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Digital health: a blessing or a curse?


1 Digital health: a curse or a blessing? How technology can advance or fail efforts to provide efficient, high-quality healthcare

2 KPMG authors Mark Britnell Chairman and Partner Richard Bakalar, MD Managing Director Ash Shehata Partner Mark Britnell is Chairman and Partner of the Global Health Practice at KPMG. Since 2009, he has supported governments and private and public organizations in more than 60 countries with business, strategies and guidelines. His groundbreaking vision for healthcare inspires actors in industrialized and developing countries and he can refer to an extensive list of publications that address the question of which approaches really work in different parts of the world (more on this at / whatworks). Mark Britnell has always been a healthcare professional, leading organizations locally, regionally, nationally and globally. He was CEO of the high-performance university hospitals in Birmingham and was instrumental in building the largest new clinic in the UK National Health Service (NHS). He also ran the NHS from Oxford to the Isle of Wight before joining its board as director general. Mark Britnell, together with former British Health Minister Lord Darzi, launched High Quality Care for All and published his first book, In Search of the Perfect Health, in October 2015. As a KPMG expert in health information technology, Richard Bakalar is pursuing the goal of data Make full use of electronic health records and other systems to improve patient care. He has extensive clinical, operational and technical knowledge and experience, including in the areas of e-health and telemedicine systems. Richard Bakalar spent 20 years in clinical medicine, initially in the US Navy, where he pioneered the use of telemedicine. He then went to IBM as Chief Medical Officer, where his work in research and clinical consulting as well as improvements to software and infrastructure paved the way for IT solutions in clinical practice. He then developed and implemented innovative IT solutions for hospitals, health systems and communities for Microsoft. He is a member of the editorial board of the journal Telemedicine and e-health and the ATA College of Fellows; from 2006 to 2007 he was also President of the American Telemedicine Association (ATA). Richard Bakalar holds a bachelor's degree from Rice University, Houston, and a PhD from Uniformed Services University of the Health Sciences, Bethesda, Maryland. Ash Shehata is a partner at the Global Healthcare Center of Excellence KPMG in the USA and has worked for various leading global IT and consulting firms in a career spanning more than 25 years, using modern technology to drive improvements, for example in areas Telemedicine, e-commerce, membership systems, customer care and health management. As Senior Executive Director Healthcare for North and South America at Cisco, Ash Shehata led the development and implementation of telemedicine solutions for key customers and government agencies. Previously, he was Vice President Health Solutions at Wellpoint, where he supported a good 32 million members with the use of corporate applications. He also held senior positions at KGT Global Technologies, IBM and Accenture. Among other things, Ash Shehata managed an annual budget of 250 million US dollars for various departments for the University of Cincinnati Medical Center. Ash Shehata holds various degrees from Xavier University in Cincinnati, including a Bachelor and MBA in Psychology and a Masters in Hospital and Health Administration. This report was produced in cooperation between KPMG International and the Nuffield Trust. Thanks to co-authors Nigel Edwards, Candace Imison, Sophie Castle-Clarke, and Robert Watson of the Nuffield Trust. (KPMG International), a legal person under Swiss law. All rights reserved.

3 Table of contents Foreword 4 Summary 6 Digitization in the healthcare sector today 10 Why has it been so difficult to use information technology successfully in healthcare up to now? 12 Seven ways to drive progress 15 Decision-making aids and standardized work processes 16 Provision of tools for the involvement and self-organization of patients 19 More proactive and more targeted care 21 Better coordination of care services 23 Easier access to specialists 25 Improving resource management 27 Constant interplay of learning and improvement 30 Die Future of technology in healthcare 32 The path to a successful IT transformation in healthcare and the contribution of KPMG 35 Authors and contributors 36 Interlocutors 39 (KPMG International), a legal entity under Swiss law. All rights reserved.

4 Foreword Digitization is making enormous strides. Compared to other industries, the healthcare sector lags significantly behind technological advances. The majority of Swiss utilities (hospitals, medical practices, etc.) have hardly made use of the potential of digitization in an international comparison. According to various estimates, only around 10 percent of all data available from utilities are actively used today. For example, the use of web portals or applications for smartphones or tablets is more of an exception. Most of the resident doctors still document on paper and the manual filling in of admission or discharge forms in the hospital is the rule. Outside of the medical context, mobile communication has become an indispensable part of most areas of our life. The use of tablets, smartphones and applications is part of everyday life. We can access and influence more and more information regardless of location, and process steps in customer interaction are optimized (e-banking or online check-in) because the underlying processes have changed radically. When investments are made in IT in the healthcare sector, it is often in order to digitize analog processes. This often happens with the effect that additional steps make processes more cumbersome. However, a fundamental redesign and rethinking have often not taken place. The question of how to deal with the challenges and opportunities of digitization is a concern of the healthcare sector worldwide. KPMG has carried out an international study on the status of digitization in the healthcare sector. The following questions were guiding: Why has it been so difficult to use information technology in the healthcare sector successfully so far? What are the digital characteristics of the sector currently and how will they develop? What are the greatest opportunities to increase productivity through technology, and what practical insights can be used for a successful implementation? We hope to be able to set new impulses for you too. 4 Digital health: a curse or a blessing?

5 Michael Herzog Partner, Sector Head Healthcare T Prafull Sharma Partner, Digital Transformation T This brochure is a translation of the study Digital health: heaven or hell? How technology can drive or derail the quest for efficient, high quality healthcare from KPMG International KPMG AG is a group company of KPMG Holding AG and a member of the KPMG network of independent member companies, the KPMG International Cooperative

