Presentazione sul tema: "Claudia Pagliari PhD FRCPE Convegno Annuale AISIS,"— Transcript della presentazione:
1 Claudia Pagliari PhD FRCPE Convegno Annuale AISIS, The Value of ICT for Health, Efficiency and Growth: Balancing Evidence and InnovationClaudia Pagliari PhD FRCPEUniversity of EdinburgheHealth Research GroupConvegno Annuale AISIS,Firenze, 15 Novembre 2013
2 Focus of talk Dual agendas of growth & health Vision for transformation & benefitsComplexity & riskDeconstructing the value chainCall for evidence-based, citizen-centric eHealthI will give examples of expected and actual value shown in several telehealth projects in EdinburghCPagliari16/5/13
3 Health IT is Big Business The global healthcare IT market is estimated to reach $ 56.7 billion by 2017 from $40.4 billion in 2012 researchandmarkets.com Report on the Global Healthcare IT Market - with Forecasts to 2017 (Report costs GBP 2923 !!)The global telemedicine market alone is expected to reach $27.3 billion in 2016, from $9.8 billion in 2010 & $11.6 billion in 2011, representing 18.6% annual growth EC eHealth Action Plan Innovative healthcare for the 21st century.
4 Hot areas for spending & investment Big Data & Analytics mHealth, Telehealth & Smart CarePersonal health & wellness systemsPersonalised & genomic medicineClinical Information Systems (EHR, CDSS, ePrescribing, Portals)Big Data & Analytics (underpinned by better capture and integration)Telehealth and mHealth (to move care from expensive state-run settings to communitiesClinical information systems, Electronic Health Records, Decision Support, Health Information ExchangeIntegration and portal technologies for coordination and efficiencyStandards & Health Information ExchangeImagingPersonalised med etc falling out of biomedical informatics and genomics.
5 Vendors, Payers, Brokers, Analysts, Users Complex Ecosystem(s)TechnologiesStakeholdersVendors, Payers, Brokers, Analysts, UsersApplicationsHIT is a complex landscape characterised by multiple, intersecting ecosystems.CPagliari16/5/13
6 Digital Agenda for Europe Pillar 1: A vibrant digital single marketPillar 2: Interoperability and standardsPillar 3: Trust and securityPillar 4: Fast and ultra-fast Internet accessPillar 5: Research and innovationPillar 6: Enhancing digital literacy, skills and inclusion *Pillar 7: ICT-enabled benefits for EU societyDigital SocietyDigital EconomyeHealtheGovernmentCPagliari16/5/13
7 Economic & social benefit “Growth and growth enhancing policies are among the top priorities of the EU policy agenda to overcome… economic and societal challenges. eHealth plays an important role in reaching this objective”2013 European Commission, DG SANCO. )But are the agendas for Growth & Healthperfectly compatible?CPagliari16/5/13
8 “The European Innovation Partnership for active and healthy ageing [aims to achieve] a triple win… better health for ….citizens, sustainable health systems and a competitive market of innovative products ...” ec.europa.eu/.../2012_sanco_017_active_and_healthy_ageing_en.pdf
9 ‘The Vision Thing’Vision statements from industry & governments are overwhelmingly positive
10 “Transformation” underpinning theme… “eHealth has a pivotal role in enabling a radical e-transformation in the way in which high quality integrated healthcare services are delivered” Nicola Sturgeon, Scottish Government.“mHealth is about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviours” Rick Cnossen, IntelShared knowledge platforms will result in a “horizontal alignment” of patients and clinicians…e.g. Marceglia et al (2012) How might the iPad change healthcare? Jn Royal Soc Med 105CPagliari16/5/13
11 Stating the obvious HIS/EHR/HIE can improve Telehealth can bring DocumentationData transferBillingData reuseEfficiency?Quality?Safety?Telehealth can bringConveniencee.g. in-home carePortabilitye.g. mobile self-monitoringAccessibilitye.g. reduced travel needFlexibilitye.g. time/format/place
12 B) improve patient outcomes The BIG PromiseseHealth willA) save moneyB) improve patient outcomese.g. "mHealth …solutions deliver health "
13 2010-13 vendors & purchasers rush towards telehealth $vendors & purchasers rush towards telehealthAISIS 2013
15 The Evidence-Hype Chasm Bellagio e-Health evaluation declaration 2011AISIS 2013
16 Dangers in ‘over selling’ "We've trialled it, it's been a huge success, and now we're on a drive to roll this out nationwide," ... "The aim - to improve three million lives over the next five years”UK Prime Minister David Cameron. 5th December 2011Headline findings announced in Parliament long before trial results were published. Researchers’ conclusions more cautious … “If used correctly…”
17 Fast forward …“..Home telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only…Telehealth did not improve quality of life or psychological outcomes “Cartwright et al (2013) Evaluation of patient reported outcomes in the Whole System Demonstrator“The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher..Telehealth does not seem to be a cost effective addition to standard support and treatment”Henderson et al (2013) Economic evaluation of telehealth in the Whole System Demonstrator
18 Testing the Value Proposition Telehealth will save moneyby supporting healthy living with LTC, keeping the elderly out of hospitalBut what will it cost to implement?Is it the technology that makes the difference?Telehealth will make moneyby offering sellable benefitsBut what type (e.g. choice, convenience, access, life years, monetary savings), and to whom?The market is willing to paywhich markets (provider, insurer, government, citizen, patient, carer) and why?
