As health expenditure outweighs GDP in many countries and the digital transformation of healthcare is seen as a way to tackle this growing cost problem, healthcare management is confronted with questions on the prioritization of investments regarding digitization, innovation and digital transformation. So, how do you decide on making smart health technology decisions? Health economics expert Prof. dr. Dominique Vandijck weighs in on the topic and on health quality.
There are ample technologies in which healthcare organizations can invest. These range from new treatments and remedies on the clinical side of the equation to digital health solutions and systems for less often mentioned areas such as healthcare facilities. Yet, whatever the nature or purpose of the technology/solution, in the end the question is if it’s worth investing in and what supports the rationale to invest – or not.
Technology investments in healthcare obviously come with quite some unique considerations since we talk about a ‘sector’ that by its very nature is all about people and care – or, at least should be. Healthcare technology very often has a direct correlation with important aspects of our lives and almost always an indirect one. Technology investments in healthcare also occur within an important societal context with effects which can’t – nor should – always be expressed in terms of financial parameters.
How do you decide on making smart investments in health technology? Considering that all healthcare systems are different that’s a question for an expert in the field of, among others, health economics and health/quality policy.
Enter Prof. dr. Dominique Vandijck. Since September 2018 Dominique Vandijck is Deputy CEO at Kerteza, a management and advice office that covers the healthcare sector. Prof. Vandijck was a speaker at the 5th Conference on Digital Health where he tackled the health technology investment question in a lecture.
Smart health technology investment decisions when healthcare resources are scarce
Kerteza helps healthcare organizations with change and project management, audits and quality control, ISO certifications and accreditations of hospitals, trainings, interim functions and more. Can you resume what you and the company do? You have a curriculum with expertise on the crossroads where medical science meets medical management if that is the right way to describe it.
Dominique Vandijck: That is indeed the right way to describe it. I’m a university professor, specialized in health economics, health policy, healthcare innovation and quality management.
It’s the reason why Kerteza asked me to also become Deputy CEO since the company helps healthcare organizations, mainly hospitals, in dealing with different types of problems and challenges. These primarily concern the implementation of health technologies, new healthcare innovations, and various healthcare management issues.
We’re very active and highly specialized in electronic patient records, the laboratory sector and quality audits. Kerteza wants to be a well-respected and an evidence-based partner in making our healthcare sector better for patients.
The 5th Conference on Digital Health is about the digital transformation of healthcare with the help technologies. Technologies are approached as a part and an enabler of a broader healthcare system transformation. What is your lecture about?
Dominique Vandijck: I talk about smart health technology investment decisions and healthcare innovations. I want to demonstrate that every well invested Euro that goes into healthcare will earn itself twice.
Yet, it’s important to note that in health economics we call everything a technology. So, it could also be a new drug, a new diagnostic or therapeutic intervention, a preventive measure, you name it. In other words: it doesn’t necessarily need to be an ICT-related technology.
And it’s in this broader picture of technology than the pure ICT one, such as for instance a new drug for cancer therapy, that we look at which technology we need to invest in or not. We always compare the costs versus the benefits since healthcare resources are scarce and we must make choices on which technologies resources are spent or not.
You could say that a technology for us is something that must produce health or wellbeing so we will spend our money in those things that result in the most health per invested Euro, that’s the rationale.
Expressing the result of an investment in health spending in terms of health produced or wellbeing looks at the outcomes that in the end matter most. Could you give more details on how such outcomes are measured for people who are not familiar with it?
Dominique Vandijck: So, we always compare the cost versus the effects whereby we have parameters enabling us to estimate the effects of technologies on people’s health. One of the most preferable ways, which we always use, is measuring the effect in terms of quality-adjusted life years (editor’s note: simply put a measure used in the economic evaluation of medical interventions or treatments, also known as QALY, that looks at both quality and quantity in terms of length of life).
Other health effects which can be measured include improved outcomes, improved survival and so on.
Improving quality of care: measuring and acting
What about criteria used in quality audits, certifications and other areas where you need health- and care-related parameters for your work?