6 Summary I think we are on the threshold of the next era of medicine. Up to 30 percent of what we are doing right now, we will do differently. Whether it is about how we examine and guide patients, how we bring in the expertise of medical professionals and care for patients in hospitals or how we assess the importance of hospitals. Robert Pearl Kaiser Permanente, USA The global view is shared that the healthcare sector is at least a decade behind other industries in using information technology to increase productivity and quality. Unfortunately, this area has often stood out in particular with problematic, overpriced and ultimately disappointing innovations in the IT area. For example, think of the British National Program for IT (NPfIT), Healthcare. gov in the USA or developers like Google who saw their innovations fail. Paradoxically, in some cases even successful innovations have made an efficient supply more difficult than beneficial. Recent surveys of US doctors have found that electronic health records (EHRs) are a major cause of professional frustration. So far, efforts by most healthcare providers to increase productivity through technology have been limited to back office efficiency and improvements to simple operations. Most of the activities related to patients, however, have not changed. While the hotel, transportation, retail, and communications and banking sectors have changed fundamentally over the past 15 years, the promises of a digital transformation in healthcare are still a long way off in most areas. A detailed look at recipes for success is instructive. It shows that through a real change in the way healthcare services are provided, organizations can also register real gains in terms of efficiency and quality, and that no success can be expected from those who simply replace analog processes with digital processes. It is necessary to rethink the purpose of services, to revise their structure and to draw lessons and insights from data. Where technology has basically only been imposed on given structures and work processes, this has led to additional workload for medical professionals and to a failure of the technological measures. This report aims to carry on with the unambitious motto as before, but digitally and with the often downright fantastic predictions about the potential of technology to completely renew the healthcare system. We got to the bottom of success and failure stories around the world to find out how productivity gains are actually possible in this sector, what organizations should (or should not) do to achieve them, and how health services are likely to change in the near future. Our result, in a nutshell: seven evidence-based major opportunities and seven lessons on how to make the best possible use of them. 6 Digital health: a curse or a blessing?

7 Seven Promising Ways to Use Technology to Increase Productivity 01 Decision-making aids and standardized work processes are essential for improvement. If care is systematized in this way, it can counteract deviations and make decision-making more precise. 03 More proactive and targeted care reduces costs and enables providers to take action earlier in order to preserve people's wellbeing, also supported by powerful analysis methods. 05 Easier access to specialists reduces the number of referrals and readmissions, as it makes it easier for providers to make the right decision right from the start. Provision of tools for patient involvement and self-organization redefines their relationship with service providers. Deductibles options can encourage meaningful user engagement, more satisfactory outcomes, and a reduction in the workload of paid workers. 04 Better coordination of care services and more effective support in cooperation between providers help to reduce costs and damage that result from fragmented and overlapping services. 06 Improving resource management can be achieved with the help of technology in rosters, patient flows, capacity adjustments and schedule improvements. A constant interplay of learning and improvement is created by linking analysis, optimization strategies and organizational development. Digital health: a blessing or a curse? 7th

8 It should never be overlooked that technology is a pioneer, so the focus should be less on the implementation of the system and more on the economic changes that the system enables. Liam Walsh KPMG, USA Seven Ways to Seize the Opportunity We have found that certain aspects of IT in healthcare can significantly increase productivity and have been shown to significantly improve outcomes. However, as the frequent disappointments and failed attempts show, digital technologies do not alone bring these improvements to light. Interviews, analyzes and our own experiences with the digital change at health service providers around the world have led us to seven central findings, based on the success stories in using the advantages and overcoming the setbacks: 1. Transformation first: The transformation results from new ways of working and not through the technology itself. A corresponding concept is required that is technologically supported and not the other way around. Everything else is based on this fundamental knowledge. 2. Human barriers, not technical ones: Most of the problems in the change process come from people, not from technology. Complex skills in the areas of personnel management and change management are therefore required. 3. System design: So far, not enough attention has been paid to the design of the systems. The technology must solve problems that are recognized as such by users, be they patients or professionals. Comprehensive knowledge of the activities as well as the needs of the workforce are indispensable here. 4. Investing in analyzes: Service providers make significant investments in digital systems far too often, but neglect the question of how to use the recorded data so that the investments never really pay off. 5. Frequent Repetition and Continuous Learning: Even with careful conception, numerous repetitions may be required as part of the system design. This is an ongoing process with cycles that can be painful at times before a system reaches its tipping point at which the investment begins to pay off. 6. Capitalize on compatibility: The fact that the greatest possible benefit in connection with technology in the healthcare sector can only come about with a delay is often essentially due to the fact that different systems cannot share and combine data. A coordinated approach with a view to a minimum level of interoperability would pave the way for companies in the health sector to move into the digital world. 7. Solid procedures for handling information and data security: Data sharing requires strict information control and security, especially against the background of the growing threat from cyber attacks. This calls for measures at national and local level to help organizations manage and share their data securely. 8 Digital health: a curse or a blessing?

9 The Future of Healthcare: Digital Curse or Digital Blessing? Some people expect the health care system to be in an almost paradisiacal state in the coming years, assuming that today's confusing and inefficient services would then be replaced by forward-looking, coordinated and personalized care. Others predict a dystopia with doctors becoming slaves to algorithms and patients drowning in a sea of ​​data and additional expectations. Both scenarios are conceivable, but a look at what leading service providers have already achieved (details on this below) should make you optimistic. Our own expectations with regard to the changes that are likely to shape the healthcare system in the next ten years are outlined here in summary: Data processing will be much more widespread, but at the same time much less visible. Employees will spend significantly less time on administrative tasks and routine communication, as automation, speech recognition and machine processing of spoken language will gain in importance. The advancing digitization of the healthcare system will lead to new roles and competencies in management, whereby analytical skills will be required above all. Organizational and professional boundaries will take a back seat, as many of the current separations between primary, secondary and tertiary care will be removed by integrated IT systems. Key questions of this study: Why has it been so difficult to use information technology successfully in the healthcare sector? What are the digital characteristics of the sector currently and how will they develop? What are the greatest opportunities to increase productivity through technology, and what practical insights can be used for a successful implementation? Digital health: a blessing or a curse? 9

10 Digitalization in Healthcare Today Healthcare is currently undergoing fundamental and rapid change worldwide, as digital technologies are becoming an increasingly normal part of everyday life. In addition to changes in hospitals and clinics, it is also becoming increasingly clear that there is movement in consumer behavior. This initiates changes from above as well as from below. The differences between the numerous tools and the ways in which they interact can be difficult to see through. Figure 1 shows a general overview of the future digital design. The focus is on patient-side technologies. This reflects the impact this new system of self-regulation and decision-making aids will have on patient perception and the quality of care. Other technologies are largely classified according to whether they are aimed at the professional groups or at the organizations, determined on the basis of their main users and their primary importance for individual patient care or for the improvement of care systems. The fact that the electronic health record spans practically the entire system makes it clear that it plays a key role in any digital strategy whatsoever. It is the foundation on which many of the other uses are based. 10 Digital Health: Curse or Blessing?

