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TRANSFORMINGHEALTHEnabling integrated CareEMEA Market StudyConnect people, processes, and informationwhere it counts – at the point of need

REPORT METHODOLOGY12Government interviewswith executives in charge ofeHealth programs at bothnational & regional levels25United KingdomWESTERN EUROPE28Germany27France188Hospital executivesfrom a telephones survey(IT & non-IT)MIDDLE-EAST & AFRICAIDC’s ContinuousMONITORINGof the healthcare sectorIT trends in Europe,35Turkey35Saudi Arabia38South AfricaMiddle-East and Africa3

INTEGRATED CAREAt The Nexus of the Health Value Chain“A re-orientated healthcare system will ensurethe future sustainability of service delivery. ”

Integrated Care At The Nexus Of The Health Value ChainTHE HOSPITAL CENTRIC SYSTEMTraditionally thecenter of gravity of thehealthcare system isthe general hospital,which still accounts for40%+of healthcare expenditure,in many developed countries.This hospital-centric system deals efficiently andeffectively with acute episodes, such as serious infections,or surgeries. These conditions require providing severaldays of acute care for a relatively small number of very illpatients.This system, however, does not deal efficiently andeffectively with noncomunicable diseases (NCDs) thatrequire continuous care for a large number of patientswhose conditions are less acute but are often associatedwith long-term disabilities and premature deaths.5

Integrated Care At The Nexus Of The Health Value ChainTHE HOSPITAL CENTRIC SYSTEMIn the U.K.,the numberof peoplewith threeor morelong-termconditionsis predictedto rise2.9M2018LargeAgeingpopulationMoreLong-termconditionswill have a significant impact on healthand social care and may requireIn fact, the World Health Organization (WHO) estimatesthat: “Nearly 80% of NCD deaths - 29 million - occur in lowandmiddle-income countries” and “More than 90% of NCDdeaths that occur before the age of 60, happen in low-andmiddle-income countries”. As a result, NCDs rose to thetop of the healthcare policy agenda in emerging countries,because their impact on younger age people are a seriousdrag on economic development. A trend that is confirmed bythis IDC-EMC study, as hospital executives in Turkey, SaudiArabia and South Africa indicated that prevention and control1.9M2008£5Badditionalexpenditureby 2018.of NCDs is as important, if not more important than otherbroad healthcare policy goals, such as increasing access toservices. (See Figure 1)Source: Lancet scientific magazine in 2012Figure 1POLICYOBJECTIVES INMIDDLE-EASTERNAND AFRICANHOSPITALSPrevention and control of non-communicable disease initiativesIncrease access to healthcare servicesAccreditation of programs and clinical patients#.###.##World Health Organizationstudies indicate that NCDsare an: “invisible epidemic...“and “The burden is growing - the number of people, familiesand communities afflicted is increasing. Common, modifiablerisk factors underlie the major NCDs. They include tobacco,Source: IDC 2013#.##Promotion of evidence-based clinical practice#.##harmful use of alcohol, unhealthy diet, insufficient physicalactivity, overweight/obesity, raised blood pressure, raisedblood sugar and raised cholesterol.”1 ----------------------------------------------------- IMPORTANCE --------------------------------------------------- 56

Integrated Care At The Nexus Of The Health Value ChainTRANSITIONING TO A SUSTAINABLE SERVICE DELIVERY MODELAn integrated caredelivery model canINCREASE PATIENTSAFETY+HELP CONTROLCOSTSLesseningthe impact of risk factorsthrough their mapping andprevention campaignsStrengtheningprimary healthcare early-detectionand treatment capabilities toreduce the risk of acute episodesat later stagesRe-orientingthe overall health system toaddress the needs of people affectedby NCDs7

Integrated Care At The Nexus Of The Health Value ChainTRANSITIONING TO A SUSTAINABLE SERVICE DELIVERY MODELHospitalsPrimary CareProfessionalGovernments & PublicEducation InstitutionsPayersPatientsThe re-orientated healthcare system will ensurethe future sustainability of service deliveryby coordinating all actors across the value chain, including hospitals, primarycare, community care, private clinics, public health authorities, payers,life-science organization and, last but not least, patients.Community &Social CareLife Science ResearchOrganizationsDay HospitalClinics & Labs8

INFORMATIONIS THE CONNECTIVE TISSUE“Patient information needs to be reliable, complete,and relevant to the context in which it will be used.”

