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MIE 2005
eHealth ImpacteHealth Impact
A A context-adaptive method of evaluating context-adaptive method of evaluating the economic impact of eHealththe economic impact of eHealth
methodological approach methodological approach and and
work in progresswork in progress
E.C. Project: eHealth Impact
EmpiricaEmpiricaGesellschaft für Gesellschaft für
Technologieforschung, Technologieforschung, Bonn, GermanyBonn, Germany
Tanjent Consultancy, Tanjent Consultancy, Hereford, UKHereford, UK
EUMEDES Agency, EUMEDES Agency, München, GermanyMünchen, Germany
Dr. Karl StroetmannDr. Karl Stroetmann Dr. Veli StroetmannDr. Veli Stroetmann
Tom Jones, FRSATom Jones, FRSA
Dr. Wendelin Dr. Wendelin SchrammSchramm
eHealth Impact Workshop
BackgroundEarlier researchMethods and toolsTwo case studiesDiscussion – please interrupt
MIE 2005
e-Health Impact [e-hi]e-Health Impact [e-hi]
QualityQuality
AccessAccess
Cost-effectiveCost-effective
= Economic and productivity= Economic and productivity
e-Health ImpactGoals
eHI promotes proven e-HealtheHI promotes proven e-HealtheHI identifies e-HealtheHI identifies e-Health
benefitsbenefitscosts costs productivityproductivity
Publicly available tool & knowledge Publicly available tool & knowledge for evaluation & future investment for evaluation & future investment http://www.ehealth-impact.org
RehabilitationTherapyDiagnosisPrevention Follow-up
Integrate, Interprete, Decide, Act
Professional
Monitoring
e-HealthCommunicate, Store, Aggregate, Compare, Report, Remind, Warn
The Ideal Situation
RehabilitationTherapyDiagnosisPrevention Follow-up
Integrate, Interprete, Decide, Act
Professional
Monitoring
e-HealthCommunicate, Store, Aggregate, Compare, Report, Remind, Warn
The Real Situation
Social insurance fragmentation
Numerous and Diverging Stakeholder Demands
PatientsPatients Handicapped and Elderly PersonsHandicapped and Elderly Persons
PhysiciansPhysicians HospitalsHospitals Pharmaceutical industryPharmaceutical industry Care management service providersCare management service providers Health insuranceHealth insurance Healthcare politics and decision makingHealthcare politics and decision making PublishersPublishers SuppliersSuppliers New playersNew players
Community
Products & ServicesHealth Portals
Demand Management
Electronic Health Record
Hospital Information System
Mobile Computing
TriageSystem
DigitalImaging
And many more…
Health PoliticsDecision Making
System DevelopmentHealth 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
Outpatient
Dept.
Specialist
Referral / Feedback
Referral / Discharge
Request & Result
Request & Result
Referral / Feedback
Request & Result
Referral / Feedback
Other Specialist
Other GP
Peer Consultation
Pharmacy
PrescriptionPrescriptio
n
Home Care
Continuing Medical Education
AdministrationDisease
Surveillanceetc.
Activity ReportsNotifiable Diseases
Pharmacy
Peer Consultation
claims / payments
Patient
Services (imaging,
ultrasound, laboratory etc.)
Request & Result
About Evidence
From a complex system…From a complex system…
……seeking evidence represents a seeking evidence represents a complex processcomplex process
… … so, no simple solutionsso, 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
Evid
en
ce in p
ract
ice
Clin
ical re
searc
hPro
duct
ion
s of
evid
ence
Registration
Origins of Evidence
Is eHI here?
…
RehabilitationTherapyDiagnosisPrevention Follow-up
Integrate, Interprete, Decide, Act
Professional
Monitoring
e-HealthCommunicate, Store, Aggregate, Compare, Report, Remind, Warn
The Ideal Situation
Why Models?