11 In view of these new constellations, it is not always easy for organizations and their managers to manage them, especially since there are numerous pitfalls. However, there is no doubt that technological transformation will be one of the most important decision-making features for the success or failure of service providers in the next ten years. Due to cost pressure and quality expectations, sticking to the technical status quo is not an option. This report is intended to help health organizations identify the most promising opportunities for significant improvements in outcomes, experience and efficiency. While the conception and development of digital health technologies are still primarily taking place in countries in the so-called West, many of these innovations are being used and adapted in emerging countries ever faster and to an ever greater extent at lower unit costs. This creates the opportunity to harmonize the potential of a digital health system worldwide, with flexible systems outstripping the previous infrastructure and service models of richer nations. Figure 1: Overview of digital innovations in the health sector Organization Management of patient flows Specialist Business process support Monitoring of vital parameters E-learning tools Online communities Wearables and apps E-personnel deployment planning Decision-making aids and electronic prescriptions Patient Tele-health Doctor to doctor Results for patients / directories Patient portals / - data Telehealth patient to doctor Mobile working Predictive analysis / risk stratification Sharing of health files, real-time data Standardized work processes Source: KPMG International Digital health: Curse or blessing? 11

12 Why has it so far been so difficult to use information technology successfully in healthcare? When a technology finds its way into an industry, it is often said that everything will change in two years. If nothing happens after the introduction, the question arises as to why it does not work as expected. And lo and behold: after another ten years it will work. Robert Wachter UCSF School of Medicine The development of IT in the health sector has recently stalled, for example in Great Britain's truncated National Program for IT (NPfIT), Australia's disappointing introduction of national personal health records or the flawed technical conception of Obamacare. In practically every health system in the world, there are examples of escalating costs, sluggish adoption, and barely discernible increases in productivity. Why has the provision of health services shown to be so resistant to digital transformation? And why have the strategies so often not paid off after large investments? A detailed analysis of the setbacks on site and at national level brings the following insight to light in particular: A service provider who is progressively positioned in digital matters is and will not be someone who simply replaces analog processes with digital ones. The implementation often failed when technology was only integrated as an additional element in existing structures, which resulted in additional work for the health staff. The technologies that provided the greatest immediate benefit have been carefully engineered and designed to make the work of staff or interaction with patients easier, with significant investment in both the tool itself and the way it works . One pattern that was evident in many of the reports was the discrepancy between high expectations for the new technology and initial annoyances and productivity losses. Ultimately, benefits often only emerged after two years or even later, but the time until this digital dry spell subsided was perceived as a major annoyance, which led to many transformation strategies being put into perspective or even discontinued. One example of this are the EHRs, the electronic health records. They are an essential cornerstone of any digital strategy, but have little direct benefit to those in the front line. In fact, most organizations experience additional inefficiency during the first phase, before the tools that build on the EHR (patient flow management, electronic prescriptions, automatic alerts and data transfer) are developed, set up and deployed. The unexpected ordeal of the EHR introduction has left many service providers in a state of paralysis, unable to return to the previous systems and unwilling to invest further in order to derive further benefit from them. 12 Digital health: a curse or a blessing?

13 Robert Wachter points out in his latest book, The Digital Doctor, that poorly designed systems have resulted in a significant increase in data entry time and a multitude of useless alerts, with some research showing that emergency physicians use almost half of their time Spend entering data. A 2013 US-wide study by the RAND Corporation among doctors documented widespread dissatisfaction with electronic health record systems and concluded the following: Most doctors welcomed the idea of ​​these files, but cited them as one of the factual main reasons for anger and dissatisfaction in the workplace . We got to the bottom of the usual shortcomings that stand in the way of the best possible use of digital technologies in healthcare and the distinguishing features of success stories. The results can be summarized in the form of the following seven key findings regarding the effectiveness of digital strategies: 1. Transformation first: It is the new ways of working that make the change, not the technologies themselves. The technology has to serve a concept, not the other way around. Everything else can be based on this fundamental knowledge. 2. Human barriers, not technical: While the criticism of new programmatics often ignites with digital systems, many of the problems can basically be traced back to the people, not the technology. If organizations are to address these problems, they must invest at least as much in organizational development programs as they do in the technology itself. Clinical and administrative management representatives must have extensive knowledge of technological systems and systems for direct care can find creative answers to questions about the design of the work. Special specialists, so-called clinical champions, can help. 1, 2 In the USA, the use of so-called Chief Medical or Nursing Information Officers (leading positions in the field of medical and nursing care) is becoming more and more widespread, often at board level. These hybrid experts, who are currently in great demand, are characterized by a valuable combination of technical skills with an understanding of clinical workflows and self-image. 3. System design: To date, too few questions have been asked about the design of IT systems in the healthcare sector. Investments must aim to provide answers to the challenges and needs of those using the systems, be they service providers or patients. Successful applications are characterized by the fact that a lot of effort has been made to understand how decision-making processes, workflows and all new information technologies influence one another. In cases in which new IT applications in the healthcare sector have failed or only ran with severe disruptions, at least one of these factors was often neglected in the planning. A functioning orientation is required Satisfied users are the most important criterion for a successful implementation of IT in the health sector. They should be effectively involved throughout the project cycle. Talk to them. Work with them to get what they want. Then go through it with them and see if this is what they wanted. And then repeat the whole thing. Dr. Kim Liu KPMG, China is changing a significant participation of the employees and great efforts to secure their commitment in the long term. Too often, however, the users of the systems are treated as passive recipients to whom changes are placed. And all too often, the systems are not tailored to the complex, high-risk work environments in the area of ​​direct support Investing in analyzes: Increases in productivity require a comprehensive redesign of work processes, the use of predictive models for the allocation of resources, a better assessment of needs, earlier intervention and the opportunity to gain experience and apply it. 1 Boonstra, A., Versluis, A., Vos, J. (2014): Implementing electronic health records in hospitals: a systematic literature review. BMC Health Services Research, 14: 370 2 Broderick, A., Lindeman, D. (2013): Scaling telehealth programs: lessons from early adopters. New York: The Commonwealth Fund 3 Cresswell, K., et al. (2013): Ten key considerations for the successful implementation and adoption of large-scale health information technology. J Am Med Inform Assoc; 20 (e1): e9 e13 Digital health: a curse or a blessing? 13th

