]]> On 13 and 14 January one of my colleagues, Jacob Knudsen and I participated in the annual meeting of the Danish Society for Quality in the Healthcare Sector, DSKS. The theme of the well-attended meeting was “Quality in the Encounter with the Patient”. During the two-day event, a number of workshops and presentations dealt with how the interaction and communication with the patient can be improved. The main message of the annual meeting was that hospital service design needs to be improved in order to meet the expectations of patients.

So what do I mean by “service design”?  According to Wikipedia, service design is “the activity of planning and organizing people, infrastructure, communication and material components of a service in order to improve its quality and the interaction between service provider and customers.”

Is this a hospital discipline? Yes, very much so. As a hospital manager you constantly have to monitor the service you give to your patients, and increasingly consider how to use digital services to meet patient expectations.

Nursing Director of the Aarhus University Hospital, Vibeke Krøll gave an excellent example of this. She told of her meeting with a young man who had been admitted to the hospital with a serious disease. He had asked her what he was supposed to do with the 18 (!) documents which the hospital had sent to him in the letter with his appointment to go to the hospital.  The incident caused hospital management to start a project to analyse patient communication. The analysis ended with a pilot project where appointment letters were sent electronically to the patients and where the large number of documents had been reduced to a minimum. After the introduction of the digital appointment letters, patient satisfaction was measured and – perhaps not surprisingly – a large proportion of both young and elderly patients were very satisfied with the new initiative.

Nursing Director Vibeke Krøll concluded her presentation with an appeal to the hospital staff audience to go home and have a closer look at the communication with their patients.

One of the workshops of the annual meeting cast a light on the ways in which digital communication can improve the experience of patients. Among the list of digital services discussed were webbooking, text reminders, self-service check-in at the hospital, the ability to communicate with the hospital ward, clear display of waiting times, apps with various kinds of patient related information, and others. Many of these techniques are available and well-established.

So perhaps we should follows Vibeke Krøll’s suggestion.

]]> A new Danish national strategy for telemedicine is about to be decided upon – but will it deliver more than words?
My daughter is a diabetic type 1 and has been so for 11 of her 20 years. She regularly takes time off from University to go to the University Hospital in Aarhus, where she meets some excellent diabetes doctors, helping her and giving her the ability to manage her diabetes and control her long-term blood sugar levels. She’s a very busy young lady – not only studying Molecular Medicine, but also doing elderly care in a part time job, visiting and helping an elderly handicapped woman, doing her sports, seeing her boyfriend and pursuing all the social stuff you do as a full time student. She is very much empowered and keen on coping – coping with life in general, and coping with her diabetes. She is very active in communicating by iPhone, laptop etc. with her friends, with university – but not with the hospital! She has to attend her regular appointments – taking time out from other activities, travelling by bus to and from the hospital to meet the doctor – often after some waiting time, which she of course kills by communicating digitally.
She is not alone. Approximately one third of the Danish population has a least one of the most common chronic diseases. And many of these could be treated more efficiently and with a substantial cost saving for society by using telemedicine.
Therefore I was very enthusiastic when I was invited to comment on the draft for the national strategy for telemedicine. In my opinion telemedicine is a win-win. Patients will gain and so will society. The focus of the strategy was to ensure further penetration of existing telemedicine solutions that were ‘known to work.’ The new government has committed to focus on telemedicine, with ambitious and binding goals for e.g. regions and hospitals.
What are the recommendations?
The Danish National telemedicine strategy has more than 20 recommendations to ensure a focus on citizen-centric treatment across sectors. Here are some examples to give you a flavor:
• Binding goals for using existing video conferencing platforms (for translation, doctors’ conferences, visits, control, discharging conferences and telepsychiatric consultancies)
• Wound treatment from a centralized wound treatment center for all municipalities
• Binding goals for knowledge sharing of telemedicine experience for all municipalities and regions
• National prioritization of chronic diseases to be addressed by telemedicine
• Funding to maximize penetration of telemedicine solutions
• Financial incentives for adopting telemedicine treatment
• Financial models for development and support of a common IT-infrastructure
• National standards and reference architecture for e.g. security, clinical data and booking
• Citizen gets easy access to healthcare data, and self reported data are used in healthcare
Reading through the recommendations it is very clear that there are a lot of stakeholders involved in formulating and realizing this. And it is very clear that this is not only about technology – but about organizational and financial incentives. So my thumbs up for this!!
Will the strategy succeed?
Any strategy should be focused, actionable and backed by necessary funds. It’s not yet possible to judge this strategy on these criteria – because the focus, actionable and funding parts are left to the next phase of the work.
Hopefully this work will result in a clear focus on one or two chronic diseases, which can showcase the potential of telemedicine. But even with a clear focus, the actions and funds to back this, it will be a long journey for all stakeholders involved. And definitely not a quick win.
Therefore I’m afraid that my daughter will have to continue for at least the next few years with time-consuming visits to the University Hospital. These are currently the best option for her. But they’re a waste of time for her and for me. I hope the strategy will get telemedicine to fly, and soon.

