The APSS contribution to the European Innovation Partnership on Active and Healthy Ageing Stefano Vettorazzi (APSS), Clinical Governance Unit

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1 Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. The APSS contribution to the European Innovation Partnership on Active and Healthy Ageing Stefano Vettorazzi (APSS), Clinical Governance Unit 15 th European Health Forum, Gastein, 4 October 2012

2 Index CONTEXT APSS Profile Our territory: the Autonomous Province of Trento THE JOURNEY: The approach Phase I: citizens & patients data integration Phase II: data extension to strategic partners Phase III: connecting systems directly to the citizen TREC: the APSS-PAT Personal Health Record (PHR) Issues to be considered The double challenge The answer: TreC, a PHR Lessons learned CONCLUSIONS Critical success factors: our experience 2

3 APSS profile in 2011 APSS (Azienda Provinciale per i Servizi Sanitari) is the local healthcare provider of the Autonomous Province of Trento, a Recognized for Excellence in Europe organization within the EFQM recognition scheme. Its mission is to provide its constituents, living in the Trentino Region, with the following services: Health promotion; Preventive medicine; Primary and hospital care; Rehabilitation and long term care; Psychiatric care 8,040 employees ( healthcare professionals) 723 Independent contractors (General Practitioners, Pediatricians, and other doctors) 2 hubs and 5 spokes acute hospitals (1,750 beds), several outpatient clinics (2,600+ booking lists) 146 Pharmacies Agreements with private accredited hospitals (670 beds), outpatient clinics and nursing homes (56, with 4,390 beds) 1,1 billion turnover (financially viable) 3

4 Our territory: the Autonomous Province of Trento ^ Population 536,967 * (60,6 M) (* 1 Jan 2012, corresponding to 0,9% of the Italian population) Population density (201) GDP per head * 31,244 (23,467 ) (* 2011, 33% above the national average) Unemployment rate * 4.4 % (8.4 %) (* 2010; July 2012: Italy = 10,7; EU27 = 10,4) Tourist day stays (2010) 29,8 M Birth rate (x 1,000) 10.0 (9.1) Life expectancy* M = 79,7 yrs (79,2) (*at birth, 2010) F = 85,2 yrs (84,4) Crude mortality rate 8.7 x 1,000 (9.7 x 1,000) Infant mortality rate 2.3 x 1,000 (3,6 x 1,000) Population > 65 yrs 19.7 % (20,3 %) Ageing index (2010) 125,4 (144,5; EU27=111,3) Average age (2010) 42,8 yrs (43,5) Expenditure on health* 2,105 (1,848) (* 2011, per capita, 14% higher) A complex and diverse geographical territory ^ Corresponding figures for Italy in brackets

5 Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. The journey

6 The approach As from 2004, an incremental approach to e-health was implemented, based on some general principles: Citizens Personal Health Record systems aligning needs to strategy; ensuring a correct implementation; starting from the data; extending services beginning from strategic partners to citizens Professionals (external) Recipients Primary care systems This approach has been implemented according to 3 different phases: I.citizens & patients data integration; Professionals (internal) Hospital care systems I II III II.data extension to strategic partners; III. connecting systems directly to citizens. Integration 6

7 Phase I: citizens & patients data integration In setting-up its e-health system, the APSS has decided to follow an approach focused on implementing those functionalities enabling information to be immediately available to all professionals, rather than extending them within a specific area. Systems being used by the radiology, laboratory medicine, and pathological anatomy Units, i.e. the biggest producers of diagnostic information, were therefore the perfect candidates for the initial phase. During the timeframe, the standardization of the diagnostic systems enabled APSS to achieve the following results: unification of 7 laboratory systems into only one solution, managing about 13 M exams per year; implementation of a PACS solution (Picture Archiving and Communication System) having currently a capacity of 10 Terabytes per annum (1TB= gigabytes); standardization into one integrated solution of the different applications being used by the Pathological anatomy. During the same timeframe was further developed the Hospital Information System (SIO), a webbased solution including the main common functionalities needed for patient management, accessible by all health care professionals. Among the SIO functionalities, the most important one with respect to the different sub-systems integration is the central data repository, a centralized archive for all records and other documents produced by all sub-systems, accessed on a daily basis by about 4,000 professionals. 7

