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Meeting healthcare challenges: what are the challenges and what is the role of e-health?


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Lecture by Dr Richard Smith. For more lectures, see

Published in: Health & Medicine
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Meeting healthcare challenges: what are the challenges and what is the role of e-health?

  1. 1. Meeting healthcare challenges: what are the challenges and what is the role of e-health? Richard Smith Chief executive, UnitedHealth Europe
  2. 2. Agenda <ul><li>Two pictures </li></ul><ul><li>Characteristics of a good health system </li></ul><ul><li>Health systems now </li></ul><ul><li>The four major challenges </li></ul><ul><li>The need for transformation: how can e-health help? </li></ul><ul><li>Three “pet” themes </li></ul><ul><ul><li>Information for doctors and patients </li></ul></ul><ul><ul><li>Free access to research for all </li></ul></ul><ul><ul><li>Identifying patients at risk </li></ul></ul><ul><li>Barriers to transformation </li></ul>
  3. 4. Fee for serv i ce for the rich Marks and Spencer style managed care for the middle classes Safety net service for the poor The way all health systems will be. Uwe Reinhardt
  4. 5. Characteristics of an optimal health system: Institute of Medicine <ul><li>Safe </li></ul><ul><li>Effective, evidence based </li></ul><ul><li>Patient centred </li></ul><ul><li>Timely, no waiting </li></ul><ul><li>Efficient, avoids waste </li></ul><ul><li>Affordable, sustainable </li></ul><ul><li>Equitable, no variation by gender, ethnic group, etc </li></ul><ul><li>Constantly improves </li></ul>
  5. 6. IOM report: the problem <ul><li>Between the health care we have and the care we could have lies not just a gap, but a chasm </li></ul><ul><li>A system full of underuse, inappropriate use, and overuse of care </li></ul><ul><li>Unable to deliver today’s science and technology; will be even worse with innovations in the pipeline </li></ul><ul><li>A fragmented system characterised by unnecessary duplication, long waits, and delays </li></ul>
  6. 7. IOM report: the problem <ul><li>Poor information systems; disorganised knowledge </li></ul><ul><li>“ Brownian motion” rather than organisational redesign </li></ul><ul><li>A system designed for episodic care when most disease is chronic </li></ul><ul><li>Health care providers operate in silos </li></ul><ul><li>Driven by producers rather than consumers of care </li></ul>
  7. 8. The major challenges <ul><li>Quality and safety </li></ul><ul><li>Access </li></ul><ul><li>Responsiveness/usability </li></ul><ul><li>Affordability </li></ul>
  8. 9. How safe is health care? <ul><li>Less than one death per 100 000 encounters </li></ul><ul><ul><li>Nuclear power </li></ul></ul><ul><ul><li>European railroads </li></ul></ul><ul><ul><li>Scheduled airlines </li></ul></ul><ul><li>One death in less than 100 000 but more than 1000 encounters </li></ul><ul><ul><li>Driving </li></ul></ul><ul><ul><li>Chemical manufacturing </li></ul></ul><ul><li>More than one death per 1000 encounters </li></ul><ul><ul><li>Bungee jumping </li></ul></ul><ul><ul><li>Mountain climbing </li></ul></ul><ul><ul><li>Health care </li></ul></ul>
  9. 11. How to respond? <ul><li>Institute of medicine identified electronic patient records as an essential step in improving safety and quality </li></ul><ul><li>Reduce complexity </li></ul><ul><li>Optimise information processing </li></ul><ul><ul><li>checklists, reminders, protocols </li></ul></ul><ul><li>Automate wisely </li></ul><ul><li>Use constraints </li></ul><ul><ul><li>for instance, with needle connections </li></ul></ul><ul><li>Mitigate the unwanted side effects of change </li></ul><ul><ul><li>with training, for example. </li></ul></ul>
  10. 12. Problems of access <ul><li>40 million without insurance in the US </li></ul><ul><li>Long waits for hospital appointments, diagnostic tests, elective surgery in the US </li></ul><ul><li>Difficulty getting access to GPs in the evenings and at weekends </li></ul><ul><li>Long distances to travel for some--for example, patients with cancer from south west Scotland </li></ul>
