HEALTH GROUPING, EEIGProjecto da Corrida Consulting, Ltd
consensual que o futuro da sade passa pelos Registos Mdicos
Electrnicos (RME) ou Registos de Sade Electrnicos. A adopo desta
tecnologia confronta-se porm com grandes dificuldades que resultam
da ausncia de standards, da resistncia dos mdicos e dos elevados
custos de implementao e de manuteno. Esta resistncia dos
profissionais de sade a utilizarem os RMEs parece resultar dos
elevados custos associados ao software e s redes e ainda a uma
clara diminuio da produtividade, que alguns mdicos estimam em menos
10 a 20% . Novas solues so portanto necessrias. Os programas
residentes na internet web based software e a computao em nuvem,
podem ser a soluo para estas dificuldades. Acresce tambm que todas
as propostas existentes no mercado no se adaptam ao mtodo clnico
(caso a caso) que se aproxima mais da chamada produo por projectos.
Uma proposta inovadora da Corrida Consulting incorporar os
conhecimentos e as ferramentas da gesto de projectos na gesto dos
casos clnicos. Com o Health Grouping, EEIG a Corrida Consulting
procura reunir parceiros interessados em desenvolver uma plataforma
para a sade que integre: a) RME b) Computao em nuvem c) Gesto de
Projectos As empresas a integrar esta EEIG podero candidatar-se a
fundos europeus, para I & D nesta rea, promover standards e
candidatar-se a concursos a realizar dentro e fora da UE,
optimizando recursos e knowhow. Os desafios so grandes e o esforo
de todos bem necessrio. Joaquim S Couto, MD, MBA CEO Corrida
Consulting, Ltd
HEALTH GROUPING, EEIG
Carta de apresentao 1. Infraestrutura de Cuidados de Sade ICS 2.
Health Care Framework HCF 3. Medicina Orientada por Projectos POME
4. Agrupamento Europeu de Interesse Econmico 5. European Economic
Interest Grouping 6. Anexos: a. Overview of International EMR/EHR
Markets Accenture (public domain document) b. Project management
can help to reduce costs and improve quality in health care
services Artigo publicado no JECP
Infraestrutura de Cuidados de Sade Health Care FrameworkMelhor
sade para todos Better healthcare for allA ICS uma ideia inovadora.
O seu objecto o desenvolvimento de uma Infraestrutura digital para
os sistemas de sade, baseada nos princpios da Gesto de Projetos.
Consiste numa plataforma de software, residente na internet
(computao em nuvem ou cloud computing), desenvolvida para armazenar
e processar registos de sade electrnicos (RSE), atravs das
ferramentas da Gesto de Projetos (GP). Este conceito associa, pela
primeira vez, RSEs, a computao em nuvem e a Gesto de Projetos, para
criar uma infraestrutura destinada a gerir a prestao de servios de
sade de acordo com o princpio de que cada caso clnico um projecto e
deve ser gerido como tal (1), para garantir a mxima eficcia e
qualidade. Os RSEs tm um enorme potencial para melhorar a qualidade
dos servios de sade (2,4), mas os benefcios tm sido limitados pelos
custos de administrar grandes redes computacionais e pela
dificuldade de integrar os dados disponveis. A computao em nuvem
pode diminuir os custos do armazenamento das grandes quantidades de
informao gerada pelos RSEs e pode disponibilizar estes dados, de
forma instantnea, a uma escala global e de modo seguro. A computao
em nuvem tambm minimiza os custos do software proprietrio para as
empresas que fornecem servios de sade. Os programas podem ser
instalados na nuvem e operados atravs de thin clientes, web
browsers, tablets e outros dispositivos mveis, sem necessitar de
software local. Esta soluo pode ser utilizada por grandes
organizaes assim como por consultrios, sem os custos punitivos de
uma pequena operao. Uma sondagem efectuada pela Comisso Europeia
(3), em 2007, demonstrou que 87% dos mdicos europeus usam
regularmente computadores e que 48% destes tm ligaes de banda larga
internet facilitando o desenvolvimento e a implementao da ICS.
Finalmente, o conhecimento e as ferramentas da Gesto de Projetos
podem ser utilizados para integrar toda a informao disponvel para
fornecer resultados de excelncia aos doentes, atempadamente, com
controlo de custos e com a mxima qualidade. A Gesto de Projetos uma
componente essencial deste conceito ICS. Uma vez que os resultados
procurados por cada doente so nicos (tal como num projecto), a
adopo de uma produo por projectos tem um enorme potencial para
controlar os custos e, em simultneo, melhorar a qualidade. Os
mdicos e os outros profissionais de sade podem utilizar o ICS para
gerir todas as actividades e processos relacionados com os doentes,
incluindo o planeamento, o agendamento, a monitorizao (ex:
relatrios normalizados, notificaes, alertas, bases de dados
centralizadas), o controle da qualidade (ex: planos de qualidade,
satisfao dos utentes, feedback), critrios de sucesso (ex:
resultados obtidos), tradeoffs entre o custo, o tempo e a
qualidade, e o controle de custos. Modelos de PM (templates) podem
fornecer guidelines aos clnicos. Ao mesmo tempo, a Gesto de
Projetos tambm pode fornecer as ferramentas para comparar
diferentes prestadores de servios, um desafio que at agora, tem
sido praticamente impossvel de atingir. Um estudo recente sobre as
tecnologias de informao na sade, conduzido pelo Center Medicare
Advocacy (4), enunciou os benefcios que se podem obter de um uso
mais intensivo das ITs nesta rea, reconhecendo tambm os obstculos.
Ns pensamos que a ICS pode alavancar os benefcios e reduzir os
obstculos.
Benefcios:1. Diminuir o crescimento da despesa 2. Facilitar a
coordenao de prestao de servios 3. Aumentar a segurana atravs da
Gesto de Doenas 4. Reduzir a sobre utilizao dos exames
complementares de diagnstico 5. Monitorizar e detectar epidemias O
ICS pode reduzir os custos das ITs, em hardware, software e gesto
de redes. Tambm, a adopo da produo por projecto na sade, juntamente
com as correspondentes ferramentas de software, pode facilitar a
coordenao da assistncia mdica, a gesto clnica e o controle de
custos.
Dificuldades:1. 2. 3. 4. Financiar os custos iniciais Criar
formatos normalizados para a partilha de informao Garantir a
confidencialidade e a privacidade do sistema Partilhar o custo da
implementao
Absorver os elevados custos iniciais, partilhar o custo da
implementao e criar formatos estandardizados, est no centro da
computao em nuvem. A ICS, ao adoptar a computao em nuvem,
beneficiaria da experincia acumulada nesta rea. A confidencialidade
e a privacidade podem ser melhor geridas centralmente, em vez de em
pequenas redes. A ICS INFRAESTRUTURA DE CUIDADOS DE SADE pode
representar um paradigma disruptivo para as indstrias da sade,
abrindo caminho para uma concorrncia de soma positiva. A
INFRAESTRUTURA DE CUIDADOS DE SADE tambm se enquadra na economia do
conhecimento, focada no sector tercirio.
ANLISE SWOT:Foras
Melhoria da qualidade dos servios de sade com custos inferiores.
Possvel apoio da UE para melhor integrao dos cuidados de sade na
Europa.
O programa pode ser implementado em fases. Os diversos parceiros
(Hospitais, Companhias de Seguros, etc.) podem ter os seus prprios
workflows e layouts. Fraquezas
Pode suscitar preocupaes sobre a privacidade dos dados. Mtodos
biomtricos para aceder aos registos de sade electrnicos podem ser
usados para ultrapassar esta dificuldade. Oportunidades
A maior parte dos pases esto actualmente a considerar reformas
dos sistemas de sade. Os registos digitais parecem ser a grande
tendncia. A possvel integrao com pacotes de software comerciais,
como por exemplo a Microsoft Project, pode representar grandes
oportunidades de negcio. Ameaa
Arena muito competitiva. Necessrio promover parcerias entre
empresas que se especializaram na gesto da sade, empresas de
hardware, empresas de software e empresas de Gesto de Projetos.
Bibliografia:1. Couto, J.: Project management can help to reduce
costs and improve quality in health care services. J Eval Clin
Pract., Jan; 14 (1): 48-52, 2008
AbstractRationale, aims and objectives
Health care spending has increased steadily over the last 50
years, but there is a consensus that this trend cannot continue
indefinitely. The ideal solution would bring about cost reductions
coupled with improvements in quality, but this has remained an
exclusive goal. In this article, a novel idea is proposed that
consists of adopting a project type of production in health care,
instead of the current mass production methods used in the modern
health care factories.
MethodsThe author demonstrates that health care services in
general and medical services in particular, fit the category of
projects. This is accomplished through a comprehensive study of the
mains features of projects and medical services and comparative
analysis.
Results and ConclusionThe author infers that the productivity
gains by Project management to so many other human endeavors can be
brought to health care. Its also claimed that if project management
were adopted in health care, then physicians would be the natural
project managers because of their proficiency with casuistic method
(one-off, non-repetitive production) and because of their
experience in managing their patients cases that is indeed what
doctors have been doing for as long as their profession exists.
STUDY CONFIRMS PAPERLESS HOSPITALS ARE BETTER FOR PATIENTS.2.