Stucture EvidenceStucture EvidenceStandardised ComparisonsStandardised Comparisons Identify variables and leversIdentify variables and leversSimulate the futureSimulate the futureSupports decision makingSupports decision making
An Example
Diabetes Care pilot contracts in several Diabetes Care pilot contracts in several German countries:German countries: Target: integrated care, improving quality of Target: integrated care, improving quality of
diabetes care AND being economicaldiabetes care AND being economical Introduction of a type-2.2 diabetes: „not likely to Introduction of a type-2.2 diabetes: „not likely to
reach diabetes related complications“reach diabetes related complications“ Saxonia-Anhalt: „completing the age of 65“Saxonia-Anhalt: „completing the age of 65“ The consequence: Later referral to The consequence: Later referral to
diabetologists, less tight metabolic control, less diabetologists, less tight metabolic control, less education, (less expenditure for elderly, education, (less expenditure for elderly, discrimination of women ?)discrimination of women ?)
CE of Diabetes Care for the Elderly
Standard Care 100% MAU/ACE + 100% EYE Screen + CV Risk Control-35000
-30000
-25000
-20000
-15000
-10000
-5000
0
5000
10000
Age 45
Age 50
Age 55
Age 60
Age 65
Measures
CLYG [€]
Standard Care
100% MAU/ACE
+ 100% EYE Screen
+ CV Risk Control
-35000
-30000
-25000
-20000
-15000
-10000
-5000
0
5000
10000
UKPDS baseline (53 yrs)
UKPDS six years (59 yrs)
FQSD (65 yrs)
CE of Diabetes Care for the Elderly
CLYG [€]
Why Models?
Stucture EvidenceStucture EvidenceStandardised ComparisonsStandardised Comparisons Identify variables and leversIdentify variables and leversSimulate the futureSimulate the futureSupports decision makingSupports decision making
„„Imagination is more important than Imagination is more important than knowledge“ (knowledge“ (Albert EinsteinAlbert Einstein))
Stop 1
Questions and comments on this Questions and comments on this sectionsection
Room for DiscussionRoom for Discussion
Earlier research
REVI EW OF 612 STUDI ES - P S WHI TTEN ET AL
0%
20%
40%
60%
80%
100%
% of studies
with cost data
without cost data
Earlier research
TYPE OF COST DATA I N STUDY BY P S WHI TTEN ET AL
0%
10%
20%
30%
40%
50%
60%
70%
Line Eqpmnt Project Conusltation Support Patient travel Services Other travel I npatients
Type of cost data
Earlier research
TYPE OF CONCLUSI ON I N STUDY BY P S WHI TTEN ET AL
0%
10%
20%
30%
40%
Save money Save t ime and
money
Cost eff ective Not conclusive Other None
Types of conclusions
Earlier research
Factors not includedFactors not included
Development, implementation, Development, implementation, operatingoperating
ProcurementProcurementProject managementProject management
TrainingTrainingHelp desk …>Help desk …>
Earlier research
>… factors not included>… factors not included
Change managementChange managementUnit costsUnit costs
AffordabilityAffordabilityObsolescenceObsolescence
FinancingFinancing
Earlier research
Two previous case studiesTwo previous case studies
Patient costs and benefitsPatient costs and benefits
Providers costs and benefitsProviders costs and benefits
E-health utilisationE-health utilisation
Development implementation Development implementation operationoperation
Earlier research
Two previous case studiesTwo previous case studies
Net economic return - 5 to 6 yearsNet economic return - 5 to 6 yearsFirst impact - two years from liveFirst impact - two years from live
Provider investment costProvider investment costPatients benefitPatients benefit
Need sustained resourcesNeed sustained resourcesUtilisation drives benefitsUtilisation drives benefits
Earlier research
Two previous case studies Two previous case studies e-health findingse-health findings
Quality and effectivenessQuality and effectivenessImproved work settingImproved work setting
Better resource utilisationBetter resource utilisation
Balance financial focusBalance financial focus
Earlier research
E-health investment should be E-health investment should be approached as a clinical approached as a clinical
developmentdevelopment
e-hi methods and tools
Three stepsThree steps
EvaluationEvaluation
ForecastingForecasting
Initial business case modelInitial business case model
Methods and tools
Cost benefit analysis (CBA)Cost benefit analysis (CBA)
Cost effectiveness analysis (CEA) ?Cost effectiveness analysis (CEA) ?
