Accenture Connected Health: The Drive to Integrated Healthcare Delivery

8/9/2019 Accenture Connected Health: The Drive to Integrated Healthcare Delivery

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Connected Health:

The Drive to IntegratedHealthcare Delivery


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Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Making the Case for Connected Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Progress Toward Connected Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Overcoming the Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. The Dynamics of Successful Connected Health . . . . . . . . . . . . . . . . . . . . . . . . .

5. Assessing the Current State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6. The Future of Connected Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Country Overviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Physician Survey Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Executive Summary



This report documents the findings of a year-long international study of connectedhealth, entailing extensive interviews of health leaders, surveys of physicians andcase studies across eight countries: Australia, Canada, England, France, Germany,

Singapore, Spain and the United States.These national health systems are diverse, with models varying from predominantlysingle payer health services to systems of competing insurers and providers. But allof these countries’ health systems—and, indeed, all those in developed countries—areunder similar financial pressures, not just from current global economic conditionsand rising healthcare costs, but also from changing populations that are posing newchallenges in meeting increased and more personalized demands for care.

To improve quality and access while getting a grip on cost, these health systems areall, in one form or another, taking action to integrate healthcare.

Integrated healthcareIntegrated healthcare delivery linksmultiple levels of care management,coordinates services and encouragesprofessional collaboration across a rangeof care delivery. Integrated healthcareis not about structures or commonownership or bearing insurance risk; it isabout networks and connections—oftenbetween separate organizations—thatfocus the continuum of healthcaredelivery around patients and populations.

The models of integrated healthcare varyin emphasis and focus. In some countries,the approach to integrated care entailscontracts with private providers; inothers, legislation is encouraging groupsof coordinated healthcare providers to

form new organizations to provide careto defined populations. Whatever theapproach, the objective is to ensure thatthe most appropriate and efficacious careis provided where and when it is needed,offering the potential of achieving betterhealth outcomes while controlling costs.Common among all these approaches aresignificant initiatives to share information onquality, costs and outcomes across healthcaredelivery—the core of connected health.

Connected healthConnected health is an approach tohealthcare delivery that leverages thesystematic application of healthcareinformation technology to facilitate theaccessing and sharing of information, aswell as to allow subsequent analysis ofhealth data across healthcare systems.But connected health goes beyondthe management of patients’ clinicaldata to encourage communication andcollaboration among all of the variousstakeholders involved in a patient’shealth.

Connected health is achieved with arange of information and collaborationtechnologies. Electronic medical recordsand other clinical applications, data

repositories and analytic tools, connectedbiomedical devices and telehealthcollaboration technologies all enableconnected health. Most importantly,those solutions must rest on a foundationof technology and data standards andsecurity that ensures the confidentialityof personal health information.

The ambition of connected health is toconnect all parts of a healthcare deliverysystem, seamlessly, through interoperablehealth information processes andtechnologies so that critical healthinformation is available when andwhere it is needed. By structuring andexchanging healthcare information tocenter care delivery around the patient ora defined population, connected healthfacilitates improved care coordination,disease management, and the use ofclinical practice guidance to help reduceerrors and improve care. In so doing,connected health is a key enabler ofintegrated healthcare delivery. Figure 1represents the connected health eco-system.

Executive Summary



Figure 1 - The connected health ecosystem

Analytics

Primary

Care

Secondary

Care

DiagnosticServicesPharmacies

Other Care

Settings

Security

& Privacy

Single

Patient

View

Standards

Collaboration

Coordination

Payer &

Financier

Policy

Makers &

Government

Agencies

Our research framework

Our global research shows that thereis no single way to achieve the highperformance information sharing at thecenter of connected health. The journeyto connected health begins from astarting point that is usually unique toan individual country or health system.Structure, finance, size and culturalissues—including public and professionalattitudes to privacy—all play a part inshaping the journey. However, despitethese differences, it is clear from our case

studies that the journey to connectedhealth can be regarded as comprisingthree key stages of organizational andsystems development, each requiringgreater healthcare IT functionality.Increasing functionality, in turn, bringsgreater levels of value to clinicians,organizations and patients.



Figure 2 - The journey to connected health

We identify the three stages of theconnected health journey as:

• Healthcare IT adoption—the planning,construction and use of a digitalinfrastructure.

• Health information exchange—the exchange of captured health

information between clinicians,across administrative groups and withpatients.

• Insight driven healthcare—the use ofadvanced analysis of data to betterinform clinical decision-making,population health management andthe creation of new care deliverymodels.

Through our research, we have learnedthat there are 17 key functionalitiesof connected health that drive valuethrough these three stages of the journey.These include electronic entry of patientnotes, clinical decision support, electronicreferrals, ordering and prescribing,communicating with other physicians or

patients via secure email and the captureand analysis of data for improvementof clinical care protocols. The 17functionalities can be thought of as beingin four groups of connections:

• Between clinical practitioners withinan organization.

• Between clinical practitioners indifferent organizations.

• Between clinical practitioners andpatients.

• With sophisticated data analytics.

As functionality and breadth of adoptionacross the health system increase, sodoes the potential for increased benefits.The use of more of the connected healthfunctionalities enables the creation ofgreater levels of value:

• Clinical efficacy—early benefits fromhealthcare IT adoption and HIE includereductions in duplicate diagnostictests, quicker access to vital patientinformation at the point of care andreduced administrative costs.

• Shared knowledge—deepening HIEand connectivity can help reduce

medical errors and improve carequality, for example through druginteraction alerts, greater use ofevidence-based care protocolsand new capabilities in managingpopulation care, which increase thepotential for preventative and low-cost care for chronic conditions. Theseadditional benefits require deliberatepolicy changes, clinical workflowredesign and innovation.

•Care transformation—advancedanalysis of data captured andexchanged in the first two stagesinforms clinical decision-making,population health managementand the creation of new caredelivery models, including patientself-management and better carecoordination across settings.

The stages of the journey The functionalities

of connected health

The levels of value

Healthcare IT adoption

Health information

exchange

Insight driven

healthcare

Connected clinical practice

Connected to clinical

practitioners in other

organizations

Connected to patients

Connected to analytics

Clinical efficacy

Shared knowledge

Care transformation



Although there is close alignmentbetween the stages of the journey,the groups of connected healthfunctionalities and the levels of valuecreation, our research demonstratesthat each demands careful, dedicatedplanning, management and expertiseif the benefits of connected healthare to serve the interests of clinicians,healthcare organizations, patients, payersand society as whole.

Progress toward connected healthThe national progress made in developingconnected health in each of the eightcountries that are included in our studyvaries a great deal, in terms of whereeach country is on the journey andthe levels of value being created. Toassess progress at the national level, we

conducted extensive secondary researchon connected health programs andinitiatives in each of the eight countriesand interviewed first-hand more than160 healthcare leaders, includinggovernment officials, clinicians, healthinformation specialists, academics andanalysts.

In addition, to gain an on-the-groundassessment of each country’s progresstoward connected health, we surveyed

more than 3,700 physicians in theeight countries, asking them aboutthe prevalence and use of many ofits functionalities, as well as aboutperceived benefits and challenges. Thefindings from the survey enabled us todevelop the Accenture Connected HealthMaturity Index, comparing the relativeprogress of each country with regard toits adoption of healthcare informationtechnology and the exchange ofinformation between different clinicians

and organizations. The index wasdeveloped separately for primary careand for secondary care.

The results show wide discrepancies indevelopment between countries andbetween sectors within countries. Forexample, while England is a leader inprimary care, it lags behind in secondarycare. In the United States, maturity ofsecondary care connected health is well

ahead of that in primary care. Whilemany national or regional health systemsdo have several components in placeand routinely in use, no country hasdeveloped all of the components fully.

