The Fifth Conference

UZ BRUSSEL’S CLINICAL WORKSTATION STREAMLINES INFORMATION FLOWS AND ENABLES EVIDENCE-BASED MEDICINE
To streamline the massive information and clinical processes in UZ Brussel, the university hospital has developed a Clinical Workstation. Physicians and nurses use this system for almost all their activities, and it gives them a complete picture of the patient’s medical history. The Clinical Workstation even integrates clinical decision support systems, which help doctors to practice evidence-based medicine.

Since 2000, UZ Brussel is extensively using an in-house developed Clinical Workstation (CWS) to streamline the massive information and clinical processes in the university hospital. Rudi Van de Velde, CIO of the hospital, explains that this system is able to offer its users (550 physicians and 1400 nurses) a holistic view of their work: “With this clinical workstation, our users have access to all patient and hospital related information within one system using a consistent user interface, which minimises training and optimises the work experience.”

Physicians use the CWS for almost all their activities, including order entry, scheduling (radiology, pathology, surgical and other activities), reporting, medication and admission. Physicians also have a complete picture of the patient’s medical history at their fingertips: “We seamlessly integrate hospital applications, re-use many software components, and effectively manage change more efficiently. On a daily basis, physicians and nurses access patient records 25,000 times, schedule 4,000 appointments, capture more than 5,000 medical reports and process over 9,500 medical orders. Ninety percent of these interactions are completed in less than one second.”

E-TRINITY, A LEADING HEALTHCARE SYSTEM INTEGRATOR, RELIES ON A UNIQUE METHODOLOGY TO DRIVE CHANGE IN THE HEALTHCARE SECTOR
e-trinity is purposefully changing the way healthcare is doing business. Its founder is attracted to the healthcare field because of its inherent difficulty on one hand and the potential and vital efficiency improvement of healthcare delivery on the other hand. This magnetic appeal of detecting improvement and defining solutions keeps Jeroen Van Maercke and his company e-trinity on the forefront of the healthcare evolution. Jeroen weighs in on why he’s drawn to this particular challenge and his hopes for the industry.

Facing the future

Healthcare isn’t sustainable. It is a failed state about to collapse. Healthcare delivery organizations are facing a huge challenge. They face a rapidly increasing demand due to the aging demographic. Meanwhile, both the evolution of healthcare and treatment possibilities are progressing vastly. Since the emergence of social networks and healthcare communities, the patient has been claiming a more active role in his healthcare and wellbeing. This in turn places pressure on the various healthcare organizations to redefine their mission and position in society. Last but not least, the increased financial stress on healthcare budgets forces healthcare organizations to optimize their processes and collaborate with others to limit and/or share their investments.

Gaining the necessary perspectives

I’ve always worked in healthcare, starting over 10 years ago with Quadrat in 1997. Industry has only one motivation – margin for profit – with a single leader responsible. It was here I climbed the corporate ladder until I worked on the global introduction and training of a software program. The years of traveling took its toll and in 2003 I opted for a job with the University Hospital Antwerp.

Instead of working for hospitals, I was in one. I soon learned that a healthcare organization is different from an industry organization. There is not a single leader in a hospital that can make decisions and be held solely responsible for them. Revenue in hospitals is generated by (often-independent) doctors utilizing and paying for the hospitals facilities. In many cases, the lack of clear responsibility resulted in conflicts of interest, power struggles on simple matters, and delayed business decisions. It was a frustrating experience that so few decisions were made and a limited amount could be accomplished.

A SOCIAL NETWORK FOR CHRONICALLY ILL PEOPLE IS GENERATING A WEALTH OF HEALTHCARE DATA
While much of the debate about improving the United States’ healthcare system — one of the world’s largest — has centered around companies and government figures, the social networking website Patients Like Me has tried to approach the complex and often vexing issue by putting more information in the hands of individual patients, and inviting them to share. Co-founder Ben Heywood, currently the President and Director of Patients Like Me, believes a reassessment of privacy and better use of data is necessary to take healthcare into the 21st century.