]]> Participating in a debate and dinner in Brussels on Wednesday the 30^th of November, Microsoft Vice-President John Vassalo handed over a manifesto to members of the European Commission and European Parliament.

It makes the case that “Better Health is everybody’s business” and traces the interconnectedness of key issues in healthcare with admirable clarity: managing chronic conditions, coordinating provision of care outside hospitals, making better use of technology in a climate in which reductions in spend appear inevitable. The impact of this on policy makers? We need them to:

• Accelerate the adoption of technologies that have proven value and benefits in order to reach scale
• Re-invest savings in research, innovation, reduction of public debt, and local growth and employment
• Avoid simply cutting costs, and focus on policies for sustainable health

I think this manfesto is a milestone in clarifying the principles and issues in the sector and showing how to prioritize getting real impact and doing more with less. Check it out here.

A Capgemini contribution to this Microsoft event “Partnering for better health” was a presentation on cloud, and specifically our recent G-Cloud point of view “The Government Cloud: Time for Delivery”. I introduced our eight step journey to the cloud (featured on page 17 of the report), which is a framework for ensuring that cloud is used to revitalize the delivery models and strategies of organizations, and not only to lower their ICT spend.

With governments and healthcare providers across Europe having to make savings, but also continue to improve the quality of the healthcare in line with citizens’ expectations, cloud offers the potential for reducing infrastructure costs, and could also help providers and payers exchange health information more easily to achieve better outcomes.

We’ll be returning to the theme of cloud at HIMSS 12 in February as part of our work in the Knowledge Center there. Come see us to learn more!

]]> Management of innovation in healthcare will be key to the future of healthcare systems. Especially the nationwide uptake of innovations requires creative strategic thinking and stamina. The US “meaningful use” program is one way to foster the uptake of IT in clinical practice. This financial incentive to start using electronic health records (EHRs) in a meaningful way, linked to contractual obligations to do so in the long run, definitely has provided a boost in the uptake of EHRs. In the behavioral health sector in The Netherlands the association of health provider organizations have taken it upon themselves to devise a strategy to foster innovation. This strategy is inspired by their own vision on the role of innovation in the future of behavioral health.

Key issue for executives in behavioral health in The Netherlands is the fact that they are not able to achieve innovation through IT. Their IT vendors were hardly able to keep up with legal and regulatory requirements. Most innovations were small scale, isolated, and usually not integrated with the core patient administration and (rudimentary) electronic health record systems. Rather than relying on the national government, they decided to take matters in their own hands. This was four years ago, at the end of 2007. In the meantime they have made considerable progress and are currently implementing innovative applications that support the healthcare professional in documenting and communicating care rather that burden him (or her) with administrative chores.

It does, however, require stamina and determination. There is no quick fix to the adoption of innovations. Executive involvement and leadership has proven to be key to the process. At first the executives had a key role in setting the scope and objectives and ensuring the involvement of their healthcare professionals and IT visionaries. Next they had to take the lead in regional meetings to convince their fellow executives. In this step they established a common set of requirements and strategies to attain an innovative IT solution, agreed to by their own national behavioral health provider association, GGZ Nederland. The formation of a majority group for a joint procurement process was the next hurdle that required executive leadership. During this process it was not easy to keep everyone committed and even now it is not easy to get everyone to actually contract with the vendors that made it across the finish line of the joint procurement of EHR solutions.

Right now the executives are taking responsibility for setting up strong and professionally run user groups that will continue to work with the individual IT vendors to achieve the vision that is embedded in the common EHR requirements for behavioral health. At the same time, a process is being created for maintaining the requirements specifications. This will keep the innovation going and will incorporate the experiences in the day-to-day practice of the behavioral health professionals. It is all about adoption, not about technical innovation itself.

]]> During the ONC All Grantee meeting last week there were a number of discussions regarding how HIEs can add value to sharing of Public Health data (e.g., immunizations, reportable diseases, reportable lab results, vital statistics, etc.). These discussions offered insights, lessons learned, and observations regarding potential barriers. ONC plans on posting the knowledge elements on their website so you can find them there (or let me know and I can share what I learned).

