Healthy Ageing, Chronic Disease Management,

and Co-production of Health and Care

in the European Union

- seen in a combined medical and ICT perspective

From Diseases to Health

Niels Boye

Physician, specialist in Endocrinology and Internal Medicine

Klinisk Informatik (ClinicalInformatics.dk)

Healthy Ageing, Chronic Disease Management,

and Co-production of Health and Care

in the European Union

- seen in a combined medical and ICT perspective

From pathology-oriented to outcome focused Niels Boye

Physician, specialist in Endocrinology and Internal Medicine

Klinisk Informatik (ClinicalInformatics.dk)

Who Am I Physician, specialist in Endocrinology and Internal Medicine with a conventional clinical and scientific career in biomedicine ending – at least for now - as head of a evaluation unit for acute admissions

For more than 15 years active in ICT for Health

Danish Technological Institute , AAL unit

Ambient Assisted Living Joint Programme

The PREVE project

Conventional healthcare cannot by organizing the delivery of care cheaper and smarter, by better coordination and collaboration – with or without conventional “ICT for Health” - by (mass)production counteract the challenges in health and welfare that Western societies are facing

We must provide ways to organize the consumption of care provisions more intelligent and with higher impact

Pre –requisites (my interpretation)

Conventional healthcare cannot by organizing the delivery of care cheaper and smarter, by better coordination and collaboration – with or without conventional “ICT for Health” - by (mass)production counteract the challenges in health and welfare that Western societies are facing

We must provide ways to organize the consumption of care provisions more intelligent and with higher impact

Pre –requisites (my interpretation)

as phrased by Mr. Barrosso:

Two more healthy years for European citizens (in 2020)

A triple win for Europe • Enabling EU citizens to lead healthy, active and

independent lives until old age

• Improving the sustainability and efficiency of social and health care systems

• Developing and deploying innovative solutions, thus fostering competitiveness and market growth

European Innovation Partnerships on Active and Healthy Ageing

7

Innovation in support of older people…

• At Work – Staying active and productive for longer

– Better quality of work and work-life balance

• In the Community – Overcoming isolation & loneliness

– Keeping up social networks

– Accessing public services

• At Home – Better quality of life for longer

– Independence, autonomy and dignity

8

AHAIP – what? Main areas of work

Innovation in Prevention and early diagnosis

Innovation in Integrated Care

Innovation in Active and Independent Living

Communication and Awareness

9

AHAIP – The Wider Picture

Po

licy

Are

as

FP7 ICT & Ageing well

FP7 eHealth

AAL CIP ICT &

Ageing well

CIP eHealth

Ageing well action plan

eHealth action plan

Public Health Programme

Struct ural

Funds EIB ESF

JPI

More Years,

Better

Lives

Active and Healthy Ageing Partnership

FP7 Health

Natio nal

funds

Time to market

So as my preliminary conclusion

http://ec.europa.eu/active-healthy-ageing

The areas of e-health and ambient assisted living are attaching increasingly European attention and funding

No new instruments or procedures will be introduced, integration of health, prevention and AAL activities are anticipated in broad Joint Programmes

A bureaucratic overhead should ensure a steady course towards a common vision and recruit the Memberstates co-funding – on the other hand it might give a better flow from idea to product in the market

PREVE partners

Valtion teknillinen tutkimuskeskus, VTT

Aarhus University

Fondazione Centro San Raffaele del Monte Tabor

Universidad Politécnica de Valencia

www.preve-eu.org

www.preve-eu.org

Directions for ICT Research in Disease Prevention

What is a disease ?

What is a disease ?

The international Classification of Diseases is a continuation of a classification of dead-causes - mainly developed between 1850-1900 by a series of international congresses. http://www.who.int/classifications/icd/en/HistoryOfICD.pdf

1452- 1519

The disease classifications (ICD), coding, grouping, and “complexity reducing computing” have been giving much more insight in disease causes, disease progressions, and abilities in treatment - but still ON THE GROUP LEVEL

BUT this general computing paradigm will not be enough to ensure HEALTH on the INDIVIDUAL level and it will only result in endless discussions of semantics.

We must turn to non-complexity-reducing computing

WHO definition of Health (1946) (individual level)

“a state of complete physical,

mental, and social well-being

and not merely the absence of

disease or infirmity”

Taking offset in the WHO Health definition – then prevention and procrastination of disease are meaningful for

Preservation of health, cognitive, and physical functions

The rest of this talk will be about The evidences and foundation How to orchestrate it and the IT? Potential business models(?)

