Un nuovo perspective dedicato all'importanza della trasparenza nel settore sanità, con un confronto internazionale - A cura di Daniela Scaramuccia, Partner, e Nunzio Guida, Associate dell'ufficio di Milano Dicembre

1. PERSPECTIVE DECEMBER 2013
TRANSPARENCY
IN HEALTHCARE
DATA TRANSPARENCY
IS A NEVER ENDING
ISSUE THA HAS
T
GENERA
TED A GROWING INTEREST WITHIN
SEVERAL INDUSTRIES,
INCLUDING HEAL
THCARE
Daniela Scaramuccia, Nunzio Guida

2. Transparency in healthcare
Published by
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December 2013
Written by:
Daniela Scaramuccia, Nunzio Guida
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3. CONTENTS
OVERVIEW
5
WHY TRANSPARENCY IN HEALTHCARE
7
DIFFERENT STAGES OF TRANSPARENCY EVOLUTION
9
CORNERSTONES FOR A TRANSPARENT HEALTHCARE SYSTEM
15
NEXT CHALLENGE? CHRONIC DISEASES MANAGEMENT
17
AUTHORS
18
PERSPECTIVE TRANSPARENCY IN HEALTHCARE

4. Transparency can be a strong
driver for improvement and also
help develop trust within the
healthcare system, which is at
the heart of the doctor-patient
relationship
4–5

5. OVERVIEW
DATA TRANSPARENCY IS A NEVER ENDING ISSUE THAT
HAS GENERATED A GROWING INTEREST WITHIN SEVERAL
INDUSTRIES, INCLUDING HEALTHCARE. WHILST THERE
HAVE BEEN RELATIVELY FEW FULL IMPLEMENTATIONS OF
TRANSPARENCY WITHIN THE HEALTHCARE SECTOR TO DATE, IT
IS BELIEVED THAT THERE IS MUCH MORE YET TO BE ACHIEVED.
HISTORICALLY, THE SPREAD OF TRANSPARENT HEALTHCARE
INFORMATION HAS ENCOUNTERED A RANGE OF BARRIERS.
THE LACK OF TRUSTED AND COMPARABLE INFORMATION,
ALONG WITH THE OPPOSITION FROM BOTH HEALTHCARE
PROVIDERS AND INSTITUTIONS HAVE BEEN POSING OBSTACLES
TO TRANSPARENCY. HEALTHCARE PROFESSIONALS OFTEN
HAVE NEGATIVE PERCEPTIONS OF TRANSPARENCY; INSTEAD
OF PERCEIVING IT AS A POTENTIAL FORCE FOR GOOD, THEY
FREQUENTLY ASSOCIATE IT WITH UNWANTED INTERFERENCE
FROM AUTHORITATIVE PARTIES, GUIDED BY SUSPICION AND
NEGATIVE MOTIVATIONS RATHER THAN THE WIDER AMBITION
OF IMPROVING HEALTHCARE.
WE STRONGLY BELIEVE TRANSPARENCY CAN BE A POTENT
DRIVER FOR IMPROVEMENT AND ALSO HELP DEVELOP TRUST
WITHIN THE HEALTHCARE SYSTEM, WHICH IS AT THE HEART
OF THE DOCTOR-PATIENT RELATIONSHIP.
THIS PERSPECTIVE DISCUSSES BENEFITS FROM TRANSPARENCY
IN HEALTHCARE AND PROVIDES A RANGE OF INTERNATIONAL
EXAMPLES WHERE IT HAS BEEN DEPLOYED SUCCESSFULLY.
AS WELL AS HIGHLIGHTING THE POTENTIAL OPPORTUNITIES,
THESE BEST PRACTICES ALSO IDENTIFY THE KEY SUCCESS
FACTORS TO IMPLEMENT TRANSPARENCY WITHIN HEALTHCARE.
PERSPECTIVE TRANSPARENCY IN HEALTHCARE