Information Is The Connective TissueENABLE INFORMATION SHARINGWITH INTEGRATED RECORDSFigure 2EMEA HOSPITAL SECTORBUSINESS PRIORITIESOrganizational restructuring and M&A activities are not a businesspriority while patient care and satisfaction are at the top of the list.Information is the connective tissue for integrated carethat increases patient safety - The level of coordination#1Patient care and satisfactionenchancement1 ------------------------ IMPORTANCE ---------------------- 54.14.4and collaboration required by integrated care deliveryacross the health value chain is a step-change,particularly for hospitals that have been at the center ofSensitive data protectionRegulatory compliance4.03.94.34.3the delivery system for over a century.Clinical performanceimprovement3.94.3The need to coordinate among hospitals and other stakeholders will spur some consolidationOrganization contribution tobusiness goals3.84.1but the vast majority of integrated care delivery will have to be enabled by cross-enterpriseinformation sharing, through the creation of integrated patient records.Increase staff satisfaction3.84.0When complemented by appropriate organizational processes and incentives, informationtechnologies provide healthcare decision makers the meaningful and timely insights tomake planning, management and service delivery decisions that improve patient safety andsatisfaction, while controlling costs, across the end-to-end patient experience.Reducing operational costsCommunication and externalrelations improvement3.84.03.84.0In fact, patient care and satisfaction are the top business priorities for the hospital executivesProcurement efficiency3.83.9interviewed as part of this study. Taking precedence over regulatory compliance, and sensitivedata protection. (See Figure 2)Multi-channel strategies tosuport patient services3.64.1Hospital executives also feel patient safety outweighs cost controls.Organizational restructuringand consolidation activities3.73.8Western EuropeMiddle East & AfricaSource: IDC, 201310

Information Is The Connective TissueTHE VALUE OFINFORMATION INSIGHTSInsights extracted from integrated patient records willbe precious in a wide-variety of use cases, from hospitaladministrative processes, to clinical decision support,to collaboration of university hospitals with life-scienceresearch organization.Administrative information sharingcan drive value for money in anti-fraud, and resource optimization.Clinical information sharingcan help doctors apply the latest findings of medical research, thusproviding personalized and evidence based care services. This willenable providing better care for patient current conditions andefficiently preventing complications and new disease developments.Life-science research organizationscan improve clinical trial design and results analysis, speeding upresearch times, results accuracy and bench-to-bedside translation.11

Information Is The Connective TissueINTEGRATED CAREINFORMATION MANAGEMENT CHALLENGESIntegrated care is not an entirelynew business model. And soare the related informationtechnologies that support it, suchas telemedicine, electronic healthrecords and clinical decisionsupport systems. Pilot initiatives,particularly in Western Europe,North America and Australia havebeen running, for the past tenyears; and in emerging countries,for the past three or four years.However, full-blown transformationhas been hindered by a number ofbusiness and technical challenges.Governance modelsThe transformation from traditional service delivery, tointegrated care implies profound change in the governanceof national healthcare systems and in the organizationof individual providers. The fact that “organizationalrestructuring and consolidation” activities rank very low,among top business priorities, confirms the difficulty ofdriving change. (Link to Figure 2)Big dataIn many healthcare organizations, the BI/DW technologystack cannot leverage clinical documentation that is by natureunstructured. This has thwarted efforts by providers tocreate highly structured data warehouses common to otherindustries. Clinical data is also extensive, inconsistent andmultidimensional, creating issues for warehouse designers.These BI architectures, and the scalability of the underlyinginfrastructure, will be challenged further by the increase indata volume, velocity and variety. (See Figure 3)Regulatory complianceIn jurisdictions where cultural and religious considerationsare carefully considered, lack of data privacy legislation hasslowed down information integration. However, advancesin IT security tools and information assurance managementpolicies and practices permit further progress.Cultural changeWithin any given healthcare organization, the technicalrationality of IT professionals and suppliers often collides withmanagerial rationality of hospital managers and the medicalrationality that puts clinical care at its center. Effective changemanagement during an implementation project becomesessential to educate staff about the potential benefits andrisks to their daily routine, as well as their involvement inensuring patient safety.Figure 3EMEA HOSPITAL SECTORBIG DATA ADOPTION DRIVERS5--------------- IMPORTANCE ----------13.453.913.55Western Europe3.683.603.83Middle East & AfricaVolume Variety Velocity12

