Ebook: Information Technology Business Models for Quality Health Care: An EU/US Dialogue

Information technologies have been substantiated and found to be invaluable in preventing health care errors and improving the outcome of health care (e.g., physician order entry; computerized patient education). These technologies are cost-effective, yet they are not reimbursed and their business value is often questioned. There is significant confusion regarding the adequate demonstration of the clinical value of information services to justify reimbursement. Lack of financial reimbursement works as a disincentive to the development and utilization of information technologies while this very fact, the limited use of these technologies, is the cause of insufficient evidence of their effectiveness, a condition for reimbursement. Recognition of this vicious cycle and a need to create a break in this cycle has led to this dialog initiative on health care information technologies. The purpose of this book is to explain the process of health information technology transfer and to advance the business case for existing as well as innovative technologies that improve health outcomes and patient safety. As a combined treasure of the best knowledge, expertise and experience in the field of health care information technologies, the authors help us identify possible solutions to economic, structural, legal, cultural, and institutional barriers in the use of information technologies to provide safe and accessible healthcare to all, especially to the underserved populations. They represent professionals from clinical areas, health care management, law, finance, payer institutions, information technology industry, government and health services research to discuss how innovative information technologies can become widely applied to clinical and business solutions. The book is divided into three sections, each consisting of six chapters around the section theme. The first section, Health Information Technology: A Business Perspective, sets the stage for business models of information technology and encourages one to look at health information technologies from a business perspective. The authors in the second section discuss how information technology offers cost-effective solutions to benefit all those in need of health care. The third section consists of chapters that provide real world examples of how health care information technologies are helping patients, especially those residing in hard-to-reach remote locations, receive care and education in a timely manner, and how health care providers can receive continuous medical education through distance learning. The collection of these chapters represents a diverse set of viewpoints and experiences about information technologies in health care, barriers to their development and implementation, and strategies to overcome these barriers. It is evident that the necessary hardware and infrastructure, communication protocols, vocabularies, and other essential standards need to be in place for cost-effective interaction among various points of health care delivery. However, the ultimate beneficiaries of all health care interventions are people, especially those seeking care and hoping to achieve a better quality of life. We wil l need to keep peopl e as a critical variable in the equation that computes cost-effectiveness of information technologies in health care. The Center for Health Care Quality at the University of Missouri-Columbia in collaboration with the School of Public Health at Saint Louis University and Quality Improvement Working Group of the American Medical Informatics Associationconvened a two-day conference in Columbia, Missouri, in May 2002. This book comes out of the conference "Business Models for Health Information Technology: An EU/US Dialogue" held at the University of Missouri-Columbia, May 14-15, 2002.

Information technology (IT) such as computerized physician order entry, computer-based decision support and alerting systems, and electronic prescribing can reduce medical errors and improve the quality of health care. However, the business value of these systems is frequently questioned. At present a number of barriers exist to realizing the potential of IT to improve quality of care. Some of these barriers are: the ineffectiveness of existing error reporting systems, low investment in IT infrastructure, legal impediments to reforms, and the difficulty in demonstrating a sufficient return on investment to justify expenditures for quality improvement. This paper provides an overview of these issues, a framework for considering business models, and examples of successful implementations of IT to improve quality of patient care.

The health care industry is in crisis. From patient safety concerns to wasteful operations to overburdened workforces, health care is ripe for reinvention. In “Health Care Information Technology: Better Care, Better Business,” Glenn Tobin discusses the aspects of health care in need of transformation; the reasons why health care information technology is the right solution; and the benefits to be realized from implementing IT.

Healthcare delivery is undergoing major changes in order to reduce spiraling costs without sacrificing the quality of care. Patients and consumers are at the center of these changes. Telemedicine is growing rapidly. It offers many advantages to different healthcare players, yet still faces many entry barriers. Medical technology companies developing telemedicine products have to consider the market needs, the customer, the product development aspect, the business model, and the long process of market penetration, in order to choose the commercially correct idea and successfully bring it to the market.

The “systems” approach to reducing medical errors is increasingly viewed as dependent upon technology. Issues with the legal system, however, may impede needed reforms. Historically there has been a pervasive disconnect between the legal system and changes in healthcare business models and structures. Further, difficult legal issues will accompany care that is increasingly technologically-mediated. This chapter identifies some of the most serious disconnects and makes suggestions for needed reform.