A family tragedy led to the founding of Patients Like Me

Unfortunately my brother got diagnosed with Lou Gehrig’s disease back in 1999, so my family got really involved in ALS research. So my brother, Jeff Kohl and I decided to start Patients Like Me out of the experience of caring for our brother, researching ALS and talking to other patients about what they were going through. We found that there was a real dearth of information, for everyone, about what happened to “patients like me;” outcomes, symptoms, treatments that patients were taking. We saw there was really no good way of finding and sharing that information. Seeing that need, we started a registry on ALS in 2004, launched the first site in 2006 and have been growing ever since.
One of the core beliefs of Patients Like Me is that “information can change the course of a disease.”
It’s all about getting the right treatment for the right patient. In the healthcare industry as a whole, there just isn’t data that allows one to do that; it’s just not part of the system. Part of what the communities we create on our site do is help share that information. Our data sets have quickly become some of the largest in the world. We had a researcher on fibro myalgia talk to our community about eight months after our launch and he said “you have the richest data set on fibro myalgia anywhere in the world.”

How data can help solve the healthcare system’s problems

These data sets allow you to begin modeling a disease, so you can really understand what happens to an individual patient. That way, when something new comes on the market — a new drug, a new product, a biomarker, etc. — you can rapidly understand whether or not it works, and for which patients. One of the big problems with healthcare is that we don’t measure in the right ways. If you think about what you do in business or in your everyday life, one of the first steps is measurement. To measure is to know. When healthcare does measure lots of stuff, it doesn’t measure what’s ultimately most important: the patient’s quality of life. In the realm that we deal most in — chronic conditions — there’s no measurement over time. The data our patients provide becomes an incredible source for measuring value, then you can spend healthcare dollars where they’re most valuable instead of just spending healthcare dollars, which is what happens now. Patients can browse and use the data to better understand their own — or others’ — conditions, and the data can prove useful to other parts of the healthcare system as well.
Sometimes being able to see other patients’ experiences acts almost like a kind of intervention; 20 percent of people in our mood disorders community, for example, actually report needing less care because of being a member of patients like me. That lowers healthcare dollars.
Primarily we’re also partnering with pharmaceutical companies who really want to understand — from a clinical standpoint and a market standpoint — how patients are experiencing their disease and how they perceive and utilize their products and services. This allows the company to improve their product; it’s a way of partnering companies and patients together around the data that’s being shared in the community.
People are used to being very private about their healthcare situation, and there are laws that back that up, making access to healthcare information stricter than almost any other sort of record. But there are issues with that mentality.
Every day, millions and millions of dollars are spent, trying treatments, whether they’re old and true methods or newer, more experimental ones. But often we don’t learn from all that trial-and-error, because this data isn’t collected. Even when it is collected, this important information is usually kept siloed in hospitals or universities. The reality is, there’s tremendous value in sharing that information.
All of these privacy protections that have been put in place are actually, as a society, reducing our ability to further research disease states, reduce healthcare costs, and have real conversations about the tradeoffs of treatments for different diseases.
The beauty behind our openness philosophy is that people learn that when they start sharing what happens to “patients like me” they can learn about their own healthcare and help the whole society.

Social networking improves patients’ wellbeing

Some of these diseases are very isolating, and with that isolation comes depression, which only worsens the condition. Having a social connection is healing in and of itself. Knowing that sharing this information is helping yourself and others is another way it improves a patient’s quality of life.
Also, we hear all the time from patients in our multiple sclerosis community, for example, that “the rest of the people in my life just don’t understand what I’m going through.” Just having other people who do understand the condition can really be an outlet for some of the frustration of dealing with these serious illnesses.

