Transcript ehtel whit cph 2008-11-03 - European Institute for Health

eHealth Roadmaps:
Design Principles
Angelo Rossi Mori
eHealth Unit, CNR-ITB
CNR-ITB
EHTEL EUROREC Symposium, Copenhagen 2008-11-03
why there is a need for
eHealth roadmaps ?
from local initiatives on "health informatics"
to the deployments of "connected health"
in large jurisdictions
nomen omen
connected
health
health
eHealth
ICT
for health
ICT
healthcare
informatics
IT
medical
informatics
1970
1980
innovation
on products
1990
2000
2010
innovation
on health system
design of the eHealth policies
• most eHealth policies today
reflect technology – driven decisions,
i.e. they are not directly linked
to the healthcare policies, e.g.
– WHO's "Gaining Health"
– elderly care
– integrating health and social care
beyond the operational workflows
• so far: focus was on prescriptions,
booking, diagnostic reports,
discharge summaries …
• now: regional infrastructures,
e.g for the longitudinal EHR
• future: support to clinical pathways,
governance (appropriateness & quality),
patient empowerment (consumer's trends)
1. the "Ptolemaic" approach
• the current approach
is mostly technology - centred
• the product-based innovation
is driven by the opportunities
offered by eHealth solutions
(e.g. booking, transfer of prescriptions, …)
• the health system is able to cope with
limited "organisational traumas"
the Ptolemaic approach
1. focus on
eHealth solutions
2. deploy from them
the strategical
opportunities
3. cope with
organisational
micro-traumas
this approach is not scalable !
• eHealth requires large-scale programs
which are pervasive and accelerated
• the health system is not able to cope
with too large macro-traumas
• we should go back
to the healthcare policies
and to the “political readiness”
to put them in practice
the ideal process
high level
policy
objectives
action
lines
Interoperability
and Cooperability
solutions
healthcare
targets
Information and
Communication
issues
add a "Copernican" approach …
a parallel action line should put
the healthcare policies in the centre
– healthcare plans involve
structural decisions on the care system,
and may bring to
innovative organisational models
– support and enable the new care processes
by suitable ICT solutions
– impact on the decisions by professionals
and on the behaviour of citizens
a Copernican approach
1.focus on
health policies
2.decidealth
health
strategies
3.deploy
organisational
changes &
ehealth policies
healthcare policies in the centre
consider how decision makers
look for a sustainable evolution:
– by shifting resources from acute care
to chronic care and prevention
(elderly, mother and child, oncology, …)
– by integrating social and health care
– by encouraging patient empowerment,
– by promoting clinical governance, etc
policy issue 1 - safer decisions,
quality of care processes
• increase the influence on risk management
•
•
(e.g. medical errors and patient's errors)
by timely providing adequate knowledge
to assist proper decisions
increase the quality of care processes,
i.e. declaring and following
explicit reference clinical pathways
increase the mutual awareness
about what other clinicians
are knowing, doing or planning on the patient
policy issue 2 – sustainable
evolution of healthcare
the increasing cost of healthcare requires
a rationalisation of services provided,
without a negative effect on quality of care, by
– continuity of care,
– patient empowerment,
– accurate governance based on routine data
(with timely indicators, also to allow for
self-assessment of healthcare professionals)
policy issue 3 – improve access
to services
• simplification of the paperwork
• rationalisation of organisational and
administrative processes
– increase of efficiency of operational workflows
(e.g. prescriptions, booking, reports, …).
• effective portals, with practical information and
authoritative clinical knowledge
e- Health: it’s time to drop the “e-” ?
• Ptolemaic approach
– ehealth solutions
– strategic opportunities
– organisational changes
• Copernican approach
– health policies
– health strategies
– organisational changes & ehealth policies
a toolkit for the M I C K :
the Management of Information,
Communication and Knowledge
how to carry on
a balanced and coherent deployment
of the various components
of the "connected health" ?
the Management of Information,
Communication and Knowledge
the available tools for the MICK:
• EPR of each individual professional
• practical services (booking, reports, …)
• information portals, also for informal carers
• clinical knowledge, incl. clinical pathways
• home devices (surveillance, data capture)
• lifelong EHR (for professionals)
• PHR (for citizens)
• social networks, web 2.0
MICK – a comprehensive view
subject
of care
health / social
professional
informal
actor
health / social
manager
operator of
contact centre
common substrate of data, information and knowledge
clinical
data
administrative home
data
devices
individual data
practical
information
clinical
knowledge
procedural
instructions
local/universal resources
other
services
social
networking
services
four layers of intervention
1. infrastructure and basic services
2. operational workflows
3. support to care processes
4. governance of the healthcare system
2 lower layers, Ptolemaic approach
L1. enabling infrastructures and services
– hw, sw, networks,
– regulations,
– identification of citizens and professionals
– authentication, authorization
L2. to improve the efficiency
of operational workflows
– booking, prescribing, reporting, portals, ...
