Presentation carried out by Niels Boye during the presention of MCI Healthy Living in Valencia the 29th Setember, 2011. Healthy Ageing, Chronic Disease Management, and Co-production of Health and Care in the European Union

1. Healthy Ageing,
Chronic Disease Management,
and
Co-production of Health and Care
in the European Union
- seen in a combined
medical and ICT perspective
From Diseases to Health
Niels Boye
Physician, specialist in Endocrinology and Internal Medicine
Klinisk Informatik (ClinicalInformatics.dk)

2. Healthy Ageing,
Chronic Disease Management,
and
Co-production of Health and Care
in the European Union
- seen in a combined
medical and ICT perspective
From pathology-oriented to outcome focused
Niels Boye
Physician, specialist in Endocrinology and Internal Medicine
Klinisk Informatik (ClinicalInformatics.dk)

3. Who Am I
Physician, specialist in Endocrinology and
Internal Medicine with a conventional clinical
and scientific career in biomedicine ending –
at least for now - as head of a evaluation unit for
acute admissions
For more than 15 years active in ICT for Health
Danish Technological Institute , AAL unit
Ambient Assisted Living Joint Programme
The PREVE project

4. Pre –requisites (my interpretation)
Conventional healthcare cannot by organizing the delivery
of care cheaper and smarter, by better coordination and
collaboration – with or without conventional “ICT for Health” -
by (mass)production counteract the challenges in health
and welfare that Western societies are facing
We must provide ways to organize the consumption of care
provisions more intelligent and with higher impact

5. Pre –requisites (my interpretation)
Conventional healthcare cannot by organizing the delivery
of care cheaper and smarter, by better coordination and
collaboration – with or without conventional “ICT for Health” -
by (mass)production counteract the challenges in health
and welfare that Western societies are facing
We must provide ways to organize the consumption of care
provisions more intelligent and with higher impact
as phrased by Mr. Barrosso:
Two more healthy years for European citizens
(in 2020)

6. European Innovation Partnerships on Active and Healthy Ageing
A triple win for Europe
• Enabling EU citizens to lead healthy, active and
independent lives until old age
• Improving the sustainability and efficiency of social
and health care systems
• Developing and deploying innovative solutions, thus
fostering competitiveness and market growth

7. Innovation in support of older
people…
• At Work
– Staying active and productive for longer
– Better quality of work and work-life balance
• In the Community
– Overcoming isolation & loneliness
– Keeping up social networks
– Accessing public services
• At Home
– Better quality of life for longer
– Independence, autonomy and dignity
7

8. AHAIP – what? Main areas of work
Innovation in
Integrated
Care
Innovation in Innovation in
Prevention Active and
and early Independent
diagnosis Living
Communication and Awareness
8

9. AHAIP – The Wider Picture
Active and Healthy Ageing Partnership
 Public Health Programme
JPI
 FP7
Health
Policy Areas
More
  
Years, eHealth action plan

Natio

FP7 Struct
Better CIP eHealth ural nal
Lives eHealth Funds funds
EIB
Ageing well action plan
ESF
FP7 ICT &
Ageing well  AAL
 CIP ICT &
Ageing well
9
Time to market

10. So as my preliminary conclusion
The areas of e-health and ambient assisted living
are attaching increasingly European attention and funding
No new instruments or procedures will be
introduced, integration of health, prevention and
AAL activities are anticipated in broad Joint Programmes
A bureaucratic overhead should ensure a steady course
towards a common vision and recruit the Memberstates
co-funding – on the other hand it might
give a better flow from idea to product in the market
http://ec.europa.eu/active-healthy-ageing

11. PREVE partners
Valtion teknillinen tutkimuskeskus, VTT
Aarhus University
Fondazione Centro San Raffaele del
Monte Tabor
Universidad Politécnica de Valencia
www.preve-eu.org

12. Directions for ICT Research in Disease Prevention
www.preve-eu.org

13. What is a disease ?

14. What is a disease ?
The international
Classification of Diseases
is a continuation
of a classification
of dead-causes -
mainly developed
between 1850-1900
by a series
of international
congresses.
http://www.who.int/classifications/icd/en/HistoryOfICD.pdf

15. 1452- 1519

17. The disease classifications (ICD), coding, grouping,
and “complexity reducing computing”
have been giving much more insight in disease
causes, disease progressions, and abilities in
treatment - but still ON THE GROUP LEVEL
BUT this general computing paradigm will not be
enough to ensure HEALTH on the INDIVIDUAL level
and it will only result in endless discussions
of semantics.
We must turn to
non-complexity-reducing computing

19. WHO definition of Health (1946) (individual level)
“a state of complete physical,
mental, and social well-being
and not merely the absence of
disease or infirmity”

20. Taking offset in the WHO Health definition –
then prevention and procrastination of
disease are meaningful for
Preservation of health, cognitive,
and physical functions
Side remark: An update in the conceptual idea of
diseases as tightly coupled to pathology may be
instrumental
The rest of this talk will be about
The evidences and foundation
How to orchestrate it and the IT?
Potential business models(?)