STATEWIDE
Johns Hopkings
Medicine.http://www.hopkingsmedicine.org/Press_releases/2009/01_26_09.htlm
3. What
Percentage of General Practitioners in Europe Use
Computers?Health
Beat.http://www.ihealthbeat.org/data-points/2008/what-percentage-ofgeneralpractitioners-in-europe-use-computers.aspx
4. HEALTH
INFORMATION TECHNOLOGY AS A HEALTH CARE REFORM TOOL.Center for
Medicare
Advocacyhttp://www.medicareadvocacy.org/Print/2009/Reform_09_06.04.HIT.htm
5. Christensen,
C.M.: The Innovators Prescription: A Disruptive Solution
for Health Care. MCGraw Hill, 20046. Porter,
M., Teisberg, E.: Redefining Health Care: Creating Value-Based
Competition Results. Harvard Business Press, 2006
HEALTH CARE FRAMEWORK Project-based Health care FrameworkBy
Joaquim Couto, MD, MBA * Better health care for all
The Health Care Framework (HCF) is a novel idea. Its an object
the development of a new digital framework for health care, based
on the principles of Project Management. It would consist of a
software platform (based on cloud computing) designed to store and
process health care information, together with the management tools
of Project Management. This idea would bring together, for the
first time, paperless medical records, cloud computing and project
management, to build an innovative framework to manage the delivery
of health care services according to the principle that each
patients cases a project and should be managed as such (1), in
order to obtain cost-efficiency gains and ensure the quality of the
results delivered. Digital medical records have a huge potential to
improve the quality of health care services (2, 4), but its
benefits have been hindered by the high costs of running large
computer networks and by the difficulties of integrating the
available data. Cloud computing can minimize the costs of storing
the large amounts of data generated by medical records and it can
make this data available, instantly, on a global scale, in a secure
fashion. Cloud computing can also minimize the costs of proprietary
software for health care providers. Programs can be installed in
the cloud and operated through thin clients, web browsers, and
mobile devices without requiring software installations. A solution
can be used by large organizations as well as by individual
practitioners, without the punitive costs of a smallscale
operation. A survey conducted by the European Commission (3), in
2007, demonstrated that 87% of the European physicians already
use
computers regularly and that 48% have broad band connections,
there by facilitating the development and implementation of the
HCF. Finally, the knowledge and tools of project management (PM)
can be used to integrate all available information, in order to
deliver excellent results to patients, on time, on budget, and with
the highest quality. Project management (1) is an essential and
innovative part of this program (idea).Since the results demanded
by each patient are unique (just like in a project), the adoption
of a project type of production has an enormous potential to
control costs and, at the same time, improve quality. Doctors and
other health care professionals can use the HCF to manage all
patient related activities and processes, including planning,
scheduling, monitoring (ex: standardized reporting methods,
notifications, centralized information bases), qualitycontrol (ex:
means-ends, quality plans, satisfaction, feedback), success
criteria (ex: target achieved, cost-time-quality tradeoffs) and
cost control. PM templates can provide useful guidelines to
practitioners. Simultaneously, PM can also provide the tools to
compare the results obtained by different providers, a challenge
that, so far, has been almost impossible to achieve. A recent study
about health information technologies, conducted by the Center for
Medicare Advocacy (4), listed the benefits that can be accrued by a
more intensive use of its in healthcare, as well as recognizable
obstacles. We find that HCF can leverage the benefits and greatly
minimize the obstacles.
Benefits:1. Slowing Growth in Health Care Expenditures 2.
Facilitating Care Coordination 3. Increasing Patient Safety
Managing Chronic Conditions 4. Reducing the Over utilization of
Laboratory Testing and Imaging Services 5. Monitoring and Detecting
Disease Outbreaks The HCF can reduce it costs, with hardware,
software and management of the infrastructure. Also, the adoption
of a project production in healthcare, together with the necessary
software tools can facilitate care coordination, disease management
and cost control.
Obstacles:1. 2. 3. 4. Absorbing High Start-Up Costs Creating
Standard Formats for Data Sharing Assuring Confidentiality and
Privacy of HIT Systems Sharing the Cost of Implementation
Absorbing high start-up costs, sharing the cost of
implementation and creating standard formats, is at the very core
of cloud computing. Therefore HCF would definitely minimize these
obstacles. Confidentiality and privacy can be managed more
professionally in a centralized manner than in multiple small
networks. The HCF or HEALTH CARE FRAMEWORK can offer a new paradigm
for the Health Care Industries, disrupting the status quo (5) and
paving the way for a positive sum competition (6). The HEALTH
FRAMEWORK is also an idea that fits the profile of the knowledge
economy, focused on the tertiary sector. It can generate highly
skilled jobs and create value through innovation.
SWOT Strengths Better quality health care with lower costs.
Possible EU support for health care integration in the EU. Program
can be implemented in phases.Different customers (hospitals,
insurance, etc) can have their own work flows and layouts.
Weaknesses Need to be careful about privacy concerns. Biometric
data could be used to access medical records and overcome this
difficulty. Opportunities Most countries are currently reforming
their health care systems. Paperless seems like the trend. Possible
integration into software packages like Microsoft Project can be
business opportunities. Threats Competitive field .Possible needs
to bring together different companies that are specialized in
health care management, hardware, software and Project
Management.
References:1. Couto, J.: Project management can help to reduce
costs and improve quality in health care services. J Eval Clin
Pract., Jan; 14 (1): 48-52, 2008
AbstractRationale, aims and objectives
Health care spending has increased steadily over the last 50
years, but there is a consensus that this trend cannot continue
indefinitely. The ideal solution would bring about cost reductions
coupled with improvements in quality, but this has remained an
illusive goal. In this article, a novel idea is proposed that
consists of adopting a project type of production in health care,
instead of the current mass production methods used in the modern
health care factories.
MethodsThe author demonstrates that health care services in
general and medical services in particular, fit the category of
projects. This is accomplished through a comprehensive study of the
main features of projects and medical services and a comparative
analysis.
Results and ConclusionThe author infers that the productivity
gains brought by project management to so many other human
endeavors can be brought to health care. Its also claimed that if
project management were adopted in health care, then physicians
would be the natural project managers because of their proficiency
with the casuistic method (one-off, non-repetitive production) and
because of their experience in managing their patients cases that
is indeed what doctors have been doing for as long as their
profession exists.
2.STATEWIDE STUDY CONFIRMS PAPERLESS HOSPITALS ARE BETTER FOR
PATIENTS.Johns Hopkins Medicine
http://www.hopkinsmedicine.org/Press_releases/2009/01_26_0
9.html
3. What Percentage of General Practitioners in Europe Use
Computers?Health beat.
http://www.ihealthbeat.org/data-points/2008/whatpercentage-ofgeneral-
practitioners-in-europe-usecomputers.aspx
4.HEALTH INFORMATION TECHNOLOGY AS A HEALTH CARE REFORM
TOOL.Center for Medicare Advocacy.
http://www.medicareadvocacy.org/Print/2009/Reform_09_06.0 4.HIT.htm
5. Christensen, C.M.: The Innovator's Prescription: A Disruptive
Solution forHealth Care. McGraw Hill, 2004 6.Porter, M., Teisberg,
E.: Redefining Health Care: Creating Value-BasedCompetition on
Results.Harvard Business Press, 2006 *Author:Joaquim S Couto MD,
MBA Av. da Boavista, N. 117 Sala 301 4050-115 Porto Portugal +351
962094454 [email protected]
Corridaconsulting
POMEProject Oriented Medicine
CORRIDA CONSULTING
Avenida da Boavista | 117 | 3 | sala301 | 4050-115 Porto
|Portugal Telefones [+351] 226 005 446 / 447 | Fax [+351] 226 004
913 E-mail: [email protected]
POME Project Oriented MedicineA sade est em crise. Uma crise
profunda e, at agora, sem fim vista, condicionada por factores de
natureza poltica, econmica, social e tecnolgica. As populaes, nos
pases ocidentais, tm expectativas de acesso universal e geral a
cuidados de sade, gratuitos ou tendencialmente gratuitos na sua
prestao. Ainda, exigem a eliminao das listas de espera e a garantia
total da qualidade dos servios prestados. Os Governos tm procurado,
at ao limite, satisfazer estas expectativas, mas o impacte econmico
dos programas assistenciais pblicos acaba por se reflectir
negativamente noutras reas de investimento, obrigando a escolhas
politicamente complicadas e onerosas. Basta pensarmos que os custos
com a sade j atingiram 10% a 15% do PIB, nos pases desenvolvidos,
para compreendemos, de imediato, a situao. Fenmenos de natureza
demogrfica e social afectam tambm este quadro. O envelhecimento das
populaes sobrecarrega os sistemas de sade, porque os seniores
necessitam de mais servios e at de servios mais dispendiosos. Por
outro lado, a imigrao para a EU de milhes de indivduos, sem os
quais a nossas economias estagnariam, colocam desafios adicionais
que se traduzem em custos. A vertiginosa evoluo tecnolgica outra
vertente que no podemos esquecer porque afecta o tempo de vida dos
equipamentos e o seu perodo de amortizao, assim como obriga a
despesas constantes de formao. Torna-se portanto prioritrio
assegurar a eficcia de cada euro gasto na sade, de modo a obter o
mximo de produtividade, com a melhor qualidade e ao mais baixo
custo possvel. Esta perspectiva, sobre a qual no pode deixar de
existir consenso, levou-nos a inquirir sobre a melhor forma de
organizar a produo de servios de sade. A POME ou Project Oriented
Medicine uma proposta de optimizao da produo de servios de sade
atravs da
adopo dos conhecimentos e tcnicas do PM Project Management
(Gesto de Projectos) pelas unidades de sade. A ideia original foi
divulgada num artigo publicado no Journal Evaluation in Clinical
Practice, da Blackwell, de 2006, da autoria Joaquim S Couto, com o
ttulo Project management can help reduce costs and improve quality
in health care services (Anexo Neste texto analisaremos o contedo
desse artigo e abordaremos aspectos prticos na adopo do PM na sade.
of de to I). os
A GESTO DE PROJECTOS PODE AJUDAR A REDUZIR CUSTOS E A MELHORAR A
QUALIDADE DOS SERVIOS DE SADENeste artigo so analisados os diversos
tipos de produo de bens e servios para se defender a tese de que s
a produo por projectos se adequa bem sade. So definidos os
conceitos bsicos, as competncias essenciais que devem ter os
gestores de projectos e ainda so dados exemplos de como o PM se
pode integrar na gesto mdica. O autor critica tambm as correntes
que propem a massificao da produo dos servios de sade e afirma que
embora os servios de sade de destinem a grandes massas, seria
contraproducente tentar produzi-los em massa. A produo, a
transformao de inputs em outputs, tem sido genericamente
classificada em produo em massa, por lotes ou por projectos. A
produo em massa, tipificada na produo do Ford Modelo T,
caracterizada pela produo de grande nmero de itens idnticos. A
produo por lotes ocorre quando a procura impe a modificao dos
outputs a intervalos previsveis. Por exemplo, na produo de papel
para paredes; a produo pra, os equipamentos so reconfigurados e a
produo de novo retomada sem quebrasat prxima reconfigurao. A produo
por projectos usada para itens individuais que s so produzidos uma
vez. A organizao da Expo 98 ou de um aeroporto so exemplos
grandiosos deste tipo de itens, mas os mesmos conceitos podem ser
aplicados a quaisquer produtos nicos.