2 new, upper layers,
Copernican approach
L3. to improve the quality of shared care
– synergy of actors
(clinical pathways, clinical data sets)
– patient empowerment
L4. to improve the governance
of the healthcare system
– structural actions to modify the system
(indicators)
L1. basic tools and services
to enable the other layers
• Various large jurisdictions are envisaging
national (federal) and regional programmes,
– to develop coherent inter-sectoral infrastructures
(e.g. by eGovernment actions
and generic standard, e.g. HTML, XML)
– to develop health-specific infrastructures
• Stakeholders have an increasing attention
– to define and adopt regulations and standards
– to make plans for specific educational activities
for the public and healthcare professionals
L1. basic tools and services
to enable upper layers
• build the technological infrastructure;
• set up the proper regulatory framework,
including connectivity, security, privacy;
• produce or adopt standards
and reference documentation
to achieve semantic interoperability;
• set up a certification process on quality
and safety of eHealth solutions
L2. to improve efficiency
of operational workflows
• to improve speed, quality, quantity of procedures
•
•
performed with a given amount of resources.
stereotypical situations (e.g. prescriptions,
discharge letters, test reports, …)
were the topic for intense activities
on interoperability standards in last 15 years
largely independent from the actual patients
conditions: most of them do not influence
appropriateness of procedures and clinical
decisions, i.e., the intrinsic nature of
healthcare services is not altered
L2. to improve efficiency
of operational workflows
• provide services to improve
the current workflow-oriented services
• provide a basic electronic assistance
to clinicians and managers
• provide support to Public Health Systems,
on epidemiology, management and
planning (secondary usage of information).
L3. to improve the quality
of care processes
rationalisation of the processes
of care provision
by a problem-oriented perspective:
support the daily clinical decisions
of multiple healthcare professionals
and a more effective behaviour
of patients and clinicians
with the capture, storage and transmission
of specific data items, depending on
the particular context within the care plan
L3. to improve quality
of care processes
• advanced services
on information and knowledge
for clinicians
• services for the
empowerment of health consumers:
citizens, patients, their families
and caregivers
disciplined vs. fuzzy environments
L2 - disciplined environments
• diagnostic services (orders and reports), booking,
admission, discharge letter, …
• systematic interactions, stable workflows
• inter-operability, standard messages
L3 - fuzzy environments
• human co-operation, clinical communication
• clinical pathways, datasets, narrative !
• co-operability, document-based approach
L4. to improve governance
of healthcare system
• information support
– to discover bottlenecks
– to negotiate among stakeholders
– to decide for systemic actions
•
•
by the analysis of accurate and timely data,
directly taken from the routine care processes
of each individual patient
more effective management of services and
refinement of medium- and long- term policies,
increase in quality and appropriateness
(better control on resources)
L4. to improve governance
of healthcare system
• re-engineering of care processes
– structural actions on the healthcare system
to increase quality and appropriateness
of care provision
• enabling innovative organisational models
• production and evaluation
of eHealth roadmaps
– support change management processes
for eHealth deployment
eHealth evolution: driving factors
modernisation
of healthcare processes
inter-sectoral activities
towards Information Society
(e.g. eGovernment plans)
L1
supported by ICT solutions
gradual evolution of
ICT market in healthcare
L2
eHealth roadmaps
(on deployment and research)
L3
L4
re-balance the focus among
L1 infrastructures,
L2 operational workflows
L3 support to care processes
L4 governance
by a policy-driven roadmap
EHTEL-Eurorec, Copenhagen 2008-11-03
non-technological factors
•
•
•
•
•
•
regulations,
education,
economics,
involvement of all kinds of stakeholders,
role of public agencies to support
the deployment and the research,
ways to involve the research community
developing criteria
for roadmap design
i.e. the metrics to select
and prioritize actions
that could satisfy the local priorities
and the EU eHealth Action Plan
– on the deployment;
– on the processes
of change management;
– on the potential role of authorities
a balanced action plan ?
a roadmap should mediate
among the different values on
- D1, direct economic factors
- D2, systemic benefits
- D3, technological feasibility
- D4, cultural feasibility
perceived by each stakeholder
about each potential initiative
EHTEL-Eurorec, Copenhagen 2008-11-03
D1. direct economic factors
• suitability to attract resources
•
•
•
to activate and maintain the programs ?
economic benefit
with respect to the investment ?
timeliness of return of investments ?
more efficiency of the care system ?
a subjective evaluation (1 to 4) of each factor
yelds an average value for this dimension
D2. systemic benefits
• positive impact on the citizens' satisfaction ?
