also, the management tends to perceive the
technology as too expensive and with too many disruptions due to malfunctioning. These mentioned problems undermine the trust of personnel and thereby possibly the safety of clients and quality of care.
Considering the recent changes, the perceived problems and possible new implementations of a telecare monitoring system, it is unclear to De Trans whether an optimal configuration has been reached between personnel, care processes during the nightshift and investments made in the telecare monitoring system. In other words, De Trans wants to know how to create a better design that results in a successful utilization of an event-driven telecare system.
Therefore the aim of this thesis is to analyze current perceived problems and describe the required steps towards a better design and use of the telecare system. This is especially relevant because of the planned implementations of telecare in the future with the use of an external contact center.
1.4 Research Question
How can the used telecare in the nightshift be redesigned in order to create an even-driven care process with use of a telecare system and what are thereby the key factors for a successful utilization?
1.5 Sub-‐questions
1. What is the current care process during the nightshift?
2. What are the key success-factors in designing and utilizing an event-driven telecare system? 3. What are the implications of a possible redesign, for example the external contact center as
foreseen in the pilot project?
1.6 Scope
The following constraints are applied to this research:
1. Only clients with the ZZP 4+4 profile are supported with technology.
2. Only the care process during the nightshift (when the telecare monitoring system is used) is considered.
3. Only group homes with a similar use of technology and residential facilities at the De Trans Rolde location are taken into account.
Definition of event-driven
From a thesis viewpoint, an event is an automatic warning, an incident that results from a
measurement or other acquisition of descriptors of a state (the client state in this case) and indicates a relevant deviation from the normal state.
1.7 Outline of thesis
Chapter 1 briefly introduces the De Trans organization and its care services. It presents the problem statement, research question and a brief overview of this thesis.
Chapter 2 presents the research approach, i.e. the methodology used to answer the research question.
Chapter 3 presents the relevant background information in the following order: – Telecare monitoring literature
o Definition of telecare
o What is an event-driven telecare system? o The complexity of telecare
o Key factors for a successful implementation
Chapter 4 presents the analysis of the current care processes during the nightshift and the current utilization of the telecare system.
Chapter 5 presents possible directions for a successful utilization of the telecare system by examining the planned telecare pilot at De Trans with the use of an external contact center, and by discussing the a better design and key factors for success.
Chapter 6 presents the conclusions of this thesis and recommendations for future work.
2 Research approach
This chapter describes the approach chosen to answer the research questions and the procedures used. A background will be created from existing studies and literature in Chapter 3.
The OBS systems approach (Simon, H.A., 1979), is a system thinking approach and problem-solving method that helps to:
1. Define the problems as clearly as possible.
2. Analyze the problem and identify alternative solutions.
3. Select from the alternatives and develop the most viable solution mix. 4. Implement and test the solution.
5. Evaluate the effectiveness and value of the solution.
Figure 3.1 –Steps in the Analysis phase
This is followed by a description of the adjustments that need to be carried out for the “TO BE” situation. Furthermore, what consequences does the proposed pilot at De Trans with the use of a contact center have for the care process and the current utilization of the telecare monitoring system? How can one determine the right deployment of personnel and how can one correctly deal with alarms in a manner that safeguards the safety of clients and quality of care?
Figure 3.2 – Steps for the TO BE design phase
Analysis TO BE design (Future) implementation
Chapter 4
Process and problem description Telecare monitoring system Bottlenecks current situationTO BE Design Analysis
Chapter 5,6,7
Pilot solution De Trans Solution towards
3 Literature review
3.1 Telecare monitoring literature
Telecare or telemedicine?
One problem for researchers in the field of care technology is the loose terminology (Nagendran et al., 2000). “Telecare”, “telehealthcare”, “telemonitoring” and “telemedicine” are all used
interchangeably, sometimes within the same document, and have different meanings to different people. All of these terms describe the remote delivery of health and social care using ICT (Barlow, J., Bayer, S., Curry, R. 2005).
“Telecare can be defined as a set of services bringing care directly to the end-user. This differs from telemedicine, which covers ICT-based systems to facilitate the exchange of information between health care professionals” (Barlow, J., Bayer, S., Curry, R. 2005).
“Telecare systems mitigates harm by reacting to untoward events and raising a help response quickly. Telecare is specifically different from telemedicine and telehealth. Telecare refers to the idea of enabling people to remain independent in their own homes by providing person-centred
technologies to support the individual or their carers.”
(Department of Health, England , 2008).
