European Innovation Partnership for Active & Healthy Ageing

European Innovation Partnership for Active & Healthy Ageing

AA7. Electronic Care Records / ICT / Teleservices group

Lessons learnt from eHealth projects in six EU Regions

Roberto Dandi

LUISS Guido Carli University and EIP AHA B3

Angelo Rossi Mori

CNR-ITB Italy and EIP AHA B3

Aim of this document

We aim to provide some comments on the interviews conducted by John Crawford (IBM and EIP AHA B3) from February to April 2014 to representatives of 6 EU regions (Basque, Galicia, Catalonia, Saxony, Northern Ireland, and Attica/Greece) in order to understand critical success factors and lessons learnt.

Background information

The literature on organisational change management (Todnem, 2005) has identified several critical success factors that need to be taken into account in managing change. In synthesis, the common ground of the different perspectives (Kanter et al 1992; Kotter, 1996; Luecke, 2003) includes:

-Developing a vision and a strategy

-Establishing a sense of urgency

-Creating a guiding coalition/ identifying the leaders and sponsors

-Developing enabling structures

-Communicating the vision to stakeholders

-Reinforcing change through policies, rules, systems

-Consolidating change through quick wins, local changes

-Monitoring results

By commenting the best practices in the implementation of regionalElectronic Health Records (such as those in Sweden, Hong Kong, Andalucia, Jordan, Lombardia, and in the USA - Veterans' Administration, Kaiser Permanente), Denis Protti (2014) identified similar success factors, among which the most important is organizational, clinical, technical, and political leadership. In particular, successful EHR cases have these leadership features:

-Vision, Shared Values, Courage, Stamina

-Pragmatic Priority Setting (Start Small)

-Solid Governance Structures

-Resourcing and Incentives

-Commitment to Training and Support

-Environment for Change

-Communicate, Communicate, Communicate

-Process Improvement and Quality

-Adapt Legislation, Policy and Regulations

-Patience (ROI takes time)

This framework may be used to interpret the 6 cases under scrutiny in order to understand what worked best and what can work in other settings.

Maturity models of regional eHealth programs

Before undergoing the analysis of the organizational changes, we applied the framework of the LITIS project (LITIS is the Italian acronym for Levels of Technological Innovation in Healthcare) to understand the scope of the different eHealth programs across the 6 regions. This framework was developed by the Italian Consiglio Nazionale delle Ricerchetogether with Federsanità ANCI - the Italian Federation of hospital and local healthcare trusts and municipalities, with the aim to measuring the level of accomplishment of eHealth interventions across healthcare organizations (Tamburis et al. 2012).

LITIS identified 165 indicators in order to assess the level of innovation across 3 types of services (or functions) and 3 types of enabling components. The functions are:

-F1: Functions about citizens, as participation and access to the healthcare services;

-F2: Functions about health operators, related to prevention, assistance and care;

-F3: Functions about healthcare management and governance.

In particular, the F2 macro-area was in turn divided into three sub-categories:

-F2a: Functions about the single healthcare operator (including the EMR systems);

-F2b: Ancillary functions (e.g. prescriptions, laboratory reports, certificates);

-F2c: Functions about the clinical collaboration among professionals (including

the EHR systems)

The Enabling Components include as well three macro–areas:

-C1: Technological infrastructures;

-C2: Application infrastructures;

-C3: Organizational elements for the eHealth governance

In table 1, we included all the programs presented in the interviews across the different LITIS dimensions. As evident, the activities most covered by an electronic infrastructure are those concerning services for coordinating health professionals.

The three regions in Spain appear to be the most developed both in terms of scope of the programs and in term of eHealth governance. All the three regions have created an innovation unit devoted to coordinate the eHealth investments across providers. Also, they clearly developed a strategic roadmap coherent with the overall Health Plans and health needs.

It is worth noting that there is a reinforcing link between eHealth Systems usage and eHealth Governance: the more the EHR is diffused the more the Regional authorities and the Regional Innovation Unit may gather data to improve the system, stratify risks of the population, and develop better strategic plans.