14 None of these aspects can be achieved without analytical skills that the organization draws in from outside or acquires itself, and without new tools that are ideally made available to medical professionals in real time. Successful providers have invested heavily in developing their own analysis skills and competencies in the field of software development. In this way, they can learn from clinical and other data and derive knowledge. 5. Repetition and Learning: Getting technology up and running is an ongoing, deep process. Even if design has been carefully planned and executed, multiple iterations may be required, making this process an ongoing one of possibly several cycles. Until the system reaches the point at which the investment pays off, some steps can be quite unpleasant. In reports of failed projects, there is often a tendency to overestimate short-term profits, to give too little importance to major changes to the workflow, to automation and to the redesign of processes and instead to focus on reducing transaction costs. What is essential for success is the knowledge that it is an ongoing process, not a one-off event with immediate, resounding success. 6. Capitalize on compatibility: A coordinated supply and the use of the advantages presented here are only possible if a context-dependent exchange of data between different environments is possible. Organizations can promote compatibility in different ways: First of all, it should be noted that customer-specific adaptation of the electronic health records is important for productivity, but can also lead to obstacles to data exchange if different service providers use the same system, but with different network providers work. It should also be kept in mind that there is no consensus on the question of whether a single system is better than several that are linked by a technical intermediary, which is why it must be ensured in each case that the advantages of both systems are carefully weighed against each other. In this context, Kaiser Permanente has postulated that horizontal integration trumps vertical maximization. 7.Solid procedures for handling information and data security: A study carried out by KPMG, in which 223 health care payers and health service providers were surveyed, found that 81 percent of those surveyed had been victims of cyber attacks in the past two years and only those Half of the respondents felt they were adequately armed to defend themselves against attacks 4. Solid information handling guidelines are essential to ensure the secure and effective handling of confidential patient data. Robust and transparent mechanisms for internet governance are also helpful in gaining the trust of patients so that they agree to the exchange of the protected data of their health records between different care settings. The English program suffered major setbacks at this point. 5 The flow of thoughts shapes decision-making and can be improved or deteriorated by the way digital information is displayed on a computer screen or on a mobile device. So having a concept that the right information is presented to the right person at the right time is essential. Richard Bakalar KPMG, USA 4 Bell, G., Ebert, M. (2015): Health Care and Cyber ​​Security: Increasing Threats Require Increased Capabilities, KPMG USA 5 Triggle, N. (2014): How did it go so wrong? BBC News 14 Digital Health: Curse or Blessing?

15 Seven ways to drive progress If you take a closer look at the most powerful and digitally best positioned healthcare providers worldwide and the more moderately innovative organizations in emerging countries, you will primarily notice seven ways in which productivity and quality can be increased in the field of care. We get to the bottom of each of these possibilities by highlighting their characteristics and potential benefits, as well as some of the experiences with them. 1 Decision-making aids 2 Provision 3 More proactive 4 Better ones 5 Easier and standardized work processes for aids for the integration and self-organization of patients and more targeted care Coordination of care services Access to specialists 6 Improvement of resource management 7 Constant interplay of learning and improvement of digital health: curse or blessing? 15th

16 Decision-making aids and standardized work processes You are admitted with a stroke and now the following happens: With just one click on the computer, the admitting doctor creates the full program from laboratory tests, nutrition and physiotherapy to medication. Robert Pearl Kaiser Permanente, USA A major problem with all health systems is that care often falls short of evidence-based best practice. For example, studies conclude that 10 to 15 percent of cases are diagnosed with errors, and one prescribing error study found 52 such errors in every 100 patient admissions. 6, 7 Technologies that support clinical decision-making and operations provide important opportunities to reduce deviations in care. At the same time, they increase the accuracy and speed of decision-making. In the future, not only clinical guidelines and specifications will make such a contribution, but also the automated evaluation of clinical data, for example genomic data. There is much to suggest that such tools can increase the quality of such processes, and there is some evidence that they can also reduce costs. 8, 9 However, difficulties are to be expected from decision support systems in clinics (Clinical Decision Support Systems CDS systems); Employees may accept them with skepticism for fear of losing their independence. CDS systems range from extremely passive electronic aids (for example hyperlinks to guidelines) to very proactive ones that can be triggered automatically with just one click.In the coming years, recommendations to staff will probably be abandoned more and more from independent, specific clinical scenarios and instead focus on much more comprehensive consultations. Technical decision-making aids, for example for prescribing services, CDS systems are often combined with computerized physician order entry systems (CPOE systems), which are used to coordinate drugs, examinations and measures. If handwritten structures based on personal delivery are replaced by integrated CPOE and CDS systems, this can result in considerable time savings and increased security. Various valuable advantages are mentioned in the literature: 6 Berner, E. S., Graber, M. L. (2008): Overconfidence as a cause of diagnostic error in medicine. Am J Med; 121 (5th addendum); Lewis, P.J., Dornan T., Taylor, D., et al. (2009): Prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug Saf .; 32 (5); Jaspers, M. W. M., Smeulers, M., et al. (2011): Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. Journal of the American Medical Informatics Association 18 (3); Fillmore, C. L. (2013): Systematic review of clinical decision support interventions with potential for inpatient cost reduction. BMC Med Inform Decis Mak; 13: Digital Health: Curse or Blessing?

