MIE 2005 eHealth Impact A context-adaptive method of evaluating the economic impact of eHealth methodological approach and work in progress

E.C. Project: eHealth Impact Empirica Empirica Gesellschaft für Technologieforschung, Bonn, Germany Tanjent Consultancy, Hereford, UK Tanjent Consultancy, Hereford, UK EUMEDES Agency, München, Germany EUMEDES Agency, München, Germany Dr. Karl Stroetmann Dr. Karl Stroetmann Dr. Veli Stroetmann Dr. Veli Stroetmann Tom Jones, FRSA Tom Jones, FRSA Dr. Wendelin Schramm Dr. Wendelin Schramm

eHealth Impact Workshop Background Earlier research Methods and tools Two case studies Discussion – please interrupt

MIE 2005 e-Health Impact [e-hi] QualityAccessCost-effective = Economic and productivity

e-Health Impact Goals eHI promotes proven e-Health eHI promotes proven e-Health eHI identifies e-Health eHI identifies e-Health benefits benefits costs costs productivity productivity Publicly available tool & knowledge for evaluation & future investment Publicly available tool & knowledge for evaluation & future investment

e-Health Measurements Who Who Why Why What What How How Where Where When When Who benefits Who benefits

RehabilitationTherapyDiagnosisPreventionFollow-up Integrate, Interprete, Decide, Act Professional Monitoring e-Health Communicate, Store, Aggregate, Compare, Report, Remind, Warn The Ideal Situation

RehabilitationTherapy Diagnosis PreventionFollow-up Integrate, Interprete, Decide, Act Professional Monitoring e-Health Communicate, Store, Aggregate, Compare, Report, Remind, Warn The Real Situation Social insurance fragmentation

Numerous and Diverging Stakeholder Demands Patients Patients Handicapped and Elderly Persons Handicapped and Elderly Persons Physicians Physicians Hospitals Hospitals Pharmaceutical industry Pharmaceutical industry Care management service providers Care management service providers Health insurance Health insurance Healthcare politics and decision making Healthcare politics and decision making Publishers Publishers Suppliers Suppliers New players New players

Community Products & Services Health Portals Demand Management Electronic Health Record Hospital Information System Mobile Computing Triage System Digital Imaging And many more… Health Politics Decision Making System Development Health Financing Health Standards Science patient provider payer e-Health Interfaces

Hospital Home GP practice / public primary care centre Re-imburser / insurance Home Nursing Educational Centres Outpatie nt Dept. Speciali st Referral / Feedback Referral / Discharge Request & Result Referral / Feedback Request & Result Referral / Feedback Other Speciali st Other GP Peer Consultation Pharma cy Prescripti on Home Care Continui ng Medical Educatio n Administration Disease Surveillance etc. Activity Reports Notifiable Diseases Pharma cy Peer Consultation claims / payments Patient Services (imaging, ultrasound, laboratory etc.) Request & Result

About Evidence From a complex system… …seeking evidence represents a complex process … so, no simple solutions

- Clinical trials / intervention studies - Epidemiological studies - Metaanalyses / systematic review and many more … Evidence based Clinical Guidelines Health Technology Medicine Assessment Clinical Pathways Disease Management Programme Evidence in practice Clinical research Productions of evidence Registration Origins of Evidence Is eHI here? …

RehabilitationTherapyDiagnosisPreventionFollow-up Integrate, Interprete, Decide, Act Professional Monitoring e-Health Communicate, Store, Aggregate, Compare, Report, Remind, Warn The Ideal Situation

Why Models? Stucture Evidence Stucture Evidence Standardised Comparisons Standardised Comparisons Identify variables and levers Identify variables and levers Simulate the future Simulate the future Supports decision making Supports decision making