ProjectosO Project Management Institute (PMI), no Project
Management Book of Knowledge (PMBOK 2004), define um projecto como
uma tarefa temporria, efectuada para criar uma tarefa temporria,
efectuada para criar um produto, servio ou resultado nico.
Temporrio significa que cada projecto tem um princpio e um fim
definidos. No se refere durao do projecto mas apenas afirma que um
projecto no um esforo continuado, finito! Como, por exemplo, a
construo de uma casa que tem de ser concluda entregue no prazo
estipulado, no oramento estipulado e de acordo com as especificaes
constantes no caderno de encargos. As equipas que se formam
para
executar um projecto dissolvem-se quando o projecto termina e so
afectadas a outras actividades ou projectos. nico, refere-se
singularidade do projecto e no significa a ausncia de elementos
repetitivos. Na construo de uma casa h muitos elementos repetitivos
mas o projecto nico porque tem clientes diferentes, a localizao
diferente, os fornecedores podem ser diferentes, etc. O
desenvolvimento progressivo definido outra caracterstica dos
projectos que resulta da sua natureza temporria e nica. Progressivo
significa que se desenvolve por etapas e por incrementos sucessivos
(PMBOK 2004). Por exemplo, numa casa o projecto pode iniciar-se
apenas por uma localizao e medida que a equipa responsvel vai
conhecendo melhor os objectivos do projecto e os requisitos
essenciais. Neste sentido, estritamente tcnico, os servios de sade
so projectos. Todos so temporrios porque tm um princpio e fim bem
definidos, todos so nicos porque os doentes so uma singularidade e
todos se desenvolvem progressivamente, medida que os tcnicos se vo
inteirando do caso e delineando o espectro de resultados desejveis
para a situao clnica em causa. Um programa um conjunto de projectos
orientados para a obteno de certos objectivos comuns. No caso da
sade, tratar um doente, por exemplo, com obesidade pode ser um
projecto. Contudo, um programa para combater a obesidade numa
determinada populao envolve, normalmente, um conjunto de
projectos.
Gesto de ProjectosA gesto de projectos (PM) a aplicao de
conhecimentos, competncias, ferramentas e tcnicas aos processos
(actividades) do projecto com vista a assegurar os cumprimentos dos
seus requisitos (PMBOK 2004). O gestor de projectos a pessoa
responsvel por levar a bom termo o projecto. Segundo o PMBOK, gerir
um projecto inclui: 1.Identificar os seus requisitos 2.Estabelecer
objectivo claros e realistas
3.Balancear o espectro do projecto contra os requisitos de
qualidade, tempo e custo 4.Adaptar as especificaes e planos s
expectativas dos diferentes Stakeolders
Competncias especficasOs conhecimentos, mtodos, ferramentas e
competncias do PM esto bem documentados e so do domnio pblico.
Contudo os especialistas em PM sublinham que as equipas que gerem e
executam projectos devem ter conhecimento que abranja: 1. 2. 3. 4.
5. O chamado Project Management Body of Knowledge Conhecimentos da
rea especfica de aplicao do projecto Compreenso do contexto do
projecto Conhecimentos e competncias genricos de gesto Competncias
relativas ao relacionamento interpessoal
Entre as ferramentas e tcnicas especificas do PM (competncias
especificas) til destacar brevemente algumas, como a chamada
estrutura de decomposio do trabalho (WBS) ou Work Break Down
Structure, o mtodo o caminho critico (CPA) ou Critical Path
Analysis, para percebermos com se podero aplicar sade. O WBS uma
decomposio hierrquica do trabalho a efectuar pela equipa de
trabalho, orientada pelos respectivo requisitos, para atingir os
objectivo do projecto. Simplificando, uma decomposio de todo o
trabalho a efectuar em pequenos pacotes mais gerveis, isto , mais
fceis de executar e controlar. Este procedimento permite que cada
pacote do WBS seja oramento e sequenciado num diagrama que
explicite possveis dependncias lgicas. O CPA um mtodo, desenvolvido
pela DuPont, para analisar diagramas de execuo de projectos e
calcular possveis datas precoces de incio e concluso de pacotes de
actividades e possveis datas tardias de incio e concluso dos mesmos
pacotes. Pacotes, ou actividades, sem tempo de sobra, isto , sem
intervalo entre a data de incio precoce e a data tardia de concluso
definem um caminho
crtico. Qualquer atraso na execuo de uma tarefa que se encontre
no caminho crtico afecta o prazo e o oramento do projecto. A EVA um
processo de monotorizao da execuo de projectos que determina
desvios no prazo ou no oramento de um projecto. um mecanismo de
controlo. Apesar de todos o projecto serem nicos, possvel recorrer
a algoritmos e solues pr-formatadas de sucesso comprovado que
correspondam s melhores prticas. Durante todo o ciclo da vida do
projecto, as variveis interdependentes: tempo, custo e qualidade,
tm de ser equilibradas e o melhor resultado possvel , por sim
dizer, o ponto de equilbrio perfeito.
Aplicao sadeUma vez que os servios de sade so, tecnicamente,
projectos legtimo inferir que possvel obter ganho de produtividade
na sade pela adopo das tcnicas e ferramentas do PM . No artigo
referido apresentado o exemplo de um doente com varizes primrias
dos membros inferiores e o projecto do respectivo tratamento.
definido o mbito do projecto, o WBS, a CPA e a EVA.O mbito do
projecto discutido abertamente com o doente/cliente. Quais sos os
objectivos a atingir e como ir ser avaliado a sucesso do projecto.
Por desenvolvimento progressivo encontrada uma soluo para o caso
especfico em anlise. A partir dessa soluo elaborada uma WBS, a CPA
e estimado um prazo e um oramento. As ferramentas de controlo de
execuo permitem alertar para possveis desvios e para as necessrias
correces. No paradigma actual os tcnicos de sade preocupam-se
apenas com a qualidade dos servios e, mais recentemente, com a
produtividade dos departamentos funcionais em que operam. No
sistema POME, so introduzidas e adicionadas as variveis tempo e
custos de modo a conseguir a equilbrio ideal.
No paradigma actual um doente com varizes adicionado lista de
espera e a performance da unidade funcional (Departamento de
Cirurgia) avaliada pelo nmero de intervenes efectuadas, na unidade
de tempo (ex.: Por ano). No sistema POME a soluo encontrada pode
ser melhor adaptada a cada caso em anlise. Muitos doentes com
varizes apenas pretendem conhecer os riscos que correm e, quando no
correm riscos significativos, muitas vezes optam por no se submeter
a qualquer tratamento. Outros necessitam de intervenes cirrgicas,
mas sem urgncia e estas podem ser marcadas a longo prazo, com
significativa poupana de recursos. Ainda, outros necessitam de
intervenes urgentes e no devem ir para quaisquer listas de espera.
No POME, a produtividade e o sucesso no so avaliados em funo do
output funcional, mas sim em funo da concluso com sucesso do
projecto. A avaliao da performance das unidades de sade pela
produtividade funcionais agrava custos e compromete o sucesso dos
projectos, em particular os prazos e a qualidade. Como Michael
Porter afirma, no seu livro Redefining Health Care, em sade os
resultados devem ser avaliados ao longo de todo o ciclo de
tratamento e no por intervenes discretas.
Experincias pilotoA nica experincia conhecida, at data, de
utilizao do PM em servio de sade, foi efectuada em Nova Iorque, por
David Kaufman (Anexo II), para avaliar se estas tcnicas tm
capacidade para auxiliar a garantir que os perodos de internamento
no excedem os previstos nas tabelas de GDHs (Grupos de Diagnstico
Homogneo). O mtodo de David Kaufman, designado Project Rounds, uma
aplicao do PM, que privilegia a varivel tempo, como elemento de
sucesso. O mtodo compreende: 1.Avaliao clnica 2.Planeamento
3.Agendamento 4.Monotorizao e controlo
Os resultados, embora preliminares, permitiram concluir que o PM
pode contribuir para optimizar os cuidados de sade a doentes
internados e, talvez mais importante, determinar que os tcnicos de
sade, em particular os mdicos, se adaptam com facilidade aos novos
mtodos de trabalho.
