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Aisis - 2013 Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità The Value of ICT for Health,

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Presentazione sul tema: "Aisis - 2013 Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità The Value of ICT for Health,"— Transcript della presentazione:

1 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità The Value of ICT for Health, Efficiency and Growth: Balancing Evidence and Innovation Claudia Pagliari PhD FRCPE University of Edinburgh eHealth Research Group Convegno Annuale AISIS, Firenze, 15 Novembre 2013

2 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Focus of talk –Dual agendas of growth & health –Vision for transformation & benefits –Complexity & risk –Deconstructing the value chain –Call for evidence-based, citizen- centric eHealth

3 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità The global healthcare IT market is estimated to reach $ 56.7 billion by 2017 from $40.4 billion in 2012 researchandmarkets.com 2013 Report on the Global Healthcare IT Market - with Forecasts to 2017 (Report costs GBP 2923 !!) 2013 Report on the Global Healthcare IT Market - with Forecasts to 2017 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. Health IT is Big Business

4 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Hot areas for spending & investment Big Data & Analytics mHealth, Telehealth & Smart Care Personal health & wellness systems Personalised & genomic medicine Clinical Information Systems (EHR, CDSS, ePrescribing, Portals)

5 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Technologies Stakeholders Vendors, Payers, Brokers, Analysts, Users Applications Complex Ecosystem(s)

6 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Pillar 1: A vibrant digital single market Pillar 2: Interoperability and standards Pillar 3: Trust and security Pillar 4: Fast and ultra-fast Internet access Pillar 5: Research and innovation Pillar 6: Enhancing digital literacy, skills and inclusion *Pillar 6: Enhancing digital literacy, skills and inclusion Pillar 7: ICT-enabled benefits for EU society eHealth eGovernment Digital Society Digital Economy Digital Agenda for Europe

7 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità 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 & Health perfectly compatible? Economic & social benefit

8 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità 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 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Vision statements from industry & governments are overwhelmingly positive The Vision Thing

10 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità underpinning theme… Shared 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 105 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, Intel 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. Transformation

11 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Telehealth can bring –Convenience e.g. in-home care –Portability e.g. mobile self- monitoring –Accessibility e.g. reduced travel need –Flexibility e.g. time/format/place Stating the obvious HIS/EHR/HIE can improve –Documentation –Data transfer –Billing –Data reuse –Efficiency? –Quality? –Safety?

12 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità eHealth will –A) save money –B) improve patient outcomes e.g. "mHealth …solutions deliver health " The BIG Promises

13 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità $ vendors & purchasers rush towards telehealth AISIS 2013

14 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Where are we? (It depends…)

15 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Bellagio e-Health evaluation declaration 2011 AISIS 2013 The Evidence-Hype Chasm

16 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità "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. 5 th December 2011 Headline findings announced in Parliament long before trial results were published. Researchers conclusions more cautious … If used correctly… Dangers in over selling

17 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità 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..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 Henderson et al (2013) Economic evaluation of telehealth in the Whole System Demonstrator Fast forward …

18 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Testing the Value Proposition Telehealth will save money by supporting healthy living with LTC, keeping the elderly out of hospital But what will it cost to implement? Is it the technology that makes the difference? Telehealth will make money by offering sellable benefits But what type ( e.g. choice, convenience, access, life years, monetary savings), and to whom? The market is willing to pay which markets (provider, insurer, government, citizen, patient, carer) and why?

19 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Complexity, impact & value What you think youre buying (off-the-shelf solution) may not be the same as what youre 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) procurement Sponsored evaluations typically last <6 mth Dilemma for modernisation

20 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Unpicking the value chain Insights from telehealth research in Edinburgh AISIS 2013

21 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Supported COPD monitoring PhaseDriverIntervention?MethodSponsor Procure- ment Sale of concept by major vendor. Goal to reduce admissions through home telehealth Tech: VC, monitoring, decision support, education Vision: Nexus of GP & patient Researchers flag importance of formative evaluation Design & set-up Questions over readiness, fit, configuration Planning process shifts emphasis to nurse-led service with call-centre Qualitative observation & interviews Technology supplier Trial in practice Need for evidence of value & safety Specialist nurse-led service with or without telehealth. No call centre or VC RCT with embedded qualitative Study Gov. research programme Quantitative: 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 & optimisation Pinnock et al, (2013, BMJ); Stoddart et al (2013, BMJ Open); Ure et al (2011, PCRJ)

22 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità mHealth for asthma PhaseDriverIntervention?MethodSponsor Formative pilot Producer seeking insights to inform developments Mobile self-monitoring via peripherals with automated feedback Qualitative studyIndustry Trial in practice Need for evidence of outcomes & practicality Updated version of product RCTAsthma charity Quantitative –No difference in clinical outcomes –Both groups improved, suggesting telehealth not the critical factor (care optimised in both groups) –Phone more expensive Qualitative Most likely to be used by people adapting to asthma –Issue for market segmentation & value Ryan et al. (2012) British Medical Journal 344:e1756 Pinnock et al. (2009) Clin Exp All 37

23 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità PhaseDriverIntervention?MethodSponsor Post market Academic & clinician interest Common consumer device purchase Equivocal evidence Mobile reminders to check BP using peripherals linked to mobile phone. Automated feedback & advice with weekly clinician review and immediate response if outwith safe thresholds RCTGovernment health research agency + supplier (kit) Results from trial: –Significant improvement in BP compared to usual care. No difference in other outcomes –Increased prescription of drugs in the actively monitored group. –Clinician and nurse time (and cost) also increased Interpretation: –Telehealth made readings impossible for primary care staff to ignore, leading to increased use of antihypertensives, but did not influence patient lifestyle –Technology as catalyst, not cause Padfield et al (2012) Early Results from the Health Impact of Telemetry- Enabled Self-monitoring (HITS) Trial. Conference paper. British Hypertension Society Supported home BP monitoring AISIS 2013

24 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità mHealth for paediatric diabetes PhaseDriverIntervention?MethodSponsor Development & evaluation Poor medication compliance in adolescents. Reported benefits of costly goal-directed interventions Scheduled SMS messages tailored to personalised clinical goals and motivational drivers (push support) RCT with embedded qualitative study Diabetes charity and mobile network provider Quantitative : –No difference in Hba1c compared to usual care –Increase in clinic visits –Increase in self-efficacy and self-reported adherence Qualitative: –Patients actively sought interaction with a system designed mainly to push messages –Some believed the automated messages were coming from a human –Soft benefits (e.g. self-efficacy) may add value downstream e.g. aiding transition to intensive insulin therapy Franklin et al (2006 ) Diabetic Medicine Franklin et al (2008) JMIR 10 (2)

25 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità So, where is the value-add? Intended & realised benefits dont always match Users co-create value e.g. though general quality improvement, unmeasured consumer benefits etc. …and risks e.g. dependency on automated agents; ineffective workarounds; subversion e.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 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità 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 Plan Health 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 Key messages from the literature

27 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Growth & health are imperfectly aligned as outcomes of innovation. The Field of Dreams hypothesis is risky Without better evidence current levels of spending on cant easily be justified Dilemma for modernization vs evidence cycles Creative paradigms needed to evaluate HIT programmes while they happen Value creation and RoI can be hard to capture, as human & technical systems interact Evaluation should take account of the citizen and not just the health system The risks of not evaluating will grow as evidence-based purchasing becomes the norm Concluding thoughts

28 Aisis Associazione Italiana Sistemi Informativi in Sanità Valutazione del Valore derivante dallutilizzo di ICT in Sanità Thank You


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