19 Complexity, impact & value What you think you’re buying (off-the-shelf solution) may not be the same as what you’re actually getting (opportunity to reconfigure your service)Need to ask:What process changes are needed to implement this service?What is the real change agent?Likely costs vs. savings?Will early losses give way to long-term gains?Risks of vision-based (not evidence-based) procurementSponsored evaluations typically last <6 mthDilemma for modernisation
20 Unpicking the value chain Insights from telehealth research in EdinburghAISIS 2013
21 Supported COPD monitoring PhaseDriverIntervention?MethodSponsorProcure-mentSale of concept by major vendor. Goal to reduce admissions through home telehealthTech: VC, monitoring, decision support, educationVision: Nexus of GP & patientResearchers flag importance of formative evaluationDesign & set-upQuestions over readiness, fit, configurationPlanning process shifts emphasis to nurse-led service with call-centreQualitative observation & interviewsTechnology supplierTrial in practiceNeed for evidence of value & safetySpecialist nurse-led service with or without ‘telehealth’. No call centre or VCRCT withembedded qualitative StudyGov. research programmeQuantitative: No difference in admissions or mortality. Clinical indicators improve in both trial arms. Prescribing costs increase.Qualitative. Vision very different from what emerged. Patient satisfaction high (perceived safety, access, legitimisation). Uncertainty over ‘normal’ readings. Key change agents: high nurse-patient engagement; service redesign & optimisationPinnock et al, (2013, BMJ); Stoddart et al (2013, BMJ Open); Ure et al (2011, PCRJ)
22 mHealth for asthma Phase Driver Intervention? Method Sponsor Formative pilotProducer seeking insights to inform developmentsMobile self-monitoring via peripherals with automated feedbackQualitative studyIndustryTrial in practiceNeed for evidence of outcomes & practicalityUpdated version of productRCTAsthma charityQuantitativeNo difference in clinical outcomesBoth groups improved, suggesting telehealth not the critical factor (care ‘optimised’ in both groups)Phone more expensiveQualitativeMost likely to be used by people adapting to asthmaIssue for market segmentation & valueRyan et al. (2012) British Medical Journal 344:e1756Pinnock et al. (2009) Clin Exp All 37
23 Supported home BP monitoring PhaseDriverIntervention?MethodSponsorPost marketAcademic & clinician interestCommon consumer device purchaseEquivocal evidenceMobile reminders to check BP using peripherals linked to mobile phone. Automated feedback & advice with weekly clinician review and immediate response if outwith safe thresholdsRCTGovernment health research agency + supplier (kit)Results from trial:Significant improvement in BP compared to usual care. No difference in other outcomesIncreased prescription of drugs in the actively monitored group.Clinician and nurse time (and cost) also increasedInterpretation:Telehealth made readings impossible for primary care staff to ignore, leading to increased use of antihypertensives, but did not influence patient lifestyleTechnology as catalyst, not causePadfield et al (2012) Early Results from the Health Impact of Telemetry-Enabled Self-monitoring (HITS) Trial. Conference paper. British Hypertension SocietyAISIS 2013
24 mHealth for paediatric diabetes PhaseDriverIntervention?MethodSponsorDevelopment & evaluationPoor medication compliance in adolescents.Reported benefits of costly goal-directed interventionsScheduled SMS messages tailored to personalised clinical goals and motivational drivers (‘push support’)RCT with embedded qualitative studyDiabetes charity and mobile network providerQuantitative :No difference in Hba1c compared to usual careIncrease in clinic visitsIncrease in self-efficacy and self-reported adherenceQualitative:Patients actively sought interaction with a system designed mainly to ‘push’ messagesSome believed the automated messages were coming from a humanSoft benefits (e.g. self-efficacy) may add value downstream e.g. aiding transition to intensive insulin therapyFranklin et al (2006 ) Diabetic MedicineFranklin et al (2008) JMIR 10 (2)
25 So, where is the value-add? Intended & realised benefits don’t always matchUsers co-create valuee.g. though general quality improvement, unmeasured consumer benefits etc.…and riskse.g. dependency on automated agents; ineffective workarounds; subversione.g.Trust in digital assistants (Pagliari et al 2012, St Health Tech Inform 181: Effects of CDSS fatigue . Kesselheim et al. 2012, Health Affairs, 30, no.12
26 Key messages from the literature Large gap between stated and proven benefits of eHealth technologies. Evaluative evidence needed to guide investments decisions Black AD, Car J, Pagliari C, Anandan C, Cresswell K, et al. (2011) The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview. PLoS Med 8(1):Barriers to deployment include limited large-scale evidence of cost-effectiveness, lack of reimbursement models; high start-up costs.European Commission eHealth Action PlanHealth IT cannot by itself improve health value, but it can make possible new care delivery models to achieve much larger value.Payne TH, Bates DW et al. Healthcare information technology and economics. J Am Med Inform Assoc 2013;20: doi: /amiajnl
27 Concluding thoughtsGrowth & health are imperfectly aligned as outcomes of innovation. The ‘Field of Dreams’ hypothesis is riskyWithout better evidence current levels of spending on can’t easily be justifiedDilemma for modernization vs evidence cyclesCreative paradigms needed to evaluate HIT programmes while they happenValue creation and RoI can be hard to capture, as human & technical systems interactEvaluation should take account of the citizen and not just the health systemThe risks of not evaluating will grow as evidence-based purchasing becomes the norm