According to the definitions above, telecare is related to monitoring activity changes over time and the continuous and automatic remote monitoring of clients to enable independent (safe) living. Telecare will raise a call for help in emergency situations, such as a fall, a seizure or a fire. This thesis examines the key success factors in the utilization of a telecare system that enables an event-driven care process. More specifics of an event-driven telecare system are therefore researched. What is an event-driven telecare system?
Martin et al. distinguishes three generations of telecare systems. The first generation refers to relatively simple systems with panic buttons, where clients have to personally operate the system to call caregivers in case of an emergency.
reliable and capable in detecting dangerous situations (Brownsell, S., Blackburn, S., Hawley, M.S, 2007).
The third generation systems use sophisticated ambient intelligence technology that is able to detect changes in patterns that may not be readily observable (Martin, T. 2009). However, studies shows that the third generation system can be described as developmental in nature. This raises the concern that unevaluated telecare applications are being deployed, and may, in some cases, be exposing vulnerable people to increased risk. (Brownsell, S., Blackburn, S., Hawley, M.S, 2007).
The main benefits of telemonitoring for patients can be summarized as follows (Dijkstra, J., Jurriëns, J.A., Van der Mei, R.D. 2006):
• Thanks to telemonitoring, medical experts can receive an alarm earlier than without the use of telemonitoring. This can prevent serious disorders after an emergency.
• Neither patients nor health care professional need to travel for regular monitoring compared to older monitoring systems that are not event-driven.
• The idea that medical experts receive an alarm in case of an emergency can give clients a sense of safety.
The complexity of telecare
In the case of telecare applications, “user needs” are especially complex due to the variety of
stakeholders, and include their compatibility with service delivery organization and the capability for integration with existing systems that support service delivery (Barlow et al., 2003b; Sixsmith & Sixsmith, 2000).
Coordinating these stakeholders and finding an appropriate model for recovering and sharing costs makes the mainstream implementation of telecare far more challenging than setting up a pilot project. According to Bayer et al. (2007), the conceptual and practical leap from pilot to mainstream telecare service is considerable. When assessing the costs and benefits of telecare, care should be taken when comparing services aimed at different client groups. Pilot projects are usually time-limited and involve extra effort and motivation to ensure their success. Moreover, they can be subject to initial teething problems and may disrupt existing work routines.
technology issues (Bowles, K.H., O’Connor, M., Hanlon, M.D., Naylor, M.D., Riegel, B., Weiner, M., Glick, H., 2012).
Another barrier to the successful utilization of a second-generation telecare system is false positive alarms. From a thesis viewpoint, an alarm event is an automatic warning, an incident that results from a measurement or any other acquisition of descriptors of a state (the client state in this case) and indicates a relevant deviation from the normal state (Bowles, K.H., O’Connor, M., Hanlon, M.D., Naylor, M.D., Riegel, B., Weiner, M., Glick, H., 2012)..
With the deployment of devices that have alarm capabilities and generate optic and acoustic alarms to alert staff to either a change in the patient’s condition or a malfunction of the equipment, studies show that up to 90% of all alarms in care monitoring are false positives. In many cases, they result from measurement and movement artifacts (Imhoff, M., Kuhls, S. 2005).
The multitude of false alarms leads to a dangerous desensitization of the care staff toward genuine alarms. Although alarms are an important, indispensable, and sometimes lifesaving feature of devices, not only can they be a nuisance, but they can also compromise the quality and safety of care due to their frequent false positive alarms. Moreover, even in the case of a true and valid alarm, further problems arise, as devices from different vendors may annunciate the same alarm instance in different ways, and different alarm instances may result in similar alarms from different devices. (Borowski, M., Siebig, S., Wrede, C., Imhoff, M. 2011).
According to Imhoff, M et al. there are two major issues: the correct identification of a situation that needs to be alarmed, which can be considered a detection and decision problem, and the consistent and unambiguous annunciation of this alarm, which can be considered a user interface and human factor problem. (Imhoff, M., Kuhls, S. 2005).
What are key factors for a successful design and utilization of telecare systems?
Implementation success can be seen as a crucial prerequisite in order to attain the intended innovation benefits. Postema et al. (2012) identified in their study ten key influencers divided over five
with even greater complexity than in, for example, hospital care (Postema, T.R.F., Peeters, J.M., Friele, R.D., 2012).
The categories used: technological context (1), external context (2), user context innovation-value fit (3), organizational climate (4), and implementation strategy (5) - are considered to be general parameters when evaluating health care implementation success (Postema, T.R.F., Peeters, J.M., Friele, R.D., 2012) and can be used as a framework for this thesis and the utilization of telecare at De Trans.
