Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Exploring healthcare inefficiencies: the case of health care appointments Trillium II Workshop at MedInfo2018

135 views

Published on

Balancing access, efficiency, and quality in health care aspires digital health interventions. Aging populations, high prevelance of chronic disease, and shortages in the health workforce, build the case for augmented coordinated care and citizen participation. However progress has been slow partly due to limited use of consistent standards and tools, and gaps in trust and skills for collaboration and information sharing. Integrated management of resources for face-to-face and remote appointments linked to personal health records, provider and patient facing apps, and diagnostics may improve access to quality care. Starting with a patient case, we discuss standard interfaces and data formats for appointments to explore challenges for patients and providers in emerging blended models of health care, as we strive for particiaption, productivity, professionalism, and accountability. Health care appointments will be discussed with initiatives from Denmark and Norway as the backdrop of the new generation of interoperability standards exemplified by HL7 FHIR initiative.
Morten Brunn-Rassmussen, Mediq, Odense, Denmark
Jan Petersen MedCom, Odense, Denmark
Anne Moen, University of Oslo, Oslo, Norway
Petter Hurlen, Akershus University Hospital, Lørenskog, Norway
Catherine Chronaki, HL7 Foundation, Brussels, Belgium





Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Exploring healthcare inefficiencies: the case of health care appointments Trillium II Workshop at MedInfo2018

  1. 1. Exploring healthcare inefficiencies: the case of health care appointments Funded under H2020-72745
  2. 2. 2 Overview striving for the triple win in health care fine balancing act for costs, efficiency, and quality emerging blended models of care placing appointments at the center of productivity remote vs face-to-face; scheduled vs. drop-in; group vs individual appointments augmented with patient-generated data; patient- and provider-facing apps; personal health records redefining participation, productivity, professionalism, accountability role of eStandards Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China
  3. 3. 3 Access to appointments unable to get same day appointments: 50% Norway, 41% Sweden, 42% United states, 19% NL 40-64% after hours without going to emergency, 25% NL NL Consult app before access to GP Is this telling about, which health system is better? August 24, 2017,Exploring healthcare inefficiencies: the case of health care appointments Source: 2016 commonwealth survey in 11 countries. http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf
  4. 4. 4 Chinese appointment app in Hangzhou… Exploring healthcare inefficiencies: the case of health care appointments Select Doctor, Date, and Time, receive confirmation by SMS
  5. 5. 5 A Chinese emergency appointment experience at MedInfo2017 August 24, 2017,Exploring healthcare inefficiencies: the case of health care appointments
  6. 6. 6 Connected Care in the US and the Patient Experience August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments http://surescripts.com/connectedpatient/default.html
  7. 7. 7 Exploring healthcare inefficiencies: the case of health care appointments Catherine Chronaki - introduction Petter Hurlen – complex and simple cases Jan Petersen – environment in Denmark Morten Brunn-Rasmussen – Danish appointment Anne Moen – zooming out Discussion – can standards help reduce inefficiencies and increase quality in blended models of complex care? Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China
  8. 8. Healthcare inefficiencies The case of appointments Olav´s story (and Jon´s) Petter Hurlen Akershus University Hospital petter@hurlen.no
  9. 9. One doctor One patient One appointment
  10. 10. # Care Visits 1 GP Every now and then
  11. 11. # Care Visits 1 GP Every now and then 2 Cardiologist 1 Twice a year, private Lab tests 1 week before, private lab 3 Cardiologist 2 Every two year, Hospital 1 Lab tests 1 week before, Hospital 1 lab Admission Fasting before 4 Vascular surgeon 4 times a year, Hospital 2 CT scan 1 week before / cancel, Hosp.2 5 Physiology Same day as 3, Hospital 2
  12. 12. # Care Visits 1 GP Every now and then 2 Cardiologist 1 Twice a year, private Lab tests 1 week before, private lab 3 Cardiologist 2 Every two year, Hospital 1 Lab tests 1 week before, Hospital 1 lab Admission Fasting before 4 Vascular surgeon 4 times a year, Hospital 2 CT scan 1 week before / cancel, Hosp.2 5 Physiology Same day as 3, Hospital 2 6 Nephrologist Every six weeks, Hospital 3 Lab tests 4 days before, at Hospital 3 lab 7 Haemathologist Twice a year, Hospital 3 Lab tests 4 days before, at Hospital 3 lab 8 Neurologist Once a year, Hospital 3 Cognitive test Same day, Hospital 3 SUM 30-40 appointments/year