Striking a balance between selling and using data while protecting patients

Obviously, we’re on the forefront of this field, so finding a balance is very tricky and we work hard to maintain it. We let patients know, as best we can, the risks of sharing information so they can decide what they do or don’t want to share. In keeping with our philosophy, the patient is ultimately in control of how much they share.
In our partnerships, we explicitly say this data cannot be re-identified. They cannot use our website or other data sets to re-identify our patients. That way they’re just using the data to improve their business, and they are contractually obligated to not do some of the things they could do quite easily if they re-identified the data and attached it to individual patients.

Expanding the community

Our goal, long term, is to open Patients Like Me up to as many diseases as possible; currently, we have 19 conditions and 80,000 patients. While that’s a good start, we really want to open this community up to a wider audience. Our goal is a million patients in the next couple of years and give every last one of those patients tools to better manage and understand their illness.

BRUNO HOLTHOF, EX-MCKINSEY CONSULTANT AND CURRENTLY CEO OF ZNA, BELGIUM’S LARGEST HOSPITAL NETWORK, TALKS ABOUT THE FUTURE OF THE BELGIAN HEALTH CARE SYSTEM AND THE OBSTACLES TO OVERCOME.
Bruno Holthof is well-placed to have an opinion about the future of the Belgian health care. A medical doctor by training, Dr Holthof spent 15 years at consulting firm McKinsey&Company giving strategic advice to hospitals and pharmaceutical companies around the world. Since 2004 he is back in Belgium running the country’s largest hospital network. Comprising 3 general hospitals and 6 specialized hospitals, ZNA is also a top ten European health care provider. In this interview, Bruno offers his vision on the future of health care from a Belgian perspective.

Changing demographics and disease patterns

Let’s start by talking about the coming changes in the demand for health care, because that will have a dramatic impact on the way we need to organize our health care system. The main trend in this regard is the changing demography and the associated changes in disease patterns. We keep talking about the ‘graying’ of the population but in fact today we’re experiencing the ‘whitening’ of the population. What I mean is that we see a tremendous growth in the age categories 75+ and 85+. These people tend to have multiple organ malfunctioning. This means that we’ll need to treat these patients using a multidisciplinary approach and expand our geriatrics divisions. Furthermore, we will see a significant increase in dementia and hence we will need to increase our capacity for managing this condition, not only in institutional settings but also via home care and day care centers. All this is going to happen—we can predict this with confidence—and Antwerp will be hit fastest in Flanders.
Another key trend is the increasing birth rate, especially among immigrant families. This has implications for our pediatrics and maternity divisions. We also expect a further reduction in the maternity stay—from 4-5 days to 2- 3 days. Once we get to 3 days we’ll need to organize the entire process differently, probably by shifting to a single room model as opposed to moving the patient from a delivery room to a residential room.

Organizing around the needs of the patient

The advances in technology and medicine are making it possible to reduce stays for a whole range of conditions. Hence the hotel capacity of hospitals will need to be reduced and day care expanded. Such evolutions require a constant change in infrastructure, technology and organization. Children for example, are increasingly treated in day clinics. To better organize ourselves around the needs of the child we have been expanding our pediatric day clinic. The basic idea is to make sure that the flow through the day clinic is child friendly all the way and happens as smoothly and quickly as possible. At our hospital we’ve organized it as an adventurous journey from Green land to Sun land. The journey starts in Green land, a play area, where the child and the parents are welcomed and registered. The first diagnostic tests are done there. Then they move one to the next ‘country’ where they get their operating clothes and place their baggage in a locker. Afterwards it continues on foot or in a bed to the operating theatre. At the end of the journey the child arrives in Sun land where it is rewarded with an ice cream. At every stage we’re using playful methods to explain what is going on and the child can make choices too at several points in the process. It is a nice example of care being organized around the needs of the child and the parents.

Patients certainly are becoming more vocal and we need to adapt to this evolution. Also with regard to dementia for example, we are developing clear charters to make sure that we treat patients and their families with respect. It is important that we do not only focus on the medical side but also on, for example patient’s hair care and manicure because people with dementia tend to lose the ability to take care of themselves. It all has to do with respect.

