eHealth: what is the potential for better integration, delivery and cost effective care across Europe?. McDaid D. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. eHealth: what is
the potential for
better integration,
delivery and cost
effective care
across Europe?
David McDaid
eHealth Week 2010, Barcelona, March 2010
European Observatory on Health Systems and Policies and LSE Health
& Social Care, London School of Economics
E-mail:d.mcdaid@lse.ac.uk

2. Structure
• Challenges to health care systems in
Europe
• The potential role of eHealth in better
integration and delivery of care
• Making an economic case for investment
• What do we know?
• How can economic incentives be used to aid
in the facilitation of eHealth solutions?

3. Challenges to
health care systems

4. Total health expenditure as % of
gross domestic product (GDP)
12
11 Austria
Belgium
Bulgaria
Cyprus
10 Czech Republic
Denmark
Estonia
9 Finland
France
Germany
8 Greece
Hungary
Ireland
Italy
7 Latvia
Lithuania
Luxembourg
6 Malta
Netherlands
Poland
5 Portugal
Romania
Slovakia
Slovenia
4 Spain
Sweden
United Kingdom
3 EU
2
1970 1980 1990 2000 2010

5. Population distribution EU25 1950-2050
Source: European Commission 2008

6. 77% of disease burden in Europe on
Personal Costs non-communicable, often chronic
disease
Many socio-economic impacts
Educational opportunities curtailed
Reduced chances of employment
Reduced chances of career progression
Impacts on families/informal carers

7. The potential role
of eHealth in
integration &
delivery of care

8. Integrated care
• Shared care: integrated care across
primary, secondary and specialist care
services
• Continuity of care: aided by better
integration of care delivery between health
and non-health sectors – e.g. social care
• Person centred: Provision of services that
best meet individual needs
• Team orientated: Need for collaborative
working relationships, frequent
communication, and flexibility of
practitioners

9. eHealth and Integrated care
• Shared electronic health records
• Electronic messaging systems
• Opportunities for iterative dialogue
between clients and physicians
• Systems to help facilitate rapid
access to clinical services
• Telehealth applications to help
maintain independence and community
based living

10. Hillestad et al , Health Affairs, 2005

11. Making an economic
case for investment

12. Economics Economics is an important input into
decision making process in health policy
Resources are not unlimited; economic
information can help determine how
best to make use of resources but……
Cannot be used in isolation; many other
factors (fairness, equity, political
concerns etc) influence decision making

13. Economic questions that can aid decision making
• Costs of inaction: What are the economic
consequences of not tackling chronic diseases?
• Costs of action: What would it cost to intervene by
investing in eHealth measures?
• Cost-effectiveness of action: What is the balance
between what cost to intervene and gains in outcomes,
e.g. health status, quality of life etc?
• Levers for change: What economic and other
incentives can encourage more use of those
interventions that are thought to be cost-effective and
less use of those interventions which are not?

14. Making the case
So is there an economic
case for investment in
eHealth to promote
better integrated care?

15. What do we know?
• Mixed evidence base and limited cost data
• Potential benefits not just to health sector, but to other
payers e.g. social care, social welfare
• Evidence for interventions in specific settings and
targeted at specific population groups – e.g. diabetes,
mental health, high risk pregnancy monitoring, heart
failure and cardiovascular disease
• Focus on return on investment rather than on health
related impacts
• US dominated: relatively few studies conducted in other
settings; relatively little focus on broader implementation
context issues

16. Electronic Health Records
• AHRQ systematic review in 2006
• Link between EHR and better performance of
providers in 3 US and 1 Dutch Studies
• All cost benefit analyses reported substantial
savings, but up to 13 years to break even
• But conservative: very few studies reported
economic benefits from improvements in health
outcomes
Shekell, Morton & Keeler 2006

17. Electronic Health Records
• Long standing EHR system in primary care
practices in Denmark
• Admission into hospital automatically triggers
notification to primary care services
• 50 minutes saved per day in primary care practice,
telephone calls to hospitals reduced by 66%, and
€2.3 saved per message, of which there are 60
million per year.
• The cost of a typical EHR is about €4 (US$6) per
patient per year, which includes network
connectivity charges Protti & Johansen 2010

18. Telehealth
• Relative paucity of economic evaluations, or even
discussion of cost
• Focus on cost offset rather than health benefits
• Systematic review 1990 – 2007 [Bergmo 2009]
• 33 economic evaluations – cost & health outcomes
• Inconsistent use of economic evaluation methods;
sometimes poorly reported – making comparison
difficult
• E.g. only 25% looked at costs of lost productivity

19. The Scottish Telecare Development Programme (TDP)
• Country-wide TDP from 2006.
• 7900 had telecare packages by March 2008.
• Costs avoided of £11 million.
– increased speed of discharge from hospital once
– clinical need is met, as well as reductions in unplanned
hospital and care home
– admissions, nights of sleepover care purchased, home
check visits and waking
– night cover
Beale, Sanderson & Kruger 2009

20. Decision Support Systems
• Can, if well implemented, improve prescribing practices,
avert costs and promote better health outcomes
• Model of cost benefit of DSS within acute hospital in
England. [Karnon et al 2008]
– Not cost effective if focus solely on health care costs
– But highly cost saving – £31 million over 5 years if value of health
losses averted included
• Guideline driven DSS for blood tests in primary care in
Netherlands [Poley et al 2007].
– €670 per practice – development & installation costs
– €847 costs from blood tests avoided in 6 months

21. Facilitating the
implementation of
cost effective
eHealth interventions

22. Better use of evidence
• Better synthesis and marshalling a better of
existing evidence from large scale pilots and
mainstream implementation - what works, and what
context.
• Need to strengthen economic case
– Estimating full costs of implementation, prospective &
retrospective economic analysis, modelling longer term
costs and benefits

23. Changing incentive structures
• Tackling barriers to uptake and co-ordination
across sectors
• Financial incentives to help encourage uptake
– E.g. in Denmark physicians and specialists paid for e-
mail communications with patients. The fee for e-mail
consultations, which are primarily about lab results, is
twice that for telephone calls.
• (Voluntary) joint budgeting arrangements – remove
disincentives to invest across sectors - SOSCAM
partnerships in Sweden between employment and
health services

24. Facilitating implementation
• Establishing mechanisms for awareness raising,
dialogue and exchange of information
• National health system integrator e.g. MedCom in
Denmark
• Pursue process-led innovation
– adaptation or re-engineering of organisational flows,
involving many professionals, all working for different
organisations but coming together to offer one
integrated pathway in health and social care to support
continuity of care.
• Improving the usability and interoperability of
technology

25. In Summary
– Potential for eHealth interventions to aid in better
integration of care but……
– Need better understanding of evidence and context for
implementation
– Critical to identify
• Costs of implementation
• Costs averted
• Economic benefits of improved health outcomes
– Economic incentives can be used to influence uptake
– Look to ensure developments are an integral element of
care delivery process

26. WHO Health Evidence Network Policy Briefs
Series on e-health issues
1:3:25 Format
Highlight policy challenge
Brief review of evidence
Sets out policy options
indicating strengths and
weakness’
Look at ways to facilitate
implementation in different
contexts and systems across
Europe
http://www.euro.who.int/HEN