  13. 13. # Care Visits 1 GP Every now and then 2 Cardiologist 1 Twice a year, private Lab tests 1 week before, private lab 3 Cardiologist 2 Every two year, Hospital 1 Lab tests 1 week before, Hospital 1 lab Admission Fasting before 4 Vascular surgeon 4 times a year, Hospital 2 CT scan 1 week before / cancel, Hosp.2 5 Physiology Same day as 3, Hospital 2 6 Nephrologist Every six weeks, Hospital 3 Lab tests 4 days before, at Hospital 3 lab 7 Haemathologist Twice a year, Hospital 3 Lab tests 4 days before, at Hospital 3 lab 8 Neurologist Once a year, Hospital 3 Cognitive test Same day, Hospital 3 SUM 30-40 appointments/year 9 Home nurse Three times a day
  14. 14. # Care Visits 1 GP Every now and then 2 Cardiologist 1 Twice a year, private Lab tests 1 week before, private lab 3 Cardiologist 2 Every two year, Hospital 1 Lab tests 1 week before, Hospital 1 lab Admission Fasting before 4 Vascular surgeon 4 times a year CT scan 1 week before / cancel 5 Physiology Same day as 3, Hospital 2 6 Nephrologist Every six weeks, Hospital 3 Lab tests 4 days before, at Hospital 3 lab 7 Hematologist Twice a year, Hospital 3 Lab tests 4 days before, at Hospital 3 lab 8 Neurologist Once a year, Hospital 3 Cognitive test Same day, Hospital 3 SUM 30-40 appointments/year 9 Home nurse Three times a day
  15. 15. For Jon – the appointment is the care process For Olav – the appointment is an element in the care processes Jon Olav, and Nora
  16. 16. The Danish experiences Jan Petersen, Chief Consultant MedCom, Denmark Exploring healthcare inefficiencies: the case of health care appointments
  17. 17. 17 What is MedCom? • MedCom is established in 1994. • The Regions, Local Government and the National government decided to make MedCom permanent, with the following aims: • “MedCom shall contribute to the development, testing, dissemination and quality assurance of electronic communication and information in the health sector with a view to supporting good practice in patient care.” – MedCom is financed by: – The Ministry of Health – The Danish Regions – Local Government Denmark/Municipalities
  18. 18. 18 Prerequisites for eHealth and standardization in Denmark • Unique Person ID - life-long and multi-purpose since 1968 • National registration of hospital contacts since1976 • Legal authorization registry for health care professionals • Health provider/organization registry since 2006 • National security services • National health service – tax financed • National it-strategies • National classifications and terminology • - and a multi-vendor policy within eHealth • Combination unique to Denmark
  19. 19. 19 • A lot of work already done by international experts • Open the Danish market for international vendors • Make opportunities for the Danish vendors on the international market • Maintaining a dynamic market – following new trends Why international standards?
  20. 20. 20 Danish HL7 CDA-Ver 2 profiles – one of many
  21. 21. 21 The Danish Health Data Network • Exchange of data: • Messaging – One-to-one – One data provider - One data consumer • Web service – One-to-many – One data provider – Many data consumers • Index lookup – Many data provider – Many data consumers
  22. 22. 22 Complex / Simple patient’s appointments – support for planning • The cross-sector overview of patient appointments will leverage: – Quality of care – increased co-ordination – Limit duplication of procedures – Gain a rapid overview of the patient’s appointments – Patient can keep track of appointments – Existing bookings can be seen in planning new appointments – Provides a rough overview regarding past and planned health care services in the patient’s care plan • Appointments will be a part of the National EHR overview for citizens and health care professionals on The national Health Portal sundhed.dk https://sundhedsdatastyrelsen.dk/-/media/sds/filer/rammer-og-retningslinjer/digitaliseringsstrategi/digitally-support-complex-crosssector-patient-pathways.pdf?la=da https://www.sundhed.dk/borger/service/om-sundheddk/ehealth-in-denmark/
  23. 23. 23 Multi-vendor > interoperability • Interoperability – how to secure it in a multi-vendor environment – Common interfaces – standards – profiles – Robust Internationale standards – National consensus – including clinical and technical co-operation in national profiling – Testing and Certification of al vendor products – Robust testing and certification operation (ISO 9001) – Monitoring the use of MedCom approved standards – Publishing which vendor passes the certification
  24. 24. 24 • Think small – disseminate big • Only one challenge at a time • Standardization by demand • If you cannot explain your strategies/plans in plain language – it will probably never work in the real world • Building the infrastructure along the way • Define problem – choose the right tool • There is no silver bullet! Lessons learned
  25. 25. Exploring healthcare inefficiencies: The case of health care appointments Profiling international standards Morten Bruun-Rasmussen mbr@mediq.dk MEDIQMEDINFO 2017. Hangzhou, China. August 24 2017.