Evidence of the benefits from healthcareIT adoption and from the system-wideexchange of data is emerging from

several of the healthcare systems that westudied. But there are major barriers thatcan stand in the way to connected health.These barriers include:

• Systems and policies—includingthe absence of coherent strategies,misaligned financial incentives anda lack of adequate interoperabilitystandards.

• Organization and management—including prohibitive costs,

lack of collaboration betweenorganizations, technical limitationsof existing systems and poor projectmanagement.

• Clinicians and end users—includingphysician resistance to technologiesand changes to working practices thatburden their productivity or add tocosts.

• Patients and the public—includingconcerns over privacy and data

security and a lack of appropriateregulation.

Many health service organizations aroundthe world are overcoming these barriersusing a range of tools, including strategicplanning and change management,extensive stakeholder engagement,clinical governance, policy development,legislative changes and financialincentives, among others. Drawing on in-depth case studies, we present examples

of health systems that have worked toovercome the barriers and, by doing so,moved closer to realizing the benefits ofconnected health.

The dynamics of successfulconnected healthFrom analysis of our research findings,we identify six key dynamics thatcharacterize those systems andorganizations that are successfullyprogressing on the journey to connectedhealth by creating the new relationships

and practices that will ensure valueoptimization:

1. Vision and leadership focusedon improved health outcomes—Connected health is a means to anend. Clarity about the benefits of theend state is essential before buildingthe healthcare IT infrastructure.Connected health must be partof a clear vision about improvedquality, enhanced access to careand better control of costs, which

is communicated to, and embracedby, all stakeholders in the healthcaredelivery organization.

2. Strategic change management—Connected health is not a tacticalintervention in an organization orsystem. Development of connectedhealth entails significant carefullyorchestrated organization-widetransformation that aligns directlyto mission and vision and that

can affect culture, managementand clinical systems, behavior andpatient-provider-payer interactions,well beyond the changes required intechnology alone.

3. Robust technology infrastructure—Connected health builds upon robusthealthcare IT infrastructure that iscompatible with organizational visionand objectives and governed by clearstandards of health information

interoperability and exchange. In theabsence of coherent healthcare ITarchitecture that is expressly designedto ensure interoperability, ad hocsolutions typically fail to realizepromised returns on investments.

4. Co-evolution—Connected healthdevelopment strikes the right balancebetween strong leadership and visionfrom the top and the opportunity



for bottom-up experimentationand innovation to build ownershipand change practices across theorganization. Global experiencedemonstrates that top-downapproaches alone fail to build clinicalbuy-in and bottom-up approachesalone seldom achieve system-wideinteroperability – both of which areneeded for success.

5. Clinical change management—Connected health succeeds best whenchange to frontline healthcare deliveryworks in parallel with strategic changemanagement (dynamic 2) at theorganizational level. Sophisticatedanalytics can identify needs forchange and provide an evidencebase that can help re-shape clinicaldecision-making and healthcare

protocols. Without a strong frameworkof clinical governance, peer reviewand performance management acrossthe system, clinical changes can befragmented, disruptive and inefficient.

6. Integration drives integration—Connected health entails a virtuouscycle, fostering clinical and business

process integration, which inturn places new demands on newtechnologies and needs for parallelservice delivery development. Thisrequires organizations to put in placeproject management processes thatorchestrate the five dynamics listedabove, and to continually reassesstheir roles, what services they provideand how those services need to bedeveloped, extended and connected.

There is little scope for integratingdifferent levels of care if theorganizations or systems of each aredisconnected, either technologically orclinically.

The success achieved so far in the eightcountries of our study is the result ofthe national-level vision for connected

health, including related policy andregulatory initiatives, as well as theoperational initiatives implementedwithin individual health systems andorganizations. To measure their progress,we have mapped the innovations andefforts in the eight countries against thesix dynamics of connected health success.The figure below summarizes our analysis

Figure 3 - State of the connected health dynamic-country comparisons

Australia Canada England France Germany Singapore Spain US

Vision andleadership

Strategicchangemanagement

Robusttechnologyinfrastructure

Co-evolution

Clinicalchangemanagement

Integrationdrivesintegration

= recognized need/initial steps

= progress being made

= strong performance

= sustained excellence



We believe that the six dynamics ofconnected health success provide asolid basis for planning and embarkingupon the connected health journey. The journey begins with intensive analyses ofexternal uncontrollable factors and of anorganization’s own internal, manageablecapabilities. To help healthcare leadersundertake that continuing assessment,we have structured a diagnostic templatebased on the six dynamics, includingexternal, contextual factors that needto be monitored and questions aboutinternal organizational capabilities thathave to be tested and retested.

The future of connected healthThe dynamics of connected health createa virtuous cycle of integration that willshape the future of both connected

health and healthcare. The beginningsof major change are already underway,including:

• Integrated systems that blendelectronic medical records withmethods of communication, remotecare and process management tobuild seamless systems and workflows.

• Redirection of healthcareinterventions away from expensivehospital settings through the use oftelemedicine, remote care and mobilehealth.

• Engagement of citizens in their healthand wellness through a variety ofconnected health tools including thecreation and use of personal healthrecords. There is great potential totransform the role of patients intheir own wellbeing through shareddecision-making, active engagementwith care teams, condition monitoringand chronic disease management.

• Genomics, which will offer thepossibility of personalizing treatmentand wellness plans, present clinicianswith a powerful range of analyticaland diagnostic tools, and enablemanagers to coordinate care, targetresources and improve public healthoutcomes.

These changes and others will drivegreater integration of healthcare, whichcan ensure that the most appropriate andefficacious care is provided where andwhen it is needed and offer the potentialof better health outcomes and greatercontrol of costs.

Moving forward on the journeyWe strongly advocate that organizationsor systems that are embarking on theconnected health journey begin with aclear assessment of their own currenthealthcare IT functionalities and adetailed analysis both of their owninternal, manageable capabilities and ofthe external uncontrollable economic andpolitical factors that will influence their journey. We believe that the six dynamicsof connected health success that we

identify from our global research providea solid basis for such analysis.

Our research also demonstrates that“biting off more than one can chew”can result in failure. The manageablechange and planned incremental actionthat we observed in the more successfulnational and system initiatives shouldencourage those who recognize that the journey forward is made one step at atime. Overly ambitious plans—especially

if they are undertaken without firstestablishing a sense of ownership acrossthe organization and especially withphysicians—can be a mistake.

Unlike some other journeys, the marchto connected health and toward moreintegrated healthcare will not cease.Health information will likely remainfragmented in dispersed organizationsfor some time to come, irrespectiveof how care is organized or financed

nationally. But new clinical developments,technology advances and the growingneeds and demands of patients willconstantly present new challenges andpossibilities for healthcare deliverysystems and organizations. Connected

health is not a one-time investment;it is a permanent and evolving part ofoperations, which requires sustainedfinancial backing, technical expertise,organizational change and political will.

Our study clearly demonstrates thatconnected health offers massiveopportunities for forward-thinking

healthcare leaders to achieve the aims ofincreased quality, sustained access andmanaged cost. And this report showsthat there are many organizations on the journey from which we can learn.



Our methodology in brief In this study, Accenture set outto determine the distinguishingcharacteristics of advanced connectedhealth systems and to gather and shareinsights from today’s leaders.

Our study consisted of four strands ofresearch. First, we undertook a literature

review, assisted by researchers at the New York Academy of Medicine, to examinewhat other researchers have done in thefield to date on the subject of healthcareinformation technology and “connectedhealth,” and we conducted in-depthsecondary research to assess progress inplanning and implementing connectedhealth across eight countries. The eightcountries were: Australia, Canada,England, France, Germany, Singapore,

Spain and the United States.

