Strategic intelligence monitor on personal health systems, phase 3 (SIMPHS3) : renewing health Carinthia (Austria) case study report.
Date: 2015-09-14
Institutions: Institute for Prospective Technological Studies
Subjects: Austria, case study, data collection, diabetes, health care, health care system, health policy, new technology, organisation of health care, public health, research report, telemedicine

Strategic Intelligence Monitor on 
Personal Health Systems Phase 3 
(SIMPHS3) 

Renewing Health Carinthia 
(Austria) 
Case Study Report 
Authors:  
Ignacio  Peinado,  Elena  Villalba,  Francisco 
Mansoa and Alberto Sánchez 

Editors: 
Leocadio  Rodríguez  Mañas,  Wilco  Graafmans  and 
Fabienne Abadie 

2 0 1 5  

Report EUR 27263 EN 

 
 
 
 
European Commission 
Joint Research Centre 
Institute for Prospective Technological Studies  

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expressed does not imply a policy position of the European Commission. Neither the European Commission nor any person 
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All images © European Union 2015 

JRC95546 

EUR 27263 EN 

ISBN 978-92-79-48390-5 (PDF) 

ISSN 1831-9424 (online) 

doi:10.2791/257521 

Luxembourg: Publications Office of the European Union, 2015 

© European Union, 2015 

Reproduction is authorised provided the source is acknowledged. 

Abstract 
Renewing Health is a European project (February 2010-December 2013), partly funded by the European Union under the 
ICT  Policy  Support  Programme,  part  of  the  Competitiveness  and  Innovation  framework  Programme  (CIP),  with  a  total 
budget  of  €14  million  and  European  co-financing  of  €7  million.  The  project  aimed  to  implement  health-related  ICT 
services  through  large-scale  real-life  test  beds  for  the  validation  and  subsequent  evaluation  of  innovative  eHealth 
services, using a patient-centred approach and a rigorous common assessment methodology. 
This  case  study  focuses  on  the  Austrian  Partner  of  the  project:  the  Carinthia  region  and,  more  precisely,  KABEG 
(Krankenanstalten Betriebsgesellschaft), the hospital management company in the region.   
In RENEWING HEALTH, KABEG integrated a set of telemonitoring solutions into their existing systems for two target groups 
- patients suffering from Diabetes Mellitus Type II and patients suffering from COPD – in order to carry out two pilots to 
test the effects of the resulting system. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acknowledgments 

The  authors  wish  to  thank  and  acknowledge  the  following  experts  for  their  valuable 
comments and collaboration during the fieldwork process: Alexandra Strecker and Hannes 
Steinberger for their support in organising the visit to Kabeg and all the information they 
provided on the case and Kurt Possnig, Heinz Trabe and Robert Astner as well as all other 
professionals who participated in the interviews. 

1 

 
 
Preface 

The Strategic Intelligence Monitor on Personal Health Systems (SIMPHS) research started in 
2009 with the analysis of the market for Remote Patient Monitoring and Treatment (RMT) 
within Personal Health Systems (PHS). This approach was complemented in a second phase 
(SIMPHS2)  with  the  analysis  of  the  demand  side,  focusing  on  needs,  demands  and 
experiences  of  PHS  by  healthcare  producing  units  (e.g.  hospitals,  primary  care  centres), 
healthcare professionals, healthcare authorities and patients amongst others.  

Building on the lessons learnt from SIMPHS2 and from the European Innovation Partnership 
on Active and Healthy  Ageing initiative, SIMPHS3 aims to explore the factors that lead to 
successful  deployment  of  integrated  care  and  independent  living,  and  define  the  best 
operational  practices  and  guidelines  for  further  deployment  in  Europe.  This  case  study 
report is one of a series of case studies developed to achieve these objectives. 

The outcomes of SIMPHS2 are presented in a series of public reports which discuss the role 
of governance, innovation and impact assessment in enabling integrated care deployment. 
In addition, through the qualitative analysis of 27 Telehealth, Telecare and Integrated Care 
projects  implemented  across  20  regions  in  eight  European  countries  investigated  in 
SIMPHS2,  eight  facilitators  have  been  identified,  based  on  Suter’s  ten  key  principles  for 
successful health systems integration.  

The eight main facilitators identified among these as necessary for successful deployment 
and adoption of telehealth, telecare and integrated care in European regions are:  

Interoperable information systems 

  Reorganisation of services 
  Patient focus 
  Governance mechanisms 
 
  Policy commitment, 
  Engaged professionals 
  National investments and funding programmes, and  
 

Incentives and financing.  

These  eight  facilitators  have  guided  the  analysis  of  the  cases  studied  in  SIMPHS3  and  a 
graph showing the relative importance of each facilitator is presented in each case study. 

In  addition  to  the  above  facilitators  analysed  in  each  case  report,  a  specific  section  is 
dedicated  to  the  analysis  of  care  integration.  It  should  be  noted  that  the  definition  of 
vertical  and  horizontal  integration  used  in  this  research  is  taken  from  the  scientific 
literature in the field of integrated care.1  This definition differs from the one mentioned in 
the  European 
Innovation  Partnership  on  Active  and  Healthy  Ageing  Strategic 
Implementation  Plan.2 We  define  horizontal  integration  as  the  situation  where  similar 
organisations/units  at  the  same  level  join  together  (e.g.  two  hospitals)  and  vertical 
integration  as  the  combination  of  different  organisations/units  at  different  level  (e.g. 
hospital, primary care and social care). 

1   Kodner, D. (2009). All together now: A conceptual Exploration of Integrated Care.  
2   http://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/steering-

group/operational_plan.pdf (page 27) 

2 

 
 
 
 
                                              
Table of contents 

ACKNOWLEDGMENTS ....................................................................................................................................... 1 

CASE OUTLOOK .................................................................................................................................................. 5 

1  BACKGROUND ............................................................................................................................................. 7 
AUSTRIA ............................................................................................................................................................................ 7 
THE AUSTRIAN HEALTH SYSTEM ................................................................................................................................. 7 
CARINTHIA REGION ...................................................................................................................................................... 14 
KABEG .......................................................................................................................................................................... 15 

1.1 
1.2 
1.3 
1.4 

2 

INTEGRATED CARE ANALYSIS ............................................................................................................. 16 
DIMENSIONS OF INTEGRATION ................................................................................................................................. 16 
IMPACT............................................................................................................................................................................ 16 
DRIVERS AND BARRIERS ............................................................................................................................................. 18 
HEALTH PROFESSIONAL AND PATIENTS .................................................................................................................. 20 
INFORMATION AND COMMUNICATION TECHNOLOGIES ....................................................................................... 20 
GOVERNANCE AND POLICY SETTING ........................................................................................................................ 22 
ORGANISATION AND PROCESSES.............................................................................................................................. 24 
REIMBURSEMENT MODEL AND ECONOMIC FLOW ................................................................................................. 26 

2.1 
2.2 
2.3 
2.4 
2.5 
2.6 
2.7 
2.8 

3  TRANSFERABILITY .................................................................................................................................. 27 

4  CONCLUSIONS ......................................................................................................................................... 27 

REFERENCES .................................................................................................................................................... 29 

ANNEX ................................................................................................................................................................ 30 

3 

 
 
 
 
LIST OF TABLES 

Table 1: 

General information about the Austrian Healthcare System ............................................................ 8 

Table 2: 

Least-cost table, DIABETES and COPD........................................................................................................ 18 

Table 3: 

Ethical issues ............................................................................................................................................................. 23 

Table 4: 

Legal issues ................................................................................................................................................................ 23 

Table 5: 

Primary Clinical Outcomes of Diabetic Patients .................................................................................... 30 

Table 6: 

Secondary Clinical Outcomes of Diabetic Patients .............................................................................. 31 

Table 7: 

SUTAQ Results Diabetic Patients .................................................................................................................... 32 

Table 8: 

Primary Clinical Outcomes of COPD Patients .......................................................................................... 33 

Table 9: 

Primary Clinical Outcomes of COPD Patients .......................................................................................... 34 

Table 10: 

SUTAQ Results COPD patients ......................................................................................................................... 34 

Table 11: 

Types of resources included in the estimation of costs .................................................................... 35 

Table 12:  Analysis of cost differences .............................................................................................................................. 35 

Table 13:  Cost of different services for different groups (Rounded values)  .............................................. 36 

LIST OF FIGURES 

Figure 1: 

Health expenditure per capita in Austria and in the Europe WHO's region ............................... 8 

Figure 2: 

Evolution of health systems expenditure as % of GDP ........................................................................ 8 

Figure 3: 

Flowchart of Health Care Responsibilities in Austria .......................................................................... 11 

Figure 4: 

Funds Origin ............................................................................................................................................................... 13 

Figure 5: 

Data Flow in KABEG's ICT infrastructure ................................................................................................... 21 

Figure 6: 

Organisations involved [authors’ creation] ............................................................................................... 24 

Figure 7: 

Facilitators of Renewing Health in Carinthia ........................................................................................... 28 

4 

 
 
 
 
 
 
Case outlook 

Renewing Health was a European project (February 2010-December 2013), partially funded 
by  the  European  Union  under  the 
ICT  Policy  Support  Programme,  part  of  the 
Competitiveness  and  Innovation  framework  Programme  (CIP),  with  a  total  budget  of  €14 
million  and  European  co-financing  of  €7  million.  The  project  aimed  to  implement  health-
related  ICT  services  through  large-scale  real-life  test  beds  for  the  validation  and 
subsequent evaluation of innovative eHealth services, using a patient-centred approach and 
a rigorous common assessment methodology. 

It involved a consortium of 9 European regions in: Austria, Italy, Denmark, Sweden, Norway, 
Spain,  Finland,  Greece  and  Germany.  One  of  the  pre-requisites  of  the  CIP  programme  for 
the projects was the existence of developed solutions that could be scaled up and tested as 
pilots. In the case of Renewing Health, the participating regions had already implemented 
some  operational  solutions  related  to  the  telemonitoring  and  the  treatment  of  chronic 
patients  suffering  from  diabetes,  chronic  obstructive  pulmonary  disease  (COPD)  or 
cardiovascular  disease  (CVD)  at  local  level.  The  services  included  self-management  of 
diseases  for  the  patients,  promoting  compliance  to  treatment  and  helping  healthcare 
professionals  to  detect early  signs  of  worsening  in  the  monitored  pathologies.  During  the 
lifespan of the project, these existing solutions were scaled up and integrated into the local 
health information systems in order to be tested as pilots in the different project settings. 

This  case  study  focuses  on  the  Austrian  Partner  of  the  project:  the  Carinthia  region  and, 
more  precisely,  KABEG  (Krankenanstalten  Betriebsgesellschaft),  the  hospital  management 
company in the region.   

