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Prepared by the European Health Telematics Association for the HFE Book “2050: A Health Odyssey: Thought provoking ideas for policy making”.
Introduction
eHealth refers to the use of modern information and communication technologies (ICT) to meet the needs of citizens, patients, healthcare professionals, healthcare providers as well as policy makers. It is a shorthand label for the wide range of uses to which information technologies are put in the healthcare setting, encompassing health related labels such as Health Informatics, Health Telematics, Telemedicine and Telehealth. eHealth is not a set of products, tools or applications but a range of responses to a set of requirements in the context of improving and transforming healthcare services..
The traditional measure of value in health for ICT has been cost reduction and cost savings; in the current context of a seemingly inevitable rise in demand and GDP %age for healthcare, this remains a strong factor for policy makers. However as eHealth has matured, it has become clear that this is only one side to the added value proposition.
The three key criteria of the EC Action Plan are Access, Quality of Care and Cost Containment and these, along with the overriding need for increased equity, are the starting points for new ways of looking at added value for all levels of healthcare policy from the citizen through to the European Social Model.
There are three broad streams:
- patient and professional mobility
- citizen centred health systems
- improved quality and efficiency of healthcare availability
This implies change, improvement and transformation of current and traditional processes of delivery taking advantage of advances in medicine, drugs and treatments, logistics, research and information technology. This makes the isolation of added value much more than just cost savings since these changes are often not a matter of choice but an imperative. The effect and value will be reflected in other areas of healthcare than the original process location.
Looking to the future in health is an inexact science; change takes a long time to percolate through to widespread delivery. The approach is to consider three timeframes:
- current conceptual change looking at realisation and deployment
- transformation that is necessary or clearly desirable based on current thinking (including radical and innovative ideas)
- informed speculation (including global and macro-social and economic thinking).
The time frames used are arbitrary - 2010; 2030, 2050 and precision declines rapidly. The aim here is to consider views of the future which can form inputs to the baseline thinking for policy makers at all levels.
Scenario One – current conceptual thinking to 2010
There are two main strands:
Costs: governments have to find ways to contain the remorseless rise in the cost of providing care in the developed world; governments in the developed world have to find affordable ways to provide a reasonable level of care.
Viability: most governments face the huge challenge of existing healthcare processes and models which over the next decade will be unable to cope with increasing demographic change, current demand crises and growth in expectations.
Two main focus points emerge:
- No Choice
Some of the main process areas under active consideration include those where there is no option other than radical change:
- Care for Chronic Conditions
- Disease management
- Integration of care including social care
- Surveillance and public health across Europe
- Adaptation to demographic changes and increasing demands
- Patient safety (including medication errors)
- Patient empowerment and involvement
- Knowledge support for clinical professionals and for other health and social care professionals, carers, patients, citizens and others
- Good practice care profile norms
As an example at a recent conference the diabetes scenario in France was described:
There are 3 million diabetic sufferers in France (of whom 500,000 are severe cases).
Using conservative practice guidelines this generates the need for 5.5 million clinical hours per year. There are 1 million hours resource available and the prognosis is the number of diabetics will double within ten years. The current process model is untenable and transformation is the only option. This could mean harnessing other resources including “expert patients”, mass access and education tools to improve knowledge, self management and the sharing of information experiences. This is an “epidemic” where self management holds the key to the reduction of the high costs associated with later complications.
The scenario is not unique to France but is there also for Europe as a whole.
The patient safety scenario is along similar lines: the numbers of deaths and readmissions through medical misadventure are becoming public knowledge. The transformation of the culture of blame will have to be based on eHealth responses.
Similar “no option” scenarios exist for other process areas.
- Investment
This scenario derives from a series of underlying facilities that are fundamental to achieving the three key criteria where there is a second and often more levels of value to be derived:
For Equity of Access it must be possible to share information which is secure, understandable, and available to everyone who is entitled to see it, irrespective of their location, educational capabilities or socio-economic situation.
This requires secure access infrastructure, common terminology, multi-lingual capability at each level. eHealth has a major added value contribution; the value is additive as succeeding levels are reached. The rationalisation for the National Programme for Information Technology in England is based on the overriding need to have a national information infrastructure in place to enable the sharing of health information and electronic health care records.
For Quality of Care information about care processes are required to be captured, stored, secured, shared, monitored and compared – here the processes to be incorporated within the value chain are more complex and diverse.
For Cost-Containment these things have to be done within an overall context, and the costs assessed not just for the primary application, but as part of an overall programme which fits into and is supported by the levels above Some existing barriers will have to be tackled for example sharing of patient data is still illegal in some EU countries, there is no European pharmacopoeia, and interoperability of health systems and electronic health records remains a serious challenge.
The most fundamental challenge is the incremental process of implementing electronic record systems at local levels which can form the basis for a longitudinal electronic health record. Technology is not the limiting factor – most of what is needed exists already in some (often imperfect) form; what is missing can be generated by industry in what is one of the largest global markets. The mobile phone, the clockwork laptop today are exemplars and others will emerge.
Added value for eHealth has to be based on requirements to change, improve and transform health processes to provide better or new services consistent with the local, regional, Member State and European actions plans. These have to be described in terms of health processes. The metrics will vary from case to case. This could be simple reductions as per the Call centre example (cost per individual care); the capability to increase the delivery of a required service as per the diabetes example; a particular capability to deliver a service using eHealth solutions as per the English NPfIT; the support of enhanced facilities via eHealth as per access to clinical knowledge systems or remote diagnosis. There will be many other cases but the common factor is that added value is holistic and spread across a number of institutions or care delivery services.
The two principles of subsidiarity and market forces rather than just the Social Model aspirations should be the drivers for an internal market – these will provide the best combination of full access to safe, high quality and efficient health services within the Union.
