Meeting healthcare challenges: what are the challenges and what is the role of e-health?

Meeting healthcare challenges: what are the challenges and what is the role of e-health?

Richard Smith

Chief executive, UnitedHealth Europe

© Copyright UnitedHealth Europe. All rights reserved.2

Agenda

Two pictures Characteristics of a good health system Health systems now The four major challenges The need for transformation: how can e-health help? Three “pet” themes– Information for doctors and patients– Free access to research for all– Identifying patients at risk

Barriers to transformation



Fee for service for the rich

Marks and Spencer style managed care for the middle classes

Safety net service for the poor

The way all health systems will be. Uwe Reinhardt


Characteristics of an optimal health system: Institute of Medicine

Safe Effective, evidence based Patient centred Timely, no waiting Efficient, avoids waste Affordable, sustainable Equitable, no variation by gender, ethnic group,

etc Constantly improves


IOM report: the problem

Between the health care we have and the care we could have lies not just a gap, but a chasm

A system full of underuse, inappropriate use, and overuse of care

Unable to deliver today’s science and technology; will be even worse with innovations in the pipeline

A fragmented system characterised by unnecessary duplication, long waits, and delays


IOM report: the problem

Poor information systems; disorganised knowledge

“Brownian motion” rather than organisational redesign

A system designed for episodic care when most disease is chronic

Health care providers operate in silos Driven by producers rather than consumers of

care


The major challenges

Quality and safety Access Responsiveness/usability Affordability


How safe is health care?

Less than one death per 100 000 encounters– Nuclear power– European railroads– Scheduled airlines

One death in less than 100 000 but more than 1000 encounters– Driving– Chemical manufacturing

More than one death per 1000 encounters– Bungee jumping– Mountain climbing– Health care



How to respond?

Institute of medicine identified electronic patient records as an essential step in improving safety and quality

Reduce complexity Optimise information processing – checklists, reminders, protocols

Automate wisely Use constraints– for instance, with needle connections

Mitigate the unwanted side effects of change– with training, for example.


Problems of access

40 million without insurance in the US Long waits for hospital appointments,

diagnostic tests, elective surgery in the US Difficulty getting access to GPs in the

evenings and at weekends Long distances to travel for some--for

example, patients with cancer from south west Scotland



Role of e-health in responding

Increase efficiency of the system Fundamental role of data (and intelligent

use of data) in “commissioning” Information systems like NHS Direct Telemedicine allowing diagnosis, treatment,

and access at a distance


Responsiveness/usability of the system

Finding your way into the system and navigating through it can be very hard

Many patients get lost in the system--particularly those with complex conditions

Care doesn’t feel personalised Patients don’t feel listened to Patients are not involved enough in

decisions about their care


How can e-health help?

A single electronic record accessible to the patient and by all health professionals

Allow a single access point to a health system Help with navigation through the system


Affordability

Need people to be “fully engaged” with their health

But increases in productivity may be more important



Successful health system reform

Controversy

without impact Transformation

Improved

Status quo outcomes

Effective implementation

Eff

ectiv

e s y

stem

des

ign

Source: derived from DU

© Copyright UnitedHealth Europe. All rights reserved.20Copyright ©2005 BMJ Publishing Group Ltd.

Quam, L. et al. BMJ 2005;330:530-533

Fig 3 Annual expenditure per employee on information and communication technology in United Kingdom in different economic sectors, 2000


Quam, L. et al. BMJ 2005;330:530-533

Fig 1 Risk adjusted mortality from cancer against length of stay for institutions in New York State. The size of the circle indicates the number of patients treated


Three pet issues

Information supply to health workers and patients

Free access to research for all Measuring the risk of patients:

responding to need not demand




Current problems

Our current information policy resembles the worst aspects of our old agricultural policy, which left grain rotting in thousands of storage files while people were starving. We have warehouses of unused information rotting while critical questions are left unanswered and critical problems are left unresolved. Al Gore


Words used by 41 doctors to describe their information supply

Impossible Impossible Impossible Impossible Impossible Impossible

Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming

Difficult Difficult Difficult Difficult Daunting Daunting Daunting Pissed off Choked Depressed Despairing Worrisome

Saturation Vast Help Exhausted Frustrated Time consuming Dreadful Awesome Struggle Mindboggling Unrealistic Stress Challenging Challenging Challenging Excited Vital importance


The information paradox

Doctors are overwhelmed with information but cannot

find the information they need when confronted with a question.

Muir Gray


Water, water everywhereNor any drop

to drink


A vision of a better information tool for clinicians 1

Part of the information system that doctors use as they see patients

Able to answer highly complex questions Connected to a large valid database Electronic Fast


A vision of a better information tool for clinicians 2

Easy to use Portable Prompts doctors in a way that’s helpful not

demeaning Connected to the patient record Gives evidence related to individual patients A servant of patients as well as doctors Provides psychological support


The importance of all research beingfree to everybody

everywhere


Why provide free access to research?

Ideas breed ideas, and ideas are precious Because it’s now possible, and a powerful

vision of the future exists Economic: avoid paying twice Avoid Balkanisation--easier to do the

systematic reviews that are essential for modern health care



A vision of something better

If you have an apple and I have an apple and if we exchange these apple then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas.

George Bernard Shaw



A vision of something better

"It's easy to say what would be the ideal online resource for scholars and scientists: all papers in all fields, systematically interconnected, effortlessly accessible and rationally navigable, from any researcher's desk, worldwide for free.”

Stevan Harnad


Money

Most research is funded by public money: why pay twice?

99% of the value of a piece of research is in the research itself not in the processes that lead to publication—yet it is the publishers who get the profits

Publishers have consistently raised their prices above inflation: economics of the madhouse

Some journals cost £20 000 a year to subscribe Can be made available to all for less money per

article


Balkanisation

If you are a gastroenterologist the research that might matter to you may be in 30 different journals

The difficulty of doing systematic reviews Important research articles are all over the place,

some in Pubmed, many not Even if you can find the stuff, it costs a fortune to

gather it all together (systematic review on research misconduct -£2000 to get photocopies)


Risk stratification of patients

Rank an entire population by their risk of needing care in the future Requires more than simple past experience Combine data from hospital, general practice, prescribing, registry,

census, and possibly other data--and can predict future use of resources accurately

Can then reach out to these patients--and be driven by ned rather than demand

Can construct programmes around them--case management, disease management, self amanagement

Those programmes themselves depend crucially on good informatics tools

Such a move holds the potential to do reduce inequalities in health


Roland, M. et al. BMJ 2005;330:289-292

Emergency admissions and emergency bed days per person for patients [≥]65 in 1997-8: comparison of those with two or more emergency admissions in 1997-8 ("high risk") with general

population (England)


Change=burning platform x vision x next steps


Barriers to transformation

Inbuilt resistance to change: “Better to suffer the ills we have than to fly to others we know not off”

Losers very vocal, winners quiet. Nicolo Machiavelli Lack of vision Lack of leadership Vested interests Technical problems Resources: money, people The challenge with informatics tools is not just to produce and install

them but to get people to use them well


"The Sicilians never want to improve for the simple

reason they think themselves perfect; their vanity is

stronger than their misery.”


Entrepreneurs are simply those who

understand that there is little difference

between obstacle and opportunity and are able

to turn both to their advantage.

Niccolo Machiavelli


Health & Medicine

Meeting healthcare challenges: what are the challenges and what is the role of e-health?