In RENEWING HEALTH, KABEG integrated a set of telemonitoring solutions into their existing 
systems  for  two  target  groups  -  patients  suffering  from  Diabetes  Mellitus  Type  II  and 
patients  suffering  from  COPD  –  in  order  to  carry  out  two  pilots  which  aimed  to  test  the 
effects of the resulting system. Prior to the project, KABEG already had a system in place 
for  the  collection  of  nursing  data,  as  well  as  disease  management  processes  for  chronic 
patients suffering from  diabetes, and to some  extent for  patients with COPD. The aim of 
the Carinthian telemonitoring project within Renewing Health was to establish a permanent 
infrastructure and an integrated treatment process for Diabetes Mellitus Type II and COPD 
using  integrated  electronic  systems.  The  services  targeted  diabetes  and  COPD  in  the 
outpatient  areas  of  three  KABEG  hospitals,  which  cooperated  directly  with  the  patient,  or 
with  the  treating  nursing  homes  and  mobile  nurses.  Patients  measured  some  parameters 
(blood  sugar,  blood  pressure  and  body  weight  in  the  case  of  diabetes;  COPD  Assessment 
test and body weight in the case of COPD) every day, using blood sugar meters, scales and 
blood  pressure  measuring  devices  provided  for  free,  for  automatic  transmission  of 
measurement readings. Patients were empowered to do the readings themselves. However, 
in cases where patients were assisted by home nurses, the latter were trained to use the 
service  for  them.  These  measurements  were  automatically  registered  in  the  Health 
Information System (HIS) on a weekly basis for diabetes, monthly for COPD or immediately 
if  measurement  values  fell  outside  a  given  range,  and  therefore  required  immediate 
attention  by  healthcare  providers.  The  responsible  General  Practitioner  (GP)  checked  the 
data to devise further treatment when required. Finally, a monthly report was sent to the 
patients and, if desired, to their GPs.   

Within  the  scope  of  the  Renewing  Health  project,  KABEG  recruited  193  diabetes  patients 
and  65  COPD  patients  to  evaluate  the  system.  The  results  of  the  pilots  showed  that 

5 

 
 
telemonitoring based on the previously cited variables did not improve patient outcomes. In 
terms of economic impact, although the patients in the control group generated more costs 
due to the slight difference in hospital days, results are not conclusive due to differences 
between the characteristics of the compared groups.  

The  project  was  completed  though  some  systems  are  still  running:  there  are  11  diabetic 
patients  who  are  still  using  the  web  portal  to  enter  their  parameters  and  to  check  their 
health progression over time. It is unclear whether the services will be mainstreamed in the 
future. Regarding COPD, as the results of the trials were not conclusive, the implementation 
of a telemonitoring solution for COPD patients was considered low priority, pending further 
studies. In the case of diabetes the results of the trials demonstrated a reduction in costs, 
but with low statistical significance. Organisational issues and costs need to be addressed 
in order to mainstream the service.  

In  relation  to  government  settings  and  policy,  it  is  worth  mentioning  that  Austria  is 
preparing  a  Health  Reform  which  includes  eHealth  and  telemedicine.  Until  then,  the 
potential regulatory changes that may occur and the possible scenarios for further eHealth 
implementation remain unclear. However, KABEG plans include the implementation of their 
system  into  hospitals  and  other  institutions.  KABEG  aims  to  get  at  least  30  patients  into 
permanent care, and a further  increase (50%) of patients is planned for  2016. There are 
also  pending  negotiations  with  other  health  institutions,  e.g.  the  local  health  insurance 
company, where the system could be used in ambulatory care. 

6 

 
 
 
 
1  Background 

1.1  Austria 

The Republic of Austria is a federal republic of roughly 8.5 million people in Central Europe. 
It is landlocked and bordered by the Czech Republic and Germany to the north, Hungary and 
Slovakia to the east, Slovenia and Italy to the south, and Switzerland and Liechtenstein to 
the west. The territory of Austria covers 83,855 square kilometres and has a temperate and 
alpine  climate.  Austria's  terrain  is  highly  mountainous,  lying  within  the  Alps;  only  32%  of 
the country is below 500 metres and its highest point is 3,798 metres. 

Today,  Austria  is  a  parliamentary  representative  democracy.  The  capital  and  largest  city, 
with a population exceeding 1.7 million, is Vienna. Austria is one of the richest countries in 
the  world,  with  a  nominal  per  capita  GDP  of  $46,330  .The  country  has  developed  a  high 
standard of living and in 2011 was ranked 19th in the world for its Human Development 
Index. Austria has been a member of the United Nations since 1955, joined the European 
Union in 1995, and is a founder of the OECD. Austria also signed the Schengen Agreement 
in 1995, and adopted the European currency, the euro, in 1999. 

As in the rest of OECD countries, the Austrian population is still ageing, although it is in the 
final stage of this demographic transition. The proportion of under 15 year olds is expected 
to drop to 14.3% (from 17% in 2000), while the proportion of over 64 year olds is set to 
rise to 19.5% (from 15.5%) by 2020. 

As a federal republic, Austria is divided into nine states (Bundesländer). The states are not 
mere administrative divisions but have some legislative authority distinct from the federal 
government,  which  is  responsible  for  health  care  legislation  and  administration  of  the 
Health  Care  System  and  other  important  issues  (food  safety,  military,  monetary  and 
banking systems).  

The Constitutional Finance Law establishes a framework for financial relationships between 
the federal government, the regions and the local authorities. Moreover, it states how taxes 
are allocated at the different levels.   

1.2  The Austrian Health System 

The Austrian Health System provides universal coverage, including a wide range of benefits 
and  high-quality  care,  to  all  Austrian  and  EU  citizens.  Free  choice  of  providers  and 
unrestricted  access  to  all  care  levels  (general  practitioners,  specialist  physicians  and 
hospitals)  are  characteristic  features  of  the  system.  Population  satisfaction  is  well  above 
the EU average. Income-related inequality in health has increased since 2005, although it is 
still relatively low compared to other countries. The health-care system has been shaped by 
both the federal structure of the state and a tradition of delegating responsibilities to self-
governing  stakeholders.  On  the  one  hand,  this  enables  decentralised  planning  and 
governance,  adjusted  to  local  norms  and  preferences.  On  the  other  hand,  it  also  leads  to 
fragmentation  of  responsibilities  and  frequently  results  in  inadequate  coordination.  This 
trend shows two main consequences: patient satisfaction, as the system provides tailored 
care depending on regional and personal demands; and budget imbalances: the costs of the 
health-care  system  are  well  above  the  EU15  average,  both  in  absolute  terms  and  as  a 
percentage  of  GDP  (10.8%  vs.  10.4%  in  2011)  (European  Commission,  2013).  For  this 
reason,  efforts  have  been  made  for  several  years  to  achieve  more  joint  planning, 
governance  and  financing  of  the  health-care  system  at  the  federal  and  regional  level.  In 

7 

 
 
2005, Austria created the Federal Health Agency and regional agencies, in order to intensify 
the  cross-stakeholder  coordination  and  foster  more  homogeneous  health  care  provision. 
However, as in any health system, a number of challenges remain. Table 1 presents general 
information  about  the  Austrian  Healthcare  System.  As  shown  in  Figure  1  and  Figure  2 
below health expenditure per capita and as a percentage of GPD are above the European 
average. 

Table 1 - General information about the Austrian Healthcare System 

Geographical coverage km2 
Inhabitants per km2 
Number of inhabitants 
Life expectancy at birth, years 
GDP (2014), billion $ 

GDP per inhabitant (2014), $ 

General Practitioners /1,000 inhabitants (2010) 
Nurses  
National  Budget  for  Health  services  management  (2013), 
billion $ 
Health care professionals / 100,000 inhabitants 
Health care budget, € per inhabitants (2013) 
Hospital beds (2011) 
Hospital beds/1,000 habitants (2012) 

83,871 
98.04 
8,495,000 
78 males – 83  females4 
361,000 

42,600 

4.78 
7.83 
40,555 

1,274.53 
5,066.02 
68,758 
8.2 

Source: (Hofmarcher, 2013) and WHO 

Figure 1 - Health expenditure per capita 
in Austria and in the Europe WHO's 
region 

Figure 2 - Evolution of health systems expenditure as 
% of GDP 

Source (Hofmarcher, 2013) 

Source (Hofmarcher, 2013) 

8 

 
 
 
 
 
 
 
 
According  to  the  2013  health  system  review  on  Austria  (Hofmarcher,  2013)  and  WHO 
20133 data,  Austrians  are  much  more  satisfied  with  their  health  system  than  most  other 
Europeans. This could be explained by the high level of coverage and provider choice that 
Austrian  patients  generally  enjoy  and  by  the  decentralised  planning  and  governance  that 
allows the system to cater for local needs and preferences. 

Nevertheless,  there  are  important  structural  imbalances  in  healthcare  provision,  with  an 
oversized  hospital  sector  and  insufficient  resources  for  ambulatory  care  and  preventive 
medicine.  Austria  also  has  stark  regional  differences  in  utilisation,  in  both  curative  and 
preventative  services, 
including  hospital  beds,  specialist  physicians,  outpatient 
rehabilitation, psychosocial and psychotherapeutic care and nursing. There are clear social 
inequalities  in  the  use  of  medical  services,  such  as  preventive  health  check-ups, 
immunisation  or  dentistry.  One  of  the  key  weaknesses  of  the  health-care  system  stems 
from the scarce funds allocated to the prevention of illnesses and conditions. Spending on 
preventive  medicine,  at 2%  of  total  health  spending,  is  significantly  lower  than  the  EU15 
and  OECD  average  (both  3%)  (Hofmarcher,  2013),  and  also  has  a  below-average  rate  of 
growth. It remains to be seen whether the focus on health promotion and prevention of the 
'framework  health  goals'  approved  in  2012  will  be  translated  into  precise  measures, 
whether  clear  responsibilities  for  implementation can be  assigned, and whether  sufficient 
funding  will  be  made  available.  This  would  probably  improve  the  health  of  the  Austrian 
population and would help to reduce costs associated with preventable diseases. 

This lack of investment in prevention may have been the trigger for the increased incidence 
of  preventable  diseases.  Consequently,  non-infectious  preventable  diseases  such  as 
cardiovascular problems and neoplasms associated with smoking are important causes for 
hospital stays and death in Austria. Life-style habits may also affect this trend, especially 
in  young  people  (27%  of  Austrian  15-year-olds  smoke,  17%  in  OECD).  Moreover  obesity 
rates have increased remarkably in the last years (the prevalence rate of obesity in adults 
has increased from 8.5% to 12.8% in the period 1990 - 2010) (OECD, 2012).  

The Federal Constitutional Law stipulates that responsibility for regulation of most health-
care system areas lies primarily with the federal government, which handles it through ‘the 
Federal Ministry for Health issues’. The latter is responsible for the supervision  of hospital 
and  ambulatory  care  and  related  legislation.  Nevertheless,  the  Regional  Health  Funds  are 
the  operating  bodies  in  hospital  care,  and  they  must  ensure  hospital  bed  capacity  and 
financing.  

Each  Federal  State  has  its  own  governing  body,  called  the  Regional  Health  Platform,  in 
which  all  the  relevant  stakeholders  are  represented  (Federal  Government,  Land,  local 
authorities and Chambers of Physicians). 