The role and value of eHealth is in supporting and enabling this combination at all levels and the key criteria for success for eHealth lies within the “So What” test – does it benefit the patient and citizen in terms of better, safer, more accessible, higher quality healthcare services?.
For policy makers there are two key issues – how will they deal with the “chronic care epidemic” and how will they enable ubiquitous access and self-management.
Towards the end of this period eHealth becomes a redundant label - eHealth becomes part of the process, like the telephone.
Scenario Two - Transformation: Looking forward to 2030.
The label eHealth has become redundant, though it is still in the process of becoming the norm support mechanism – deployment has taken longer than expected and other factors have conspired to extend the realisation.
The picture of health has changed – it is beginning to become an informed bottom up process – the paternalism has gone or morphed into high value service offerings. The trends over this period can be summarised as follows:
- integration of health information across all segments including social care, prevention, education and self management
- the realisation of patient centred (or rather citizen centred care)
- removal of distance, location, social, educational and economic status as barriers to access
- concentration on the effective and convenient management of chronic conditions
- personalised care, intelligent data sourcing and syntomic profiling
- increasing specialisation of acute care
- emergence of the “care manager” and “intelligent carer” function
- ubiquitous access and feedback environments
- development of commodity and consumer markets within healthcare
- “just in time” and personalised business models
- widespread use of care advice, monitoring and treatment compliance networks balancing a shrinking healthcare professional population.
- addition of convenience as a key quality criteria to access, quality and cost effectiveness
- change in the supply business model to a demand based, prevention oriented, self management directed model.
- development of synergistic top down models in terms of public health, emergencies, pandemics, quality control and comparative assessment.
Ideas for policy making.
- clear definition of the consequent effects of policy at various levels – European policy will only be effective if it contributes to better care on the ground locally
- policy makers will need to interact with all the stakeholders to ensure consistency and avoid conflict and duplication
- if citizens are to become more responsible and active then policy must make this easier, more cost / tax effective, less regulation impaired.
- policy makers will need to understand trends, supply and demand changes, innovation and take these into account.
- the current business model for healthcare is flawed in many ways; often policy makes this worse, is a force for conservatism and tradition and as such often counter productive.
- priority will be simple effective self management matched by increasing clinical excellence in dealing with the failures, the emergencies and the unpredictable.
- the most cost effective investment (on a global basis) remains the education of the young mother group and access to necessary treatment and prevention mechanisms in the first five years of life not just in the developed nations but everywhere (linked to poverty abolition).
- for the developed world, policies which improve quality of life rather than longevity will become the focus; for the rest of the world the first five years of life are crucial, thereafter maintenance of quality of life supersedes the need for “failure “care. Care rather than Cure has to be the watchword.
- removing obvious barriers: regulations, terminology, pharmacopoeia, access to good practice, patient safety cultures, infrastructure, EPR’s & EHRs, CPOE, ETP …..
- vehicles for integrating multi-level policies for deployment
- sharing and consensus of health issues - how policy can help?
- practical incentives to involve all stakeholders – working together for health
Scenario 3 - Looking forward to 2050
This is now in the realms of futurism –projections this far forward will be fundamentally influenced by non health developments –societal development, global economic change, the impacts of global warming, other world events and many other factors. Within this period, most of what we can see ahead, both desirable and undesirable, will be possible – the developed world will have at least partially succumbed to the onset of ambient intelligence though this will have taken hold with different emphases. Every one will have access to eHealth. The key issues for health may no longer be in healthcare but in the availability of information, clean water, food, subsistence within stable societies; the prevalence or otherwise of corruption, inequality, economic exploitation.
Within the context of what we currently view as healthcare the trends can be perceived as:
- self-management and self-managed prevention become key components based on personalised profiles.
- chronic conditions will be an accepted part of everyday life for a significant part of the population, considered not as disease but more like stress, pollution and commuting.
- acute clinical care becomes specialised feeding self-management as its priority with acute treatment linked to self-management failure, to unpredictable episodes at personal, group and community level
- genomics, syntomic profiling and other omic advances will also feed self-management
- information is everywhere but much of it will regress to data and only some will move on to knowledge
- pharmaceuticals will separate into personalised commodity distribution networks, production and research
- healthcare will become health; part of everyday life like work.
This is no utopia. Other challenges, man made, natural and externally generated, will present this world with a similar level of crises, hatred, exploitation, disasters, and political incompetence. Despite all our best efforts to eradicate disease, to simplify healthcare, to provide a safe, happy environment for our children’s children, nature and man’s pattern breaking, the momentum of complexity and the normal doses of chaos will continue.
Conclusions.
The more we look to the future, the more clearly hindsight shows the opportunities we have wasted. We have spent thirty years developing what we now call EPR systems and still not everyone has one. We have spent twenty years talking about standards in healthcare IT and we are still talking. We have spent ten years talking about telemedicine and got virtually nowhere. We have spent 5 years talking about eHealth and still most people do not know what it is, how it will help them and what are the benefits.
In 2005 eHealth tells us some of the things that can be done now to help transform healthcare but also that some difficult decisions have to be made and then acted upon in concert by the stakeholders. There is no added value in talking about eHealth – but only in harnessing it to help improve healthcare delivery. The emphasis, the responsibility for policy makers is now to find ways of getting everyone involved to work together to make it happen, for everyone and everywhere.
The message for policy makers is clear. The stakeholders need help and encouragement to work together to make eHealth happen to generate the added value to be secured from transformation of health processes to deliver safe, accessible high quality healthcare for all.
Original article written by David Lloyd-Williams of Silicon Bridge on behalf of EHTEL for publication by HFE in 2006
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