  26. 26. Profile definition MEDIQ • A profile is a selection of definitions and options from standards or other specifications. • Profiles provide developers a clear implementation path. • Profiles give purchasers a tool that reduces the complexity and cost of implementing interoperable systems.
  27. 27. Profiling process MEDIQ International standard International profile National profile • Broad coverage • Not specific • Not useful for implementation • Not useful for daily operation • For a specific use case • Constrains are done • Can be implemented • Not useful for daily operation • For a specific use case • Further constrains are done • Useful for implementation • Useful for daily operation
  28. 28. Communication Application level Logical level Technical level presentation clinical content model format & storage transmission Semantic interoperability Technical interoperability terminology functionality presentation clinical content model format & storage transmission terminology functionality Clinical Interoperability Continuity and quality Organisational level Interoperability and the ALT-model
  29. 29. Defining content is challenging MEDIQ
  30. 30. Appointment data to be shared MEDIQ The data are discussed and agreed in a group with 20-25 people form hospitals, municipalities, general practitioner and vendors
  31. 31.  Appointment identification code  An unique appointment code, generated by the filler system  Patient  The person, who are booked for a health care service  Appointment requester  The organization/person who have ordered the appointment via the placer system  Appointment registrant  The organization/person who have booked the appointment via the filler system  Start date and time  Start date and time when the appointment is to take place  End date and time  End date and time when the appointment is to conclude  Health care organization  The responsible health care organization/person for the appointment  Location  The visit address for the appointment  Reason  The reason why the appointment is scheduled  Status  The status for the appointment (booked or deleted) Appointment content MEDIQ
  32. 32. 1. The profile can be implemented (in DK) 2. The profile are a constrain of the standards (no addition) 3. The original standard shall be used where possible 4. The used language shall be the same as the standard (English) 5. Datatypes in the standard shall be carried on in the profile 6. Danish agreed national coding shall be used in the profile 7. Mandatory data element in the standard shall also be mandatory in the profile 8. Optional data elements in the standard shall be avoided in the profile 9. Optional data in the standard can be mandatory in the profile 10. The use of an optional data element shall be well defined 11. The profile shall include a description of the intended use 12. The profile shall include information for future maintenance Profiling: 10 commandments MEDIQ
  33. 33. Anne Moen, Faculty of Medicine, University of Oslo Exploring health care inefficiencies: the case of health care appointments Collaboration – Coordination
  34. 34. Episodic encounter • Defined problem – (sub) acute situation – Clear start – stop Series of interdependent encounters • Interacting problems – co-morbidities, – Team approach; activities – expertise – resources – services • Activities to manage chronic condition(s) – Monitor the disease – regular follow up by specialist(s) – Trajectory of treatment and supported self – care Appointment is either
  35. 35. Data elements - “appointments” • Scheduled appointment ≠ used appointment – Were the patient seen ? – What happened in an appointment ? • Type of appointment – f2f consultation (traditional) – Tests; prepare for f2f consultation – eVisits – teleconsultation • Time to appointment – access to care – Urgency, maximum wait time
  36. 36. Coordination – Collaboration • for citizen – Coordination – self serve re. appointments • Booking – single or multiple resources in encounter • Overview of history and future plans – Collaboration • for health providers – Coordination of resources • Overview, continuity – Collaboration – team approach • Mobilizing resources, expertise & experience, tests
  37. 37. Appointment overview for .. • Coordination of information – Integrated data view or search in multiple screens – Scheduled appointment ≠ used appointment • Collaboration – sharing information – Easy – to – use; complete/comprehensive information – Granularity of information relative to logistic / clinical use – Policy for cancellation – changes • Coordination of care – Benefit and beneficiaries – Planning – seeing same team & resources ?