17 Between 23 and 92 percent reduction in throughput times in the laboratory 10 Reduction in medication errors by 48 percent 11 Less need for auxiliary staff 12 The decision-making aids are not only recommended for doctors, but can also be of great use to other employees, especially in areas where there is only limited access to other hospital staff and patients. Standardized work processes and one-click automatisms CDS systems can be further developed in such a way that protocols can be integrated into customer-specific processes through which the entire supply path is effectively standardized. Doctors who treat patients according to this guideline then have to follow clear processes and perform specific tasks. In this way, a consistently high standard of care is guaranteed. However, clinicians should always deviate from this extreme of proactive options if a patient's individual needs so require. Intermountain Healthcare, a company that has developed standardized clinical workflows, encourages clinicians to deviate from the map when it comes to serving the patient, which in turn improves the system. Standardized workflows can be taken one step further with one-click automatisms or one-click regulations. In this case, information is routed to a workflow engine, which in turn initiates a process that initiates all the tasks and processes required for the specific process. The benefits of such a system in terms of productivity and coordination of care are obvious, but the introduction of one-click automatisms can be difficult. The process must first be coordinated between several teams and often also between different organizations and extensive training of the nurses is required after the establishment. Intermountain's Approach to Standardizing Clinical Processes Step 1: A particularly important clinical process is selected and an evidence-based best practice guide for the process is developed. Perfection is not expected at this point. Step 2: The guide is incorporated into clinical processes using the electronic health record by defining a course of action for a disease that must be followed once a clear diagnosis is made. Step 3: Collect data on situations in which health professionals deviate from the protocol, short and long term clinical outcomes, and patient satisfaction. Intermountain devotes considerable resources to analyzing and learning from this data. Step 4: Doctors are advised that no protocol will fit every patient and that they must be careful to adapt to the patient's needs. The underlying idea is to allow deviations among patients, but limit those among doctors. Step 5: A feedback loop is integrated for continuous improvement of the process. 10 Niazkhani, Z., et al. (2009): The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review. Journal of the American Medical Informatics Association 4/16, Radley, D.C., et al. (2013): Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. J Am Med Inform Assoc 1; 20 (3); Stone, W. M., et al. (2009): Impact of a computerized physician order-entry system. Journal of the American College of Surgeons 208.5; Digital health: a blessing or a curse? 17th

18 Concrete findings Avoid dulling warnings: some hospitals receive warnings from doctors on average every month. The greater the number of such notifications, the greater the risk that they will be switched off and ignored by the addressees. 13 There are many approaches to this problem. For example, it is possible to reduce the number of warning messages, to distinguish important warning messages (by sound and color) from others and to request reactions from clinicians to certain warning messages (e.g. answering a question). Do not rush decisions regarding an automated technology solution: When Intermountain thinks about standardizing clinical work processes, it first works on paper. This visualizes how they can be implemented in practice, and opportunities for improvement are discussed before they are integrated into the technology system. Using protocols as a learning tool: No protocol is right for every patient. Doctors must adapt files and transcripts to suit the patient, relying on their own judgment. An unexpected risk can also lie in over-fulfillment: Problems arose at Intermountain because doctors accessed standardized prescriptions too quickly, which in some cases did not result in the most sensible care for the patient. 13 Roshanov, P.S., Fernandes, N., Wilczynski, J.M., et al. (2013): Features of effective computerized clinical decision support systems: meta-regression of 162 randomized trials. BMJ, 346: f Digital Health: Curse or Blessing?

19 Provision of tools for patient involvement and self-organization Patients should be involved at an early age, if they are in good health or at risk of chronic illness, because then we can support them in adopting behaviors that will help them break out delay the disease or mitigate its consequences. This leads to considerable savings and productivity increases in the long term. Richard Bakalar KPMG, USA It will soon be feasible to monitor even patients in need of intensive care at home. Richard Ashby Metro South, Australia Technology is redefining the relationship between patients, healthcare providers and the healthcare system. Aids for active involvement, education and self-management offer patients meaningful opportunities to shape their own health and care, which can lead to a reduction in transaction costs in the short term and a streamlining of treatments in the long term. Patient Portals and Access to Clinical Records Numerous healthcare providers, particularly in the United States, have established patient portals. Patients can use it to access their medical data, such as discharge reports, medications, information on vaccinations and laboratory results. Particularly advanced platforms now also offer patients the option of creating and tracking their personal care plans, requesting prescription updates, making appointments, accessing their directory of health education information and exchanging encrypted messages with their healthcare provider. While no savings in connection with productivity have been demonstrated so far, the experiences that have been made with such projects, for example OpenNotes in the USA, have so far been positive. Patients who have immediate access to their providers' medical records state that they have a better understanding of their health and are better able to control it themselves, and that it is easier for them to adhere to treatment guidelines. In addition, it has been proven that treatment errors are detected earlier in this way. In the UK, the Hurley Group, the NHS’s leading general practitioner organization, has launched the WebGP system, giving patients access to pharmaceutical advice, emergency services and full administrative transactions, as well as online consultations with their doctor. The evaluation of the pilot project showed that in 60 percent of the consultations in this way (which usually lasted no longer than three minutes) questions could be clarified. Nine months after launch, the number of patient visits to a practice center was noticed, saving pounds a year and allowing the facility to close. Health networks for patients An increasingly important source of advice and information are online networks for patients, in which they share their knowledge and experiences. PatientsLikeMe is with Digital Health: Curse or Blessing? 19th

