integrated health networks utopy or reality? the impact of the ... - Chuv

UNIVERSITA DELLA SVIZZERA ITALIANNA
Master Net-MEGS
INTEGRATED HEALTH NETWORKS
UTOPY OR REALITY?
THE IMPACT OF THE E-HEALTH.
Crina Tabita Nicolescu
Relatore: Prof. Marco Meneguzzo
Proof reading by Prof. Ann Van Ackere, University of Lausanne
Co-relatore Dr Marzio Della Santa
Lugano, April 2006

Research questions:
- Does integration of health care delivery represent a solution for the problems that
the Swiss health system and globally modern health systems are facing? How can
be assessed the efficiency of the integrated healthcare delivery networks?
- Do information systems and especially e-health represent a first step towards
formally integrating health care delivery in the Swiss health care system?
Methodology used: literature review and case study
Key words: health systems and organisations, integrated health care delivery networks,
information and communication technology, e-health
2

HEALTH NETWORKS ORGANISATION.
UTOPY OR REALITY?
The impact of the electronic health
INTRODUCTION………………………………………………………………5
THESIS OUTLINE……………………………………………………………...6
1. THE HEALTH SYSTEM. LIMITS AND CHALLENGES…………………….8
1.1. Definition of Health Systems (WHO)…………………………………..8.
1.2. The Swiss health system………………………………………………...9
1.2. The necessity of coordination of the health organisations…………….. 15
2. THE HEALTH NETWORKS ………………………………………………… 17
2.1. Definition…………………………………………………………………..17
2.2. Characteristics……………………………………………………………...18
2.3. Models of networks………………………………………………………..20
2.3.1. Informal networks………………………………………………..20
2.3.2 Different approaches on converging health care into health networks
…………………………………………………………………………..21
2.3.3. From the informal towards formal networks –the success key for the
health networks organization?..............................................................................21
2.3.5. Formal networks………………………………………………….22
2.3.5.1 Horizontal integration…………………………………..22
2.3.5.2 Vertical integration……………………………………...23
2.3.5.3 Types and pertinence of health networks.........................24
2.3.6.1 Examples of health networks………………….27
2.4 The Swiss situation…………………………………………………………34.
2.5. Results of systematic literature review……………………………………...39
2.6. Health networks assessment ………………………………………………..44
3

3. APPLICATIONS. THE INFORMATIVE SYSTEM AS SUPPORT OF HEALTH
NETWORKS ORGANIZATION………………………………………………44
3.1. E-HEALTH. TOWARDS INTEGRATING HEALTH CARE?...................44
3.1.1. Definition of electronic health…………………………………....44
3.1.2. The informative system in the health system…………………….45
3.2. Conditions and dimensions…………………………………………………48
3.3. The electronic prescription…………………………………………………50
3.4. Telemedicine and healthcare processes…………………………………… 56
4. Examples of initiatives in electronic health field……………………………………58
4.1. INTERNATIONAL EXPERIENCES……………………………………64.
4.2. PROJECT “RETE SANITARIA” TICINO- the health card as instrument for
the coordination of the Tessin’s healthcare actors …….………………………………69.
CONCLUSIONS………………………………………………………………………75.
References
Attachments
4

INTRODUCTION
Motivation
The principal objective of a health system is to improve health and its principal function
is to deliver health care services. Nowadays, hierarchical bureaucracies and fragmented,
unregulated markets have serious flaws in the organisation of health care services. A
flexible integration of the health providers may mitigate these increasingly important
problems.
The wide diffusion of technology and the increasing use of information and
communication technologies open new opportunities for services and products and
consequent business. While technology diffusion penetrated health care services too,
health systems have not known yet a profound system change. Mechanism and health
care provided services are essentially unchanged.
Research shows that adopting new technologies into the health care system may
constitute an essential condition for imposing change in organising health systems and
integrating health care delivery.
Objectives
Initial efforts of this work focused on the comprehension of the present situation and the
necessity of reorganising health systems. I further analysed current models of network
organisation and experimental projects for adopting electronic health care instruments.
Health care networks are a very important current topic for all modern health systems.
Modern health systems are confronted with a disproportionate increasing of the health
expenditure, and are searching for solutions to alleviate the crisis they are facing.
Although there is rare empirical evidence of the economic benefits that health care
delivery integration may bring, as assessing economic results require a long term view,
there are many research results and international examples of integrated health care
5

delivery as a solution for the difficulties that health systems are globally facing but also
as the resource needed in order to enhance the effectiveness of health care systems.
Thesis outline
This thesis' first part, mostly theoretical, begins with the definition of the health
system and its present limits, presenting the economical context and the difficulties
to whom the health system is confronted both at a Swiss and international level. In
this critical context, there have been numerous experiments of reforming the
health system with the aim of reorganising it in order to increase its efficiency.
These reforms usually occur through legislative modifications and entail the
organisation of the performance of the health care processes, healthcare demand,
and the financing of the system. Nowadays more than ever, it is necessary to
identify new solutions. Ideally, the organization into health networks may
constitute a potential solution for the problems that the health systems are globally
facing.
The next chapter of the thesis aims at defining the health networks and at
explaining their various models by exploring the two basic models: informal
networks and formal ones. For the part concerning the informal networks my
purpose is to further analyse the use of the e-health instruments as essential
prerequisite for network organisations. Further on I present the concrete forms of
the health network organisation within the Swiss health system and internationally.
I then present some of the most important experiences reported in the literature.
The third part defines the electronic health and inquires on its role as a foundation
for the constitution of health networks. Later on, the aim is to define and
characterise the administrative and clinical applications of e-health in the Swiss and
international health system.
Can the electronic health instruments represent the key to success for the coordination
of the healthcare actors?
6

The applications are then analysed under four fundamental dimensions for the
health networks organisations: the economic, technical, cultural and legal
dimensions.
With the third chapter begins the practical part of the thesis presenting the
example of the most important applications of electronic health: the telemedicine
and electronic prescription. How to take advantage of the enormous clinical and
economic potential that is brought by these technologies? How does telemedicine
take part in the healthcare processes? Do managed care or case management
constitute possible solutions for the Swiss health system? In which manner do
external factors affect management decisions and a possible reorganization into
health networks? These are questions to which this thesis does not want to offer
"the solution" but I aim to analyse the situation from an actual and perspective
point of view.
The forth chapter presents the practical example of the Project “Rete Sanitaria” in
Ticino. The Health Card represents a first instrument of e-health with the aim of
improving the coordination of Ticino’s health professionals, enhance efficiency and
clinical effectiveness.
Further more I analyse the international experience in this field. In order to achieve
a global view of the efforts made by governments, practitioners and researchers, it
is necessary to analyse several international experiences as health plans and
organised delivery systems and the empirical evidence they may bring.
The last part is dedicated to the conclusions. The realization of Integrated health
Networks has the substantial objective to combine the requirements of accessibility
with quality and efficiency and in this purpose, the use of the electronic health
instruments can constitute the support. The Integrated health Networks represent
a vision of the future in the health system. The electronic health represents as well a
vision of the future within health systems. This thesis aims to analyse if and how
could this become reality.
7

1. HEALTH SYSTEMS. LIMITS AND CHALLENGES
1.1. Definition of Health Systems (WHO)
Health systems consist of all the people and actions whose primary purpose is to improve
health. They may be integrated and centrally directed, but often health systems are
fragmented and decentralised. After centuries as small-scale, largely private or charitable,
mostly ineffective entities, they have grown explosively in the last century as knowledge
has been gained and applied. They have contributed enormously to better health, but
their contribution could be greater. Failure to achieve that potential is due more to
systemic failings than to technical limitations. It is therefore urgent to assess current
performance and to judge how health systems can reach their potential.
A health system includes all the activities, which have the purpose to promote, restore or
maintain health (WHO report, 200). The first objective of a health system represents
incontestably the health improvement but in reason of the sometimes enormous cost of
healthcare and its unpredictibility it is important to establish mechanisms that guarantee
the repartition of risks and financial protection. The second objectif of a health system
has to be the equity of the financial contribution. A third objectif, the capacity of
response to the population's expectations in other fields than healthcare reflects the
necessity of valuing the dignity and the freedom of person as well as the privacy of the
information.
Every day, life of countless people depends on health systems. From providing secure
birth conditions to geriatric care accorded to fragile persons without damaging their
personal dignity, health systems exercise an important responsibility for people of all
ages. They are indispensable to a healthy development of individuals, families and
societies in the whole world.
8

1.2. The Swiss health system and health systems globally are facing emerging
challenges.
Demographic changes resulting in an overall aging population consequently
increases demand of care for chronic and degenerative illnesses, greatly soliciting
fragmented 1 health systems. The innovative medical technology diffusion and the use
of information and communication technologies in health care are increasing quality
of provided care but also adding complexity, increasing demand and therefore
increasing costs. Analysing WHO reports, global health expenditure turns out to be
increasing more than 2 the GDP.
Exhibit 1 Evolution of health system costs and GDP
Source: Office fédéral de la Statistique, 2005
In which social context can we place the issue of the Swiss health system's future? In a
context of crisis of values and ideas? Healthcare finds itself at the center of the change
1 Question of precedence between different specialities, increasing time and costs
2 The World Health Report 2003 - shaping the future
9

affecting the society. In an environment influenced by a level of comfort without
precedent and by technological conquests, by the decline of the ideologies of the 20th
century, the evolution through the society and health care systems are passing trough, is
sometimes considered with scepticism. Health care is constantly faced with this crisis and
has to adapt to the evolution of the social context its definition of ethics limits and its
objectives. Health systems are standing in front of an intersection. Which road should
each of them take?
Characterised by liberalism and federalism, Switzerland has an extremely well developed
healthcare system. 3 The liberal element restricts state activity to guaranteeing health care
‘when private initiative fails to produce satisfactory results’ 4 . As a Confederation, the
national authorities can only legislate when empowered to do so by the constitution 5 . This
includes only the guaranteeing of social insurance, the regulation of medical
examinations and qualifications, and certain public health activities.
“There is a mantra in Swiss healthcare politics, a phrase one hears again and again:
healthcare in Switzerland is of excellent quality, but quite expensive”. 6 , 7 Indeed,
according to OECD statistics, Switzerland manage the third most expensive system in the
world – behind only the USA and Germany. The long term cost evolution is problematic:
over the period 1999-2000 health expenditure raised of 4, 8% annually which is twice the
rate of GDP. Though if calculated in US $ PPP, Switzerland outspends all countries in
the European region.
3 Jacobs, R and Goddard, M., Social Health Insurance Systems in European Countries, Centre for Health
Economics, York, 2000.
4 Jacobs, R and Goddard, M., Social Health Insurance Systems in European Countries
6 Kneubuhler, and Gebert, ‘Reinventing the Wheel’, paper presented at the 17th International Conference of
ISQua, Dublin, 13th-16th September 2000.
7 Le système de santé suisse –diagnostic pour un patient. Credit Su isse, Economic Briefing No 30
10