In  the  ambulatory  and  rehabilitation  sectors,  as  well  as  in  the  field  of  medication, 
healthcare is organised through negotiations between the 22 Social Security Institutions or 
the Federation of Austrian Social Security Institutions on the one hand, and the Chambers 
of  Physicians  and  pharmacy  boards  (which  are  organised  as  public  law  bodies),  the 
statutory  professional  associations  of  midwives  and  other  healthcare  professions  on  the 
other. This cooperation works within a legally-defined framework to safeguard care and the 
financing of care. In some fields, social health insurers fulfil their obligation to ensure care 
provision  through  their  own  facilities.  Social  Security  Institutions  work  as  self-governing 
bodies, and cover some services like health insurance, pension benefits and work accident 

3   http://www.who.int/countries/aut/en  

9 

 
 
                                              
insurance.  On  the  basis  of  agreements  (‘state  contract’),  the  federal  and  regional 
authorities  are  mutually  obliged  to  safeguard  health-care  provisioning  in  their  areas  of 
responsibility. 

There are other important institutions involved in the implementation of health care: 

  The  Supreme  Health  Board  which  is  a  medical-scientific  committee  which  advises 

the Health Ministry on medical questions.  

  Gesundheit Österreich GmbH (GÖG), the institute for research and planning for the 
health  care  system  which  is  divided  into  three  sections:  the  Austrian  Federal 
Institute for Health, the Healthy Austria Fund and the Federal Institute for Quality in 
the Health Service.  

  The  Austrian  Agency  for  Food  and  Health  Safety  (AGES)  which  is  mandated  at 

national level to carry out a variety of tasks in the field of food safety.  

  The Federal Health Agency, a public fund and a separate legal entity at federal level. 
The  Federal  Health  Agency  is  the  central  facility  for  superregional  and  cross-
sectional  planning,  governance  and  finance  of  the  healthcare  system.  Federal 
resources are distributed by the Federal Health Agency to the nine regional health 
funds  in  accordance  with  a  pre-agreed  schema,  established  by  the  Federal  Health 
Commission. 

  The  Federal  Ministry  of  Labour,  Social  Affairs  and  Consumer  Protection  which  is 
responsible for matters relating to social security, with the exception of health and 
occupational health insurance. 

  The  Federal  Ministry  of  Science  and  Research,  responsible  for  university  education 
of physicians and for the legal and structural management of universities offering 
medical training 

  The  Federal  Ministry  of  Finance  which  is  responsible  for  taxation,  budgeting, 

financial markets and financial equalisation, among others.  

This  decentralisation  may  generate  fragmentation  and  lack  of  coordination,  which  makes 
the  Austrian  health  system  more  costly  than  average  and  could  hamper  its  performance. 
This is  why there has been on-going reform  since 2005, which has led to the creation of 
the  Federal  Health  Agency  and  regional  health  platforms  in  order  to  intensify  cross-
stakeholder  coordination  at  all  levels  and  promote  outpatient  care.  Figure  3 below  shows 
an  overview  of  all  the  different  healthcare-providing  bodies  in  Austria  and  their 
relationships. 

10 

 
 
 
Figure 3 - Flowchart of Health Care Responsibilities in Austria 

11 

 
 
 
 
 
 
The economic model of the Austrian health care system is supported mainly by two funding 
sources (Hofmarcher, 2013): 

  Public  funding  (77.5%  of  total  expenditure):  These  funds  come  from  taxes  and 
social insurance contributions. 99.9% of the Austrian population is a member  of a 
health  insurance  company.  Membership  depends  on  the  place  of  residence  and 
profession, so the insurance companies do not compete for funds.  Every member in 
the system has the right to access a broad set of services. Nevertheless, some of 
them require an extra payment (e.g. prescriptions). People fulfilling specific criteria 
related to their social circumstances are exempted from paying these charges.  

The guiding principle behind the system is that the provision of treatment must be 
sufficient, appropriate and should not exceed what is necessary. 

  Private  funding  (22.5% of  total  expenditure):  the  Austrian  population  is  entitled  to 
contract  extra  health  care  services  with  private  health  providers.  Some  health 
insurance  companies  offer  their  members  the  possibility  to  choose  a  particular 
physician and better hospital facilities.  

Payment of providers differs depending on the source of financing and the type of provider. 
Public  and  non-profit-making  hospitals  providing  statutory  services  receive  a  DRG4-based 
budget.  Most  health  insurance  funds  use  a  mixed  payment  system,  combining  flat-rate 
payments  (per  patient,  per  quarter  –  basic  service  compensation)  and  fee-for-service 
payments  to  pay  for  ambulatory  services  provided  to  their  members.  The  composition  of 
health spending is as follows: 

  43%  for  inpatient  care  (much  higher  than  the  OECD  average).  Austria  has 
acknowledged  that  the  inefficiency  of  its  prevention  plans  might  be  the  cause  of 
this trend. 

  26% - ambulatory care 

  17% - pharmaceutical products 

  7.1 % - long-term care at home 

  3.6% - administration of health care. 

  1.5% - prevention 

  1.2% - organisation 

  1% - patient transport 

As  reported  in  Statistics  Austria  2011  (Statistics  Austria,  2011),  the  total  public  health 
expenditure  in  Austria  in  2010  amounted  to  €23,689  million  (94.7%  of  the  total  health 
budget)  in  2010.  The  remaining  €1,326  (5.3%)  are  invested  in  anticipating  future  needs 
and  in  research.  More  specifically,  €456  million  are  dedicated  to  health  research.  These 
funds are allocated to support the clinical overheads of the three university hospitals and 
their  research  staff.  This  support  has  grown  at  a  rate  of  5.7%  per  year  since  2005 
(Hofmarcher, 2013).  

4   Disease Related Group 

12 

 
 
 
 
                                              
Figure 4 - Funds Origin 

Source: Hofmarcher, 2013 

In  order  to  optimise  healthcare  provision  in  Austria,  both  the  national  Government  and 
other stakeholders have created a legal framework that aims to facilitate the integration of 
ICT  solutions  into  healthcare  provision.  The  Health  Reform  Act  of  2005,  including  the 
‘Health Telematics Act’, defines the legal basis for implementing eHealth services in Austria. 
The first successful case of eHealth was the implementation of an e-card system back in 
2005. Up to 8 million beneficiaries and 12,000 general practitioners were provided with an 
e-card comprising basic administrative data about the beneficiary (i.e. name, academic title, 
insurance  number,  card  serial  number  and  user  group  identification).  The  e-card  works 
mainly as an e-Identification system, and provides access to other applications that require 
secure patient identification. The e-card does not store any medical or other health-related 
data.  

The ELGA (Elektronischer Gesundheitsakt) Act, passed in Austria in 2012, creates the legal 
basis  for  the  country’s  first  national  Electronic  Health  Record  infrastructure,  which  will 
provide  semantic  interoperable  sharing  of  several  types  of  medical  documents  amongst 
Austrian healthcare  providers. The  ELGA  system will not involve the central storage of all 
patient data. Instead, the service will only maintain a centralised registry of the locations of 
individual-related  health  data.  Health  data  are  defined  as  personal  data  that  provide 
information  about  the  physical  or  psychological  state  of  an  individual,  including  the  data 
collected  to  assess  the  individual’s  state,  as  well  as  data  collected  for  the  purposes  of 
preventive medicine or healthcare provision, for diagnosis, treatment or care methods, for 
provision of care, prescribed or taken medicines, medical aids, etc. In addition, the ELGA will 
comprise information about living wills, powers of attorney and a “patient summary” based 
on the application of patients’ rights in cross-border healthcare. The ELGA system consists 
of the following components: 

1.  Patient Index, 

2.  Healthcare Provider Index, 

13 

 
 
 
3.  Registry, 

4.  Data Storage, 

5.  Access Control Centre, 

6.  Logging System, 

7.  E-Health Access Point.  

The  health  data  stored  in  the  ELGA  system  will  make  health  data  in  electronic  format 
available  to  authorised  EHR-Healthcare  Providers  and  EHR-Participants,  without  reference 
to  location  and  time.  The  Austrian  Ministry  of  Health  will  operate  an  Electronic  Health-
Directory Service (EHDS) that will (1) support the legitimate use of health data in electronic 
format,  (2)  improve  information  about  health-related  services,  and  (3)  support  planning 
activities  and  reporting.  EHR-Healthcare  Providers  will  be  registered  with  the  EHDS  by 
authorised  registration  bodies,  under  the  responsibility  of  the  Federal  Ministry  of  Health 
and the Federation of Austrian Social Insurance Carriers.  

According to the ELGA Act, the following data should be available for hospitals, the General 
Accident Insurance and care institutions from 1 January 2015: 

1.  Clinical discharge reports from hospitals. 

2.  Laboratory results. 

3.  Results of diagnostic imaging by members of the medical profession. 

4.  Medication data, by members of the medical profession. 

5.  Medication data, by pharmacies or drug dispensing doctors at dispensation. 

6.  Other results. 

From 1 July 2016, this information should be available for pharmacies, freelance doctors, 
group  practices  and  authorised  independent  clinics.  From  1  July  2017,  private  hospitals 
should  be  integrated  into  the  ELGA  system.  According  to  the  law,  living  wills,  powers  of 
attorney  and  authorised  data  of  the  medical  registers  should  be  integrated  by  1  January 
2017. Finally, on 1 July 2022, freelance dentists, dental group  practices and independent 
dental  clinics  should  be  integrated.  As  of  today,  physicians  are  obliged  to  introduce  data 
about the patients they attend in the common health data repository. 

1.3  Carinthia region  

Carinthia  (German:  Kärnten)  is  in  the  Eastern  Alps  in  the  southernmost  Austrian  state 
(Land).  Carinthia  has  560,000  inhabitants,  about  1,000  physicians  in  the  outpatient  area 
and  some  950  hospital  physicians.  There  are  11  hospitals  of  different  sizes  and 
specialisations, 12 homecare organisations and nearly 60 care units for citizens who need 
care, often older people.  

In  2000,  the  Carinthian  Regional  Health  Board  started  a  project  to  establish  coordinated 
telemedicine in Carinthia. The main goals were to implement or provide:  

  Teleradiology between different hospitals in acute (1,100 cases a year) and routine 

cases, 

  A  description  of  former  treatments  (about  1,400  a  year),  also  provided  by 

radiological institutes,  

14 

 
 
  A Carinthian (in-)patient record (>800,000 patients with 3.8 million hospital stays), 

  Secure clinical  records  for  the  outpatient  area  (more  than  50,000  a  year,  strongly 

increasing).  

In  Carinthia,  the  collection  of  clinical  data  in  homes  is  currently  in  place  as  part  of  the 
homecare  assistance  package  for  patients  suffering  from  chronic  diabetes  and  COPD. 
However, the use of remote patient monitoring systems is not foreseen. Measurements are 
taken  with  traditional  medical  devices  without  communication  facilities  and  are  manually 
entered into a PDA for later transmission to the relevant hospital.  

In addition, the regional Ministry of Social Affairs implemented a GPRS/UMTS-based mobile 
treatment,  using  centralised  storage  and 
documentation  system  for  homecare 
communication  between  the  providers  involved.  These  include  12  nursing  organisations 
with  about  1,500  employees,  which  provide  about  880,000  hours  of  assistance  to 
thousands  of  patients,  many  of  whom  are  chronically  ill.  These  organisations  are  co-
financed by the Carinthian Government. The staff of all these organisations currently uses 
the same mobile system to collect and transmit data from patients’ homes. 

