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Medtronic, Inc. (“Medtronic”) offers RemoteView, which permits a user (“Programmer User”) of the Medtronic CareLink® 2090 Programmer (“Programmer”) to allow the viewing of information presently displayed on the Programmer screen with one or more individuals in remote locations anywhere in the world (“Remote Viewer”), including remote health care professionals or Medtronic representatives.
Limited License Grant. You are hereby granted a nonexclusive, nontransferable, terminable, nonassignable, nonsublicensable, limited license to install and use a copy of the Licensed Software solely for authorized and legitimate purposes. You may not otherwise copy, use, modify, reverse engineer, decompile, disassemble, create derivative works based on, or integrate with other systems or programs the Licensed Software without the prior written consent of Medtronic. You shall have sole responsibility for any fees or charges, including service or data charges, incurred by you in connection with your use of the Licensed Software. You shall not remove any proprietary or other legend or restrictive notice contained or included in the Licensed Software or other documentation associated with such Licensed Software. You agree to maintain any and all copyright, trademark, and other notices on the Licensed Software and any associated documentation.
Licensed Software Functionality and Data Use, Collection, Viewing, and Transfer.
“Active Remote Viewer” as referred to herein shall mean a Remote Viewer that has installed the Licensed Software and has at the relevant point in time an active network connection to a Medtronic server via the Licensed Software.
By installing or using the Licensed Software or clicking any acceptance button in connection with this Agreement, you acknowledge, understand, agree to, and consent to all of the following, including when you are an Active Remoter User:
) Registration. To obtain access to the Licensed Software, you must register at the Medtronic RemoteView website and establish a user name and password. All information that you provide in connection with such registration must be complete, accurate, and truthful. The user name and password are personal to you and must not be shared with anyone else. You will also not attempt, directly or indirectly, to disable, bypass, or defeat any password protection associated with the Licensed Software. Medtronic reserves the right to deny or disable any user name or password or request for any user name or password.
) Your Personal Information. Medtronic will collect information in connection with your registration and installation and use of the Licensed Software, including your first and last name, your email address, a selected security question(s) and your corresponding answer(s), your address, and your telephone number. You agree that Medtronic may store this personal information about you on a Medtronic server, including a server located in the United States of America.
) Session Key. To view the information on the Programmer, the Remote Viewer must generate a Session Key that must be shared with and entered by the Programmer User. “Session Key” as used herein means a unique token active for a limited period of time generated by the Remote Viewer. You agree not to share this Session Key with anyone other than the Programmer User who has initiated the specific session.
) Logging of Session Activity. Each time you log in to the Licensed Software, Medtronic will collect information about your activity, including in an aggregated log or database, regarding you and your session, including your name, username, computer name, IP address, operating system details, and session details (including transferring and sharing activity, start and end times, view only or control activity, and any chat messages between or among any Active Remote Viewers. You agree that Medtronic may store any personal information about you on a Medtronic server, including a server located in the United States of America.
) Active Remote Users. When you are an Active Remote Viewer: (1) you will be able to view the name and/or user name of any other Active Remote Viewer who is logged into the same Medtronic server; and (2) any other Active Remote Viewer who is actively logged into the same Medtronic server will be able to view your name and/or user name. The Licensed Software also permits one Active Remote Viewer to share the information being viewed to any other Active Remote Viewer. You must not share any information from the Medtronic programmer, including with any other Active Remote Viewer, absent the express permission from the Programmer User that is allowing you to view the information.
) Availability. Medtronic has limitations on the number of users that can concurrently log in to the Licensed Software at any given time. Thus, installation of or accessing the Licensed Software does not guarantee that it will be available to you for use at any time.
Permissions. By installing and using the Licensed Software, you represent that you have permission to do so from any associated clinic, hospital, or medical practice and that your use of the Licensed Software complies with any policies or requirements of such associated clinic, hospital, or medical practice. You are also responsible for confirming that the Programmer User has obtained any necessary patient consent before allowing you to view any patient information via the Licensed Software.