Exhibit 2 Part of health expenditure related to the GDP, 2003
So does spending more ensure better health care? And if so, what are the conditions?
There are at least four other notable features of the Swiss health care system:
Preferences of potential patients determine a health system's structure. The Swiss
population of only seven million divided in four language communities is
involved in a three level political influences. With a GDP per capita of 15-20%
above other western countries, Swiss population expects high quality health care
services.
Decentralisation of political power. Constituted of 23 cantons, three of which
divided in two, the Swiss Confederation encloses in fact 26 individual health
systems interconnected by the Federal Health Insurance Act.
11

A high degree of competition. There are three markets where both insurers and
providers compete for the patients as customers.
Unusual private-public mix. Swiss health care insurance combines public,
subsidised private and fully private healthcare in a unique manner 8 . The Swiss
health system is funded trough a combination of private and public funds. The
particularity is the proportion of public funds which is one of the lowest among
western European countries.
As for the health insurance, the Swiss system has three components: compulsory
basic social insurance; voluntary supplementary insurance; and compulsory sickness,
old-age and disability insurance.
Comparing the Swiss and American health systems in a controversial article
published in JAMA 9 , Herzlinger et al. found that Switzerland's consumer-driven
health care system achieves universal insurance and a high quality of care at
significantly lower costs. Unlike other systems in which the choice and most of the
funding for health insurance is provided by third parties, such as employers and
governments, in the Swiss system, individuals are required to purchase their own
health insurance.
The positive results achieved by the Swiss system may be attributed to its consumer
control, price transparency of the insurance plans, risk adjustment of insurers, and
solidarity. However, the constraints the Swiss system places on hospitals and
physicians and the scarcity of provider quality information may excessively limit its
impact 10 .
Is the Swiss health system a consumer-driven one? In a time when politicians,
deciders, practitioners and scholars wonder about the future of the health system and
try to identify solutions for its problems, can Swiss population, as potential patients
trust its health system? What are the problems and what could be the solutions?
8
Ten Key Points to ensure Good healthcare in Geneva and Switzerland’, Geneva News Publishing
Company, 1999
9
Journal of the American Medical Association
10
Consumer-Driven Health Care, Lessons From Switzerland, Regina E. Herzlinger, DBA; Ramin Parsa-
Parsi, JAMA. 2004;292:1213-1220.
12

One of the more expensive and complex health systems, the Swiss health system
faces an increasing expenditure therefore an imposing need for regulation and
reorganisation. The organisational chart of the Swiss health system stresses its
complexity.
Exhibit 3 Swiss health system organisational chart
13

Exhibit 4 Swiss Health System Organisation Chart
Swiss Health System Organisation Chart
In order to understand the functioning of the Swiss health system it is necessary to
analyse its organisational chart and hierarchical relations. Analysing the presented
figure and its organisation it is obvious that the complexity of the Swiss health system
would benefit from a reorganisation and reduced complexity.
14

1.2. The necessity of coordinating health care. Towards integrated health
care networks
Dimension Scores – Problem ratings reported by patients
Exhibit 5 Problem ratings reported by patients
Source
From the problems rated by the Swiss patients, the continuity and the transition of
health care provided ranks first. Therefore, the necessity of assuring the continuity of
care especially nowadays when patients with chronic and degenerative illnesses call
for consulting more specialists, and their treatment follows different steps in different
institutions, from primary care to long-term palliative care provided to elderly
population.
Another imposing condition for assuring a continuity of care and facilitating the
transition of patients from a specialist to another, or between different institutions on
different periods of time is the information following the patient.
Health care services aim at protecting and improving health care status. If they
succeed or not depends on the services provided and on the manner in which they are
being organised.
15

Exhibit 6 Process Overview in Health care
On a low-level view, every healthcare provider (hospital or individually practicing
physician) performs processes of all three types: clinical, support and management
processes. In an intermediate level, every treatment of a patient requires processes of
the same three types, but the processes are taking place between multiple providers of
care. In the scenario of a highly fragmented healthcare service providing, integration
of healthcare processes between multiple providers is of vital importance.
Both administrative and hierarchical institutions of fragmented and unregulated
systems face serious gaps: only a flexible integration of autonomous or semi
autonomous providers of health care services may mitigate these problems.
16

2.1 Definition of health networks
2. INTEGRATED HEALTH NETWORKS
As inpatient or outpatient organisations become more autonomous, the system of
providing services risks becoming fragmented. A fragmentation may result both at the
same level and type of care provided (hospitals, ambulatory services or public health
programs) as at different care levels. The fragmentation of health care has negative
effects on the effectiveness and equity of any organisation or even health system unless
there is a form of integration between the semi-autonomous created units.
Health networks are generally presented as a form of organising health care activities.
They aim to allow unlocking system's components and bring them to cooperate and
therefore improve overall performance. In this perspective and after having analysed
problems to which overall health systems are confronted, it appears almost redundant to
try to identify reasons for the necessity of the integration of the healthcare and makes it
more important to propose on organisational diagnosis of the crisis situation and to
examine the characteristics and properties of a network integration.
New network services organisations are becoming an essential interface between
inpatient and outpatient care. Their human, organisational and technological innovative
aspects concretise around new cooperative health care practices placing patients at
thecenter of the system. They raise the problem of the management of complexity
imposing a global view of patients and organisations. Health networks rely on tools of
information sharing as information and communication technologies, which modify
relations between health practitioners and patients, became actors of their own health
status.
The history of the notion of "networks" has for a long time been analysed on two aspects:
technical materiality and representation, as they rely on the complementarities of two
17

components: human and technical. For L. Sfez, a network is "the technology of the
spirit" 11
2.2. Health networks characteristics
Health networks are after all networks of actors 12 whom postures and interactions are
interesting to analyse. H. Sérieyx et al. (1996) opposed the network functioning to
hierarchical functioning according to the tailorian model still regulating nowadays
organisations.
Nowadays the health system is confronted to a continuous rising costs of medicine - it
costs substantially more to provide good quality health services, and earlier detection
means the pathway of treatment is longer.
With few exceptions, globally changing birth patterns, together with a general decline in
mortality rates (often, paradoxically, due to improvements in healthcare) have led to an
increasingly ageing population and a commensurate rise in total health costs.
Facing the demographic changes, the technological mutations, could health networks
allow a new form of organisation enhancing quality health care services at a global level
of the Swiss health system, all of this while managing costs?
Health networks are becoming the XXI century paradigm. The term “network” serves to
define what has primarily been called a system or structure, stressing the importance of
circulation, exchange, complementarities, trust, and coordination. The network seems
“the solution” for generating resources in difficult budgetary situations.
There is an abundant and considerable literature on the importance and necessity of
creating “enterprise networks” based of the principle of increasing productivity and
achieving economies of scale. Could the same principle be applied to the health care
sector? Transferring the term into health care field, we can identify “health care
networks”, “coordination networks” and “hospital networks”.
11 Musso, 2003
12 Lazega-1998, Wasserman-1994
18

But the analogy is delicate: is it valid to apply in the social, health care and mainly non
profit sector principles coming from the for profit enterprises providing products and
services?
Is it possible to improve productivity within health organisation and maintain the quality
of services provided?
The often-declared reason for the integration of health care is economical or budgetary.
This narrow vision aims at reducing health care costs by institution and procedure in a
context of free competition and social policy. Additional objectives are improving the
quality of services provided and cooperation needs. It is therefore imperative to improve
procedures in order to enhance the dependence between health expenditure and results.
According to the meaning given to the term “network” there are different types of
networks: networks as an intermediary between people and places, externality networks
promoting the idea of persons interconnected for a service, the network as a territory
organisation, and the network as a tool of coordination and transaction.
Between flexibility and formality, there are a wide variety of health networks within the
Swiss health system; therefore it is necessary to question the reasons for creating these
networks and the modalities of their origin and organisation. Aren’t networks sometimes
the pretext for hiding corporate interests under modern terms and objectives? Are they
really meant to improve quality and reduce costs of health care?
These are questions my thesis tries to answer without pretending to provide the correct
and universally valuable solutions. My starting point tends to identify simple answers to
complex problems and situations.
19

Informal networks
The informal networks refer to the voluntary grouping of health actors aiming at
improving their coordination and communication. The relations between the actors
forming an informal network are not contractual, so there is no legal responsibility.
Participation is voluntary. The health information systems and their application usually
constitute the essential condition for the organisation within a network. There are several
international and Swiss examples of informal networks resulting from the circulation of
the information between different health structures types. The applications the electronic
health further analysed as the e-prescribing, the telemedicine or as first instrument the
"smart card" are the fundaments for the creation of an informal network.
There are several barriers for the management and the feasibility of this type of networks.
Subjective factors include: resistance to change, mistrust between the participating actors,
new operational habits. But there are also important objective factors, as: financial
requirements for the implementation of health information systems, legal conditions of
reglementation and technical conditions.
Informal networks do not conform to the hierarchical or market organisation but to forms
less knows or used in our nowadays society: the "fief" or the "clan" 13
Exhibit 9 Networks collocation
13 Boisot & Child, 1988, 1996
20

Source: P. Huard, Cours MHEM 2005
Different approaches on converging health care into health networks
Health networks began developing in Europe from the middle 1980s according to two
different approaches. J.-P. Domin (2004) opposes a conventionalist approach towards
health networks to a communitarian approach corresponding also to an opposition health
care/cure. The conventionalist approach strongly inspired by the American HMO's 14 ,
aimed in priority to rationalise cure provided improving continuity and pertinence and
therefore control costs. This approach emanated mainly from the hospital structures and
insurance groups.
Nevertheless some networks have disappeared and on a short term, and causes might
have been the demotivation of promoters, rival ties and mostly financial problems, the
number of health networks has progressively increased their influence on the health
system remaining yet limited.
Other typologies can still be considered. B. Rey differentiates the "team" networks where
the value created is acquired due to a synergy effect, the "group" networks, where the
value created results from the increase in the individual productivity of each actor. M.
Gadreau distinguishes the networks "resources accumulation" of the "generating
resources" one. Other classifications of resources distinguish networks according to their
14 Health Maintenance Organisation
21

ecourse on information technologies: there are networks relying mostly on
communication technologies, and others disposing of an information technology system.
Therefore one may classify networks according to the importance given to their main
objectives.
The main objectives of health networks are the improvement of access to the health
system, the quality of care services, and the cost control.
22