1.4  KABEG  

KABEG  (Landeskrankenanstalten-Betriebsgesellschaft)  is  the  company  that  manages  the 
five  regional  hospitals  of  Carinthia  (Klagenfurt,  Villach,  Wolfsberg,  Laas  and  the  Gailtal 
Clinic).  They have 2,700 beds for  regular  patients and 266 for  chronic patients. Its 6,350 
employees  provide  inpatient  care  for  70-80%  of  the  Carinthian  population.  It  is  a  body 
constituted  under  public  law  with  its  own  legal status.  It  was  founded under  the  Hospital 
Operations Act of 25.2.1993 (now the Carinthian Hospital Operations Act or KABEG). KABEG 
manages and controls the use of funds in the interests of the taxpayer, by strictly adhering 
to  commercial  guidelines  and  the  objectives  set  by  the  regional  government.  The  main 
focus  is  on  the  management,  co-ordination  and  continued,  dynamic  development  of  the 
region’s  hospitals,  with  particular  emphasis  on  investment  planning  and  organisational 
development5. 

As a company working within the healthcare market, KABEG undertakes to safeguard core 
medical and nursing skills with a fully operational risk management system.  

In  2002,  the  Regional  Health  Board  of  Carinthia  established  a  Coordinating  Unit  for  all 
Carinthian  e-health  and  telemedicine  activities.  Since  then,  KABEG  has  worked  on  the 
design and implementation of new  initiatives in  this field. Moreover, KABEG has been the 
main coordinator of this Unit in which physicians, public insurance companies, social service 
departments and delegates from different healthcare organisations were also involved. 

Three  hospitals  from  KAGEG  have  participated  in  Renewing  Health:  Klagenfurt,  Laas  and 
Villach.  In addition, six outpatient care clinics, two nursing homes and one mobile  nursing 
organisation have collaborated.  

The aim of the pilot in Carinthia was to establish and extend the services and infrastructure 
required  to  manage  and  assess chronic  patients  with  COPD  and  Diabetes.  A  few patients 
are still using the system and KABEG has plans to further expand the services. 

5    Information provided by KABEG 

15 

 
 
                                              
2 

Integrated care analysis 

2.1  Dimensions of integration 

KABEG was responsible for the implementation of the Renewing Health project in Carinthia. 
The pilots conducted by KABEG as part of the Renewing Health project that focused on two 
target groups: Type II Diabetes Mellitus (T2DM) patients and Chronic Obstructive Pulmonary 
Disease (COPD) patients. Most of the professionals (Diabetes and COPD physicians, home 
nurses, etc.) who were involved in the project worked for KABEG. In addition, mobile nurses 
from the Austrian Red Cross and independent General Practitioners (GP) also participated in 
the initiative. From the beginning, KABEG defined the responsibilities  of each professional 
for  the  remit  of  the  project.  For  instance,  independent  GPs  did  not  have  access  to  the 
patient’s  history  and  his  or  her  physiological  parameters  but  were  informed  about  the 
health condition of the patients by the hospitals' outpatient departments. 

For the lifespan of the project, one can say that there was some integration between the 
three  different  hospitals  from  KABEG,  and  also  between  the  other  professionals  and 
institutions,  and  KABEG  played  a  central  role  in  coordinating  the  initiative.  The  type  of 
information  sharing  and  the  clear  definition  of 
integration  consisted  mainly  of 
responsibilities  amongst  professionals,  while  organisational  mechanisms  remained 
separate.  

In order  to support the flow of information among the different organisations involved in 
the  project,  KABEG  developed  a  set  of  guidelines  on  communication  and  cooperation 
between mobile nurses, home nurses, general practitioners and GPs in the outpatient area. 
Moreover, a framework was created to integrate different Health Information Systems and 
different  services.  This  framework  included  the  devices  that  acquired  and  automatically 
transmitted  information  about  physiological  parameters  (HbA1c,  blood  sugar,  blood 
pressure for diabetes) to the HIS; CDA documents that ensured the integrity and security of 
the information; a call centre for supporting COPD patients; dedicated software installed on 
the  mobile  nurses’  PDAs  that  allowed  them  to  upload  patient  data  and,  finally,  the  web 
portal, that allowed patients to upload their  parameters and supported them with reports 
and reminders. Doctors in  the outpatient area could use the platform  to check the health 
status  of  patients  and  to  change  Disease  Management  Processes  (DMP).  These  changes 
were  recorded  in  reports  and  shared  with  the  GPs  in  Primary  Care  and  with  the  nurses 
involved. 

2.2 

Impact 

The  main  objective  of  the  Renewing  Health  pilots  in  Austria  was  to  test  the  effects  of 
integrated services on patients’ quality of life, clinical parameters and patients’ satisfaction 
and  to  evaluate  organisational  framework  and  economic  aspects,  through  a  randomised 
controlled trial. 

As  requested  by  the  Renewing  Health  project,  the  Model  for  Assessment  of  Telemedicine 
(MAST) (Kidholm, 2012) approach was used to assess the impact. The results are described 
in  a  publicly-available  summary  report  (Steinberger  H,  2014)  and  in  two  more  detailed 
internal reports that were used to generate this case study.  

Regarding  the  impact  on  patient  outcomes,  quality  of  life  -  measured  through  the  SF36 
questionnaire  (Jenkinson,  1993)  (Ware,  1992)  -  was  the  primary  clinical  outcome 

16 

 
 
considered. In addition, as a proxy for diabetes control, HbA1c6 levels were measured and 
for COPD, the St. George’s Respiratory questionnaires7 were used. As secondary outcomes, 
the number of hospitalisations and clinical visits, and patient acceptance were measured.  

Patient  acceptance  was  evaluated  using  the  Service  User  Technology  Acceptability 
Questionnaire  (SUTAQ)  (Newman,  2011).  This  questionnaire  includes  22  items  (or 
questions)  expressed  on  a  6-point  Likert  scale  (from  1=  ‘Strongly  agree’  to  6=  ‘Strongly 
Disagree’).  The  dimensions  evaluated  comprise  Utility,  Effect  on  health  status,  Effects  on 
access to care, Effect on healthcare / social care, Privacy, Suitability and Satisfaction. The 
patients  in  the  intervention  group  answered  this  questionnaire  after  3  months  and  again 
after 12 months.  

For  diabetes,  KABEG  carried  out  a  randomised  controlled  parallel-group  unblinded  trial  in 
the 3 hospitals. 193 Type II Diabetes Mellitus  patients (older than 18 and with HbA1c >= 
6.5) were recruited, out of which 162 completed the study: 101 (out of the 117 recruited) 
in the intervention group and 61 (out of the 76 recruited) in the control group. Data were 
collected at the beginning of the trial, during the study period and one year after start. 

The SF36 questionnaire was used and HbA1c levels were measured at the beginning of the 
study  and  after  12  months  for  both  groups,  in  order  to  evaluate  the  primary  clinical 
outcome  of  the  new  intervention.  The  results  did  not  show  any  significant  differences 
between groups as a result of the intervention (see Table 5 in Annex). Besides, secondary 
clinical  outcomes  such  as  cholesterol  levels,  body  weight,  Body  Mass  Index  (BMI),  blood 
pressure  and  triglyceride  levels  were  also  monitored.  For  those  variables,  no  significant 
effect was found as a result of the intervention (see  Table 6 in Annex). Overall, it can be 
concluded that from a clinical point of view, the new services based on telemonitoring did 
not bring any statistically significant differences in any of the clinical variables assessed.   

KABEG did not register any remarkable impact on the number of clinical visits. Especially in 
the case of Diabetes, patients still had to visit primary care in order to monitor and assess 
their HbA1c levels every three months. This made it difficult to assess the use of services 
since both groups attended the clinical centre very often, no matter how they felt. Thus, in 
order to evaluate the impact another measure would be needed.  

The evaluation of patient acceptance using the SUTAQ questionnaire, which patients in the 
intervention group answered after 3 and 12 months (see results in Table 7 Annex), showed 
an  improvement  in  how  patients  perceived  quality  of  care  during  the  study.  Personal 
concerns were moderate and improved during the study.  Satisfaction was high throughout 
the study, although patients did not find the service suitable as a substitute to actual care. 

In addition, 65 COPD patients (COPD Gold Class III or IV) were included in the study: around 
one third  in  the control  group  (28 patients) and two thirds in  the intervention group  (37). 
These  low  numbers  reflect  the  difficulties  linked  to  the  recruitment  of  COPD  patients, 
whose advanced age and fragile health condition usually mean a relative lack of interest in 
participating  and  lack  of  skills  to  use  the  system.  Data  were  collected  at  the  beginning, 
during  the  treatment  process  and  at  the  end  of  the  trial  after  one  year.  Baseline 
characteristics  showed  significant  differences  between  the  intervention  and  the  control 
group, making it difficult to generalise the results.    

6   http://www.nlm.nih.gov/medlineplus/ency/article/003640.htm  
7   http://www.thoracic.org/assemblies/srn/questionaires/sgrq.php  

17 

 
 
                                              
In  the  COPD  trial,  the  SF36  and  St.  George’s  Respiratory  questionnaires  analysis  did  not 
show  differences  between  groups  (see  Table  8  and  Table  9).  Again,  no  differences  were 
found in  the frequency of visits. Regarding patient acceptance (see  Table  10), the results 
suggested  that  how  the  care  received  was  perceived  was  rather  good  at  the  start  but 
worsened significantly after one year, meaning that the degree of satisfaction with the care 
received decreased. Patients’ views on whether the service should become a substitute for 
traditional  care  also  deteriorated  over  time.  On  the  other  hand,  patients'  concerns  and 
privacy  issues  remained  quite  moderate  during  the  use  of  telemonitoring.  The  decreased 
satisfaction could therefore be related to organisational changes and to the way eHealth-
supported treatment was provided in the clinics involved. 

For  the  evaluation  of  the  economic  impact,  the societal  perspective  was  chosen,  which  is 
the  most  comprehensive  as  it  includes  all  costs  related  to  hospital,  general  practitioners, 
medical specialists, patients and their relatives. Table 11 in Annex gives an overview of the 
type  of  costs  considered  in  the  analysis,  the  methods  for  data  collection  and  the 
estimations obtained at patient or group level.  

KABEG carried out a cost-minimisation analysis (CMA) on both the control and intervention 
groups,  which  was  based  on  the  assumption  that  the  outcomes  were  equivalent  in  each 
group in order to determine the least-cost alternative (see Table 2). 

Table 2 - Least-cost table, DIABETES and COPD 

Total running costs DIABETES 
CMA=min(Ct-Ca) 
Total running costs COPD 
CMA=min(Ct-Ca) 

Intervention 
€2,006.33 

€6,056.73 

-€114.60 

-€1,617.90 

Control 
€2,120.93 

€7,674.63 

During  the  Renewing  Health  project,  it  was  estimated  that  a  patient  of  the  control  group 
generated an extra €114.60 costs per year in the case of diabetes and €1,617.90 per year 
in  the  case  of  COPD.  These  costs  included  intramural  (inpatient  days,  outpatient  visits), 
extramural  (visits  at  the  general  practitioner  and  the  medical  specialist)  and,  for  the 
intervention group, telemonitoring (devices, visitations) costs (see Table 12 in Annex.  