Key success factors:
1. Technological context
a. Influencer 1: stability and reliability of technology use.
Evidently, the stability and reliability of the technology is crucial in service delivery and adoption of the technology. The stage of maturity of the technology increases the complexity of financing the investment, since considerable costs are involved during the design and implementation period, not all of which are covered by the supplier.
b. Influencer 2: experience of the technology partner.
Studies show that the manner in which the care technology was developed and installed differed between the organizations. Experienced suppliers are more desirable for success because they are able to deliver reliable support and reliable technology.
c. Influencer 3: level of content-goal alignment.
The content provided through the technology infrastructure must match the goals of the homecare organization and the home telecare services it aims to provide. This is called the importance of content-goal alignment.
2. External context
a. Influencer 4: the stability of infrastructural and operational financing.
The stage of maturity of the technology increases the complexity of financing the investment, since considerable costs are involved during the design and implementation period, not all of which are covered by the supplier.
Collaboration with other parties is perceived as a major factor accelerating the
implementation, especially since the effects of home telecare services are not limited to the care provided by the homecare organization.
3 User context: innovation-value fit
a. Influencer 6: The virtual-physical-physical care alignment.
Inadequate understanding of user needs has been shown to be a major barrier in the implementation of smart homes technologies. This is partly due to suppliers pursuing a technology-push, rather than demand-pull approach, resulting in a gap between client requirements for systems that are useful for managing everyday tasks and the available products (Barlow & Venables, 2003).
b. Influencer 7: continuous assessment of the direct and indirect effects of virtual service delivery on all user groups.
4 Organizational climate
a. Influencer 8: the availability of a comprehensive framework for support, with sufficient top management support and a basic set of procedures.
5 Implementation strategy
a. Influencer 9: the level of involvement-goal alignment. b. Influencer 10: Orchestration of a champion-led roll-out. Conclusions and literature review
According to the two definitions above, telecare is related to health care delivered from a distance and the continuous and automatic remote monitoring of clients to enable independent (safe) living. This thesis examines the key success factors in the utilization of a telecare system that enables an event-driven care process.
Benefits of telecare for patients:
• Thanks to telemonitoring, medical experts can receive an alarm earlier than without using telemonitoring. This can prevent serious disorders after an emergency.
• The idea that medical experts receive an alarm in case of an emergency can give clients a sense of safety.
In the case of telecare applications, “user needs” are especially complex because of the variety of stakeholders, and include their compatibility with service delivery organization and the capability for integration with existing systems that support service delivery (Barlow et al., 2003b; Sixsmith & Sixsmith, 2000).
Identified barriers or key factors for a successful utilization of a telecare: • Technological context
• External context
• User-context: innovation-value fit • Organizational climate
• Implementation strategy
With the use of these identified key factors and related influencers, it should be possible to create a systematic approach for a better design and utilization of the current used event-driven telecare system in the context of the current perceived problems regarding the telecare system.
4 Analysis
This chapter first discusses the current situation based on an initial screening of De Trans. For the night situation, a diagnosis is made of the current care process and the use of the telecare monitoring system.
4.1 Process and problem description
The starting point when a person becomes a client of De Trans is an intake interview with the client or legal guardian, during which the necessary and agreed care needs are recorded in an individual support plan called the IOP (Individual Support Plan). The IOP is translated into the activities needed by the client and performed by the staff of De Trans, consisting of personal care, supporting guidance and medical activities. These activities are based on time standards per activity and connected to the direct nighttime labor requirements. This results in a schedule with the deployment of the individual staff as the starting input for the planned care process during the nightshift.
The information flow regarding the care process in the nightshift is shown in Figure 4.1.
Figure 4.1 – Information flow during the nightshift
AS-IS Process description of the care process during the nightshift
The nightshift starts at 10:30pm with the shift handover from the late shift via verbal communication as well as the use of the electronic health records system. This software, called PlanCare, consists of an individual support plan in electronic format. It can either be retrieved from a computer and individualized or be pre-printed for a specific disease, condition, or nursing diagnosis and individualized for the specific patient.
Care technology Care process -‐ nightshift
Delivery of unplanned care service Delivery of planned
PlanCare also contains reports on the clients and any specific developments from previous shifts that are relevant for the next shift. The nurses make their first round along clients to carry out the planned
care services at around 1:30am, helping patients with their medication, visits to the bathroom and
other planned care services from the IOP. This planned round currently takes the nurses about 2½ hours.
Three nurses are on duty during every shift, one of whom is the head nurse. One nurse at a time sits in the control room of the telecare monitoring system and operates the system if necessary. Every hour, another nurse operates the monitoring system and, in the meantime, the other two nurses sit in the coffee room next door.
