Aisis - 2013 Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante...

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in Sanità

The Value of ICT for Health, Efficiency and Growth: Balancing Evidence and Innovation

Claudia Pagliari PhD FRCPEUniversity of EdinburgheHealth Research Group

Convegno Annuale AISIS, Firenze, 15 Novembre 2013

Aisis - 2013


• Focus of talk– Dual agendas of growth & health– Vision for transformation & benefits– Complexity & risk– Deconstructing the value chain– Call for evidence-based, citizen-

centric eHealth

Aisis - 2013


• The global healthcare IT market is estimated to reach $ 56.7 billion by 2017 from $40.4 billion in 2012 researchandmarkets.com 2013 Report on the Global Healthcare IT Market - with Forecasts to 2017 (Report costs GBP 2923 !!)

• The global telemedicine market alone is expected to reach $27.3 billion in 2016, from $9.8 billion in 2010 & $11.6 billion in 2011, representing 18.6% annual growth EC eHealth Action Plan 2012-2020 - Innovative healthcare for the 21st century.

Health IT is Big Business

Aisis - 2013


• Hot areas for spending & investment

• Big Data & Analytics

• mHealth, Telehealth & Smart Care

• Personal health & wellness systems

• Personalised & genomic medicine

• Clinical Information Systems (EHR, CDSS, ePrescribing, Portals)

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàComplex Ecosystem(s)

Aisis - 2013


• Pillar 1: A vibrant digital single market

• Pillar 2: Interoperability and standards

• Pillar 3: Trust and security

• Pillar 4: Fast and ultra-fast Internet access

• Pillar 5: Research and innovation

• Pillar 6: Enhancing digital literacy, skills and inclusion *

• Pillar 7: ICT-enabled benefits for EU society

• eHealth• eGovernment

Digital SocietyDigital Economy

Digital Agenda for Europe

Aisis - 2013


“Growth and growth enhancing policies are among the top priorities of the EU policy agenda to overcome… economic and societal challenges. eHealth plays an important role in reaching this objective” 2013 European Commission, DG SANCO. http://www.ncbi.nlm.nih.gov/pubmed/23510978 )

But are the agendas for Growth & Health perfectly compatible?

Economic & social benefit

Aisis - 2013


“The European Innovation Partnership for active and healthy ageing [aims to achieve] a triple win… better health for ….citizens, sustainable health systems and a competitive market of innovative products ...” ec.europa.eu/.../2012_sanco_017_active_and_healthy_ageing_en.pdf

Aisis - 2013


Vision statements from industry & governments are overwhelmingly

positive

‘The Vision Thing’

Aisis - 2013


underpinning theme…

Shared knowledge platforms will result in a “horizontal alignment” of patients and clinicians… e.g. Marceglia et al (2012) How might the iPad change healthcare? Jn Royal Soc Med 105

“mHealth is about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviours” Rick Cnossen, Intel http://www.ihealthbeat.org/features/2011/mhealth-closing-the-gap-between-promise-and-adoption.aspx#ixzz2TvzDCwn4

“eHealth has a pivotal role in enabling a radical e-transformation in the way in which high quality integrated healthcare services are delivered” Nicola Sturgeon, Scottish Government. http://www.scotland.gov.uk/Resource/Doc/357616/0120849.pdf

“Transformation”

Aisis - 2013


• Telehealth can bring– Convenience

e.g. in-home care

– Portabilitye.g. mobile self-monitoring

– Accessibilitye.g. reduced travel need

– Flexibilitye.g. time/format/place

Stating the obvious

• HIS/EHR/HIE can improve– Documentation

– Data transfer

– Billing

– Data reuse

– Efficiency?

– Quality?

– Safety?

Aisis - 2013


eHealth will– A) save money

– B) improve patient outcomes

e.g. "mHealth …solutions deliver health "www.mhealthalliance.org/about/frequently-asked-questions

The BIG Promises

Aisis - 2013


$

2010-13 vendors & purchasers rush towards

telehealthAISIS 2013

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàWhere are we? (It depends…)

Aisis - 2013


Bellagio e-Health evaluation declaration 2011

AISIS 2013

The Evidence-Hype Chasm

Aisis - 2013


"We've trialled it, it's been a huge success, and now we're on a drive to roll this out nationwide," ... "The aim - to improve three million lives over the next five years”

UK Prime Minister David Cameron. 5th December 2011

Headline findings announced in Parliament long before trial results were published. Researchers’ conclusions more cautious … “If used correctly…”

Dangers in ‘over selling’

Aisis - 2013


“The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher..

Telehealth does not seem to be a cost effective addition to standard support and treatment”

“..Home telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only…

Telehealth did not improve quality of life or psychological outcomes “

Cartwright et al (2013) Evaluation of patient reported outcomes in the Whole System Demonstrator

Henderson et al (2013) Economic evaluation of telehealth in the Whole System Demonstrator

Fast forward …

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàTesting the Value Proposition

Telehealth will save money by supporting healthy living with LTC, keeping

the elderly out of hospital •But what will it cost to implement?

•Is it the technology that makes the difference?

Telehealth will make moneyby offering sellable benefits

•But what type (e.g. choice, convenience, access, life years, monetary savings), and to whom?

The market is willing to pay•which markets (provider, insurer, government, citizen,

patient, carer) and why?

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàComplexity, impact & value

• What you think you’re buying (off-the-shelf solution) may not be the same as what you’re actually getting (opportunity to reconfigure your service)

• Need to ask:• What process changes are needed to implement this

service?• What is the real change agent?