As  shown  in  Table  13  in  Annex,  the  greatest  difference  between  control  and  intervention 
groups  related  to  inpatient  stays.  Patients  in  the  control  group  incurred  more  stays  with 
more bed-days, which was particularly the case for patients with COPD. However, because 
of the differences in the baseline characteristics these results are not conclusive. 

2.3  Drivers and barriers 

The  main  drivers  of  the  case  are  technology  on  the  one  hand  and  the  fact  that  specific 
funding was received to develop and pilot the services on the other. 

KABEG aimed to build and maintain an interface which would be as simple as possible. This 
is an important point, as the users and the target population are older people who might 
not  be  able  to  handle  complex  systems.  In  addition,  KABEG  built  the  services  upon  an 
already  existing  and  running  HIS.  The  three  hospitals  were  already  using  a  robust 
information  system.  The  integration  of  the  new  data  and  communication  platform  was 
therefore  easy  from  a  technological  point  of  view.  Moreover,  the  professionals  involved 

18 

 
 
 
 
were  used  to  this  ICT  environment  and  the  training  they  received  was  neither  too 
complicated nor too time consuming.  

Besides,  despite  the  complexity  of  the  Austrian  Health  System  and  the  multiple  funding 
sources,  sufficient  funding  was  made  available  according  to  the  experts  consulted.  The 
regional government was committed to the initiative and insurance companies supported it 
from the very beginning.   

With regard to barriers, the lack of a specific board for telemedicine applications hindered 
the  implementation  of  the  initiative.  Problems  related  to  the  initial  workload,  technical 
support, the coordination of the involved organisations, and patient motivation would have 
been easier to deal with through a managing body. 

Another  crucial  barrier  was  the  recruitment  of  patients,  especially  in  the  case  of  COPD. 
Patients  must  be  carefully  recruited  for  the  treatment  to  be  successful.  Their  age  and 
cognitive  capacities  must  be  considered,  as  they  have  to  deal  with  technology.  Moreover, 
they  have  to  be  willing  to  join  the  initiative  and  participate  actively.  In  addition,  COPD 
patients are generally older, and their health status is worse than that of diabetes patients, 
so recruitment in this population group was more difficult.  

The  additional  workload  was  also  underestimated.  The  Renewing  Health  services  did  not 
substitute any other running service but constituted an additional task in the professionals’ 
daily activity which raised concerns or even complaints.  

The  initiative  also  encountered  some  difficulties  with  the  introduction  of  new  protocols. 
Clinical  partners  already  used  disease  management  protocols  to  treat  chronic  patients, 
which  made  it  difficult  to  introduce  new  disease  management  protocols,  especially  with 
regard  to  the  frequency  of  physiological  parameter  data  collection  and  the  amount  of 
stored data. The integration of physiological parameters of chronic patients in the hospital 
information  system  is  seen  as  an  advantage,  but  established  standard  organisational 
procedures  are  not  easy  to  change.  Some  stakeholders  are  less  willing  to  change  than 
others which can hinder further development.  

In addition, participating in studies often means additional tasks which usually come with 
direct additional resources. This was not the case in Renewing Health, sometimes making it 
difficult to involve some professionals.   

The  lack  of  official  communication  standards  amongst  the  involved  institutions  also 
hindered implementation. KABEG created ad hoc standards for the remit of the project, but 
if the service were to be mainstreamed, this would have to be revised and agreed upon. It 
was particularly difficult to coordinate home nurses and Red Cross nurses, which resulted in 
disruptions to patient care.  

Finally, defining a funding model for a health service in Austria is complex as it is a Federal 
State  with  many  political  levels  and  involving  many  different  entities.  For  instance, 
hospitals  are  financed  by  the  central  government,  the  region  and  public  insurance 
companies.  Home  nursing  is  financed  by  the  regional  government  and  mobile  nursing  is 
financed  by  the  region  and  by  patients.  Outpatient  care  is  supported  by  public  insurance 
companies. Indeed, this complex system delayed the implementation of Renewing Health.  

As  mentioned  before,  the  results  of  the  pilots  carried  out  within  the  Renewing  Health 
project are not conclusive enough to warrant the integration of the telemonitoring system 
into routine practice. Although the pilots demonstrated some cost reductions in the case of 
patients with diabetes, the return on investment that might result from the integration of a 

19 

 
 
telemonitoring solution into routine practice is unclear. So far, there is no dedicated funding 
for  eHealth  or  telemonitoring  activities  although  there  is  ongoing  work  to  create 
agreements  between  the  Austrian  government  and  the  various  regional  governments, 
which  might  enable  and  facilitate  eHealth  implementation.  These  agreements  will  be 
common  for  all  national  and  regional  eHealth  initiatives  and  will  address  all  health 
providers in all regions. One of the main goals of these agreements is the use of ICTs to 
facilitate cooperation, coordination and understanding among different bodies, which has to 
be achieved by 2016. 

2.4  Health professional and patients 

The  professionals  involved  in  the  pilot  project  included  practitioners  from  the  3  KABEG 
hospitals, the Austrian Red Cross home nurses and independent General Practitioners.  

The  nurses  and  specialists  at  the  hospitals  were  responsible  for  recruiting  the  study 
participants,  while  nurses  from  the  Red  Cross  delivered  home  care.  Specialists  were 
responsible  for  reviewing  the  digital  reports  of  the  data  submitted  by  the  patients,  for 
inviting them to additional examinations if necessary, and for informing them about their 
health status.  

Professionals from KABEG and the Austrian Red Cross received specific training prior to the 
start  of  the  project.  Home  nurses  of  the  Austrian  Red  Cross  received  an  introduction  and 
training  into  the  new  functions  of  the  updated  PDA  system  and  additional  devices 
(Bluetooth blood pressure and blood glucose measurement devices) together with the new 
version of their system. Professionals in the hospitals were trained for the system changes 
made  to  the  usual  hospital  software.  These  changes  were  minimal  and  therefore  only 
required a short introduction. Medical doctors received individual training of around 75 min 
and nurses of around 45min. 

The  perception  of  professionals  about  the  new  telemonitoring  system  was  analysed  by 
KABEG  through  focus  interviews  carried  out  in  two  groups  (one  composed  of  health 
professionals  and  the  other  of  technical  and  organisational  support  staff)  and  through 
questionnaires.  In  general,  professionals  had  a  good  perception  and  acceptance  of  the 
telemonitoring  system.  However  some  issues  arose  such  as  usability  problems  with  the 
Active Devices and the additional workload that the implementation of the Renewing Health 
system generated. 

Patients were considered by KABEG as central to the project and  as people who must be 
treated in a special way. Like every project involving people, Renewing Health had to ensure 
that  all  the  principles  of  bioethics  and  medical  ethics  were  fulfilled.  The  project  complied 
with the ethical principles included in Table 3 (see Section 2.6). 

2.5 

Information and Communication Technologies 

The  implementation  of  the  Renewing  Health  integration  strategy  is  based  on  the 
incorporation  of  Personal  Health  Systems  into  the  existing  Health  Information  Systems, 
expanding  the  functionalities  to  collect,  send  and  receive  CDA  (i.e.  Clinical  Document 
Architecture)  standard  documents.  These  CDA  documents  enable  and  facilitate  the 
communication  between  stakeholders  (through  the  health  portal  and  the  mobile  nursing 
system) and with the rest of the Austrian health system. 

KABEG  had  already  developed  its  own  Health  Information  System  in  the  three  hospitals 
under its responsibility prior to the start of the project. In addition, three other companies 

20 

 
 
were  involved  in  the  development  of  the  IT  infrastructure.  The  Carinthia  State  was 
responsible  for  organisational  tasks  such  as  the  coordination  of  all  the  entities  and 
providers  working  on  the  IT  system.  Moreover,  the  State’s  IT  department  hosted  and 
handled  the  Health  Web  Portal,  which  was  developed  by  Groiss  Informatics.  Ilogs,  an 
Austrian  telemedicine  company,  developed  the  PDA  Software  for  mobile  nursery  (called 
Mocca). 

A1 Telekom Austria, the leading mobile  and communication operator  in Austria supported 
the project by providing KABEG’s hospitals and the recruited COPD patients with the devices 
they  needed  to  implement  the  intervention.  Moreover  they  built  the  network  for  data 
exchange,  installed  the  devices  at  the  patients'  homes  and  offered  support  from  their 
technical department in order to ensure proper functioning8.  

All  communications  were  supported  through  an  internal  Internet-based  network,  a  call 
centre and SMS (reminder for patients). Users and professionals were assigned an account 
and credentials to enter the web portal. Each web portal user had access to certain areas. 
Patients had access to some information regarding their treatment, while physicians were 
only given access to the history of those patients under their responsibility. 

Figure 5 - Data Flow in KABEG's ICT infrastructure 

Source: KABEG 

As illustrated in Figure 5, the information was collected at the patient’s home in four ways: 
1) through the Active Devices, which automatically sent the information to the HIS; 2) via 
nurses’ PDAs; 3) by manual collection with traditional devices, the data being entered into 

8,  http://www.a1.net/newsroom/en/2011/05/a1-telekom-austria-unterstutzt-e-health-initiative-innovatives-

eu-projekt-offnet-karnten-die-tur-in-gesundheitsversorgung-der-zukunft/ 

21 

 
 
 
 
 
                                              
the web portal via a personal computer or a smartphone; and 4) via the Call Centre, for the 
oldest patients. 

All this information was sent to the Automatic  Collecting System, which generated a CDA 
document. This document was  subsequently stored in  each patient history file in  the HIS, 
and made available to the physicians in the outpatient area and the GPs. This information 
was  used  for  Disease  Management  Process  fine-tuning.  Moreover,  patients  could  see 
statistics  in  the  web  portal,  which  gave  them  an  overview  of  their  health  condition. 
However,  in  order  to  get  full  information  about  their  health  condition,  patients 
communicated with the outpatient departments. 

The Mocca application was developed by Ilogs for the mobile nurses from the Red Cross to 
help  them  look  after  chronic  patients  during  the  Renewing  Health  pilot.  The  application 
included:  1)  the  Mocca planning  module  (i.e.  the  working schedule,  resource  management 
and  route  optimisation);  2)  the  Mocca  mobile  device,  which  allowed  nurses  to  take 
measurements from patients; and 3) the Mocca care application which included healthcare 
documentation  based  on  existing  technical  standards.  KABEG’s  idea  is  to  scale  up  its  HIS 
and electronic network to the whole Austrian hospital health care system, ELGA. Indeed, the 
development of the KABEG HIS was aligned with ELGA in order to ensure better integration 
in the coming years when ELGA is ready. However, the Renewing Health project per se will 
not be not integrated  

2.6  Governance and policy setting 

To set up and run the project, KABEG defined the governance model and the processes to 
be  followed  by  all  stakeholders  and  the  role  of  each  professional  involved.  The  legal 
framework did not have to be  modified  to implement the project since the Austrian legal 
system  already  supported  eHealth  activities.  However,  in  order  to  continue  in  the  future, 
some  specific  legislation  may  be  needed  to  regulate  communication  and  cooperation 
among  the  different  tiers  of  healthcare.  There  is  also  a need  for  legislation  to  guarantee 
patients  security  and  safety.  A  Health  Care  Reform  is  currently  under  discussion.  This 
reform  would  affect  the  system  at  national  level,  and  might  be  a  trigger  for  scaling  up 
projects such as Renewing Health. The Austrian government is cooperating with the regional 
Health  Departments  to  design  this  Health  Care  Reform  which  will  define  regulations  that 
clarify issues related to eHealth amongst others.  

