Getting to visible – information, integrated care, and Ireland: Moving from fragmented to integrated care

Anthony StainesICT Strategy Unit, System Reform Group, HSESchool of Nursing and Human Sciences, DCU

Summary

● Challenges● Some misconceptions about these

● Where are we● Where do we need to go● How are we going to get there

Challenges

● We can overcome these, if we want to

Ageing population

● Increasing life expectancy● Increasing healthy life expectancy● Both good

Rising prevalence of chronic disease

● Series of Irish studies from the IPH and the NCRI

● All the chronic diseases studied, so far, will rise in prevalence from 2010 to 2020

● The rise is 20% to 60%● Partly due to ageing● More due to fixable lifestyle risks

Rising prevalence of multi-morbidity

● Most of the money is spent on people, no all elderly, with more than one chronic disease

● This is multi-morbidity● It poses significant personal, clinical, and health

system challenges, all of which have to be met

Mean no. of conditions by sex and age (TILDA)

Distribution of US health expenditure http://www.nihcm.org/images/stories/Dat

aBrief3_Final.pdf

Where we are

Irish health system structures

● Complex fragmented system● Paper based system● Largely manual communications, except in

General Practice

Complex system

● Roughly 8,000 health providers with contracts to the public service

● Two-tier hospital care system● High user charges for primary care services

● Perverse incentives

● Primary care poorly developed except general practice

● Weakening private insurance market

Fragmented care

● Too much care delivered in a very busy acute hospital system

● Poor communications● Primary and community care underused,

unsupported, and underdeveloped

Budget cuts

● Budget falling fast, and likely to continue to fall● Population rising, and ageing quickly● Business as usual will not do!

Changes in expenditure (OECD)

Strong political leadership – ex-GP

Changes happening

● Strong political leadership● Integrated care● Care at the lowest level of complexity● Move to community and primary care● Free GP care, initially for children under 6● Generic prescribing● Hospital groups and Money follows the patient● Moving to Universal Health Insurance

Information

● Astonishingly little● What there is, is well used● Poor information systems

● Little information on clinical activity● Poor information for staff and for managers at every

level

● Only GPs have access to good systems, albeit mostly confined to individual practices

Where do we need to go?

Integrated care

Integrated care

● Patient centred care – the 'Medical Home'● Shared care following agreed clinical pathways

between primary and secondary care● Includes GPs, hospitals, and community staff● Tools to support the implementation of these

pathways do not (yet) exist in Ireland

An example – Ran Balicer, Clalit, Israel

● ICT supported, data driven, patient centred integrated care in a health fund covering 4 million people

● 6% fall in hospital readmission rates for the elderly

● 60% reduction in inequalities in the quality of care between centres

● Very good RoI

An example – Paul Grundy, IBM, Vermont

● Patient centred medical home with working ICT● Family practice based community coordinators● Agreed care pathways● 10% reduction in insurance costs● 60% reduction in the rate of complications of

Type II diabetes

ICT principles

● The right data accessible to the right people at every clinical encounter● ICT is to support clinical work directly● Information for Health/Business Intelligence comes

out of clinical ICT systems● Audit, research, planning, accountability all driven

by clinical activity

Steps

● There is no simple solution● We do not have a blank slate

● Learn from other peoples' failures, and successes

● No big bang!● Will be done, in stages, over 4 to 8 years

● Must achieve visible results on a relevant time scale● Keep the momentum up

● It will keep changing forever

Process

● Patient centred process focussed on clinical care

● ICT development supports business needs● No ICT only projects● Technology is easy, and quite cheap● The hard bit, and most of the cost, is in changing

how people do things

Infrastructure

● HSE spends under 1% of the budget on ICT● Ought to be at least twice this● There is past underinvestment to deal with

Individual Health Identifier

● Legislation moving through the Seanad this week

● Critical building block for everything else● The challenge for the system will be getting the

IHI into all of the existing records● Data sharing will still be a problem● Legislation will be required to share data

effectively

Supporting activity

● Clinicians● Patients● Managers

Clinical support

● The right data accessible to the right people at every clinical encounter● Good EMR/EHR as a skin over the data for

clinicians● Good adaptable decision support tools

● Mobile access is required by many staff● Tools and data systems to support innovation in

ICT and health care delivery● Health information standards throughout the

system

Patient support

● Full support for self-care● Access to appointments, basic data, test

results, prescriptions, and more for patients, and, as appropriate, families and carers

● Mutual support for patients e.g.● Expert patients● Support groups● Carer support

Management support

● Flexible reporting systems● Configurable and open● Build on e.g. NQAIS work● Able to accommodate changes over time● Generate necessary canned analyses● Provide for more complex work

Technology

● Several technology solutions can be envisaged● Final choice will come from engagement with

industry to find optimum solutions● Technology is not the real issue

Models

● Build on the good existing systems - no 'rip and replace'

● No big bang● Build common infrastructure● Data accessible through agreed international

standards● Data accessible through open, documented,

APIs● Service oriented architecture

Innovation

● Allow innovation, building tools for staff and patients to manage and use their data

● Rapid feedback of activity and outcomes at individual, unit, facility, region and organisation level

Success or failure?

● Governance● Leadership● Buy-in

● Patients● Clinical● Managerial

● Trust● Resources

Acknowledgements

● My colleagues in HSE, in the ICT Strategy unit, in the School of Nursing and Human Sciences in DCU, and many others for invaluable discussions

● Olga McDaid and the Tilda Study

References

– Rechel B, Grundy E, Robine JM, Cylus J, Mackenbach JP, Knai C, McKee M. Ageing in the European Union. Lancet. 2013 Apr 13;381(9874):1312-22. PubMed PMID: 23541057.

– Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: the challenges ahead. Lancet. 2009 Oct 3;374(9696):1196-208. PubMed PMID: 19801098.

– McDaid O, Hanly MJ, Richardson K, Kee F, Kenny RA, Savva GM. The effect of multiple chronic conditions on self-rated health, disability and quality of life among the older populations of Northern Ireland and the Republic of Ireland: a comparison of two nationally representative cross-sectional surveys. BMJ Open. 2013 Jun 21;3(6).PubMed PMID: 23794595

References

– Glynn LG, Valderas JM, Healy P, Burke E, Newell J, Gillespie P, Murphy AW. The prevalence of multimorbidity in primary care and its effect on health care utilization and cost. Fam Pract. 2011 Oct;28(5):516-23. PubMed PMID: 21436204.

– Erixon F, van der Marel E. What is Driving the Rise in Health Care Expenditures? An Inquiry into the Nature and Causes of the Cost Disease. [Internet]. Brussels: ECIPE; 2011 p. 27. Report No.: 05/2011. Available from: http://www.ecipe.org/publications/what-is-driving-the-rise-in-health-care-expenditures-an-inquiry-into-the-nature-and-causes-of-the-cost-disease/

References

– CSO. Population and Labour Force Projections 2016 - 2046 [Internet]. Dublin, Ireland: Central Statistics Office; 2013. Available from: http://www.cso.ie/en/releasesandpublications/population/populationandlabourforceprojections2016-2046/

– Przywara B. Projecting future health care expenditure at European level: drivers, methodology and main results [Internet]. Brussels, Belgium: European Commission; 2011 p. 85. Report No.: 417. Available from: http://ec.europa.eu/economy_finance/publications/economic_paper/2010/ecp417_en.htm