During the night, alerts may be generated by the telecare monitoring system due to client illness, distress or unexpected behavior during the night. These alerts are triggered by the telecare monitoring system, resulting from a measurement or other acquisition of descriptors of a state (the client state in this case) that indicates a relevant deviation from the normal state. This normal state and thresholds for a relevant deviation is configured individually per client in the telecare system.
The nurse in the control room makes an assessment of the alert based on personal knowledge of the client, the IOP and camera images (if installed). The nurse can also converse with the client using the system, or listen from a distance without any action required from the client. The assessment is used to determine a possible deployment of a nurse to deliver unplanned care.
The shift ends at 6 in the morning with the nurse reporting in the IOP and the shift handover to the following nurses on duty.
Care process Planned care tasks:
-‐ Administering medication to a client -‐ Checking on sick clients
-‐ Changing client position in bed -‐ Helping clients use the bathroom Unplanned care tasks:
-‐ Guiding wandering clients back to bed -‐ Nursing clients with a seizure
-‐ Cleaning bedwetting clients (when necessary)
-‐ Assisting clients creating nuisance due to behavioral problems Observed problems with the telecare system
During several visits to De Trans, nine interviews were conducted. These interviews were semi-structured and had the following goals: first, to discuss the most important issues regarding the care process during the nightshift, second, the use of the current telecare monitoring system, and third, how a better utilization of the telecare system can be achieved by a better design.
1. Concerning: Assessment: assessing client alert
Problem: Wrong trigger/too many (false) alarms
Who experiences the problem: Nurses operating the telecare system
Domain: Technological context
2. Concerning: Assessment: using telecare system
Problem: Not knowing how/not wanting to use the
telecare system in an event-driven manner
Domain: Innovation-value fit / Organization climate
Who experiences the problem: Nurses operating the telecare system
3. Concerning: Management information
Problem: Absence of information about the
number of alerts generated by the system. No information about the amount of disruptions due to malfunctioning.
Domain: Organization climate
Who experiences the problem: Management of De Trans
4. Concerning: Operational costs of the telecare
system
Problem: Not in control of (operational) costs
Domain: Organizational climate
4.2 Telecare monitoring system at De Trans
The observed problems (described in previous paragraph) are all related to the current utilization of the telecare monitoring system, which is why a more in-depth analysis of the telecare system has been made.
Monitoring configuration
The implemented telecare system is not the same for each client’s home but comprises all of the following central components: a broadband connection to the technical room using a fiber-glass connection, a camera with pan, tilt, zoom capabilities, voice-over IP (VOIP) communication between the client and remote care provider, door and window break sensors, acoustic sensors and motion detection sensors. The acoustic and motion sensors were used to alert remote caregivers when there was activity in the residence during the night that might need their direct attention. This is helpful because, at night, the remote caregivers view up to 32 different camera feeds from multiple clients.
Figure 4.1.3 – Telecare components in group homes The event that triggers the alarm is activated by one of the following sensors:
Movement sensors:
Consists of infrared movement sensors to detect whether a client: • Is out of bed
• Can be configured based on time (for example, after 10 minutes out of bed -> generate alert) Acoustic sensors:
Monitoring based on sound levels with an acoustic threshold that triggers the alarm. This is used for detection of:
• Status of client sleeping
• Client having an insult (epileptic disorder)
Panic buttons:
A client can make a call to a nurse using a panic button (pendant). When the button is pushed, a connection is made with the control room at De Trans, where the nurse can speak to the client and listen to the situation. Nurses are also always equipped with panic buttons for possible emergency situations that may be life threatening.
The remote caregivers are equipped with a mobile phone with a panic button, through which they are within reach of the central cockpit and can call for help in emergency situations. These calls for assistance can be life threatening (a matter of life and death), such as when a client attacks a nurse. In short, the panic buttons are used for:
• Alarm triggering by a client
• Call made by nurse for assistance during an emergency
Bed sensors:
A bed sensor employing a foam-filled mattress pad connected pneumatically to a pressure sensor to detect presence, pulse, and movement in bed.
Bed sensors are used for:
• Detection if a client has a seizure
Analysis of triggered events/alarms
In order to analyze the current number of events during the night, the log files, containing over 50,000 records, were used. The log files were imported into a database using a web application (created especially for this purpose). The relevant sets of data were then collected and plotted on graphs using queries (see Appendix for more information on the web application used).