Dominique Vandijck: There are several types of possible parameters. We normally divide them into structure measures, process measures, and outcome measures.
Structure measures can, for instance, be about questions whether there is a checklist, a procedure for hand hygiene, an APD process (editor’s note: Approved Procedural Documents), you name it. An example of an outcome measure could be, for example, the one-year outcome after an acute myocardial infarction. Process measures can relate to various actions which have been taken such as prescriptions, therapeutic interventions, etc. In most cases it’s one of these categories or a combination of the three.
Editor’s note: Prof. Vandijck points to the so-called Donabedian model, a framework that is used in clinical audits, which essentially are quality improvement processes. The selected and used criteria can be classified into the three categories which the Donebian model proposed and Dominique Vandijck refers to (structure, process and outcome). Criteria depend on the scope, topic and goals of the concerned audit.
A clinical audit is often represented as a cycle whereby data collection and analysis are an important part. Yet, patients can also be involved in other ways?
Dominique Vandijck: Mostly, yes. The patient-related data is the type of personal data that gets recorded in patient records and obviously anything regarding the patient is key.
While we can measure many different types of parameters, the most important ones are patient-related outcome measures or patient-related experience measures.
Everything we do in healthcare deals with or about patients – and making them better – so each parameter and measure – which you try to follow up – that involves the patient is always better.
Talking about measuring: recently you pointed to an article citing Dutch Prof. Jan Kremer that, essentially said too much time is spent on measuring and not enough on improving quality of care. You seemed to agree and emphasized that, in addition to numbers, indicators and averages, we must above all learn to look at and deal differently with quality, with more attention to learning culture, open principles and dialogue, as well as the quality of decision-making.
Dominique Vandijck: That’s indeed what I believe. It’s quite a difficult topic really. The ‘external measurement’ as we do it now is good, and it led to quite some improvement in healthcare. However, today there is too much measurement for external reasons and, so, a lot of time goes to monitoring, recording data and similar activities. Consequently, less time goes to improvement indeed.
In the end, we measure to evaluate and, if all is well, we evaluate to draw smart conclusions and take smart decisions: to make things better, for instance by changing existing procedures or other forms of improvements.
I believe we must gradually move from a model that is focused on quality control to one that evolves towards quality planning whereby the question is what you are going to do with all the data and information you get. Next, we need to move from quality planning to quality improvement since data becomes information from the moment it’s useful and a lot of the data which we have in healthcare now isn’t always useful.
The essential role of health records in an integrated healthcare approach
Electronic patient records; it’s a topic with quite some debates and challenges. You mentioned it as one of the health technology implementations you deal with most. Nearly everyone agrees: they’re important and, as Wouter De Ploey said, even a necessary foundation. One of many challenges, on top of interoperability and the time they take, is a lack of information sharing as research seemed to indicate again. What’s your take?
Dominique Vandijck: I think that health records are extremely important since we evolve towards an integrated healthcare approach and one of the main problems in healthcare and healthcare quality issues is the fact that there is too less communication and coordination between and among healthcare professionals, organizations etc.
Sharing information, preferably on the same platform, is one of the most critical factors towards a well-functioning, integrated system in my view.
However, and this refers to your previous question, at the same time I think that we are too focused on just measuring data and putting them all in records. We should use the data in a more pragmatic way: a way that helps healthcare professionals working more efficiently, that provides relevant information to patients etc.
And then there is the health technology investment decision side. People sometimes say they will use a new healthcare technology or innovation. Even if we can’t predict the future, as health economists it’s our role to make the best possible estimation about the current and future impact of such investments to help decide whether it will be a good investment or not, on the short, mid-term and long run.
So, when implementing an electronic patient record system it’s important to not just hope it will work but to set it up in a way that it works as it is meant to, also taking in mind what I just mentioned with integrated healthcare, the need to use data in a pragmatic way and the challenges regarding communication.
