1. Getting to visible – information,
integrated care, and Ireland: Moving
from fragmented to integrated care
Anthony Staines
ICT Strategy Unit, System Reform Group, HSE
School of Nursing and Human Sciences, DCU

2. Summary
●
Challenges
●
Some misconceptions about these
●
Where are we
●
Where do we need to go
●
How are we going to get there

3. Challenges
●
We can overcome these, if we want to

4. Ageing population
●
Increasing life expectancy
●
Increasing healthy life expectancy
●
Both good

5. Rising prevalence of chronic
disease
●
●
Series of Irish studies from the IPH and the
NCRI
All the chronic diseases studied, so far, will rise
in prevalence from 2010 to 2020
●
The rise is 20% to 60%
●
Partly due to ageing
●
More due to fixable lifestyle risks

6. Rising prevalence of multi-morbidity
●
●
Most of the money is spent on people, no all
elderly, with more than one chronic disease
This is multi-morbidity
●
It poses significant personal, clinical, and health
system challenges, all of which have to be met

7. Mean no. of conditions by sex and
age (TILDA)

8. Distribution of US health expenditure
http://www.nihcm.org/images/stories/Dat
aBrief3_Final.pdf

9. Where we are

10. Irish health system structures
●
Complex fragmented system
●
Paper based system
●
Largely manual communications, except in
General Practice

11. Complex system
●
Roughly 8,000 health providers with contracts
to the public service
●
Two-tier hospital care system
●
High user charges for primary care services
●
●
●
Perverse incentives
Primary care poorly developed except general
practice
Weakening private insurance market

12. Fragmented care
●
●
●
Too much care delivered in a very busy acute
hospital system
Poor communications
Primary and community care underused,
unsupported, and underdeveloped

13. Budget cuts
●
Budget falling fast, and likely to continue to fall
●
Population rising, and ageing quickly
●
Business as usual will not do!

14. Changes in expenditure (OECD)

15. Strong political leadership – ex-GP

16. Changes happening
●
Strong political leadership
●
Integrated care
●
Care at the lowest level of complexity
●
Move to community and primary care
●
Free GP care, initially for children under 6
●
Generic prescribing
●
Hospital groups and Money follows the patient
●
Moving to Universal Health Insurance

17. Information
●
Astonishingly little
●
What there is, is well used
●
Poor information systems
●
●
●
Little information on clinical activity
Poor information for staff and for managers at every
level
Only GPs have access to good systems, albeit
mostly confined to individual practices

18. Where do we need to go?

19. Integrated care

20. Integrated care
●
●
●
●
Patient centred care – the 'Medical Home'
Shared care following agreed clinical pathways
between primary and secondary care
Includes GPs, hospitals, and community staff
Tools to support the implementation of these
pathways do not (yet) exist in Ireland

21. An example – Ran Balicer, Clalit,
Israel
●
●
●
●
ICT supported, data driven, patient centred
integrated care in a health fund covering 4
million people
6% fall in hospital readmission rates for the
elderly
60% reduction in inequalities in the quality of
care between centres
Very good RoI

22. An example – Paul Grundy, IBM,
Vermont
●
Patient centred medical home with working ICT
●
Family practice based community coordinators
●
Agreed care pathways
●
10% reduction in insurance costs
●
60% reduction in the rate of complications of
Type II diabetes

23. ICT principles
●
The right data accessible to the right people
at every clinical encounter
●
●
●
ICT is to support clinical work directly
Information for Health/Business Intelligence comes
out of clinical ICT systems
Audit, research, planning, accountability all driven
by clinical activity

24. Steps
●
There is no simple solution
●
●
We do not have a blank slate
Learn from other peoples' failures, and
successes
●
No big bang!
●
Will be done, in stages, over 4 to 8 years
●
●
●
Must achieve visible results on a relevant time scale
Keep the momentum up
It will keep changing forever

25. Process
●
●
Patient centred process focussed on clinical
care
ICT development supports business needs
●
No ICT only projects
●
Technology is easy, and quite cheap
●
The hard bit, and most of the cost, is in changing
how people do things

26. Infrastructure
●
HSE spends under 1% of the budget on ICT
●
Ought to be at least twice this
●
There is past underinvestment to deal with

