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 FRCPE
University of Edinburgh
eHealth Research Group
Convegno Annuale AISIS,
Firenze, 15 Novembre 2013
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
• Focus of talk
– Dual agendas of growth & health
– Vision for transformation & benefits
– Complexity & risk
– Deconstructing the value chain
– Call for evidence-based, citizencentric eHealth
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Health IT is Big Business
• 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.
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
• 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)
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Complex Ecosystem(s)
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Technologies
Applications
Stakeholders
Vendors, Payers, Brokers,
Analysts, Users
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Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Digital Agenda for Europe
• 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
Digital Society
Digital Economy
• eHealth
• eGovernment
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Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Economic & social benefit
“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?
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
“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
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‘The Vision Thing’
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Vision statements from industry &
governments are overwhelmingly
positive
Aisis - 2013
“Transformation”
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
underpinning theme…
“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
“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
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
Aisis - 2013
Stating the obvious
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
• HIS/EHR/HIE can
improve
–
–
–
–
–
–
–
• Telehealth can bring
– Convenience
e.g. in-home care
Documentation
Data transfer
Billing
Data reuse
Efficiency?
Quality?
Safety?
– Portability
e.g. mobile selfmonitoring
– Accessibility
e.g. reduced travel need
– Flexibility
e.g. time/format/place
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The BIG Promises
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
eHealth will
– A) save money
– B) improve patient outcomes
e.g. "mHealth …solutions deliver health "
www.mhealthalliance.org/about/frequently-asked-questions
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Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
$
2010-13 vendors &
purchasers rush towards
telehealth
AISIS 2013
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Where
are we? (It depends…)
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
The Evidence-Hype Chasm
Bellagio e-Health evaluation declaration 2011
AISIS 2013
Aisis - 2013
Dangers in ‘over selling’
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
"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…”
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Fast forward …
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Cartwright et al (2013) Evaluation of patient reported
outcomes in the Whole System Demonstrator
“..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 “
“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..
Henderson et al (2013) Economic evaluation of telehealth in
the Whole System Demonstrator
Telehealth does not seem to be a cost
effective addition to standard support
and treatment”
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Testing 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 money
•
by 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?
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Complexity, impact & value
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
•
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
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
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 Sanità
Supported COPD monitoring
•
•
Phase
Driver
Intervention?
Method
Sponsor
Procurement
Sale of concept by major
vendor. Goal to reduce
admissions through
home telehealth
Tech: VC, monitoring,
decision support,
education
Vision: 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 with
embedded 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
Aisis - 2013
Pinnock et al, (2013, BMJ); Stoddart et al (2013, BMJ
Open); Ure et al (2011, PCRJ)
mHealth for asthma
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Phase
Driver
Intervention?
Method
Sponsor
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
Ryan et al. (2012) British Medical Journal 344:e1756
Qualitative
Most likely to be used by people adapting to asthma
–
Issue for market segmentation & value
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Pinnock et al. (2009) Clin Exp All 37
Associazione Italiana Sistemi Informativi in Sanità
Supported
home
BP monitoring
Valutazione del Valore
derivante dall’utilizzo
di ICT in Sanità
Phase Driver
Intervention?
Method
Sponsor
Post
market
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)
Academic & clinician
interest
• Common
consumer device
purchase
• Equivocal
evidence
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 TelemetryAISIS 2013
Enabled Self-monitoring (HITS) Trial. Conference paper. British
Aisis - 2013
Hypertension
Society
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
mHealth for paediatric diabetes
Phase
Driver
Intervention?
Method
Sponsor
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 Medicine
Franklin et al (2008) JMIR 10 (2)
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
So,
where
thedall’utilizzo
value-add?
Valutazione
del Valoreis
derivante
di ICT in Sanità
•
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
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Key messages from the literature
• 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 costeffectiveness, 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
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Concluding thoughts
• 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
Aisis - 2013
Associazione Italiana Sistemi Informativi in Sanità
Valutazione del Valore derivante dall’utilizzo di ICT in Sanità
Thank You
[email protected]
Aisis - 2013