Quality as the main motivation in healthcare decisions and health technology investments
You teach at several universities, including at the Faculty of Medicine and Life Sciences of Hasselt University. Previously we interviewed Valerie Storms of the Mobile Health Unit of the university. A lot of innovation with a focus on value, evidence and quality but still, for innovative companies it’s hard with little resources available so they need to find them elsewhere. Valerie also mentioned some success factors for mHealth applications. What is key for a new technology to be adopted in your view?
Dominique Vandijck: It indeed isn’t easy. For companies with new technologies it’s important to demonstrate that the technology has a clinical value. The physician needs to see the added value of using that kind of technology and thus the clinical value it offers.
If there’s also a practical added value, it will be used by the clinician. Secondly, if it can help a patient get better access to healthcare it will likely be used on the condition that it is very easy to use.
If a healthcare organization invests in a new technology, it will invest less in current technology. That is why quality matters so much. The trick is not to do more and more but to do the right things. Quality above quantity.
We also need to keep all the demographic evolutions in mind that make healthcare in the future far more complex than it is today. So, governments and healthcare institutions tend to be careful where they spend their money now and new companies with new technologies need to find resources elsewhere indeed.
You offer advice to the government. Do you recommend them to focus on quality too? In the end, as Valerie also reminded, the shift will be from the current fee-based system to a quality-based system and value-based care models.
Dominique Vandijck: Absolutely. I think that quality should be the number one focus in all healthcare decisions and that we all should be driven by it instead of by other motivations.
And you need to make a health economic evaluation for each healthcare decision. That might not necessarily make it the best decision, but it will be a better decision than one that isn’t supported by a health economic evaluation.
Given the pressure on healthcare and the importance of organizing it in the best possible way with, among others, the mentioned challenges, in everything we do in healthcare we need to consider the cost on one hand and the expected effects on the other of any technology we consider and compare one to the other. If we make health economic evaluations, we can make sure to pick the technologies that will deliver the most value instead of technologies with some waste.
Hospital networks: upscaling and rationalizing when choices need to be made
Another topic that lives in Belgium are hospital networks. You recently also said that the current fee-based financing model whereby we continue to reimburse the number of treatments and patients instead of the outcomes and the quality is one of the obstacles to build hospital networks.
Dominique Vandijck: Yes, indeed.
What do you think about the planned evolution towards hospital networks? As Wouter Deploey said, scale is one important factor.
Dominique Vandijck: It’s effectively about scaling up and a rationalization of medicine. You simply can’t offer all kinds of medical disciplines and interventions everywhere, so choices need to be made. It’s about costs but also about quality.
If you perform a specific surgical procedure 30 or 40 times per year in an area such as lung cancer or pancreas surgery, you simply will have better clinical outcomes than if you do it only once or twice a year. And by working with networks instead of with hospitals and other healthcare facilities all over the place you can achieve this degree of specialization, rationalization and at the same time cost reduction.
Collaborating is important. By bringing experts together in a network you can enhance the quality and reach the other objectives. Yet, at the same time, the competition will shift from the hospitals to the levels of the networks and competition is important for quality care and innovation Wouter De Ploey says. Your view?
Dominique Vandijck: I certainly agree. There will be competition between hospital networks but also internationally. Now, I also believe in the importance of the right culture and the common sense of physicians: they just want to be the best, make sure that they provide the best possible care, innovate, improve etc. and we need to have that trust in physicians.
You raised the point of international competition. Healthcare tourism?
Dominique Vandijck: Absolutely. It’s also how evidence evolves right now. If a certain technology in, for instance the US, demonstrated that the doctor who uses it has better outcomes compared to a technology we use over here, you can be sure that physicians will ask to have that kind of technology here as well.
They always want to use the newest and the most innovative technology. Physicians will always learn new techniques. Medicine isn’t just about the current state but always evolves and so do physicians. If there’s a new technique that makes a patient better, decreases length of stay or makes things better in other ways, they will use it.
Speaking about hospitals: what do you see as main challenges for hospitals, the area you’re most active in?