KABEG  wanted  to  ensure  compliance  with  certain  ethical  issues  from  the  very  beginning 
which is why they included guidelines in their initial protocol to that effect (see Table 3).  

22 

 
 
 
 
 
 
 
 
 
 
Table 3 - Ethical issues9 

Issue 

How the issue was 
addressed 

Patient autonomy 

Consent to treatment 

Access and equality 

Privacy and security 

Public information in different 
formats; available in clinics or 
hospitals 
Consent to treatment  

Autonomy 

Assessment of risk 
and benefit 

Different kinds of 
telemonitoring and reminder 
systems were implemented, 
but no enforcement was 
foreseen 
Inclusion criteria and training 

Implementation 

A patient information pack was created, staff 
were trained to deliver oral guidance on the 
written information, and patients’ consent was 
recorded in writing. Patients could withdraw after 
considering the written guidance at any time. 

Cultural, religious and ethical issues are not 
included; SUTAQ provided insights into patients’ 
perception about these topics.  

The patient had the possibility to choose the tool, 
and to decide whether to receive reminders or 
not.  

KABEG developed the telemonitoring application and the study pilot in compliance with the 
existing  legal  framework.  They  aimed  to  comply  with  their  social  objectives  and  fulfil 
patients’ rights, while avoiding possible future liability problems (see Table 4).  

Table 4 - Legal issues10 

Issue 

How the issue was 
addressed 

Clinical accreditation  Only staff in the selected 

Device certification 

clinics participated 
CE certificate 

Information 
governance 

Only for systems already in 
use or systems subject to 
agreement  

Professional liability 

Liability insurance 

Implementation 

Only devices accepted by public insurance were 
supported 
Special privacy and security agreements 
Use of citizen card for User and patient 
identification possible 
Use of Information security systems by providers 
Treatments involving the use of telemedicine 
included 

The project received strong support from policy makers who are working on plans for the 
possible  implementation  of  ICT-based  solutions,  especially  for  diabetes,  cardiovascular 
diseases and social care. 

9   Internal report provided by KABEG 
10   Internal deliverable provided by KABEG 

23 

 
 
 
 
 
 
 
 
 
 
 
                                              
2.7  Organisation and processes 

The implementation of Renewing Health in Carinthia was possible thanks to the cooperation 
of  several  organisations,  under  the  leadership  of  KABEG.  KABEG  had  the  initial  idea, 
recruited all the stakeholders, coordinated the initiative and made it possible to implement 
telemonitoring  within  the  disease  management  processes  in  Carinthia.  Moreover,  most  of 
the  care  professionals  who  were  involved  in  the  project  worked  for  KABEG  (the  Diabetes 
and COPD physicians, home nurses, etc.).  

The European Commission also played a key role in Renewing Health by financing 50% of 
the  total  budget  for  implementation  (€400,000).  The  Austrian  government  and  the 
Carinthia  regional  government  support  hospital  system  funds.  They  also  established 
specific goals for the use of ICT in care provision as a way of reducing expenditure. Public 
Insurance  Companies  and  Social  Security  Institutions  also  contributed  to  the  Renewing 
Health project by providing outpatient care services and by financing part of hospital care.  

Some technology companies were also involved in Renewing Health. They created, ran and 
maintained  the  Health  Information  System,  the  system  for  data  collection  and  the 
electronic  network  which  enabled  personalised  care  provision.  A1  Telekom  designed  and 
provided  users  with  the  measuring  devices  (Active  Devices)  and  later  developed  the 
application for smartphones. Gross Informatics built the web portal for data collection and 
physician-patient communication. Ilogs developed the MOCCA application that was used by 
mobile nurses on their PDAs. 

Finally,  the  Austrian  Red  Cross  managed  mobile  nursing,  with  resources  from  Public 
Insurance Companies and private contributions. Independent General Practitioners (GP) did 
not get strongly involved in the initiative. KABEG gave them access to patients' history and 
physiological  parameters  in  order  to  ensure  good  disease  management  and  support 
decision making. Figure 6 illustrates the cooperation among all the above stakeholders.  

Figure 6 - Organisations involved [authors’ creation] 

24 

 
 
 
As coordinator of the initiative, KABEG developed a common Disease Management Process 
(thereafter DMP) that had to be supported by the overall system. This DMP was developed 
in  collaboration  with  health  professionals,  mainly  from  KABEG,  and  all  participating 
stakeholders were later trained in its implementation. Some changes were needed in order 
to  enable  the  implementation  of  the  new  disease  management  process  in  all  involved 
organisations. First of all, the involved organisations had already established protocols for 
dealing  with  chronic  patients.  The  new  DMP  affected  these  protocols,  especially  the 
frequency of vital parameter data collection which also determined the amount of stored 
data.  The  integration  of  vital  parameters  on  chronic  patients  in  the  hospital  information 
system  was  seen  as  an  advantage,  but  the  modification  of  established  standard 
organisational procedures was met with some resistance.  

In order to coordinate the process between the involved stakeholders, several factors were 
taken into account. Nevertheless, the following difficulties emerged: 

  The level of cooperation between GPs and especially nurses differed between clinics. 
Sometimes  there  was  little  will  or  possibility  to  cooperate  between  different 
professional groups.  

  The involved hospitals had different approaches to the treatment of patients, some 
used a standard treatment process, others a case-by-case treatment process. Some 
treated primarily inpatients, others also dealt with outpatients.  

KABEG  was  conscious  that  its  communication  system  was  not  effective.  Prior  to  the 
application of the Renewing Health intervention, all information exchange was based on e-
mails.  The  communication  was  neither  fast  nor  efficient  enough,  as  doctors  received  too 
many  e-mails  related  to  their  patients  under  diabetes  treatment  and  it  was  difficult  for 
them to determine which of them reported severe conditions or which events required fast 
response. Moreover, GPs needed to check their mail box very often if they wanted to be up 
to  date.  Therefore,  KABEG  modified  the  communication  processes  and  remodelled  the 
system in two ways:  

1.  Internal Changes:  

 

Implementation  of  the  telemonitoring  application:  Results  from  periodic  tests 
started  to  be  stored  in  the  patient  record  of  the  health  information  system  (HIS). 
They therefore became available to doctors and nurses at any time and location. In 
total, the 193 Type II Diabetes Mellitus patients (older than  18 and HbA1c >= 6.5) 
and  the  65  patients  diagnosed  with  COPD  who  participated  in  the  pilots  uploaded 
information into the HIS during a period of 12 months.  

  Day-to-day  running  of  the  service:  the  service  had  to  be  provided  without  the 
patient physically visiting the clinic. Important parameters about their disease status 
had  to  be  assessed  to  make  sure  they  fell  within  safe  ranges  in  order  to  prevent 
sudden  or/and  critical  worsening  events.  The  GP  established  some  thresholds  for 
each  patient  after  the  initial  examination.  Those  thresholds  could  be  updated  and 
re-set by the doctor depending on the patient’s evolution.  

2.  External Changes 

 

Implementation of the telemonitoring application: Patients were empowered to care 
for  themselves  and live as independent a life as possible. However, they were not 
always able to carry out the treatment process or identify the worsening conditions 

25 

 
 
that needed a fast-response as patients did not always enter all the parameters. In 
order  to  overcome  these  constraints,  KABEG  developed  an  SMS-based  reminder 
system,  which  was  much  faster  than  a  web  portal  or  a  call  centre.  This  system 
sends patients reminders by SMS when they fail to enter their parameters, and also 
sends emails to physicians if they fail to comply.  

  Day-to-day running of the service: it became possible  to make additional contacts 
with  patients  by  telephone.  Patients  often  wished  to  communicate  with  their  care 
professionals  more  often  than  the  usual  contacts  regarding  their  treatment. 
Practitioners in the outpatient area were not used to dealing with additional reports 
concerning the status of the disease, and clarifications and changes to the routine 
practice were needed in order to enable this. 

2.8  Reimbursement model and economic flow 

KABEG  received  €400,000  EU  funding  for  Renewing  Health  which  was  used  mainly  for 
implementing the study and managing the project. If Renewing Health is implemented more 
widely  in  the  future,  it  would  be  necessary  to  develop  a  legal  framework  which  clarifies 
financing sources. The Austrian funding model is complex, and economic flows come from 
different administrative bodies (Federal Government, Region, Insurance Companies). 

Renewing Health involved mainly the outpatient area, which  is fully covered by insurance 
companies. This facilitated the implementation of the initiative. Besides, home nursing and 
mobile nursing were supported by the Regional Government, which was fully committed to 
the  initiative.  The  telemedicine  services  were  included  in  the  regular  and  universal  health 
package of services without additional payment, which made it easy to include patients. 

In general, patients had no costs or nearly none. The services were partly free during the 
study. The Call Centre had to be paid by the patients themselves (about 3€ a month), for 
the  web  portal  the  patients  need  to  access  the  internet  via  PC  or  Smartphone,  so  there 
were very low running costs. Active devices, the blood glucose measuring devices and blood 
pressure measuring devices for the web portal patients were free for patients. During the 
project, test strips for the blood glucose measurements were free for the patients who did 
not need to take insulin. For patients who needed insulin, test strips were paid  for by the 
health insurance company.  

There is currently no dedicated funding for eHealth or telemonitoring activities. There is on-
going  work  on  creating  targeted  agreements  between  the  Austrian  and  the  regional 
governments,  which  might  enable  and  facilitate  eHealth  implementation  (i.e.  the  Health 
Reform).  These  targeted  agreements  will  become  common  practice  for  all  national  and 
regional governments and for the health providers in the regions. One of the main goals of 
these  agreements  is  the  use  of  ICTs  to  facilitate  cooperation,  coordination  and 
understanding  among  different  bodies.  The  goals  defined  in  these  targeted  agreements 
have to be achieved by 2016.  

The  main  cost  saving  achieved  through  Renewing  Health  relates  to  the  reduction  of 
inpatient stays. The main beneficiaries of the intervention in terms of economic outcomes 
would  therefore  be  the  regional  and  federal  governments,  while  public  insurance 
companies,  which  also  support  inpatient  care,  would  not  see  any  economic  improvement. 
This means that in order to involve the GPs, an incentive system may be needed.  

26 

 
 
Since  major  health  care  reform  is  pending  in  Austria,  it  is  not  possible  to  predict  what  a 
reasonable economic model would look like in the future, since this will largely depend on 
the actual measures taken after the reform. 

3  Transferability 

The case is well documented since it was deployed as part of a European project and public 
reports  are  accessible  through  the  official  project  website.  Moreover,  in  2015  the  most 
relevant scientific results obtained in the pilots will continue to be disseminated in relevant 
conferences and publications.  

So  far,  the  services  have  not  been  transferred  to  other  regions,  although  the  experts 
involved  have  been  in  contact  with  other  regions.  KABEG  performed  a  transferability 
assessment  during  their  pilot  study.  It  was  based  on  the  positive  feedback  from 
government, insurance companies, hospital staff and some selected patients.  