  38. 38. Exploring healthcare inefficiencies: the case of health care appointments Catherine Chronaki euoffice@HL7.org Funded under H2020-72745
  39. 39. 39 Patient summaries: our navigator in the health and social care ecosystem “Bring the Power of Platforms to Health Care” using data to drive: [Bush & Fox, HBR November 2016] administrative automation networked knowledge resource orchestration Elements to consider: appointments, technology, and productivity  virtual and f2f just-in-time appointments Context: Patient summary as a window to a person’s health or personal dashboard: Medications, allergies, vaccinations problems and procedures, labs, diagnostic imaging recent or planned Encounters, implantable devices advance directives Exploring healthcare inefficiencies: the case of health care appointments eStandards need to • help build trust • unlock the power of health data • facilitate decision support • navigate the health system August 24, 2017, Hangzhou, China
  40. 40. 40 Connected Care in the US and the Patient Summary promise August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments http://surescripts.com/connectedpatient/default.html
  41. 41. 41 Connected Care and the Patient experience: organization coordination For any two organizations to meaningfully coordinate care on behalf of a patient, they must know which patients they should be coordinating care for know which providers those patients see have procedures in place to determine when, how and what patient information to communicate with each other have the tools, processes, and technology to be able to transfer and effectively use that information. August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments http://go.surescripts.com/hubfs/Whitepaper-all-healthcare-is-not-local-1.pdf
  42. 42. 42 eStandards – eHealth Standards and Profiles in Action for Europe & Beyond Vision of the global eHealth ecosystem  people have navigation tools for safe and informed health care  interoperability assets fuel creativity, entrepreneurship, and innovation eStandards will:  nurture digital health innovation  strengthen Europe’s voice & impact  enable co-creation and trusted provider-user relationships Base Standards Use Case based Standards Sets Assurance and Testing Live Deployment Feedback and Maintenance Tooling and Education Forums and Monitoring eStandards Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China
  43. 43. 43 Innovation is where standards are most needed: to unlock data for trust & flow Today: Massive health data accumulated in silo EHR systems serving documentation purposes. We need to move from passive documentation to active use of information and knowledge creation: activation! Patient summaries defined at the macro level: cross-border exchange for emergency or unplanned care at a national level. Need to address communities and individuals! Standards and profiles address a predefined exchange of information. Need flexible use of available content and structure, recognizing national, regional or local jurisdictions trust & flow! Shaping the future: Focus on the top level: systems of innovation! Systems of record – documentation systems -EHRs Systems of differentiation – profile based data exchange Systems of innovation – unlock data and user experience + + - - C h a n g e G o v e r n a n c e Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China
  44. 44. 44 What do we need to make digital health work with standards and interoperability? Co-create to make it real using standards Governance to make it scale for large-scale deployment Alignment to make it flourish in a sustainable way Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China
  45. 45. 45 HL7 FHIR appointment v3.0.1 https://www.hl7.org/fhir/appointment.html August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments
  46. 46. 46 FHIR Appointment has Maturity level 3 Conditions: (level 0) FHIR resource or profile (artifact) has been published on the current build. (level 1) the artifact produces no warnings during the build process and the responsible WG has indicated that they consider the artifact substantially complete and ready for implementation (level 2) the artifact has been tested and successfully exchanged between at least three independently developed systems leveraging at least 80% of the core data elements using semi-realistic data & scenarios based on at least one of the declared scopes of the resource e.g. connectathon. These interoperability results must have been reported to and accepted by the FMG (level 3) the artifact has been verified by the work group as meeting the Trial Use Quality Guidelines subject to a round of formal balloting has at least 10 implementer comments in the tracker from at least 3 organizations resulting in at least one substantive change August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments
  47. 47. 47 Recommendations from health market collaborative Make explicit what each player is bringing to the effort Establish shared aim Don’t reinvent the wheel Make it flexible Prioritize on the basis of impact and difficulty Expenditures and impact on patients Level of complication and risk Ease of standardization Benefit to the health systems Choose simple metrics and goals Better, faster, more affordable care Use one improvement methodology Fix the business side Source: The employer-led revolution, Big Idea, HBR July 2015 August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments
  48. 48. 48 Six Forces That Can Drive Innovation—Or Kill It. Players The friends and foes lurking in the health care system that can destroy or bolster an innovation’s chance of success. Funding The processes for generating revenue and acquiring capital, both of which differ from those in most other industries. Policy The regulations that pervade the industry, because incompetent or fraudulent suppliers can do irreversible human damage. Technology The foundation for advances in treatment and for innovations that can make health care delivery more efficient and convenient. Customers The increasingly engaged consumers of health care, for whom the passive term “patient” seems outdated. Accountability The demand from vigilant consumers and cost-pressured payers that innovative health care products be not only safe and effective but also cost-effective relative to competing products. Source: HBR May 2006: Why innovation in health care is so hard August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments
  49. 49. Exploring healthcare inefficiencies: the case of health care appointments Discussion
  50. 50. Exploring healthcare inefficiencies: the case of appointments 50
  51. 51. Exploring healthcare inefficiencies: the case of appointments 51
  52. 52. Exploring healthcare inefficiencies: the case of appointments 52

×