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Posts Tagged ‘cost-effective’

The process from research to market for any drug includes, in a nut-shell, four phases: identify the need, research, test, and bring it to the market. The last two tasks could be translated into proving the efficacy of the drug (testing), and proving its efficiency (bringing it to the market) so that it is cost-effective. Are all those phases undertaken when dealing with eHealth systems? I think that a clear no is the answer. And if any of those phases are clearly missing, they are the last two a) is the eHealth system more efficient than the current system? b) is the eHealth system cost-effective? Therein lies probably one of the keys to the lack of adoption of eHealth systems across the EU in particular and the world in general.

We’ll assume that organizations are rational entities (I know it is a big assumption) and will not plunge into costs just for the sake of it. So, let us think that if an organization launches the research effort to develop a new eHealth system, it is because it has spotted a need for such a system.

Now for the testing phase. We all know that no drug will be approved if it has not been properly tested. We also understand that the specifications for testing an eHealth system, even if they could be inspired in the methodology for drug testing, have to be adapted to the particularities of ICT. We cannot expect an app to go through the same process as a drug. Developing an app is in the range of thousands of euros, while the development phase for a drug is in the order of millions of euros. But some kind of testing should be done and its results made public so as to prove the efficacy of the system. Please go to any of the online stores that sell apps and check how many include, or make reference to, their efficacy tests results.

eHealth has also a particular characteristic that a drug does not: eHealth interferes with the healthcare process in a way that a drug doesn’t. In this respect, testing the efficacy of a particular eHealth system poses some problems since the efficacy effect is spread throughout the whole healthcare system, while a drug focusses clearly on its effect on patients.

But if testing eHealth has been, in the best of cases, a patchy process, efficiency is completely forgotten. How can we convince a healthcare provider to adopt a particular eHealth system without demonstrating its cost-saving potential? How many eHealth systems do you know that have carried out any of the available techniques for measuring the probable added value to the patient and the healthcare provider? And again we should recognize the difficulty involved in evaluating the efficiency of eHealth. It is not only the previously mentioned spread effect across the healthcare system, but also its effect across other systems such as the social care system. In fact, sometimes an eHealth system has a more profound effect on the social care system than on the healthcare system itself.

But all those difficulties should not blind us to the need to perform, and make available to the public, the testing procedure and the added value calculation of our eHealth systems. I would recommend that the healthcare authorities who have started to approve certain apps, such as in Andalusia or England, make available the results of the efficacy and efficiency evaluations of those apps they approve.

