mie 2005 ehealth impact a context-adaptive method of evaluating the economic impact of ehealth...

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

e-Health Measurements

Who Who WhyWhyWhatWhatHowHowWhereWhereWhenWhenWho benefitsWho benefits

RehabilitationTherapyDiagnosisPrevention Follow-up

Integrate, Interprete, Decide, Act

Professional

Monitoring

e-HealthCommunicate, Store, Aggregate, Compare, Report, Remind, Warn

The Ideal Situation



Professional

Monitoring


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?

…



Professional

Monitoring


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



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

Kind & Gezin

Patient benefits

Significant impact on the economic case

QualityAccess

Cost-effective

Kind & Gezin

Kind & Gezin

Productivity

Sustainable improvements

Stable resources

Kind & Gezin

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

Kind & Gezin

Vaccination Database Vaccination Database UtilisationUtilisation

Stop 3



Business Case Model

E-health impactE-health impact

KnowledgeKnowledge

PossibilitiesPossibilities

ReturnsReturns

RisksRisks

Business case


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


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


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


Business cases

critical factorscritical factors

changemanagement

benefitsrealisation plan

patientdialogues

better performance


eHealth Impact Model

http://www.ehealth-http://www.ehealth-impact.orgimpact.org

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

Models & e-Health

Optional?Optional?

Need data!Need data!

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

mie 2005 ehealth impact a context-adaptive method of evaluating the economic impact of ehealth...

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