Tab. 1 – A comparison of regional eHealth projects across LITIS dimensions

Basque / Catalonia / Galicia / N. Ireland / Greece / Saxony
F1 Information about healthcare services, for the citizen / Osarean / transparencia.gencat.cat ; canal.salut / Citizen Portal (not ready)
F1 Administrative streamlining and booking procedures / Osarean / Health Card / Unique Citizen ID; Citizen Portal (not ready) / Electronic Health Card
F1 Support to the citizen for care processes / Osarean / School of Health; Tele-consultations / Telehealth / Tele-psychiatry; Remote Consultations / eHealth Ser-vices ; Cardio-vascular telemedicine
F2a Information and knowledge for the professionals / Medical Information Database
F2a Support to individual healthcare professional / Telehealth / Teleconsultations
F2b Dematerializa-tion of prescriptions, medical reports, certificates / Personal Health Channel / ePrescription System
F2c Support to cooperation in care processes / Osabide Global / HC3 / IANUS / Electronic Care Record ; NIPACS; Tele-medicine; Re-ferral system / ePrescription System; Palliative care record / Sax Telemed ; Stroke Net
F2c Diffusion of Electronic Health Record (EHR) systems / Osabide Global / HC3; Personal Health Channel / IANUS / Electronic Care Record
F2c EHR prerequisi-tes (infrastructures and settlements) / HC3 / IANUS / Electronic Care Record ; NIPACS / Electronic Health Card infrastructure
F3 Administration /Finance & Control / Risk Stratifi-cation; ARCHO / HC3 / Health Card; HTA / Risk Stratification
F3 Supplying and Logistics (Warehouses) / Innova-Saude
C3 Organizational elements for the eHealth governance / eHealth roadmap; Regional innovation unit (since 2009) / eHealth roadmap; Regional innovation unit (since 2006) / eHealth roadmap; Regional innovation unit (since 2010) / Innovation policy (since 2013); integrated health and social care / 2 eHealth units: National eHealth Board& Hellenic eHealth Network / no regional eHealth facili-ty; one national slow eHealth unit; privacy/confidenciality regulatory issues

Maturity models assess the readiness of an organisation or region in adopting and using a technology. Maturity models have been applied mostly at the organisational level. We can cite three experiences:

1. Denis Protti’s readiness model.
2. HIMSS Analytics EMR Adoption Model
3. Italian LITIS model

HIMSS Analytics has developed a methodology to automatically score the 4000+ hospitals in the HIMSS

Analytics Database (derived from the Dorenfest IHDS+ Database™) on their level of EMR implementation.

HIMSS Analytics’ EMR Adoption Model identifies and scores a healthcare provider’s EMR capabilities, ranging

from limited ancillary department systems to a fully paperless EMR environment.

Critical success factors and lessons learnt

Following the organizational change literature and Protti’s application to the implementation of longitudinal EHRs across regions, and with table 1 in mind, we can identify the following success factors in the 6 regions:

1. Vision, strong political support, solid governance structures.

In the three Iberia regions, we find a“strong ministerial and political support for continued investment, and the organizations and governance systems are in place to deliver improvements” (interview to Catalonia representatives). This support is evident in the strategic plans for eHealth, in the set-up of the regional innovation units for coordinating eHealth efforts across providers, in the funding and investments which are adequate to the needs. Last but not least, technology in these regions is not developed per se but it is strictly linked to the health needs and healthcare goals of the regions. In the Basque region, the strategic areas are clearly identified (Population Focus, Prevention and Promotion, Patient Autonomy, Continuity of Care, and Adapted Interventions) and investments in technology are supporting them. On the contrary in Greece the eHealth Roadmap lacks a clear priority setting since “there is not enough detail to discern where, when and how investments will be made”. Saxony lacks a solid governance structure since there is no regional innovation unit, while the national one is not promoting decisions down across regions.