BreakevenBreakeven
ProductivityProductivity
AffordabilityAffordability
Business casesBusiness cases
Methods and tools
CBACBA
Impact on all actors in communitiesImpact on all actors in communities
Future marginal benefitsFuture marginal benefits
Future marginal costsFuture marginal costs
Monetary value attached to benefits Monetary value attached to benefits over timeover time
is is notnot concerned concerned with cost with cost savingsaving
CBA Evaluation
Accept Evaluate
Evaluate Refuse
Cost
Benefits
Methods and tools
CEACEA
Aims to find the minimum cost of Aims to find the minimum cost of meeting a given targetmeeting a given target
Benefits not estimatedBenefits not estimated
Not used by e-hi so farNot used by e-hi so far XX
Practice data rarely availablePractice data rarely available CBA based on patient cohorts from different CBA based on patient cohorts from different
countriescountries
Subgroup analysis is not availableSubgroup analysis is not available
Transfer between different healthcare Transfer between different healthcare
systems?systems?
Precision of findings (Precision of findings (ππ) ?) ?
Should be updated when new evidence Should be updated when new evidence
availableavailable
Limitations of eHI
Methods and tools
Development of Development of costs and costs and benefitsbenefitsK&G CUMULUATI VE DI SCOUNTED COSTS AND BENEFI TS I NCLUDI NG BENEFI TS OF VACCI NATI ON
WI TH AND WI THOUT E-HEALTH
-10,000,000
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
YEARS
EU
RO
S
costs without e-health
costs with e-health
benefi ts - cost savings andvaccination benefi ts
Methods and tools
ProductivityProductivity
Unit costsUnit costs
Throughput per personThroughput per person
Resource utilisationResource utilisation
Methods and tools
Marginal change in productivity
K&G - % I NCREASE I N VACCI NATI ONS 1996 TO 2011
-2%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
YEARS
% C
HA
NG
E I
N V
AC
CIN
AT
IO
NS
EA
CH
YE
AR
% change in vaccinations
Methods and tools
AffordabilityAffordability
Not part of e-hi evaluationsNot part of e-hi evaluations XX
… … but, e-health needs long term but, e-health needs long term financing to change and restructure financing to change and restructure
resourcesresources
Methods and tools
Business casesBusiness cases
Economic case - quality, access, cost Economic case - quality, access, cost effectiveeffective
Financial case – affordability, Financial case – affordability, sustainable financesustainable finance
Select the right e-health applicationSelect the right e-health application
Methods and tools
DataData
Point of care and e-health use
Healthcare providers’ resourcesPatients and carers
Data needed for healthcare e-health application
Costs
Healthcare service rangeAccess goals
Disease, diagnosis or treatment group
Workload
Benefits
Clinical and working practices
Quality standards
Methods and tools
Sensitivity analysisSensitivity analysis
Tests and underpins all analysisTests 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 eHealthservice without eHealth service with eHealthservice with eHealth estimate for a service estimate for a service
without eHealth that without eHealth that has been replaced by has been replaced by eHealtheHealth
Development costsDevelopment costs InvestmentsInvestments Change managementChange management Project managementProject management Running cost of health Running cost of health
servicesservices Benefit for patients, Benefit for patients,
professionals and professionals and payerspayers
Stop 2
Questions and comments on this Questions and comments on this sectionsection
Room for DiscussionRoom for Discussion
Two case studies
Flanders Vaccination DatabaseFlanders Vaccination Database
NHS Direct OnlineNHS Direct Online
Kind & Gezin
Flanders vaccination databaseFlanders vaccination database
Vaccination goalsVaccination goals
Data for plans and strategiesData for plans and strategies
Productivity solutionProductivity solution
In-house developmentIn-house development
Kind & Gezin
Long term trendsLong term trends
Sustainable economic benefitSustainable economic benefit
fromfrom
productivity gainsproductivity gains
Kind & Gezin
DevelopmentsDevelopments
Vaccinet – online ordering and stock control Vaccinet – online ordering and stock control underwayunderway
More usersMore users
Citizen access to vaccination recordCitizen access to vaccination record
Stop 3
Questions and comments on this Questions and comments on this sectionsection
Room for DiscussionRoom for Discussion
Business Case Model
E-health impactE-health impact
KnowledgeKnowledge
PossibilitiesPossibilities
ReturnsReturns
RisksRisks
Business case
E-health impactE-health impact
Possibilities need imagination and visionPossibilities need imagination and vision
Do all decision takers have these to Do all decision takers have these to succeed?succeed?