Information Is The Connective TissueINTEGRATED CARE: INFORMATION MANAGEMENT CHALLENGESFigure 4EMEA HOSPITAL SECTORIT ORGANIZATION PRIORITIESIntegrated and secureaccess to data andapplicationsProven data privacyprotectionAlign IT projects and buildflexible IT systems tosupport strategic businessSpeed and cost of regulatorycompliance adaptationImprove quality of IT skillswithin the organization1 ------------ IMPORTANCE ---------- 54.184.394.134.564.064.234.014.204.014.28Siloed legacy architecturesTo build an integrated patient record, information currentlysitting in fragmented administrative and departmentalsystems must be pulled together. A top priority to surveyrespondents. (See Figure 4) This demand is expected to increaseas more patient histories are digitized and must be combinedwith medical images, pathology tests and administrativepatient information in order to provide optimal clinical andcare management.Figure 5EMEA HOSPITAL SECTOR2014 ICT BUDGET OUTLOOKFigure 6EMEA HOSPITAL SECTOR2014 ICT BUDGET BREAKDOWN19% 18%12%23%Western Europe20%15%39%Middle East & Africa54%Upgrade Innovate Compliance MaintainImprove IT governanceLower costs of IT3.934.253.903.5712%32%4%43%7%48%12%14%17%29%BudgetNational healthcare services are mostly seeing a positivebudget outlook from survey respondents. (See Figure 5)However, a large share of hospital ICT budgets are committed46%to maintaining and running legacy systems and infrastructure,Western EuropeMiddle East & Africa(See Figure 6) leaving a small share of funding to radically innovateexisting solutions.Maturity of ICT service deliveryWestern European countries have achieved a relatively highlevel of maturity of their ICT infrastructure and now mustfree up resources from maintenance budgets to continuouslyimprove through consolidation, shared services and cloudcomputing. Emerging countries, on the other hand, sufferless from legacy maintenance issues, but rather haveexperienced hindrances finding skilled workers. (See Figure 4)56%46%37%65%UK Germany France TurkeyPositive OutlookIncrease Same Decrease38%SaudiArabia66%SouthAfricaData qualityAs care becomes patient centric, volume, speed, granularity,and variety of patient data will become more susceptibleto risks of errors. Patient information needs to be reliable,complete, and relevant to the context in which it will be used,so that clinicians, administrators and patients can not onlytrust it, but so that it positively increase quality and outcomes.The time aspect, however, should not be neglected, as therate in which individuals are affected by chronic diseases willchange slowly as populations continue to grow.13

DOCUMENTLIFECYCLE MANAGEMENT“IT solutions strongly contribute to building thesolutions needed for integrated patient records.”

Document LifeCycle ManagementAN INFORMATION-CENTRIC INTEGRATED CARE MODELCoherent archiving, retention, and disposal and most importantly,integrated access and interpretation of data can give administrative andclinical decision makers valuable insights for effectively planning,managing and operating business processes.Solutions that support structuredand unstructured informationcapture, archival and accessacross multiple EMR, EHR, COPEand departmental applicationsby decoupling the data from thebusiness logic.Cloud computingBig data & analyticsDocument life cycleSOLUTIONS15

Document LifeCycle ManagementINTEGRATED CARE GEOGRAPHIC SCOPEInternational eHealth initiativeshave been promoted over the years by the EuropeanCommission to ensure the free and safe flow of workersand tourists. However, beyond a standard European HealthInsurance Card for patient identification and access to A&Eservices, EU member states have achieved little in terms ofcross-border information sharing so far.National eHealth strategies,which include building integrated patient records, havebeen launched in countries such as the U.K., France andSaudi Arabia. These initiatives, however, still face challengesthat need to be addressed, such as change managementrequirements.Region-wide integrated healthand eHealth programshave been the prevalent model in countries like Germany,Spain, Italy and the Nordics. In large regions with manypatients and hospitals, the governance challenges arestill big, but more manageable than at the national level.Decisions regarding data standards, procurement andprogram implementation can be managed through pilots andescalation mechanisms, built to reconcile points of view atthe regional level, where the overall budget is held.Community healthcare providersrevolve around one or a small group of hospitals that act asa small ecosystem. This is also the geographic scope of mostpatients’ mobility. The majority of patient interaction withhealthcare providers takes place in the area where they live.The challenges thatnational programsencounter in supportingintegrated care andintegrated patient recordsindicates that a purely topdownnational approachis not viable. As a result,policy-makers are breakingdown national programsinto community-level pilotsand regional-level projectsthat are more sustainablein the long-term.19