20 more than members, perhaps the best-known network that covers, for example, complaints. It gives patients the opportunity to seek information and recommendations (provided by other people with the disease) about their condition, share ideas, follow up on their symptoms, and then discuss this information with their healthcare provider. The data collected represent a valuable tool for research and 60 studies are already based on the network. Wearable Devices and Apps The number of apps and wearable health devices has grown explosively in recent years. However, it is not clear how this will affect public health and the nature of the interaction between patients and healthcare providers. Devices such as the FitBit smartwatch collect enormous amounts of individual health data and patient portals such as Patients Know Best (see page 24) meanwhile also enable this data to be integrated into the electronic health record. So far, the main focus has been on apps and devices that promote physical well-being, such as pedometers and calorie counters, as well as sleep and heart rate monitors, and on apps and devices that are designed for a specific illness. Tools for complex and cost-intensive cases, on the other hand, do not yet play a major role. One of the respondents explained the reluctance of developers to use these types of apps as follows: they are too complicated and unattractive, the return on investment is too unclear, the time to pay off is too long [and] they have to develop them Applications to know too much about the patient. (David Blumenthal, Commonwealth Fund) Against the background of this market failure, the question arises to what extent the health sector should offer incentives for innovation in order to close this gap. Such data are clearly justified in relation to health promotion and self-management as well as for the purpose of changing behavior. However, the fact that the focus is currently on the devices or biosensors rather than the information they generate is a major obstacle to meaningful applications. In addition, there are still security concerns about the use of mobile technologies, especially in unregulated markets . A systematic evaluation carried out in 2015 of 79 apps that had been certified as clinically safe and trustworthy by the UK's NHS Health Apps Library found that 66 percent transmitted unencrypted information over the Internet. 14 Concrete findings Ensure user-friendliness of patient-side technology: When developing portals or other technical aids for patients, it is essential that they are both easy to use and attractive for patients, otherwise there is a risk that they will be poorly accepted. In the case of apps and mobile devices for the health sector, the procedure for converting data into meaningful, usable information must be carefully considered: The transfer of data from patient devices to electronic health files will be There are no one-size-fits-all solutions. The sooner we acknowledge this fact, the better we can develop and implement meaningful programs that best involve patients in their own care. Aaron Berk KPMG, Canada Online consultation hours in Denmark Since 2009 general practitioners in Denmark have also had to offer their patients advice via. In 2013, the number of these consultations was four million, representing 11.2 percent of all general medical consultations in the country. Patients report that they benefit from having quick access to their doctor regardless of the time of day and that they find it easier to bring up uncomfortable topics. The doctors concerned appreciate the ability to answer direct questions more quickly, but they also have concerns about the lack of personal contact and possible misunderstandings in the written communication. only pay off when significant investment is made in analytical capabilities. These applications and devices are most likely to benefit if they are designed and targeted for specific groups. 14 Huckvale, K., Tomas Prieto, J., Tilney, M., Benghozi, P. J., Car, J. (2015): Unaddressed privacy risks in accredited health and wellness apps: a cross-sectional systematic assessment. BMC Medicine, 13: Digital Health: Curse or Blessing?

21 More proactive and more targeted care Soon, patients will no longer go to hospitals, but hospitals will be looking for patients. Jagruti Bhatia KPMG, India If the condition of a larger group of patients worsens according to a recognizable pattern over two or three days and certain behaviors intensify problems or symptoms. And if you record this systematically then you can also intervene. Adam Darkin's Medtronic There is tremendous potential for cost savings when intervening earlier with more proactive and targeted care. Powerful analytical tools can help identify early warning signs in outpatient and inpatient settings, thereby avoiding a significant number of deaths and inpatient treatments. Patient data can be used to assess clinical risks. This gives healthcare providers the opportunity to target resources where they are most needed and to target problems where early intervention is beneficial. In this field, technologies can quickly bring about improvements and savings, which is why investments are particularly useful here, especially in the hospital environment. And as genomic information is increasingly routinely captured in clinical examinations, the importance of such analyzes will grow. Predictive Analysis Even more accurate predictions of future health care needs can be expected from the analysis of electronic data sets. With the help of computer-aided algorithms and the extensive use of clinical and prognostic algorithms for re-admissions (Clalit, Israel) Clalit, as Israel's largest non-profit health insurer and health care provider, has 3.8 million people connected. The company has developed an algorithm for predicting readmissions that is applied to all patients admitted to one of the 27 hospitals that are affiliated with Clalit. In practice, this means that doctors have access to a daily list of all of their patients who have been discharged from any hospital in the country. The patients are listed on this list in the order of the calculated risk of re-admission. The doctors can then set a process in motion that is already firmly integrated in the electronic health record: the patients are called and asked about their risk factors; inquire whether they have the medication and support they need. In the course of a study on this procedure, a 4 percent decrease in the readmission of high-risk patients in 30 days was found. Shadmi, E., Flaks-Manov, N., Hoshen, M., Goldman, O., Bitterman, H., Balicer , R. (2015): Predicting 30-Day Readmissions With Preadmission Electronic Health Record Data, Med Care 2015; 53: Digital Health: Curse or Blessing? 21

22 patient demographic data can be used to create risk scales that can be used to identify patients with an increased risk of avoidable readmissions.For example, Northern Arizona Healthcare in the United States found that by giving risk scales to the nurses responsible for discharges, emergency readmissions decreased 45 percent. However, analyzes are not only suitable for the prevention of inpatient readmission, but can also be used to determine which people from a certain group are very likely to use health services in the near future. Technical aids for so-called case finding are widespread today, but were not used optimally in the past because they could only access limited, outdated data of poor quality. The systems of the future will use not only electronic clinical information (which is cheaper to obtain), but also information from home control equipment and even, in some markets, personal information held by retailers or telecommunications providers. Vital Signs Monitoring and Early Detection of Patients at Risk Remote monitoring technology has significant potential for reducing the avoidable use of health resources and is aimed at cost-effectively spending staff time where it is needed most. A number of specially developed systems have shown promising results for the home and clinical environment, for example VitalPAC in Great Britain (see right). In the US, Cerner developed a system to detect early symptoms of sepsis, an often overlooked disease and one of the most common causes of preventable harm. Cerner estimates that by continuously monitoring critical medical indicators with this system, the inpatient mortality rate could be reduced by 24 percent and the length of inpatient stays could be reduced by 21 percent, saving US dollars per patient. Concrete findings Apply solutions for monitoring vital parameters across the board: Some hospitals have tried to use solutions for monitoring vital parameters in one or two wards instead of in the entire complex. A doubling of the workload and administrative effort, which was caused by the attempt to bring separate paper-based and electronic systems under one roof, was then ascertained. This suggests that systems for monitoring vital parameters should be implemented throughout the hospital so that the greatest possible benefit can be drawn from them. Exercise care in selecting data for predictive analysis: Research into case-finding predictive models has shown that the greater the number of detailed data sets, the greater the accuracy of an analysis. 16 For urgent interventions, systems that use clinical and population-based real-time data are likely to be medically more useful than those based on retrospective data sets. Make the most of unstructured data: The majority of health data is unstructured (e.g. records from doctors and nurses) and it will be crucial to find ways to use this data as effectively as possible. This can mean that technological solutions are developed that structure this data, for example through machine processing of spoken language and text mining. In-Office Vital Signs Monitoring: VitalPAC, UK VitalPAC is a hospital technology solution that includes a range of products for electronic patient monitoring. These include VitalPAC Nurse for the identification of high-risk patients using early warning scales, VitalPAC Doctor for mobile access to patient information in real time and the optimization of handovers and task prioritization, and VitalPAC IPC for infection control. According to VitalPAC tests in British hospitals, the following significant improvements were reported, among other things: a decrease in mortality by 15 percent, the number of cardiac arrests by 70 percent, unplanned transfers to intensive care units by 50 percent and norovirus outbreaks by 90 percent as well as a shortening of hospital stays generally. According to the company, the system stands for four to six times the return on investment. ( 16 Billings, J., Georghiou, T., Blunt, I., et al. (2013): Choosing a model to predict hospital admission: an observational study of new variants of predictive models for case finding. BMJ Open; 3: e Digital Health: Curse or Blessing?