6. Exhibit 1
48% of surgery admissions are provided by hospitals located outside
the residential area of patients
Outside the region
Outside the residential area
Same area
100%
90%
80%
70%
60%
50%
48%
40%
30%
20%
0%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
AVERAGE
10%
Exhibit 2
Patients with a higher level of education tend to choose higher volume medical institutions
Hospital admissions of patients affected by breast cancer, according to educational qualification and number
of breast surgeries per institution, Year 2009
Low volume (0-30 surgeries)
Mid volume (31-150 surgeries)
60%
65%
30%
High volume (over 150 surgeries)
70%
30%
10%
No educational qualification /
elementary school diploma
25%
5%
5%
Junior high school diploma
Senior high school diploma
-
10%
2%
Degree
+
EDUCATION LEVEL
Source: Value Partners Management Consulting
88%

7. WHY TRANSPARENCY
IN HEALTHCARE
In addition to the aforementioned
strengthening of trust in the doctorpatient relationship, multiple benefits
are driven by transparency. Three are
the most relevant in our experience.
First of all, transparency enables citizens’ right of choice. Research shows
that when citizens are aware of relevant
information concerning healthcare services, they tend to exercise their right
of choice. They travel to receive the best
treatment rather than relying on services immediately available in a particular
geographical area.
Even in regions with good healthcare
systems, for example, on average over
45% of patients choose to go to hospitals located outside the area they live in
(Exhibit 1).
Propensity of citizens
to exercise their right
of choice is strongly linked
to education levels
Nevertheless, research indicates that
the propensity of citizens to exercise
their right of choice is strongly linked to
education levels. Transparency, together
with access to information, becomes
an essential tool to increase the equality of access to services in a healthcare
system, which aims at being universal
(Exhibit 2).
PERSPECTIVE TRANSPARENCY IN HEALTHCARE
Second, transparency fosters improvement in healthcare performance.
In general, the release of information
and the subsequent comparison of
healthcare systems in different regions
directs the flow of patients and fosters
all operators to improve their own
results and share best practices.
The same phenomenon occurs, for
instance, in universities, where the
release of international rankings directs
the flow of students towards particular
institutions.
According to the QS World University
Ranking for 2012/2013, the number of
students enrolled in the top 100 universities increased at a growth rate 3-time
higher than that of those universities
ranked towards the bottom.
Third, transparency drives productivity increase. Release of data encourages operators to improve their own
productivity in response to the positive pressure generated by increased
comparability.
A typical example can be found
in cases of reduced average waiting
times in hospitals whose data is made
public.

8. Exhibit 3
NHS Choices offers a wide range of services to meet users needs
Supports citizens in choosing the most suitable
health services. Users can
specify the nature of required procedure and a postcode or town to compare
relevant institutions against
certain criteria
Guide provides citizens
with information on diseases and relative treatments.
It also offers symptom control measures and online
support
Patients’ comments and
feedbacks
Provides an unbiased and
evidence-based daily
analysis of the science behind health stories making
the news
A guide to social care
Exhibit 4
Transparent information enable citizens’ right of choice
Screenshot of page that appears when you ask for information on hip surgery in the London area
Once one has chosen the
nature of treatment and
the geographical area,
it is possible to generate
a set of institutions to be
compared
Selection of volume, quality, outcome and efficiency
indicators, which help with
user choice
User ratings (similar to Trip-Advisor)
Source: NHS Choices website

9. DIFFERENT STAGES
OF TRANSPARENCY
EVOLUTION
The level of transparency within a health
service is typically linked to its stage of
development. In fact more advanced national systems usually offer an improved
flow of information about financial,
operational and clinical performance.
Nevertheless, also in most advanced
countries, the level of transparency
granted by Institutions is very different.
The UK represents one of the most
high-profile examples of a transparent approach to healthcare provision.
The National Health System (NHS) has
developed an online portal to help
provide citizens with the necessary tools
to benefit from well-informed health
decisions: “NHS Choices”. This idea is
referenced explicitly within the pay-off
of “NHS Choices” itself: “Your health,
your choices”.
“NHS Choices” was launched in 2007
and has built its success by adopting a
model that actively involves and generates benefits for all relevant stakeholders, including citizens, operators and
sponsors.
The primary objective of the content
provided on the website is to deliver
a comprehensive service offering to
citizens (Exhibit 3). These services
range from the release of over 650
performance indicators related to different health services, so as to allow users
to best choose the hospital or practice
that suits their needs (Exhibit 4) to
services which aid the self-management
of health issues including symptom
checkers, medical examination bookings
and advice on how to follow a healthy
lifestyle etc.
PERSPECTIVE TRANSPARENCY IN HEALTHCARE
Furthermore, “NHS Choices” helps to
improve health services through the provision of services to professionals such
as information on specific treatments,
training services and guides to specific
health services. In addition, the website
also publishes performance results
organised by health unit and provider.
The value that the “NHS Choices”
website brings to stakeholders is evident
from the growth in the number of its
users.
Since 2011, the number of users registered on NHS Choices has increased by
over 76% and now has over 27 million
visitors per month. As a result, the NHS
Choices website is the most popular
European Portal for healthcare.
Further results collected through
surveys (Exhibit 5) also highlight the
benefits that this service brings.
This benefit is not merely limited to citizens, however, with positive feedback
also coming from industry professionals
who consult the website both for themselves and their patients - 12% of them
use it every day, 67% more than once a
month and 90% would suggest using it
to colleagues (Exhibit 6).
Driven by its success, each year it integrates new initiatives to try and improve
its service offering to citizens through
an increased quantity of information
being offered and the development of
new services and new channels.
As part of its multi-channel approach,
NHS Choices has also been present
on both Facebook and Twitter since
2010, and has attracted over 150,000
followers.