CareScience™, Inc. is a public company (NASDAQ: CARE) that originated ten years ago to commercialize risk adjustment and complication predictions developed by the Wharton School of Business and the University of Pennsylvania School of Medicine. Over the past decade, the company has grown to approximately 200 clients and 150 employees. Among the “firsts” recorded by the company, CareScience was the first to offer a clinical decision support system as an Application Service Provider (ASP), the first to offer peer-to-peer clinical data sharing among health care provider organizations and practitioners (Santa Barbara Care Data Exchange), and the first to provide a care management outsourcing arrangement.

When we think about health care IT, we don’t just think about clinical automation with the movement to computerized physician order entry (CPOE), but also the need to upgrade legacy financial and administrative systems to interact with clinical systems. Technology acceptance by physicians remains low, and computer use by physicians for data entry and analysis remains minimal. We expect this trend to change, and expect increased automation to represent gradual change. The HCIT space is dynamic, with many opportunities, but also many challenges. The unique nature of the end market buyers, existing business models, and nature of the technology makes this a challenging but dynamic area for equity investment.

In November 1999, the Institute of Medicine (IOM) released a report that focused on patient safety in the United States (U.S.), in which it estimated that up to 98,000 people die in U.S. hospitals each year from medical errors. In March 2001, the IOM released a follow-up report encompassing a broader range of quality issues in the U.S. health care system. It concluded that health care in the U.S. is plagued by a variety of problems which stem from an outmoded system that does not provide high-quality care on a consistent basis. The IOM also outlined a strategy for redesigning U.S. healthcare to achieve safe, dependable, high-quality care, which emphasizes information technology as an integral part of the solution. In 2001, the Agency for Healthcare Research and Quality (AHRQ) spent $50 million on initiatives to reduce medical errors and improve patient safety. The crux of these initiatives was a series of solicitations that form an integrated set of research and demonstration projects for reducing medical errors in multiple health care settings. This chapter will discuss some of these initiatives, focusing on the role of clinical informatics in the Agency’s efforts to improve the safety and quality of health care in the U.S.

High quality, computer-interpretable, patient-specific knowledge at the point of need is essential, as we seek to incorporate decision support and other approaches in clinical information systems to achieve safety and increased quality of health care. This gives rise to the need for shared, standards-based approaches to representing the knowledge and tools for management of it.

Patients today demand a stake in the care of their own health. The expectation is that patients who take responsibility for their own care will communicate more effectively with their health care team and be productive citizens in our society. Medical technology today and those products visible on the horizon, coupled in a telehealth network, provide promise to empower patients to participate fully in the management of their own health. Technology alone, however, will not integrate the elements required for an effective telehealth system. This chapter considers the non-technical matters of this issue such as trends in the medical device industry, trends in the point of care, public health care policies, and the role of government regulation, working together to achieve these public health goals.

It is estimated that over three-quarters of a million people are injured or die in hospitals each year from adverse drug events. The majority of medical errors result from poorly designed health care systems rather than from negligence on the part of health care providers. While there is considerable evidence that information technology can be used to significantly reduce medication errors and adverse events, information technology, to be effective, must be implemented using a systems approach. This paper reviews three studies that have used a systems approach to investigate the causes of medication errors and the effectiveness of information technology in preventing adverse drug events. Significant reduction of medication errors and adverse drug events requires systemic implementation of information technology, improvements in the reporting of errors, and integration with other systems designed to detect and prevent errors.

Despite the increasing role of information technology in health care, its use still lags behind that occurring in other sectors. Factors contributing to this include the complex health care environment and conflicting political agendas. Building political support for information technology in health care depends on understanding the importance of stakeholders and the environment in which they operate. It is important to involve stakeholders early in the process of implementing new information technology in order to identify needs, barriers, and non-starters. Understanding the historical experience of the community and its past attempts at using information technology is also important. Quality of care issues, nursing shortages, cost control concerns, health insurance costs and coverage rates, institutional solvency, and overwhelming paperwork are current problems in the healthcare environment that can hinder willingness to invest in information technology. Ironically, information technology can also help remedy these problems. Impact on workflow, privacy of personal health information, and system reliability, interoperability, and the ease of updating the system can all have political ramifications with regard to acceptance and implementation of information technology.