Evoluo na continuidadeO POME no obriga a rupturas, oferece, pelo
contrrio uma nova perspectiva de anlise dos problemas de sade e o
potencial de fazer mais e melhor com os mesmos ou at com menos
recursos. O paradigma actual de prestao de cuidado de sade fixou-se
na qualidade de servio prestados e na produtividade das unidades
funcionais, menosprezando olimpicamente a variveis custo e tempo. O
contributo do PM integrar, em equilbrio, a qualidade, os custos e o
tempo, de modo a oferecer servios que correspondam e satisfaam a
necessidades dos doentes/clientes. Esta nova viso permite novas
estratgias para a rea de sade, tanto no sector pblico comono
privado, e a implementao de medidas de gesto que eliminem
conflitos, alinhem interesses e, em ltima anlise, vo ao encontro
dos desafios que se colocam. As organizaes funcionais dos chamados
hospitais-fbrica (R.Herzlinger) no do a resposta necessria, porque:
1.So pouco flexveis 2.Isolam a gesto dos profissionais 3.Isolam as
diferentes unidades funcionais, entre si 4.Esto desadequadas a um
fluxo de trabalho descontnuo e muito variado 5.As hierarquias tm
tendncia a bloquear a realizao de projectos 6.Esto demasiado
focadas sobre o output funcional 7.No permitem a formao de equipas
transversais 8.Ignoram os custos e o tempo que leva cada projecto
9.Alimentam o chamado pensamento de grupo 10.No exploram a
multidisciplinaridade
11.No tm uma cultura de risco 12.No conseguem nivelar a utilizao
de recursos, precavendo-se para situaes de maior procura com
excesso de capacidade, custa de downtime quando esta decresce. O PM
supera estas dificuldades: 1.Designando claramente os responsveis
pelo sucesso dos projectos 2.Atravs de matrizes de responsabilidade
(TRM Task Responsability Matrix) 3.Com equipas multidisciplinares
coesas 4.Definindo as actividades crticas para o sucesso do
projecto 5.Eliminando as barreiras funcionais 6.Nivelando a
utilizao de recursos 7.Partilhando a utilizao de equipamentos
8.Trabalhando com oramentos e analisando prospectivamente os custos
9.Analisando a relao tempo/custo 10.Focando no verdadeiro da
qualidade 11.Alinhando o interesses do decisores com o interesse
dos clientes 12.Apostando na formao contnua.
O PROJECT MANAGEMENT MATURITY MODEL (PMMM) A MUDANAA adopo do PM
na sade constitui uma mudana estratgica que ter melhores
possibilidades de sucesso se for planeada segundo os modelos
comprovados. Atendendo a que a gesto de sade tem pouca experincia
com a gesto de projecto, sugerimos que a mudana para o POME siga um
modelo faseado, como o PMMM Project Management Maturity Model de
HarolKerzner, do International Institute for Learning, Inc. Neste
modelo, a excelncia em PM atinge-se em cinco fases: 1. 2. 3. 4. 5.
Linguagem comum Processos comuns Metodologia singular Benchmarking
Melhoria contnua
Linguagem comum (Durao de meses at 1 a 2 anos) a fase em que a
organizao acorda para o PM! O principal objectivo desta fase a
formao. A formao deve incluir todos os funcionrios da empresa e
inicia-se com a gesto. Os executivos podem necessitar de cursos
mais aprofundados, que em regra envolvem uma semana de formao
contnua. Nesta fase, em que se desenvolve uma linguagem tcnica
comum, quando surge, a maior parte das vezes, a maior resistncia
mudana.
Processos comuns (Fase que se sobrepe e contnua a fase
1)Reconhece-se a utilidade do PM, a todos os nveis da organizao, e
a necessidade de sistematizar processos, controlar custos e
equilibrar a qualidade com o tempo e os custos. Segundo H.Kerzner
esta fase tem um ciclo de vida que passa pelas fases: a)
embrionria, b)aceitao pelo executivo, c)maturidade, d)crescimentoe
e)aceitao pelos operacionais.
A principal resistncia encontrada nesta fase que a metodologia
do PM pode ser percebida como perda de flexibilidade e capacidade
de adaptao. Outra resistncia significativa aparece quando se
procura introduzir um processo de contabilidade horizontal.
Metodologia singular (Durao varivel, atingindo vrios anos) a
fase em que os interesses do todo so aceites e reconhecidos como
tendo prioridade sobre os interesses funcionais. Tanto quanto
possvel devem ser adoptados os mesmos mtodos em todas as
actividades da organizao de modo a criar sinergias e uma cultura de
cooperao, com forte apoio da administrao. Adopta-se o chamado PM
informal, baseado em directivas gerais, em vez de procedimentos
rgidos. Continua a formao e treino em PM e exalta-se a excelncia
comportamental, reconhecendo as diferenas entre os comportamentos
que se adaptam linha de montagem e os que se adaptam ao PM (sic)
.
Benchmarking processo de comparar continuadamente as prticas da
organizao com a melhores prticas globais na mesma ou noutras
indstrias (sic).O objectivo procurar uma melhoria contnua. Passa
por estabelecer um centro de excelncia em PM ou um PM Office e
focar sobre o benchmarking quantitativo (processos e metodologias)
e qualitativo (cultura).
Melhoria continuaNesta fase incorporam-se os resultados do
benchmarking no planeamento e implementao de melhorias, para
assegurar a excelncia da organizao e as vantagens competitivas
resultantes dessas excelncias.
OCEANO AZULA adopo da POME constitui uma mudana significativa
para as organizaes e um impacto enorme nas respectivas culturas. As
dificuldades e os problemas no devem contudo ofuscar as
oportunidades que se abrem, em territrios pouco navegados e sem
competio. O que Chan Kim e Rene Mauborgne chamam oceanos azuis.
CONCLUSOH uma crise na sade, que se manifesta em todos os pases
ocidentais. Trata-se de uma crise com mltiplas origens e que
obviamente no se vai desvanecer com nenhuma soluo milagrosa. Esta
crise obriga, porm, a examinar o modo como os cuidados de sade so
produzido e a introduzir, sempre que possvel as melhorias
necessrias, para conseguir melhor eficcia. Neste texto introduzido
um conceito novo, a POME, como proposta para melhorar a produo dos
servios de sade. uma proposta inovadora que parte de uma reflexo
sobre a natureza dos servio de sade, enquanto objectos de produo e
estabelece o seu enquadramento adequado numa produo por projectos e
no, como tem vindo a ser tentado no ltimos anos, numa produo em
massa, em organizaes compartimentadas segundo funes. ainda sugerido
um meio para adoptar a metodologias do PM na sade. O PMMM. Em ltima
instncia as solues a adoptar dependero de cada organizao, das suas
vises, objectivos e estratgias. A finalidade deste texto dar
continuidade ao artigo original da autoria de Joaquim S Couto e
abrir as portas da POME a todos os que se interessam por estes
assuntos.
Leituras sugeridas:Anexo I Couto, JS: Project management can
help to reduce costs and improve quality in healthcare services.
Accepted for publication in 2006, JECP Anexo II Kaufman, D: Using
project management methodology to plan and track inpatient care.
http://www.jcrinc.com /11375/ Sites: PMI http://www.pmi.org APOGEP
Associao Portuguesa de Gesto http://www.apogep.pt/ Livros Porter,
M. e Teisberg, E.: Redefining Health Care, Harvard Press 2005
Herzlinger, R. Et al: Consumer Driven Health Care, Harvard Press
2004 Kerzner, H.: Using the Project Management Maturity Model,
Wiley 2005 PMBOK 2004: PMI
PROJECT MANAGEMENT CAN HELP TO REDUCE COSTS AND IMPROVE QUALITY
IN HALTH CARE SERVICESBy Joaquim Couto, MD, MBA Management is the
art of getting things done through people-Mary Parker Follet
AbstractHealth care spending has increased steadily over the
last fifty years but there is a consensus that this trend cannot
continue indefinitely. The ideal solution would bring about cost
reductions coupled with improvements in quality, but this has
remained an illusive goal. In this article a novel idea is proposed
that consists of adopting a project type of production in health
care, instead of the current a project type of production in health
care, instead of the current mass production methods used in the
modern health care factories. The author demonstrates that health
care, instead of the current mass production methods used in the
modern health care factories. The author demonstrates that health
care services in general, and medical services in particular, fit
the category of projects and, therefore, infers that the
productivity gains brought by project management to so many other
human endeavors can be brought to health care. The author also
claims that if project management is adopted in health care, then
physicians would be the natural project managers because of their
proficiency with the casuistic method (one-off, non-repetitive
production) and because of their experience in managing their
patient s cases that is indeed what physicians have been doing for
as long as their profession exists.
IntroductionPhysicians are true managers. They are managers not
only because they master the art of getting things done thought
people, to use to beautiful words of Mary Parker Follet (Follet
1982), but also because, physicians devote most of their practice
to setting goals and allocating resources, to achieve them, in the
most efficient and judicious possible. Physicians have managed
their patients (clients) cases for centuries with great success.
Over the last fifty years, however, a revolution occurred in health
care. Medical specialization drove physicians away from their
management responsibilities and attracted them to more operational
duties. At the same time, professional managers, highly concerned
with the bottom line, made their appearance in the health care
scene because of the huge capital investments necessary for health
care facilities to continue offering the latest medical technology.
The result was the emergence of the modern health-care factory, a
highly bureaucratic facility with a functional structure run by
command and control, more focused on productivity ratio than on
customer satisfaction. With our modern and sophisticated
health-care factories, are we better off today? Life expectancy has
never been so high, but there is disillusionment amongst health
care workers and, most alarmingly, governments and think tanks
consider that the current health care provision system are
unsustainable, and agree that changes are necessary. Sending in
health care, which varies between 8 and 14% of GDP in most western
countries, cannot continue to grow indefinitely (Herzlinger
2004).Costs have to be slashed, but managers bleakly wonder why?