Horizontal integration
Formal integration
Horizontal integration occurs when two or more independent firms producing
substitutable services form either a single firm or a strong inter-organisational alliance.
The motives for this type of integration are economies of scale and increased market
power.
Within health care, horizontal integration involves affiliation under the same
management of organisations that provide a similar level of care. Usually it involves
consolidation of resources among organisations with the goals of increasing efficiency
and taking advantage of economies of scale 15 . The evidence suggests that medical group
practices are merging in order to achieve an increased efficiency and leveraged markets
(Robinson and Casalino, 1996). These horizontal integrations represent the first step in
the market’s evolution towards realising integrated health networks. (1)
Evidence from existing studies of horizontal integration in health care (Shortell et al.)
while analysing mostly hospital mergers and hospital cost functions, shows that there are
modest achieved economies of scale within hospitals. If Dranove and Shanley(1995)
claim that hospital mergers do not result in lower production costs, another study by
Hospital Research and Educational Trust(1993) did find reduced costs among merged
hospitals. Similarly, the Health care investment analysts(Greene, 1994) show that
hospital costs do diminish after the merger.
Exhibit 10 Example of horizontal hospital integration
15 Integrated health systems: Promise and performance, Conrad, Douglas A; Shortell, Stephen M
Frontiers of Health Services Management; 1996; 13, 1; ABI/INFORM Global
23

Governance
and strategic
coordination of
horizontal
relationships
Governance e
coordinamento
strategico delle
relazioni
verticali
Beginning
90
(1990
Comunity
Care Act)
1996
End ‘90
Current
situation
(DoH, 2004)
purchaser-provider split.
Emphasised competition between actors responsible of production
Decentralising and .organisational autonomy
General Practitioners) as a pillar of the system
Emphasised partnership in providing health care services.
Cordination in contracting requesting not only service definition but also
activity division between various sectors.
“total purchasing” initiatives where GPs are responsible for wide services
provided to their patients
Introduction of primary care groups in England with lager responsibilities
of purchasing and providing health care services also responsible of
integrating health services with long term social services.
Introduction of ulterior mechanism of coordination of health organisations
(NHS Plan 2000):
� Health improvement programmes
� Local strategic partnerships
� Health action zones
� Commun Budget for sanitari and social services.
Strategic coordination of health services:
� Partnership of health organisation
� primary care trusts
� Orient fusion strategies .
Strategic vertical coordination of health care services suppose the presence of a
narrowed number of actors who coordinate on two levels and is characterised by
elements of hierarchy, centralised management of resources, limited
After the ’80, the strategic coordination of the centre has been under a decentralising
process of its responsibilities followed by an increase of inter-organisation networks.
Source: Cepiku, Ferrari, Greco, Governance e coordinamento delle reti di aziende
sanitarie: Italia e Svizzera a confronto
24

Exhibit 11 Example of vertical integration
Vertical integration
The vertical integration refers to the combination in a single firm or a
strong inter organisational alliance of two or more firms previously
independent but whom products and services constitute input or outputs
from the production of the other’s firm services. The main reasons for
the vertical integration are mainly the reduction of the transaction costs
between separate production processes and reduction of average
production costs by sharing common inputs across related production
processes.
Studies conducted by Klein, Krawford et al., 1978 show that the vertical
integration and consequently the economies of scope are most likely to
result in positive effects for the consumers.
In health care, the vertical integration involves affiliation under the
same management of organisations that provide different levels of care.
Goals include increasing efficiency.
25

Exhibit 12 Situation of networks according to partners number and
intervention variety
Intervention variety -
Source: P. Huard, Cours MHEM 2005
In the exhibit number X, cases corresponding to horizontal integration suppose others
generalists practitioners integration in order to modify the process of delivering care to
general population as potential patients. There is no selection conforming to a particularly
disease or pathology.
The vertically integrated network has a more modest size whereas a large scale of
interventions treating a particular population or pathology. Therefore it is called
specialised or chain networks.
The network in its broad sense regrouping all health components and treats all problems
of a population within a territory.
2.3.5.3 Types and pertinence of health networks
Analysing the various types of health networks according to two complementary
perspectives: the general abstract forms and the concrete realisation whom example we
can find in different countries, and their pertinence regarding the types of problems that
sanitary activity must treat, there are general forms of health networks divisible in three
categories:
+
Partners number
- +
Horizontal integration
Vertical integration Integrated networks
-integrated health networks, close to hierarchical organisation
26

- Labile health networks close to the market process
-cooperative networks close to the canonical form of the networks
The integrated health network is a type where components are situated under the
authority of a decision centre. The asymmetrical cooperation is being stabilised by
arrangements and contractual engagements. The decision centre can be occupied by one
of the units participating to the functioning of the whole, whether they are care providers,
funding holders, deciders or larger coalitions.
Quality and cost are two sides of the same
coin …
anything you do to one affects the other
As for the labile health networks the buyer approaches providers of health care services
in a punctual manner, according to the particularly needs of the process of health care
(prise en charge) this type of networks does not necessarily involve the continuity nor the
engagement. The problem associated to contingent relationships is the quality of services
and forecasting quality level according to the previous experiences of the customer with
the service provided by the supplier.
The cooperative networks differ of the other two types by the asymmetric dimension, less
important, as the different units are collaborating on a balanced and well-stable position.
27

Exhibit 13 Network organisation collocation
Source Studio di fattibilità. Progetto Rete Sanitaria, M. Della Santa, I. Cassis
Health network characteristics combine in a certain measure those of the market and
hierarchical organisation. A network is in the same time stable and flexible. Stability is
due to the time delay needed to develop not yet integrated cooperation relationships
whereas flexibility its due to the variance of the contribution of every collective activity.
Those two joint characteristics create interesting capacities for networks. Flexibility
allows networks to limit their costs and continually adjust used resources, while the
stability of cooperation relationships allows experience accumulation, learning
experiences in order to enhance competencies, especially enhance cooperation between
participating actors.
Hierarchical
organisation
Network
organisation
Market
organisation
28

Examples of health networks
An empirical analyse of the health networks allows a better understanding of their
general principles of organisation, the characteristics and properties, through the diversity
of the modalities of their concrete functioning. Observing different health networks also
allows esteeming the advantages and disadvantage of the different types of the health
networks. Finally, it enable us to consider potential corrections and adjustments of the
problems encountered, therefore potential organisational innovations associated with the
health networks.
The "Managed care" or the "organized care system"(Wagner, 1993), aims at improving
the efficiency of the health system. The recent development of managed care is caused by
a general context characterised by the high level of the health expenditure, which guided
involved actors of the funding process to become aware of the necessity of controlling
and reverse this evolution.
I will further present the two main forms of the managed care: the Health Maintenance
Organisations (HMO) and the preferred Providers organisations (PPO).
The HMOs are often presented as the best example of integrated health networks. In
reality it is a question of establishing a general frame that may create different situations
(Weiner and Lossovoy, 1993). HMOs offer prepaid, comprehensive health coverage for
both hospital and physician services. An HMO contracts with health care providers, eg,
physicians, hospitals, and other health professionals, and members are required to use
participating providers for all health services. Members are enrolled for a specified period
of time.
The principles on which the HMOs are based are 16 :
• The HMO is first a regrouping of a range of resources enabling patients' care
• constitutes a dispositive combining the two functions of care and insurance, for a
population of members
16 Pierre Huard, Cours Universitaires UDEASS, Ascona, 2003
29

Components
relative
position
Equilibrium
• The financing has a contractual prepaid basis (forfait). The members have to pay a
fixed prime for the insurance of the care delivery if needed.
These few principles give to the HMO a different functioning logic, as opposed to
previous situations when posterior funding made care providers indifferent to high costs.
Within HMOs, care providers are lead to pay a greater attention to the costs induces by
their choices. The risk is that the emphasis given to costs may affect the quality of health
care services provided.
In the same logic the incentives for the cost containment may lead to cream skimming of
risks strategies. These two negative reactions could be mitigated by regulation and by the
impossibility of the HMOs neglecting the quality of the health care delivered. And finally
if the quality is being neglected, nevertheless the asymmetry of the information,
nowadays more informed and empowered patients may leave the network. In order to
reduce its fix costs, the HMO has to increase its membership number, therefore adopt as
criteria the efficiency, one of the merits of this form of network.
The concrete forms that HMO's may take are: the staff, group, network, Individual
Practice Association (IPA), direct contract.
Exhibit 14 HMO forms
Integration Cooperation
Dispersion
30

Legend:
R1- Integrated health networks
R2- Fund holders
R3- Hospital-city network(RHV HIV)
Source: P. Huard, Cours MHEM 2005
In the staff model, the physicians are HMO's employees on a "closed panel" basis, so
that external physician do not have the possibility of intervening. The possibility of direct
control of the physician employed is providing an efficience advantage. Difficulties and
disadvantages are generated by the limited choice of the patients only between the
HMO's physicians, the heaviness of the dispositif.
Physicians are employed by the HMO
Paid by salary
Bonus with performance & productivity
Closed panel
large degree of cost & utilization control
Limited access and costly to develop
In the group model, physicians are employees of a group with whom the HMO contracts.
In the networks model, the HMO contracts with several groups sometimes small primary
care groups. The financing is on a global capitation basis, the group is financially
responsible for its patients and it is paying the solicited physicians.
HMO contracts with a multispecialty physician group practice to provide
all physician services
Captive Group vs. Independent Group
Closed panel; good cost control/utilization
Not fixed salary for physicians
Limited choice
31

In the IPA 17 model, the HMO is contracting with an association of liberal physicians who
have their own medical practice, their own clients and medical cases history. It is an open
panel situation as the participation is opened to external physicians. This type of
organisation allows the HMO to provide a wider range of services. The HMO funds the
IPA on a global capitation basis, and the IPA remunerates the physicians combining
capitation and retaining a provision for covering negative results originating from
uncovered costs. This represents an incentive for the physician in order to achieve
effectiveness. IPA model with its two balanced components can defend its member's
interest in the negotiations with the HMO and the HMO can contract with several IPA.
In the direct contract model, the HMO contracts directly with physicians and does the
recruitment for physician services. There is a better choice of physicians instead the
disadvantage may be the difficult management and lack of leadership
HMO direct contract model
HMO contracts with more than one group of physicians
Commonly with multiple group of primary care physicians (PCP)
Can be open or closed panel HMOs
PPO (Preferred Provider Organization)
The PPO represents a delivery system where providers are under contract to an insurance
company or health plan to provide care at a discount or negotiated rate. There is freedom
of choice among In-Network providers, including specialists. When In-Network
providers are used, out-of-pocket expenses are lower and no claim forms are required.
They are entities that employer health benefit and health insurance contract to purchase
services characterized by providers with utilisation management and agreed payment.
There is a limited size of provider panels and it can go out-of-network with higher co
pay. Example: the American Blue Cross Blue Shield plans.
PPOs are characterised also by a selected provider panel, negotiated and rapid payment
rates and the consumer choice.
17 Individual Practice Association
32