• organizational impact on care provision ?
•
•
(ability to promote new organizational models,
contribution for a sustainable evolution
of the health system)
impact on the jurisdiction as a whole ?
(less absences from workplace, new jobs,
opportunities for industry, etc);
improvement of the quality of care ?
D3. technological feasibility
• existence of success stories and know-how ?
•
•
•
(both on ICT in general and on specific solutions)
low critical mass of the programs and scalability ?
(intrinsic modularity of faced problems,
possibility to tolerate co-existence of paper flows
with electronic flows)
availability of enabling infrastructures and
presence of components that may be integrated ?
adequacy of the technical skills of the users ?
D4. cultural feasibility
• predisposition of involving the users from
•
•
•
cultural and organizational point of view ?
degree of non-dependence from incentives,
regulations and agreements ?
awareness of managers and professionals,
presence of innovators and
suitable ICT specialists ?
support from public debate
and consensus of public opinion ?
the decisions are "political"
the technical debate can inform the decisions
• It is not possible to sum up the scores
across the 4 different dimensions.
• The final judgement remains subjective.
• However, it is possible to systematically
compare the different points of view
for each stakeholder,
so that the political decision can take
their perceived values into account
EHTEL-Eurorec, Copenhagen 2008-11-03
3 examples of assessment
1. continuity of care in steady situations,
with shared care plans [L3]
2. governance of care processes,
by means of timely indicators
from routine clinical data [L4]
3. ePrescribing workflow,
from the GP's offices to the pharmacy
and to the reimbursement [L2]
example 1
continuity of care
in steady (chronic) situations,
with multiple actors and
shared care plans
feeling as a "system"
• synchronization of activities
•
•
•
•
•
performed by different actors
common explicit goals
common care plans
integration of social and health care
proactive role of the patient and the family
ICT support to communication
all actors should feel as a "system"
with the patient at the centre
sharing of structured data
current trends:
• from the longitudinal EHR infrastructure
– life-long patient history
• to ICT services to synchronize activities
– timely sharing of relevant data in shared care
from "connecting systems" to "connecting people":
send to each actor the data needed for his tasks
create the framework
for collaboration
• Notifications of care mandates
•
•
WHO is involved? (including informal carers)
Notification of contacts
WHICH ACTIVITY is actually being performed?
Notification of health issues + plans
WHY is being done? (orchestrate mutual roles)
to behave as a coherent "system"
[source: RIDE deliverable on Policies and Strategies]
health mandate
statement […]
defining the scope and limits
of the specific role
assigned to one health care party,
and delineating its responsibilities […]
[source: CONTSYS, a CEN standard]
to collaborate, actors must first be aware
of the respective roles and responsibilities
needs for shared care
initial idea on EHR
main
modality
actual needs
preserving historical synchronization of
data, from birth to
activities: timely
death
sharing of data
objective informative, clinical
organizational
(process)
care
sequence of
mandates care mandates
coherent set of
parallel
care mandates
(history)
over time
to behave as a system …
initial idea
on EHR
kinds of
any kind of
clinical
document
documents
internal
structure of any format
documents
functionalities
actual needs for shared care
notifications of
mandates and contacts
+ a few kinds of documents
structured according to
suitable agreements
(e.g. HL7-CDA R2 + CCD)
make clinical
first, process data on
documents
mandates and contacts
available to
(organisational data items)
authorized users
variants of Patient Summaries
• unpredicted situations
require a generic Patient Summary
• the management
of a steady chronic condition
requires a task-dependent variant
of the citizen’s clinical profile, i.e.
a "Focused Outline"
for each stable chronic condition
50
Focused Outline: CCD + CDA L3
• a CCD document to share
a small core set
of highly meaningful,
structured data items (CDA level 3)
for each stable chronic disease
– for actual care provision and
– to compute governance indicators
• suitable for immediate large scale deployment
51
[L3] continuity of care
in steady situations
simulation
of assessment
example 2
accurate governance
of care processes,
based on timely indicators from routine data
(also to allow for self-assessment
of healthcare professionals)
[L4] accurate governance
of care processes
simulation
of assessment
example 3
e-prescribing
workflow
from GP to pharmacy
and reimbursement
[L2] transfer of prescriptions
from GP to pharmacy
simulation
of assessment
[L3]
continuity
of care
[L4]
governance
[L2]
prescriptions
thanks !
contact:
• Angelo Rossi Mori
• [email protected]