Dominique Vandijck: One of the main challenges is to make those hospital networks work with much more cooperation, a centralization of medical activities and interprofessional as well as interdisciplinary collaboration.
Another big challenge is the use of data in that context. If we will not be able to share data through electronic patient record systems, the integrated care of networks will not be possible.
In its project management approach, Kerteza uses lean, with among others Kaizen and the ‘5S’ model. There is somewhat of a discussion about value-based care versus lean, what’s your take on that?
Dominique Vandijck: That’s indeed an existing debate and quite a difficult one. Here as well I believe there is a high need for a pragmatic approach.
It’s about health economic evaluations and I think that if we know what kind of technology offers the most value, then that will be the technology to invest in right now. If things change over time, it’s possible that we need to take another decision but, regardless, now it’s good to invest and to finance those technologies that offer the most value for money.
Patient-centricity and the human dimension in digital healthcare
A while ago you were at an event on the patient and the care provider relationship. It’s an essential relationship. What are the characteristics of a strong relationship between both in your view?
Dominique Vandijck: In my view trust is certainly among the main ones and very good access is also essential.
Access, also in the sense of not spending too much time behind a screen in patient-facing situations to mention a quite often heard criticism in these days of the previously mentioned electronic patient record systems?
Dominique Vandijck: Certainly. There also needs to be a pragmatic approach in registering and monitoring data and other things so that there remains enough time for patient contact. This is still what most patients want and expect.
Where do you see the main changes of technologies in care? Wouter De Ploey said that he didn’t see too much impact on running the hospital with new technologies like robots or even telemedicine. For him, the main role of technologies is in the medical, the clinical part.
Dominique Vandijck: I agree with Wouter. Care is still a human given and there are still many things in that human dimension which you can’t automate, or at least: it’s very difficult.
So, I also do believe that the clinical dimension is the most important one where technology can and has to play its role and where we will see most changes with new medical technologies that make treatments more effective, for instance.
Healthcare insurers increasingly go for approaches whereby sensor data enable to adjust premiums or care plans are adjusted in function of lifestyle habits. One could say that it is a way of incentivizing a healthy lifestyle since often it goes hand in hand with coaching and so forth. Yet, it could also mean that people with a less healthy lifestyle in a way are punished so to speak. What do you think about these evolutions? Is healthcare more a matter of policy and the government and do you think these kinds of approaches by commercial companies should be embraced and be part of the healthcare discussion?
Dominique Vandijck: I think it is a government matter and find some evolutions quite freaky to be honest. I can’t understand that people think that those with less healthy lifestyles shouldn’t be treated in the same way for reimbursement and so forth. That’s a deontological and ethical issue.
Many people do not choose to live less healthier lifestyles. We are the lucky ones who know what to do and what not to do. It’s often about lifestyle-related diseases but many diseases, even if you live less healthy lifestyle, have a genetic or other origin so for me rewarding or the opposite would be discriminative.
Our Belgian healthcare system is quite unique in the world because the three basic principles it is built upon are 1) to make if affordable for everybody, so it has to be sustainable and everybody should be able to pay for healthcare, 2) it should be qualitative and 3) we have the solidarity principle which means everyone has access to the healthcare system. I fear that from the moment we will start with these kinds of ideas, you will end up with a very discriminative system.
However, if a patient explicitly agrees to share data and all is in line with personal data protection regulations there is a positive side as well. Looking at it from the health economic perspective, it’s important to note that many outcome parameters obviously aren’t about surviving a disease but also about quality of life or wellbeing which can mean different things to different people.
In that sense, such intermediate outcome parameters could be considered as additional parameters to support a decision regarding the investment in a specific technology or treatment.
So, it is worth thinking about these intermediate outcomes whereby people have various views on what quality of life, for instance, means. This could even be about how various people look at their current health state after having had a disease or treatment. What might be satisfactory for one might not be for the other.
Maybe we can compare such parameters to current health states or current lifestyle and in that regard, it would be good to have more of these intermediate patient outcome measures.
Thank you for your time and insights!