Second, we commissioned Ipsos Mori, aninternational market research agency, tohelp conduct 160 interviews with healthsystem leaders across the same eightcountries. Between them, these expertsbrought a range of strategic perspectiveson the topic. The experts included:

• Government officials involved inregulating, funding and/or deliveringconnected health.

• Clinicians and clinical organizationsinvolved with healthcare delivery.

• Payer/commissioner organizations thatare responsible for healthcare funding.

• Healthcare information technologyexecutives tasked with developingtechnological frameworks forconnected health systems, as wellas purchasing and managing thosesystems.

• Academics and analysts with a broad

view of the national picture.

These expert interviews provided us withoverall insights into the adoption ofhealthcare IT solutions, and particularlyhow far the exchange and use of health

information has progressed in differentcountries and regions. The interviews alsoexamined the barriers and enablers tofurther progress, and explored experts’views on the future vision and desiredoutcomes for connected health in eachcountry.

Third, working with M3 Global Research,

we conducted an online survey of morethan 3,700 physicians in the eightcountries (500 each in Australia, Canada,England, France, Germany, Spain andthe US, and 200 in Singapore). We drewrespondents from a panel composedof primary and secondary/specialistcare doctors who have registered totake part in market research. Primarycare physicians are those from generalpractice and family medicine. Secondarycare physicians included specialists ina number of fields including surgery,neurology, endocrinology, rheumatology,oncology and cardiology. The surveyenabled us to measure the actual levelof “connectedness” in each country,by providing comparative data onphysicians’ use of different functionalitiesof connected health. The surveyalso captured attitudinal data on theperceived benefits of connected healthwith respect to several dimensions of

quality, access and cost, and exploredphysicians’ views on the barriers andincentives to encourage adoption and use.

Finally, we conducted further in-depthsecondary research and consulted withacademic experts and other subjectmatters experts to compile a list ofhealth systems and organizations thatare widely seen to be leading the wayin connected health. Then, working inpartnership with the Altarum Institute,

a US-based health system researchorganization, we developed 10 case studiesof connected health systems that representthe benchmark for current good practice.These case studies were based on extensivesecondary research and interviews with

senior executives across the health systemsthat brought a broad range of political,strategic, technical and clinical experience.The case studies helped us to betterunderstand the link between the adoptionand use of electronic medical records(EMR) and health information exchange(HIE) solutions, and the resulting benefitswhich accrue to health systems, to the

patients they serve and to populations.

This research has provided us with deepinsights into the critical success factors fororganizations to deliver more effective,efficient and affordable healthcarethrough the use of healthcare IT. Altarum’sproject director, Dan Armijo, contributedto chapter 1 on “Making the Case forConnected Health.”

The case studies are: Denmark, Indiana

HIE (United States), Lombardia (Italy),Intermountain (United States), Madrid(Spain), Kaiser Permanente (UnitedStates), Hong Kong, Midi-Pyrénées(France), Scotland and Singapore.

The core Accenture team that conductedthe research were: JulieMcQueen, GregParston, Lisa Larsen, Henry Kippin, HayleySaldanha, Corinne Levey, Amy Berk, SimonKaiser and Heather Heathfield.

The team was advised by Prof. DenisProtti of the University of Victoria andDr. Alan Garber, formerly of StanfordUniversity.



1. Making the Case forConnected Health



Healthcare leaders around the world are looking for new ways to improve thequality of healthcare delivery and expand access to vital services for increasinglydiverse and demanding populations. At the same time, they are trying to get a grip

on the rising costs of healthcare.National health systems are diverse, with models varying from predominantlysingle payer health services in countries like the United Kingdom and New Zealand,to systems of competing insurers and providers, such as in Germany and theUnited States. But most countries’ health systems—certainly those in developedcountries—are under similar financial pressures, not just from current globaleconomic conditions, but also from changing populations that are posing newchallenges in meeting increased demands for care. People are living longer and,

with older age, are suffering more chronic ailments that require sustained but notnecessarily intensive care. People are also demanding better, more personalizedand more convenient services from their health providers. At the same time, thecosts of healthcare itself are being driven constantly upwards by new clinical andpharmaceutical interventions and by new medical technology and equipment.

Across all these national systems, a common thread is apparent: they are all, in oneform or another, taking action to integrate healthcare.

Integrated healthcareIntegrated healthcare delivery linksmultiple levels of care management,coordinates services and encouragesprofessional collaboration across a rangeof care delivery. Integrated healthcareis not about structures or commonownership, but rather about networksand connections—often between separateorganizations—that focus the continuumof healthcare delivery around patients

and populations. It is clinical and financialaccountability to a defined set of patientsor a population that ties together deliveryorganizations.

Models of integrated healthcare varyin emphasis and focus. In some Spanishregions, for example, the governmenthas contracts with private providers toprovide both primary and secondary care

at a fixed price. In Swedish counties, asimilar arrangement has been extendedto include social care, a model akin to oneadopted by some English health servicecommissioning agencies. In the UnitedStates, legislation is encouraging groupsof coordinated healthcare providers toform accountable care organizations,which provide care to defined populationsand are held accountable for quality, costand overall care. In Australia, national

and state programs are seeking waysof integrating primary care, bringingtogether general practice, nurses, alliedhealth professionals and visiting medicalspecialists; in Canada, similar provincialprograms are focusing on integrating carefor families and the elderly.

By ensuring that the most appropriateand efficacious care is provided whereand when it is needed, these kinds

of integrated care schemes offer thepotential of achieving better healthoutcomes for individual patients andbetter health for the wider community.Integrated care offers the furtherprospect for governments and healthcaresystems to ensure service capacity meetsthe needs of their population whileachieving better control of costs.

Although countries with very different

health systems are pursuing differentstrategies toward integrated care, thosethat are leading the way also have incommon significant initiatives to harnessthe power of connected health to supporttheir progress. Sharing information onquality, costs and outcomes—the coreof connected health—is essential tointegrated healthcare delivery.

1. Making the Case for Connected Health



Connected healthWe define connected health as anapproach to healthcare delivery thatleverages the systematic application ofhealthcare information technologiesto facilitate the accessing and sharingof information, as well as to allowsubsequent analysis of health data acrosshealthcare systems.

Recent rapid advances in healthcare ITprovide the potential for innovation andintegration through sharing informationacross systems, and between differenthealthcare providers. These advanceshave some basic components: electronicmedical records (EMR) that allowproviders to capture and store patientcare information electronically, andenables clinical decision support systems

(CDSS) and computerized physicianorder entry (CPOE); health informationexchange (HIE); and analytics; andtechnologies that directly engagepatients. All of these are importantbuilding blocks in improving overallhealthcare quality and efficiency.

Leveraging the value of thesetechnologies requires strong incentivesand a clear policy framework, and weare seeing a number of governments

beginning to provide this. In the UnitedStates, for example, recent healthcarelegislation and direct financial incentivesfor providers are driving healthcare ITadoption. In the Netherlands, a recentlaw establishes that e-prescribingshall be mandatory by 2012. And alegislative review in Singapore to enableHIE between institutions triggeredthe creation of a national electronichealth record (NEHR) in just 18 months.Today, more than 95 percent of primary

care physicians in New Zealand, theNetherlands, England, Australia, Spain,parts of Italy and all of the Scandinaviancountries use an ambulatory careelectronic health record.

The ambition of connected health is toconnect all parts of a healthcare deliverysystem, seamlessly, through interoperablehealth information processes andtechnologies so that critical healthinformation is available when andwhere it is needed. By structuring andexchanging healthcare information tocenter care delivery around the patient or

a defined population, connected healthfacilitates improved care coordination,disease management, and the use ofclinical practice guidance to help reduceerrors and improve care.

In so doing, connected health is a keyenabler of integrated healthcare delivery.The leaders of today’s successful healthsystems and organizations understand thisand know that progress toward the long-term outcomes of quality, access and costcontrol cannot be achieved without thecreative leveraging of healthcare IT andthe systematic development of HIE.

