e-health and Healthcare Organization

Josep M. Piqué, MD.Hospital Clínic, Barcelona

Healthcare deliveryHealthcare delivery

Payment systemsPayment systemsPayment systems

ICTICTICT

Patient & society demandsPatient & society demandsPatient & society demands

Social, demographic &epidemiologic evolutionSocial, demographic &

epidemiologic evolutionSocial, demographic &

epidemiologic evolutionTraslational research &technology innovation

P4 Medicine

Predictive, Preventive, Personalized, and Participatory

At present, the three major hindrance to achieve the above mentioned objectives are:

1. The lack of an integrative approach to diagnose, treat, and prevent the health problems from different departments in the same healthcare level organization.

2. The huge fragmentation of organizations among primary care, social care, and specialized care.

3. The lack of communication and standardization between different healthcare electronic medical records.

We need to increase the efficiency and outcomes of basic, clinical and epidemiological research and facilitate faster translation into clinical practice, particularly in the field of age-related chronic diseases and conditions.

It is also necessary to personalize care and to move from reactive to preventive and predictive medicine.

Fragmented healthcare systems

Conflict AreaConflict AreaArea of potentialdevelopment

Area of potentialdevelopment

Competition

Collaboration

vs

Hospital fragmentation

Fragmented healthcare systems

Behaviour and attitudes of health professionals.

Lack of education for professionals promoting coordinated efficient work.

Lack of citizen’s education on a rational use of healthcare systems.

The payment systems that in many cases do not encourage coordinated work.

Increasing the efficiency of hospital organization

Wards ICU Day Care

DiagnosticUnits

Proc

ess

Uni

ts

Refe

renc

eph

ysic

ian

Instituts, Departments, Services

Proc

ess

Uni

ts

HOSPITALCommunity

Care

FamilyPhysician

Nurse

SocialWorker

HomeCare

Transplant

Dementia

COPD

CHF

TerritorialHealthcareTerritorialTerritorialTerritorialHealthcareTerritorialHealthcare

Hospitals vs territorial healthcare

Adaptation of health services to chronic patients (shared care arrangements across the system)

Adaptation of health services to chronic patients (shared care arrangements across the system)

Patient

Consultant

Relatives & care givers

PrimaryCareTeam

Mobile teams

Emergencyteam Case

Manager

Home

Primary Care

Hospital

Permanent Comission

TechnicalManagement

Team

TechnicalManagement

Team

TechnicalManagement

Team

Process 1

Process 2

Process 3

Process 4

Em

erge

ncie

s

Soc

ial C

are

Hea

lthTr

ansp

ort

Hom

eC

are

Ped

iatri

cca

re

Pha

rmac

y

RedesignImplementation

& follow-up

Men

tal h

ealth

IT

Operational Committees

Territorial Health Care ComissionBarcelona Esquerra

Territorial Health Care ComissionBarcelona EsquerraBarcelona Esquerra

Territorial Health Care ComissionBarcelona Esquerra

Spe

cial

ized

Car

e

Institutionsrepresentative

Territorial Information SystemsTerritorialTerritorial Information SystemsSystems

PlatformPlatform

Primarycare

Primarycare

Primarycare

Hospital 2Hospital 2Hospital 2Hospital 1Hospital 1Hospital 1

Administrator

Homecare

Homecare

Homecare

Web

Firewall

Charging

IISWeb Server

IISWeb Server

SQLServer

Windows 2003File Server

NetworkSwitch

Socialcare

Socialcare

Socialcare

Process managementProcess management

PatientsProfessionals

- Commorbility personalized management - Multimedia access to suport center- Patient self-management of health- Remote follow-up- Multidisciplinary working team

What do we need?

Process-oriented multidisciplinary working teams

To share information based on health problems

To implement evidence based clinical pathways

Health outputs evaluation based on cost-benefit analysis

Pay-for-performance (P4P) taking into account patientneeds and new approaches to deliver healthcare

Working teams sharing information100%

75%

50%

25%

1-3 4-5 6-10 11-50 ≥50Size of practice (number of physicians)

N Engl J Med 2010:362;192-5

Adoption of EHR according to the practice size

Diverticulitis

Angina

Breast fibrosis

Breast cancer risk

Apendicitis

Penicillin allergy

3456907834569078 1975 1980 1985 1990 1995 2000 2005

IP OP OP OP OP

OP Eme IP OP OP OP OP

OP DC OP OP

OP OP OP

Eme IP OP

1975 1980 1985 1990 1995 2000 2005

IP OP OP OP OP

OP Eme IP OP OP OP OP

OP DC OP OP

OP OP OP

1975 1980 1985 1990 1995 2000 2005

IP OP OP OP OP

OP Eme IP OP OP OP OP

OP DC OP OP

Problem oriented information system

Decision-making support

Decision-making support

Decision-making support

Expert patient-self-care

Expert patient-self-care

Expert patient-self-care

Problem 1

Problem 2

Problem 3

MultidisciplinaryWorking team

MultidisciplinaryWorking team

MultidisciplinaryWorking team

Home care

Primaryphysician

Case-managementnurse

Day-carehospital

Social care

Problem oriented and evidence-based healthcare approach

Weinstein M and Skinner J. N Engl J Med 2010

Health outputs evaluation based on cost-benefit analysis

Gov

ernm

entC

ontr

ol

Patie

ntor

Com

mun

ityC

ontr

ol

Tendency

Protector

(homogeneousprotection for theoverall communitybased on governmentunderstanding)

Connecter

(services organizedaccording to thecommunity or individual needs decided by a participatory approach)

Who has the moneyMoney for what?EducationInformationIT systemsIT systems

Who has the moneyMoney for what?EducationInformationIT systems

DriversDriversDriversDrivers

Personalyzed and participatory care

P4PIT systems

Who has the moneyMoney for what?EducationInformationIT systems

PEducationPEducation4Education4Education PP4P

Investment forecast in health information technology

20

15

10

5

$ bn

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

CSC Healthcare. The Economist, April 18th 2009

Patient data-analysissupporting medical

practice and drugs research

Electronic health records

Health informationexchange