The Austrian Health Ministry is aware of the need to implement telemonitoring solutions for 
the treatment of chronic patients throughout its care system and not only in pilots or small-
scale projects (e.g. Carinthia, DiabMemory in Lower Austria). In this context, they created a 
commission to advise on the provision of eHealth related treatment.  

KABEG considered different points of view: 

  Scalability: KABEG expects that results would be similar if the initiative was scaled 
up to country level. They base their opinion on the simple and flexible architecture 
of  the  system.    Defined  Disease  Management  Processes  (DMPs)  and  information 
transmission through CDA documents facilitate scaling up. Moreover the experience 
of KABEG with supporting the infrastructure can be  a driver  for  implementation in 
other regions.  

On  the  other  hand,  the  complex  funding  system  in  Austria  and  the  absence  of  a 
clear framework for eHealth services provision could hinder the process. In addition, 
all the regions in Austria are subject to similar organisational restrictions. Although 
this  homogeneity  could  be  a  barrier,  it  could  also  facilitate  scaling  up.  If  the 
necessary organisational changes are produced in one region with successful results 
other regions could solve the same problems following the same steps.  

  Generalisability:  KABEG  is  considering  the  possibility  of  applying  telemonitoring 
solutions for other patients, i.e. not only for those suffering from diabetes or COPD. 
They consider that the successful experience dealing with diabetic patients and the 
established infrastructure may be a catalyst for widening the selection criteria. 

4  Conclusions 

The  Renewing Health  case  in  Carinthia  represents  an  integrated  care  service  for  diabetes 
and  COPD  patients.  Since  it  was  part  of  a  European  Project,  KABEG  received  dedicated 
funding that has helped promote the initiative and commit the different stakeholders of the 
region to the deployment of these services.  

The  project  was  evaluated  through  a  randomised  control  trial  in  terms  of  both  patient 
outcomes and economic impact. Regarding the clinical outcome, no major differences were 
found  between  the  group  which  received  the  interventions  and  the  control  groups. 
Regarding the economic impact, results suggest that savings can be derived from the use 

27 

 
 
of  the  service,  although  due  to  differences  in  the  characteristics  of  the  intervention  and 
control groups, the results were not conclusive.  

With  regard  to  the  use  of  ICT  by  the  patients,  some  differences  were  apparent.  Diabetic 
patients  used  the  system  without  problems  and  reported  a  good  experience.  In  contrast, 
COPD  patients  (with  worse  health  status)  were  not  able  to  use  the  remote  monitoring 
system,  so  monitoring  tasks  were  delegated  to  the  dedicated  nurse.  In  order  to  provide 
COPD  with  special  support,  a  dedicated  call  centre  was  set  up,  supported  by  A1  Telekom 
Austria.  

From  a  technical  standpoint,  one  of  the  main  objectives  of  the  Carinthian  branch  of  the 
Renewing  Health  project  was  to  establish  and  extend  a  robust  infrastructure  and  an 
integrated  treatment  process  using  electronic  systems.  Before  the  project  started,  KABEG 
counted on a set of technology-based services, such as: (1) the collection of common data 
on  nursing  with  mobile  devices  during  home  care,  (2)  clinical  records  for  the  outpatient 
area,  and  (3)  HIS  support  for  physicians  and  nurses.  During  the  course  of  the  project, 
personal  health  systems  were  integrated  into  the  architecture  in  order  to  support  the 
remote collection of medical data. However, the lack of conclusive results obtained during 
the project trials compromise the deployment of such a telemonitoring system and its use 
in  general  practice.  Organisational  issues  and  costs  –  i.e.  not  all  Active  Devices  are 
supported by public insurance companies  – need to be further explored in order to finally 
bring the telemonitoring service into standard practice, and to keep it up and running. 

The smooth cooperation between the institutions involved at different levels represented a 
good basis  for  integration of care delivery. Some barriers still need  to be  solved, such as 
the definition of standards for communication amongst professionals.  

To  sum  up,  Figure  7  shows  the  main  facilitators  (Villalba,  2013)  that  characterise  the 
KABEG  case,  interoperable  information  systems  and  policy  commitment  being  the  main 
ones.  These  two  drivers  are  followed  by  governance  mechanisms  already  set  in  place  to 
foster integrated care, taking into account the focus on patients and national investments 
and funding programmes at a hospital and regional level. Lastly, incentives and financing, 
and  engaged  professionals  play  a  minor  role  in  this  case, but  they  could  hamper  the  full 
deployment of the initiative at a regional level. 

Figure 7- Facilitators of Renewing Health in Carinthia  

28 

 
 
 
 
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valuation+-+Carinthia.pdf  

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29 

 
 
 
Annex 

This  annex  includes  the  main  tables  for  the  impact  extracted  from  reports  provided  by 
KABEG.  

Table 5 - Primary Clinical Outcomes of Diabetic Patients11 

Outcome 
Measure 

Intervention 

Control 

HbA1c 

SF-36: Physical 
Functioning 0-
100 Score 
SF-36: Role 
Physical 0-100 
Score 
SF-36: Bodily 
Pain 0-100 
Score 
SF-36: General 
Health 0-100 
Score 
SF-36: Vitality 
0-100 Score 

Baseline 
(t1) 

After 12 
months 
(t2) 

Baseline 
(t1) 

After 12 
months 
(t2) 

Median (SD) 
Median 

8.7  
(1.9)  
8.1 
72.5 
(25.2)  
80 

63.8 
(24.3) 
62.5 

62.2 
(31.0) 
62.0 

62.2 
(16.6) 
62.0 

7.5  
(1.5)  
7.2 
77.1 
(22.3)  
85 

72.5 
(25.1) 
75.0 

66.5 
(30.0) 
64.0 

69.4 
(18.8) 
72.0 

8.1  
(1.2)  
8.0 
69.2 
(25.8)  
75 

58.5 
(29.5) 
56.3 

59.8 
(33.6) 
62.0 

62.6 
(19.3) 
64.5 

7.5  
(1.1)  
7.5 
74.9 
(24.1)  
85 

68.3 
(29.3) 
75.0 

66.7 
(30.9) 
72.0 

67.9 
(17.9) 
67.0 

58.4 
(19.3) 
62.5 
81.3 
(22.1) 
87.5 

63.2 
(19.1) 
68.8 
81.3 
(26.6) 
100.0 

56.3 
(25.7) 
53.1 
80.1 
(23.1) 
87.5 

61.6 
(23.6) 
62.5 
86.7 
(18.8) 
100.0 

Mean difference 
after 12 month 
between groups 
(95% CI) 

P 
value 

-.6a (-1.3 to 0.05) 

.025 

-1.1b (-7.9 to 5.9) 

.884 

-1.1 (-10.3 to 8.1) 

.986 

-2.7 (-13.0 to 7.7) 

.793 

1.9 (-3.9 to 7.7) 

.154 

-0.5 (-7.0 to 5.9) 

.869 

.965 

.120 

-6.6 (-14.4 to 1.3) 

-2.2 (-12.2 to 7.7) 

72.1 
(18.8) 
80.0 

70.7 
(24.5) 
75.0 

78.7 
(25.3) 
91.7 

77.7 
(28.4) 
100.0 

67.5 
(28.2) 
75.0 

SF-36: Social 
Functioning 0-
100 Score 
SF-36: Role 
Emotional 0-
100 Score 
SF-36: Mental 
Health 0-100 
Score 
SF-36: PCS 
Physical 
Component 
Score 
Notes: 
-  Data  are  mean  scores  (SD)  and  medians;  differences  between  groups  after  12  month  were  compared  by 
using Mann-Whitney-U-tests. 
- a: a negative value indicates a higher improvement for intervention group. 
- b: a negative value in SF-36-differences indicates a higher improvement for control group. 

43.7 
(10.4) 
44.9 

72.2 
(21.7) 
75.0 

76.1 
(19.6) 
80.0 

72.6 
(20.1) 
80.0 

46.3 
(9.6) 
48.0 

45.1 
(9.9) 
46.1 

47.9 
(9.5) 
49.4 

-3.5 (-9.3 to 2.3) 

.13 (-2.8 to 3.1) 

.254 

.445 

11 Internal report provided by KABEG: Deliverable D15.7-1 Final Pilot Evaluation – Carinthia Cluster 1 Version 
1.0 by Renewing Health and KABEG 

30 

 
 
 
 
 
 
 
                                              
Table 6 - Secondary Clinical Outcomes of Diabetic Patients11 

Outcome 
Measure 

Intervention 

Control 

Baseline 
(t1) 

After 12 
months 
(t2) 

Baseline 
(t1) 

After 12 
months 
(t2) 

Median(SD) 
Median 

P value 

Mean difference 
after 12 month 
between groups 
(95% CI) 

Weight 

Cholesterol 

HDL-
cholesterol 

197.6 
(53.1) 
188.0 
LDL-cholesterol   112.1 
(42.5) 
99.0 
47.1 
(12.6) 
45.5 
90.74 
(20.0) 
88.0 
31.2 
(5.3) 
30.9 
88.9 
(12.6) 
88.0 
153.7 
(23.1) 
149.0 

Blood Pressure: 
Diastolic 

Blood Pressure: 
Systolic 

BMI 

186.1 
(51.3) 
173.0 
107.6 
(44.2) 
92.5 
48.1 
(16.9) 
45.0 
90.3 
(19.3) 
90.0 
31.2 
(5.3) 
30.9 
84.8 
(12.6) 
85.0 
148.7 
(23.6) 
145.0 

Triglyceride 

233.5 
(260.7) 
165.5 

181.4 
(125.2) 
152.5 

186.8 
(37.8) 
188.0 
107.5 
(36.3) 
106.0 
48.2 
(16.8) 
47.0 
90.2 
(19.0) 
93.0 
31.3 
(6.0) 
31.1 
86.7 
(12.9) 
88.0 
150.4 
(21.3) 
149.0 

155.1 
(78.0) 
141.0 

185.2 
(41.6) 
176.0 
104.3 
(38.7) 
92.5 
51.3 
(17.6) 
47.5 
89.9 
(19.0) 
91.0 
31.3 
(6.0) 
31.1 
85.2 
(13.0) 
86.0 
149.3 
(21.1) 
148.0 

157.0 
(90.7) 
139.0 

9.9c (-3.0 to 22.9) 

.821 

1.3 (-10.7 to 13.2 

.166 

-2.1 (-6.3 to 2.2 

.773 

0.4 (-1.5 to 2.3) 

.155 

0.05 (-0.6 to 0.7) 

.972 

2.5 (-2.3 to 7.4) 

.182 

3.9 (-4.6 to 12.3) 

.220 

54.0 (-15.0 to 123.0) 

.057 

Notes:  
-  Data are mean scores (SD) and medians, differences between groups after 12 month were compared by 

using Mann-Whitney-U-tests. 

-  A positive value in SGRQ-differences indicates a higher improvement for intervention group. 