Disease Management
A type of product or service now being offered by many large pharmaceutical companies
to get them into broader healthcare services. Bundles use of prescription drugs with
physician and allied professionals, linked to large databases created by the
pharmaceutical companies, to treat people with specific diseases. The claim is that this
type of service provides higher quality of care at more reasonable cost than alternative,
presumably more fragmented care. The development of such products by hugely-
capitalized companies should be the entire indicator necessary to convince a provider of
how the healthcare market is changing. Competition is coming from every direction--
other providers of all types, payers, employers (who are developing their own in-house
service systems), the drug companies.
Exhibit 15 Disease Management
Source: Agency for Health Care Administration - February 2000
33

Studies 18 indicate that disease management has the potential to accomplish the following:
• Prevent/Delay Complications of Chronic Health Conditions
• Reduce Costs
• Improve Health Outcomes/Quality of Life
• Foster Self-Care/Self-Management
• Promote Patient Accountability
• Promote Continuity of Care
• Strengthen Provider/Patient Relationships
• Improve Patient Satisfaction
• Promote Efficient Use of Health Care Resources
• Increase Productivity
For all of the DMOs 19 , effective disease management requires a coordinated approach to
patient care. At the core of each program’s operations is a patient care team. These teams
are comprised of specially trained and experienced registered nurses, a medical
director(s) who specializes in the disease to be managed, and most often a committee or
board that oversees services and plans of care for the recipients
Case Management
Case management represents the process by which all health-related matters of a case are
managed by a physician or nurse or designated health professional. Physician case
managers coordinate designated components of health care, such as appropriate referral
to consultants, specialists, hospitals, ancillary providers and services. Case management
is intended to ensure continuity of services and accessibility to overcome rigidity,
fragmented services, and the misutilization of facilities and resources. It also attempts to
match the appropriate intensity of services with the patient's needs over time.
Many hospitals and integrated health networks are turning to case management as a
means to control costs by more effectively managing resource utilization. The problem
18 Agency for Health Care Administration - February 2000
19 Disease Management Organisations
34

arises when an organization does not define the scope of case management or does not
identify criteria specific to the needs of the organization and the population it serves.
Integrating case management into the existing organizational structure and systems is key
to its success.
A case management program is designed so that the nurses can work with any client
within the health system, regardless of the diagnosis of provider. A variety of challenges
surfaced: maintaining visibility within a large health care system; working with varied
approaches to client care issues; and being clinically knowledgeable in the variety of
chronic illnesses. Hospital admissions, physician and emergency department visits and
costs are measured after establishing a nurse case management program
The concept of "trajectory of the patient" is at the heart of the problems of the
health networks. It corresponds to a logical process: the construction of a production
chain of a service with the participation of the patient himself. But, with patients
manifesting different pathologies it is not always easy to set it up, in particular for the
older people.
The American HMOs have emphasised the role of the IT systems in order to assure the
continuity and prevent the redundancy of care provided and consequently reduce costs.
All the problems are far from being solved. The challenge is to jointly ensure the
interaction of the applications and the data security. Interesting achievements took place
in Europe. Hygeianet is the network of information in health of the island of Crete.
Started in 1995 and developed with the support of the European Union, Hygeianet,
centred on a divided medical file, offer home care services, services of teleconsultation of
clinical information for the hospitals in particular for the emergencies. In Spain, the
Autonomous Community of Andalusia developed projects (Evisand in télémédecine and
shared medical file Diraya) preceded by the European Union (Silber, 2003).
In France, each hospital, even each ward has its own information system. The Grouping
for the Modernization of the Hospital Information system (GMSIH) tries to harmonize
and improve the information systems.
"a health network is a voluntary regrouping of medical establishments and other suppliers
of services. Its members pursue goals shared as regards and assumption of responsibility
stock management. The health network has the legal personality"
35

(According to the article 2a of the law on the planning and the financing of the
establishments of public interest (LPFES) of Canton of Vaud/Switzerland.)
The integrated health networks rely on the formation of complete therapeutic and
preventive chains. They count on better information of the population and an active
participation of the patients in the management of their health and their diseases. With the
health networks, the reform thus aims another operation of the health services, conceived
like a system, differentiated but strongly interdependent, of health organisations
associated to primary care. The reform privileges first of all the health and care needs of
population and patients. This option answers a double challenge, the continuity of the
care and the control of the expenditure of health, by the recourse to the most suitable care
channel and by the joint organization of the principal services of support.
The health institutions and the independent experts share many values, communes within
medical professions. However, the specialization and the great diversity of the practices
maintain the approaches and the different cultures: private proactive, emergency units,
unit of palliative care, or equips with prevention, each one defends its approach and its
design of health, disease and in the manner of preventing or of meeting the needs for the
community and patients.
36

Swiss health networks in progression?
Data from the year 2000 shows us that there were 520 000 insured people within Swiss
health networks, which represents 7,2 % of the entire population, from whom 98’500 in
28 HMOs and more than 350’000 within 50 health networks “family doctor” 20 .
Exhibit 7 Swiss health networks situation
Diffusion of “managed care” plans (2002)
Some of them characterised by flexibility and others very structured, Swiss health
networks present diversified organisational forms, often built in analogy with the Nord
American experiences: from the regrouping of complementary competencies by partners
aiming at acquiring experience to the creation of societies or administrative networks
with economic objectives. In the last case, they are microsystems adapted to new
marketing forms faraway from the network created by professionals or patients.
20 « Des réseaux gagnants, des réseaux perdants ?» Propositions pour des réseaux de santé
ambulatoires en Suisse, Forum 2005 Santé-Gesundheit, 2001
37

Differently distributed within cantons, the percentage of the population who selected one
of the alternative insurance forms with restricted freedom of choice varied in 2002
between 0.3% (in Canton Uri) and 27.5% (in Canton Thurgau), reaching a percentage
share of slightly less than 7.6% of the adult population on a national level.
After 5 years marked by significant increases in the number of members, from 1999
onwards there has been a progressive loss of interest for these particular forms of
insurance, their diffusion and membership registered a decrease in 2002 compared to the
previous year, for the first time.
Most managed care plans offered nowadays in Switzerland are a somewhat weaker
version of US managed care programs (for example, family doctor gatekeepers are still
reimbursed on a fee-for-service base). However, the few capitation based managed care
plans (in which 1.9% of the Swiss population is enrolled) show significantly lower per
capita health expenditure than the ordinary plans for all classes of age.
Why did the expansion of the alternative forms of insurance within the Swiss population
begin to decrease after only five years?
The incentives for the population and potential patients to choose the capitation scheme
of the managed care models are aside of the quality perceived and the freedom of choice,
most importantly, the premium reductions.
Premium reductions are a function of relative cost savings compared to conventional
(fee-for-service) models. Studies in Switzerland about HMO cost savings agree upon
their cost advantage, but to variable extent. Findings range from 26% 21 to 40%. However,
studies also note the phenomenon of adverse selection in MCO(Managed care
Organisation) insurance models. Baur et al. reported high potential cost savings resulting
from the cream skimming of members due to an above-average presence of younger and
potentially healthier participants. Zweifel et al. also report tendencies of HMO
participants to cancel contracts in favour of conventional insurance in case of negative
health development, which suggests an extension of minimum contract durations.
Actual cost advantages in HMO partially seem to arise from lower expense on
pharmaceutical products, where an average HMO contractor only incurs 40% of cost
21 P. Zweifel and L. Steinmann. Nachfolgeprojekt Incentives - Management Summary, 2003.
38

accrued by traditional contractors 22 . Additionally, HMO patients are hospitalized less
often (hospitalization rate of 9% compared to 16.8% in traditional models) and typically
also released earlier. Klingenberger also observes the consultation frequency of HMO
patients to stand only marginally behind traditional patients. Therefore, it is not entirely
clear to what extent the reported cost savings by HMOs as well as MCOs in general
actually represent the results of more efficient healthcare, or whether how these savings
have been induced by healthier population sub samples due to adverse selection.
Most large Swiss healthcare insurance companies nowadays are offering managed care
insurance models, promoting premium reductions of up to 25% in case of participation
in HMOs.
(up to 10% in PPO) compared to conventional insurance models. When comparing
actual offers of four selected insurance companies, average HMO premium offers
underbid traditional offers by approximately 19%, or 56 CHF per month on average 23
Exhibit 8 Health insurance premium reduction by type of insurance
Source: http://www.krankenkasse.org/kolpingthreeclicktool, 2004
Market studies by Zweifel et al. have analysed the perceived market value of an
abandonment of free healthcare provider choice by Swiss public. Results show what level
of reduction premiums are required to induce HMO participation and results also show
that choices vary with the definition criteria of accessible healthcare providers.
Physician Limitation by Cost -103
Physician Limitation by Quality -53
22 D. Klingenberger. Health Maintenance Organizations in der Schweiz - Darstellung und
Kritik. IDZ Forschung - IDZ Information 1/2002, 2002. URL http://www.wzn.de/hmo-schweiz.pdf.
23 Comparis. Krankenkassen - Vergleich Grundversicherungen. 2004. http://www.comparis.ch/
39

Physician Limitation by Efficiency -42
Limitation of Hospital Coverage -37
Source: Average Public Value of Healthcare Access Limitation in CHF
In Switzerland, the institutions called to work in the health networks must federate their
actions around the following values:
the prevention of the diseases and the care carried out by the recognized networks
are a service of public interest to the population. For this reason, a recognized
network conforms to the provisions envisaged by the Law on the public health
(LSP), the Law on the planning and the financing of the medical establishments
of public interest and the health networks (LPFES) and the Law on the assistance
with the people resorting to medico-social lodging (LAPRHEMS). It respects in
particular some essential principles:
Obligation to deliver care to any person to whom the equipment enables it to take
charge of (within the meaning of article 4, al.2 of the LPFES).
-the disease prevention and the health care delivered by the recognized networks
are a service of public interest to the population.
Equity to the access to health care and equal treatment for any policy-holder
(within the meaning of the compulsory insurance of the care envisaged by
LAMal, the federal Law on the sickness insurance).
Continuity of care based on a global vision of the person and a person's
environment.
Safety of the care and conformity to the established standards.
Provision of necessary information for the use of the health services by the
population.
the members of a health network respect the ethical values recognized by the
international community, in particular:
Autonomy and respect of the person and values.
Respect of the patient's rights.
40

Refusal of the therapeutic eagerness.
Relief of the physical and psychic pain.
providing long term health care.
the health networks refer finally to the following values
free choice of the doctor and the services of care, for an assumption of
responsibility strongly individualized and conditioned by quality such as
the patient perceives it.
contractual freedom among the authorized options of insurance.
increased Autonomy of the health care providers within the framework of
contractual relations.
Viability of the assumption of responsibility, based on the research of the
best therapeutic options and the care services best adapted.
Quality of the health services.
Culture of the innovation.
Research and development to ensure the adaptation of the care knowledge
and the most recent practices.
41

