The following are true (do you agree?):
1. Sophisticated telemonitoring technology and integrated applications exist today and are delivering benefits to patients.
2. These telemonitoring technologies exist as services (as in SOA services) that communicate with standard messages that can be integrated into a patient's EMR at his/her doctor's office and/or their PHR.
3. Patients with chronic conditions are gaining outcome based benefits.
4. Adoption rates are high for segments of the population.
5. Strong results are being realized when telehealth and telemonitoring capabilities are brought together (send biometrics and then talk about them with your care provider).
6. Results include significant cost savings.
7. Unfortunately providers are not getting paid to utilize these capabilities. The perverse reimbursement models that exist today must be fixed in the US and around the world.

For the past 2 years, Capgemini clients have experienced these capabilities as enablers of healthcare transformation requiring new ways of working; new skills and attitudes; and new ways of managing performance...the technology is the easy bit. Now they want to be properly paid for their efforts.

What about you? What are you seeing? Do you think the recent Medicare Telehealth bills (US) will help move things forward?

First, there is last week's story describing the medical identity theft extortion letter received by Express Scripts. This story is troubling on several fronts. First, someone found their way to gain access to 50,000 patient records that were assumed to be secured. Second, the criminals are holding the records hostage and hope to make money this way (i.e., pay us or we release the records to the public). Third, the story gives the public another reason not the trust in the security of their health data which will slow the adoption of EHR/PHR/HIE.

Elsewhere, additional medical identity theft stories appear in which individuals use the identity of others as a way to access care they cannot afford (i.e., you receive a bill for a surgery you did not have). Here the implications are severe. The first is the obvious theft of services, fraud, potential credit impacts, and depletion of available health insurance benefits. The second and more concerning impact is the health data residing in the victim's EMR/EHR/PHR will be incorrect leading to potential patient safety issues...how will corrections be managed? by who?

Will the national and local HIT initiatives be able to harden the security for HIT enough to resist such attacks? Is the government (no matter which country) doing enough to deter and enforce the protection of medical identity? Does the public know enough to adequately protect themselves?

What is happening in your regions? How are you avoiding the derailment of health transformation?

This discussion reminded me of a meeting between healthcare management and computer science researchers some years ago. The researchers were looking for "true" innovations, whereas the managers were much more looking for methods to succesfully introduce and incorporate existing technology in their healthcare organization. Given the fact that the outcomes were to be presented to the Dutch Science Foundation as part of the computer science research program, you can imagine which perspective received most attention.

Meanwhile, subsidized programs from both the Ministry of Health and the Ministry of Economic Affairs in The Netherlands focus on the adoption of proven pilot innovations, rather than on projects developing the next innovation in the application of Health IT. For instance, a program supporting the adoption of videoconferencing as part of multidisciplinary oncological meetings, in which an outside consultant participates from a distance, has been carried out succesfully over the last few years. This can hardly be called a break-through technological innovation, but it does illustrate the dilemma that healthcare organizations face. Is technological innovation getting in the way of large-scale adoption? Are we investing lots of money in yesterday's technology?

Reading the EU Services Directive and the Benchmarking done to the Global Trust Center Policy on Enabling Trust in the Digital World it do invite to some thoughts about the future.
The Global Trust Center is a non-profit independent international organisation that develops policy, best practice and guidance to enable trust in digital interactions. See also Wikipedia.
Is this a “revolution” in the area of identity infrastructure? I think it could be! The demand for interoperability in the identity environment is rapidly rising. Process and roles, verification, traceability, integrity, IPR etc. the list is long on the requirements. In healthcare I think that sharing local/regional/national care records really pinpoints trust issues like consent for example.
The healthcare sector, with all interoperability projects like the EU epSOS working on EHR-interoperability between 12 countries, really benefits if the identity infrastructure could be solved in a better way and perhaps with a “Jericho” viewpoint. What do you think?

Do we have an upcoming dispute between a more centralized landscape with fewer actors in the market and strong regulations vs. a marketplace containing a lot of actors in all sizes on a services oriented framework? What are your visions?