Making the right connectionsOur global research shows that the journey to connected health begins froma starting point that is usually unique toan individual country or health system.Structure, finance, size and culturalissues—including public and professional

attitudes to privacy—all play a part inshaping the journey. But from thesedifferent starting points, we can identifythree stages:

1. Healthcare IT adoption—theplanning and construction of adigital infrastructure for capturingpatient data, built on decentralizedapproaches to data collection throughelectronic medical records and patienthealth records.

2. Health information exchange—whichallows organizations to promotethe exchange of captured healthinformation between clinicians andacross administrative groups, withina strong governance framework thataims to improve care coordination viabetter accessibility to higher quality,more structured data.

3. Insight driven healthcare—duringwhich advanced analysis of datacaptured and exchanged in the firsttwo stages can better inform clinicaldecision-making, population healthmanagement and new care deliverymodels, including identifying whenalterations in clinical protocolsare needed, virtual care provision,

telemedicine and other electronictools that empower healthcareconsumers.

Although the gains of improved quality,access and cost control are optimized inthe third stage, benefits accrue throughall three stages—benefits that, howeversmall, can induce further developmentsand support organizational change. The journey from healthcare IT adoption toinsight driven healthcare is sequential,

in that each stage builds on priorcapabilities, but the journey is notalways linear. Each stage can influencedevelopments in the others. For example,building information exchange betweenlegacy healthcare IT systems in separatehealthcare institutions can lead to morestandardized templates for data collectionwhich were first developed in theadoption stage.

From our research, we have identified 17key functionalities of connected healththat drive value across these three stagesof the journey. These can be thought ofas being in four groups of connections:those between clinical practitionerswithin an organization; between clinicalpractitioners in different organizations;between clinical practitioners andpatients; and with sophisticated dataanalytics. The groups of connections alsolargely coincide with the three stages

of the connected health journey. Theseconnected health functionalities arepresented in Figure 4.



Figure 4 - The functionalities of connected health

Connected clinical practice• Hospitals/physician offices use electronic tools to reduce the administrative burden of health care delivery (e.g. e-scheduling or e-billing)

• Physicians capture patient data electronically

• Physicians receive electronic alerts/reminders while seeing patients (e.g. prompts regarding contraindications or preventative care)

• Physicians use clinical decision support systems (CDSS) to help make correct diagnostic treatment decisions at the point of care

Connected to clinical practitioners in other organizations

• Physicians communicate electronically with clinicians in other organizations (e.g. via secure email)• Physicians are notified electronically of patients’ interactions with other health organizations (e.g. admission to hospital)

• Physicians send or receive referrals electronically to/from health professionals in other organizations (e.g. for specialist appointments)

• Physicians electronically access clinical data about a patient who has been seen by a different health organization (e.g. hospital, laboratory)

• Physicians send prescriptions electronically to pharmacies (e-prescribing)

• Physicians send order requests electronically (e.g. for tests)

• Physicians receive clinical results electronically that populate patients’ electronic medical records

Connected to patients• Patients can book/change/cancel appointments with their physicians online

• Patients can communicate with their physicians electronically via secure email or video conferencing

• Patients can electronically access their own medical information (e.g. lab results, medications, imaging results, etc)

• Patients can monitor and record their own health indicators and share information with their physicians or with other approved clinicians

Connected to analytics• Healthcare organizations capture and analyze care data and use this to identify needs for improvement in clinical care protocols and

clinical outcomes across the organization

• Public health agencies use system-wide clinical data for population health reporting, allowing them to carry out analysis to monitor

trends and manage disease in the population

H e a l t h c a r e I T

A d o p t i on

H e a l t h I nf or m a t i on

E x c h a n g e

I n s i gh t D r i v e

nH e a l t h c a r e



Realizing value from connectedhealthThe effective use of healthcare IT toadvance quality of care, expand accessand control costs takes many forms. Attheir center lies the ability of technologyto expand access to health information,improve the integrity of healthinformation and organize and presentthat information so that a variety ofstakeholders can execute their roles in thesystem more efficiently and effectively.

The benefits that can accrue fromconnected health systems—even in theearly stages of the journey—are many.Evidence of the benefits from healthcareIT adoption and from the system-wideexchange of data, is emerging fromseveral of the healthcare delivery

systems that we studied. They showthat connected health facilitates’ carecoordination and integration, diseasemanagement, reduction of clinicalerrors and the use of care protocols andclinical practice guidelines, as well asproviding opportunities for administrativeand clinical cost savings. As systemfunctionality and breadth of adoptionincrease, so does the potential forincreased benefits.

We identify three levels of valuecreation, from early, relatively smallreturns to producing value through caretransformation. While the third levelmay be the ultimate end goal, manyhealth systems start with business casesthat target early value as a means ofdemonstrating quick wins and buildingstakeholder buy-in.

The three levels of value creation are:

• Clinical efficacy. Many benefitsof EMR adoption for physiciansand patients materialize almostimmediately. These “early value”benefits can include reducingadministrative activities and costs,eliminating duplicate lab and

radiology tests, improving patientsafety through 24/7 access tocomprehensive, legible medical recordsand speeding up access to patientmedical histories and vital informationat the point of care to improve thepatient experience and supportclinical decision-making. At this level,strong vision and leadership is vitalto make sure any initial disruption toworkflows or “bedding in” of systemsis translated into a gradual ROI and

visible improvements in patient care.• Shared knowledge. Deepening HIE and

connectivity can help reduce medicalerrors and improve care quality.Examples include such patient safetybenefits as drug interaction alerts,sophisticated tools to enhance clinicaldecision-making through evidence-based care protocols, and innovationsand new capabilities in populationcare, which increase the potentialfor preventative and low-cost carefor chronic conditions. Improvingefficiency and systematically reducingwaste and duplication can createsignificant cost savings. At this level,benefits realization requires moredeliberate policy changes, workflowredesign and a willingness to innovateon the part of clinicians.

• Care transformation. The greatestlevel of value is created by analyzingrich data sets to accelerate clinical

research and to improve diagnosticand treatment protocols. Healthanalytics enables comparativeperformance review and managementthat can improve the quality of careand the coordination of diseasemanagement along the continuumof care. This in turn enables deeperintegration, facilitating new modelsof patient-led care through self-management, the use of mobile

technologies, and care coordinationacross settings. Critical to this levelis the ability to harness and mine thedata to drive improvements and toshare successful practices that addvalue across the system.

Evidence of the benefits from healthcareIT adoption and from the system-wideexchange of data, is emerging fromseveral health systems that we studied.The appendix includes descriptions ofthe connected health activities of 10health systems that are leading the wayin implementing healthcare IT and alreadyrealizing value from their investments.

Through these case studies, we havelearned that while some benefitsmaterialize early, the potential to create

more value and to transform care deliveryincreases as the breadth of adoption andfunctionality of healthcare IT increases, asrepresented in Figure 5.

The cost of investment in electronicmedical records and HIE—in money, timeand, in the early stages of the journey,even in small losses of productivity—is notinsubstantial. Policymakers, health systemleaders and clinicians need to approachbenefits creation proactively and with

a long-term view. The most successfulhealth systems target and celebrate earlywins, but maintain a focus on the long-term value of care transformation.



Figure 5 - Three levels of value creation

Note: There may be a short period where valueis lost as the system ‘beds in’ after initial golive (e.g. disruptions to existing work flows)

Functionality, levelof integration etc

Breadth of adoption(e.g. number of organizations connected, volume/completeness of data)

Clinical efficacy

A more efficient processing system• Accelerated capture and transfer

of information and reduction inadministrative activities and costs

Fewer medical tests• Reduction of duplicate lab/radiology

tests by ensuring availabilityof results

Improved patient safety

and emergency care• Fast access to comprehensive, legible

patient records and results that canoptimize treatments and proceduresat the point of care

Improved patient experience• Ability to demonstrate ‘we know

you’ during patient visits

Shared knowledge

Fewer medical errors and increasedoverall care quality• Alerts for adverse drug interactions and

reminders for proper timing of tests,etc.