2.4. A systematic review of the literature
After a systematic literature review (PubMed, AbiInform data bases) I retained and
analysed several international articles.
A review of the the evidence for horizontal and vertical integration involving hospitals,
found a gap between the integration rationales exposed by providers and those cited in
the academic literature. They found that integration fails to improve hospitals‘economic
performance 24
This article offers lessons from hospitals' efforts during integration process and finally
suggests alternative models for achieving integrated delivery of health care services:
-Customized integration and disease management (strategy focusing integrated
medical delivery for high-cost chronically ill patients)
-IT-integrated health care (using ICT for introducing the EMR use towards the so
called, digital hospitals)
-Patient-integrated health care (empowers individuals to coordinate their health
information, act as self or their own gate keeper; eg smart cards)
After a decade of experience, the IDN 25 did not reach the expected economic
performance. Actually “nothing worked”. The paper summarizes the evidence for this
conclusion beginning with the late 1980 and tries to identify the causes for most
integration processes’ failure and present lessons to learn from this experience.
The Health 21 report of the WHO 26 , provides practical advices on optimal methods of
organising and financing health systems. In this report, the WHO emphasises the
importance of an integrated health system. In an integrated health system, health
promotion, disease prevention, diagnosis, treatment, rehabilitation and care have to
constitute a continuous link of actions in order to improve health gain. There is an
increasing need for a structural and functional integration of the health service and health
24 Integrated Delivery Networks: A detour on the road to integrated health care? By Lawton R.
Burns and Mark V. Pauly (Health Affairs , volume21, Number 4, 2002)
25 Integrated Delivery Networks
26 WHO-Regional office for Europe. Health 21. The health for all policy framework for the WHO European
Region. Copenhagen, 1999
42

care system, which at present is very fragmented. The functions of an integrated health
service should meet the epidemiological needs of the population. These needs should
form the basis for the priority setting, and for the planning and provision of services.
Shortell and Gillies 27 , claim that in anticipation of reforms in response to increasing
health expenditure, the managed care sometimes referred to as “integrated delivery
networks” or “organised delivery systems”, has taken a new meaning.
These structures combine the organisation, financing, and delivery of health care as
response to the demographics and economics in different regions. This organisation
should provide appropriate care in a seamless continuum that uses scarce resources most
effectively. In their paper, S. Shortell et al., outline their research on organised delivery
systems, describe the barriers such systems face, and raise key policy questions that must
be answered.
Studies about the organised delivery systems and the performance of the first generation
of multihospital systems show no superior cost, quality or access performance compared
to independent hospitals 28 . 29 That is an understandable result as it might be difficult to
achieve economies of scale and scope for hospitals or organisation unrelated to each
other or to integrate pieces of the system in order to deliver cost-effective health care
services. The remaining question is whether on a long term vision or the next generation
of integrated health systems will achieve superior performance.
Reviewing eleven evolving integrated delivery systems, Shortell's study finds that these
systems will be successful if they achieve service integration at a clinical level. Shortell’s
review define clinical integration as "the extent to which patient care services are
coordinated across the various personnel, functions, activities and operating units of a
system" 30
Authors also find that there is a generally positive relationship between the level of
integration and composite financial performance relative to competitors.
27
The New World of Managed care : creating organised delivery systems, by S. SHortell, R. Gillies and D.
Anderson
28
S. Shortell, "The evolution of Hospital Systems", Downling " Alliances as a structure for integrated
delivery systems"
29
S. Shortell, Strategic choices for America's hospitals : Managing Change in Turbulent Times, 1990
30
R. Gillies et al. "Conceptualizing and Measuring Integration: Findings from the health systems
integration study", Hospital and health services administration, 1993
43

Examples of Swiss integrated health networks
“Les réseaux de soins” Canton Vaud, Switzerland
Swiss health system is assumed as an example of public governance applied to the health
field. The public governance model is considered as being an expansion, integration of
the New Public Management paradigm. 31 This evolution concerned especially the politic
and administrative level. Other changes concerned the refinement of instruments of
involving stakeholders in the definition and implementation of public policies, an
evolution of relationships of collaboration internal and external to the public
administration(PA) and the accountability of the PA toward general population 32 .
Health care networks in Canton Vaud
Trials towards establishing health are networks in the Canton of Vaud date years ago.
Introduced in 1997 as an answer to the challenges that the health system was facing, they
had a first experimental phase (1997-2002) when they were projected, designed and
implemented. The next step (2004-2007) is designed in order to assessing, reformulate
network strategy and network management.
Exhibit 16 Health care networks in Canton Vaud
31 Meneguzzo, 1995
32 Jones et al, 2004
44

sette poli di
raggruppamento
AROVAL
ARC
ReSCo
ARSOL
ReNOVA
ARCOS
Santé-Broye
ASCOR
FS Chablais
Source: “Lettre des réseaux”(2002), www.nops.vd.ch
Facing a « laissez faire » regulation and increasing health expenditure, but especially an
overall increasing aging population with a prevalence of chronic care and degenerative
illnesses, creation of health networks meant to be a solution for the Canton Vaud.
The strategy constituted of the organisation of NOPS(Nouvelles Orientations de Politique
Sanitaire) en 1997 was an interesting answer to these problems. Their objective was the
implementation of:
Regulation by funding and information
Change management and health care networks
Exhibit 17 Coordination mechanism of health networks, Canton Vaud
45

Sistema d’informazione comune
Medicina
ambulatoria
Reti specializzate di cura,
circoscritte a una malattia
(diabete, asma, …)
ospedale
Riabilitazione
Coordinazione
Homese case
per anziani
Reti NOPS
Cure a domicilio
Ricovero
a domicilio
HGS
Orientazione
e liaison
Acquisto e rimunerazione
di prestazioni (no concordato)
Source: Governance e coordinamento delle reti di aziende sanitarie: Italia e
Svizzera a confronto, D. Cepiku, A. Greco, D. Ferrari
46

HEALTH NETWORKS ASSESSMENT
Health networks assessment encouters major debates and difficulties. Depending of the
network type, it is necessary to evaluate the performance of the networks under four
dimensions:
-clinical assessment
-economical
-satisfaction evaluation(of clients, users, practitioners ecc-stakeholders in general)
.-health programs
Exhibit 23 Health networks evaluation
In order to evaluate health networks there were created different models and scales. In
France, there were proposed and used ANAES model (1999, 2001, 2004). These different
models assess three main aspects: cooperation, advantages and costs
The auto-evaluating model of the ANAES assesses five aspects:
• initial presentation of a network
• evaluation of integration of users and practitioners
• evaluation of functioning of the network(management, coordination, organisation,
internal functioning,
• evaluation of the quality of taking in charge of patients
47

• economic evaluation (financial evaluation, budgetary evaluation and internal
control and audit)
Cooperation and coordination of health actors should rationalise the use of capacities
which implies(see exhibit X below):
• Reducing the hospital use only for acute care episodes,
• Reducing dysfunctions and unnecessary consummation
• Regrouping functional activities
therefore reducing costs.
Exhibit 23 Does coordination of care reduce health costs?
48

Medical research has made such progress,
that there are practically no healthy people
any more." Aldous Huxley (1894-1963)
3. E-HEALTH. TOWARDS INTEGRATING HEALTH CARE.
Information technology is one of the most influential factors reshaping the health care
organisations.
Integrated information systems are defined as computer systems capable of managing and
directing information to and from practitioners across the continuum of care at the point
of service that allows practitioners to track care decisions and results 33 .
Information and communications technology (ICT) is increasingly being used in
management of chronic illness to facilitate shared services (virtual health networks and
electronic health records), knowledge management (care rules and protocols, scheduling,
information directories), as well as consumer-based health education and evidence-based
clinical protocols.
3.1.1 Definition of electronic health (e-health)
"e-health is an emerging field in the intersection of medical informatics, public health
and business, referring to health services and information delivered or enhanced through
the Internet and related technologies. In a broader sense, the term characterises not only
a technical development, but also a state-of-mind, a way of thinking, an attitude, and a
commitment for networked, global thinking, to improve health care locally, regionally,
and worldwide by using information and communication technology."
33 Conrad & Shortell, 1996,
49

Health-care is an information-intensive and knowledge-demanding sector, which is why
electronic health solutions are so important in this field. The European Commission 34
(EC) has been initiating and funding research and development activities regarding
Information and Communication Technologies (ICT) for health, or "eHealth", since
1988. These programmes covered priority topics like electronic health-care records,
regional and national health networks, telemedicine in homecare and care-at-the-point-of-
need to support continuity of care concepts, systems to support people to stay healthy,
and systems and tools to support health professionals to work more efficiently and safely
on patients. During the 15-year span of the programmes, the European Union (EU) has
contributed about 500 million Euro to approximately 400 R&D projects, support
activities, best practice and studies covering technical, clinical, ethical, legal,
organisational and market issues. eHealth has shown proven benefits in application fields
as improved access to care, care at the point-of-need, citizen-centred care, improved
quality and cost containment. Such applications were emphasised at the EU High Level
eHealth Conferences in Brussels, Belgium, in 2003, and in Cork, Ireland, in 2004.
eHealth is now on the governmental agenda of EU Member States to be implemented on
a broader scale. In line with this development, the Commission has taken a number of
policy initiatives. A European Union Action Plan for a European eHealth Area was
published by the Commission in April 2004 and endorsed by the EU health ministers in
June 2004. This means that, for the first time, Europe has a coherent agenda for the
implementation of e-health
The ten "e"s of the e-health 35
What does electronic health instruments bring in the health care sector? Studies and
initiatives emphasise that a wide use of e-health may enhance effectiveness not in the
detriment of the quality.
34 Int J Circumpolar Health. 2004 Dec;63(4):310-6, European Commission activities in eHealth, Olsson S,
Lymberis A, Whitehouse D
35 What is e-health? G Eysenbach (J Med Internet Res 2001;3(2):e20)
50

1. Efficiency - one of the promises of e-health is to increase efficiency in health
care, thereby decreasing costs. One possible way of decreasing costs would be by
avoiding redundant or unnecessary diagnostic or therapeutic interventions,
through enhanced communication possibilities between health care
establishments, and through patient involvement.
2. Enhancing quality of care - increasing efficiency involves not only reducing
costs, but at the same time improving quality. E-health may enhance the quality of
health care by allowing comparisons between different providers, involving
consumers as additional power for quality assurance, and directing patient streams
to the best quality providers.
3. Evidence based - e-health interventions should be evidence-based in a sense that
their effectiveness and efficiency should not be assumed but proven by rigorous
scientific evaluation which will lead to reducing or even eliminating medical
errors, adverse effects, unnecessary costs.
4. Empowerment of consumers and patients - by making the knowledge bases of
medicine and personal electronic records accessible to consumers over the
Internet, e-health opens new avenues for patient-centred medicine, and enables
evidence-based patient choice.
5. Encouragement of a new relationship between the patient and health
professional. From a paternalistic approach, towards a true partnership, where
patient is informed and decisions are taken in a shared manner.
6. Education of physicians through online sources (continuing medical education)
and consumers (health education, tailored preventive information for consumers)
7. Enabling information exchange and communication in a standardised way
between health care establishments and organisation all along the value chain or
the therapeutic process in health and social care.
8. Extending the scope of health care beyond its conventional boundaries, in both a
geographical sense as well as in a conceptual sense. e-health enables consumers to
easily obtain health services online from global providers.
9. Ethics - e-health involves new forms of patient-physician interaction and poses
new challenges and threats to ethical issues such as online professional practice,
informed consent, privacy and equity issues.
51