National programs for the introduction and use of Electronic Health Records are usually at the center of attention for professionals and politicians alike. The nature of these programs makes them vulnerable to a diversity of criticisms. The fact that a long-term perspective is taken, with high ambitions and serious impacts, often calls for lengthy procedures in terms of policy setting, stakeholder buy-in, open tendering, and specific legislation. One of the major trade-offs to be made is on the technological dimension: how to balance between state-of-the-art and the current installed base of systems and their legacy technology. The fact that the architecture is usually designed at the beginning of the long-running program makes it an easy target for arguments that it doesn't keep up with current technology.

Communication is key to refuting these arguments and keeping the program in perspective. It helps when clear governing mechanisms are in place for architecture development and the renewal of parts of the specifications. Such mechanisms can be designed to achieve the necessary balance between proven technology and current innovations, and to keep that balance in place over the lifetime of the EHR infrastructure. Leaning too much towards innovation will call for major redesign during a project that is already hard to really get off the ground. The old adagium - Perfection kills Progress - is applicable here as well. We would like to hear your experiences in coping with this dilemma.

Is quality a kind of “silver bullet” in this context? Making the care providers able to estimate result, measure result and do a follow up compared to quality index perhaps stimulate the willingness to enter data even for others to see. A kind of quality process inspiring the academic talent and competition. In Israel, Clalit Kaplan Medical Center , I saw a quality process like this but with quality index instead of estimates starting the process. The results were astonishing! If the process and information models integrate estimates, measures, follow up and show the gaps to quality indexes in an as automated way as possible it will heavily improve the cost – benefit ratio as I see it. What do you think?

Knowing the dangers involved, the team designed a combined technological and organizational solution that effectively circumvented the dangers and delivered promising results for improving the quality, efficiency, and safety of care. One of the authors comments on these outcomes in a short video featured on YouTube. So, in the future we could see the following headlines in the national press much more often: "Chips save lives in hospitals". What could help in achieving these results?

In our entry for ‘Semantic Interoperability’ Robert Stegwee asks the question “if semantic interoperability is equally important to the healthcare professional, why is it still unknown territory to the majority?”.

Similarly, how do we account for individual expectations for the use of information technology to facilitate better care for individuals? They are getting older. They are becoming more likely to suffer from a long term chronic condition. They are educated consumers with expectations of getting what they want/need whenever they desire. They have been using technology in every other part of their life and see HIT as a reasonable approach.

How will care communities deal with these expectations and demands? There are many transformational ideas and programs underway including:
• Payment for results
• Proactive care services (see example Telehealth & Telecare entry by Jason Crellin)
• Restructuring of reimbursement models
• Increasing transparency of care costs and quality of care
• Introduction of competition into national care services
• And of course, national/regional HIE, EHR, PHR, EMR implementation programs

We see that these pressures and forms of response are appearing in virtually every nation, region, and care community, demanding specific responses suited to individual needs and expectations of the players. There is a clear need to balance the expectations and the complex value network that spans these players (i.e., hospitals, general practices, clinics, diagnostic service providers, payers, government, pharmacies, volunteer organizations, and patients). There are many examples, but consider the perverse incentives that exist when attempting to implement a proactive care service or share patient information through HIT. How do we get everyone to participate? How do we realign the value proposition incorporated into the reimbursement models?

Our experience indicates that healthcare transformation will require new levels of collaboration. The collaboration needs to actively engage all parties at the same time. The collaborative process needs to be sustained beyond the onetime instances. Collaboration needs to be supported by strong communications, agreed standards, and shared views of the community’s health economy (the value network).

That’s how we approach this global challenge. What are you seeing in your care community? Is collaboration working? Are the “players” working together with new levels of connectedness and cooperation? What are the key incentives that have made this happen? We welcome your contributions, be they positive or more skeptical.

• 65 percent of respondents have gone online to learn about a medical condition, and 38 percent have used their insurance company's online tools to learn more about their care, up from 29 percent in 2007.


• The research also revealed that Americans continue to have concerns about privacy and thus require assurances from all parties that store personal data that information is secure.


• 47 percent had a preference for doctors who use EHRs and 61 percent had a preference for insurance companies who employed EHRs.


• 51 percent agreed that health IT should be a top priority for the next president to ensure that all Americans have access to their own personal medical records electronically. Kaiser Permanente is leading the way to make this vision a reality.