• Closer monitoring of populations ofpatients (e.g. electronic registries) thatimproves chronic care management

• Increased delivery of patient care byphysicians that adheres toevidence-based guidelines andprotocols (particularly in chronicdiseases)

Potential for cost savings• As a result of improved efficiency and

quality and decreases in error andredundancy

• Savings from legacy systems‘retirement’

• Reduced cost of medical recordsoperations

Care transformation

Potential to dramatically accelerateclinical research• Makes possible the combination of

clinical data from millions of patients,enables rapid learning of the value(and cost) of new medical technology

and disease treatments

More accessible and better developedmeasures of clinical performance• Comparisons on clinical practice,

outcomes, costs, reimbursement ratesetc that can contribute to operationalimprovements and development of newclinical protocols

Patient centered care/patientempowerment• New models of patient care, e.g. Web

enabled consults and home monitoring;education around self-management;better coordination of care acrossmultiple providers

Increased public health monitoring anddisease management• Data on disease trends and other

medical conditions can be easilyaggregated and detected over a widevariety of patients, and individuallytailored treatments can be establishedand monitored for complex patients

Our case studies showed that therealization of value from coordinatedhealthcare IT investments takes manyforms: increased administrativeefficiency; improved management ofclinical processes (reducing unwarrantedvariation, individualizing care, moreregular use of evidence); better patientengagement, enabling shared medicaldecision-making; better managementof population health objectives; andfostering a learning environment throughadvanced data analytics. Each connectedhealth organization or system that westudied focused on realizing a particularsubset of these benefits. The focus ofeach initiative was largely determinedby the primary stakeholders leading theeffort, the availability of funding, the

policy and funding environment andthe perceived likelihood of success. Butthe greater benefits only accrue withincreased functionality and informationsystems integration.



Summarizing the benefits of connectedhealth is complex because of the multitude ofstakeholder interests involved, the variationsin maturity and functional emphasis across

“successful” efforts and the relative absenceof robust system-wide ROI studies.

Attributing specific cost, quality and patientoutcomes to activities that would not havebeen possible without a correspondinghealthcare IT investment is always difficult,given the influences on organizations and

systems of many confounding environmentalfactors. Value can be misattributed,unintended consequences missed, the impactof conflicting incentives overlooked andthe true drivers of value misunderstood.For example, simple HIE offers improvedinformation access that can foster betterpatient care coordination, which in turnshould improve the quality of care delivered,which should result in improved clinicaloutcomes for individual patients and, inaggregate, improved population-level healthindicators. Within all of these linkages,if one is just looking for correspondingchanges in population-level metrics, it iscertainly possible to misattribute changes,or the lack of them, to particular healthcare

IT capabilities. Effective evaluation ofhealthcare IT programs requires an approachthat recognizes this, captures both dynamicand cumulative impacts along the value chainand uncovers missed opportunities.

The countries we studied showed varyinglevels of maturity in managing and measuringvalue realization. Some connected healthprojects have been proposed, planned and

implemented without a consensus aboutthe performance gains expected or thedirect mechanisms to achieve these andonly limited means to oversee investmentprogress. Clearly, there are also manycomplexities in monitoring performancein a multi-stakeholder environment wherepriorities and policies are subject to change,

baselines move, program leadership changeshands, technology and evidence evolves,and so on. Furthermore, it is quite commonfor these types of complex programs tosuffer from limited mechanisms to overseethe investment (are we getting the valuewe intended?), a failure to portray lessonslearned adequately (what underlies providers’reluctance to use a certain function?) andan inability to manage the achievement ofperformance objectives effectively acrossorganizations and time. Understandingthe value of particular connected healthinvestments in such a fluid environment canbe extremely challenging.

The challenges to measuring value

18 | Connected Health: The Drive to Integrated Healthcare Delivery www.accenture.com/connectedhealthstudy



The benefits to differentstakeholdersThe value of connected health isoptimized through the coordinatedefforts of many stakeholders. Whileall stakeholders benefit, it is useful toview the specific advantages from thedifferent perspectives of the clinician,the organization/system, the patient, theinsurer or payer and the wider populationor society as a whole. The managementdecisions from which the benefits ofconnected health derive often take intoaccount implicit tradeoffs between thedifferent stakeholders’ interests.

It is important for healthcare leaders tohelp the various stakeholders understandwhat it takes to maximize benefitsfrom connected health investments.

Incremental development and small, earlywins—particularly at the first stage ofhealthcare IT adoption—are important tosecuring organization-wide ownership andcommitment to continued development.However, the greatest value of connectedhealth lies in the long term changes toclinical processes and health that thestages of HIE and application of healthinformation analytics bring. There are manypoints along the journey to connectedhealth where compromises will be made

to adjust for the impact of interveningvariables (such as policy changes,funding limitations, technical issues ofinteroperability in view of dissimilarplatforms, semantics, etc.). In reality, thesecompromises can mean it takes longer fora fuller range of benefits to be realized.Those that have been remarkably successfuldemonstrate a deep understanding of thetime requirements of the value chain, theimportance of managing expectationsaccordingly and the need to plan their

activities over the long term.

Value to cliniciansIntegrated and well-organized patientinformation can make providers moreeffective in a number of ways. One of themost important is the opportunity to usetheir time with a patient more efficiently,diagnose accurately, explore treatmentoptions together, and help with patienteducation.

" We have access to many more types

of decision support than we did on

paper. Now, we all use order sets

that are developed regionally with

an evidence basis to guide people

towards best practices.... We have

things like drug allergy alerting and

drugs interaction alerting, maximum

dose alerting—and that all happens at

the point of care, so when I enter an

order I am warned about those things

immediately. It does not have to wait

for a pharmacist to notice or a nurse

to notice an issue and call me.”

−Ben Broder, M.D., Ph.D., KaiserPermanente SCAL, Systems Solutionsand Deployment, Inpatient EMRPhysician Lead

Another significant area of benefitto providers is the ability to queryand analyze the complete populationof patients for whom they and theircolleagues are responsible. Becausethe impact of healthcare IT on patientoutcomes and costs of care are difficultto measure and may take several years tocome to fruition, the ability to generatepatient registries is seen as an early proxymeasure for the impact on quality ofcare. Although they can be paper-based,organizations with electronic healthrecords are considerably more likely tohave registry capabilities.

Patient registry functionalities supportbetter care by identifying candidatesfor preventative tests and vaccinations,tracking the management of certainchronic conditions and identifyingpatients who may not be complying with

treatment regimes. In this way, providerscan manage the health of populationsof patients more effectively and reportperformance on quality measures. KaiserPermanente, a US-based integrateddelivery system, has developed a PanelSupport Tool, which links evidence-based care guidelines to Kaiser’s EHR,highlighting gaps in care for individualpatients and analyzing performanceacross panels of patients and care teams.

The program has increased adherenceto evidence-based care and improvedoutcomes for patients with a variety ofchronic conditions. It has also enhancedcontinuity of care, and reduced relianceon resource-intensive office visits.

Value to healthcare organizations/systemsAs patient-centric views of data allowmore efficient and coordinated actionacross the health system with HIE,the aggregations of that data alloworganizations to measure system-wideperformance and see how far it isimproving. Connected health systemscan generate valuable performanceinformation to improve workflow, safetyand efficiency within health systems. Ourstudy of connected health initiatives in

Hong Kong and Intermountain Healthcarefound several examples of system-wideimprovement efforts, all fostered by thecollection, measurement and reportingof clinical practices. These efforts, andothers, highlighted the need to makecomplementary organizational changesto leverage healthcare IT systems, trackperformance and quality measures,encourage the use of reminder systemsand checklists for providers, and offerconstant feedback on performance.