My “take away” was this. HIEs have the opportunity to provide significant value to Public Health organizations, care providers, and laboratory service providers by simplifying and reducing the numerous point-to-point communications that exist today or are being planned on. As an “Enterprise Service Bus (ESB)” solution, the HIE can deliver each of the various message types (e.g., IRs, RLRs, etc.) between the providers and the Public Health authority.

The barriers are not trivial. Some are interpreting current State laws to prevent an intermediary in the flow of information. Some Public Health organizations see their role as needing to build capabilities that are duplicative of the HIE. Current Public Health systems are not enabled to communicate via standard messages (and are using this fact as a means to diverting meaningful use requirements).

Like most aspects of HIE implementation strategies, until there is collaboration in the overall HIT strategy of a region/state, there is significant risk in overbuilding health messaging services within a region.

]]> Every year we observe an increase in patients asking for more influence on their own health care treatment plans. More and more patients can articulate their wishes and needs with respect to the health care they receive and they are increasingly able to take charge of their own healthcare process, of their own wellbeing.

To take charge of your own healthcare, you should have access to your own healthcare information. Not only the GP or hospital specialist, but also the patients should have at least access to their own medical records. Preferably they should also have the ability to correct errors and add data and observations they make at home or on the road.

A few weeks ago the Dutch Healthcare Inspectorate published a report (called “State of Health Care 2011”)[i] in which they conclude that “Although an increasing number of hospitals and other care institutions have adopted the use of digital patient files, the exchange of information between those institutions (and their computer systems) remains unsatisfactory. Patient information is often fragmented between several different institutions or even several departments within one and the same institution.”

The Healthcare Inspectorate also finds that “The exchange of information between cure and care and local mental health departments is often poorly organized. The same may be said of aftercare and palliative care for patients, following their discharge from a hospital or psychiatric clinic.”

The main recommendations given as result of this report, mentioned in a speech by Project Chief Inspector, Patient Safety, International Liaison and ICT in Healthcare Jan Vesseur at the MIC conference[ii] 10 November, 2011, are:

• Develop a centrally available set of key medical data. In a short interview I had with him after his speech he clarified that he was referring to the CCR/CCD initiative in the Rotterdam area in the Netherlands;
• Health care institutions should implement a formal policy for the responsible transfer of information between professionals, both within and beyond the institution itself. This is to ensure amongst others that patients are able to gain access to their own records on request. Mr. Vasseur made reference to the online EHR www.medischegegevens.nl of the MCH Hospital in The Hague.

The aims of the Health Information Exchange initiatives Capgemini is participating in are exactly in line with these recommendations. It is now up to the combined care providers in a region to come to reason and start creating exchange plans. The standards are defined, the technology is available, the patients need it and the government will enforce it, if necessary. We are here to help the health care providers with these tasks at hand.

What do you think should be the first step taken by the individual health care provider?

]]> Airlines do it; bookstores like Amazon do it; your hairdresser does it: Let the customer make their own bookings. But with the exception of the UK (where Choose and Book offers the possibility for patients to book their own hospital appointment), hospitals have been very late in allowing  their patients to make appointments themselves.

The Regional Hospital of Horsens, in Midtjylland Denmark, however, has been the first in Denmark to open up its booking module to patients. In a demonstration project, the hospital has given selected patients access to change their appointments online. So far only a limited number of patients have access, but after the first month the hospital has widened the scope and included additional patients in the project. So far patients can only see the appointments for the hospital in Horsens, but with the next version of their online booking system, patients will be able to see all appointments in the Danish Region Midtjylland with its 1.2 million inhabitants.

The Chief Medical Officer of the Regional Hospital of Horsens, Jørgen Schøler is very pleased with the new web booking facility: “We are constantly looking for new ways to operate and to ensure that the patients benefit from new approaches. We strive to engage patients in their treatment and everyone will benefit when we succeed in getting the patients to take an active part in this. Web booking is a step towards giving the patients more possibilities to do so.”

The perspectives in the web booking project are evident. Every year patients in Region Midtjylland have a total of 1.8 million bookings. Almost all appointments are changed at some stage, a process which involves staff at the hospital and takes up their time. If a number of these changes can be performed by patients themselves, valuable resources can be spared. And the patient will feel that service is improved since long waiting times on the phone are avoided.

]]> Fraud and abuse are growing problems in the healthcare sector. According to the Global Health Care Anti-Fraud Network, www.ghcan.org, a global partnership between international organizations, $260 billion (€180 billion), approximately 6 percent of global healthcare spending is lost to fraud each year.