Your Acknowledgements. You acknowledge that the Licensed Software is not the exclusive method of viewing information from the Programmer and that the Licensed Software is not the exclusive method by which to obtain a patient’s implanted cardiac device data, including any data on the Programmer. You also acknowledge that the Licensed Software is not intended to be used as a life-sustaining or interventional tool during medical emergencies. You further acknowledge that Medtronic is not, and shall not be deemed to be, a provider of patient health care services by virtue of its provision of access to the Programmer screen information via the Licensed Software. You also acknowledge that information from the Licensed Software is not an electronic medical record and use of the Licensed Software does not in any way relieve you from using your best medical judgment to determine a proper course of treatment for patients.
Security/Privacy of Patient Data. Your use of the Licensed Software and any Session Keys shall be solely for legitimate and lawful purposes and not for any malicious purpose. You are solely responsible for and will use your best efforts in maintaining the confidentiality and security of any copies of the Licensed Software as well as any user name, password credentials, and any Session Keys that can be used in accessing the Licensed Software, a Medtronic server, or any information from a Programmer. You are solely responsible for and will use your best efforts in keeping any patient information you may receive or view in connection with the Licensed Software confidential and secure, and you will not attempt to capture or copy any patient information you view in any electronic or hard copy format without the express permission of the Programmer User. You will be responsible for any obligations or liabilities associated with any lost, stolen, or otherwise compromised patient information.
Reporting Issues and Feedback. You agree that you will report any issues or questions, technical or otherwise, regarding the Licensed Software promptly and directly to Medtronic. If you submit any comments or ideas to Medtronic, in the absence of a separate agreement regarding such submissions, you grant to Medtronic an unrestricted, royalty-free, irrevocable license to use, reproduce, display, perform, modify, transmit, and distribute such ideas in any medium and agree that Medtronic is free to use them for any purpose. In addition, Medtronic has no obligation to provide continued maintenance and support to you in connection with the Licensed Software. Any maintenance and support services provided by Medtronic shall be at Medtronic’s sole discretion.
Limitations of Liability.
THE LICENSED SOFTWARE IS PROVIDED TO YOU “AS IS,” AND MEDTRONIC EXPRESSLY DISCLAIMS ANY AND ALL WARRANTIES WITH RESPECT TO THE LICENSED SOFTWARE AND YOUR USE THEREOF, INCLUDING WITHOUT LIMITATION ANY IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE, AND NONINFRINGEMENT. MEDTRONIC DOES NOT WARRANT THAT THE USE OF THE LICENSED SOFTWARE WILL BE UNINTERRUPTED OR ERROR-FREE.
Legal Compliance. You shall at all times use the Licensed Software in compliance with all applicable laws. You shall ensure that your installation and use of the Licensed Software complies with all applicable export and import laws, regulations, orders, and policies of the United States of America and any other applicable jurisdiction. You represent and warrant that (i) you are not located in a country that is subject to a U.S. Government embargo, or that has been designated by the U.S. Government as a “terrorist supporting” country, and (ii) you are not listed on any U.S. Government list of prohibited or restricted parties.
Term, Termination, Modifications, and Support. This Agreement shall be in effect from the date when you first install or use the Licensed Software. Medtronic may modify, amend, or terminate this Agreement at any time, including by providing notices or an updated version of this Agreement on a Medtronic website. Medtronic may modify, disable, or terminate your use or Medtronic’s support of the Licensed Software at any time, including by providing notices on a Medtronic website. All obligations which are ongoing in nature shall survive termination or expiration of this Agreement. At any time upon Medtronic’s request (including via a notice on a Medtronic website), you agree to promptly delete and terminate use of any and all copies of the Licensed Software. In addition, upon Medtronic’s request, you agree to provide written verification that you have destroyed all copies of the Licensed Software together with the manner, date, and time of such destruction.