Organizations can also benefit fromadopting new models of care delivery.In Denmark, for example, the OdenseUniversity Hospital, which has reachedstage 6 on the HIMSS maturity model1,has been working with MedComInternational in developing healthcareIT solutions to facilitate high-qualitycare in patients’ homes. For example,patients with COPD (often referred toas smokers’ lung disease) are equipped

with a ”briefcase” that allows liveimages and sound as well as datameasurement to be monitored at homeand quickly transferred to the hospitaleither via the Internet or a satelliteconnection. At the hospital, the doctorcan evaluate and guide the patient as ifthe patient was present at the hospital.The data transmitted from the patient’s

1 http://www.himss.org



home enables the hospital to performsystematic monitoring and controlthe quality of the treatment. Earlyevaluations demonstrate key benefits:patients feel safe and comfortable athome, readmission rates are down bymore than 50 percent, patient stays inhospital have been reduced by five dayson average, the relationship betweenstaff and patients is significantlyimproved and the overall cost of care isreduced.

The use of patient-physician secureemail at Kaiser Permanente (KP) providesa competitive advantage for theorganization. The impact of patients’use of the secure email function hasbeen gauged by measuring the impacton certain Healthcare Effectiveness Data

and Information Set (HEDIS) measures,specifically for patients with diabetes,hypertension, or both. A study of 35,423adult patients with those conditions inKP’s Southern California region comparedthe rates at which nine HEDIS measureswere met two months after patientsbegan using secure email with providers.They observed a 2.0 - 6.5 percentagepoint improvement on all nine measures.The association between use of emailand HEDIS scores, as well as the 7 to

10 percent reduction in primary careoffice visits from members using securemessaging, suggests that secure email canhelp improve individual care experiencesand the health of populations while alsoreducing per capita costs of care.

Value to patientsConnected health offers many benefitsto patients. These range from fairlystraightforward gains in coordinationbetween providers that reduces patient

frustration (being asked for the sameinformation repeatedly or having to waiton the phone to schedule appointments)to the benefits that arise from advancingpatient-centric information and processes.From a cost containment point of view,patients benefit from avoiding unneededtests and treatments and unnecessary

hospitalizations. Access to well-structuredlongitudinal patient information acrossorganizations can improve diagnosticaccuracy, decrease errors, reduceunnecessary procedures and facilitate thebest possible treatment decisions.

" Originally the ‘killer app’ for

GPs using computers was repeat

prescribing because it removed

handwriting issues which risked the

wrong drugs being administered.

ePrescribing now organizes all of

the prescription information making

that process much more streamlined.

These days, though, one of the

main advantages of healthcare IT

for GPs is document management

systems, meaning that lab results are

available the next day, rather than

it taking a week or 10 days to go

through all of the paperwork.”

−Frank Sullivan, GP and Professor ofHealth Informatics, NHS Tayside

Patients will receive better medical careif they and their healthcare providershave access to robust decision aides andaccurate information about previousencounters. In Scotland, for example, the

Emergency Care Summary is receivingmillions of accesses each year and ishelping to ensure that clinicians haveaccess to critical information—includingbasic patient details and a summary ofprescriptions, allergies and adverse drugreactions—to help them deliver safe carewithin the emergency setting.

Similarly, in Hong Kong, the prevalenceof errors—such as medication,prescription, transcription andtransfusion errors—has been reducedfollowing the implementation of theClinical Management System (CMS) andelectronic patient record (EPR). Aftercomparing incidents of misidentificationsin laboratory tests before and afterintroducing a barcode system, the numberof incidents at one hospital had droppedfrom 132 to just two.

The most complex patients requireteam-based care, and the informationflows possible in connected healthsystems allow such teams to functionmore effectively. In Kaiser Permanente’smultispecialty medical groups, forexample, physicians and other cliniciansshare a vast clinical knowledge base thathelps them to practice physician-ledteam-based care (comprising physicians,clinical pharmacists, nurses, caremanagers, medical assistants, techniciansand others), and in so doing improvepatient outcomes and reduce costs.

Patients also benefit from clinical qualityimprovement activities. For example,Intermountain Healthcare (IHC) hasreported many examples of improvedpatient outcomes resulting directly

from the more effective use of data andstandardization of care. The proportionof cardiac patients receiving appropriatemedications at discharge has increased by50 percent to proportions of more than90 percent. This has resulted in significantreductions in mortality and readmissionrates of congestive heart failure and heartdisease patients. IHC is now in the top3 percent in the US for low readmissionrates for heart attack, heart failure andpneumonia patients.

Value to payers/insurersConnected health systems allow theperformance of hospitals, physicians,nursing homes and other providers tobe evaluated. Performance metrics cansupport value-based purchasing effortsand help to identify performance outliersand fraudulent activities, whether fundedby government or independent insurers.Comprehensive and accurate patientinformation also supports efficient care

delivery through improvements incaremanagement, which can keep patientsout of high cost settings like hospitalsand emergency rooms. Widespreadinvestment in healthcare IT also fostersimprovements in administrative efficiency.Given the economic burden of growinghealthcare costs, these capabilities are ofconsiderable value to healthcare payersand insurers.



Indiana Health Information Exchange’s(IHIE) Quality Health First (QHF) program,for example, operates as a clinical qualityand value-based reimbursement service.Combining data from insurance providerswith data within the virtual patientrecord, QHF provides quality reportingand an integrated pay-for-performanceprogram across multiple payers in the

state. The program is both intended togenerate revenue from participatingpayers and provide quality-basedinformation to participating physiciansthrough monthly reports. Insuranceproviders reap financial benefits fromthe improved health of their populations,while providing funding both for theoperations of QHF and to supply incentivepayments to providers who improve theirquality of care.

Using information contained in electronichealth records (EHR), Lombardia’sdata warehouse enables analysisfor administrative purposes such ashealthcare planning, resource planning,and epidemiological analysis. The totalinvestment in healthcare IT capabilitiesin Lombardia over 10 years was between €800 million and €1 billion. A 2010 studyfor the European Commission found anoverall positive socio-economic impact of

the healthcare IT platform over 10 years.In 2007, about five years after the region-wide expansion of the system began,annual net benefits were first realized.By 2010, cumulative net benefits wereestimated to be about €143 million.

Value to society as a wholeThe aggregation of health informationacross organizational boundariesoffers many possibilities for improvingpopulation health. Patterns of illness

can be revealed, disease outbreaks andrare patterns of adverse events can bedetected and public health indicatorscan be measured. For example, the PublicHealth Emergency Surveillance System(PHESS) is a core early component

of IHIE’s initiatives. PHESS collectsinformation from Indiana hospitalemergency departments to supportanalysis to identify bioterrorism, diseaseoutbreaks and other public healthemergencies.

Population-level views also enhancethe ability of the system to detect

unwarranted variation in clinical practice,as well as evaluate the comparativeeffectiveness of treatments related topopulation characteristics not alwaysadequately explored during clinicaltrials. These uses can uncover significantrelationships between risk factors,treatments and outcomes and can alsosupport the mass identification andcontact of patients when needed (forexample, in the event of a medicationrecall). In Hong Kong, for example, whenthousands of patients had received abatch of contaminated medication in2009, the Health Authority was able toidentify 35,000 patients and contact2,000 chemotherapy patients (who weremost at risk) within a day.

Because they can help organizations tocompare effectiveness data, connectedhealth systems can accelerate the creationof empirical medical evidence of the link

between specific clinical interventionsand observed patient outcomes. Throughanalyzing those relationships acrossthousands of patients, connected healthsystems enable a wide array of evidence tobe gathered about competing treatmentapproaches, prevention strategies, thefrequency of certain complications, andthe effect of management efforts on theprogression of disease. The outcome willbe increased average life spans and betterquality of life.

