November 2006

E-HEALTH AND THE HEALTHCARE SYSTEM

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Acommonly accepted definition of e-Health is the application of Information and Communi-cation Technologies to all of the activities of health care.  The benefits derived from e-Health apply to both health systems at large, “public health,” and the individuals they serve.  Shall we be proud of our accomplishments to date? What are the real issues?

What can a digital health system accomplish?
A fully digital health system can improve service at so many levels, that no list can be exhaustive.  Some of the key benefits of e-Health include:

• Individual medical error is reduced, whether for diagnosis or prescription thanks to increased coordination among healthcare professionals and realtime access by healthcare profe-ssionals to quality information resources
• Greater medical coverage and follow-up are ensured, thanks to both telemedicine consultations and continuous monitoring devices
• Toxic products can be more quickly withdrawn, since pharmacological side effects can be flagged through large-scale use of electronical medical records
• Epidemics can be spotted sooner
• Emergency transport is reduced, and appointments are better programmed
• Primary prevention is facilitated, through the identification of at-risk profiles
• Patient compliance can be improved through reminder services
• Redundant services are reduced, freeing resources for other tasks
• Costs can be better evaluated, because the information is available and policies adjusted accordingly
• Last but not least: citizen-patients can be reassured by the quality of such a system, its integrated control mechanisms, and their own ability to access their full medical information from anywhere in the world

eHealth is a work in progress. Many countries have named a national coordinator or  taskforce, or at a minimum assigned the subject to the tasks of the national health ministry. But no national system provides all of the e-Health services at the present time

How far have e-Health systems progressed?
e-Health is a work in progress. Many countries have named a national coordinator or  taskforce, or at a minimum assigned the subject to the tasks of the national health ministry. But no national system provides all of the above services at the present time.

The Veterans Health Administration, an integrated health system serving American veterans, comes closer than most in taking advantage of e-Health. VISTA (Veterans’ Health Information System and Technology Architecture) is an integrated clinical database and electronic medical records system that supports the daily management and delivery of health care services. VISTA has the largest number of active electronic medical records in the world;  approximately five million.  Medication error in VA hospitals has been brought to near zero. The medical reminder and alert system is active at all consultations.

The largest health maintenance organisation in the US, Kaiser Permanente, counting 8 million members, is also rolling out its ‘HealthConnect’ program  that integrates the clinical record with appointments, registration and billing.

Both the Veterans Health System and Kaiser Permanente are recognized for their accomplishments in terms of quality of care made possible by the e-Health component of their system. The Veterans Health System has been especially cited for its respect of quality guidelines, which is significantly superior to other systems.
While these are both extremely impressive, the total population served by electronic medical records in the United States represents four percent of the 300 million Americans.

The Scandinavian countries have a long tradition of computerisation, electronic records, and telemedicine. But none of them offers all of these services to all citizens.

The National Health Service in the UK or NHS, has embarked on a 10-year programme aiming to make the UK fully “connected for health,” by linking all 30,000 professionals and 300 hospitals, creating an active EMR (Electronic Medical Report) for each citizen, implementing a booking service and electronic prescription. However, the programme ‘Connecting for Health’ has become a highly divisive, political issue. Delays and public criticism are in the forefront of British media.

Why is e-Health not yet more advanced?

1.  e-Health has been asked to satisfy changing objectives.
The definition of e-Health’s priorities has evolved, impacting the nature of the plans made to further e-Health’s develop-ment. New goals have been added on top of previous ones, making it increasingly difficult to satisfy expectations. The first objective to gain national and international attention was the elimination of medical error thanks to e-Health, as stated by Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, of the Committee on Quality of Health Care in America, Institute of Medicine.  A report by the Institute of Medicine in 1999 estimated that  tens of thousands of Americans died each year from errors that could have been avoided, given a more computerised health system.
This objective was followed by a second goal announced in various European countries and in the United States, of using e-Health to reduce the cost of healthcare by eliminating redundant prescriptions and consultations.  A third objective is for e-Health to help make health systems more patient-centric. And a fourth is to use e-Health to eliminate fraud in health reimbursement systems.