10. Exhibit 5
Results of the NHS Choices website are positive, both in terms
of usage trends and of users’ satisfaction
USAGE (MILLIONS OF VISITORS PER MONTH)
USERS’ FEEDBACKS (FROM PATIENTS)
Would you recommend
NHS Choice to other people?
+76%
Would you recommend NHS
Choice to other people?
2%
27
9%
Lifestyle Improvement
26%
7%
11%
35%
Symptoms control
39%
15
Medical information
5%
7%
79%
86%
2011
2013
Yes, absolutely
Yes, probably
No
Not sure
Exhibit 6
Even feedbacks from professionals using NHS Choices is positive
PROFESSIONALS USING NHS CHOICE (%)
WHY PROFESSIONALS CONSULT THE WEBSITE (%)
Specialist
21
Family doctor
16
Practice manager
12
Pharmacist
9
Registered nurse
8
Hospital manager
8
Information on health services
27
Information on a healthy lifestyle
13
Better management of already existing diseases
12
Junior specialist physician
Symptoms checking
7
5
Getting news on healthcare system
8
Training search
16
Information on long-term disabled citizens
Junior specialist nurse
6
Receptionist / Assistant
6
Booking a medical consultation at the hospital
7
Information on how to solve dependences
(e.g. alcohol)
NHS management
4
• 90% would suggest it to
a colleague
• 12% use it everyday
• Over 68% use it more than
once a month
Source: NHS Choices Annual Report 2012-2013
4
2
Job search
5
Information on vaccines for travels
Subscribing to the information service
3
2

11. In addition to the effective involvement
of all relevant stakeholders, the success
of NHS Choices has been attributed
to its governance mechanism and the
website’s content offering. The governance model was designed in such a way
so as to generate commitment and approval among all involved parties by the
Department of Health. This was realised
through the creation of committees,
composed of representatives from each
of the relevant institutions, who defined
the program guidelines and worked to
achieve set targets.
Florida has recently taken steps to
revise their informational health website,
run by the Agency for Health Care Administration (AHCA). It aims at simplifying access to information relating to the
quality of different medical services, associated fees and relevant performance
levels in a way which is easily understandable for all. The website is divided
into two sections - one for citizens and
one for professionals – so as to most
efficiently convey the information in a
targeted manner.
From a content perspective, the portal
doesn’t merely focus on the comparison of performance between different
medical organisations, but also provides
citizens with a range of easily accessible
educational services (Exhibit 7).
PERSPECTIVE TRANSPARENCY IN HEALTHCARE
Interestingly, the portal also includes
a “symptom navigator”, which is a tool
that allows the user to identify symptoms and hence develop a preliminary
diagnosis (Exhibit 8).
In a similar manner to other countries,
the Ontario province of Canada also
splits their website into two separate
sections.
The first section of the website aims
at providing citizens with information
on a range of topics including which
services are available throughout the
province, where the nearest doctor
is located and the waiting times for
diagnostic procedures and surgeries in
different hospitals (e.g. CAT, MRI scans
etc.). In addition to giving information
to citizens, the website aims at reducing
the administrative burden on citizens
by making medical forms, such as those
used for x-ray scans or for disabled
citizen home assistance requests, available online.
A secondary section of the website
helps providing relevant information to
healthcare professionals. This section
of the website includes information
focused on healthcare programmes
and their level of usage as well as
legislative updates. Professionals are
also able to find advice on how best to
manage medical emergency situations
(e.g. influenza pandemics, blood supply
problems). This website thus enables
healthcare professionals to improve
their level of service in both everyday
situations as well as in extraordinary
circumstances.

