I attended last week in Brussels the meeting of the International Insurance Association (AIM) Disease Management group.  The AIM is a grouping of autonomous health insurance and social protection bodies operating according to the principles of solidarity and non-profit-making orientation. This meeting was one of a series of meetings organized by AIM on the topic of business models and sustainability of healthcare focusing especially on Personal Health. I will details some of the presentations that seem to me outstanding.

The meeting started with a very interesting report of the visit in Israel of the AIM members. Rachele Kaye (Director, Maccabi Institute for Health Services Research) presented the main features of their integrated IT system for healthcare. We learned that all information flows in Maccabi Healthcare are digitized, a health portal is opened for the individuals enrolled in their insurance and the health professionals can access all relevant information regarding a patient. The continuum of care seems preserved in this setting. More impressive was for me the concentration of lab test and the real time access to results from any point of the health care facilities. Some words about the healthcare in Israel: There is an universal social health insurance system, managed by 4 competing HI funds (mutual benefit society) with an open enrollment and a free choice of HI funds. The total health expenses are presenting 7.9% GDP which are 66.5% public and 33.5% private.  Maccabi Healthcare is one of the 4 health insurance fund covering 24% of the market (1.780.000 members), supplying health services both via its own facilities and through outside providers that are paid on a capitation basis. Maccabi Healthcare principles in Chronic Disease management are the multidisciplinary team and a model based on pro-active intervention by team members based on EBM, integrated IT (registries, reminders, ...),empowering patients (active role in the management plan), monitoring clinical quality measures, improved patient centered services (web-based services, call center, free choice, direct access, reduced bureaucracy..), high tech services (telemedicine, EHR..) and a dynamic management method (managerial IT, trained mid-managers physicians, rewarding continuous improvement with a large set of indicators). One of the most interesting feature of their eHealth solutions is related to the patient information booth (self-service stations for patients),  allowing them to printout : lab results, X Ray results, fill in physiotherapy follow-up questionnaire and access education material on lifestyle and basic measurements (BMI).

Another interesting presentation was done by Mr Maghiros from IPTS (Institute for Prospective Technological Studies - IPTS - Joint Research Centre - European Commission). The IPTS, based in Seville (Spain), is a part of Directorate General JRC of the EC which groups 7 Research Institutes across Europe. The mission of IPTS is to "provide customer-driven support to the EU policy-making process by researching science-based responses to policy challenges that have both a socio-economic as well as a scientific / technological dimension". The institute is conducting a study called Strategic Intelligence Monitor for Personal Health Systems that aims to unveil the barriers to adoption of personal health systems (PHS) perceived as a key patient and consumer driver (driver of the economy - Lead-Market) and decongestion of secondary care infrastructure (chronic disease segment). In the IPTS vision, people are in the center of the healthcare system and the personal health systems can be divided in 3 categories:

There are a number of questions that IPTS will tackle in the following month, such as the role of Personal Health Systems in the future healthcare, known barriers to adoption, positive motivation, policy initiatives, barriers to public health re-imbursements, how will prevention and wellness become reimbursed, the insurance as a driver for change.

Len Deacon from South Africa made a brilliant presentation emphasizing the difference between healthcare in the developed and developing countries. In few words in developed countries  we are talking about delivery of care at home, move away from hospital-based treatment, move to prevention  and remote monitoring as a way of cutting high costs and preserving or increasing the quality of care.  In developing countries we are talking about extending healthcare to more of the uncovered (State/Public),  Public/Private Partnership (extending care), monitoring intervention for "at risk" members (Coaching / disease management), preventing future illness (communication, coordination of care, wellness - prevention of HIV/Aids, demand management). South Africa has specific problems related to a discrepancy in wealth distribution, high unemployment, many languages (11), low life expectancy due to high prevalence of HIV (11% of the population). The model emphasized by the speaker is total health management across continuum of care:

This model implies an absolute interdependence between the patient, the doctor and the medical scheme. The patient is empowered but in strict cooperation with the health professional. The type of interventions  performed are detailed above (right image).

Very interesting is the proposed methodology to act on the high risk patients. After a local study the risk identified can be grouped:

The categories at high risk are proposed changes in behaviors, incentives, wellness and disease management programmers in order to allow them to change their risk category (see above right picture).

The coaching program and use of Personal Health Systems has been studied on year basis and the results are quite impressive: on more then 20.000 members of the insurance, 2800 have been coached according to the risk and the ROI was about 1:1,8 (3,660 million R - about 450.000 USD net savings in one year). This makes about 160 USD/person/year.

The message of Len is suite clear: we can achieve high return on investment only by a close collaboration between the individual, the health professional, the insurance and the employer. The last two categories can bring the sustainability, the incentives and the institutional support for achieving a total health management.

Very interesting also was the study performed by Abbott on the compliance and adherence of the patients to their treatment (Patient Adherence Research Project). 