2. Cost-benefit analyses of e-Health are inconclusive
Cost-benefit analysis in healthcare is itself a recent discipline.  So, for a strictly cost-oriented decision maker, it would be premature to make e-Health a priority without more research, although the clinical results are generally excellent.
When the Rand Institute simulated the potential savings of a health system (Hillestad et al, ‘Can electronic medical record systems transform health care? Potential health benefits, savings, and costs’, Health Affairs, Sep-Oct 2005) wherein 90% of the population would benefit from an EMR,  the results were quite different from what would be expected. The greatest gains were found in the reduction of hospital stays and in prevention programs, rather than in ordinary medical practice.

Benefit of Prevention programs made possible by e-Health


Motivated by the lack of cost-benefit data in Europe, the European Commission published a study in 2004 (www.cfst.dk/dwn9144)  regarding the cost benefit of electronic patient referral letters in Denmark. The authors sought to answer the question of whether it is cheaper to communicate a referral letter between private practices and a hospital, by post, fax, or email.

Why pick the  seemingly small and unexciting subject of ‘transferral’ letters? By focusing on a very specific, low tech question, the authors were able to pro-vide solid data. And this study provided the opportunity to examine the econo-mics of the ill-understood relationship between hospital and in-city practice.

The precision of the analysis was remarkable. The conclusion was that an emailed referral generated a savings of  USD 0.82 per year per Danish inhabitant, despite the required infrastructure. The result was based, to a large extent, on the 1,33 days gained by the electronic message. Extrapolated to a country of the size of France, the gain would be the equivalent of USD 51.04 million.



3.  e-Health programs benefit little from knowledge transfer
We have a long way to go before a cost-benefit analysis, as thorough as the Danish example, can be applied to all of the steps of eHealth. Health systems are complex and generate too much information to analyse thoroughly, in terms of cost benefit.  Communication among IT specialists internationally has not  led to a true transfer of knowledge and experience among the
key programs. The variation in size of budget and cost per inhabitant in eHealth programs confirms that the programs are quite different in scope and definition; there are for example, ‘small budget’ and  ‘large budget’ programmes, the former spending under USD 25.53 per person per year, the latter ten times as much.
How do these different countries define infrastructure? Can the electronic medical record be a fully operational file in the ‘small budget’ countries?  Does  a large budget  lead to greater success?

4. Citizens are not pushing policymakers to support e-Health
People who do not work in the field of e-Health have little or no reason to be informed about the subject. They are therefore not pushing policymakers to support e-Health, and many oppose e-Health on the grounds of insufficient protection of confidential data.  Professionals will also be allowed to withhold information that they consider it dangerous for the patient to see. While lawmakers felt that this was the price to pay for the creation of the electronic medical record, one can regret that the full potential of the EMR will not be attained.

5. The burden of the conversion to e-Health systems may appear unfair
The introduction of e-Health practices  changes the business of medicine, directly impacting the professionals working in the system.  Integrated healthcare systems are better able than others to absorb that impact.

Why should one hospital or practitioner bear the cost of new tools, enabling them to link up to other hospitals and medical practices? 
Why should professionals accept the fact that their records suddenly become available for inspection and comparison, unless they report to an employer who makes this mandatory?

If new software lengthens the duration of an appointment, how will healthcare professionals get through their workload, unless adjustments have been made elsewhere in the system?
We can see through these examples that  integrated healthcare systems are at an advantage in adopting e-Health measures. They can develop pilot operations and roll them out, benefit from economies of scale, and establish clear targets for the healthcare professionals and organisations they run. 

What are the components of an e-Health system? 
A fully digital national e-Health system would include:

• A wired infrastructure providing ubiquitous broadband access,
• Computer workstations and mobile devices for professionals, available on site at consultations, operating rooms, emergency areas, ambulances and so forth
• Intuitive software programs for electronic medical records, assisted diagnosis, and prescription
• Telemedicine programmes linking patients to specialists
• Phone triage systems for patients seeking assistance
• Monitoring devices for the chronically ill
• Professionals trained in the use of hard and software and motivated to use the above
• Well-informed citizens who take an active role in their own health-maintenance programs

How do we get there?
We have made remarkable progress in the past ten years, in terms of introducing the connected computer to healthcare. If we wish to truly take advantage of all that e-Health can offer,  we need to transform healthcare itself into an integrated industry, where teamwork, process control, and evaluation are ordinary facts of life.

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