10. Equity - to make health care more equitable is one of the promises of e-health,
but at the same time there is a considerable threat that e-health may deepen the
gap between people not having internet access or computer skills, therefore a
population without benefit from electronic health instruments diffusion. The
digital divide currently runs between rural vs. urban populations, rich vs. poor,
young vs. old, male vs. female people, and between neglected/rare vs. common
diseases.
e-Health has been identified as one of the priority objectives of the e-Europe 2005 Action
Plan. It refers to health services and information delivered and exchanged through the
Internet and related technologies. e-Health ambitions as defined by the EU's health
ministers in 2003 are to facilitate information exchange between citizens, patients,
healthcare professionals and providers as well as policy makers. The Commission
currently estimates the e-Health industry turnover at 11 billion euros.
e-Health has so far been impeded by several factors such as the lack of broadband
connections or an insufficient penetration of the Internet among the general public. Some
experts have pointed to doctors' traditionally conservative views about changing
professional practices as being the main factor impeding e-Heal
The e-Health action plan identifies practical steps to build a "European e-Health Area":
• National level: By 2005, Member States are asked to develop national and
regional e-Health strategies. A public portal will be launched to provide "one-stop
shop" access to information on health in the entire EU.
• Interoperability: By 2006, national healthcare networks should be "well
advanced" in their efforts to better exchange information and 'talk' to each other.
As part of this effort, standards for electronic health records are to be agreed so
that patients can be identified and information made easily readable and
exchangeable over the network. Movement of patients and healthcare professional
should as a result be made easier.
• Networks: By 2008, health information and services are to become commonplace
and accessible over both fixed and wireless broadband networks. Expected
services include teleconsultations, prescriptions available online. So-called
52

"Grids" are to be set up to boost the networks' computing power and ability to
interact.
Meanwhile, an important step is to be made with the introduction of a European health
card as of 1 June 2004. The card is set to replace current administrative procedures to
cross-border healthcare in the EU (forms E111, E128, E110, etc.) with a single
personalised card.
"New technologies and services make access [to health care] faster and easier, reduce
errors, and improve the effectiveness of health care systems" 36 . "This area - that covers
both health care and e-Health technologies - is where Europe and European business is
strong, and these changes must be further supported.
Health Information Network Europe ( HINE) - an association of ICT businesses involved
in e-Health and managed by Deloitte - will present an upbeat view of current market
developments in healthcare at the European eHealth Ministerial Conference in Ireland.
HINE will focus on the practical benefits expected from the large-scale use of
information technologies to support health policies. It will lobby for more government
support in healthcare information technologies.
In a series of important papers, David Cutler, Mark McClellan, and their colleagues argue
persuasively that the benefits from many technological innovations more than justify the
rising costs of health care. 37 Emerging technologies that offer medical benefit but require
substantial capital investment pose a challenge to hospitals and hospital-based health
systems, whose leaders make most purchasing decisions independently of one another. 38
36 Information Society Commissioner, Erikki Liikanen
37 D.M.Cutler and M. McClellan, “Is TechnologicalChange inMedicineWorth It?” HealthAffairs 20, no. 5
(2001): 11–29; and D.M. Cutler, YourMoney or Your Life: StrongMedicine for America’s Health Care System
(New
York: Oxford University Press, 2004). The pioneering study is D.M. Cutler et al., “AreMedical Prices
Declining?
Evidence from Heart Attack Treatments,” Quarterly Journal of Economics 113, no. 4 (1998): 991–1024.
38 How Hospitals Confront New Technology, Health Affairs, January/February 2006
53

3.2. Conditions and dimensions
In order to implement e-health instruments within health systems, four different
dimensions should be analysed and assessed:
• technical dimension
• cultural dimension
• legal dimension
• economic dimension
The economic dimension aims to evaluate the opportunity for the health operators
to organise into networks in order to analyze its impact from an economic point of
view and the impact on the costs and the total efficiency of the sanitary
organizations.
The technical dimension analyses the material requirements for the realisation of a
health network, the necessary know-how to the inside of every structure and the
relationships between the various actors sanitary and trained to you.
The cultural dimension, often neglected, occupies a fundamental role. A
reorganization of such important dimensions involves first of all a cultural change.
At an international level, the experimentation of the electronic health instruments
has stimulated the cultural change and created the indispensable premises to the
establishment of a coherent and effective legal base.
The legal dimension analyzes legal implications of the networks organisation in the
health system. Currently debated arguments are patients’ privacy and security and
equally patients and health professionals date protection.
54

Exhibit 18 Dimensions of e-health instruments implementation
Application Technical Cultural Legal
Economic
dimension dimension dimension
dimension
PACS 39 Most Important Important, necessities Most
Important cultural legislation
important-High
change reglementation, investments
problems of data needed for
security
financing
implementation
RIS 40 important medium medium important
Health card medium Most
important
medium important
HIS 41 important Importantchange
of
operational
habits, HR
training
Less important Most important
Telemedicine medium important Less important important
Electronic important Most Important -
important
prescribing
important necessited legal
reglementaion of
digital signature, data
security, patient's
privacy
(each dimension has been ranked from less important to most important)
39 Picture Archiving and Communication System
40 Radiology Information System
41 Hospital Information System
55

ELECTRONIC PRESCRIBING
3.3. E-prescribing, a tool of the e-health
The Electronic prescribing(E-prescribing) refers to the transmission of prescription
information from prescribers to a pharmacy that is created, stored and transmitted via
electronic means, (e.g., by computer or hand held device). It includes allowing
pharmacies to transmit refill requests to the prescriber and prescribers to respond with
their authorization, denial, or changes. The term electronic prescriptions would not apply
to prescriptions communicated either by facsimile ("Fax") or verbally in a telephone
conversation 42
Technology and information management are most important factors for enabling a new
vision of the health care process, a vision evolving from the current managing
components of care to a new one that manages overall health status and chronic illness.
The current vision of the health care process focuses on the episode of care, places the
hospital at the centre of the health delivery system. The quality is assessed trough
patients' perception and cconsumer and employer view access and amount of health care
as the gold standard.
The future vision of the health care process focuses on the health of the population,
disease prevention and the integrated care of chronic illness. There is a pro active primary
care well integrated with specialty providers. The quality assessment shifts to a scientific
based view and with a clear purpose of improving health. The role of the consumer also
changes, becoming actively engaged in health promotion and being informed and
involved in the decision making process.
42 http://www.hc-sc.gc.ca/hcs-sss/ehealth-esante/res/thesaurus/index_e.html
56

The health care delivery process improves as technology use migrates from
administrative transaction to clinical e-commerce thereby obtaining improved outcomes
of health and costs.
Exhibit 19 Health care delivery process, situation of e-prescribing
Basic
Connectivity
Claims
Processes
Source: e-Prescribing’s Impact on Cost and Quality: Implications for Pay-for-Performance
Initiatives, HIT Summit West , March 7, 2005
Medical
Management
• ER Notifications
• Formulary
Management
• Alerts and
Reminders
• Auto-Adjudication
• Pre-Certification
Clinical solutions brought by electronic prescribing offer a feasible system to improve the
quality of the health care delivery process while reducing the costs incurred.
Clinical
Support
• e-Prescribing
• Patient Recruitment
• Disease Registries
• Electronic Med
Record
• Virtual Visits
57

Exhibit 20 E-prescribing a decision support
Decision Decision Support
Support
EMR
Integration
Electronic
Connectivity
Medications Management
Supporting Patient Data
Standalone Prescription Writer
Reference Information
Electronic prescription refers to the use of an electronic device to enter, modify, review,
and output or communicate prescription orders.
The more a system is sophisticated, more are the improvements and opportunities that e-
prescribing can enforce in order to achieve reduced costs, improved quality, errors
reduction, and enhance work flow efficiency.
The benefits that e-prescribing can bring are: the improvement of the quality, cost
reduction-improved efficiency, reduced medical errors-improved safety.
– Improves patient safety with an “informed” prescription
– Provides access to more patient information at the point of care
– Frees resources to provide new, consultative, and value-added services
58

– Less waiting and confusion due to clarification calls between pharmacy,
payer, and prescriber
– Reduces errors due to incomplete levels of information and transcription
Exhibit 21 E-prescribing involvements
In the United States, the potential impact of e-prescribing at a national level has been
judged to achieve 29 billion $ savings. 43 In an article called Computerized prescribing 44,
authors claim that electronic prescribing in the practice of medicine is a change that is
overdue. Virtually all prescriptions in the United States are still handwritten. Instead,
medications should be ordered on a computer interacting with 3 databases: patient drug
history, scientific drug information and guideline reference, and patient-specific
(weight, laboratory) data.(see exhibit) Current problems with prescribing on which
computerized prescribing could have a positive impact include
(1) drug selection;
43 eHealth Initiative, 2003
44 Computerized Prescribing, Building the Electronic Infrastructure for better medication usage, by G.
Schiff, D. Rucker, JAMA april1, 1998
59

(2) patient role in pharmacotherapy risk-benefit decision making;
(3) screening for interactions (drug-drug, drug-laboratory, drug-disease);
(4) linkages between laboratory and pharmacy;
(5) dosing calculations and scheduling;
(6) coordination between team members, particularly concerning patient education;
(7) monitoring and documenting adverse effects; and
Exhibit 22 Prescription process
Source E-health initiative, 2005
(8) postmarketing surveillance of therapy outcomes. Computerized prescribing is an
important component of clinician order entry. Development of this tool has been impeded
by a number of conceptual, implementation, and policy barriers. Overcoming these
constraints will require clinically and professionally guided vision and leadership.
60

HEALTH INFORMATION NETWORKS
Communications network are designed to suit the health sector and the provision of
health information via an assortment of electronic devices (computers, printers, scanners,
etc.) connected for mutual exchange of digital information.
England constituted the National Health authority within the NHS aiming at
implementing the national strategy: National Health Informatics Strategy -“Making
Information Count” towards integrating health care. Examples on various countries
implementing health information networks are numerous.
HEALTH INFORMATION SYSTEMS
A health information network represents a developed or adopted system of information
management which combines personnel, policies, hardware, software, and other resource
elements for collaboration in the administration, collection, transformation and
dissemination of information in a health care organization. Health information systems
assist in the streamlining of organizational, functional activities, the improvement of
organizational resource management and the collection of patient records. Not used as a
reference to information technology, communications networks or health information
resource management.
The electronic health record (EHR) is an evolving concept defined as a longitudinal
collection of electronic health information about individual patients and populations.
Primarily, it will be a mechanism for integrating health care information currently
collected in both paper and electronic medical records (EMR) for the purpose of
improving quality of care. Although the paradigmatic EHR is a wide-area, cross-
institutional, even national construct, the electronic records landscape also includes some
distributed, personal, non-institutional models.
61