An Example Diabetes Care pilot contracts in several German countries: Diabetes Care pilot contracts in several German countries: Target: integrated care, improving quality of diabetes care AND being economical Target: integrated care, improving quality of diabetes care AND being economical Introduction of a type-2.2 diabetes: „not likely to reach diabetes related complications“ Introduction of a type-2.2 diabetes: „not likely to reach diabetes related complications“ Saxonia-Anhalt: „completing the age of 65“ Saxonia-Anhalt: „completing the age of 65“ The consequence: Later referral to diabetologists, less tight metabolic control, less education, (less expenditure for elderly, discrimination of women ?) The consequence: Later referral to diabetologists, less tight metabolic control, less education, (less expenditure for elderly, discrimination of women ?)

CE of Diabetes Care for the Elderly CLYG [€]

CE of Diabetes Care for the Elderly CLYG [€]

Why Models? Stucture Evidence Stucture Evidence Standardised Comparisons Standardised Comparisons Identify variables and levers Identify variables and levers Simulate the future Simulate the future Supports decision making Supports decision making „Imagination is more important than knowledge“ ( Albert Einstein )

Stop 1 Questions and comments on this section Questions and comments on this section Room for Discussion Room for Discussion

Earlier research

Factors not included Development, implementation, operating Procurement Project management Training Help desk … >

Earlier research >… factors not included Change management Unit costs AffordabilityObsolescenceFinancing

Earlier research Two previous case studies Patient costs and benefits Providers costs and benefits E-health utilisation Development implementation operation

Earlier research Two previous case studies Net economic return - 5 to 6 years First impact - two years from live Provider investment cost Patients benefit Need sustained resources Utilisation drives benefits

Earlier research Two previous case studies e-health findings Quality and effectiveness Improved work setting Better resource utilisation Balance financial focus

Earlier research E-health investment should be approached as a clinical development

e-hi methods and tools Three steps EvaluationForecasting Initial business case model

Methods and tools Cost benefit analysis (CBA) Cost effectiveness analysis (CEA) ? BreakevenProductivityAffordability Business cases

Methods and tools CBA Impact on all actors in communities Future marginal benefits Future marginal costs Monetary value attached to benefits over time

is not concerned with cost saving is not concerned with cost saving CBA Evaluation AcceptEvaluate Refuse Cost Benefits

Methods and tools CEA Aims to find the minimum cost of meeting a given target Benefits not estimated Benefits not estimated Not used by e-hi so far X

Practice data rarely available Practice data rarely available CBA based on patient cohorts from different countries CBA based on patient cohorts from different countries Subgroup analysis is not available Subgroup analysis is not available Transfer between different healthcare systems? Transfer between different healthcare systems? Precision of findings (π) ? Precision of findings (π) ? Should be updated when new evidence available Should be updated when new evidence available Limitations of eHI

Methods and tools Development of costs and benefits

Methods and tools Productivity Unit costs Throughput per person Resource utilisation

Methods and tools Marginal change in productivity

Methods and tools Affordability Not part of e-hi evaluationsX … but, e-health needs long term financing to change and restructure resources

Methods and tools Business cases Economic case - quality, access, cost effective Financial case – affordability, sustainable finance Select the right e-health application

Methods and tools Data Point of care and e-health use Healthcare providers’ resources Patients and carers Data needed for healthcaree-health application Costs Healthcare service range Access goals Disease, diagnosis or treatment group Workload Benefits Clinical and working practices Quality standards

Methods and tools Sensitivity analysis Tests and underpins all analysis

Data / Information collected 3 time periods Planning & development stage Implementation stage Running stage for routine operation 3 settings: 3 settings: service without eHealth service without eHealth service with eHealth service with eHealth estimate for a service without eHealth that has been replaced by eHealth estimate for a service without eHealth that has been replaced by eHealth Development costs Development costs Investments Investments Change management Change management Project management Project management Running cost of health services Running cost of health services Benefit for patients, professionals and payers Benefit for patients, professionals and payers information is needed on the numbers of: -patients serviced -items processed, such as x-rays, drugs, analyses and messages -colleagues serviced, such as second opinion, expert consultancies -prices and costs before and after attached to these services for each unit of workload Benefits for patients These include: Faster service Time saved Better information Longer life Faster recovery Less pain and stress Benefits for professionals, nurses, other staff, administration These include: More reliable data Improved access to data Better communications Improved effectiveness Improved efficiency.