Table 4.1.1 shows a mean of 106 generated events per hour by the telecare system during the night. As stated above, one person mans the current control room of the telecare system, which means that a nurse has 34 seconds to handle each alarm. The percentage of alerts handled by the nurses in the control room is currently 39.4 %, which suggests that 34 seconds is too little time to handle all the alerts.
Data 10 PM – 8 AM Amount of alerts Alert / Hour Accepted by nurse
Event Number Alert / Hour Percentage
Acoustic alarms 740 74.0 19.1%
Panic buttons 287 28.7 93.7%
Out-of-bed / wandering alert 23 2.3 17.4%
Wrist alarm transmitters 8 0.8 50.0%
Total generated events 1058 105.8 39.4%
Table 4.1.1 – Events generated by telecare monitoring system
To gain a better understanding of the alerts generated and their distribution during the nightshift, an analysis has been made for each specific alert/alarm.
Alerts by acoustic triggering
Every client has specific “telecare profile settings” in which the hardware components are configured to the specific needs of the client. In the case of acoustic triggering, the profile is activated between 10:30am and 6:30pm with different acoustic thresholds for every client. For example, a restless client who makes a typical sound during a seizure has a lower threshold than another client who normally sleeps quietly. This minimalizes the invasion of privacy. Examining the distribution during the night,
70% 2%
1%
27% AcousLc alarms
Out of bed alerts Alert by wrist alarm transmiMer
the graph shows a mean of 74 events per hour and two peaks in the events generated by the system between 10:30am and 1:00pm and between 5:30pm and 6:30pm (Figure 4.1.3.).
Figure 4.1.3 – Distribution of acoustic alarms during the night
As stated in Chapter 3, studies show that up to 90% of all alarms in care monitoring are false positives. In this case, the peak is at 160 alerts per hour and an average of 74 alerts per hour. The administrative handling of the alerts in the telecare system is much lower than the received alerts, which raises the question of whether the system is only used for listening to the client and not for an event-driven care process (i.e. action in response to an alert).
Out of bed alerts / Wrist alarm transmitter
0 20 40 60 80 100 120 140 160 180 AcousLc alarms Accepted by nurse
0 1 2 3 4 5 6 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00
Figure 4.1.5 – Out of bed alerts Figure 4.1.6 – Wrist alarm transmitter Alerts by panic button
Figure 4.1.6 – Distribution of alerts by panic buttons during the night
In the case of De Trans, there should be greater focus on these issues and possible methods tried to resolve the problem of false alarms and a wrong assessment of alarm events by the nurses in the contact center.
Cost of current telecare monitoring system When examining the costs of the current used telecare monitoring system, an investment has been made of €354,915 for phase I and €364,280 for phase II, totaling €719,195 over the years 2008-2009. These are the directly related investments in the telecare system and installment of the components.
Other indirect related costs, such as structural preparations in the buildings or necessary
infrastructure, are excluded for the purpose of this thesis. With a linear depreciation set at 5 years, the annual cost regarding this deprecation of the telecare system is €143,839. According to de interviews,
0 20 40 60 80 100 120
Panic buMon alarm Accepted by nurse
7% 3% 57% 33% System malfuncLons MutaLons Service contract New investments
De Trans does not currently have the necessary level of insight into the current operational costs of the telecare system.
The financial records from last year have therefore been analyzed in order to divide the costs into system malfunctions, mutations due to changing needs of clients or personnel, new investments and the fixed service costs due to a service contract with the installer of the telecare system, Avics ICT (Table 4.1.6).
Depreciations System malfunctions System mutations Service contract New Investments Total 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 €143,839 €12,311.38 €4,816.53 €100,853.69 €58,145.59 €319,966.19
Table 4.1.6 –Cost of ownership of the current telecare monitoring system at Rolde
System malfunctions
Figure 4.1.8 – System malfunctions in telecare system 2011 Summary of current bottlenecks
1. Too many false alarms/alerts generated
2. Incorrect use of telecare system/adoption by personnel 3. Malfunctions and disruptions of process
4. Not in control of (operational) costs 5. Absence of management information
The next section describes solutions to resolving those aspects that require improvement.
0 10 20 30 40 50 Solved interrupLo ns False reported Solved interrupL ons False reported
CriLcal business process 14 27
Next business day 14 19
5 TO BE design at De Trans
5.1 Pilot event-‐driven telecare with a contact center
De Trans gave the green light for a new pilot in 2012, in which the newly implemented telecare system is used as an addition and a resource to deliver 7 times 24 hours of unplanned care to clients, regardless of their location. Alarms and client care needs are directly communicated from the telecare system to an external contact center located in Meppel, namely Zorgcentrale Noord (hereinafter abbreviated as ZCN).