21. Are there any evidence in the
health dimension?

22. Co-production of Disease Prevention
Connections between Risk Factors and Conditions
Citizen Modifiable Risk Factors
Tobacco smoking Conditions
Citizen Modifiable Risk Factors
Type 2-diabetes
Alcohol consumption
Preventable cancer
Diet
Cardiovascular disease
Physical inactivity
Osteoporosis
Obesity
Non-Modifiable Risk Factors Musculoskeletal disorders
Accidents
Hypersensitivity disorders
Working environment
Mental disorders
Environmental factors
Chronic obstructive
pulmonary disease
Family history and gender

23. Example: Evidence of food having impact in Cardio
Vascular Disease
CVD=Cardiovascular Disease,
CI = Confidence interval
Reduction i CVD
disease risk (%) Reference
(95% CI)
Wine 32 ( 23-41) Circulation 2002;105:2836-44
(150 ml/day)
Fish 14 (8-19) Am J Cardiol 2004;93:1119-23
(114 gr 4x/week)
Dark chocolate 21 (14-27) JAMA 2003;290:1029-30
(100g/day)
Fruit and vegetables 21 (14-27) Lancet 2002;359:1969-74
(400 g/day)
Garlic 25 (21-27) Arch Intern Med 2001;161:813-24
(2.7 g/day)
Almonds 13 (11-14) Circulation 2002;106:1327-32
(68 g/day) Am J Clin Nutr 2003;77:1379-84
Combined effect 76 (63-84)
Franco OH et al. BMJ 2004;329:1447-50.
A “polymeal” of the above would cost 21.60 Great British Pounds per week (2004)
and give an average increase in life expectancy of 6.6 years for men and 4.8 years for women
And give men 9.0 years more life without heart disease for women (8.1 years).

24. Impact of medical evidence

25. Was it Insulin, the proactive care model
or the personification that did the job?
YES, all of them
(except maybe INSULIN per se)

26. ICT for health?
Let’s look at telemedicine first

28. We identified 53 systematic reviews that focused on
assessing the impact of eHealth interventions on the
quality and/or safety of health care and
55 supplementary systematic reviews providing
relevant supportive information.
(approximately 46.000 primary papers)

29. We found that despite support from policymakers,
there was relatively little empirical evidence to
substantiate many of the claims made in relation
to these technologies.

30. Whether the success of those relatively few
solutions identified to improve quality and safety
would continue if these were deployed beyond the
contexts in which they were originally developed,
has yet to be established.
Importantly, best practice guidelines in
effective development and deployment
strategies are lacking.

31. Whether the success of those relatively few
solutions identified to improve quality and safety
would continue if these were deployed beyond the
contexts in which they were originally developed,
has yet to be established.
Importantly, best practice guidelines in
effective development and deployment
strategies are lacking.

32. Conclusions: There is a large gap between
the postulated and empirically demonstrated
benefits of eHealth technologies.......
In the light of the paucity of evidence in
relation to improvements in patient outcomes,
as well as the lack of evidence on their cost-effectiveness,

33. So the conclusion must be –
we should do something else and in another way.
We will come back to this.............

34. The Present Digital Health
“Biological age” (“years”)
Demand-side 100
AAL
Supply-side Driven
0 100 %
(100% Patient
Citizen)
Prevention Tele
med
0

35. The Citizen as Co-producer of Health –
enabled by ICT
Health Service Delivery
Citizen as proactive subject
Client Centred Approach
Patient Centred Medicine Citizen as co-Producer of Health
Disease prevention
Disease compensation
PREVE (Disease cure)
Models & Concepts
Assisted living
Maturity of ICT
User as Operator
Expert Systems User as User
Corporate Centred Contemporary Layman Systems
State of the Art Individual Centred
Ambient Assisted Living
in ICT and
Empowerment
Citizen as object

36. The Digital Health Continuum
100% 100 %
Citizen Patient
Synergism?
Impact
Impact ?
70% of chronic diseases are preventable
70% of healthcare activities (costs) are spend on chronic diseases
Chronic non-communicable diseases and conditions are much more prevalent among older
citizens
SYNERGY OF PHARMACUTICALS AND COPRODUCTION OF HEALTH HAVE POTENTIAL OF A HIGH
IMPACT IN THE OLDER SEGMENT OF SOCIETY
Contemporary health provision service model
Citizen as Co-producer of Health (CPH)

37. The Digital Health Continuum
100% 100 %
Citizen Patient

38. Special
Preven- AAL Chronic Tele- Health legal and
tion Disease medicine Care
and
regulatory
Profes-
Lifestyle Shared sional issues
Change Management apply
Management
D D
Know-
D D ledge
Society Hospital

39. The Co-production Service
Architecture (eco system)
diabetes as example
General Super-
Practice market
Specialist- Restaurant
centre
Car
Pharmacy
Farm
Museum
Hospital
Home Sports centre Work
Next section: Models and information flows

40. Co-production – a formal definition
Coproduction of health is a term we use to represent
that health considerations and knowledge can be embedded
and utilized in any activity in society and
that synergies between professional healthcare,
selfcare, informal care, and commodity will be turned
into “health added value”.