23 Better coordination of care services Many patients receive their health care in several ways, none of which is individually tailored to them with an appropriate team. The supply is only partially guaranteed. Neil Williams Medicom Innovation Partner An increasing number of patients are in contact with various specialists and practices without it being clear who is responsible for their care. Without effective coordination, however, there is a high risk that services will be provided twice or missed and that patients will have bad experiences with care. Digital technologies are already being used successfully in numerous industries to streamline and better coordinate complex services, and this is exactly what is happening more and more in the healthcare sector. Shared information on social and medical care can be combined to form a comprehensive picture of the patient and his situation. Such a presentation can help multidisciplinary teams collaborate and improve their clinical decisions, which can be particularly important in cases where lifestyle and environmental factors have a significant impact on the general health of the patient. If all health care providers can immediately access all information about a patient, it is very likely that the necessary services can be provided more quickly and unnecessary steps, such as duplicate examinations, can be avoided. Supporting Integrated Care for Patients with Diabetes: Western Diabetes Institute and ClickMedix, USA The Western Diabetes Institute is an integrated practice unit in California that offers various services necessary for diabetics. As part of a partnership with ClickMedix, a company in the field of mobile health care, a number of cross-departmental services are used there, including tools for patient involvement and self-assessment, teleconsultation with an expert network and monitoring with real-time results. The exchange of reports and care plans between a patient and the various medical authorities can, for example, enable a significantly better adjustment of his blood sugar values. In addition, treatment planning is quicker and cheaper. According to ClickMedix, doctors can look after four to ten times more patients with this system than without. At the same time, the number of hospital visits by people with multiple chronic diseases fell by 50 to 90 percent. Digital health: a blessing or a curse? 23

24 In the UK, inpatient teams can use Nervecentre to seek recommendations from specialists in other specialties by contacting them via instant messages. The specialist to whom the message is sent receives, together with the referral details, all other patient information, the current observations and results of the treating team, as well as information on the location in the hospital. Referred patients are automatically included in the plans of the receiving team (which enables uncomplicated integration into their rounds) and the referring team can see the status and result of the referral. A more radical way of ensuring that all relevant professionals have direct access to integrated clinical data is to put the entire file in the hands of the patient. The patient portal Patients Know Best (see below) has chosen this approach, which enables its users to manage and save their clinical data themselves and to control access to them. Concrete findings Support informal exchanges between health professionals: Automated systems through which clinical results or opinions are exchanged can have a negative impact on informal interpersonal exchanges on the views and recommendations of various healthcare providers and their teams. In complex cases, however, such communication often provides important and useful impulses for medical decisions. Physical or virtual options for exchanging information between providers are indispensable in the healthcare sector. Many technologies are currently in use to standardize and improve care at the hospital level. The next stage is to apply the same way of thinking at the system level, i.e. where chronic diseases require completely new ways of working in outpatient treatment. Alberto De Negri KPMG, Italy Patients Know Best (PKB) The PKB platform, which was originally founded for patients with complex or rare diseases or with multiple diseases, offers patients and their carers the option of setting up an account in which all clinical information from various service providers is stored (be it laboratory results, notes from the family doctor or clinical reports on outpatient treatments). With the system, which is available in 14 languages, all healthcare providers authorized by the patient can log in and view the entire file. In addition, PKB has a directory with information on self-help (including videos and links) and thus promotes the independence of patients. In addition, patients and medical staff can communicate via instant messaging and use video conferencing for online consultation hours. CEO Dr. Mohammad Al-Ubaydli explains the PKB basic idea as follows: The best way to achieve integration is to give the patient authority. Ultimately, it is they who are involved in every appointment and interaction. 24 Digital health: a curse or a blessing?

