Health Transformation

Innovation in Health IT

Last week we had an interesting discussion on innovation in Health IT. Based upon the EHR-S Functional Model we produced a reference model for EHR Systems in the Behavioral Health sector in The Netherlands. The discussion focussed on the degree of innovation incorporated in the reference model. Some participants commented that the reference model lacked true innovation, whereas others insisted that the model already incorporated quite a lot of functions that are not present in any EHR System in Behavioral Health today.

This discussion reminded me of a meeting between healthcare management and computer science researchers some years ago. The researchers were looking for "true" innovations, whereas the managers were much more looking for methods to succesfully introduce and incorporate existing technology in their healthcare organization. Given the fact that the outcomes were to be presented to the Dutch Science Foundation as part of the computer science research program, you can imagine which perspective received most attention.

Meanwhile, subsidized programs from both the Ministry of Health and the Ministry of Economic Affairs in The Netherlands focus on the adoption of proven pilot innovations, rather than on projects developing the next innovation in the application of Health IT. For instance, a program supporting the adoption of videoconferencing as part of multidisciplinary oncological meetings, in which an outside consultant participates from a distance, has been carried out succesfully over the last few years. This can hardly be called a break-through technological innovation, but it does illustrate the dilemma that healthcare organizations face. Is technological innovation getting in the way of large-scale adoption? Are we investing lots of money in yesterday's technology?

Trust in the Digital World

How can the rights to identity. legality, privacy and intellectual property that we enjoy in the physical world, be mirrored in the digital world?
“Further safeguards are needed to protect consumers’ rights, to ensure that citizens can access services regardless of their location or social condition and to ensure that the infrastructure they use is trustworthy.”
—Mr. José Manuel Durão Barroso, President of the European Commission at CeBit Trade Fair, March 2008

Reading the EU Services Directive and the Benchmarking done to the Global Trust Center Policy on Enabling Trust in the Digital World it do invite to some thoughts about the future.
The Global Trust Center is a non-profit independent international organisation that develops policy, best practice and guidance to enable trust in digital interactions. See also Wikipedia.
Is this a “revolution” in the area of identity infrastructure? I think it could be! The demand for interoperability in the identity environment is rapidly rising. Process and roles, verification, traceability, integrity, IPR etc. the list is long on the requirements. In healthcare I think that sharing local/regional/national care records really pinpoints trust issues like consent for example.
The healthcare sector, with all interoperability projects like the EU epSOS working on EHR-interoperability between 12 countries, really benefits if the identity infrastructure could be solved in a better way and perhaps with a “Jericho” viewpoint. What do you think?

A "Future Vision"

Working with the generic process models in healthcare I see a trend in preparing for more services oriented thinking and more demand for centralized functions like patient overview, security infrastructure and patient centric portals, drugs etc. in a national perspective. Sweden is moving strong on this path and I can see similar trends in the other Nordic countries.
Future vision.JPG In the other hand I see a strong technical potential coming in parallel. Take a look at Microsoft future vision video by clicking on the picture at the end of the linked webpage on the left side.

Do we have an upcoming dispute between a more centralized landscape with fewer actors in the market and strong regulations vs. a marketplace containing a lot of actors in all sizes on a services oriented framework? What are your visions?

Perfection kills Progress

Recently, in a publication in the well-circulated magazine for medical professionals in The Netherlands "Medisch Contact", the Dutch Ministry of Health, Welfare and Sports was criticized on their plans for the national Electronic Health Record. The authors accuse the Ministry of restricting innovation "whilst Web 3.0 is forthcoming".

National programs for the introduction and use of Electronic Health Records are usually at the center of attention for professionals and politicians alike. The nature of these programs makes them vulnerable to a diversity of criticisms. The fact that a long-term perspective is taken, with high ambitions and serious impacts, often calls for lengthy procedures in terms of policy setting, stakeholder buy-in, open tendering, and specific legislation. One of the major trade-offs to be made is on the technological dimension: how to balance between state-of-the-art and the current installed base of systems and their legacy technology. The fact that the architecture is usually designed at the beginning of the long-running program makes it an easy target for arguments that it doesn't keep up with current technology.

Communication is key to refuting these arguments and keeping the program in perspective. It helps when clear governing mechanisms are in place for architecture development and the renewal of parts of the specifications. Such mechanisms can be designed to achieve the necessary balance between proven technology and current innovations, and to keep that balance in place over the lifetime of the EHR infrastructure. Leaning too much towards innovation will call for major redesign during a project that is already hard to really get off the ground. The old adagium - Perfection kills Progress - is applicable here as well. We would like to hear your experiences in coping with this dilemma.

The ‘business viability’ of HIE/EHR?

Another viewpoint of the work around generic process models in healthcare is what value will it provide and to whom!
“Knowing is not enough; we must apply. Willing is not enough; we must do.”—Goethe
The National Board of Health and Welfare in Sweden have formulated these bullets in the context of “Good care” inspired of the report from Institute of Medicine.

• Goals:
Safety, effectiveness,
patient-centeredness,
timeliness, efficiency, quality and equity
• Three guiding strategies:
Patient-centred, knowledge-based and care-flow based systems
• Quality as a system feature

Is quality a kind of “silver bullet” in this context? Making the care providers able to estimate result, measure result and do a follow up compared to quality index perhaps stimulate the willingness to enter data even for others to see. A kind of quality process inspiring the academic talent and competition. In Israel, Clalit Kaplan Medical Center , I saw a quality process like this but with quality index instead of estimates starting the process. The results were astonishing! If the process and information models integrate estimates, measures, follow up and show the gaps to quality indexes in an as automated way as possible it will heavily improve the cost – benefit ratio as I see it. What do you think?