Rationing health care? Compromising quality? The ideal solution
would reduce costs whilst improving quality, but this has remained
as illusive goal. Regina E. Herzlinger (Herzlinger 2004), of
Harvards Business School Health Care Initiative, thinks that the
solution to this conundrum will only emerge with the implementation
of consumer driven health care systems. She reminds those in doubt
that most experts also scoffed at Henry Fords promise to improve
both costs and quality in
automobiles, and id it! How? Though mass production - Focusing
on production, with an early stage focused factory and an
integrated system. In her vision, focused health-care factories,
like the Shouldice clinic, in Canada, can do the trick and help
improve both costs and quality in health care. Clearly, this sounds
like a passionate defense of more mass production in health care.
Unfortunately, I fear that dead white men like Mr. Taylor or Mr.
Ford will not be able to help us, because their time and motion
studies or the assembly line have a rather limited use in medicine.
The casuistic approach used by physicians does not permit the
standardization of processes necessary for mass production (Tonelli
2006, Miles et al 2006). Production, the transformation of inputs
into outputs, has been generically classified into three categories
mass production, batch production and project production. Mass
production, typified in the production of Ford Model T, is
characterized by the production of a large number of identical
items. Batch production is used when outputs are required to be
modified at specific intervals to accommodate particular market
demands, like the color and texture of wallpaper. When changes
become necessary the production system is shut down, retooled and
reconfigured, and the process started up again to produce the next
batch. Project production is used for one-off, individual items. As
a result of this singularity, there is no previous learning curve
on which to rely and high levels of complex management planning and
control may be required (Roberts et al 2004).Building a house, for
instance, falls within this latest category because of the
uniqueness of the problems that are likely to be encountered in
each project. Organizing a social event, or, on a grander scale,
the construction of the Channel Tunnel are also projects. Health
care delivery, in this classification would obviously fit in the
project production category, because each patient s case presents
unique problems that require tailored solutions and, therefore, are
one-off, non-repetitive items. Physicians managing patients cases
would be considered project managers, from a production
perspective.
In this paper I assert that medical care fit perfectly in the
general scope of project management. Physicians can therefore,
utilize the knowledge, techniques and tools of the project
management to optimize health care delivery, with greater benefits
or patients and society at large. The simultaneous control of costs
and quality that project management has delivered to so many human
endeavors can and should be adopted in health care.
ProjectsA project is defined in the Project Management Book of
Knowledge (PMBOK 2004) o the Project Management Institute (PMI) as
a temporary endeavor undertaken to create a unique product,
service, or result. Temporary means that very project has definite
beginning and a definite end. It does not say anything about the
duration of the project itself but only that a project is not an
ongoing effort, it is finite. The construction of a building it is
the most obvious example, with a clear life cycle from inception to
conclusion. The client wants the building concluded and delivered
on time, on budget and according to the specifications put forward
in the statements of works (SOW).The teams that are assembled to
carry out specific projects are disbanded when each work is
concluded and are reassigned to others tasks, precisely because of
the temporary nature of projects. The uniqueness of project
deliverables is another essential characteristic of the projects.
Uniqueness describes only the projects singularity and does not
imply the absence of repetitive elements. In the construction of a
building there are many repetitive elements but each building is
unique because of different ownership, location, contractors and so
on. Progressive elaboration is another characteristic of project
that is closely related to their temporary and unique nature.
Progressive means developing in steps, and by continuing
increments. For example, the projects scope will be broadly
described early in the project and made more explicit and detailed
as the projected team develops a better and more complete
understanding of the objectives and deliverables (PMBOK 2004). The
project of a building can start only with a purpose and location
and be developed in steps and by continuing increments. Do medical
services qualify to be considered projects? Certainly! All medical
services that I can think of are temporary, unique and developed in
steps. They are temporary because they have a definite beginning
and a definite end, they are unique each patient is a
singularity and they develop in steps, as the physician develops
a more complete understanding of the scope of the services or
results that are to be delivered. In this text I shall use the
example of a patient with varicose veins to demonstrate my
contention that medical services fit the general category of
projects, because of the enormous prevalence of this problem in the
population, the familiarity that physicians have with venous
disorders and also because it is one of pathologies that I treat
most frequently. The project starts when the patient with varicose
vein first seeks medical assistance for her problem. The scope of
the medical service to be delivered (the project) is assessed in
the first office visit. What is the service to be or result that
the patient (the client) seeks? Most of my patients want to be
relieved of their symptoms and want to improve their looks .After
an initial evaluation, I usually order a Doppler exam and, if I
suspect that surgerysgoing to be necessary , blood tests and ECG.
When the results of these exams are available, I discuss with the
patient the possible options for her treatment.The scope of the
services awaiting delivery then become clearer and usually a
specific course of action is chosen. When surgery is considered to
be necessary further arrangements need to be made. I have to book
the case in a local hospital, a team has to be assembled for the
surgery and a timetable has to be drawn. Adjustments are usually
necessary as the case progresses, either at the patients request or
due to do the availability of the resources. Eventually the patient
is discharged, once the agreed services or results are delivered.
This scenario, a familiar one to any health care professional,
illustrates the temporary, unique and progressive nature that
characterizes medical services and qualifies them as project. The
physician should be regarded as a project manager working for a
client whose the patient. Sometimes patients with varicose veins
just seek advice, a prescription for a pair of elastic stockings or
a medical report to take to their family physician. Does that
service qualify as a project? Yes! It is a one-off, non-repetitive
activity that cannot be standardized. My
recommendations vary according to a multitude of factors, like
the patients age, gender, profession, place of residence and so on.
It is a service that does not take the time and planning necessary
to carry out a surgical procedure, however the duration or the
difficulty are not the criteria by which a service qualifies as a
project , it is so because it is finite and unique. At this point
it is useful to distinguish between a project and a program. A
program is defined as a set of identifiable projects aimed at
achieving some goal or objective (Roberts t al 2004). Programs do
not have end dates and will run until a decision I taken to stop
them. The classical textbook example of a program would be a
governments program to reduce pollution. In the health status of
the populations and these programs are usually composed of specific
and identifiable projects. A program to fight avian flu can include
projects to develop a new vaccine and at the same time projects to
divulge information and increased general awareness in the public
about the problems posed by the avian flu virus. Projects can be
added or removed from a program according to its general goals and
objectives. The effort to provide lifelong health care assistance
to any individual in a given population can be regarded and managed
as a program and particular services that are necessary during the
life of that individual can be regarded as project.
Project ManagementProject management is the discipline that
deals with the management of the projects, forgive the tautology.
In the PMBOK PM is defined as the application of knowledge, skills,
tools and techniques to project activities to meet project
requirements. Project management is accomplished through the
application and integration of the project management processes of
initiating, planning, executing, monitoring and controlling and
closing.The project manager is the person responsible for
accomplishing the project objectives. The PMBOK goes on to specify
that managing project includes: 1. Identifying requirements. 2.
Establishing clear and achievable objectives. 3. Balancing the
competing demands for quality, scope, time and cost. 4. Adapting
the specifications, plans, and approach to the different concerns
and expectations of the various stakeholders. Project management
point out element of project management first came to light in the
great construction works of history, like the Pyramids, the Great
Wall of China, or the Roman roads and aqueducts. Now, this cant be
entirely true because it would make project management the second
oldestprofession in the world and, physicians, we know that lightly
unlikely. The history of PM can be traced back to the second half
of the twentieth century. It started with the arm race and the need
for the US defense industries to control the large overruns, in
time and cost, of their projects. Crucial landmarks were the
development of the Program Evaluation and Review Technique or PERT
(developed in 1958 for the Polaris missile submarine program) and,
almost at the same time, the development of the Critical Path
Method or CPM, by DuPont Corporation. Professional bodies emerge in
the late 60s. In the USA is the PMI Project Management Institute
and in the UK the APM Association of the Project Management. The
APM produced its Body of Knowledge in 1988 and collaborated in the
preparation of the British Standard BS6079 (1996) as well as in the
European Standard ISO100006 (1997). These documents helped to frame
PM as a profession. The international body that coordinates PM
globally is the International Project Management Association
(IPMA).
Core CompetenciesThe knowledge, methods, tools and skills use in
PM are well documented and in the public domain. However, as
experts in the field point out effective project management
requires that the project management team understands and use
knowledge and skill from at least five areas of expertise. 1. The
Project Management Body of Knowledge. 2. Application area
knowledge, standards and regulations 3. Understanding the project
environment. 4. General management knowledge and skill. 5.
Interpersonal skills. Amongst the tools and the Techniques that are
unique to PM (core competences), it is useful to describe very
briefly a few, such as the work breakdown structure (WSB), critical
path analysis (EVA), to demonstrate their potential impact in the
delivery of medical services. Once defined a projects scope that is
the work that needs to be accomplished to deliver a product,
service, or result with the specified features and functions the
project manager is responsible for breaking down the work to be
done into smaller, more manageable pieces of work. The WBS can be
defined as a deliverable-orientated hierarchical decomposition of
the work to be executed by the project team, to accomplish the
projects objective (PMBOK 2004). This procedure allows that each
piece of work, or activity, can then be budgeted and sequenced in a
diagram, or schedule network that set logical dependencies amongst
the different activities that need to be performed. The CPM is a
method developed by the DuPont Corporation (Nokes et al 2003) to
analyze schedule networks and provide information about early start
an finishing dates, for all scheduled activities. Activities with
no spare time, that is with a zero difference between their early
starting dates and late finishing dates are considered critical and
define a Critical Path. Any delays in the activities in the
critical pat influence the schedule and the budget of the project.