41. Co-production – a formal definition
Coproduction takes place in an “ecosystem”,
which is cross-sectional to the formal organisation
of society. In the eco-system are formed
“value networks” that share information resources
and can generate the “value propositions”
which are the basis of the “business models”
that fund the services delivered and consumed by
citizens (consumers, not patients).

42. Co-production – formal
In “Governance for health in the 21st century: a study
conducted for the WHO Regional Office for Europe”
(dated 18th of August and presented in the 61th
session at Baku, Azerbaijan, 12–15 September 2011) -
coproduction of health is seen as one of the main
pillars of future healthcare.

43. Co-production (Sweden)
Co-production means plugging into a service
the knowledge, energy and commitment of its
users and those close to them, who really
understand and care about the service.
This means treating users and communities as
assets, not obstacles.
In this way, co-produced services can produce
more of the outcomes that really matter to users.

44. Data–Information–Knowledge-
Decisions
• Data is a simple value-set without context, than can be stored and
exchanged electronically - if there is technical interoperability e.g. 130/95
• Information is a simple message where the value-set is provided a
predefined context. Information can be exchanged electronically if there is
semantic interoperability (e.g. blood pressure measured to the value of 130/95 mmHg)
• Knowledge is information provided a dynamic personal and
organisational context and in relations to other knowledge. Knowledge can
be utilized and exchanged using computer-models and ontologies (e.g.
blood pressure of 130/95 is abnormal i for Peter a 25 year old diabetic patient)
• Decisions are made on the basis of knowledge
www.preve-eu.org

45. The Personal Guidance Systems
Service model
diabetes as example
Commodity service providers
Information
Health providers
Knowledge
Personal
Data device
Exercise
Diabetic

46. The Machine-room of the “Citizen as
Co-producer of Health”
the ECO-system building blocks
Political, social, economic
Co- Choice
producers architectures
Data
Information HealthGPS
(digital avatar)
Knowledge access
Platform services (security, ID)
PHR

47. Choice architectures embody the regulations, policies,
and incentives at societal level
Co-production / ecosystem / value networks / business
models are where services are delivered and consumed
by citizens (consumers, not patients)
ICT enables and supports this

48. B
Example GPS
A Analogue problem
A-D transformation
Digital model representation
Calculation
D-A transformation
Analogue presentation (map)
Decision support

49. Skagen, Denmark
year 2017

50. Childrens menu

53. Decision support (information flows)
Clinical Data- and
Information
encounter
flow
EHR
HMO/ Research/
Region Pharmaceutical Co Health-PGS
Quality Virtual Individual Model
Assurance Digital avatar
Healthcare
Co-production
Research Hospital Patient-NGO/
Trusted information banker and
brooker

54. Infrastructure

55. Platforms and
databases

56. Customization:
App-store
Virtual Individual Model

57. But what is healthcare actually “selling”

58. Knowledge
Philosophical Abstract models,
theories, paradigms
layer
(abstract)
Heuristic
Mechanisms, archetypes, patterns
layer methods
(general)
Phenomenological
layer Phenomenons, problems, acts
(specific)

59. In storytelling
Philosophical Philosophy, hate, life, love,
layer and death
(abstract)
Heuristic
layer Stereotypes, story-type
(general)
Phenomenological
layer Action, plot, story line
(specific)

61. Knowledge in (western) medicine
Philosophical Pato-anatomical disease model,
layer Gene-theory
(abstract)
Heuristic
layer Diagnoses, Syndromes,
(general) Methods
Phenomenological
layer Patient specific knowledge,
(specific) Acts, Treatments, Observations,
Signs, Symptoms

63. What is a
Healthcare provision
The first public
demonstration of
anaesthesia
16th of October 1846
Detail from a painting
(1882) of Robert Hinckley
Massachusetts General
Hospital, Boston

64. Team
work Knowledge
Manual work
Technology

65. Delivering healthcare and care provisions
in a co-production eco-system
could be “packaged” as:
Knowledge: Evidence based knowledge in activity-related
model based applications
(transition from pathology-focused to activity focused
ICT may also be a good idea in the Electronic Health
Record)
Manual work: professional healthcare, selfcare, informal
care, and commodity actors
Teamwork – communication: Support for the DIGITAL
HEALTH CONTINUUM
Technology: Social technologies (Web2.0)

66. The Age of Networked Intelligence:
1. Openness
2. Sharing
3. Integrity
4. Interdependence
As the characteristics of
legal and security issues

67. Business model framework

68. Messages to take home:
To serve personalized, individual health
needs we should:
Create a parallel information flow
serving an eco-system with model-based
non-complexity reducing computing in
which health is co-produces health
This could create new business opportunities and
lower the total costs of health care, provide
morbidity compression, and hence more healthy life
years

69. Have a happy ageing!