Emerging EHR models present numerous challenges to health care systems, physicians,
and regulators. An article provides explanation of some of the reasons driving the
development of the EHR, describes three different EHR models, and discusses some of
the practical and legal challenges that health care providers potentially face both during
and after EHR implementation.
TELEMEDICINE
Definition
Telemedicine is defined as the use of information and communications technologies to
enable the provision of clinical health care services like medical diagnosis and primary
patient health care between geographically separated individuals. Preference is given to
narrower terms when relevant or applicable. 45
Telemedicine and healthcare processes
In which measure at present the control, the monitoring and the management of the
patients at distance, supported by the Telemedicine and the systems of ICT management,
viewed as the means of the video communication, are improving the processes of health
care delivery and in particularly the home health care integrated and associated long term
cure, in order to assure the continuity of cure provided to the patient?
Using ICT and telemedicine facilitates exchanging informations between practitioners
and between patient and health professionals. I reduces social cost(non monetary costs)
of diseases in terms of time and transfer, allows delocalizing an important part of the
nurse care conforming to the particular needs of the patient. It is the information
circulating and not the patients having to transfer or being carried from home to different
45 Blignault, Ilse and Meredythe Crane, Australian Telehealth Glossary of Terms (Queensland
Telemedicine Network, 1999). [27 June 2001] Formerly available at
http://www.health.qld.gov.au/qtn/pdf/glossary.pdf
62

institutions of care. Telemedicine has a great potential, especially in regions with largely
spread population. A mostly important need is being imposed nowadays with and
overally aging population and prevalence of chronic illnesses needing home long term
care.
Telemedicine is based on a systemic approach, foreseeing cooperation between health
actors and structural exchange of information between different IT applications . The
exchange between IT application supposes an effective interoperability between
heterogeneous applications and the structural integration of clinical data.
Infrastructurs needed for exchanging information are:
• Electronic mail server
• Notification server
• Clinical documentation server
• Server for the cooperative treatment of patients
• Server for managing personal medical card
Main services provided by the use of telemedicine are:
• Tele-diagnosis
• Tele-assistance
• Tele-consulting
• Tele-rescue
Different studies and e-health initiatives promote a wide implementation of telemedicine.
It does certainly require huge investments in the IT infrastructure, change management
techniques, training of HR medical resources as it changes the process of health services
delivery for the chronic ill or old population. On long term telemedicine assures cost
containment and quality of care improvement as well as enhancing health actors'
coordination.
63

International experiences in implementing e-health
European background
After long negotiations, the European Council decided in March 2002 in Barcelona that a
European Health Insurance Card is to be introduced in the member countries by 2005.
Health Smart card in the European Union
Experiments have been conducted
in most European countries (notably in
Germany, France and Italy), but in Canada,
the US and Japan as well, where the health
card has been
Introduced not only to make more efficient
the administrative procedures (insurance card)
but also to improve the quality of health care
(health card).
This card replaces the formulary E111, and consequently facilitates access to health
services abroad and thus improves mobility.
Austria- The e-card
Health insurances companies in 1996 realized that the purpose of the European Health
Insurance Card alone would not justify the cost required for its development. Austria
64

therefore decided to integrate the European and the Austrian health insurance card into
one "e-card".
The Austrian e-card is a chip card for insured people, which will replace the vouchers
previously, needed for health service utilisation and thus will offer paper-free access to
all health care services. Currently its main purpose is to demonstrate a patient's eligibility
for services. The e-card's future purpose is to enable providers to access patient data.
Subsequent cards will be used to store health relevant information if patients wish so.
The low degree of integration between providers in the Austrian health care system is
suspected to result in expensive diagnostic services performed more often than necessary.
Patient e-cards in combination with provider key-cards should enable providers to get
access to existing diagnostic results stored centrally.
During the introductory phase, the main purpose is to demonstrate a patient's eligibility
for services.
The card is limited to information relevant for patient identification (Key card) but at first
is not meant to store health data on it.
Main objectives
- e-cards shall offer paper-free access to social security and health care services for 8
million Austrians and are to replace the vouchers needed in the old system
- administration of the health and social security system is thought to be facilitated by this
application of modern technology; this should help all four groups involved, health
insurance, patients, providers and employers
- the same card integrates also the European health insurance card needed for service
utilization in other EU countries
- the e-card will be equipped with a signature function. Thus it will be possible in the
future to extend its application for identification purposes also outside of the social
security and health sector
Cost efficiency: Early estimates (1999) by social insurance institutions were that
efficiency gains caused by the e-card system will offset their introductory costs within
two years. Total cost then was estimated at 700-800 Mio ATS (51-58 Mio €). The
65

technical difficulties and time delays during the implementation process raise doubts that
efficiency gains will indeed cover the cost of introducing the card. 46
E-health as field of activity between information technology, healthcare, and business
administration holds great potential of improving healthcare efficiency, patient value, and
cost development, and will profoundly influence relationships between professionals and
patients.
However, the adoption of e-healthcare is severely lagging behind the progress of other
service markets in spite of technological feasibility. To a great extent, unsatisfactory
introduction is caused by immanent problems of healthcare systems. These unfavourable
conditions also obstruct by actors' resistance to change, mistrust and bad communication
between actors as well as concerning problems of data security and privacy.
46 Health Policy Monitor, Austria, e-card. Oct. 2004
66

healthcare is delivered in a very fragmented way, mostly due to specialization among
care providers. It would therefore be imperative to pass information from one institution
or individual to another in a timely and efficient manner in order to fill the gaps between
different providers of healthcare across the patient’s treatment path.
Information passing is at the core of e-healthcare functionality: providing all healthcare-
related information anytime, anyplace, to anyone necessary in a timely and usage-
oriented manner. By sharing information, e-healthcare has the ability to integrate existing
and support new kinds of healthcare services. In analogy to supply chain theory,
information integration applies to two dimensions:
- Horizontal Integration: Information exchange within the same level of care (e. g.
connecting information from previous to current general physicians related to one
patient)
67

- Vertical Integration: Information exchange between different levels of care (e. g.
connecting information from preventive, stationary and post-incident care related to one
patient)
Both kinds of information integration could ensure information passing across individual
treatment paths, and across geography. This goal requires the collaboration of medicinal
practice, business, legal, and information technology.
Based on the information and communication technology, e-health’s impact within and
between health organisations has impact at two levels: communication and organisation.
When looking at e-health from a functional point of view, Kacher, Wiest and
Schumacher(2000), have identified five elements:
- Content: Medical information databases Healthcare provider directories
- Commerce: Online pharmacies and shopping portals Transfer of healthcare billing data
- Connectivity: Interconnection of involved parties (physician, laboratory, pharmacy,
hospital, insurance)
- Computer Application: Applications enabling content providing
- Care (Telemedicine): Physician to physician: Teleconsultation, teleeducation Physician
to patient: Telediagnostics, teletherapy, telemonitoring
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4. Examples of initiatives in electronic health field
4.1 PROJECT "RETE SANITARIA" TICINO SWITZERLAND
Towards a new generation of health information and communication technology-
Smart card "Carta Sanitaria" Tessin, Health Network Project
A cultural and technological project at the same time, “Rete Sanitaria” promotes a first
instrument for introducing electronic health to the Tessin’s health care system: the health
card “Carta sanitaria”.
E-Health is a dual concept: the contextual application of ICT, and a second concept as
organizational tool and communication tool.
Moving towards the health communication of tomorrow the “Carta sanitaria” smart card
looks for an approach that can engage the audience in a change process by improving the
healthcare process, patient-physician communication and the cooperation between health
system's actors. The emerging questions are how do computer and technology influence
individuals' behaviour? In which way will be the patient-physician relationship
influenced by the new technology?
The smart card will not replace patient-physician communication, as technology is not
“the” solution for health care, but an important enabling factor. Healthcare is not
technology driven, but healthcare is driven by patients' and health professionals' needs.
Needs’ evolution through time, has transformed the doctor-patient relationship from
medical paternalism to enhanced autonomy.
The health card is promoting a model for shared decision making, acknowledging that
though the final choices reside ultimately with patients, only trough physician
cooperation can the patient be empowered to make meaningful decisions that serve him
best. For such a model to function effectively, connecting the re-establishment of trust in
doctor-patient relationship and the adoption of patient centred communication with an
appropriate use of the health card is crucial.
Providing the physician with immediate objective information, the Health card will also
reduce consultation time. The challenge for the health professionals is not to lose this
time but to consider it as an investment for a future more efficient care process that will
lead not only to an increased patient satisfaction, economic impact (reduced costs, wasted
69

esources), health outcome but also increased patient compliance, reduced malpractice
claims, for finally increasing physician satisfaction too.
Still it is important to remember that electronic health is a timely tool for healthcare
systems and society and that technology in healthcare is not an aim but has an important
role as means to an end.
Exhibit 24 Condition needed for the implementation of a health network. “Rete
Sanitaria” s current situation
Source Studio di fattibilità. Progetto Rete Sanitaria, M. Della Santa, I. Cassis
The conditions needed for the constitution of a health network are as mentioned: legal,
cultural, economical, and organisational. The minum level required and the actual
position iat a cantonal level are as in the figure at a different level.
In November 1997, the State Council of the Canton of Tessin stated that: "the necessity of
coordinating ambulatory and stationary health organisations is becoming more acute
here as anywhere. It is necessary to use in every occasion the structure and the service
most appropriated in order to incur inferior costs at a comparable result"
According to this objective, in March 1999, in the context of the cantonal administration
analysis, called Administration 2000, the Great Council approved the governmental
proposal of implementing the project "Health Network Coordination".
70

The Council has afterwards considered a multitude of aspects; financial incentives,
central planning, cultural and social change, technology, and provider coordination. In
the final development, the project has chosen to focus efforts on two pillars:
• Technology dissemination
• Cultural and social influence
Exhibit 25 Overview of a fragmented health system. The position of “Rete
sanitaria”
Source Studio di fattibilità. Progetto Rete Sanitaria, M. Della Santa, I. Cassis
These factors and final objectives of the project are the improvement of the health and
social actor's coordination and the integration of the Tessin's fragmented, complex and
redundant health system. The exhibit number X above shows a preview of the health
system and its fragmentation.
In order to align to the European Standards, Switzerland will adopt from 2008 the Federal
Insurance e-card. That could change the view on the Tessin's project and its acceptance
not only by patients and stakeholders but might also influence the vote on the project
passing from the experimental phase to the implementation, by the Great Council in June
2006.
71