NayaMed International Sárl Customers: Whether the RemoteView feature shall be used in connection with NayaMed customers or devices shall be solely within the discretion of NayaMed International Sárl. If the Licensed Software is used connection with NayaMed customers or devices, this Agreement shall be directly between you and NayaMed with respect to those uses.
Case study examining how Germany is using population-based integrated care to handle an increase in multimorbidity patients.
The ageing of the German population and lifestyle-associated changes in health status are leading to an increase of multimorbidity patients who require a co-ordinated care plan involving numerous health providers, social services and a regime of multiple medications. However, the German health system is fragmented, making such coordination a challenge not only for the patient but also the providers. This is one of the most important issues facing the German healthcare system, and one that is potentially solved through population-based integrated care.
Gesundes Kinzigtal (GK) GmbH, located in south-western Germany on the banks of the Kinzig River, is a joint venture of OptiMedis AG, a publicly traded healthcare management company and a regional interdisciplinary network of physicians and psychotherapists. The GK programme, which organises the care of nearly half of the 71,000 people living in the Kinzigtal region, integrates value-based principles to address fragmentation of care, bolster investment in prevention and improve the quality of life, while avoiding unnecessary long-term costs.
“Fragmentation of health services is quite severe in the German healthcare system. This causes gaps in information as patients transition between in-patient and outpatient services, which affect the patient’s continuity and quality of care co-ordination,” explains Christian Melle, a project manager in the Administration and Research Department at GK GmbH. “The GK programme and design of services are constantly evaluating ways to improve information flow, IT integration and value, and build patient trust.”
Launched in 2005, GK GmbH received a €4m investment from two sickness funds that are part of Germany’s publicly funded health insurance. The goal of the investment was to save costs in the care provided to persons covered by the funds without compromising the quality of care they received (OptiMedis AG and the sickness funds agreed to share the realised savings). The GK programme, which translates to “healthy Kinzig valley”, is available without additional cost to everyone insured by the sickness funds living in the Kinzigtal region; in Germany, those earning less than €59,400 are automatically enrolled.
The GK programme, which translates to “healthy Kinzig valley”, is available without additional cost to everyone insured by the sickness funds living in the Kinzigtal region.
GK GmbH applies value-based care through the “Triple Aim”1 method for population-based health, popularised by the Institute for Healthcare Improvement, a UK-based non-profit. The Triple Aim focuses on three concurrent goals — improving the experience of care, improving the health of populations and reducing per-head costs of healthcare — through a multidisciplinary public health approach that involves health professionals and social care and other welfare services. Such services are essential to the long-term quality of life, improving recovery and sustaining health, but they are not easily measured and tracked — quantitative assessments are paramount in assessing value-based health impact. Furthermore, a multidisciplinary approach is unusual in the German health system, which has traditionally been organised around medical conditions.
Germany faces the challenges of an ageing population — as of 2017, slightly more than a fifth (21.4%, or 17.7m) Germans were 65 years of age or older.2 The increase in immigrant populations in recent years has helped to alleviate some of the demographic pressures on Germany’s statutory health funds, according to Steffen Waiss, policy officer in the political department at GKV-Spitzenverband, the National Association of Statutory Health Insurance Funds in Germany. Membership more than doubled between 2015 and 2016 and most new members were between the ages of 20 and 30. However, the flow of migrants and subsequent demographic changes appear unlikely to continue at the same pace given recent political changes in Europe, including Chancellor Angela Merkel’s decision to not seek re-election.
Thus, as Germany’s overall population continues to age, the need for value-based programming has become more pressing, leading to GK GmbH’s integrated care approach garnering attention nationwide.
The GK programme is not designed solely to provide services for multimorbidity patients. But this patient population often has the most complex and costly care plans. Therefore, for many providers, they are frequently the first cohort targeted for an integrated care plan. The co-ordination of GK’s services related to those with multimorbidities emphasises information sharing, peer consultation among care providers, and care co-ordination to maximise patient compliance and improved outcomes.