EVA is a type of milestone monitoring applied specifically to
determine cost and schedule variance for components sections of a
project (PMBOK 2004).Cost variance provide information about the
difference between the budgeted cost of the work performed and the
actual cost and is a fundamental tool of cost control.
Although, by definition, each project is unique, project
managers can use templates from previous projects to draw their
WBS, and therefore resort to models and solutions that proved
successful in the past. Throughout the lifecycle of a project, I
see the project manager as a juggler, simultaneously juggling three
interdependent variables that are time, cost and quality. The
ultimate performance depends on the perfect equilibrium of these
variables.
Medical practiceSince medical services fall within the category
of projects it is perfectly legitimate to infer that physicians can
obtain productivity gains by learning PM and adopting its
techniques and tools. In the example that I provide, of the patient
with varicose veins, it is obvious that the project to be delivered
by me, the scope of which is eliminate the patients varicose veins
and therefore most of its symptoms, can be decomposed into several
smaller pieces of work that can be scheduled and budgeted
separately. A schedule network, of these different items, can be
drawn, a critical path determined and budget estimate calculated.
The Project Logical Evaluation (PLE) is the process of taking the
WB packages and determining the sequence in which is they are to be
carried out (Nokes et al 2003).In my example, the blood tests, ECG
and Doppler exampackage have to be completed before the surgical
procedure itself, but their relative sequence is flexible. The
final cost and the quality of my project depends on the cost and
quality of each package and the way they are assembled. Using PM,
we can procure the package suppliers that offer item with the best
price/quality relationship and bring down costs at the same time
that quality is safeguarded or upgraded. The WBS templates are
tools that be extremely useful to physicians that adopt PM.
Although each project is unique, a WSB from a previous project can
be used as a template for a new project, since some project will
resemble another prior project to some extent (PMBOK 2004).
Therefore a practicing physician can use the experience drawn from
previous cases and apply it to current ones, benefiting from the
experience and knowledge of his/her colleagues. Evidenced-base
medicine proponents have always pointed out that clinical practice
is frequently erratic because its not necessarily based on the best
evidence available but on content expertise and clinical experience
(Sackett, 1996).WSB templates can integrate pathophysiological
principals and the best epidemiological evidence available, a well
a clinical expertise, experience and value to provide solution that
are uniform, yet flexible enough, to satisfy the unique demands of
each patient.
Information technologies (IT) are crucial n PM. Although there
are no clear cut rules, it is generally believed that it is
fundamental to manage large projects or a large number of small
projects simultaneously. From my readings and experience, I
identified a rule of thumb that I call the 12/12 rule. It is
beneficial, or even indispensable, when the project manager handles
more than 12 cases simultaneously and each case is composed of 12,
or more, identifiable pieces of work .In a retrospective analysis
of my own practice I realized that I was handling simultaneously an
average of approximately 60 cases and that each case involved, on
average, 12 to 18 pieces of work. We can therefore extrapolate that
using PM to deliver medical services and result is going to require
the support of specialized software platforms. The time that we
were managing out patients cases with a pad, a pen and the space
between our ears is probably over!
DiscussionProject management has been extensively used in the
health care industries. It has been used, for example, in the
construction of new health care facilities, to implement it
projects or by pharmaceutical industries to develop new drugs. The
PMI recognized this when it created a Special Interest Group (SIG)
for health care: It is our belief there is a need for a healthcare
SIG to serve the needs of the PMI membership that work in
healthcare. Specifically, health plans, health care providers,
clearinghouses, business partners, or consulting firms. Subsets of
this population include those who implement projects specific to
information technology, regulatory, obligations, business process
re-engineering, etc. The Health Care Industry is changing like
never before and I beginning to recognize the need for project
managers (PMI 2006). The novelty, in this paper, is to propose that
PM can and should be used to deliver medical services and results.
This concept as far as I can tell, from searching the medical
literature, in English, and web sites dedicate to PM, is entirely
new and was never theorized or discussed in the specialized
literature. I started by demonstrating that the delivery of medical
services fits the general category of projects, as defined in the
PMBOK, of the PMI. This is an epistemological premise that appears
undisputable. Secondly, I affirmed that, since the delivery of
medical service is a project, in the PM sense, there are gains to
be obtained by adopting PM techniques. Health care productivity can
be increased, costs can be slashed and quality can improve. This, I
realize, is something that will have to be demonstrated
empirically, but it is more than simple wishful thinking. It is a
legitimate conclusion of the first premise since PM has delivered
those results to all other industries that use it. It can,
therefore, be inferred that PM will accrue the same benefits to
health care. Fortunately, this is an empirically falsifiable
conclusion. The examples provided are too basic to support the
second conclusion and are included only to demonstrate that the
problems analyzed correspond to real and practical situation that
physicians deal with on a daily basis.Situations that can benefit
from better planning, team work and improved communication between
all involved in health care.
In the introduction to this paper, I tried to put in context
some of the problems that affect the management and delivery of
health care services. In my point of view, part of those problems
result from the erroneous categorization of health care services as
mass products and accordingly the attempt to mass produces them in
health care factories. The strategies implement at a functional
level, in these factories, constantly collide with the flexibility
required for project production, originating difficulties that
waste energies and resources. The end result is an impossibility to
curb costs while maintaining or improving quality, an illusive goal
that has become a sort of Holy Grail for health care managers. The
focused health care factories, that Regina E. Herzlinger(Herzlinger
2004) regards as a means to achieve the goal, correspond, only, to
one of those rare instances where mass production can be used. The
Shouldice Clinic that Herlinger sees as an example to follow, only
treats hernias and developed an assembly line to treat them. It is
a solution that cannot be generalized. If there is a Holy Grail, if
it is possible to bring down costs while improving quality, Im
convinced it is only going to happen thought a counter revolution
in health care that puts the physicians back at the helm of the
entire management of their patients cases, like true projects
managers.
ConclusionThe production method for delivering health care
services in general or medical services in particular, is analyzed
in this article. Its proposed, and demonstrated, that medical
services before belong to the general category of projects and,
therefore, productivity gains can be achieved in health care if an
adequate method of production is employed. It is also stated that
if project management is used to deliver health care services,
physicians are the natural project managers.
Acknowledgements I was studying project management for my MBA
when I received an email from Prof. Andrew Miles to comment (Couto
2006) on an article, by M. R. Tonelli, proposing a casuistic
approach to integrate evidence intro clinical practice (Tonelli
2006). The idea to use project management to deliver medical
services was inspired by reading Tonelli`s articles because the
casuistic approach that is proposed results from the some
singularity that is present in projects. I would like to
acknowledge also the contribution of my daughter Sarah Couto with
suggestions and editing of this text.
BibliographyAPM - Association of Project Management.
http://www.apm.co.uk Couto J.(2006) Can we forget how to treat
patients? Commentary on Tonelli (2006), Integrating evidence into
clinical practice: an alternative to evidence-based
approaches.Journal of Evaluation in Clinical Practice12, 248-256.
Follet M.P (1982) Dynamic Administration - The Collected papers of
Mary Parker Foller. Hippocrene Books, New York, USA. Herzlinger
R.E.(2004) Consumer driven Health Care Implications for
Providers,payers and Policy-makers. Jossey Bass Wiley. San
Francisco, CA, USA. IPMA - International Project Management
Association.http://www.ipma.ch
Miles A., polychronis A., Grey J.(2006) The evidence based
health care debate 2006. Where are we now? Journalof Evaluation in
Clinical Practice12, 239 -247.Nokes S., Greenwood A.(2003) The
Definitive Guide to Project Management. PrenticeHall, Edinburgh,
UK. PMBOK (2004) A Guide to the Project Management Book of
Knowledge. Project Management Institute, USA PMI Project Management
Institute.Http://www.pmi.org Roberts A., Wallace W.(2004) Project
Management. Edinburgh Business School Course, Heriot-Watt
University, Edinburgh. Sackett D., Rosenberg W., Gray J., Haynes
R., Richardson W. (1996) Evidence Based Medicine: What it is and
What it isn`t. British Medical Journal 312, 71- 72 Shouldice Hernia
Center.http://www.shouldice.com
Tonelli M.R (2006) Integrating evidence intro clinical practice:
an alternative to evidence- based approaches. Journal of Evaluation
in clinical Practice12, 248-256. * Joaquim Couto, MD, MBA Av. da
Boavista, 117 Sala 301 4050-115 Porto Portugal
http://www.joaquimcouto.com [email protected]
Using Project Management Methodology to Plan and Track Inpatient
Care Article-at-a-Glance BackgroundEffective care of each patient
throughout a hospital admission involves executing a specific set
of tasks to produce a favorable outcome within an appropriate time
frame. The ProjectRoundsTM methodology, which can be implemented
using widely available software, incorporates the principles of
project management in planning and control hospital inpatient care.
It consists of four stages-clinical assessment, planning,
scheduling, and tracking.
Overview of ProjectRounds and ExampleAs an example, a
68-year-old-man is admitted with pneumonia. In clinical assessment,
the admitting physician uses an assessment tool that prompts her to
list all patient`s clinical issues, define the conditions that need
to be met to discharge the patient, highlight special problems, and
list any consultations, diagnostic test, and procedure that are
planned. In planning, the work breakdown structure-a tabulation of
all the tasks in the project (the admission) is created. In
scheduling, a project schedule is generated, and in tracking, the
clinical team evaluates and monitors the project`s course. During
interdisciplinary clinical rounds, the progress of the patient`s
hospital care can be tracked and quantified by employing the
percent complete method. Tracking can be used as a dashboard,
providing a concise summary of the care that needs to be and has
been rendered to the patient.