Business case
E-health impactE-health impact
Annual returns from about year 3Annual returns from about year 3
Cumulative returns beyond year 6Cumulative returns beyond year 6
Depend on right e-healthDepend on right e-health
Change managementChange management
Business case
E-health impactE-health impact
Risks of optimism years 1 to 2Risks of optimism years 1 to 2
Underestimating impact years 6 to 10Underestimating impact years 6 to 10
Understating costsUnderstating costs
Overstating benefitsOverstating benefits
Business cases
investment frameworkinvestment framework
technicalassessment
servicedevelopment
financial andeconomic case
patient benefits
provider e-health investment decisions
Business cases
investment frameworkinvestment framework
marketshare
demandmanagement
increasedvolumes
extra income
provider e-health investment decisions
Business cases
critical factorscritical factors
changemanagement
benefitsrealisation plan
patientdialogues
better performance
provider e-health investment decisions
NHS Direct Online
Information serviceInformation service
Health encyclopaediaHealth encyclopaedia
Best treatmentsBest treatments
Self-help guideSelf-help guide
Directories of local health services …>Directories of local health services …>
NHS Direct Online
>… Information service>… Information service
Common health questionsCommon health questions
Interactive tools health space for Personal Interactive tools health space for Personal informationinformation
Personal health enquiriesPersonal health enquiries
NHS Direct Online
Long term trendsLong term trends
Dramatic utilisation growthDramatic utilisation growth
Sustainable economic returnsSustainable economic returns
Reducing unit costsReducing unit costs
NHS Direct Online
UtilisationUtilisation
NHS DI RECT ONLI NE - FORECAST VI SI TS 2000 TO 2011
-
5
10
15
20
25
30
35
00/ 01 01/ 02 02/ 03 03/ 04 04/ 05 05/ 06 06/ 07 07/ 08 08/ 09 09/ 10 10/ 11
total visitors
new visitors
repeat visitors
NHS Direct Online
Economic returnsEconomic returns
NHS DI RECT ONLI NE - ANNUAL NET PRESENT COSTS AND BENEFI TS
0
10
20
30
40
50
60
70
80
90
100
1999/ 00 2000/ 01 2001/ 02 2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09
net present benefi ts
net present costs
NHS Direct Online
Reducing unit costsReducing unit costs
NHS DI RECT ONLI NE - PRODUCTI VI TY I N UNI T COSTS FORECAST TO 2008
-
0. 20
0. 40
0. 60
0. 80
1. 00
1. 20
1. 40
1. 60
1. 80
2. 00
2002/ 03 2003/ 04 2004/ 05 2005/ 06 2006/ 07 2007/ 08 2008/ 09
cost per visit
cost per visitor
Data / Information collected Change managementChange management
cost for training of staff by persons such as cost for training of staff by persons such as internal and external teachers, consultantsinternal and external teachers, consultants
time and salaries of staff involved in training time and salaries of staff involved in training by teachers, time consumption on self-by teachers, time consumption on self-teaching/learningteaching/learning
recruitment costs for new staffrecruitment costs for new staff cost for re-positioning or lay-off of staff no cost for re-positioning or lay-off of staff no
longer involved in the process due to new longer involved in the process due to new process, new technologyprocess, new technology
cost implications of changes in work processescost implications of changes in work processes training of professional users and patientstraining of professional users and patients
Data / Information collected
ServicesServicespatients servicedpatients serviced items processed, such as x-rays, drugs, items processed, such as x-rays, drugs,
analyses and messagesanalyses and messagescolleagues serviced, such as second colleagues serviced, such as second
opinion, expert consultanciesopinion, expert consultanciesprices and costs before and after prices and costs before and after
attached to these services for each unit attached to these services for each unit of workloadof workload
Data / Information collected Health service costsHealth service costs
Number of full time equivalent (FTE) staff involved at Number of full time equivalent (FTE) staff involved at each of the three stages, qualifications/salary per year:each of the three stages, qualifications/salary per year:
management and project leadermanagement and project leader users: professionalsusers: professionals support staff, such as help desks.support staff, such as help desks.
Quantities and prices for consumables used during the Quantities and prices for consumables used during the process, including software licences, materials, other process, including software licences, materials, other supplies, networking costs and telecommunications.supplies, networking costs and telecommunications.
Fees for consultantsFees for consultants