31 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 7 - SUTAQ Results Diabetic Patients11 

Outcome 
Measure 

Intervention 
after 3 
months 

Intervention 
after 12 months 

Mean difference after 
12 month between t1 
and t2 (95% CI) 

P value 

Median (SD) 
Median 

F1: enhanced care 

F2: increased 
accessibility 

F3: privacy & 
discomfort scale 

F4: care personnel 
concerns 

F5: kit as 
substitution 

F6: satisfaction 

5.2  
(0.9) 
 5.6 

4.9  
(1.1)  
5.3 
2.4  
(1.2)  
2.3 
2.6  
(1.5)  
2.7 
3.6  
(1.3)  
4.0 
5.7  
(0.6)  
6.0 

5.4  
(1.0)  
5.8 

5.2  
(1.2)  
5.8 
2.1  
(1.0)  
2.0 
1.9  
(1.2)  
1.3 
3.5  
(1.2)  
3.7 
5.6  
(0.8)  
6.0 

-0.11a (-0.3 to 0.9) 

.058 

-0.25a (-0.6 to 0.05) 

.015 

0.38b (-0.0 to 0.8) 

.065 

0.64b (0.20 to 1.1) 

.007 

0.13a (-0.3 to 0.6) 

.590 

0.01a (-0.2 to 0.2) 

.734 

Notes: 
-  Data  are  mean  scores  (SD)  and  medians;  differences  between  groups  after  12  month  were  compared  by 
using Mann-Whitney-U test.  

32 

 
 
 
 
 
 
 
 
Table 8 - Primary Clinical Outcomes of COPD Patients12 

Outcome Measure 

Intervention 

Control 

Baseline 
(t1) 

After 12 
months 
(t2) 

Baseline 
(t1) 

After 12 
months 
(t2) 

Median (SD) 
Median 

SF36-Physical 
Functioning 

Role Physical 

SF36-Bodily Pain 

SF36-General 
Health 

SF36-Vitality 

SF36-Social 
Functioning 

SF36-Role 
Emotional 

SF36-Mental 
Health 

SF36-PCS Physical 
Component Score 

SF36-MCS Mental 
Component Score 

Notes: 

48.2 
(24.5) 
45.0 
40.7 
(20.0) 
43.8 
55.6 
(28.8) 
52.0 
49.3 
(14.4) 
45.0 
44.0 
(16.4) 
43.8 
67.4 
(24.4) 
75.0 
53.4 
(28.8) 
50.0 
59.5 
(19.9) 
60.0 
38.1  
(7.6)  
37.6 
41.8 
(11.7) 
40.6 

39.8 
(31.5) 
40.0 
35.9 
(25.0) 
31.3 
55.3 
(32.6) 
51.0 
47.3 
(25.1) 
45.0 
44.6 
(27.9) 
40.6 
61.2 
(33.9) 
62.5 
53.7 
(33.6) 
45.8 
59.6 
(26.7) 
60.0 
36.1 
(10.3) 
35.2 
42.7 
(14.8) 
41.0 

35.0 
(27.4) 
20.0 
19.5 
(19.2) 
25.0 
59.1 
(40.2) 
72.0 
40.1 
(26.7) 
40.0 
38.3 
(25.1) 
37.5 
58.6 
(36.7) 
87.5 
27.6 
(28.7) 
25.0 
53.1 
(26.6) 
60.0 
35.3 
(11.3) 
34.1 
35.0 
(13.1) 
36.4 

22.8 
(15.4) 
30.0 
28.9 
(20.9) 
28.1 
52.8 
(39.1) 
41.5 
36.3 
(21.3) 
33.5 
35.5 
(22.4) 
31.3 
64.1 
(36.8) 
75.0 
45.8 
(29.0) 
45.8 
56.6 
(27.8) 
62.5 
31.0  
(9.2)  
31.0 
41.0 
(14.6) 
42.9 

Mean 
difference 
after 12 
month 
between 
groups 
(95% CI) 

3.8 (-9.4 to 
16.9) 

-14.2 (-31.1 
to 2.7) 

6.1 (-17.2 to 
29.3) 

1.9 (-14.2 to 
18.0) 

3.4 (-14.1 to 
20.9) 

-11.7 (-33.0 
to 9.6) 

-17.9 (-43.3 
to 7.4) 

-3.3 (-17.7 
to 11.2) 

2.3 (-3.3 to 
7.8) 

-5.1 (-14.6 
to 4.5) 

P value 

.616 

.156 

.340 

.617 

.769 

.263 

.118 

1.00 

.412 

.292 

-  Data  are  mean  scores  (SD)  and  medians,  differences  between  groups  after  12  month  were 

compared by using Mann-Whitney-U-tests All scores are 1 - 100 
A negative value in SF-36-differences indicates a higher improvement for control group 

- 

12 Internal deliverable provided by KABEG: Deliverable D15.7-5 Final Pilot Evaluation – Carinthia Cluster 5 
Version 0.4 by Renewing Health and KABEG 

33 

 
 
 
 
 
 
 
                                              
Table 9 - Primary Clinical Outcomes of COPD Patients12 

Intervention 

Control 

Baseline 
(t1) 

After 12 
months 
(t2) 

Baseline 
(t1) 

After 12 
months 
(t2) 

Median (SD) 
Median 

69.0 
(18.0) 
72.7 
68.9 
(22.9) 
75.8 
42.6 
(20.9) 
42.8 
54.6 
(18.1) 
56.4 

61.2 
(27.6) 
66.0 
62.4 
(28.4) 
69.4 
42.3 
(23.3) 
47.2 
50.8 
(24.0) 
57.7 

74.0 
(20.1) 
70.8 
76.3 
(17.2) 
77.8 
55.1 
(17.9) 
57.2 
64.8 
(15.3) 
65.4 

67.4 
(24.2) 
73.3 
79.3 
(13.5) 
79.1 
54.3 
(20.1) 
55.6 
64.2 
(17.7) 
64.6 

P value 

Mean 
difference 
after 12 month 
between groups 
(95% CI) 

1.3 (-19.0 to 
21.5) 

.721 

9.5 (-3.5 to 22.6) 

.315 

-0.5 (-14.4 to 
13.4) 

.989 

3.2 (-9.8 to 16.3) 

.849 

Saint George’s 
Questionnaire  
Outcome Measure 

Symptoms score  

Activity score  

Impacts score  

Total score  

Notes:  

-  Data  are  mean  scores  (SD)  and  medians,  differences  between  groups  after  12  month  were 

compared by using Mann-Whitney-U-tests. 
A positive value in SGRQ-differences indicates a higher improvement for intervention group. 

- 

Table 10 - SUTAQ Results COPD patients12 

Outcome 
Measure 

Intervention after 
3 months 

Intervention after 
12 months 

P value 

Mean difference 
after 12 month 
between t1 and t2 
(95% CI) 

Median (SD) 
Median 

.432 

.036 

4.7 (1.1) 4.8 

5.3 (0.8) 5.6 

0.58a (-0.0 to 1.2) 

2.5 (1.5) 2.3 

4.4 (1.5) 4.9 

2.5 (1.4) 2.3 

4.8 (1.1) 4.9 

0.32a (-0.6 to 1.2) 

F1: enhanced 
care  
F2: increased 
accessibility  
F3: privacy & 
discomfort 
scale  
F4: care 
personnel 
concerns  
F5: kit as 
substitution  
F6: satisfaction  
Notes: 
- Data are mean scores (SD) and medians; differences between t1 (after 3 months) and t2 (after 12 months) 
were compared by using Wilcoxon tests. 

0.46b (-1.0 to 1.9) 

0.58a (-0.1 to 1.3) 

0.06a (-0.2 to 0.3) 

0.08b (-1.0 to 1.2) 

5.6 (0.6) 6.0 

3.4 (1.3) 3.3 

2.6 (1.8) 1.3 

2.2 (1.4) 2.0 

2.8 (1.3) 2.7 

5.5 (0.6) 6.0 

.656 

.673 

.568 

.098 

 

 

a: a negative value in SUTAQ differences indicates a higher agreement with the aspects of 
the kit at t2. 
b: a  positive  value in SUTAQ differences indicates a  higher agreement  with the aspects of 
the kit at t2 

34 

 
 
 
 
 
 
 
 
 
 
 
Type of Costs 

Table 11 - Types of resources included in the estimation of costs 
Method 
Collection 

Estimation  at  patient 
or group level 

Data 

of 

Investment in the telemedicine application 

Education of Staff 

Questionnaire to staff 

Group level 

Running Costs 

Intramural Area 

Transmission 

Travelling 
expenses 

Persons time 

time used by staff - education 
of patients 
time  used  by  staff  -  medical 
treatments 
number 
visitations 
standard rate special devices 
standard rate internet portal 
km home-hospital 
km home-doctor 

telemedicine 

of 

interview  with 
documentation 

staff, 

Patient level 

HIS-System 

documentation 

Patients data 

time used by patient 
Time used by relatives 

Questionnaire, patient 

Effects on patient use of health care  

Intramural Area 

Extramural Area 

Number of outpatient visits 
Number of inpatient days 
Inpatient days per stay 
Number of contacts with GP 
Number  of  contacts  with 
consultant 
Number  of  contacts  with 
emergency doctor 
Number  of  stays 
hospitals (not KABEG) 

in  other 

HIS-System 

Patient level 

Questionnaire patients 

Table 12 - Analysis of cost differences11 

Case 

Number of 
Patients 

Total cost 
intervention 
group 
 (per patient) 

Total cost control 
group 
(per patient) 

Mean difference 

DIABETES 

Base Case 
Men 
Women 
Patients aged >70 
Patients aged<71 

COPD 
Base Case 
Men 
Women 
Patients aged >70 
Patients aged<71 

193 
110 
83 
37 
156 

65 
44 
21 
19 
156 

2,006€ 
2,022€ 
1,988€ 
1,548€ 
2,103€ 

6056.73€ 
5580.53 € 
7186.59€ 
5651.76€ 
2,103€ 

35 

2,121€ 
2,157€ 
2,067€ 
1,571€ 
2,283€ 

2,121€ 
2,157€ 
2,067€ 
1,571€ 
2,283€ 

-115€ 
-135€ 
-79€ 
-23€ 
-180€ 

-1617.90€ 
-112.38€ 
-2249.20€ 
-3966.14€ 
-3374.68€ 

 
 
 
 
Table 13 - Cost of different services for different groups (Rounded values) 11 

Cost of 
outpatient visits 

Cost of 
inpatient stays 

Costs of GP 

Cost of Medical 
specialists 

DIABETES 

Base case  

Intervention 
Control 

Men 

Intervention 
Control 

Women 

Intervention 
Control 

Aged>70 

Intervention 
Control 

Aged<71 

Intervention 
Control 

COPD 

Base case  

Intervention 
Control 

Men 

Intervention 
Control 

Women 

Intervention 
Control 

Aged>70 

Intervention 
Control 

Aged<71 

Intervention 
Control 

122 
114 

94 
129 

141 
94 

70 
78 

124 
125 

122 
36 

93 
11 

191 
80 

67 
38 

127 
33 

71 
65 

75 
64 

66 
67 

95 
105 

67 
55 

88 
120 

99 
104 

51 
142 

82 
130 

89 
109 

43 
59 

43 
68 

43 
45 

42 
123 

43 
43 

192 
138 

176 
140 

245 
136 

278 
121 

182 
158 

1245 
1794 

1291 
1808 

1188 
1773 

767 
1178 

1344 
1971 

5143 
7180 

4700 
6237 

6188 
8877 

9687 
6170 

4742 
8526 

36 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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