12. Exhibit 7
FloridaHealthFinder.gov is built around easy access to information
and organized into different sections
Specific sections for
patients and professionals
Support to facilitate information access
Public reporting includes
quality, fees and institution
performance
Educational service
enabling the user
to get a deeper knowledge
on medical issues
Exhibit 8
The symptom navigator enables an easy identification of symptoms,
and a corresponding link to a preliminary diagnosis
Screenshots of the symptom navigator, possible causes and additional information on symptoms
SYMPTOMS DESCRIPTION
PRELIMINARY DIAGNOSIS AND ADDITIONAL INFORMATION
Identification of preliminary
diagnosis for the selected
illness
Symptom are identified
by selecting the form
of illness and patient type
(man/woman/child)
Information on possible
causes and suggestions for
treatment of symptoms
Source: Florida Agency for National Health Care Administration (www.floridahealthfinder.gov)
12 – 13

13. Singapore has also made great steps in
promoting a transparent approach to
its national health service. Through their
website, the Ministry of Health provides
information to citizens on how to have
access to the healthcare system, news
and fees charged for different services.
Moreover, through the website, data
concerning the level of services offered by hospitals to citizens are also
released, including occupation rates
within hospitals and waiting times for
particular services. This so as to foster
competition between institutions, but
also supporting citizens empowerment
and choices.
Italy is at an evolutionary stage of transparency within healthcare. However,
thanks to the collaboration between national and regional institutions including
the Ministry of Health and the National
Agency for Regional Health Services
(Agenas), progresses have been made
within the last few years. In this context,
two specific initiatives are worthy of
mention:
In Italy, whilst these actions
to promote transparency
are undoubtedly positive, they
have not yet realized the full
potential of transparency
PERSPECTIVE TRANSPARENCY IN HEALTHCARE
• Outcomes National Program (Programma Nazionale Esiti) by Agenas
– introduced in 2008, the program
publishes hospital assistance outcomes for all the Italian medical institutions comparing their performance
to a series of indicators. These data
are available only to authorities and
institutions of the National Health
Service and was published for the
first time in 2011.
• Regions Network (Network delle
Regioni) – introduced in 2008, the
program enables performances
comparison between providers and
PCTs (ASL) of the regions involved
in the network. Shared data include
efficiency, waiting times, patients satisfaction. Since 2010, the report has
become public and accessible to all
stakeholders, but yet, for the wider
public it is not ready to use.
Therefore in Italy, whilst these actions
to promote transparency are undoubtedly positive, they have not yet realized
the full potential of transparency. Information are shared within stakeholders,
while users have little access to it and,
anyhow, struggle to interpret these data
if they are not professionals or sector
experts.

14. The need for transparency from a user’s
perspective is clear. As a result, private
companies have begun to design and
implement public reporting initiatives,
for instance:
• Dr Foster: a privately founded English
website provided through the collaboration between the Information
Centre for Health and Social Care,
relevant health organisations and
local authorities. This portal provides
comparative information on the
UK’s health and social care services,
helping citizens decide the most
appropriate healthcare solution for
them according to geography and
procedure
• Healthgrades: an American website
that specialises in the release of
important data about doctors and
hospitals. The site is divided into four
sections: users, doctors, hospitals and
consultants. This separation enables
the delivery of information in a more
targeted and tailored manner helping
to make the service more effective.
It attracts around 225 million visitors
per year
14 – 15
• Doveecomemicuro.it an Italian website recently developed by a group
of researchers led by the Università
Cattolica-Policlinico Gemelli in Rome
with the aim at assisting citizens in
their healthcare choices.
The launch is very recent and it is
early to measure success, however,
the first day the website recorded
36.000 individual visitors and
300.000 visited web pages.