Side remark: An update in the conceptual idea of diseases as tightly coupled to pathology may be instrumental

Are there any evidence in the health dimension?

Citizen Modifiable Risk Factors

Co-production of Disease Prevention Connections between Risk Factors and Conditions

Type 2-diabetes

Preventable cancer

Cardiovascular disease

Osteoporosis

Musculoskeletal disorders

Hypersensitivity disorders

Mental disorders

Chronic obstructive pulmonary disease

Conditions Tobacco smoking

Alcohol consumption

Diet

Physical inactivity

Obesity

Accidents

Working environment

Environmental factors

Citizen Modifiable Risk Factors

Non-Modifiable Risk Factors

Family history and gender

Reduction i CVD

disease risk (%)

(95% CI)

Reference

Wine

(150 ml/day)

32 ( 23-41) Circulation 2002;105:2836-44

Fish

(114 gr 4x/week)

14 (8-19) Am J Cardiol 2004;93:1119-23

Dark chocolate

(100g/day)

21 (14-27) JAMA 2003;290:1029-30

Fruit and vegetables

(400 g/day)

21 (14-27) Lancet 2002;359:1969-74

Garlic

(2.7 g/day)

25 (21-27) Arch Intern Med 2001;161:813-24

Almonds

(68 g/day)

13 (11-14) Circulation 2002;106:1327-32

Am J Clin Nutr 2003;77:1379-84

Combined effect 76 (63-84)

Franco OH et al. BMJ 2004;329:1447-50.

CVD=Cardiovascular Disease, CI = Confidence interval

A “polymeal” of the above would cost 21.60 Great British Pounds per week (2004) and give an average increase in life expectancy of 6.6 years for men and 4.8 years for women And give men 9.0 years more life without heart disease for women (8.1 years).

Example: Evidence of food having impact in Cardio Vascular Disease

Impact of medical evidence

Was it Insulin, the proactive care model or the personification that did the job?

YES, all of them (except maybe INSULIN per se)

ICT for health?

Let’s look at telemedicine first

We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. (approximately 46.000 primary papers)

We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies.

Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.

Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.

Conclusions: There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies....... In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness,

So the conclusion must be – we should do something else and in another way. We will come back to this.............

“Biological age” (“years”)

0

100 %

Patient

0

100

(100% Citizen)

AAL

Tele med

Prevention

Demand-side

Supply-side Driven

The Present Digital Health

Client Centred Approach Patient Centred Medicine

Ambient Assisted Living

Health Service Delivery

Maturity of ICT

Citizen as object

User as Operator Expert Systems Corporate Centred

User as User Layman Systems Individual Centred

Citizen as co-Producer of Health

Contemporary State of the Art in ICT and Empowerment

PREVE Models & Concepts

Citizen as proactive subject

Disease prevention Disease compensation (Disease cure) Assisted living

The Citizen as Co-producer of Health – enabled by ICT

The Digital Health Continuum

100 % Patient

100% Citizen

Contemporary health provision service model

Citizen as Co-producer of Health (CPH)

Impact

Impact ?

Synergism?

70% of chronic diseases are preventable 70% of healthcare activities (costs) are spend on chronic diseases Chronic non-communicable diseases and conditions are much more prevalent among older citizens SYNERGY OF PHARMACUTICALS AND COPRODUCTION OF HEALTH HAVE POTENTIAL OF A HIGH IMPACT IN THE OLDER SEGMENT OF SOCIETY

The Digital Health Continuum

100 % Patient

100% Citizen

Tele- medicine

D

Chronic Disease

Shared

Management

D

AAL

D

Preven- tion and

Lifestyle Change

Management

Society Hospital

D

Health Care

Profes- sional

Know- ledge

Special legal and regulatory issues apply

Hospital

Pharmacy

Specialist- centre

General Practice

Home

Restaurant

Super- market

Museum

Sports centre

Farm

Work

Car

The Co-production Service Architecture (eco system)

diabetes as example

Next section: Models and information flows

Co-production – a formal definition

Coproduction of health is a term we use to represent

that health considerations and knowledge can be embedded

and utilized in any activity in society and

that synergies between professional healthcare,

selfcare, informal care, and commodity will be turned

into “health added value”.