The two definitions must be kept in memory:

Compliance (from Vermeire et al.. J Clin Pharm Ther (2001) 26, 331-342)

.The extent to which a person's medicine-related behavior coincides with medical advice

.Assumption that "rational" patient behavior means following medical advice precisely

.Paternalistic: doctor makes choices and directs patient to follow

Adherence (from World Health Organization - Adherence to long term therapies: Evidence for Action (2003))

.The extent to which a person's behavior - taking medication, following a diet and/or executing lifestyle changes - corresponds with agreed recommendations from a healthcare provider;

Often ignored, the problem of compliance is much more important then assumed.  The prevalence of non-adherence is 40% to 60% in arthritis (Belcon, M.C. et al (1984), Arth and Rheum, 27: 1227-1233; 1984. Hicks, J.E. (1985),Comp Ther, 11: 31-37), 15% to 43% among organ transplant recipients (Didlake, R.H. et al (1988),Trans Proc, 20(3): 63-69; Rovelli, M. et al (1989),Trans Proc, 21: 83-834), 18% to 70% in the treatment of depression (Engstrom, F.W. (1991) in J.A. Cramer and B. Spilker, eds., Patient Compliance in Medical Practice and Clinical Trials, Ravens Press, New York, NY; Myers, E.D. and A. Branthwaite (1995), Br J Psych, 160: 83-86.), up to 50% of patients on hypertensive medications cease treatment. Of those staying on treatment, 33% do not take sufficient medication to control their blood pressure (Vermeire et al. 2001, J Clin Pharm Therapy, 26(5):331-34).

What is cost of non-compliance? Research shows that in the U.S. non-adherence causes 125,000 deaths annually (Smith, D. (1989). Compliance packaging: A patient education tool. American Pharmacy, NS29 (2)), non-adherence costs an estimated $100 billion a year in direct and indirect costs (National Council on Patient Information and Education. (1995). Prescription Medication Compliance: A Review of the Baseline of Knowledge. Washington, DC), approximately $47 billion of this cost is associated with 8.8 million drug-related hospitalizations per year (Friend, T. (1995). Health and education. USA Today, Tuesday, October 3, 1995. 4D).

It is believed that: Increasing the effectiveness of compliance interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments (Haynes RB et al. Interventions for helping patients follow prescriptions for medications. Vol. 1. Oxford: The Cochrane Library, 2001).

As a solution there are foreseen (see bellow) interventions in the area of  awareness, communication among stakeholders including patients and healthcare professionals as well as personal health systems making easy the correct drug intake for patients.

In such a context, my presentation emphasized the advantages of Personal health solution notably of the Microsoft solutions around the Disease management, Case Management and Health & Wellness.  Hence, one of the keystone of personal health systems is the Healthvault platform. Developed after a thorough assessment of the patients and healthy individual needs, the platform offer a wide range of services (storage and communication of health data in several standards, communication with medical devices, alerts and statistics.) which can be easily adopted by a variety of health institutions. We see the use of Personal Health system as a way to shift healthcare from cure towards care, enhancing awareness, favoring behavioral changes and information as well as increasing communication between health professionals and the individual.

The patient involvement in health care is seen as a key aspect for improving healthcare outcome and solutions such as HealthVault platform can enable this side of the equation. Moreover, the addition of AMALGA UIS on the platform could solve the interoperability issue with heterogeneous Hospital Information Systems and populate the Patient Health Record with the data stored in hospital. 

But why I started with the trust and usability as title? In order to achieve an efficient disease management system one should think that two of the most important barriers are the trust and usability. Let's take a closer look: usability has been one of the major cause of failures in the IT programs; with a poor design, the health professionals loose time, can add other errors of interpretation and finally abandon the use of the software. The IT industry must take a particular care on these aspects. Microsoft issued the Common User Interface guidelines  as a result of a project funded by the UK NHS.  As a formal definition, the Microsoft Health Common User Interface (CUI) provides User Interface Design Guidance and Toolkit controls that address a wide range of patient safety concerns for healthcare organizations worldwide, enabling a new generation of safer, more usable and compelling health applications to be quickly and easily created. Moreover, several IT programs across Europe  initiated by the governments and/or insurance companies have encountered resistance from the health professionals. Imagine how difficult would be to change the behaviors of the health professionals and persuade them to use new IT tools, change the way they are working and communicating. One solution to the trust problem would be to allow them to decide on the care path, on the design of the IT tools and to involve them in the overall organization of a chronic disease management program. In exchange, performance and quality management should be enabled so as a program of incentives. There is no other solution to the trust problem then the collaboration, active involvement of the health professionals in any of the insurance and governmental healthcare programs. The same stand for the patients trust. Patient associations and customer rights association should be deeply involved in large IT programs in order to achieve adherence of the users from the inception of the initiatives.

The IT solutions are available and must be wisely assembled in a comprehensive eHealth solution that will help all the stakeholders (favoring change in behavior, empowering users, increase adherence to the treatment,  increase health care user communication and information), while being trusted, usable and sustainable.

Dr Octavian Purcarea

Global Solution Manager

Worldwide Health

Microsoft