Customized care

Customizing treatment to an individual’s needs and characteristics will also become increasingly important. Medicine has become much more complex and specialized; and it is constantly evolving and becoming more technology-intensive. In oncology, for example, we know that the effectiveness of certain types of chemotherapy is related to an individual patient’s genetic profile. As a result, therapy needs to be customized to the needs of the individual. Also in radiation therapy it is possible to do much more targeted and precise work, using sophisticated—and very expensive—equipment. In the coming years this trend toward more personalized care will only continue, not only on the basis of medical indicators but also on the basis of patient choice. It is true that many patients are becoming more vocal but in many cases they really have to be. For an increasing number of conditions—for example, prostate cancer, hip replacements, obesity, etc—there are several ways to treat it, hence it is essential that the patient is involved in the decision making.

Quality and the measurement of outcomes

The measurement of health care outcomes is becoming hugely important. At ZNA we’re making investments with the specific intent to start measuring outcome indicators. In 2011 we begin systematically measuring outcomes. Obviously you need to be very careful in the way you do this, especially in the way you correct for risk profiles. For example, an excellent maternity department could score really poorly if you just compared perinatal mortality rates in absolute terms. That’s because a reputable department will likely attract the most difficult cases.

Information Technology is enabling a more decentralized but connected health care system

Our ambition is to become a paperless hospital. We’re far from there, but we are investing with that intent. We will be setup with different form factors: mobile laptops, tablet PCs, smart phones, screens in rooms and operating theatres, etc. All our hospitals are already linked with a fiber network in preparation for the coming boom in data traffic. I expect a tremendous evolution in technology in the coming years. Imaging, for example, is becoming amazingly complex and this will certainly create a huge load on our network. For example, we recently streamed a live heart operation to a cardiology conference in Boston. These technologies enable much closer cooperation among different stakeholders and lines of care. For example, the multidisciplinary consult in oncology today requires people to come together physically. We’re currently exploring an advanced communication platform that will allow the caregivers to come together via video conferencing while they have access to all data and images from a common interface.

The key implication of all this technology is that we’ll need fewer large hospitals. In Flanders there was a trend to build large hospitals of 1000+ beds in a single location. In the future that won’t be necessary anymore. A degree of concentration is obviously still necessary to manage expensive medical equipment—patients need to come to the specialized infrastructure. But at the level of expertise you don’t need that concentration anymore. In the coming years a specialist will be able to deploy his or her expertise much more widely, even beyond borders. This is why I’m a proponent of smaller hospitals that are designed around the needs of the patients. Patients prefer smaller hospitals too. The future of health care will be more technological, more dispersed and more collaborative across the different lines of care. Our investment program is based on that vision.

An obsolete financing system is an obstacle to innovation

Innovation is critically important if we are to keep improving the quality and outcomes of health care—and keeping it affordable. The main obstacle to innovation, however, is our financing system. Our financing system is based on the retrospective payment of medical interventions and the duration of hospital stays. To illustrate, today in 2011 we still don’t know how much we will be paid for a hip replacement performed in 2006. Not only does that make financial planning very difficult but this type of system also often is a disincentive for investing in new technology and methods. Take obesity as an example. We know that we can’t just focus on surgery; equally important are psychological support and dieting to help patients reduce weight. But we don’t get financed for all that extra care. This is absurd. The financing should be linked to weight reduction outcomes; not just surgical intervention. As a hospital we should be funded on the basis of results, which would be a tremendous incentive to innovate, to invest in new technologies and methods.

Unfortunately there is lethargy in the system. You will always have stakeholders who resist change. That’s why I suspect that change will also have to come from patients. Patients are beginning to organize themselves via social networks – that’s a good thing. For example, we are seeing patients beginning to put political pressure on the way palliative care is funded. At present the government will only refund residential palliative care which has led to the closing of several day-care palliative initiatives – the only ones that survive are run by volunteers. But lobbying by patient groups should make an impact.