• Likely costs vs. savings? • Will early losses give way to long-term gains?

• Risks of vision-based (not evidence-based) procurement• Sponsored evaluations typically last <6 mth• Dilemma for modernisation

Aisis - 2013


Unpicking the value chain

Insights from telehealth research in Edinburgh

AISIS 2013

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàSupported COPD monitoring

Phase Driver Intervention? Method Sponsor

Procure-ment

Sale of concept by major vendor. Goal to reduce admissions through home telehealth

Tech: VC, monitoring, decision support, educationVision: Nexus of GP & patient

Researchers flag importance of formative evaluation

Design & set-up

Questions over readiness, fit, configuration

Planning process shifts emphasis to nurse-led service with call-centre

Qualitative observation & interviews

Technology supplier

Trial in practice

Need for evidence of value & safety

Specialist nurse-led service with or without ‘telehealth’. No call centre or VC

RCT withembedded qualitative Study

Gov. research programme

• Quantitative: No difference in admissions or mortality. Clinical indicators improve in both trial arms. Prescribing costs increase.

• Qualitative. Vision very different from what emerged. Patient satisfaction high (perceived safety, access, legitimisation). Uncertainty over ‘normal’ readings. Key change agents: high nurse-patient engagement; service redesign & optimisation

Pinnock et al, (2013, BMJ); Stoddart et al (2013, BMJ Open); Ure et al (2011, PCRJ)

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàmHealth for asthma


Formative pilot

Producer seeking insights to inform developments

Mobile self-monitoring via peripherals with automated feedback

Qualitative study Industry

Trial in practice

Need for evidence of outcomes & practicality

Updated version of product

RCT Asthma charity

Quantitative– No difference in clinical outcomes – Both groups improved, suggesting telehealth not the critical factor (care ‘optimised’

in both groups)– Phone more expensive

Qualitative

Most likely to be used by people adapting to asthma– Issue for market segmentation & value

Ryan et al. (2012) British Medical Journal 344:e1756

Pinnock et al. (2009) Clin Exp All 37

Aisis - 2013



Post market

Academic & clinician interest•Common consumer device purchase•Equivocal evidence

Mobile reminders to check BP using peripherals linked to mobile phone. Automated feedback & advice with weekly clinician review and immediate response if outwith safe thresholds

RCT Government health research agency + supplier (kit)

Results from trial: – Significant improvement in BP compared to usual care. No difference in other

outcomes– Increased prescription of drugs in the actively monitored group.– Clinician and nurse time (and cost) also increased

Interpretation: – Telehealth made readings impossible for primary care staff to ignore, leading to

increased use of antihypertensives, but did not influence patient lifestyle– Technology as catalyst, not causePadfield et al (2012) Early Results from the Health Impact of Telemetry-

Enabled Self-monitoring (HITS) Trial. Conference paper. British Hypertension Society

Supported home BP monitoring

AISIS 2013

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàmHealth for paediatric diabetes


Development & evaluation

Poor medication compliance in adolescents.Reported benefits of costly goal-directed interventions

Scheduled SMS messages tailored to personalised clinical goals and motivational drivers (‘push support’)

RCT with embedded qualitative study

Diabetes charity and mobile network provider

Quantitative : – No difference in Hba1c compared to usual care– Increase in clinic visits– Increase in self-efficacy and self-reported adherence

Qualitative: – Patients actively sought interaction with a system designed mainly to ‘push’ messages – Some believed the automated messages were coming from a human – Soft benefits (e.g. self-efficacy) may add value downstream e.g. aiding transition to intensive

insulin therapy

Franklin et al (2006 ) Diabetic MedicineFranklin et al (2008) JMIR 10 (2)

Aisis - 2013

Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dall’utilizzo di ICT in SanitàSo, where is the value-add?

• Intended & realised benefits don’t always match

• Users co-create value • e.g. though general quality improvement,

unmeasured consumer benefits etc.• …and risks

• e.g. dependency on automated agents; ineffective workarounds; subversion

• e.g. Trust in digital assistants (Pagliari et al 2012, St Health Tech Inform 181: Effects of CDSS fatigue . Kesselheim et al. 2012, Health Affairs, 30, no.12

Aisis - 2013


• Large gap between stated and proven benefits of eHealth technologies. Evaluative evidence needed to guide investments decisions Black AD, Car J, Pagliari C, Anandan C, Cresswell K, et al. (2011) The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview. PLoS Med 8(1):

• Barriers to deployment include limited large-scale evidence of cost-effectiveness, lack of reimbursement models; high start-up costs.

• European Commission eHealth Action Plan 2012-202

• Health IT cannot by itself improve health value, but it can make possible new care delivery models to achieve much larger value.

• Payne TH, Bates DW et al. Healthcare information technology and economics. J Am Med Inform Assoc 2013;20:212-217 doi:10.1136/amiajnl-2012-000821

Key messages from the literature

Aisis - 2013


• Growth & health are imperfectly aligned as outcomes of innovation. The ‘Field of Dreams’ hypothesis is risky

• Without better evidence current levels of spending on can’t easily be justified • Dilemma for modernization vs evidence cycles• Creative paradigms needed to evaluate HIT programmes while they happen• Value creation and RoI can be hard to capture, as human & technical

systems interact • Evaluation should take account of the citizen and not just the health system• The risks of not evaluating will grow as evidence-based purchasing becomes

the norm

Concluding thoughts

Aisis - 2013


Thank You

[email protected]

Aisis - 2013 Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante...

Documents

Transcript of Aisis - 2013 Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante...