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eHealth: what is
the potential for
better integration,
delivery and cost
effective care
across Europe?



David McDaid
eHealth Week 2010, Barcelona, March 2010
European Observatory on Health Systems and Policies and LSE Health
& Social Care, London School of Economics
E-mail:d.mcdaid@lse.ac.uk
Structure
• Challenges to health care systems in
  Europe
• The potential role of eHealth in better
  integration and delivery of care
• Making an economic case for investment
• What do we know?
• How can economic incentives be used to aid
  in the facilitation of eHealth solutions?
Challenges to
health care systems
Total health expenditure as % of
        gross domestic product (GDP)
12


11                                                Austria
                                                  Belgium
                                                  Bulgaria
                                                  Cyprus
10                                                Czech Republic
                                                  Denmark
                                                  Estonia
9                                                 Finland
                                                  France
                                                  Germany
8                                                 Greece
                                                  Hungary
                                                  Ireland
                                                  Italy
7                                                 Latvia
                                                  Lithuania
                                                  Luxembourg
6                                                 Malta
                                                  Netherlands
                                                  Poland
5                                                 Portugal
                                                  Romania
                                                  Slovakia
                                                  Slovenia
4                                                 Spain
                                                  Sweden
                                                  United Kingdom
3                                                 EU


2
 1970     1980         1990        2000    2010
Population distribution EU25 1950-2050




                      Source: European Commission 2008
77% of disease burden in Europe on

Personal Costs   non-communicable, often chronic
                 disease

                 Many socio-economic impacts

                 Educational opportunities curtailed

                 Reduced chances of employment

                 Reduced chances of career progression

                 Impacts on families/informal carers
The potential role
of eHealth in
integration &
delivery of care
Integrated care
• Shared care: integrated care across
  primary, secondary and specialist care
  services
• Continuity of care: aided by better
  integration of care delivery between health
  and non-health sectors – e.g. social care
• Person centred: Provision of services that
  best meet individual needs
• Team orientated: Need for collaborative
  working relationships, frequent
  communication, and flexibility of
  practitioners
eHealth and Integrated care
• Shared electronic health records
• Electronic messaging systems
• Opportunities for iterative dialogue
  between clients and physicians
• Systems to help facilitate rapid
  access to clinical services
• Telehealth applications to help
  maintain independence and community
  based living
Hillestad et al , Health Affairs, 2005
Making an economic
case for investment
Economics   Economics is an important input into
            decision making process in health policy

            Resources are not unlimited; economic
            information can help determine how
            best to make use of resources but……

            Cannot be used in isolation; many other
            factors (fairness, equity, political
            concerns etc) influence decision making
Economic questions that can aid decision making
• Costs of inaction: What are the economic
  consequences of not tackling chronic diseases?
• Costs of action: What would it cost to intervene by
  investing in eHealth measures?
• Cost-effectiveness of action: What is the balance
  between what cost to intervene and gains in outcomes,
  e.g. health status, quality of life etc?
• Levers for change: What economic and other
  incentives can encourage more use of those
  interventions that are thought to be cost-effective and
  less use of those interventions which are not?
Making the case
                  So is there an economic
                  case for investment in
                  eHealth to promote
                  better integrated care?
What do we know?
• Mixed evidence base and limited cost data
• Potential benefits not just to health sector, but to other
  payers e.g. social care, social welfare
• Evidence for interventions in specific settings and
  targeted at specific population groups – e.g. diabetes,
  mental health, high risk pregnancy monitoring, heart
  failure and cardiovascular disease
• Focus on return on investment rather than on health
  related impacts
• US dominated: relatively few studies conducted in other
  settings; relatively little focus on broader implementation
  context issues
Electronic Health Records
• AHRQ systematic review in 2006
• Link between EHR and better performance of
  providers in 3 US and 1 Dutch Studies
• All cost benefit analyses reported substantial
  savings, but up to 13 years to break even
• But conservative: very few studies reported
  economic benefits from improvements in health
  outcomes

                                 Shekell, Morton & Keeler 2006
Electronic Health Records
• Long standing EHR system in primary care
  practices in Denmark
• Admission into hospital automatically triggers
  notification to primary care services
• 50 minutes saved per day in primary care practice,
  telephone calls to hospitals reduced by 66%, and
  €2.3 saved per message, of which there are 60
  million per year.
• The cost of a typical EHR is about €4 (US$6) per
  patient per year, which includes network
  connectivity charges                 Protti & Johansen 2010
Telehealth
• Relative paucity of economic evaluations, or even
  discussion of cost
• Focus on cost offset rather than health benefits
• Systematic review 1990 – 2007 [Bergmo 2009]
• 33 economic evaluations – cost & health outcomes
• Inconsistent use of economic evaluation methods;
  sometimes poorly reported – making comparison
  difficult
• E.g. only 25% looked at costs of lost productivity
The Scottish Telecare Development Programme (TDP)


• Country-wide TDP from 2006.
• 7900 had telecare packages by March 2008.
• Costs avoided of £11 million.
  – increased speed of discharge from hospital once
  – clinical need is met, as well as reductions in unplanned
    hospital and care home
  – admissions, nights of sleepover care purchased, home
    check visits and waking
  – night cover

                                        Beale, Sanderson & Kruger 2009
Decision Support Systems
• Can, if well implemented, improve prescribing practices,
  avert costs and promote better health outcomes
• Model of cost benefit of DSS within acute hospital in
  England. [Karnon et al 2008]
  – Not cost effective if focus solely on health care costs
  – But highly cost saving – £31 million over 5 years if value of health
    losses averted included
• Guideline driven DSS for blood tests in primary care in
  Netherlands [Poley et al 2007].
  – €670 per practice – development & installation costs
  – €847 costs from blood tests avoided in 6 months
Facilitating the
implementation of
cost effective
eHealth interventions
Better use of evidence
• Better synthesis and marshalling a better of
  existing evidence from large scale pilots and
  mainstream implementation - what works, and what
  context.
• Need to strengthen economic case
  – Estimating full costs of implementation, prospective &
    retrospective economic analysis, modelling longer term
    costs and benefits
Changing incentive structures
• Tackling barriers to uptake and co-ordination
  across sectors
• Financial incentives to help encourage uptake
  – E.g. in Denmark physicians and specialists paid for e-
    mail communications with patients. The fee for e-mail
    consultations, which are primarily about lab results, is
    twice that for telephone calls.

• (Voluntary) joint budgeting arrangements – remove
  disincentives to invest across sectors - SOSCAM
  partnerships in Sweden between employment and
  health services
Facilitating implementation
• Establishing mechanisms for awareness raising,
  dialogue and exchange of information
• National health system integrator e.g. MedCom in
  Denmark
• Pursue process-led innovation
  – adaptation or re-engineering of organisational flows,
    involving many professionals, all working for different
    organisations but coming together to offer one
    integrated pathway in health and social care to support
    continuity of care.
• Improving the usability and interoperability of
  technology
In Summary
– Potential for eHealth interventions to aid in better
  integration of care but……
– Need better understanding of evidence and context for
  implementation
– Critical to identify
  • Costs of implementation
  • Costs averted
  • Economic benefits of improved health outcomes
– Economic incentives can be used to influence uptake
– Look to ensure developments are an integral element of
  care delivery process
WHO Health Evidence Network Policy Briefs
                      Series on e-health issues
                      1:3:25 Format
                      Highlight policy challenge
                      Brief review of evidence
                      Sets out policy options
                      indicating strengths and
                      weakness’
                      Look at ways to facilitate
                      implementation in different
                      contexts and systems across
                      Europe

                      http://www.euro.who.int/HEN

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eHealth: what is the potential for better integration, delivery and cost effective care across Europe?