RUDY MATTHEUS, CHAIRMAN OF THE VOKA HEALTH COMMUNITY, OFFERS HIS VIEW ON THE CHALLENGES FACING BELGIAN HEALTHCARE AND THE POTENTIAL SOLUTIONS
As the European population ages and the prevalence of chronic disease rises, it is becoming increasingly clear that we can’t deliver higher-quality, more affordable healthcare without aligning payment incentives and improving coordination across the many providers who care for a given patient. New capabilities and healthcare models are required, which results in challenges and opportunities for our medical community, as well as our patient-clients.

The impact of the ageing population

New projections for 2010–2060, published by the European Office for Statistics, state that the number of elderly persons will rapidly increase, with the 80+ population group doubling in size by 2050. From 2015 on, deaths are projected to outnumber births in the EU27 and almost three times as many people will be 80 years or older in 2060. In Belgium (population 10 million) there are more than 1,8 million people older than 65 and 0,5 million people over 80. Eighty percent of people over 65 have a chronic disease and in the 75+ age group 85% has more than three chronic diseases.
These demographics trends will also be accompanied by a rapid growth in the number of persons with physical disabilities – about 21% of the 50+ population has severe vision/hearing/dexterity problems. Diabetes is now talked of as the epidemic of the 21st century, and parallels the worldwide explosion of heart disease.
The ageing of the European population and the associated rise in chronic conditions will lead to a growing number of older people living alone and in need of care. Simultaneously there will be astonishing but expensive advances in diagnosing and treating diseases, in a very personalized manner.
In light of these trends it is clear that the problem of care and assistance will become increasingly important both from a social and an economic perspective.

Healthcare models need to change

These trends pose a double challenge to existing healthcare delivery models. Firstly, there is a growing mismatch between traditional services and new needs – health services for example were originally designed to deal with acute rather than chronic disease. Secondly, rising demand for healthcare services is placing tremendous pressure on healthcare budgets. In response, the healthcare model will need to change dramatically. According to the Institute for Healthcare Improvement, “many healthcare systems around the world will become unsustainable by 2015. The only way to avoid this critical situation is to implement radical changes”.

New economic opportunities

The required changes will also create new economic opportunities. There are 85 million consumers in Europe over 65 years old today and this is expected to grow to 150 Million by 2050. Their combined wealth and revenues are estimated to be over €3000 billion. Clearly there is a tremendous opportunity to help empower elderly people to stay active and live independently. There also will be significant opportunities in the use of innovative approaches to improve care and make it more efficient. For example, the telecare market is expected to exceed €5 billion by 2015 in Europe alone.

Healthcare is already expanding in scope

Some significant changes are already in progress. Healthcare – traditionally focused on institutional care and on curing diseases (diagnosis, treatment) – is expanding in scope in at least two ways. The site of care is expanding its boundaries by going outside the hospital and the clinical setting and moving towards the patient’s home. And care is enlarging its scope beyond the patient domains to also encompass the support of people with special needs such as the elderly and the disabled.

Beyond the institution

Healthcare is extending its “institutional” role and is becoming personal, ubiquitous and mobile. Informal caregivers (patient’s family, friends, volunteers) are complementing the tasks of the medical professionals, but they are also under increasing pressure and need more tools. All citizens are becoming users of these new healthcare services and will be motivated and empowered to manage their own health. Currently we are witnessing a new wave of change: healthcare is pursuing a prevention objective, by focusing on health conditions through fitness, weight management and a generally healthier lifestyle. The social behavior and lifestyles, as well as the identity of the individual elder person, will change. Their requirements and consumer behavior will change both in quantitative and qualitative terms. A patient-client will become a consumer.