1. Stakeholder engagement

One recommendation you can find in any organizational change paper is “communicate, communicate, communicate!”. The same we found in successful efforts of these regions. For example, in the Basque region: “The adoption of a leadership model which combines ‘top down’ and ‘bottom up’ is also an important factor, and stakeholder engagement has been handled well.”Galicia as well has afunded multi-disciplinary team adopting the techniques of open innovation to ensure the complete alignment (‘bottom up’ and ‘top down’) and support of all stakeholders when implementing change”. On the contrary in Greece there are “significant issues with the perception of the healthcare service especially among press and commentators, and it may well be performing better than it is portrayed, so stakeholder engagement needs to be improved”. Also in many projects Public-Private Partnerships have proved to be successful, and regional innovation units often collaborate with private technology vendors which may have high competencies notaccessible within the region.

1. Environment for change

Phenomena like the disintegration of health and social services, the cultural resistance of professionals, the digital illiteracy may be barriers to eHealth adoption and diffusion if not addressed well. Instead, regions where the culture of change is already diffused may not stop the process of eHealth implementation. For example, the Basque region “has taken significant steps towards vertical integration, through the creation of Integrated Healthcare Organisations across all 10 health regions, which remove the organizational barriers between primary, acute and other services”.In Galicia nowadays the privilege to view the EPR is limited only to healthcare workers, but legislative changes are under way in order to permit the view to all other care workers. Northern Ireland since 2013 has adopted a policy framework for eHealth and funded several innovation projects aimed at reducing the cultural barriers in technology use across social and health care teams.

1. Quality improvement and transparency

Change needs to be monitored in order to understand if it contributes to the strategic goals. However, measuring the impact of eHealth on a health system is a daunting task. Given these difficulties, in Catalonia at least “there are documented expectations about the desired impact of services.For example KPI’s are being used to assess reductions in the 30-day readmission rate, even if the data itself is 2-3 months old.”. In any case, even if a direct link between eHealth investments and health systems results is not clearly measurable, still technology can be used to assess and publicize the health system performance. In Catalonia, “there is intent to offer transparency of results in the healthcare system, for example via the ‘open data’ approach taken by the Observatory of Quality of Health, and the web site transparencia.gencat.cat. Public media (TV, press) are used to convey information about eHealth services, and the independent media is generally positive in its reporting and commentary. The web site canal.salut also helps to provide good health information to citizens, and news, clinical topics and resources for professionals.” Also, information systems can be used to provide an input to the strategic decision making of health and social care providers. In the Basque region, theARCHO system is “an instrument for self-assessment of healthcare organizations with respect to their degree of readiness to cope with chronicity, based on the CCM”.

Conclusions

This short document was aimed at systematizing the interview data gathered from six regions about eHealth readiness and use in integrated care. We found a match between these results and the literature on organizational change. Also, using the LITIS framework we were able to compare regional eHealth systems in terms of their coverage of basic health and social care functions. All the regions, even if with some difficulties, are keen to improve the integration of care through eHealth. Those regions that started this journey earlier have already gained good results in terms of technology diffusion and use for integrated care. This provides hope to the late coming regions that results are not so far to be achieved. From an EU point of view, many projects, among those developed by the regions, have been funded the European Union. This confirms that the EU funding policy is on the right track in promoting integrated care through eHealth. A further step would be to igniting some knowledge exchange on eHealth implementation from successful regions to latecomer regions in order to spread out the known best practices.

References

Crawford, J. (2014). Basque, Galicia, Catalonia, Saxony, Northern Ireland, and Attica/Greece interview notes. EIP-AHA B3 internal documentation.

Kanter, R.M., Stein, B. A. and Jick, T.D (1992). The Challenge of Organizational Change, New York: The Free Press

Kotter, J.P. (1996).Leading Change. Boston, MA: Harvard Business School Press

Luecke, R. (2003) Managing Change and Transition, Boston, MA: Harvard Business School Press

Protti, D. (2014). What lessons can we learn regarding longitudinal Electronic Health Records?Accessed on Sept. 10 from

Tamburis, O., Mangia, M., Contenti, M., Mercurio, G., Rossi Mori, A. (2012). The LITIS conceptual framework: measuring eHealth readiness and adoption dynamics across the Healthcare Organizations. Health and Technology 2 (2), 97-112

Todnem, R. (2005). Organisational Change Management: A Critical Review, Journal of

Change Management, 5, 4, pp.369 – 380

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