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We are familiar with too many good ideas that never make it to the market and less frequently, brilliant marketing strategies selling a flop. A proper balance between the product and the business plan rarely occurs. That is probably why there are few companies like Zara or HM; only the chosen few can find the Holy Grail. But we all struggle to do our best and come up with the right balance that puts our product or services in the right spot in the market. The belief that that is achievable is what bring us together every time there is a gathering like this one. And the reason for this exposition is because we, the partners of AiB, believe that we are on the right track. First, let me go through briefly how the ideas that my colleagues have already explained can become a sellable thing. To start with, you may have gathered already that AiB has two heads, kind of like a Hydra.  The difference is that this one has only two heads, its breath is not poisonous but sweet, and its blood, instead of being deadly, heals. One of the heads of our friendly beast represents a service. AiB has been designed as a care service with the objective of detecting the risk of falls in the individual being cared for by a care service provider. Corresponding to that view, AiB as a service offers a complete software-hardware package that allows the care provider to screen the population under its care for a set of signs that will prompt the system to raise alarms. If this is the case, care professionals will perform a pre-evaluation of the person to double-check if the user should be included in the risk-prevention programme or if this is a false positive. Once the inclusion is decided upon, a multidisciplinary team will perform a complete check-up of the user and decide upon a personalized care plan for the user to follow. The care plan is a comprehensive set of neurological and physical exercises included in the system library, as well as any other action that the care professional decides, such as pharmacological therapy or dietetic recommendations. The system will request certain information by the user, mainly about environmental conditions, and prompt remedial actions to counter its risks. Once the personalized care plan is designed and introduced in the user terminal, the user will be asked to follow it by means of an agenda, reminders and so forth. Continuous follow-up of his or her performance will be recorded by the system, triggering alarms to the care professionals in case of deviation from the care plan or changes in the vital signs of the user. These events will allow the care professional to modify the personalized care plan accordingly. It will be obvious by now that AiB as a service is directed to socio-health organizations that can take advantage of the system to reduce the rate of falls in the population they cover, with a clear saving in the overall cost of care, which I am not going to go into since we all are aware of the cost of a hip replacement, for instance. The second nice head of our Hydra corresponds to the product that we envisage to earmark for the individual. In a nutshell, AiB as a product is a self-contained package for individual use by those concerned with their health, probably because they have already fallen or have seen their relatives fall. So it is for people who are aware of the personal cost of a fall in terms of days and/or health lost. The AiB product comprises a self-evaluation that will prompt a care plan, although obviously not at the level of the service care plan. The care plan includes a set of remedial actions that can be made in the environment, as well as physical and neurological exercises. A system of alarms will suggest the user refer to a care professional when deterioration in the performance of the user is detected. How does this translate into a business model? We have chosen the Business Model Canvas because it is as good or as bad as any other model but has the advantage of being simple and clear cut. I will concentrate on only two of the boxes of our model. First the customer segment, in the Canvas jargon. As you can see, we are targeting two completely different markets:  the professional care market and the individual, with basically the same body of knowledge.  Again our friendly Hydra comes to mind with two heads but only one body, and guarding against the perils of falls instead of the entrance to the Underworld. Second, the key activities. We have discussed a lot among the partners on how to proceed from here. We have been able to produce a thing, system and product for the prevention of falls, without killing each other.  A thing that is the sum of the efforts of very different organizations, from health care, to users, to ICT companies, to process designers, even an economist (myself). The result cannot be broken into parts so that each one takes its bit and markets it independently. So we arrived to a solution that has been in use for many years: the European Economic Interest Grouping. This legal figure is governed under European Community (EC) Council Regulation 2137/85. It allows us to continue collaborating while preserving the individuality of the members and separating the AiB undertaking from the other business of the partners. The use of the EEIG will allow the AiB partners to go on to the next step of industrializing our output. That will be our way forward. I am sorry I could not attend the event in person, but if you have any questions, feel free to ask either my colleagues present or contact me at the e-mail address shown on the screen. Thank you very much for your attention.

You can also whach the presentation at http://youtu.be/QZtK6AyvfN0

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This is a real story of a real person in a real country that, I am afraid, can be replicated across many other countries in Europe. It is a story about cuts in healthcare services and its real influences in overall expending for the Government and for the people.

Mr. XXX is a manual worker whose job implies using his arms to move thing around. After several months of feeling that his right arm was hurting, he went to visit the primary care doctor. The diagnosis was clear: a strong tendinitis that prevents him from performing  his duties until he is properly treated. So the primary care physician sent him to the traumatologist for consultation and further treatment.

And here the nightmare starts. Due to cuts in healthcare personnel, the waiting list for traumatology is such that Mr. XXX receives an appointment for 90 days from now. What are the implications? First, Mr XXX cannot work and he will be on sick leave for at least the next three months. He will be paid  by the social security a percentage of his salary, with a complement by his employer to make up for the basic 100% of his salary. Secondly, his employer will have to employ another person to fulfil Mr. XXX duties.

So the outcome is that, by cutting back on personnel disregarding the actual demand, the health service has prompted an increase on the social security budget and at the employer’sexpense, while Mr. XXX lies in bed weighing to be taken care of!

Are these the savings that we are aiming for? I certainly doubt it.