We’ve found that more and more of our clients are looking for ways to make their fraud detection systems more effective, and to comply with national and international regulations on claims validation. For example in the US, the Affordable Care Act requires providers and suppliers of healthcare to establish plans detailing how they will follow the rules and prevent fraud as a condition of enrollment in Medicare, Medicaid, or CHIP[1].

Complying with regulation while increasing the capability to detect fraud and abuse is a serious challenge. How can organizations deal with the huge volumes of claims that are made on a daily basis? As the sophistication of the techniques used by fraudsters improves, the investigators’ pleas for more funding and better resources are growing louder. Given the cost of fraud, it would seem logical that policy makers and business owners take notice.

Detecting fraud is time-consuming work which relies on investigators’ ability to gather and substantiate data. Fraudulent claims are the exception, not the norm, and finding them can be like looking for a needle in a haystack. Though the total cost of fraud and abuse is high, the time it may take to challenge small-scale fraud successfully often means that there is no business case for doing so. Integrating disparate data sources within a smart analysis platform enables the investigators to find the high-risk, high-return cases which merit the investment of precious time.

We have been working with Palantir Technologies, http://www.palantir.com/, and several clients in the healthcare sector on strengthening the approach to detecting fraud and abuse using the Palantir platform. You can read more about our approach here, Brochure – Fraud Detection, and how the technology enables us to detect rapidly changing patterns of fraud and abuse by drawing together data sets from different systems. The big idea is to automate as much as possible of the analysis, allowing investigators more capacity to focus on the claims that are likely to provide the highest yield.

Having this degree of automation allows you to see suspicious anomalies in a few hours which might previously have taken weeks to uncover, or not been brought to light at all. During one demo using a real data from a client’s workflow, we found a male patient submitting a claim for treatment of ovarian problems – which certainly warrants further investigation, if not by a fraud investigator, then by scientists!

What else is out there in healthcare fraud detection – and are there other solutions that are making a difference? 

]]> An important element of the US national HIE program (NwHIN) being led by ONC is DIRECT. Simply put, this capability leverages secure email as a means to connect providers who wish to share patient care information that exists in their EMRs. This interim solution (until HIEs are fully functional as enterprise data sharing environments) will give providers a way to meet Meaningful Use Stage 1 requirements and, therefore, be eligible for incentive payments (if a Medicaid or Medicare provider).

As 2011 comes to a close, the challenge is to meet the ONC deadline of  Dec 2011 as the date when DIRECT needs to be available to the providers. We are working to make this happen within a state HIE and will hit the deadline.

The question to readers (and to ourselves) is how do we take advantage of DIRECT to promote more expansive sharing of patient data embedded within emails? How do we combine with evolving HIE services to make the data available beyond this point to point approach. Thoughts?

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Today I arrived in Oslo for the Medical Informatics Europe conference. Here the researchers in Medical Informatics meet every year to present the results of their projects, to network, and to keep up with what is going on in the world of Health IT.

This year’s topic is User Centered Networked Health Care. It really preludes to what is seen coming to life in day-to-day healthcare as well. In an analysis of European policy we see a trend that governments are no longer treating the citizen as someone to deal with and care for, but really as an independent actor who wants to achieve personal goals and looks to the government to help when necessary. We call this the tipping point is public service delivery, when citizens take charge of the services needed to shape their everyday life.

Hopefully the developments in eHealth, as presented at the MIE conference, will be pointing in the same direction. I’m looking forward to hear about direct teledermatology and the virtual TeleRehab case study. In order to enable separate healthcare providers to (net)work together to provide seamless services to the citizen, standards are needed. Quite a portion of the program at MIE is dedicated to standards, including a plenary presentation on the usability (or not) of Health Informatics Standards by Stephen Kay. This might turn out to be an important lesson to both researchers and standards developers, to really take into account the everyday life implementation of their standards. Ontologies, terminologies, frameworks and information models are essential aspects of medical informatics. However, just studying them from a research or standards perspective might miss the point in the end. At some point we also have to study how they behave in everyday life and support the citizens in making sure they are as healthy as they want to be.

Evaluation studies, both in the area of eHealth applications and health informatics standards, are therefore increasingly important. From my group at the University of Twente, two papers will be presented on the actual evidence of using technology in everyday life, one on the nursing record, the other on the immensely cute electronic CareRabbit. This is part of a broader evaluation track that should also spike the interest of policy makers. How do we come to the decision to include eHealth in our standard healthcare practices, and pay for it? This will be the key discussion for the coming years, as eHealth needs to take off to ward off the crisis in (western) healthcare systems. Financial sustainability needs to be part of the design and evaluation of eHealth applications and standards. This, I hope, will be covered profusely by the scientific program and the partnership in innovation presented at MIE 2011, here in Oslo.