The dangers and benefits of RFID in healthcare

Recently the Dutch national newspapers featured headlines like "Chips disrupt medical equipment", referring to an article in the Journal of the American Medical Association of June 25th. Before applying RFID technology in a clinical setting, tests revealed that standard RFID technology can cause serious interference with medical equipment, resulting in serious malfunction and danger to patients. These tests had to be carried out, because no literature or standards were available that could rule out any such dangerous interference.

Knowing the dangers involved, the team designed a combined technological and organizational solution that effectively circumvented the dangers and delivered promising results for improving the quality, efficiency, and safety of care. One of the authors comments on these outcomes in a short video featured on YouTube. So, in the future we could see the following headlines in the national press much more often: "Chips save lives in hospitals". What could help in achieving these results?

Healthcare Transformation: A Mandate for Collaboration

The healthcare communities around the world are under significant pressures due to well documented challenges (i.e., aging populations and decreasing wellness; poor patient safety results; increasing patient/consumer expectations; spiraling healthcare costs; and poor integration of care. HIT for healthcare information sharing (e.g., HIE, EHR, PHR, EMR) is still an empty promise.

In our entry for ‘Semantic Interoperability’ Robert Stegwee asks the question “if semantic interoperability is equally important to the healthcare professional, why is it still unknown territory to the majority?”.

Similarly, how do we account for individual expectations for the use of information technology to facilitate better care for individuals? They are getting older. They are becoming more likely to suffer from a long term chronic condition. They are educated consumers with expectations of getting what they want/need whenever they desire. They have been using technology in every other part of their life and see HIT as a reasonable approach.

How will care communities deal with these expectations and demands? There are many transformational ideas and programs underway including:
• Payment for results
• Proactive care services (see example Telehealth & Telecare entry by Jason Crellin)
• Restructuring of reimbursement models
• Increasing transparency of care costs and quality of care
• Introduction of competition into national care services
• And of course, national/regional HIE, EHR, PHR, EMR implementation programs

We see that these pressures and forms of response are appearing in virtually every nation, region, and care community, demanding specific responses suited to individual needs and expectations of the players. There is a clear need to balance the expectations and the complex value network that spans these players (i.e., hospitals, general practices, clinics, diagnostic service providers, payers, government, pharmacies, volunteer organizations, and patients). There are many examples, but consider the perverse incentives that exist when attempting to implement a proactive care service or share patient information through HIT. How do we get everyone to participate? How do we realign the value proposition incorporated into the reimbursement models?

Our experience indicates that healthcare transformation will require new levels of collaboration. The collaboration needs to actively engage all parties at the same time. The collaborative process needs to be sustained beyond the onetime instances. Collaboration needs to be supported by strong communications, agreed standards, and shared views of the community’s health economy (the value network).

That’s how we approach this global challenge. What are you seeing in your care community? Is collaboration working? Are the “players” working together with new levels of connectedness and cooperation? What are the key incentives that have made this happen? We welcome your contributions, be they positive or more skeptical.

Telehealth & Telecare on a "long term" road to mainstream adoption?

Over the last few weeks I’ve been talking to some of the bright young things from our graduate programme. They’re working on a challenge themed around healthcare transformation, and one of the common threads they’ve been picking up on (and rightly so) is around the value of “remote patient monitoring”. Falling under the “Telehealth” “Telecare” and “Assistive Technology” banners; it’s an area with a lot of interest, but with a few notable exceptions is still relatively low-key in terms of adoption and utilisation.

Americans are using some of the basic online tools for health information

As part of National Health IT Week 2008 held in Washington, DC June 9-13, Kaiser Permanente, through independent market research company StrategyOne, released the results of a nationwide survey conducted between May 8-11, 2008 to gauge Americans awareness and perceptions of electronic health records (http://xnet.kp.org/newscenter/pressreleases/nat/nat_080612_healthit.html). Key findings indicate that Americans are using some of the basic online tools for health information. The results are interesting:

65 percent of respondents have gone online to learn about a medical condition, and 38 percent have used their insurance company's online tools to learn more about their care, up from 29 percent in 2007.

The research also revealed that Americans continue to have concerns about privacy and thus require assurances from all parties that store personal data that information is secure.

47 percent had a preference for doctors who use EHRs and 61 percent had a preference for insurance companies who employed EHRs.

51 percent agreed that health IT should be a top priority for the next president to ensure that all Americans have access to their own personal medical records electronically. Kaiser Permanente is leading the way to make this vision a reality.

It would appear that the general population is willing to utilize EHRs/internet for care information. Has anyone seen additional surveys that re-enforce or conflict with that trend?

Is it possible to have a generic process model in Healthcare?

In Sweden, the National Board of Health and Welfare, commissioned by the Government according to the National Strategy for e-Health , has the task of defining a generic process model in Healthcare. The 3 year project, started 2007-01-01, will deliver guidance for content, structure and patient centric documentation. The starting point is the profession and the citizens demand of information.
This is a way to lay the foundations for the information needed in the complete chain of care involving different care providers. “The steps before IT”.
Now half-way in the project different stakeholders contribute, from their viewpoint, in producing semantic models, information models and process models. All with the same goal: make a common regulatory framework.
From the supplier side, care system providers, there are doubts if the mission is possible.
What do you think? Is it a too academic approach and the expected result reside “above the clouds”? Inventing the wheel again (HL7v3, openEHR...)? Any other nations have done it? I am eager hearing from YOU!

About the authors