27. Individual Health Identifier
●
●
●
●
●
Legislation moving through the Seanad this
week
Critical building block for everything else
The challenge for the system will be getting the
IHI into all of the existing records
Data sharing will still be a problem
Legislation will be required to share data
effectively

28. Supporting activity
●
Clinicians
●
Patients
●
Managers

29. Clinical support
●
The right data accessible to the right people
at every clinical encounter
●
●
●
●
●
Good EMR/EHR as a skin over the data for
clinicians
Good adaptable decision support tools
Mobile access is required by many staff
Tools and data systems to support innovation in
ICT and health care delivery
Health information standards throughout the
system

30. Patient support
●
●
●
Full support for self-care
Access to appointments, basic data, test
results, prescriptions, and more for patients,
and, as appropriate, families and carers
Mutual support for patients e.g.
●
Expert patients
●
Support groups
●
Carer support

31. Management support
●
Flexible reporting systems
●
Configurable and open
●
Build on e.g. NQAIS work
●
Able to accommodate changes over time
●
Generate necessary canned analyses
●
Provide for more complex work

32. Technology
●
●
●
Several technology solutions can be envisaged
Final choice will come from engagement with
industry to find optimum solutions
Technology is not the real issue

33. Models
●
Build on the good existing systems - no 'rip and
replace'
●
No big bang
●
Build common infrastructure
●
●
Data accessible through agreed international
standards
Data accessible through open, documented,
APIs
●
Service oriented architecture

34. Innovation
●
●
Allow innovation, building tools for staff and
patients to manage and use their data
Rapid feedback of activity and outcomes at
individual, unit, facility, region and organisation
level

35. Success or failure?
●
Governance
●
Leadership
●
Buy-in
●
Patients
●
Clinical
●
Managerial
●
Trust
●
Resources

36. Acknowledgements
●
●
My colleagues in HSE, in the ICT Strategy unit,
in the School of Nursing and Human Sciences
in DCU, and many others for invaluable
discussions
Olga McDaid and the Tilda Study

37. References
–
–
–
Rechel B, Grundy E, Robine JM, Cylus J, Mackenbach
JP, Knai C, McKee M. Ageing in the European Union.
Lancet. 2013 Apr 13;381(9874):1312-22. PubMed PMID:
23541057.
Christensen K, Doblhammer G, Rau R, Vaupel JW.
Ageing populations: the challenges ahead. Lancet. 2009
Oct 3;374(9696):1196-208. PubMed PMID: 19801098.
McDaid O, Hanly MJ, Richardson K, Kee F, Kenny RA,
Savva GM. The effect of multiple chronic conditions on
self-rated health, disability and quality of life among the
older populations of Northern Ireland and the Republic of
Ireland: a comparison of two nationally representative
cross-sectional surveys. BMJ Open. 2013 Jun
21;3(6).PubMed PMID: 23794595

38. References
–
–
Glynn LG, Valderas JM, Healy P, Burke E, Newell J,
Gillespie P, Murphy AW. The prevalence of multimorbidity
in primary care and its effect on health care utilization
and cost. Fam Pract. 2011 Oct;28(5):516-23. PubMed
PMID: 21436204.
Erixon F, van der Marel E. What is Driving the Rise in
Health Care Expenditures? An Inquiry into the Nature
and Causes of the Cost Disease. [Internet]. Brussels:
ECIPE; 2011 p. 27. Report No.: 05/2011. Available from:
http://www.ecipe.org/publications/what-is-driving-the-risein-health-care-expenditures-an-inquiry-into-the-natureand-causes-of-the-cost-disease/

39. References
–
–
CSO. Population and Labour Force Projections 2016 2046 [Internet]. Dublin, Ireland: Central Statistics Office;
2013. Available from:
http://www.cso.ie/en/releasesandpublications/population/
populationandlabourforceprojections2016-2046/
Przywara B. Projecting future health care expenditure at
European level: drivers, methodology and main results
[Internet]. Brussels, Belgium: European Commission;
2011 p. 85. Report No.: 417. Available from:
http://ec.europa.eu/economy_finance/publications/econo
mic_paper/2010/ecp417_en.htm