– Because the alignment and operability is lacking, the real benefit of what digital health potentially could offer for the integration of care, cannot be realised – says Dr. Nick Guldemond, Associate Professor Integrated Care & Technology at Erasmus School of Health Policy & Management (Rotterdam).
Free flow of correct and up to date information, accessible everywhere and at any time for all the relevant carers and the patient, is essential in organising integrated health.
How would you describe the concept of integrated health?
There are various definitions for the integration of care, but they all refer to the integration and joint coordination of the activities in health and social care that anticipates the needs of the patient/citizen. From the patient’s perspective, we often require much more support and care than a single hospital intervention or service can provide. For example, surgery includes many activities before and after the actual surgical intervention to achieve the optimal outcomes: things like optimising health status before surgery (‘fitter in’ is ‘better out’) and adequate rehabilitation and social care. Therefore, the alignment of all activities is crucial for better outcomes rather than focussing primarily on the performance in the operation theatre. Another example is appropriate care for patients with multiple chronic conditions, who need a range of services from different disciplines across a range of organisations, such as hospital, primary and social care as well a combination of formal and informal care. With an ageing population and the related increases in the number of chronic conditions, the demand for integrated services to anticipate these complex needs is rising sharply. If we do not get better at meeting the needs of these patients, they will suffer more complications, which means they will require more specialist and hospital care resources. From an economic perspective, higher costs are not really affordable, both at the individual and the national levels, and we simply do not have the human resources to manage this demand. Consequently, we have to improve the health outcomes at lower costs, and succeed better in prevention.
What are the pillars in the integration of care services?
The key elements the success of integrated care are:
- Alignment and joint coordination of activities/services across organisations in the health and care sectors (dynamic team work);
- Seamless flow of information for planning and organising activities among professional and informal carers as well as for engaging and supporting patients and measuring outcomes;
- Shared decision making on the basis of values, best evidence and trans-disciplinary guidelines and protocols;
- Self-management, patient empowerment and education;
- Creation of a relevant support environment, such as taking the different personal life spheres of people into account to leverage support in: work, private, leisure and school settings, or a combination of the same;
- More attention on public health and individualised prevention;
- Community involvement at the citizen-to-citizen, neighbourhood level.
There are a few concepts that, from time to time, draw more attention: integrated health, personalised healthcare, coordinated healthcare etc. What are the most important principles related to how healthcare should be organised to be effective?
We have been discussing these integrated health concepts for almost 30 years, and they are not so different from the current very popular principles of value-based healthcare (VBHC). The integrated health and care concepts place more attention on the process of integrating the activities into personalised services and interactions between the different stakeholders, including the patient and their carers. Value-based healthcare is more oriented on outcomes, and the use of supply chain principles to optimise the processes in order to reduce costs and increase service efficiency. There is much specific jargon, hype and cult-type discussions within the groups of followers and believers. In reality, we need very different principles to achieve better health and social care work at lower cost. We need to discuss together how services could be redesigned through better alignment, integration, personalisation, communication and coordination, the integrated care approach, while currently as soon as a service is established we start work on its optimisation and measurement (VBHC). Service redesign typically happens in the workplace, at the local or micro level. However, the requirements and conditions for healthcare redesign at a local level are often also arranged at the regional or meso level, involving the relevant stakeholders, and sometimes we even need to facilitate measures such as rules and regulations at the national or macro level. However, the community and local stakeholders are key to making the healthcare transformation successful.
We need to discuss together how services could be redesigned through better alignment, integration, personalisation, communication and coordination, the integrated care approach.
Do digital health technologies help in implementing the theory of integrated health in daily practice? In what way?
As already mentioned, the free flow of correct and up to date information, accessible everywhere and at any time for all the relevant carers and the patient, is essential in organising integrated health. This is a fundamental requirement: information flow from A to B. However, while this may seem a simple requirement, it is often not possible in many countries. Accordingly, many digital health technologies cannot work across the health continuum and the organisations involved, resulting in separate stand-alone solutions that are not integrated into a coherent services structure. This means that interoperability and data sharing should have high priority in order to make digital health work. Currently, the digital health industry is too much absorbed by their individual interests, which applies to multinationals with their locked-in business strategies as well as to startups with their opportunistic and short-term focuses. I would say we need to place more attention on the social factors and the ‘why’ aspects first, because only then can we talk about the ‘how’. We need to create a shared understanding, rather than continuing to live in different stakeholder bubbles.
Some people see in digital health a Holy Grail for all the problems. Is this good thinking?
As mentioned previously, with this lack of alignment and operability, the real benefits of what digital health could potentially offer cannot be achieved. The real benefit of digital health for societies, economies and individual people is in improving effectiveness, in the planning and organising of care, rather than in popular VR applications, 3D printing or AI diagnoses. Healthcare is full of paradoxes, and one reality is that technology often makes healthcare more expensive while not necessarily improving the health of people. So we need to think carefully about the technology we should invest in.
Digital transformation in healthcare leads to easier the communication between patients and GPs, but will it reduce the inequalities, one of the biggest challenge of public health?
Considering we have yet to overcome the most fundamental requirements for sharing health and care information, reaching out to minorities or vulnerable groups of people with digital health solutions is still far ahead. Navigating our way through the health and care system is still quite a challenge, even for well educated people. Personal attention is often what is needed most, but this may be compromised for what is known as a “difficult population”. If we could use technology to create more time for professionals to give attention to these people, and to support them in collaboration with their colleagues and informal carers, we would be working smart. There are some examples where tailored software applications do help specific groups to maintain their health and social networks as well as managing their problems. But we could do better in integrating and up-scaling these applications.
Interoperability and data sharing should have high priority in order to make digital health work.
Is integrated care a matter for healthcare policy solutions, or can healthcare providers and local communities take steps to strengthen the coordination of care for patients?
I should say that it is the responsibility of all of us. It is about the transformation of society at all levels. At every level we should do what is required, using both top-down and bottom-up approaches. Clearly, we need a strong shared vision, a shared roadmap and suitable leadership to do this.
What topic in digital health is too often ignored and needs more attention?
Palliative care….end of life care is often very complex and there are many professionals involved. In general people want to die peacefully at home, with their family and loved ones, rather than in a hospital, in a sterile ICU department. So how can we help these people to spend the last phase of their lives in the most optimised environment of home?
That would be wonderful.