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

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:[email protected]

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

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1970 1980 1990 2000 2010

AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited KingdomEU

Total health expenditure as % of

gross domestic product (GDP)

Population distribution EU25 1950-2050

Source: European Commission 2008

77% of disease burden in Europe on 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

Pers

onal

Cos

ts

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 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

Eco

nomics

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?

So is there an economic case for investment in eHealth to promote better integrated care?

Making

the c

ase

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