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“A value proposition is a promise of value to be delivered and a belief from the customer that value will be experienced.” We, of course, are sure that the product or service we are offering provides value for our customer but, have we identified clearly who our customer is?
Let´s focus on the issue of identifying our customer since, if we don’t know who the customer is, how can we know what they are expecting?
Maybe we could find some answers in the AAL Joint Programme. In its web we find that “AAL aims to create better conditions of life for older adults.” So, our customers are “older adults”. But, is it really so clear cut?
For instance, «better conditions of life» is a broad aim that can only be achieved through a complex array of interventions. It requires the concerted effort of different stakeholders: what we call “Public Health”.
Public Health is “organized efforts and informed choices of society, organizations, public and private, communities and individuals”. With this in mind, the “older adult” becomes only one of the stakeholders expecting the “promise of value”. There are at least two other stakeholders. “What [should then] make a typical value proposition for AAL markets” has to take into account:
a) Payers (public or private organizations): They tend to be conservative minded. They expect new systems and processes to enhance existing infrastructures. They are looking for improvements in the efficiency of care resources.
b) Caregivers (physicians, social workers, informal caregivers): their main interest is to boost processes, leading to a smoother work-flow. They are aiming to reduce their work burden by increasing the efficacy of the care process.
c) Older adults: they are looking for trustworthy and friendly user processes, allowing for better contact with their surroundings, easy access to their data, timely feedback and guidance and, last but not least, the ability to manage their own lives without unrequested outside interference. In other words they are looking for empowerment.
Probably, due to the fact that attending to all those interests at the same time is not easy, AAL has not delivered as was expected when the European Commission launched the first call seven years ago. But don’t despair; the situation is exactly the same for other R&D programmes: «For many are called, but few are chosen.»
It is not only that these three main stakeholders are looking for different things; the real problem is that their interests diverge.
Although it is centred in mHealth, a study by PWC shows that divergence. According to this study, the main drivers in adopting mHealth for payers are:
Reduction in administrative time for medical personnel, allowing greater time for patients
 Improved quality of care and better health outcomes
 Lower overall costs of care for patients
As for professionals, they would be willing to adopt mHealth if it provides:
 Improved quality of care and better health outcomes
 Easier access to care for existing patients
 Reduction in administrative time for medical personnel, allowing greater time for patients
While end-users are driven by the following characteristics:
 Ability to access healthcare providers more conveniently and effectively
 Ability to reduce own healthcare costs
 Ability to have greater control over own health
One can easily see that the three stakeholders do not coincide in any single driver. But it is probably more telling that “Ability to take control over one’s own health” is not even a concern for payers or professionals, neither in the three main drivers nor in any of the other eight drivers included in the study. And it is precisely this empowerment that should drive most of our efforts for better care processes.
Of course, the objective of satisfying the three stakeholders at the same time is not new. Something very similar was launched by The Institute for Healthcare Improvement in the USA some time ago in “The Triple Aim” . The Triple Aim states that new designs must be developed that simultaneously pursue three dimensions:
 Improving the patient experience of care (including quality and satisfaction);
 Improving the health of populations; and
 Reducing the per capita cost of health care.
We could easily match each of the three aims to each of our three stakeholders: end-user, professional, and payer.
Seen in this light, we can identify a big problem when confronted with the difficulty of achieving that triple aim, or providing value for our three main stakeholders.
In our domain, R&D is driven mainly either by research or by ICT organizations. The presence of end-users leading consortia is anecdotic, as is that of care professionals acting as such. It is true that the EC is putting a lot of emphasis on fostering balanced consortia, but that does not mean that the project achieves that balance. What we see in forums and gatherings is that most consortia are strongly led either by research or by ICT organizations.
Is there an easy answer to this conundrum? Obviously not, we have to assume that people dedicating their lives to devising new processes aimed at improving public health are wise people and that if only a few have found the philosopher’s stone it is due to the difficulty of addressing the three fronts at the same time.
Nevertheless, there are a few rules that we should follow, the first being, who will drive the car of innovation. I strongly suggest that the end user is the one who should be at the steering wheel, if only because during all this years they have been in the back seat. If the trend is for the end user to assume more responsibilities in the care process, what we call the empowerment of the end user, then we have to design the care process according to their wishes and demands, thinking always of “Improving the patient experience of care” as the Triple Aim states. And who better than the end user will know how to improve the experience?
In the case of AAL there is an added problem with our end users. We are talking about “older adults”, so leading the consortia there should be any of the myriad of organizations of older adults.
Consider the typical AAL R&D project. Year One is the design of the proposal and the signing of the contract; Years 2 to 4 the development phase; with the following three years for the completion of the final product or service. In all, seven years for the product to be market-ready. If our end users were in the range 70-75 at the time of inception of the proposal, by the time the product or service is in the market they will be 77-82, probably too old to use what they thought was a great idea seven years previously. No problem, the end result is for people in the 70-75 range, those people who were 63-68 years old at the time of inception; nowadays almost a generation apart when it comes to ICT skills.
So, selecting the end-user leader is not so easy. The right mix of people has to be found, so that the care process and the tools to implement it go hand in hand thinking seven years ahead.
Now, let’s decide who the co-pilot should be. At this point I have to state that I may have a conflict of interest: I am an economist. But putting aside that conflict, I strongly believe that the co-pilot should be the payer. We may not like it and argue that money should not drive all our decisions, but the fact remains that “money makes the world go around” as the famous song from Cabaret tells us. We may be able to put on the market the most desirable item, but if there is not somebody willing to pay for it, we will have another Tucker car; the best but unmarketable.
And that leaves the back seat for, guess who, those who have been in the driver’s seat so far, the research and ICT organizations. They should accept the fact that they are tool makers serving end users with something that payers can afford.
If you are involved in R&D aiming at delivering value to your customer, take into account at least these 3 stakeholders: end user, payer, care giver, in that order. Otherwise, you will be doomed!