Different scenarios have been tested in order to adopt a first instrument of the electronic
health at a cantonal level. In may 2003, the Grand Council approved in unanimously the
funding of the project "Rete Sanitaria" within the Cantonal Administration, under the
responsibility of the department of Health Affairs and the State Counsellor Avv. Patrizia
Pesenti, the cantonal physician Dr. Ignazio Cassis as Project Responsible, and Dr. Marzio
Della Santa, project manager.
The Health card is meant to be a first step toward the organisation of an information
health network and further on toward integrating health care.
There are two health cards: patient's and professional's. A microprocessor and different
level of data access are ensuring data security of the contained information:
administrative data, urgent medical data and medical history.
The Smart health card was adopted and implemented initially in an experimental phase
in the urban area of Lugano. Project team and stakeholders aimed at involving:
• 2500 patients
• 40 private practices
• hospitals(Ente Ospedaliero Cantonale) and two private clinics
• 40 pharmacies
• The Ambulance service "Croce verde"
• The Home care service "SCUD"
The purpose of the project of creating an informal network with more than thirty private
practice offices, two private cliniques: St Anna and Clinica Luganese, a private
foundation- The Cardiocentro, the hospitals- EOC (Ente Ospedaliero Cantonale) and
fourty pharmacies is am ambitious aim facing though many barriers.
Stakeholders as Ethic Committee, legal advisors, patients' association, Medical(FMH)
and Pharmacies Order, and sponsors called project partners as: Swisscom IT, Trüb, TI
Solutions, Superior School of health education provided support all the way. This added
difficulties in managing different actors' needs and requests, being sometimes stuck in the
middle and assuming full responsibility of actions taken or not taken.
72

Conclusions:
My purpose was not to present technical details of the project as there are already papers
and a feasibility study presenting it 47 . Instead I wanted to identify main problems and
obvious or neglected difficulties faced when implementing this project.
The Project "Rete Sanitaria" is certainly an ambitious project bringing the future into the
present, if I may say so, and bringing innovation into the health care value chain. The
process of taking in charge patients is being changed.
Visiting and interviewing the responsible of patients' administration at Cardiocentro
Ticino, and taking part at defining several organisation charts for the process of taking in
charge patients with a Health patient electronic card I realised the change brought into the
operational habits of health practitioners as well as administrative staff.
In emergency cases the Health card may save lives, as the physician or medical staff has
immediate direct access to the patient's medical data. Adverse effects, allergies,
interactions between taken medicaments may be all avoided by the proper use of the
Health card.
It also motivates patients to take responsibility of their health status. Brief it empowers
patients and takes the step from a paternalism approach to patients empowerment.
The information accompanies the patient. From the general practitioner, to the pharmacy
or the specialist, the patient carries his medical data. In emergency cases, the Health card,
"speaks" for the patient and ambulance services have the possibility to have immediate
access to urgent needed medical data using portable health card readers.
The Health card is also used in the case of long term health care. The Service of home
care has the possibility to use the health card and avoid "forgotten" medical data by old
patients.
Analysing the clinical dimension involved by the use of the health card it is obvious that
the entire process of providing health care services has been improved, from the primary
care prevention, health promotion till the long term palliative care.
The economical dimension is still being debated and although huge reduction costs
potential is being emphasised there is a normal reluctance for accepting it. Concrete
47 Studio di fattibilità, Progetto Rete Sanitaria, M. Della Santa, I. Cassis, Claudio Benvenuti
73

economical analysis is needed but there are difficulties in the assessment, equity and
quality of care-costs reduction trade off issues.
There were a series of factors slowing down project's implementation:
• the project team's scarcity of human and financial resources,
• the normal resistance to change from partners, practitioners, patients
• the largely spread reluctance for data security and privacy,
• a narrowed fragmented view over the health system .
• change management techniques and social marketing used but maybe with delays
therefore producing late effects.
In 2007 the Grand Council will vote or not the extension of the project from an
experimental phase to a full implementation at a cantonal level.
Public health policies often fail or worsen the problems they were meat to solve. "To vote
or not to vote" is the question policy makers from Ticino will face. The positive vote will
mean a positive vote toward a future federal use of electronic health instruments. The
next step to take will be the step toward the formal integration of health care.
There is a common view on considering the adoption of electronic health instruments, the
technology into the health care and further more the integration of health care as a last
solution, a solution for the problems health care are facing.
Another common view considers each health system and sub system separately and in a
fragmented way.
In my opinion, e-health as an essential first step toward integrating care should be an aim
for a better health system. For this purpose we surely need a system thinking view
Maybe it should be considered as John Sterman claimed in a forth coming article 48 , that
what prevents us from overcoming policy resistance "is not a lack of resources, technical
knowledge or a genuine commitment to change. What thwarts us is our lack of systems
thinking capability. It requires crossing boundaries between departments and functions in
an organisation, disciplines in an academy, between private and public sector".
48 "Learning from Evidence in a Complex World", John D. Sterman,, Massachussets Institute of
Technology, forthcoming, American Journal of Public Health
74

CONCLUSIONS
For practitioners, decision makers and researchers at international level, health networks
are a topic of great interest. The consideration of the integrated health care as a "last
solution" imposed by the necessity of containing an increasing health expenditure proves
that health care stakeholders do not have a global perspective of the health system and
they continue having a fragmented view therefore maintain fragmented health systems.
My remaining question after a systematic literature review, analysing pilot projects and
international experiences of introducing integrated delivery care was why do initially
successful projects of creating health networks that should allow decreasing costs while
maintaing the quality of the health care services provided, fail?
My proposal as result of the research taken both at Swiss and international level goes to
considering the health system from a systemic point of view.
In order to understand the functioning manner of an organism, it is important to
understand its processes of searching the equilibrium 49 . Both the obvious processes and
the hidden ones. These are the reasons explaining the failure of the efforts taken for
modifying social structures. A statal economy does not work because it prevents a great
number of regulators factors that are actives in a market system, to work. Mergers of
enterprises fail under the same causes. The example of the failure of the merger of two
hospitals from Boston is relevant for understanding this thesis. Two hospitals, both
providing quality health care services, aimed at merging and creating an ensemble with
innovative technology. The new organisation lost though the attention dedicated to the
quality of the service offered to its patients and the attachment to the personnel which
previously characterised the two hospitals. The new administrative structures and their
procedures had compromised the delicate regulation processes which should have eased
the quality control, the attention paid to the employees' needs and to the good contacts
with patients.
49 Peter Senge, The fifth discipline
75

Often these mechanisms are interpreted as a management fault, unable to apply good
change management techniques for managing the normal resistance to change. Another
considered cause is the financial restriction, which prevent from installing costly
informatic and communication technologies which may enable integrating health care.
"As the world changes ever faster, thoughtful leaders increasingly recognize that we are
not only failing to solve the persistent problems we face, but are in fact causing them. All
too often, well-intentioned efforts to solve pressing problems create unanticipated ‘‘side
effects.’’ Our decisions provoke reactions we did not foresee. Today’s solutions become
tomorrow’s problems. The result is policy resistance, the tendency for interventions to be
defeated by the response of the system to the intervention itself. 50
What prevents us from overcoming policy resistance is not a lack of resources, technical
knowledge, or a genuine commitment to change. What thwarts us is our lack of a
meaningful systems thinking capability. That capability requires, but is much more than,
the ability to understand complexity, to understand stocks and flows, feedback, and time
delays. It requires, but is much more than, the use of formal models and simulations. It
requires an unswerving commitment to the highest standards, the rigorous application of
the scientific method, and the inquiry skills we need to expose our hidden assumptions
and biases. It requires that we listen with respect and empathy to others. It requires the
curiosity to keep asking those ‘‘why’’ questions. It requires the humility we need to learn
and the courage we need to lead, though all our maps are wrong."
The health needs of populations are in transition, and health systems and scientific
knowledge are changing rapidly. In order to meet these challenges, decision makers need
the tools, capacity, and information to assess health needs, choose intervention strategies,
design policy options appropriate to their own circumstances, monitor performance, and
manage change. The overall challenge is to ensure that policymakers have access to the
best evidence and tools, and that they also have the capacity to use them to enhance the
performance of their health systems.
50 System Dynamics Review Volume 18 Number 4 Winter 2002, John D. Sterman
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The 21st century health care system redesign will be composed of entities which are
characterised by:
• Information technology capabilities that continuously collect and measure health
outcomes; provide real-time, best-practices updates for clinical decision making and
patient safety (physician order entry, drug interaction and allergy software
protection);and shares health information (by means of electronic medical record or
patient portable personal health information smartcards) within a subsystem and/or
among multiple subsystems.
• Internet utilization that makes general health information available; uses e-mail for
prescription refills, to ask questions of providers, set up appointments, and accesses
personal health information 24-hours a day, 7-days a week.
• Clinical research in, and application of, genomics and pharmacogenomics to the
practice of medicine;
• The provision of primary care with coordinated access to the full continuum of
outpatient, hospital and rehabilitation and specialty care.
• Processes will focus on preventive, acute, chronic and palliative care;
• Standardized and validated health outcomes will be based on measures which are
applied fairly, risk or severity adjusted, and recognize patient behavioural factors, i.e.,
compliance;
• Incentives will be properly aligned to pay for performance;
• Administrative operations will be streamlined, centralized and/or standardized to avoid
duplication, redundancy and unnecessary costs.
• Payment systems will be reconfigured by purchasers, insurers and government to pay
for population health management, chronic disease state management and care
coordination. Traditional point of service reimbursement based on physician/patient
episode of care will be changed to reflect the new models of care. Payment methods will
incentive providers and systems to implement the redesign and pay for high quality care.
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Health networks implementation suppose profound change at both intern and extern
level.
The internal change concerns the functioning of the network, which has to produce the
targeted improvement of the cooperation between partners.
The external change concerns the relative position of health networks within the health
system and which leads to reinforcing their position.
The main problem the health system is facing is related to achieving efficiency and in this
optic health networks implementation can constitute a pertinent solution as conforming to
numerous studies. There are long debates considering the issue of whether health
networks can achieve the predicted financial performance. Some studies 51 claim that
hospitals belonging to health networks do achieve effectiveness while improving quality
of care provided. Whereas other studies 52 claim that there is no evidence on the financial
performance promised or an improvement of performance may only be achieved on a
long term. Faced with the crisis overall health systems are confronted, implementing
health networks organisation needs experimenting, learning and identifying results which
will provide the prove that cooperation in health care is both possible and needed and
that it may bring the improvement of the quality of care provided and reducing relative
costs.
51 The financial performance of hospital belonging to health networks and systems, G. Bazzoli, S. Shortell,
Inquiry Blue Cross and Blue Shield Association, Fall 2000, ABI INFORM
52 A detour on the integrated health networks road, Health Affairs, 2005
78

Appendix
79