This pilot is due to start in September 2012, in which the Nooitgedacht location in Rolde is connected to the event-driven telecare system at the Zorgcentrale Noord. The purpose is to connect the entire organization to the Zorgcentrale if the evaluation of the pilot is successful and possible improvements implemented.
Starting points for the pilot established by De Trans:
• Using relevant and proven care technology that the employee trusts.
• Central assessment of alarm events in Meppel and the decentral deployment of caregivers where needed.
• It should not be seen as a cut, but as a cost-effective design.
• Close collaboration and communication with clients and employees. • A safe work climate and normal workload for personnel.
• From unproven to proven technology.
De Trans wants to use the telecare system in an event-driven manner using a call centre (see Figure 4.2.1). The goal is to be more cost-effective and in control of care process. As stated in the
introduction, the starting points for the pilot established by the Trans were: The pilot should be the prelude to:
• Event-driven care, 24/7, 365 days a year.
• Starting at the Rolde location, followed by all other locations. • Separation between planned and unplanned care.
The analysis of the former chapter leads to the conclusion that these starting points have not been achieved and therefore, in the current situation, the pilot is doomed to fail in several areas.
Figure 4.2.1 – The use of ZCN call centre in Meppel
The next section describes a direction in the solution to the points requiring improvement and the key factors for De Trans for a successful utilization of an event-driven telecare system.
5.2 Directions for a successful design
Using the established success factors, it is possible to create a systematic approach designing a successful utilization of a telecare system by examining key factors in the following domains: Technological context, External context, User context: innovation-value fit, Organizational climate, Implementation strategy and the current analyzed problems at De Trans (Figure 5.2.1).
Figure 5.2.1 - A systematic approach towards the utilization success of a telecare system
External context
Infrastructural & operational financing
Service collaboration (ZCN, Avics, Espria)
Organization climate at De Trans
The approach shown in Figure 5.2.1 makes it possible to use the key factors to maximize the chance of success in using the telecare system and to eliminate current barriers and problems in a structured way.
The following paragraph elaborates on the proposed approach as a solution in relation to the current problems and future developments of the organization of De Trans.
5.3 Solutions to the problems
As a starting point for removing the barriers preventing a successful redesign of the current telecare system, the key factors from Figure 5.2.1 are now used to describe the actions that need to be taken by De Trans with or without the use of a contact center in future implementations.
Step 1 - determine the level of content-goal alignment of the technology Domain: Technological context
In developing telecare services, the alignment of IS strategy and IS structure (i.e. IS alignment) should be the focus of the service encounter (Froehle and Roth, 2004). Telecare’s role and function, as formulated in the IT strategy, should be supported by the appropriate IS infrastructure, processes and skills. Finally, the chosen structural alignment requires a match between business and IT processes and skills and the administrative infrastructure.
Boonstra et al. (2011) uses a framework for three telecare alignment configurations:
• Value-adding Process Chains, which require workflow applications to be seamlessly coupled with timely and smooth installation of standardized home equipment. • Solution Shop processes require a swift, but, more importantly, flexible rollout of
communication equipment and tools adaptable to any handicaps that a client may have. • Self-Help Network processes require advanced IS structures that are highly reactive to
any server problems.
De Trans needs to develop a range of telecare applications for “client demand” categories that require different value configurations if they are to be competitive. De Trans’s business model can be seen as a “Solution Shop with a broad scope” but, at the same time, it will also refer clients to community care service delivery units that amount to a “value-chain configuration”.
which the specific needs are determined for each client. These different sets of telecare services can be used to determine what infrastructural and operational financing is needed.
Step 2 - use of stable and proven technology Domain: Technological context
When examining the experiences of the technology partner: In the current situation, the technology partner is Avics ICT, an eleven-year-old company with a rapidly growing number of projects. There are certain risks with companies experiencing rapid growth and their struggle to keep up with the many tasks required to facilitate such rapid expansion. De Trans, for example, has not received technical documentation on the current telecare system and initially experienced a lack of attention to user requirements and operational impact. The more experienced the partner, the more reliable support and technology expected.
Current perceived problem technological context --> too many (false) alerts
At this time, there are relatively false alarms due to different causes, such as acoustic thresholds that are too low and the incorrect use of the trigger function of an event-driven telecare system. In other words, the system is only used for monitoring from a distance by a care giver, by which it is not the system that triggers a care action, but the care professional. He or she determines what action must be taken, based on sound or the image from the cameras. The incorrect use of the system by caregivers can be resolved with a basic set of procedures, described in more detail in Step 3: “Basic set of procedures”.