8 Phase II: data extension to strategic partners Systems integration aimed at ensuring the continuity of care could not be limited to APSS structures only. In order to extend existing systems beyond it, the next step of the APSS phased approach was to establish a link with its strategic partners, namely: GPs, Pediatricians, and those structures delivering health care on a contractual basis, e.g. nursing homes. In the 2006/2007 timeframe, a project interconnecting the APSS with GP s and Pediatricians was implemented, thus allowing to link the central records repository of the APSS (containing at present about 25 M digital health documents) directly to the medical records of about 450 GP s and Pediatricians. The project induced some important organizational and behavioral changes, e.g.: a system of interpersonal relations promoting knowledge-sharing and exchange of point of views regarding clinical decisions, enabled by the diffusion of technologies for electronic data management ; a constructive pressure (push) towards an additional informatization, induced by patients themselves asking for a digitalized information. The next phase originated by the existing flow of data towards primary care, which was used for feeding a citizen s medical record (TreC), enabling them to access their clinical data through the web. 8

9 Phase III: connecting systems directly to the citizen TreC is an electronic platform that supports patients, their families, and caregivers in personal health information management, enabling them to access, supplement, manage and share their health and well-being information Main features Hub for medical records Structured health diary Access to other family members records Currently being tested by 2,000 people Remote monitoring pilot studies (prototyping): Youth asthma, Diabetes, and Chronic heart failure A personal health record (PHR) is a digital Web-based collection of a patient s medical history in which copies of medical records, reports about diagnosed medical conditions, medications, vital signs, immunizations, laboratory results, and personal characteristics like age and weight are stored [Weitzman ER, Kaci L, Mandl KD, Acceptability of a Personally Controlled Health Record in a Community-Based Setting: Implications for Policy and Design, Journal of Medical Internet Research 2009; 11(2):e14] 9

10 Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. TreC: the APSS-PAT Personal Health Record (PHR)

11 Issues to be considered Need to include patients in monitoring and care processes, empowering laypeople and their network of care, the cornerstone of new models of care in which patients and health care personnel can work together to prevent, intervene timely and care more effectively Clinical information is often scattered around: ohospital paper-based information systems coexist with electronic ones and the latter do not always communicate each other ogps have their own systems and they exchange little information with hospitals or other institutions Technology improvement have made available to the general public many personal monitoring devices related both to health (e.g. blood pressure monitors) and wellbeing (e.g. running trackers) Patients are the only actors that are always there when something concerning their health happens 11

12 The double challenge Providing services to citizens Access to medical records Online payment for health services (not yet implemented) Personalized health information Clinical/health history in progress Providing tools to the chronic patients Personal monitoring tool Remote assistance and care Family/caregiver support for people relying on care 12

13 The answer: TreC, a PHR diabetes heart failure 13

14 TreC: the answer 14

15 TreC: lessons learned All stakeholders (policy makers, health institutions, doctors and patients association) need to be included in the early stages of the process Building the institutional infrastructure takes more resources than building the electronic one Online access to medical records fosters patient s perception of control over their health history and it opens up new opportunities of information-sharing among the (formal/informal) network of care 15

16 Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. Conclusions

17 Critical success factors: our experience Strategy Establish a clear vision and communicate it properly throughout the organization Ensure alignment among strategy, user needs and processes Hold both clinical leaders and IT accountable for the implementation Governance Provide empowerment to those in charge of the implementation Ensure effective communications and synergies among the different implementation projects Process and technology Avoid unnecessary complexity and verticalization Break large implementations into manageable phases (3-6 months) to demonstrate meaningful progress to users and management Enable clinical systems integration to support patient care processes across organizational boundaries 17

18 Impossibile visualizzare l'immagine. La memoria del computer potrebbe essere insufficiente per aprire l'immagine oppure l'immagine potrebbe essere danneggiata. Riavviare il computer e aprire di nuovo il file. Se viene visualizzata di nuovo la x rossa, potrebbe essere necessario eliminare l'immagine e inserirla di nuovo. Thank you very much for your attention