  • 1. eHealth: what is the potential for better integration, delivery and cost effective care across Europe? David McDaid eHealth Week 2010, Barcelona, March 2010 European Observatory on Health Systems and Policies and LSE Health & Social Care, London School of Economics E-mail:d.mcdaid@lse.ac.uk
  • 2. Structure • Challenges to health care systems in Europe • The potential role of eHealth in better integration and delivery of care • Making an economic case for investment • What do we know? • How can economic incentives be used to aid in the facilitation of eHealth solutions?
  • 4. Total health expenditure as % of gross domestic product (GDP) 12 11 Austria Belgium Bulgaria Cyprus 10 Czech Republic Denmark Estonia 9 Finland France Germany 8 Greece Hungary Ireland Italy 7 Latvia Lithuania Luxembourg 6 Malta Netherlands Poland 5 Portugal Romania Slovakia Slovenia 4 Spain Sweden United Kingdom 3 EU 2 1970 1980 1990 2000 2010
  • 5. Population distribution EU25 1950-2050 Source: European Commission 2008
  • 6. 77% of disease burden in Europe on Personal Costs non-communicable, often chronic disease Many socio-economic impacts Educational opportunities curtailed Reduced chances of employment Reduced chances of career progression Impacts on families/informal carers
  • 7. The potential role of eHealth in integration & delivery of care
  • 8. Integrated care • Shared care: integrated care across primary, secondary and specialist care services • Continuity of care: aided by better integration of care delivery between health and non-health sectors – e.g. social care • Person centred: Provision of services that best meet individual needs • Team orientated: Need for collaborative working relationships, frequent communication, and flexibility of practitioners
  • 9. eHealth and Integrated care • Shared electronic health records • Electronic messaging systems • Opportunities for iterative dialogue between clients and physicians • Systems to help facilitate rapid access to clinical services • Telehealth applications to help maintain independence and community based living
  • 10. Hillestad et al , Health Affairs, 2005
  • 11. Making an economic case for investment
  • 12. Economics Economics is an important input into decision making process in health policy Resources are not unlimited; economic information can help determine how best to make use of resources but…… Cannot be used in isolation; many other factors (fairness, equity, political concerns etc) influence decision making
  • 13. Economic questions that can aid decision making • Costs of inaction: What are the economic consequences of not tackling chronic diseases? • Costs of action: What would it cost to intervene by investing in eHealth measures? • Cost-effectiveness of action: What is the balance between what cost to intervene and gains in outcomes, e.g. health status, quality of life etc? • Levers for change: What economic and other incentives can encourage more use of those interventions that are thought to be cost-effective and less use of those interventions which are not?
  • 14. Making the case So is there an economic case for investment in eHealth to promote better integrated care?
  • 15. What do we know? • Mixed evidence base and limited cost data • Potential benefits not just to health sector, but to other payers e.g. social care, social welfare • Evidence for interventions in specific settings and targeted at specific population groups – e.g. diabetes, mental health, high risk pregnancy monitoring, heart failure and cardiovascular disease • Focus on return on investment rather than on health related impacts • US dominated: relatively few studies conducted in other settings; relatively little focus on broader implementation context issues
  • 16. Electronic Health Records • AHRQ systematic review in 2006 • Link between EHR and better performance of providers in 3 US and 1 Dutch Studies • All cost benefit analyses reported substantial savings, but up to 13 years to break even • But conservative: very few studies reported economic benefits from improvements in health outcomes Shekell, Morton & Keeler 2006
  • 17. Electronic Health Records • Long standing EHR system in primary care practices in Denmark • Admission into hospital automatically triggers notification to primary care services • 50 minutes saved per day in primary care practice, telephone calls to hospitals reduced by 66%, and €2.3 saved per message, of which there are 60 million per year. • The cost of a typical EHR is about €4 (US$6) per patient per year, which includes network connectivity charges Protti & Johansen 2010
  • 18. Telehealth • Relative paucity of economic evaluations, or even discussion of cost • Focus on cost offset rather than health benefits • Systematic review 1990 – 2007 [Bergmo 2009] • 33 economic evaluations – cost & health outcomes • Inconsistent use of economic evaluation methods; sometimes poorly reported – making comparison difficult • E.g. only 25% looked at costs of lost productivity
  • 19. The Scottish Telecare Development Programme (TDP) • Country-wide TDP from 2006. • 7900 had telecare packages by March 2008. • Costs avoided of £11 million. – increased speed of discharge from hospital once – clinical need is met, as well as reductions in unplanned hospital and care home – admissions, nights of sleepover care purchased, home check visits and waking – night cover Beale, Sanderson & Kruger 2009
  • 20. Decision Support Systems • Can, if well implemented, improve prescribing practices, avert costs and promote better health outcomes • Model of cost benefit of DSS within acute hospital in England. [Karnon et al 2008] – Not cost effective if focus solely on health care costs – But highly cost saving – £31 million over 5 years if value of health losses averted included • Guideline driven DSS for blood tests in primary care in Netherlands [Poley et al 2007]. – €670 per practice – development & installation costs – €847 costs from blood tests avoided in 6 months
  • 21. Facilitating the implementation of cost effective eHealth interventions
  • 22. Better use of evidence • Better synthesis and marshalling a better of existing evidence from large scale pilots and mainstream implementation - what works, and what context. • Need to strengthen economic case – Estimating full costs of implementation, prospective & retrospective economic analysis, modelling longer term costs and benefits
  • 23. Changing incentive structures • Tackling barriers to uptake and co-ordination across sectors • Financial incentives to help encourage uptake – E.g. in Denmark physicians and specialists paid for e- mail communications with patients. The fee for e-mail consultations, which are primarily about lab results, is twice that for telephone calls. • (Voluntary) joint budgeting arrangements – remove disincentives to invest across sectors - SOSCAM partnerships in Sweden between employment and health services
  • 24. Facilitating implementation • Establishing mechanisms for awareness raising, dialogue and exchange of information • National health system integrator e.g. MedCom in Denmark • Pursue process-led innovation – adaptation or re-engineering of organisational flows, involving many professionals, all working for different organisations but coming together to offer one integrated pathway in health and social care to support continuity of care. • Improving the usability and interoperability of technology
  • 25. In Summary – Potential for eHealth interventions to aid in better integration of care but…… – Need better understanding of evidence and context for implementation – Critical to identify • Costs of implementation • Costs averted • Economic benefits of improved health outcomes – Economic incentives can be used to influence uptake – Look to ensure developments are an integral element of care delivery process
  • 26. WHO Health Evidence Network Policy Briefs Series on e-health issues 1:3:25 Format Highlight policy challenge Brief review of evidence Sets out policy options indicating strengths and weakness’ Look at ways to facilitate implementation in different contexts and systems across Europe http://www.euro.who.int/HEN