eHealth Roadmaps: Design Principles

1. eHealth Roadmaps: Design Principles Angelo Rossi Mori eHealth Unit, CNR-ITB EHTEL EUROREC Symposium, Copenhagen 2008-11-03

2. why there is a need foreHealth roadmaps ? from local initiatives on "health informatics"to the deployments of "connected health" in large jurisdictions

3. nomen omen connected health health eHealth ICT for health ICT healthcare informatics medical informatics IT 1970 1980 1990 2000 2010 innovation on products innovation on health system

4. 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

5. 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)

6. 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"

7. 2. deploy from themthe strategical opportunities 3. cope with organisationalmicro-traumas the Ptolemaic approach 1. focus on eHealth solutions

8. this approach is not scalable ! • eHealth requires large-scale programswhich 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

9. the ideal process action lines healthcare targets high level policy objectives Interoperability and Cooperabilitysolutions Information and Communication issues

10. 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 professionalsand on the behaviour of citizens

11. 2.decidealthhealth strategies 3.deployorganisational changes & ehealth policies a Copernican approach 1.focus on health policies

12. 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

13. 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 awarenessabout what other clinicians are knowing, doing or planning on the patient

14. 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 forself-assessment of healthcare professionals)

15. 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

16. Health: it’s time to drop the “e-” ? e- • Ptolemaic approach • ehealth solutions • strategic opportunities • organisational changes • Copernican approach • health policies • health strategies • organisational changes & ehealth policies

17. a toolkit for the M I C K :the Management of Information, Communication and Knowledge howtocarry on a balanced and coherentdeploymentof the variouscomponentsof the "connected health" ?

18. 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

19. MICK – a comprehensiveview subject of care health / social professional health / social manager informal actor operator of contact centre common substrateof data, information and knowledge practical information clinical data clinical knowledge other services social networking administrative data home devices procedural instructions individual data local/universal resources services

20. four layers of intervention infrastructure and basic services operational workflows support to care processes governance of the healthcare system

21. 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, ...

22. 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) need for a clinical info-structure

23. L1. basic tools and services to enable the other layers • Various large jurisdictions are envisaging national (federal) and regional programmes, • to developcoherent inter-sectoral infrastructures (e.g. by eGovernment actions and generic standard, e.g. HTML, XML) • to develophealth-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

24. 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 standardsand reference documentation to achieve semantic interoperability; • set up a certification process on quality and safety of eHealth solutions

25. L2. to improve efficiencyof 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

26. L2. to improve efficiencyof 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).

27. L3. to improve the qualityof care processes rationalisation of the processes of care provision by a problem-oriented perspective: support the daily clinical decisionsof multiple healthcare professionals and a more effective behaviourof patients and clinicians with the capture, storage and transmission of specific data items, depending on the particular context within the care plan

28. L3. to improve qualityof care processes • advanced services on information and knowledge for clinicians • services for the empowerment of health consumers: citizens, patients, their families and caregivers

29. 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 connecting systems connecting people

30. L4. to improve governanceof 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)

31. L4. to improve governanceof 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 processesfor eHealth deployment

32. eHealth evolution: driving factors modernisation of healthcare processessupported by ICT solutions inter-sectoral activities towards Information Society (e.g. eGovernment plans) L4 L1 gradual evolution of ICT market in healthcare L3 L2 eHealth roadmaps(on deployment and research)

33. re-balance the focus amongL1 infrastructures, L2 operational workflows L3 support to care processes L4 governanceby a policy-driven roadmap EHTEL-Eurorec, Copenhagen 2008-11-03

34. 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

35. developing criteria for roadmap design i.e. themetrics to select and prioritize actionsthat could satisfy the local prioritiesand the EU eHealth Action Plan • on the deployment; • on the processes of change management; • on the potential role of authorities

36. a balanced action plan ? a roadmap should mediateamong the different values on - D1, direct economic factors - D2, systemic benefits - D3, technological feasibility - D4, cultural feasibility perceived by each stakeholderabout each potential initiative EHTEL-Eurorec, Copenhagen 2008-11-03

37. 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

38. 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 ?

39. 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 ?

40. 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 ?

41. 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

42. 3 examples of assessment • continuity of care in steady situations, with shared care plans [L3] • governance of care processes,by means of timely indicatorsfrom routine clinical data [L4] • ePrescribing workflow,from the GP's offices to the pharmacy and to the reimbursement [L2]

43. example 1 continuity of care in steady (chronic) situations, with multiple actors and shared care plans

44. 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

45. 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

46. create the framework for collaboration • Notifications of care mandates WHO is involved? (including informal carers) • Notification of contactsWHICH ACTIVITY is actually being performed? • Notification of health issues + plans WHY is being done? (orchestrate mutual roles) tobehaveas a coherent "system" [source: RIDE deliverable on Policies and Strategies]

47. 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, actorsmust first beawareof the respectiveroles and responsibilities

48. needs for shared care

49. to behave as a system …

50. variants of Patient Summaries • unpredicted situationsrequire 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