Document LifeCycle ManagementPatient Data Ownership & GovernanceAccording to European Union legislations, the patient is thelegal owner of his clinical and administrative data. However,national and regional departments of health, individualhospitals, or GPs end up managing patient records and areresponsible for an integrated care ecosystem. The gap ofhealth and regulatory compliance literacy is still too wide toexpect patients take full ownership of an integrated patientrecord.However, more involvement from the patient will benecessary to ensure full orchestration, as not even GPs havea full view of clinical treatments, tests and prescriptionsparticularly over a long-period of time. Patient participation isalso necessary because pieces of clinical and administrativeinformation are held by third-parties, such as private clinics,employers and private health insurance companies.Scope Of Patient Data RepositoryWhen dealing with integrated patient informationmanagement, the business objectives have an impact on thescope of the patient repository. For instance, if the objectiveis to ensure free access to A&E services, access to basicadministrative and clinical data is sufficient.But the more comprehensive the business objectives, thewider the set of data that should be archived and madeavailable for analysis. This covers health information such as:• Patient administrative data: identity, address,reimbursement entitlement, etc.• Patient history of pathologies and acute episodes• Patient history of medical tests• Patient history of medical treatment and prescribed drugsPatient Data ModelThe European Union and the United States government setup a Cooperation Initiative to promote interoperability ofElectronic Health Records, so that:• Individual patients can be empowered• Clinical outcomes can be improved• Individual patient safety and population health can beimprovedHistorically, patient data have been tightly coupled withapplication logic through proprietary data models, whichmade integration difficult. To achieve more open datamodels that ensure semantic interoperability, syntacticinteroperability and patient mediated data exchange requiresmore than making software compliant with internationalstandards. It will requires reconciling approaches with moreloosely coupled architectures that combine structured andunstructured data management tools. Something that is veryhard to deploy and manage at a national or regional level.20

Document LifeCycle ManagementIn order to orchestrate clinicalBUSINESS LOGIC &FUNCTIONAL CAPABILITIESpathways across the health value chain,clinical and administrative workflowcapabilities are required.The business objectives of integrated care managementand delivery programs influence the evolution ofbusiness logic because initiatives that are purely focusedon regulatory compliance can be satisfied with solutionsthat provide data capture, archival, retention, access,reporting and auditing capabilities.ClinicalWorkflow CapabilitiesCPOE & ElectronicPrescribingBig data and analytics enable integrated care ecosystems to extract value from integratedpatient records to apply optimal treatment and give the right incentives to providers that needto collaborate through more granular measurement of outcomes.AdministrativeWorkflow CapabilitiesPAS admission-dischargetransferfunctionalitiesto track reimbursement patterns21

Document LifeCycle ManagementUSER ACCESS / INTERFACEAccess to patient information isincreasingly moving away from puredesktop application specific UIs andbeing made available through portalsand native mobile apps.Increasingly, native mobile apps forhealthcare professionals and patientsprovide the same granularity andreal-time consistency but with userfriendlyaccess to information thanlegacy application UIs.The shift in usability enabledby mobile apps could bridge someof the patient information integrationgap, particularly in clinical dataconsumption use cases.22