Medicine today has changed in many aspects. Physician practices face enormous challenges in the form of higher costs, lower reimbursement, and managed care. Barriers in the form of physician discomfort with information technology and the costs associated with employing this technology make physicians reluctant to adopt information technology systems in their practices. Thus the problem is how to get doctors to adopt technology that can actually help them combat these challenges and problems and provide quality care to patients. This chapter discusses an appropriate and practical orientation from which to approach design and implementation of information technology for the office practice.

The Citizen Health System (CHS) is a European Commission (CEC) funded project in the field of 1ST for Health. Its main goal is to develop a generic contact center which in its pilot stage can be used in the monitoring, treatment, and management of chronically ill patients at home in Greece, Spain, and Germany. Such contact centers, using any type of communication technology, and providing timely and preventive prompting to the patients, are envisaged in the future to evolve into well-being contact centers providing services to all citizens. In this paper, we present the structure of such a generic contact center and in particular the telecommunication infrastructure, the communication protocols and procedures, and finally the educational modules that are integrated into this contact center. We present the procedures followed for two target groups of patients, namely diabetic patients, and congestive heart failure patients, in which two randomized controlled clinical trials are under way. We present examples of the communication means between the contact center medical personnel and these patients, and elaborate on the educational, user, and telecommunication issues involved.

Telemedicine is said to be helpful to both patients and providers, but we need real-world examples to demonstrate its effectiveness. This paper presents such an example. Royal Brompton, under the Tele-remedy Program of EC Telecom, conducted a project with the Children’s Hospital of Athens, Greece, to provide remote diagnosis management and continuing education for heart disease, using European ISDN technology. Preliminary results showed that, when carried out in a large scale multi-site environment, Teleremedy program significantly reduced geographic and socio-economic isolation for the patient and the professional isolation for the physician. Comparison of original vs. transmitted data revealed no significant differences, with diagnosis accuracy of 100%.

The applications of telemedicine are extremely diverse. They can be categorised as follows: teleconsulting, telemonitoring, centralised networked training as well as continuing and further education, and information systems. At the heart of telemedicine is, of course, the improvement of patient care, including care in decentralized parts of the health system. Expertise and therefore quality should be brought into the medical care system across the board by medical centers using technical aids. Particularly in rural areas, this increases a patient’s chances of being able to be treated at home, even in the presence of complications or relatively rare medical conditions. Modern information and communication technologies also allow medical establishments or groups of establishments to manage their resources more efficiently. In this paper are presented many ongoing telemedicine projects at the University of Regensburg that demonstrate that beneficial aspects of telemedicine result not only in verifiable improvements in quality of care but also in substantial savings.

People with chronic illness or disability share similar information needs that are not routinely handled by a system designed for traditional health services. Recent historical initiatives to provide alternate information systems for sharing information or coordinating services have been highly centralized, were expensive to set up and were not sustainable. We propose a novel application of peer-to-peer networking to provide an infrastructure for information exchange and service coordination. The peer-to-peer model empowers the user (citizen with disabilities) with control over the type and extent of information about themselves that is communicated and to whom. Further, the peer-to-peer model leads to a decentralized resource that grows incrementally, supported by the users, and is potentially more sustainable.

The successful implementation and operation of health care networks and the efficient and effective provision of health care services is dependent upon a number of different factors: Telecommunications infrastructure and technology, medical applications and services, user acceptance, education and training, product and applications/services development and service provision aspects. The business model and market development regarding policy and legal issues also must be considered in the development and deployment of telemedicine services to become an everyday practice. This chapter presents the initiatives, role and contribution of the Greek Telecommunications Company in the health care services area and also refers to specific case-studies focusing upon the key factors and issues of applications related to the telecommunications, informatics, and health care sectors, which can also be the drivers to create opportunities for Citizens, Society and the Industry.

The Department of Defense (DoD) has embarked on an initiative to create an electronic medical record for all of its eligible beneficiaries. The Clinical Information Technology Program Office (CITPO) is the joint-service program office established to centrally manage this multi-year project. The Composite Health Care System II (CHCS II) is the name of the system under development. Given the historical failure rate of large-scale government information system projects, CITPO has employed an incremental acquisition approach and striven to use industry best practices to the greatest degree possible within the constraints of federal acquisition law. Based on lessons learned during the concept exploration phase of this project, CITPO, in partnership with Integic Corporation, the prime integration contractor, has reengineered its software acquisition process to include industry best practices. The result of this reengineering process has resulted in a reduction of the total projected life cycle costs for CHCS II from the original estimate of $7.6 billion over a 14-year period to between $3.9 and $4.3 billion.