Summary and Next StepsApplying the tenets of project management
can optimize the process of providing health care to hospital
inpatients. Each hospital admission is work that we do only one
time, that is, it is a project. Although admissions for the same,
or similar, diagnoses may involve the performance of similar or
somewhat standardized tasks, each patient presents with a unique
set of demographic, socioeconomic, medical, and other issues.
Hence, effective care of each patient throughout a hospital
admission involves executing a specific set of tasks to produce a
favorable
outcome within an appropriate time frame. As pointed out by
Juran, a project is a problem schedule for solution .1)The paradigm
shift reflected in defining inpatient care throughout the hospital
admission as a project rather than as a component of ongoing
hospital operations is mandatory to achieving high-quality
outcomes. Moreover, by shifting hospital care into the project
environment, the body of knowledge that constitutes project
management can be brought to bear on the key issue facing
clinicians and administrators involved in hospital care-how to
balance cost, quality, and time (length of
stay[LOS])considerations. Given the LOS consideration created by
the diagnosis-related group (DRG)-based prospective payment system,
and in recognition of the prevalence of medical errors, 2) there is
an acute need to develop and implement a formalized yet flexible
methodology that allows clinicians to deliver care that maximizes
patient safety in a fiscally and temporally efficient manner. This
article describes the Project Rounds, methodology, which
incorporates the principals of project management in the planning
and control of hospital inpatient care.
Overview of ProjectRounds and ExampleAn overview of
ProjectRounds is depicted in Figure 1. An example is provided to
illustrate the details of ProjectRounds: A 68 year-old-man, A.B.,
with a history of Type 2 diabetes mellitus, chronic renal failure,
coronary artery disease, and hypertension , is admitted to the
hospital with pneumonia.
Clinical AssessmentThe admitting physician uses an assessment
tool 3) (Figure 2) that prompts her to list all the patients
clinical issues, define the conditions that need to be met to
discharge the patient, highlight special problems, and list any
consultations, diagnostic tests, and procedures that are planned.
In addition, she is prompted to anticipate factor that may delay
hospital discharge and to communicate with the patients primary
physician. In the parlance of project management, the assessment
tool prompts the clinician to the following: Enumerate all the
problems to be solved (the solved clinical problems are the
deliverable)
Decide whether or not they need to be addressed as an inpatient
or an outpatient(project scope) List the factor likely to constrain
the project the project (risk analysis) List the tests an consults
that need to be done (project logistics) Estimate the date that the
patient is to be discharged (project schedule) In addition, prompts
are provided so that the clinician does not reinvent the wheel when
dealing with diabetes, elderly patients, andother patient groups
with predictable needs. Furthermore, a prompt reminds the clinician
to contact the patients primary physician to obtain additional
information. This helps to further limit project scope and allows
earlier discharge because a wellinformed outpatient provider will
be able to deal with many issues that would have otherwise been
unnecessarily investigated and treated in the inpatient setting.
Moreover, achieving this level of interclinician communication is
an important patient safety issue and can eliminate medical errors.
The clinical assessment tool should be developed with input from
the physician who will be using it, as well as the other
interdisciplinary team members-such as non-physician providers,
nurses, and social workers-who will translate the information into
care schedule. The tool can be modified to meet the hospitals and
medical staffs specific needs. For example, additional prompts can
be added for specific patient populations. A nephrologist may want
to incorporate data germane to chronic kidney disease, whereas a
geriatrician will want additional prompts to address the needs of
older patients, and so on. Moreover, the clinical assessment tool
can be modified and improved on a continuous basis.
PlanningThe physician admitting a patient to the hospital is
faced with the same issues as any project manager delegated the
task of producing a complex deliverable. Hence, as with any
project, planningis a keyto a successful outcome. In project
management, one of the initial planning steps involves the
development of the work breakdown structure (WBS)-a tabulation of
all the tasks in the project (that is, admission).Summary tasks,
which are more general, are further broken down more detailed,
individual tasks.
The development of WBS provides the following benefits: Details
the scope of the project (as we will see later, identifying tasks
that can be done as an outpatient, and hence, eliminating these
tasks from the WBS, leads to appropriate reductions in utilization,
cost, and LOS). Allows the course of the project to be followed.
Allows cost and schedule (LOS) estimates to be made. Allows
activities to be assigned to the members of the interdisciplinary
team. The anticipated duration of each summary task is based on
average LOS data used by the prospective payment system, although
primacy is given to the clinician`s medical judgment. As noted in
the project management literature, 4) it is helpful to determine
whether a WBS already exists for your project-in this case, a care
map or clinical practice guideline. For example, if a care map for
the diagnosis and treatment of pneumonia already exists, it can be
incorporated into the WBS for that particular admission. However,
patients will often remain in the hospital longer than is necessary
because the care map or guideline per se does not address the issue
of implementation or execution of the diagnostic/treatment plan.
Moreover, clinicians often resist such tools if they are perceived
as imposed on the physician or employed in a way that supplants
clinical judgment or heuristics. ProjectRounds provides the
clinical team with the tools necessary to plan and operationalize
the clinical medicine process in a manner that is based on the
clinician`s judgment, knowledge, experience, and the ability to use
appropriate heuristics, formal decision-making methods, and
clinical intuition. Now, to return to the patient A.B., the WBS
shown in Figure 3 can be generated. The specific summary tasks and
more detailed work packages attendant to each deliverable can then
be more fully developedbay the admitting physician. For example,
the deliverable for the patient`s chronic renal failure can be
broken down into the following specific tasks; Call primary care
provider (PCP) to find out baseline creatinine Correct electrolyte
disorders Optimize volume status Exclude obstruction Avoid
nephrotoxins Adjust medication dosages
Consider angiotensin-converting enzyme (ACE) inhibitor of
patient with proteinuria Educate patient including renal
replacement options if appropriate Obtain a nephrology consult
SchedulingOnce the WBS has been developed, it is necessary to
create a project schedule. This can be performed by a nonphysician
member of the interdisciplinary team, using readily available
scheduling software. A sample hospital care project schedule is
provided in Figure 4. A significant amount of judgment is involved
in setting up the schedule. The tasks, or work packages, need to be
small enough so as to present a detailed picture of the hospital
course. However, it is necessary to avoid going intro too much
detail, lest the schedule become unwieldy and impractical. If is
important for the clinical team to work together closely and
communicate effectively. As with and new methodology, a learning
curve is to be expected, and the system will evolve and be used in
a way that will allow it to be most effectively applied at a given
organization and by a given set of health care providers. The key
is to be consistent and standardize as much as possible but at the
same time, to be flexible, given the diversity of clinical
scenarios that arise.
TrackingOnce the clinician has completed the worksheet, which
has been translated into a WBS and a hospital care schedule in
Gantt chart format, the next step is for the team to begin
evaluating and monitoring the course of the project to ensure that
everything is going according to schedule. In project management
terminology, this is referred to as the process of project and
evaluation. 5) This process-the timely undertaking and completion
of key diagnostic and therapeutic tasks- is critical to achieving
high-quality care. It is, important to pay attention to any
variance between where the patient is and where he or she should be
in his or her hospital course. The importance of this type of
variance analysis is reflected in the ORYX Initiative and the core
performance measures, as developedby the joint Commission on
Accreditation of Health Care Organization. 6) In project management
terminology, these key clinical standards can be thought of as a
tabulation of the tasks that are needed to produce key clinical
deliverables, that is, high-quality care of hospital inpatients
with
community-acquired pneumonia, heart failure, acute myocardial
infarction, and pregnancy/related conditions.
ThroughProject/Rounds, an organization can incorporate core measure
into the vaseline care schedule and then track completion of data
collection. A sample Gantt chart in provided in Figure 5. During
interdisciplinary clinical rounds, the progress of the patients
hospital care can be tracked and quantified by employing the
percent complete method. The team estimates, on a per task basis,
the percent of work that been completed and then enters this
information into a tracking Gantt using readily available
scheduling software. The software then automatically calculates the
percent completion for each summary task. A hypothetical tracking
Gantt for patient A.B., after one day in the hospital is shown in
Figure 6. Let`s examine the tracking Gantt. We want to pay
particular attention to the critical path (shown with dark bars),
which, in this case, is the treatment of the patient`s pneumonia.
As you can see, the official report of the chest x-ray is not yet
available. The patient has completed his first day of intravenous
and oral azithromycin (Zithromax). His O2 saturation was checked
and was fine, and it will not be rechecked unless there is a change
in his clinical status. The percent completion of the milestone
task, ready for outpatient treatment is about 29%, which was
derived by dividing the 4 units (days) of activity that were
completed out of possible total of 14 units (days). If the chest
x-ray had been officially read, the critical path would be 5/14 =
36% complete. Similarly, the chronic renal failure arm of the
project is being held up because the patients physician hasn`t been
contacted to ascertain the patient`s vaseline creatinine. By using
the tracking Gantt, the clinical team can remain on schedule.
Moreover, by bringing attention to activities that have been
neglected, the tracking Gantt becomes an important tool for
increasing patient safety and avoiding preventable errors. In fact,
key quality indicators can be incorporated into the project Gantt
as tasks. For example, under the miscellaneous summary task,
additional tasks such as prevent decubiti, reevaluate need for
restraints, achieve therapeutic anticoagulation, reconcile
outpatient medication list with discharge medications, can be added
depending on the specific clinical scenario. Failure to execute
these tasks will delay hospital discharge, prolong LOS, and most
importantly,
unfavorably affect quality of care and outcomes. In addition,
highlighting the fact that these tasks have not been carried out
can serve to avoid errors and adverse outcomes. The tracking Gantt
can also be used as a dashboard which provides a concise,
at-a-glance summary of the needs to be has been rendered to the
patient. The members of the interdisciplinary team charged with the
preparation of updated tracking Gantt charts will need to use
information gathered during clinical rounds and information
documented in the patient`s medical record to ensure that Gantt
chart is up to date and accurate. Moreover, consideration may be
given towards incorporating the actual Gantt charts intro the
patient`s medical record, although this will need to be thoroughly
vetted by the institution`s medical records department and medical
record/forms committee.