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Financing public services in general and health services in particular has become a hot issue. At the end of May, I was a moderator at a simultaneous video conference held in the London School of Economics (UK) and the Hospital La Fuenfría (ES). The conference brought together professionals from the UK, Finland and Spain. The aim was to discuss new approaches to care services for old people.
During the questions and answers part, a lively discussion started on how to finance the cost of taking care of an increasing older population. We all know the statistics, so we don’t need to spend any more time on this issue. As is often the case on these occasions, two different camps arose: those who think that some kind of copayment has to be introduced, – for the sake of the discussion let´s say that this group was represented by Andy Stuart – and those who think that a social system that has been working till now should be kept, represented by me.
I am of the opinion that it will be very difficult to convince people who have been receiving a service till now without direct payment to start paying for it or, as I prefer to say, “repaying”, since they will be paying for the services through taxes and through direct payment. For the sake of discussion, I said that people prefer to pay more taxes than to pay for services. My reason for saying this was based on what I see: the only people that talk about how convenient it is to lower taxes are politicians. So far I have not seen in any of the popular movements and demonstrations across the Western word any banner asking for lower taxes, although I have seen a lot asking for better (more efficient) services.
I said it also in the spirit of making my counterparts react. Maybe they were too polite but the reaction was almost nil.
Nevertheless I must not have been so off the mark. A couple of recent studies have vindicated my point of view. The first one is by Matthew L. Maciejewski et al in Health Affairs. It concludes that copayment reduces the adherence to medication. The second piece comes from a survey carried out by the leading Spanish paper “El Pais”. The survey reveals that 85% of the population prefers to pay services through taxes. So, who is demanding lower taxes? Aren’t we getting involved in an ideological battle unrelated to the wishes of the population? Maybe we should listen to their call for BETTER AND MORE EFICIENT SERVICES. Let´s use public money for this purpose and avoid corruption and waste. Maybe we don’t need more money. Maybe what we need is a structural overhaul of the care system as we know it.

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Do we really measure the efficiency of the health care system? When introducing a new ICT, do we carry out a proper cost-effective analysis comparing its outcome to different alternatives? Or do we allow ourselves to be carried away by the prospect of introducing the latest technology?

A recent study carried out by a regional health care authority in Spain supports the alert given by the WHO according to which 30% of health care processes are useless. On the same lines, a new study published in Health Affairs suggests that physicians who have access to  electronic health records are more likely to order additional imaging tests and laboratory tests than doctors who rely on paper records.

In times of crisis, when authorities are looking everywhere for ways to save,  when in most countries the easy way out has been taken by slashing the work force (physicians, nurses, …) it would be good to pause and think. Could we not take another, perhaps more difficult, route and analyze where the money really goes? Human knowledge is the most important ICT tool we have. It also has an ability that most hardware does not have: it can switch jobs and perform multiple tasks with a flexibility that no gadget can achieve. Why don´t we start carrying out comparative cost-effective analyses of alternative care processes comparing human based processes against ICT based processes? I have no doubt we will have some surprises.

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