Document LifeCycle ManagementSOFTWARE SOURCING APPROACHHospital clinical information systemarchitectures have historicallyused best-of-breed applicationsfor electronic patient record,departmental systems, CPOE,medical imaging and laboratories.These fragmented architecturesand proprietary data models havetypically focused on leading-edgebusiness capabilities for a smallgroup of administrative or clinicalusers, which did not favor buildinga consistently integrated patientrecord, not even within individualhospitals.True end-to-end suites, including all administrative and clinicalprocesses could solve the patient data integration issue andwould ensure consistent management of the platform. Butat this stage of market maturity, there are no real end-to-endsuites that can satisfy all clinical and administrative users.Rather, they are loosely coupled modules offered by thesame software provider. Sometimes they are running withdifferent UIs and on different database, application server,and operating system versions that force users to customizecode and build add-ons that jeopardize the out-of-the-boxconsistency.Figure 12A best-of- suite approach provides a more sustainable modelwith core data and business capabilities that are sitting in onesuite of products with ancillary capabilities and data beingsupported by other systems. It is in a best-of-suite scenariothat solutions like document life-cycle management andvendor neutral archive can add value by not only automatingregulatory compliance, but stitching together structured andunstructured data to create integrated patient records.(See Figure 12)WESTERN EUROPE HOSPITAL SECTORINTERDEPENDENCE BETWEEN INVESTMENTSIN DOCUMENT LIFE-CYCLE AND OTHER SOLUTIONS35%39%33%17%EHR44%39%50%21%21%DOCUMENT LIFECYCLENo plans to investMaintain CurrentPlans to invest in next 12 months41%62%VNA28% 39%38%12%26%33%21%Hospital executives that plan to investin document life-cycle managementsolutions in the next 12 months are alsomore likely to invest in EHR, particularlyin Western Europe.This investment forms the architecturalfoundation for federated access acrossthe health value-chain and in vendorneutral archives, which is a key pieceto complete the patient data repositorywith medical images coming fromdifferent PACS solutions.No plansto investMaintain currentsolutionPlans to invest innext 12 months23

Document LifeCycle ManagementINFORMATIONINTEGRATION APPROACHSoftware sourcing approaches, therelative openness of data modelsand the scope of integration areall factors that influence the waypatient data integration can beaddressed. Though, in a highlyfragmented environment, point-topointapplication connectors will benecessary to make sense of data.Alternatively, a community of providers,each with a consistent set of data residing inend-to-end suites, could build a service-orientedarchitecture that can consolidate data.With a set of best-of-suite environments, an HIE federatedarchitecture based on a master-patient index can be built to offeraccess to information that is extracted from source systems.24

ESSENTIAL GUIDANCE“Hospital executives should collaborate on a roadmap thatincludes more loosely integrated data architectures.”

Essential GuidanceINTEGRATING PATIENT INFORMATION: WHAT’S NEXT?The integrated caremanagement and deliverymodel willINCREASE PATIENTSAFETY & SATISFACTIONas demanded by hospital and other provider executives.+KEEP COSTSUNDER CONTROLas mandated by policymakers and payers.Integrating patient information in a secure mannerwill provide the connective tissue for collaborationacross the health value chain, so that patients can beattended more promptly, treatments applied moreappropriately, and unnecessary and costly interventioneliminated. To fully leverage information for improvedpatient outcomes, while complying with patient dataregulation, federated architectures must be leveraged.26

Essential GuidanceINTEGRATING PATIENT INFORMATION: WHAT’S NEXT?Hospital executives shouldcollaborate with other stakeholders acrossthe value chain on a roadmap that includes more loosely integrated dataarchitectures to combine clinical and administrative applications with:Document life-cyclesolutionsto integrate structured and unstructuredinformation, while applying regulatoryrequirements consistently.Big data & analyticssolutionsto extract insights from data sets oflarge volume, variety and velocity.Cloud computingsolutionsto ensure flexibility and scalability.27

Essential GuidanceWHAT SHOULD HOSPITALEXECUTIVES DO?The short-term.Use the information management framework toevaluate your assets (technologies, standards andpatient data), processes (clinical, administrative, andgovernance, risk and compliance related) and skillsto discover untapped opportunities in patient dataintegration and analysis. For instance, documentmanagement tools applied only to automate patientdata retention compliance could be used to improvesafety of medical orders. Start to experiment withdocument life-cycle management, big data and cloudcomputing to build collaborative pilots that involve otherstakeholders along the health value-chain.The medium-term.Design a roadmap for integrated care service deliveryand integrated patient record initiatives, which identifygaps relative to existing assets, processes and skills.Combine the gap assessments with early evaluation ofpilot projects in terms of business model sustainabilityto attract budget and scale them to include a largernumber of stakeholders, medical specialties andpatients.The long-term.Optimize clinical and administrative workflow byleveraging an integrated patient record to improvethe appropriateness of care. Consolidate benefits byclearly communicating changes and how they impactthe long-term goals. This allows new practices in patientdata archiving, retention, access and analysis to beindustrialized and new resources freed-up for newprograms.Learn moreabout this study onlineVisit our blogto be a part of the conversation.28