15. CORNERSTONES FOR A
TRANSPARENT HEALTHCARE
SYSTEM
There is no one single model for healthcare that can be applied effectively
across countries. However, by looking at
the most relevant international experiences it is possible to define which critical features determine the success of a
healthcare transparency programme.
We have identified three basic principles
on which any model for healthcare transparency programmes should be founded.
Principle 1. Centralization of information
management. Information management
functions (e.g. data gathering, analysis,
release, etc.) should be centralized and
should be overseen by a central authority controlled by the local Ministry of
Health. Centralization increases accountability and reliability as well as guaranteeing comparability of information.
Principle 2. Implementation of an effective governance structure. A governance
structure should be created that incorporates the best expertise whilst involving
key stakeholders and relevant authorities. Governance structured in this way
guarantees effective representation and
alignment of relevant parties and overcomes possible obstacles. The structure
should include (amongst others) separate
committees for strategic planning, management, coordination, and quality.
Principle 3. Development of tailored
content to meet the needs of stakeholders. Informational content should be
developed so as to meet the needs of
different stakeholders: citizens, operators and sponsors. This content should
be made available by a consolidated
information portal, and include information that enables:
PERSPECTIVE TRANSPARENCY IN HEALTHCARE
1. Comparison of performances across
institutions and best practice sharing,
so as to improve the whole system
performance. Key metrics include:
productivity indicators (e.g. number of
operations performed per hospital, per
surgeon, etc.), accessibility indicators
(e.g. average waiting time, etc.) and
effectiveness indicators (i.e. outcome/
results). In our experience it is relevant
to ensure that metrics are:
• Reliable and relevant to processes
that operators are able to impact
upon
• Selected, developed and implemented in a transparent manner
• Easily comprehensible for all
stakeholders, not only by professionals
2. Citizen empowerment. Empowerment of citizens should be enabled
by making information on hospitals
and performance available to all, and
by offering educational contents and
services to increase citizens’ ability to
manage the healthcare services they
receive. Examples of information and
services that enable citizen empowerment include the following:
• Information regarding relevant
treatment options according to
medical condition
• Information regarding particular
symptoms and medical conditions
relating to symptoms
• Online consultations, available at
short-notice
• Online booking of appointments
and examinations

16. Exhibit 9
Healthcare demand and funding are moving from hospital to district care
HOSPITALIZATION RATE TREND (HOSPITALIZATION PER 1000 INHABITANTS)
190
180
-26%
170
160
Significant decrease in the
hospitalization rate over the
last 15 years (-26%) despite
the increase in population
aging
150
140
130
120
110
100
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
HEALTH CARE FUNDING EVOLUTION
55%
50%
Since 2010 the funding
gap between hospital and
district care has deeply
increased showing a strong
tendency to move care from
hospitals to districts
(including primary care)
45%
40%
5%
0%
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Hospital care
Districts care
Collective health care
in working environment and daily experience
Note: All the analysis refer to Italian Healthcare system (2010)

17. NEXT CHALLENGE?
CHRONIC DISEASES
MANAGEMENT
Examples described in the perspective
are still primarily focused on hospital
performances. However, the demand
of care, following aging and innovation
trends, is moving more and more from
hospitals to districts (including primary
care) and home.
And the result of this, coupled with
hospitalization rate in sharp decline, is
the increase of healthcare assistance
and spending in district and primary
care services, mainly focused on chronic
disease management (Exhibit 9).
Transparency follows the
evolution of helthcare dynamics,
therefore it’s now time
to focus on the next real
challenge: chronic desease
management
PERSPECTIVE TRANSPARENCY IN HEALTHCARE
This trend implies a greater interest
in controlling district care and home
assistance providers. Therefore, it
is urgent and necessary to improve
transparency in this area, increasing the
availability of data on clinical processes,
from diagnosis to treatment and on
outcomes related to chronic diseases.
This area is still almost unexplored by
different healthcare systems. That, is
the next challenge.

18. AUTHORS
DANIELA SCARAMUCCIA
Partner, Milan Office
daniela.scaramuccia@valuepartners.com
NUNZIO GUIDA
Associate, Milan Office
nunzio.guida@valuepartners.com
18 – 19

19. Transparency enables citizens’
right of choice.
Transparency fosters improvement
in healthcare performance.
Transparency drives productivity
increase.
PERSPECTIVE TRANSPARENCY IN HEALTHCARE

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