Stop 2 Questions and comments on this section Questions and comments on this section Room for Discussion Room for Discussion

Two case studies Flanders Vaccination Database NHS Direct Online

Kind & Gezin Flanders vaccination database Vaccination goals Data for plans and strategies Productivity solution In-house development

Kind & Gezin Long term trends Sustainable economic benefit from productivity gains

Kind & Gezin

Patient benefits Significant impact on the economic case Quality Access Cost-effective

Kind & Gezin

Productivity Sustainable improvements Stable resources

Kind & Gezin

Developments Vaccinet – online ordering and stock control underway More users Citizen access to vaccination record

Kind & Gezin Vaccination Database Utilisation

Stop 3 Questions and comments on this section Questions and comments on this section Room for Discussion Room for Discussion

Business Case Model E-health impact KnowledgePossibilitiesReturnsRisks

Business case E-health impact Possibilities need imagination and vision Do all decision takers have these to succeed?

Business case E-health impact Annual returns from about year 3 Cumulative returns beyond year 6 Depend on right e-health Change management

Business case E-health impact Risks of optimism years 1 to 2 Underestimating impact years 6 to 10 Understating costs Overstating benefits

Business cases investment framework technical assessment service development financial and economic case patient benefits provider e-health investment decisions

Business cases investment framework market share demand management increased volumes extra income provider e-health investment decisions

Business cases critical factors change management benefits realisation plan patient dialogues better performance provider e-health investment decisions

eHealth Impact Model

NHS Direct Online Information service Health encyclopaedia Best treatments Self-help guide Directories of local health services …>

NHS Direct Online >… Information service Common health questions Interactive tools health space for Personal information Personal health enquiries

NHS Direct Online Long term trends Dramatic utilisation growth Sustainable economic returns Reducing unit costs

NHS Direct Online Utilisation

Economic returns

NHS Direct Online Reducing unit costs

Models & e-Health Optional? Optional? Need data! Need data!

Data / Information collected Change management Change management cost for training of staff by persons such as internal and external teachers, consultants cost for training of staff by persons such as internal and external teachers, consultants time and salaries of staff involved in training by teachers, time consumption on self-teaching/learning time and salaries of staff involved in training by teachers, time consumption on self-teaching/learning recruitment costs for new staff recruitment costs for new staff cost for re-positioning or lay-off of staff no longer involved in the process due to new process, new technology cost for re-positioning or lay-off of staff no longer involved in the process due to new process, new technology cost implications of changes in work processes cost implications of changes in work processes training of professional users and patients training of professional users and patients

Data / Information collected Services Services patients serviced patients serviced items processed, such as x-rays, drugs, analyses and messages items processed, such as x-rays, drugs, analyses and messages colleagues serviced, such as second opinion, expert consultancies colleagues serviced, such as second opinion, expert consultancies prices and costs before and after attached to these services for each unit of workload prices and costs before and after attached to these services for each unit of workload

Data / Information collected Health service costs Health service costs Number of full time equivalent (FTE) staff involved at each of the three stages, qualifications/salary per year: Number of full time equivalent (FTE) staff involved at each of the three stages, qualifications/salary per year: management and project leader management and project leader users: professionals users: professionals support staff, such as help desks. support staff, such as help desks. Quantities and prices for consumables used during the process, including software licences, materials, other supplies, networking costs and telecommunications. Quantities and prices for consumables used during the process, including software licences, materials, other supplies, networking costs and telecommunications. Fees for consultants Fees for consultants