  11. 14. Role of e-health in responding <ul><li>Increase efficiency of the system </li></ul><ul><li>Fundamental role of data (and intelligent use of data) in “commissioning” </li></ul><ul><li>Information systems like NHS Direct </li></ul><ul><li>Telemedicine allowing diagnosis, treatment, and access at a distance </li></ul>
  12. 15. Responsiveness/usability of the system <ul><li>Finding your way into the system and navigating through it can be very hard </li></ul><ul><li>Many patients get lost in the system--particularly those with complex conditions </li></ul><ul><li>Care doesn’t feel personalised </li></ul><ul><li>Patients don’t feel listened to </li></ul><ul><li>Patients are not involved enough in decisions about their care </li></ul>
  13. 16. How can e-health help? <ul><li>A single electronic record accessible to the patient and by all health professionals </li></ul><ul><li>Allow a single access point to a health system </li></ul><ul><li>Help with navigation through the system </li></ul>
  14. 17. Affordability <ul><li>Need people to be “fully engaged” with their health </li></ul><ul><li>But increases in productivity may be more important </li></ul>
  15. 19. Successful health system reform Controversy without impact Transformation Improved Status quo outcomes Effective implementation Effective system design Source: derived from DU
  16. 20. Copyright ©2005 BMJ Publishing Group Ltd. Quam, L. et al. BMJ 2005;330:530-533 Fig 3 Annual expenditure per employee on information and communication technology in United Kingdom in different economic sectors, 2000
  17. 21. Copyright ©2005 BMJ Publishing Group Ltd. Quam, L. et al. BMJ 2005;330:530-533 Fig 1 Risk adjusted mortality from cancer against length of stay for institutions in New York State. The size of the circle indicates the number of patients treated
  18. 22. Three pet issues <ul><li>Information supply to health workers and patients </li></ul><ul><li>Free access to research for all </li></ul><ul><li>Measuring the risk of patients: responding to need not demand </li></ul>
  19. 25. Current problems <ul><li>Our current information policy resembles the worst aspects of our old agricultural policy, which left grain rotting in thousands of storage files while people were starving. We have warehouses of unused information rotting while critical questions are left unanswered and critical problems are left unresolved. Al Gore </li></ul>
  20. 26. Words used by 41 doctors to describe their information supply <ul><li>Impossible Impossible Impossible Impossible Impossible Impossible </li></ul><ul><li>Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming Overwhelming </li></ul><ul><li>Difficult Difficult Difficult Difficult </li></ul><ul><li>Daunting Daunting Daunting </li></ul><ul><li>Pissed off </li></ul><ul><li>Choked </li></ul><ul><li>Depressed </li></ul><ul><li>Despairing </li></ul><ul><li>Worrisome </li></ul><ul><li>Saturation </li></ul><ul><li>Vast </li></ul><ul><li>Help </li></ul><ul><li>Exhausted </li></ul><ul><li>Frustrated </li></ul><ul><li>Time consuming </li></ul><ul><li>Dreadful </li></ul><ul><li>Awesome </li></ul><ul><li>Struggle </li></ul><ul><li>Mindboggling </li></ul><ul><li>Unrealistic </li></ul><ul><li>Stress </li></ul><ul><li>Challenging Challenging Challenging </li></ul><ul><li>Excited </li></ul><ul><li>Vital importance </li></ul>
  21. 27. The information paradox Doctors are overwhelmed with information but cannot find the information they need when confronted with a question. Muir Gray
  22. 28. Water, water everywhere Nor any drop to drink
  23. 29. A vision of a better information tool for clinicians 1 <ul><li>Part of the information system that doctors use as they see patients </li></ul><ul><li>Able to answer highly complex questions </li></ul><ul><li>Connected to a large valid database </li></ul><ul><li>Electronic </li></ul><ul><li>Fast </li></ul>
  24. 30. A vision of a better information tool for clinicians 2 <ul><li>Easy to use </li></ul><ul><li>Portable </li></ul><ul><li>Prompts doctors in a way that’s helpful not demeaning </li></ul><ul><li>Connected to the patient record </li></ul><ul><li>Gives evidence related to individual patients </li></ul><ul><li>A servant of patients as well as doctors </li></ul><ul><li>Provides psychological support </li></ul>