Navigating the journey toconnected healthThe journey to connected health, thehealthcare IT functionalities that areconstructed along the way and thevalue that can be created are graphicallyrepresented in Figure 6. Although thereis close alignment between the journey,healthcare IT development and valuecreation, each demands careful, dedicatedplanning, management and expertiseif the benefits of connected healthare to serve the interests of clinicians,healthcare organizations, patients, payersand society as whole.



Figure 6 - The journey to connected health

The stages of the journey The functionalities

of connected health

The levels of value

Healthcare IT adoption

Health information

exchange

Insight driven

healthcare

Connected clinical practice

Connected to clinical

practitioners in other

organizations

Connected to patients

Connected to analytics

Clinical efficacy

Shared knowledge

Care transformation

It is clear that health informationwill likely remain in fragmented anddispersed services and organizationsfor some time to come, irrespectiveof how care is organized or financednationally. However, even in countrieswhere progress on electronic medicalrecords is slow or incomplete, we can

see other functions being put in place,such as e-referrals or picture archivingand communications systems (PACS).The worldwide message seems to beone of seizing opportunity as well asimplementing, or at least intending toimplement, a deliberate strategy.

In the next chapter, we describe thedifferent approaches that countries aretaking on the connected health journeyand assess their progress to date.


23/280Connected Health: The Drive to Integrated Healthcare Delivery | 23www.accenture.com/connectedhealthstudy Connected Health: The Drive to Integrated Healthcare Delivery | 23www.accenture.com/connectedhealthstudy



2. Progress TowardConnected Health



In this report, we focus specifically on the development of connected health in

eight countries: Australia, Canada, England, France, Germany, Singapore, Spain

and the United States. We have studied in depth the progress toward connected

health in these countries through a mix of qualitative and quantitative interviews,reviews of published data and case studies of leading practice. We chose these

countries because they all face similar challenges around how to improve quality,

secure access and control cost—and, as is evident from the healthcare informationtechnology strategies in place, they all look to healthcare IT as a critical means of

addressing these challenges and are progressing quickly in its adoption.

During our study, we examined howthese countries, with their very differenthealth systems, are progressing in settingup connected health networks andsystems, and how they are using thefunctionalities of connected health tosupport the growth of integrated care. Insome countries, progress is more uniform

on both fronts—connected health andintegrated care—than in others; in othercountries, there are great differences inthe progress made in different regions orsubsystems.

All eight countries have chosen theirown pathways for developing connectedhealth. Each is at a different stage ofthe journey and is proceeding in its ownindividual manner. While it is difficult toplace them definitively on a continuum ofprogress or to draw definitive normative judgments of success, we certainly can

identify patterns of progress emergingwithin and across the countries.

This chapter provides an overview ofthe progress toward connected healthin each of the eight counties and brieflycontextualizes our findings againstexamples of global leading practice inother countries.

2. Progress Toward Connected Health



Figure 7 - Snapshot of the different health systems

Totalpopulation(000s)

Source: 2008 OECD data and official government websites

*Note: GP payment types: FFS: fee-for-service; Cap: Capitation-based; Salary

Healthcarespend as% of GDP

Per capitahealthcarespend

Hospital bedsper 1000citizens

Practicingphysicians per1000 citizens

Physician payment schemes*

Primarycare

Specialistambulatory

Secondarycare

Australia

Canada

England

France

Germany

Singapore

Spain

US

21, 016

33, 095

61, 412

61, 840

82, 772

4,737

44, 311

304, 228

8.7

11.4

9.8

11.8

11.6

3.9

9.5

17.4

3445

4478

3487

3978

4218

2086

3067

7960

3.8

3.3

3.3

6.6

8.2

3.2

3.2

3.1

3

2.4

2.7

3.3

3.6

1.7

3.8

2.4

FFS

FFS

Salary/ Cap/ FFS

FFS

FFS

FFS

Salary/ Cap

Salary/ Cap/ FFS

FFS

FFS

Salary

FFS

FFS

Cap

Salary

FFS

Salary

FFS

Salary

Salary

Salary

Salary

Salary

Mixed

National approaches to connectedhealthThe national approaches taken to developconnected health differ from country

to country, although there are alsosignificant levels of commonality. Theapproaches range from countries takinga “whole system” approach and seekingto execute high levels of control over thedevelopment of nationwide solutions, tocountries in which development is “locallyled” and connectivity is achieved fromthe bottom up. In the middle of thesecontrasting approaches is a “middle-out”approach, where central governmentprovides an overarching strategic

direction but the solutions are developedlocally.



Figure 8 - The extent of central control in countries’ approaches to connected health

High level of

central control

Whole system Middle out Locally-led

Low level of

central control

Singapore

Canada

United StatesGermany

France

SpainEngland

Australia

Below is a brief overview of theconnected health approaches in the eightcountries we have studies, grouped underthe three broad clusters: whole system,middle-out and locally led.

• Whole system: Singapore and

England initially have focused ondevelopment of a single solution forHIE, underpinned by a national EHRsystem. They have channeled largeamounts of funding into a single bodywith responsibility for developingthe solution and driving its adoptionacross the health system. WhileSingapore is progressing according toplan, the English National Programmefor IT (NPfIT) has encountered greatdifficulty. As a result, the current

strategy in the English National HealthService has been altered to one thatseeks local solutions rather than asingle nationally imposed system.

• Middle-out: In Canada, Germany,Australia and France, a nationalstrategy has set the overarchingdirection for development ofconnected health but withoutbuilding and imposing a nationalsolution. Professor Enrico Coiera of

the University of New South Waleshas termed this the “middle-outapproach”— a third way betweenthe top-down approach which hadcharacterized the NPfIT in Englandand the bottom-up approach ofHIEs in the United States. In thesecountries, local political bodies such as

regional authorities and/or individualorganizations design and developsolutions in line with a nationalstrategic framework for greaterconnectivity and centrally definedinteroperability standards.

•

Locally led: The United States andSpain, both of which have highlydecentralized health systems, haveadopted approaches that relyheavily on local innovation as coreto a national strategy. Independentprovider organizations or local healthnetworks in the US and regionalbodies in Spain develop their ownlocal strategies and systems in a“bottom-up” fashion. To encouragehealth information exchange, the

federal government in the UnitedStates and the central government inSpain are working toward developinga national set of standards forinteroperability within and betweensystems.

These eight countries have also optedfor quite different HIE solutions orarchitectures. Each solution is unique, butcan be classified against three differentmodels for the exchange of clinical data:

• The centralized model: In this model,

also called the warehouse model,patient medical data is collected fromlocal sources but stored in a centralrepository. All information exchangesare routed through the centralrepository.

• The federated model: In this model,also called the decentralized model,individual organizations or sub-systemshave control of the healthcare record.The individual systems are linked

through record locator services thatenable them to exchange information.

• The hybrid model: This model is amix of the centralized and federatedarchitecture. The patient medicaldata is usually stored and managedat organizational or regional levels,but information exchange is enabledthrough a central hub.

In practice, however, the distinctionbetween the three models is not clear-cut, and there are vague areas betweenthe categories.