If you ask the same doctor on possible treatments for influenza or how to handle anaphylaxis in case of peanut allergy, the answers will come directly. This is true wherever you are in the world. If a doctor wouldn't know, many patients would probably suffer or die needlessly. A number of reports and testimonials have been published on the number of patients suffering or dying from a lack of semantic interoperability. So, if semantic interoperability is equally important to the healthcare professional, why is it still unknown territory to the majority?

The key to saving lives with semantic interoperability is to take into account any patient information that is already known and available. This availability of patient information is often the main driver behind intiatives to introduce an Electronic Health Record (EHR) in healthcare organizations, regions, or even countries. However, research shows that availability of information is not a key motivator for healthcare professionals to adopt an EHR. Their motivation lies in saving time and improving medical decision making and that is where semantic interoperability of healthcare information comes into play. If we can clearly show how saving lives translates into making money, many others might embrace the concept of semantic interoperability as well. For now, I'll focus on saving lives and leave the translation to making money for future discussion.

In order to be able to take more information into account in medical decision making, while at the same time reducing the effort to process this information, we need computers to assist the healthcare professional. The vision is to combine the vast amounts of patient information and to present them to the healthcare professionals in a form that is actually helping them to care for the patient. Some of the possible forms are medical alerts, probability distributions for specific diagnoses, suggested treatment options (including personalized medication dosage) according to guidelines, or full 3D rendering of affected parts of the body.

If we are to provide a meaningful presentation of data for the healthcare professional, the available patient information has to be interpreted by the computer system. It has to "understand" the meaning of the information (i.e. the semantics of the data). This is of even more importance when the information is coming from different healthcare organizations (and usually different computer systems). Many lives are lost because vital prior information from previous visits or other professionals was not taken into account when deciding on the proper treatment for the patient. Hence, information from different computer systems need to be shared, and therefore these systems need to work together (i.e. they need to be able to interoperate).

Given the breadth and depth of healthcare information, many years have already gone into specifying the ways in which to meaningfully share this information between computer systems. A lot has been achieved, but much more work still needs to be done. That is why meetings like the one in Gothenburg are so important. However, if we keep talking about semantic interoperability, no doctor will ever spend an extra euro or dollar on systems that support these features. Rather we should talk about meaningful ways to let information help saving lives.

Below we have identified some discussion topics that we anticipate covering in this blog, but we would like to start the dialog by exploring the topics that have the greatest interest to you – our customers and our friends in the industry.

So, what do you think of these idea? Where would you like to start the dialog?

1. Will “health information infrastructure” (EHR/EMR/PHR/HIE) improve the wellness of the population?


2. Shouldn’t individuals/patients have a say in their privacy risk management (e.g., “if sharing means I might get better, let’s make it happen”)?


3. Many say that providers gain no value from the use of health information infrastructure yet they must enter all the data for the benefit of others. Are there really opportunities for these providers?


4. How will care services delivered over the health information infrastructure be transacted for reimbursement? How will services be monitored?


5. What is the role of health information infrastructures in supporting the transactions of “payment for results”?


6. Beyond the “spin”, have we really learned how to implement a successful “health information infrastructure”?


7. What do you think about growing investment in creating clinics within retail shops (e.g., CVS, Boots, Walgreens, WalMart)? Better care for patient? More effective access to care? Better value?


8. Affordability of care is directly related to the costs that care providers are facing and ultimately their financial stability. Numerous hospitals are running in deficit. What are some of the important changes hospitals can make to improve their financial position? Success stories?


9. What options, like “pay for performance” do governments have to curb the increase in healthcare costs? How do payers and providers react to changes in these regulations? How does it empower patients?


10. How can multidisciplinary care for the chronically ill be streamlined, taking into account the possibilities and preferences of the patient? How can a social non-professional network be established to support this care?


11. Preventing illness is the best way to cut health care costs. However, some prevention solutions lead to a steep increase in diagnostic procedures and even an increase in possibly unnecessary surgical procedures? Do we need different players in the field to approach prevention from a behavioral rather than medical angle?

Now its your turn. We want and need to hear your points of view and stories of success. There are two starting points for the dialog.

First, our intial entry provides a different perspective on semantic interoperability. What are your views?

Second, the topic list above is a starting point, but we need to know the topics YOU would like (us) to cover.