  25. 31. The importance of all research being free to everybody everywhere
  26. 32. Why provide free access to research? <ul><li>Ideas breed ideas, and ideas are precious </li></ul><ul><li>Because it’s now possible, and a powerful vision of the future exists </li></ul><ul><li>Economic: avoid paying twice </li></ul><ul><li>Avoid Balkanisation--easier to do the systematic reviews that are essential for modern health care </li></ul>
  27. 34. A vision of something better <ul><li>If you have an apple and I have an apple and if we exchange these apple then you and I will still each have one apple. But if you have an idea and I have an idea and we exchange these ideas, then each of us will have two ideas. </li></ul><ul><li>George Bernard Shaw </li></ul>
  28. 36. A vision of something better <ul><li>&quot; It's easy to say what would be the ideal online resource for scholars and scientists: all papers in all fields, systematically interconnected, effortlessly accessible and rationally navigable, from any researcher's desk, worldwide for free.” </li></ul><ul><li>Stevan Harnad </li></ul>
  29. 37. Money <ul><li>Most research is funded by public money: why pay twice? </li></ul><ul><li>99% of the value of a piece of research is in the research itself not in the processes that lead to publication—yet it is the publishers who get the profits </li></ul><ul><li>Publishers have consistently raised their prices above inflation: economics of the madhouse </li></ul><ul><li>Some journals cost £20 000 a year to subscribe </li></ul><ul><li>Can be made available to all for less money per article </li></ul>
  30. 38. Balkanisation <ul><li>If you are a gastroenterologist the research that might matter to you may be in 30 different journals </li></ul><ul><li>The difficulty of doing systematic reviews </li></ul><ul><li>Important research articles are all over the place, some in Pubmed, many not </li></ul><ul><li>Even if you can find the stuff, it costs a fortune to gather it all together (systematic review on research misconduct -£2000 to get photocopies) </li></ul>
  31. 39. Risk stratification of patients <ul><li>Rank an entire population by their risk of needing care in the future </li></ul><ul><li>Requires more than simple past experience </li></ul><ul><li>Combine data from hospital, general practice, prescribing, registry, census, and possibly other data--and can predict future use of resources accurately </li></ul><ul><li>Can then reach out to these patients--and be driven by ned rather than demand </li></ul><ul><li>Can construct programmes around them--case management, disease management, self amanagement </li></ul><ul><li>Those programmes themselves depend crucially on good informatics tools </li></ul><ul><li>Such a move holds the potential to do reduce inequalities in health </li></ul>
  32. 40. Copyright ©2005 BMJ Publishing Group Ltd. Roland, M. et al. BMJ 2005;330:289-292 Emergency admissions and emergency bed days per person for patients [&ge;]65 in 1997-8: comparison of those with two or more emergency admissions in 1997-8 (&quot;high risk&quot;) with general population (England)
  33. 41. Change=burning platform x vision x next steps
  34. 42. Barriers to transformation <ul><li>Inbuilt resistance to change: “Better to suffer the ills we have than to fly to others we know not off” </li></ul><ul><li>Losers very vocal, winners quiet. Nicolo Machiavelli </li></ul><ul><li>Lack of vision </li></ul><ul><li>Lack of leadership </li></ul><ul><li>Vested interests </li></ul><ul><li>Technical problems </li></ul><ul><li>Resources: money, people </li></ul><ul><li>The challenge with informatics tools is not just to produce and install them but to get people to use them well </li></ul>
  35. 43. &quot;The Sicilians never want to improve for the simple reason they think themselves perfect; their vanity is stronger than their misery.”
  36. 44. Entrepreneurs are simply those who understand that there is little difference between obstacle and opportunity and are able to turn both to their advantage. Niccolo Machiavelli