Coproduction takes place in an “ecosystem”,

which is cross-sectional to the formal organisation

of society. In the eco-system are formed

“value networks” that share information resources

and can generate the “value propositions”

which are the basis of the “business models”

that fund the services delivered and consumed by

citizens (consumers, not patients).

Co-production – a formal definition

In “Governance for health in the 21st century: a study

conducted for the WHO Regional Office for Europe”

(dated 18th of August and presented in the 61th

session at Baku, Azerbaijan, 12–15 September 2011) -

coproduction of health is seen as one of the main

pillars of future healthcare.

Co-production – formal

Co-production means plugging into a service the knowledge, energy and commitment of its users and those close to them, who really understand and care about the service. This means treating users and communities as assets, not obstacles. In this way, co-produced services can produce more of the outcomes that really matter to users.

Co-production (Sweden)

www.preve-eu.org

Data–Information–Knowledge-Decisions

• Data is a simple value-set without context, than can be stored and

exchanged electronically - if there is technical interoperability e.g. 130/95

• Information is a simple message where the value-set is provided a

predefined context. Information can be exchanged electronically if there is semantic interoperability (e.g. blood pressure measured to the value of 130/95 mmHg)

• Knowledge is information provided a dynamic personal and

organisational context and in relations to other knowledge. Knowledge can be utilized and exchanged using computer-models and ontologies (e.g.

blood pressure of 130/95 is abnormal i for Peter a 25 year old diabetic patient)

• Decisions are made on the basis of knowledge

Diabetic

Personal device

Exercise

Health providers

Commodity service providers

Data

Information

Knowledge

The Personal Guidance Systems Service model

diabetes as example

Data Information

Knowledge access

The Machine-room of the “Citizen as Co-producer of Health”

the ECO-system building blocks

Choice architectures

Co- producers

HealthGPS (digital avatar)

Political, social, economic

Platform services (security, ID)

PHR

Choice architectures embody the regulations, policies, and incentives at societal level Co-production / ecosystem / value networks / business models are where services are delivered and consumed by citizens (consumers, not patients) ICT enables and supports this

A B

Analogue problem

Digital model representation Calculation

Example GPS

A-D transformation

D-A transformation

Analogue presentation (map) Decision support

Skagen, Denmark year 2017

Childrens menu

Decision support (information flows)

EHR

Quality Assurance

HMO/ Region

Clinical encounter

Healthcare

Co-production

Health-PGS Virtual Individual Model

Digital avatar

Research Patient-NGO/ Trusted information banker and brooker

Research/ Pharmaceutical Co

Hospital

Data- and Information

flow

Infrastructure

Platforms and databases

Customization: App-store Virtual Individual Model

But what is healthcare actually “selling”

Knowledge

Phenomenological layer

(specific)

Heuristic layer

(general)

Philosophical layer

(abstract)

Phenomenons, problems, acts

Mechanisms, archetypes, patterns methods

Abstract models, theories, paradigms

In storytelling

Phenomenological layer

(specific)

Heuristic layer

(general)

Philosophical layer

(abstract)

Action, plot, story line

Stereotypes, story-type

Philosophy, hate, life, love, and death

Knowledge in (western) medicine

Phenomenological layer

(specific)

Heuristic layer

(general)

Philosophical layer

(abstract)

Patient specific knowledge, Acts, Treatments, Observations, Signs, Symptoms

Diagnoses, Syndromes, Methods

Pato-anatomical disease model, Gene-theory

The first public demonstration of anaesthesia 16th of October 1846 Detail from a painting (1882) of Robert Hinckley Massachusetts General Hospital, Boston

What is a

Healthcare provision

Technology

Knowledge

Manual work

Team work

Delivering healthcare and care provisions in a co-production eco-system could be “packaged” as:

Knowledge: Evidence based knowledge in activity-related model based applications (transition from pathology-focused to activity focused ICT may also be a good idea in the Electronic Health Record)

Manual work: professional healthcare, selfcare, informal care, and commodity actors

Teamwork – communication: Support for the DIGITAL HEALTH CONTINUUM

Technology: Social technologies (Web2.0)

The Age of Networked Intelligence:

1. Openness

2. Sharing

3. Integrity

4. Interdependence

As the characteristics of legal and security issues

Business model framework

Messages to take home:

To serve personalized, individual health needs we should:

Create a parallel information flow serving an eco-system with model-based non-complexity reducing computing in which health is co-produces health

This could create new business opportunities and lower the total costs of health care, provide morbidity compression, and hence more healthy life years

Have a happy ageing!