Because multimorbidity patients typically require a combination of medications, GK expects this multidisciplinary consultation to increase patient safety and the effectiveness of the patient’s medication regime.
For instance, six times a year physicians participate in consultations with a clinical pharmacologist to optimise the medication regimes of multimorbidity patients and the elderly. The physician submits a case report to a clinical pharmacologist who is also a geriatrician. The pharmacologist then evaluates the medications and the physician receives feedback scores with respect to their prescription behaviour and any additional feedback regarding improvement opportunities, such as which medication should be reduced or changed.3
Because multimorbidity patients typically require a combination of medications, GK expects this multidisciplinary consultation to increase patient safety and the effectiveness of the patient’s medication regime.
Operationally, a comprehensive cost-benefit analysis on a programme level is conducted approximately every 18 months by a review committee comprised of the multiple stakeholders in the patient’s care — physicians, therapists, psychologists, programme managers and GK management. The committee analyses programmes’ costs, patient outcomes and qualitative data from patients and health service providers. The committee then provides feedback to programme administrators and discusses what and how adjustments can be made to programmes and what new programming should be introduced.
The overall financial aim of GK GmbH is to improve the financial margin of the two participating sickness funds that provided the original investment. Although the data available are so far are encouraging, the sickness funds are conducting further analysis on the return on investment before considering expanding the GK programme to other regions.
A 2015 study by the King’s Fund, a health charity based in the UK, reported that between 2006 and 2010 GK GmbH generated a saving of 16.9% against the population budget for members of one of the funds, when compared with a group of its members from a different region. One of the main drivers of this saving was related to emergency hospital admissions. Between 2005 and 2010, emergency hospital admissions increased by 10.2% for patients in the GK programme, compared with a 33.1% increase for members in a different region. By improving the co-ordination of care and communications among health and social service providers, health issues can be identified more quickly and addressed before they require emergency services.
A criticism of the GK model of population-based integrated care is that it will not work in other regions. Contextually, populations can be thought of as communities, each with different demographics, health profiles, health service infrastructures and environmental settings. It is the focus on identifying and assessing population variables with multi-stakeholder consultations that drives effective programme design and care provision.
“Some feedback we received is that the Kinzig population is healthier than populations in other regions or settings such as urban areas, which we accept. Yet it was never our belief that one model or programme would blanket the German health system,” says Mr Melle. But delivering high-quality, cost-effective integrated care is a strong case for further growth and wider adoption throughout the German health system.
Although there has been little in the way of new value-oriented initiatives on the federal level, there are some efforts to create selective contracts based on value on the state level, such as for general practitioner contracts, according to Mr Waiss of GKV-Spitzenverband.
The country’s innovation fund has also launched a care co-ordination project — Regional uninterrupted service on the net — which is operating in Lower Saxony, North Rhine-Westphalia, Saxony and Schleswig-Holstein. The aim of the project, which is funded for three years with a total grant of €8.1m, is to create a regionally networked organisation that allows both non-medical and medical specialists in geriatrics to legally co-operate in a provider network in order to target multiple levels of care for vulnerable patients, across all sectors. As part of the project design, trained case managers will “document the outpatient and hospital-based risks of the ageing process of patients over the age of 70 years,” classifying each patient’s care requirements and designing care pathways. The results of the programmes for the 3,200 enrolled patients will be compared with those of 1,600 geriatric patients not taking part.4
A case study from The Economist Intelligence Unit commissioned by Medtronic.
Health Affairs, http://content.healthaffairs.org/content/27/3/759.abstract
The World Bank. https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS?locations=DE
Struckmann V, Boerma W, van Ginneken W, The Gesundes Kinzigtal programme, Germany. Page 4 http://www.icare4eu.org/pdf/Gesundes_Kinzigtal.pdf
Gemeinsamer Bundesausschuss Innovationsausschuss, https://innovationsfonds.g-ba.de/projekte/neue-versorgungsformen/rubin-regional-ununterbrochen-betreut-im-netz.174
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