Summary and Next stepsApplying the tenets of project management
can be used to optimize the process of providing health care to
hospital inpatients. ProjectRounds has been piloted on a small
scale to assess the feasibility of its implementation. Physicians
found the clinical assessment tool easy to use, and the author
could readily translate it into a Gantt chart and then intro a
tracking Gantt. Additional studies are planned to assess the effect
of ProjectRounds on LOS and quality of care and other indicators.
The ProjectRoundsTM trademark is owned by Darren Kaufman. M.D.,
M.S. Individuals, organizations, and private consultants may use
the name with appropriate attribution. Darren S.Kaufamn, M.D.,
M.S., is chief Financial Officer and Attending Nephrologist, Port
Jeff Medical Care, P.C., Port Jefferson Station, New York. Please
address reprint request to Darren S. Kaufman, M.D.,
[email protected]. References 1. Lewis J.P.: Fundamentals of
Project Management, 2nd ed. New York City: Amacom, 2002. 2.
Institute of Medicine: To Err Is Human: Building a Safer Health
system. Washington, DC: National Academy Press, 1999.
3. Setrakian J.C., et al.: A physician-centered to shorten
hospital stay: a pilot study. CMAJ 160: 1735-1737, 1999. 4. Kerzner
H.: Project Management: A Systems Approach to Planning, Scheduling
and Controlling, 7thed. New York: John Wiley and Sons, 2001. 5.
Joint Commission on Accreditation of Healthcare Organizations:
Performance Measurement in Health Care.
http://jcaho.org/pms/index.htm (last accessed Jun. 27, 2005). This
article is an exact print from the Joint Commission Journal on
Quality and Patient Safety: August 2005, Volume 31, Number 8. A
Morning Briefing:Setting the Stage for a Clinically and
Operationally Good Day The Institute of Medicine states that
organizations can improve patient safety by developing better
methods of communication and by working as a team. This article
discusses a study by an interdisciplinary leadership group that
created a system to promote effective communication and optimize
share information.Amorning briefing wad developed with specific
questions heath care workers should answer before conducting their
rounds in order to prevent information from being lost or
forgotten.
Ergonomics in Action: the Art and Science of Limiting Patient
Lifting to reduce Health Care Worker Back InjuriesHealth care
workers are at a great risk of injury cause by patient lifting. The
Joint Commission implicitly included the problem of worker injury
cause by transferring patients among its National Patient Safety
Goals for long term care, assisted living facilities, and other
health care organizations. Protecting workers against back injury
is an important part of Joint Commission safety standards and of
the Occupational Safety and Health Administrations general duty
clause. This article offers tips and resources for implementing
patient lifting programs.
Collecting Performance Measurement Data to Improve SafetyThe
quality of care, treatment, and services provided at a health care
organization depends in part on collecting performance measurement
data that allow organizations to identify problems in processes and
make appropriate changes. This article provides strategies for
health care organizations about what to measure and offers the
resources and tools required to do so.
Unannounced Surveys: The basicsThe Joint commission will conduct
all regular accreditation surveys for most types of health care
organizations on an unannounced basis starting January 1, 2006
(initial surveys will continue to be conducted on an announced
basis). What this change means for the organizations and how it
will work in relation to the full scope of the accreditation
process is the focus of this excerpt from the new JCR publication
The Joint Commissions Unannounced Survey Process. This chapter
answers commonly asked questions about unannounced surveys.
Video: Governance, Quality and safety: The Impact of joint
Commission Accreditation of Health care DeliveryGoverning boards
have the critical responsibility of representing the interest of
patients and their communities when decisions have to be made. The
scope of the Joint Commissions mission is similar in nature: to
continuously improve the quality and safety
of care provided to the general public. This video outlines for
board members how the Joint Commission helps organizations reduce
risk and develop processes that maximize quality and performance.
In addition to providing a background on Joint Commission standards
and the survey process itself, the video specifically outlines
those standards that apply to the governing board. Pay-Per-View:
Publicly Reporting Comprehensive quality and Cost data Transparency
in health care, including the public reporting of heath care
results, is an expanding and unstoppable phenomenon. Health care
systems have an opportunity to: (1) be proactive and accountable
for the care they provide, (2) help patients learn more about their
condition as a supplement to understanding the performance
measures, and (3) use public reporting to foster process of care
and outcome improvement initiatives. This article provides an
overview of the first 22 months of a transparency initiative at
Dartmouth-Hitchcock Medical Center (DHMC). An interdisciplinary
operations group worked with the various clinical programs-both
providers and patients-to identify what quality and cost measures
were most desired by patients and what measures were the focus of
the clinical programs internal measurement and reporting process. A
variety of factors is important to the transparency
initiative-senior leadersperceptions, risk management issues,
resources required for the design and maintenance of initiative,
and developing both methodological protocols and technical systems.
November Reader Poll 2002, 2003, 2004, 2005, 2006, 2007 Joint
Commission Resources, Inc.-all rights reserved.
Overview of International EMR/EHR MarketsResults from a Survey
of Leading Health Care CompaniesAugust 2010
2
About the studyAccenture conducted a study of leading health
care software, hardware and services companies to gauge the
attractiveness of eight international electronic medical record
(EMR) markets of considerable size and EMR maturity. Those markets
include Australia, Canada, France, Germany, Japan, The Nordics,
Spain and the United Kingdom (UK). Other large marketsnamely, India
and China were not studied due to conflicting opinions of overall
EMR maturity. The companies surveyed have a combined market
capitalization of more than $600 billion. As some of the largest
software vendors, medical products companies and enterprise
software providers in the world, these companies support operations
in an average of more than 90 countries. To account for the
leadership of several niche players, we also interviewed a number
of more localized companies to refine market-specific insights. We
asked survey participants a series of questions regarding the
specific international EMR1 markets and discussed key trends
emerging in each market. Respondents shared deep industry insights
as well as general perceptions of international markets based on
overall potential, market saturation, local laws and regulations,
and cultural norms. This paper summarizes the insights shared and
reports the results of specific survey questions. Where
appropriate, we have also included secondary data to support our
findings.
1. Electronic medical records (EMRs) are defined as patient
treatment records, including a patients background information and
history of patient care, maintained within a hospital or clinic.
Electronic health records (EHRs) are defined as patient health
records that include clinical data and information from multiple
sources and that are maintained outside of a single hospital or
clinic.
3
Executive SummaryMarket forces will drive growth of global EMR
markets at rates ranging from 6.6 to 9.7 percent across North
America, Europe, Latin America and Asia Pacific. The global market
is slated to be worth $19.7 billion in 2013: North America will
experience 9.7 percent growth in its EMR market from $7.4 billion
in 2010 to $9.8 billion in 2013. With 5,800 hospitals, EMR adoption
is beginning to accelerate due to ARRA incentives and penalties.
Asia Pacifics EMR market is expected to grow at 7.6 percent.
Europe, Africa and Latin America will grow at 6.6 percent through
2013 driven by government incentives and a refresh of EMR systems.
Emerging markets may be a primary growth driver globally and may
have the potential to implement innovative technologies, such as
cloud-based EMR solutions. Each country we analyzed represents a
distinctive EMR market defined by different health care systems,
competitor landscapes and local regulations and laws, requiring
customized market entry strategies. Four trends will have the most
impact on EMR growth: 1. Government incentives are believed by 71
percent of respondents to spur effective health IT adoption. The
most significant efforts include the United States ARRA incentives
and penalties and Australias $450 million e-health effort. 2. A
shortage of clinical IT specialists will shift EMR maintenance and
support strategies to outsourcing and cloud-based solutions, which
over one-third of health organizations are using in some capacity.
The shortage in Canada, as an example, requires 36,000 clinical IT
workers to sustain projects through 2014. Nearly 79 percent of
current clinical IT workers will require additional training
experience in the next year to remain active. 3. Networking the
health system across regional, national and a variety of geographic
regions will offer the largest and most challenging opportunities.
4. Global economic recovery will largely impact pace of adoption
and sustainability of resources.
Figure 1. Global addressable hospital-based EMR market size (USD
Billions)2010 Addressable market Total $15.5B 2013E Addressable
market Total $19.7B
Asia Pac $2.3
2010 2013 CAGR North America: 9.7 percent EALA: 6.6 percent
AsiaPac: 7.6 percent
Asia Pac $2.9
North America $7.4 EALA $5.8 EALA $7.0
North America $9.8
Source: Accenture analysis
4
IntroductionAround the world, electronic medical records (EMRs)
and electronic health records (EHRs) are being implemented to
improve patient care, reduce health care expenses and fundamentally
change the way in which medicine is practiced. The benefits
realized by EMRs in international markets are largely consistent
despite vast variations in health care systems, market structures,
competitive landscapes and regulatory requirements. While
international expansion remains a challenge for the companies we
surveyed, 71 percent view global markets as a growth opportunity in
the short term (13 years) and 100 percent view global markets as an
opportunity in the long term (5+ years). When asked about expansion
into global markets, most respondents mentioned a standard
approach: focusing first on their national markets, then
identifying regional expansion opportunities or select countries in
which they possess certain competitive advantages, and ultimately
shifting to true global expansion into multiple markets.
Figure 2. How critical are the Global EMR markets to your
companys long-term and short-term strategy?71%
57%
29%
29%
14%
Primary growth opportunity Long-term strategy Short-term
strategy