25 Easier access to specialists Telemedicine services bridge geographical barriers between underserved patients and the responsible medical staff. For the services this means increased quality, easier accessibility and possibly also lower costs. Nowadays, patients can contact their doctors via mobile devices, encrypted s or internet platforms. While some systems have generated demand through offerings, others have reduced the workload of healthcare professionals by effectively using s to avoid unnecessary face-to-face appointments and clinical exams. 17 Some centers have set up hotlines or addresses through which general practitioners can obtain recommendations from specialists. With the help of hunt group call technology, it is possible to direct general practitioners through a distribution list to various specialists and to identify those who are available and have the appropriate experience. The collaboration can be improved even further through video conferences, the exchange of patient files or the use of predefined, bookable appointments. Such concepts lead to the expectation that the number of referrals will decrease and that general practitioners will learn and improve the quality of their treatment in the long term. Some developers in the US are taking an even more drastic approach as they try to make traditional geographic patterns of healthcare obsolete. Services such as Spruce, HealthTap and Doctor on Demand provide instant access to remote consultations via smartphone around the clock, while apps such as MedZed and Heal offer the possibility to request a home visit via mobile devices. Telemedicine applications can be extremely helpful in extensive, very sparsely populated regions, as they can cover a large geographical area with a small number of doctors. In the future, medical teams could even operate on a larger scale on an international level, even if there are clear limits to expansion in this area due to patient, legal and data protection issues. E-ICU E-ICUs or Tele-ICUs are intensive care units (ICU stands for Intensive Care Unit) that are medically supported by a remote team through patient monitoring and monitoring as well as with the help of video conferences. Tele-ICUs are typically associated with a number of benefits, including a decrease in mortality and length of stay in intensive care units and lower staff turnover (in one case a 56 percent decrease combined with savings of over US $ 1 million 18 , $ 19.20 a year). However, if the on-site clinical staff refuses to work with the advisors through the E-ICU, this can have a significant negative impact on medical benefits and profitability. A study found a connection between the use of an E-ICU and increased hospital expenses. 21 It could be due to the fact that the on-site professionals perceived the telemedicine team as a threat or did not feel the need for further clinical support. 17 Caffery, L. J., Smith, A. C. (2010): A literature review of -based telemedicine. Stud Health Technol Inform. 2010; 161, Goran, S. (2010): A Second Set of Eyes: An Introduction to Tele-ICU, Crit Care Nurse, August 2010, Volume 30, No. 4; Kumar, S. et al. (2013): Tele-ICU: Efficacy and Cost-effectiveness approach of remotely managing the critical care. The Open Medical Informatics Journal, 6, Lilly, CM, Cody, S., Zhao, H., Landry, K., Baker, SP, McIlwaine, J., Chandler, MW, Irwin, RS (2011): Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-icu reengineering of critical care processes. JAMA 2011 Jun 1; 305 (21): Morrison, J.L., et al. (2010): Clinical and economic outcomes of the electronic intensive care unit: results from two community hospitals Crit Care Med. 2010; 38 (1): 2 8 Digital Health: Curse or Blessing? 25th

26 Concrete findings Telemedicine between patient and doctor can increase costs instead of reducing them: There are different results on the profitability of telemedicine for the patient-doctor relationship. 22, 23 When it comes to unlocking the value associated with these systems, particular attention should be paid to the following: patient selection, duplicate services, referral processes, and patient involvement and training, building confidence in safety and use. Determine suitable cases for telemedicine among medical professionals: A study found that failed teleconsultations, i.e. cases in which personal advice is still required despite the teleconsultation, could lead to additional costs of up to 709 million US dollars throughout the USA which, however, could be compensated for by a combination of and real-time interactions. 24 It becomes clear here how important it is for general practitioners to recognize the cases in which they should consult specialists via telemedical channels in order to save the patient from going to the specialist. Kaiser Permanente Telemedicine, USA Kaiser Permanente (KP), the largest nonprofit healthcare provider in the United States, has developed a variety of remote consultation systems. They include integrated video appointments and elements that telemedically network the observation stations of various hospitals in order to spread the inquiries into busy phases. In 2012, CP patients and primary care providers used the phone or secure s for their communication in almost every second case, and the organization estimates that soon 30 percent of consultations will be completely digital. There were rapid quality improvements in certain programs, for example in the teleservice for strokes: a quick assessment of the patients via video conference increased the proportion of patients treated with thrombolysis from 14 to 84 percent and the proportion of patients who responded within 60 minutes were treated with this form of therapy, increased from 16 to 52 percent 25, 26. Abiye Safe Motherhood project, Nigeria In the Nigerian state of Ondo, mobile phones are used to monitor pregnant women remotely so that the women can receive medical advice via mobile phone. Community health workers act as intermediaries between pregnant women and Abiye's maternity centers. To facilitate quick and effective communication between them and the women, these phones are being made available to pregnant women throughout the state free of charge so that they can seek medical advice when needed. The project, which is now being expanded, has reduced maternal mortality by 47 percent and child mortality by 26 percent. 22 Torre-Diez, I., et al (2014): Cost-Utility and Cost-Effectiveness Studies of Telemedicine, Electronic, and Mobile Health Systems in the Literature: A Systematic Review. Telemed J E Health 21 (2): Mistry, H. (2012): Systematic review of studies of the cost-effectiveness of telemedicine and telecare: changes in the economic evidence over twenty years.Journal of Telemedicine and Telecare 2012; 18 (1): Cusack, C.M., Pan, E., Hook, J.M., et al. (2007): The Value of Provider-to-Provider Telehealth Technologies. Charlestown: Center for Information Technology Leadership 25 Cruickshank, J., Paxman, J. (2013): 2020 Health Yorkshire & the Humber Telehealth Hub project evaluation. London: 2020 Health 26 Zhou, Y. Y., Kanter, M. H., Wang, J. J., Garrido, T. (2013): Improved quality at Kaiser Permanente through between physicians and patients, Health Affairs 29 (7), Digital Health: Curse or Blessing?

27 Improving Resource Management We should keep an eye on all factors and keep a record of how much time each process takes, and automate our scheduling. The more analyzes we have on this, the better medical professionals can make efficient decisions that will increase their productivity. Joel Haspel GE Healthcare Finnamore Considerable opportunities to increase productivity arise when technical resources from resource management, which are common in other industries, are used in personnel planning, patient flows and demand-oriented capacity planning. E-Personnel Scheduling and Mobile Working Planning and tracking of personnel assignments using electronic applications can ensure that personnel are deployed exactly where they are most needed. In this way, increases in quality and efficiency are possible. With carefully set up systems, under-staffing or over-staffing can be avoided, the dependency on replacement workers or temporary workers can be reduced and work patterns associated with less stress are made possible. E-personnel planning solutions allow the skills of employees to be matched to requirements and enable greater flexibility in the use of resources. It should be noted here that simple electronic adaptations of conventional paper plans do not meet the requirements; rather, the technology should take work planning to a new level. If they are linked to medical files, the technology can also be extended to task management and assign medical tasks to the workforce in real time. Active support for mobile working can also lead to considerable increases in productivity. Remote access to recordings via tablets and other mobile devices is driving a change in outpatient healthcare. For example, we think of electronic files that can be downloaded while on the move, which would save the staff some walking with heavy files. Apps can include CDS systems and integrated protocols to support efficient, high-quality care, and by working both online and offline, they facilitate mobile working. Digital health: a blessing or a curse? 27