New capabilities required: care coordination and outcomes measurement

The new care delivery models demand capabilities for care service coordination and an ability to track quality outcomes that were not previously required in healthcare. This should apply to all services, also home-based services. Accreditation of services needs to be approached in a much broader way and should be stakeholder driven. The financial model needs to be reorganized; financial flows should be reallocated and become more outcome-driven. What matters are healthcare results and comfort levels; not the volume of medical interventions. The government should also investigate and rethink their financing role in building infrastructure where cost calculation should be based on life cycle costing and alternative financing should be explored. To support the move to team-based models of care, healthcare systems must accommodate the information and workflow requirements of the many stakeholders and organizations involved directly or indirectly in patient care. Social dimensions should also be taken into account. The coordination of information between all actors involved is crucial. In coordinated care the healthcare delivery system provides a continuum of evidence-based, quality driven healthcare services in a cost effective manner. Coordinated care requires a change in care culture, education, infrastructure, and in the relationships between patients, clinical staff, and caregivers. It calls for the creation of “accountable care cultures” that work together in coordinated, collaborative ways to drive better disease prevention, personalized treatment and positive outcomes. Technology can support this transformation by delivering vital information and tools that meet clinician and patient needs. Healthcare will address new user groups other than the traditional patients: the elderly and people with special needs such as persons with disabilities. By taking into account the ageing of the population, this new and additional “assisting” role of healthcare will become increasingly important. Ambient Assisted Living refers to intelligent systems of assistance for a better, healthier and safer life in the preferred living environment and covers concepts, products and services that interlink and improve new technologies and the social environment. It aims at enhancing the quality of life (the physical, mental and social well-being) for everyone (with a focus on elderly persons) in all stages of their life.
Quality of Life will have a new, extended meaning where physical, psychological and social aspects are taken into account all together and the “way the patient perceives his/her overall health status” will become of paramount importance. Perception will be more dominant in the evaluation and acceptance of the services.
Hospitals – which play a significant role in the health system – should increasingly try to differentiate and complement their offerings. One-day interventions will increase and care hotels will be the place where patient recover and rehabilitate before going home. We need to design for users; the solutions need to be user- and demand-driven. Care initiatives should:

• Respect patients’ values, preferences and expressed needs
• Coordinate and integrate care across boundaries of the system
• Provide the validated information, communication, and education that people need and want
• Guarantee physical comfort, emotional support, and the involvement of family and friends; the social component.

The user-as-producer transforms the relations between consumers and markets and among citizens themselves. Furthermore, it is opening up the possibility of reconfiguring the production process around the user. In many sectors there is a gradual incorporation of users into the process of production. All the stakeholders (patients and their families, medical professionals, policy makers, health organisations, industry, institutions, insurance companies, the overall community) need to find a way to cooperate in a common effort to create solutions for a new economy and added value for the patient.

Healthcare is an ecosystem – not a factory

The efficiency and effectiveness of healthcare services are certainly becoming a major priority. More integration of information is needed, as well as integration of the logistical processes through the whole value chain and core trajectory. But we need to be careful in comparing healthcare management approaches with those used in industry. While some processes (e.g. some logistical processes) are reasonably universal and hence can be standardized, care processes don’t always lend themselves to such standardization. Care processes are very often unpredictable and unplanned. We could best describe the healthcare model as an eco system. The intelligence is in the total care-system itself. There is chemistry to the way care functions; it a complex, adaptive system—and many aspects of care are distinctly artisanal in character. All actors in the healthcare delivery process should take that paradigm into account. The opportunity for creating new solutions and the needed delivery models should be part of such an ecosystem, where catalyst intelligence binds the demand and delivery elements. Health technology assessment and multi-sector innovative approaches will be needed to bring value added care towards customers and to create new business opportunities. As such, it is in this context that the idea of “we care” gains multiple dimensions—we care for people with our brains, hands and heart. Unfortunately the implementation of new approaches in healthcare is hampered by various challenges and restraints; they deal with technological issues and lack of standardization but also – and in some case preponderantly – with political, legal, financing and cultural issues.