The threshold levels used and decision rules are related to the “technology context” domain and can be chosen based on ideas from the literature, together with common sense judgment.
Step 3 - create a basic set of procedures Domain: Organizational climate
In relation to the operational protocols, De Trans faces multiple challenges:
Current perceived problem--> using the system in an event-driven manner
Technological monitoring is often regarded as more objective, as it is continuous and only collects data. However, informed but human judgment may be necessary to interpret the data and to decide what data to collect in the first place. Employees will have to learn to trust the new system based on the right triggers to be able to call out/warn securely and reliably.
In addition, a successful division of labor is necessary when call centre nurses are connected to the ambulant nursing teams at the De Trans locations. An initial distinction is made between the nurses seeing the patient, the ambulant nurses, and those who do not have physical contact, i.e. the contact center nurses. The idea that professional caregivers should see their patients is not contested, but delegated to a fixed group of professionals, whereas the others may perform their job using the telecare system.
The clinical importance of individual differences in order to make a reliable assessment of a patient’s condition is emphasized. An actual meeting with the patient means that different variables can be considered for the diagnosis and tests and physical examinations can be carried out. Individual circumstances make all the difference here. A “shortness of breath” may not mean much for one particular patient, but may be a very severe symptom for another. When you see a patient face-to-face, you see much more, whereas, otherwise, things may escape you, even with the use of a camera with zoom.
The practical consideration of a minimum of false alarms and non-detection of an actual alarm also play an important role (step 1). Furthermore, with the use of an external contact center, as soon as an alert comes to the control room, specific personal knowledge of the individual is needed; an external operator can only share the available information in the electronic dossier (IOP).
Scheduling and planning of care professionals
An initial conclusion from the analysis would be that the planned care can be provided by one care professional during the night during a shift of 8½ hours. However, due to safety regulations, there must be one person to deliver the care service and one person in the event of an emergency. Additional staffing – Planned care:
De Trans should create a flexible team that is prepared in the case of an emergency or extra work. This involves:
• A practitioner who is available to come to the location (in the current situation, it is only possible to reach a practitioner by phone).
• A physician (provided in the current situation).
• Management contact (“unit head”) available in the case of an emergency and as response support for the nurses on duty (provided in the current situation). • A colleague with the same functional skillset who is available immediately. • Service desk for technical issues.
Additional staffing – Unplanned care:
• The right people with the right skillset at the right place within a small amount of time and based on a clear set of procedures.
Figure 4.2.3 shows how a telecare event leads to the deployment of a care professional. This process can be used in the current situation with a control room or in the situation with an external contact center.
Step 4 - create innovation-value fit based on client needs Domain: User context
Traditionally, care professionals greatly appreciate personal contact with clients. This was identified as a source of resistance towards an event-driven care process. In order to eliminate this resistance, it is important to position services not only as a replacement of physical care, but as an enhancement of care quality. Instead of one actual visit, three visits can take place.
Domain: User context
This entails the continuous assessment of the direct and indirect effects of virtual service delivery on all user groups. The innovation must also fit within the clients’ changing daily activities and needs or those of the primary caregivers. This means that the Individual Support Plan (IOP) must be up-to-date and have a direct link to the use care technology in the client’s home. For example, when caregivers conclude in the IOP that the client must be closely watched due to his or her deteriorated situation, this should result directly in specific, pre-described technology to support the needed care, in this case the use of a camera.
Current problem --> lack of management information about the utilization of the telecare system
At this time, no management information is available regarding the utilization of the telecare system. De Trans must create a knowledge system to support decisions and in order to make continuous assessments regarding:
• Reports from the telecare system regarding alerts and care delivered • Statistics about disruptions in care processes due to the telecare system • The care process and care delivered
Step 5 - involve stakeholders Domain: Implementation strategy
Step 6 - use stable infrastructural and operational financing Domain: External context
De Trans should use as much stable infrastructural and operational financing as possible for the coming years.
Step 7 - level and structure of service collaboration Domain: External context
Collaboration with the contact center (ZCN) is beneficial to the success of the utilization of the telecare system.
6 Conclusions
With the development of the new facilities, De Trans’s goal is to create a greater quality of care and life for the clients, safety reassurance for the family and social stakeholders, and a system for the personnel that supports event-driven care. De Trans wants to be prepared for the future by
establishing a care process in the changing living circumstances of clients, supported by an incident-driven telecare monitoring system that addresses these needs.
The goal of this thesis is to analyze how an incident-driven telecare system can be utilized within one central contact center, from which all alarms are processed and delegated to ambulant nurses on duty. These results should make it possible to create a better background for future decisions regarding the care process during the nighttime and implementation of technology at De Trans.