Table 1: Overview of countries’ approach to connected health

Approach Headlines Funding Standards Enablement/Incentives

Architecture

Australia

Canada

England

France

Germany

Singapore

Spain

US

Middle out Plans for apersonally controlledEHR by 2012

Mix of fundingfrom federal, stateand territory

National body,NEHTA, is taking alead in developingstandards

Practice incentivepayment program

Hybrid

Middle out Goal for apan-Canadian EHRby 2016, but as yetprogress is limited

Significant nationalfunding through thecoordinating body,CHI, coupled withstate and territoryfunding

Standards in place,but not universallyused

Incentives largelythroughreimbursement

Federated

Whole system,until recently.Now moving toa locally-ledapproach

Plan initially focusedon single buildsystem, but Englandis now adopting anew strategy basedon a staged-deliverymodel

Main funding intosingle coordinatingbody, but nowlikely to bedecentralized

Standards in placeset by theDepartment ofHealth

Quality andoutcome incentivesfor GP HealthcareIT adoption

Originallycentralized model,but moving todecentralized

Middle out Recent re-launch ofthe Dossier MedicalPersonnel with a 3year phase ofextensivedeployment

Boosted nationalfunding providesthe foundation fornew momentum

Current lack ofcommon set ofstandards

Incentives largelythroughreimbursement

Hybrid

Middle out Following recentstrategy re-fresh,the nationalelectronic healthcard is to be rolledout with fewer

mandatedfunctionalities

Mix of federalbudgets andcontributions fromhealth insurancefunds

Standards in theprocess ofdevelopment

Incentive programin place forprimary andsecondary care

Federated

Whole system Phase 1 of NationalEHR deployed inApril 2011;subsequent phasesnot yet fully defined

Main fundinginto a singlecoordinating body,MOHH

Standards in placeset by MOHH

Enablement schemefor GP adoption

Centralized

Locally-led Some regions areworld leaders inHealthcare IT, butvariation in HIEacross regionsremains a challenge

Main funding fromthe largelyautonomousregions

Minimumstandards forinteroperability setout by the Ministryof Health

Incentives in placebut varies acrossregions

Federated

Locally-led Uptake expected toincrease with MUincentives, but asyet too early to seespecific signs ofsuccess

Federal level ARRAstimulus fundingcoupled withstatewide ororganizationalinvestments

National body,ONC, is taking alead in developingstandards

Incentives andpenalties based on“meaningful use”criteria

Varies acrossdifferentnetworks andsystems



Connected health progressThe journey from healthcare IT adoptionthrough health information exchange toinsight driven healthcare is not a linearone. Each of the countries Accenturestudied has made advances in each of thedifferent stages simultaneously and on aniterative basis.

To assess progress toward connectedhealth across the eight countries, weconducted interviews with health systemleaders in each, including governmentofficials, clinicians, payers, commissioners,healthcare IT executives and academics.We also surveyed 500 physicians in eachcountry (200 in Singapore) to examinethe prevalence and use of connectedhealth functionalities and to gaintheir perspectives on the key benefits

and obstacles to connected healthdevelopment.

In the next section, we review theprogress countries are making againstthe three stages of the connected health journey.

Stage 1: Healthcare IT adoptionOver the past few decades, technologyhas dramatically changed how healthcareis delivered around the world. Today, there

are very few physicians—if any—whohave not changed some of their ways ofworking as a result of the introduction ofnew healthcare information technologies.The extent to which actual EMR systemsare in place and being used, however,varies significantly across and within thecountries.

The results of our physician surveyshow that while many national orregional health systems have several

connected health functionalities inplace and routinely in use across thesystem, no country has developed allof the functionalities fully. We find nosingle pathway to connected healthdevelopment. As shown in

Table 2, however, the most frequentlyused functionalities within the connectedclinical practice are electronic recordingof patient notes and electronic toolsto reduce the administrative burden ofdelivery. Basic decision support toolssuch as e-reminders and alerts areused relatively widely too, in particularwithin primary care in England and

Australia. More advanced clinical decisionsupport systems (CDSS) are used farless frequently; with the exceptionof Singapore and Spain, less than 20percent of physicians across primaryand secondary care stated they use thisfunctionality. Considering as a group thefour functionalities of connected clinicalpractice, healthcare IT adoption levels inprimary care are higher than in secondarycare, except in Germany, Singapore and

the US, where they are closely aligned.

Looking at the eight countries’ progresson healthcare IT adoption as a whole,there is still some way to go beforephysicians across primary and secondarycare fully adopt healthcare IT withintheir practices. Considering the fourfunctionalities together, adoption levelsrange from only 15 percent (amongsecondary care providers in England)to slightly more than 60 percent

(primary care physicians in Australiaand England). In comparison, nearly allScandinavian primary care physiciansuse the full clinical functionality of theirEMR, and most of their hospitals havea “semi-electronic health record” whichretrospectively collects key patient clinicaldata.



Table 2: Healthcare IT functions used within the practice

Accenture survey question: How often do you perform the following functions?

• Results show percentage of physicians that use “routinely.”

• Note: 1= Primary care; 2=Secondary care. Purple shows the lowest score, Green shows the highest score across all eightcountries for each of the functions.

1 2

England

47%

91%

84%

28%

63%

25%

16%

7%

13%

15%

1 2 1 2 1 2 1 2 1 2 1 21 2

Healthcare ITfunctionalities

Australia Canada France Germany Singapore Spain US

My organization useselectronic tools to reduce theadministrative burden fordelivering healthcare(e.g. e-scheduling or e-billing)

I enter patient noteselectronically either duringor after consultations

I receive electronicalerts/reminders whileI am seeing my patients(e.g. prompts regardingcontraindications orpreventative care)

I use computerized clinicaldecision support systemsto help make diagnosticand treatment decisionswhile I am seeing mypatients (e.g. real-timeaccess to evidence-basedpractice guidelines)

Healthcare ITadoption—average

70%

87%

68%

22%

62%

44%

26%

12%

12%

24%

53%

42%

20%

18%

33%

47%

29%

13%

11%

25%

57%

86%

38%

18%

50%

57%

47%

16%

18%

35%

55%

72%

24%

17%

42%

60%

76%

18%

18%

43%

38%

29%

29%

31%

32%

38%

53%

34%

23%

37%

69%

81%

46%

34%

58%

61%

62%

27%

25%

44%

60%

58%

35%

19%

43%

62%

59%

33%

22%

44%

N=3727

Note: 1=Primary care; 2=Secondary care. Purple shows the lowest score, Greenshows the hightest score across all eight countries for each of the functions



The ability to generate patient registriesis often seen as a proxy measure forthe impact on quality of care. We askedphysicians if their organizations wereable to generate a number of registrieselectronically using their healthcare ITsystems. On average, across the eightcountries, we learned that approximately60 percent of respondents were able

to generate a list of medications takenby their patients and a list of patientsby specific condition/diagnosis; andapproximately 45 percent could generatea list of patients by lab result and patientswho are due for tests. In addition,approximately a third of respondentswere able to generate data on clinicalquality of care. In each case, however,as Table 3 shows, there is significantvariation across countries.

Table 3: Ability to generate registries and quality of care data

Accenture survey question: Are you able to generate the following electronically using your organization’shealthcare information technology systems?

Australia Canada US Survey Average

List of medicationstaken by patients(including thoseprescribed by otherdoctors)

Lists of patients by

specificcondition/diagnosis

List of patients bylab result

Lists of patients whoare due for tests(e.g. mammogram)or preventative care(e.g. vaccinations)

Data relating toclinical quality of caremeasures

59.7%

60.9%

47.7%

31.7%

48.4%

42.2%

35.2%

18.2%

65.3%

57.4%

42.4%

44.9% 24.2%

France

56.4%

46.2%

30.7%

21.3%

31.5%

Germany

64.3%

75.2%

55.0%

30.4%

62.1%

Singapore

69.6%

61.8%

59.8%

52.0%

59.3%

Spain

74.7%

58.3%

41.5%

31.5%

49.3%

England

65.5%

67.1%

61.2%

56.7%

54.9% 40.6%

42.4%

62.5%

58.4%

45.7%

44.8%

34.3%

N=3727

Documents

Accenture Connected Health: The Drive to Integrated Healthcare Delivery