Claudia Pagliari PhD FRCPE Convegno Annuale AISIS, 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

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 I will give examples of expected and actual value shown in several telehealth projects in Edinburgh CPagliari16/5/13

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 2013 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 2012-2020 - Innovative healthcare for the 21st century.

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) Big Data & Analytics (underpinned by better capture and integration) Telehealth and mHealth (to move care from expensive state-run settings to communities Clinical information systems, Electronic Health Records, Decision Support, Health Information Exchange Integration and portal technologies for coordination and efficiency Standards & Health Information Exchange Imaging Personalised med etc falling out of biomedical informatics and genomics.

Vendors, Payers, Brokers, Analysts, Users Complex Ecosystem(s) Technologies Stakeholders Vendors, Payers, Brokers, Analysts, Users Applications HIT is a complex landscape characterised by multiple, intersecting ecosystems. CPagliari16/5/13

Digital Agenda for Europe 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 7: ICT-enabled benefits for EU society Digital Society Digital Economy eHealth eGovernment CPagliari16/5/13

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. http://www.ncbi.nlm.nih.gov/pubmed/23510978 ) But are the agendas for Growth & Health perfectly compatible? CPagliari16/5/13

“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

‘The Vision Thing’ Vision statements from industry & governments are overwhelmingly positive

“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. http://www.scotland.gov.uk/Resource/Doc/357616/0120849.pdf “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 http://www.ihealthbeat.org/features/2011/mhealth-closing-the-gap-between-promise-and-adoption.aspx#ixzz2TvzDCwn4 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 CPagliari16/5/13

Stating the obvious HIS/EHR/HIE can improve Telehealth can bring Documentation Data transfer Billing Data reuse Efficiency? Quality? Safety? 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

B) improve patient outcomes The BIG Promises eHealth will A) save money B) improve patient outcomes e.g. "mHealth …solutions deliver health " www.mhealthalliance.org/about/frequently-asked-questions

2010-13 vendors & purchasers rush towards telehealth $ 2010-13 vendors & purchasers rush towards telehealth AISIS 2013

Where are we? (It depends…)

The Evidence-Hype Chasm Bellagio e-Health evaluation declaration 2011 AISIS 2013

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 2011 Headline findings announced in Parliament long before trial results were published. Researchers’ conclusions more cautious … “If used correctly…”

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

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?

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) procurement Sponsored evaluations typically last <6 mth Dilemma for modernisation

Unpicking the value chain Insights from telehealth research in Edinburgh AISIS 2013

Supported COPD monitoring Phase Driver Intervention? Method Sponsor 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)

mHealth for asthma Phase Driver Intervention? Method Sponsor Formative pilot Producer seeking insights to inform developments Mobile self-monitoring via peripherals with automated feedback Qualitative study Industry Trial in practice Need for evidence of outcomes & practicality Updated version of product RCT Asthma 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

Supported home BP monitoring Phase Driver Intervention? Method Sponsor 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 RCT Government 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 AISIS 2013

mHealth for paediatric diabetes Phase Driver Intervention? Method Sponsor 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)

So, where is the value-add? Intended & realised benefits don’t 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

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 Plan 2012-202 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;20:212-217 doi:10.1136/amiajnl-2012-000821

Concluding thoughts Growth & health are imperfectly aligned as outcomes of innovation. The ‘Field of Dreams’ hypothesis is risky Without better evidence current levels of spending on can’t 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

Thank You claudia.pagliari@ed.ac.uk