To determine how an event-driven telecare system can be utilized at De Trans, the following research question has been formulated:
How can the telecare be redesigned in order to create an even-driven care process with use of a telecare system and what are thereby the key factors for a successful utilization?
To answer the main research question, three sub-questions were added.
SQ1: What is the current care process during the nightshift?
The nightshift starts at 10:30pm with the shift handover via verbal communication, as well as with the use of a health records system (Plancare). Three nurses are on duty during every shift, one of whom is the head nurse. One nurse at a time sits in the control room of the telecare monitoring system and operates it if necessary. The nurses make their first round along clients to carry out the planned care services at around 1:30am. This round currently takes about 2½ hours.
Based on the telecare system log files and conversations with staff, an analysis has been carried out of the current use of the telecare system during the night by analyzing the log files. The results:
• There is an average of 106 alerts per hour related to acoustic alarms (consisting of 70% acoustic alarms).
• On average, 39.4% of the alarms are administered as “handled” in the system, 19.1% in the case of acoustic alarms.
This leads to the following conclusions about the current utilization of the telecare system:
• There is a lack of management information on the amount of alerts and unplanned care process during the night.
• De Trans does not have the necessary insight into the future operational costs of the telecare system and is therefore not in financial control.
• The system is not used in an event-driven manner for the delivery of unplanned care. In other words, the trigger for unplanned care is the personnel, not the telecare system, which is configured individually per client.
• Some of the personnel/stakeholders distrust the system as a “gatekeeper” for triggering the delivery of unplanned care services while maintaining client safety.
SQ2: What are the key success factors in designing and utilizing an event-driven telecare system at De Trans?
Regarding the second research sub-question, literature research provided five domains that influence the key success factors: the technological context, external context, user context, organizational climate and implementation strategy. Furthermore, the utilization of telecare systems is especially complex due to the variety of stakeholders and lack of capability for integration with existing systems.
SQ3: What are the implications of a possible redesign, an external contact center as foreseen in the pilot project?
• The prerequisites for the pilot established by De Trans have not been achieved.
• The current use of the telecare system during the nightshift and related problems analyzed correlate to the key factors for the successful implementation/utilization of the telecare system.
The barriers preventing a successful utilization of the telecare system must first be removed. This is a prerequisite for a pilot with the use of a contact center and will lead to the successful utilization of the telecare system throughout the entire organization.
How can the telecare be redesigned in order to create an even-driven care process with use of a telecare system and what are thereby the key factors for a successful utilization?
With the use of the established success factors, it is possible to create a systematic approach regarding the design of a telecare system by examining key factors in the following domains: Technological context, External context, User context: innovation-value fit, Organizational climate, Implementation strategy and the current problems analyzed at De Trans (Figure 6.1).
Figure 6.1 - A systematic approach towards successful use of a telecare system 1. Technological context
– Ensure the stability and reliability of the care process through the use of proven technology.
External context Organization climate at De Trans
– Technology partners should be involved in the specific field of event-driven telecare and clients with developmental disabilities.
– In order to decrease the number of false alarms, create decision rules and threshold levels for the event triggers based on simulation modeling to test values and settings.
2. External context
– Use as much stable infrastructural and operational financing as possible for the coming years. – Good collaboration with other parties, like ZCN, is crucial for a good outcome.
3. User context: innovation-value fit
– Position and communicate telecare not only as a replacement of physical care, but also as an enhancement of care quality.
– Continuously assess the telecare used and the changing care needs of clients and caregivers using a linked IOP with specific sets of “telecare packages”.
4. Organizational climate
-‐ Formulate a basic set of procedures regarding:
o Electronic health record system: All client information must be updated daily in a software environment – which is not the case as we speak on examining the current use of Plancare.
o Additional staffing related to planned care.
o Additional staffing related to unplanned care and telecare alerts. 5. Implementation strategy
-‐ Involvement of stakeholders in De Trans’ goals.
With the above-mentioned recommendations, De Trans can use the key factors in a successful utilization of the current telecare system by eliminating barriers for success and future
implementations with or without the use of a contact center.
6.1 Limitations
The starting point for this thesis was to examine the utilization of a relatively expensive and complex event-driven telecare application as compared to a more conventional monitoring system in which the technology is only used as a simple extension of the human “senses”. An alternative route is to start with the IT domain and ask what forms of care services a telecare system can offer. This may result in a number of strategic alternatives, as one can, for example, conceive of telecare applications that fit differently positioned value configurations (A. Boonstra et al. 2011).
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