Exploring healthcare
inefficiencies: the case of health
care appointments
Funded under
H2020-72745

2
Overview
striving for the triple win in health care
fine balancing act for costs, efficiency, and quality
emerging blended models of care placing
appointments at the center of productivity
remote vs face-to-face; scheduled vs. drop-in;
group vs individual appointments
augmented with patient-generated data; patient- and
provider-facing apps; personal health records
redefining participation, productivity,
professionalism, accountability
role of eStandards
Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China

3
Access to appointments
unable to get same day appointments:
50% Norway, 41% Sweden, 42% United states, 19% NL
40-64% after hours without going to emergency, 25% NL
NL Consult app before access to GP
Is this telling about, which health system is better?
August 24,
2017,Exploring healthcare inefficiencies: the case of health care appointments
Source: 2016 commonwealth survey in 11 countries.
http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf

4
Chinese appointment app in Hangzhou…
Exploring healthcare inefficiencies: the case of health care appointments
Select Doctor,
Date, and Time,
receive
confirmation
by SMS

5
A Chinese emergency appointment
experience at MedInfo2017
August 24,
2017,Exploring healthcare inefficiencies: the case of health care appointments

6
Connected Care in the US
and the Patient Experience
August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments
http://surescripts.com/connectedpatient/default.html

7
Exploring healthcare inefficiencies:
the case of health care appointments
Catherine Chronaki - introduction
Petter Hurlen – complex and simple cases
Jan Petersen – environment in Denmark
Morten Brunn-Rasmussen – Danish appointment
Anne Moen – zooming out
Discussion – can standards help reduce inefficiencies and
increase quality in blended models of complex care?
Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China

Healthcare inefficiencies
The case of appointments
Olav´s story
(and Jon´s)
Petter Hurlen
Akershus University Hospital
petter@hurlen.no

One doctor One patient One appointment

# Care Visits
1 GP Every now and then

# Care Visits
1 GP Every now and then
2 Cardiologist 1 Twice a year, private
Lab tests 1 week before, private lab
3 Cardiologist 2 Every two year, Hospital 1
Lab tests 1 week before, Hospital 1 lab
Admission Fasting before
4 Vascular surgeon 4 times a year, Hospital 2
CT scan 1 week before / cancel, Hosp.2
5 Physiology Same day as 3, Hospital 2

# Care Visits
1 GP Every now and then
2 Cardiologist 1 Twice a year, private
Lab tests 1 week before, private lab
3 Cardiologist 2 Every two year, Hospital 1
Lab tests 1 week before, Hospital 1 lab
Admission Fasting before
4 Vascular surgeon 4 times a year, Hospital 2
CT scan 1 week before / cancel, Hosp.2
5 Physiology Same day as 3, Hospital 2
6 Nephrologist Every six weeks, Hospital 3
Lab tests 4 days before, at Hospital 3 lab
7 Haemathologist Twice a year, Hospital 3
Lab tests 4 days before, at Hospital 3 lab
8 Neurologist Once a year, Hospital 3
Cognitive test Same day, Hospital 3
SUM 30-40 appointments/year

# Care Visits
1 GP Every now and then
2 Cardiologist 1 Twice a year, private
Lab tests 1 week before, private lab
3 Cardiologist 2 Every two year, Hospital 1
Lab tests 1 week before, Hospital 1 lab
Admission Fasting before
4 Vascular surgeon 4 times a year, Hospital 2
CT scan 1 week before / cancel, Hosp.2
5 Physiology Same day as 3, Hospital 2
6 Nephrologist Every six weeks, Hospital 3
Lab tests 4 days before, at Hospital 3 lab
7 Haemathologist Twice a year, Hospital 3
Lab tests 4 days before, at Hospital 3 lab
8 Neurologist Once a year, Hospital 3
Cognitive test Same day, Hospital 3
SUM 30-40 appointments/year
9 Home nurse Three times a day

# Care Visits
1 GP Every now and then
2 Cardiologist 1 Twice a year, private
Lab tests 1 week before, private lab
3 Cardiologist 2 Every two year, Hospital 1
Lab tests 1 week before, Hospital 1 lab
Admission Fasting before
4 Vascular surgeon 4 times a year
CT scan 1 week before / cancel
5 Physiology Same day as 3, Hospital 2
6 Nephrologist Every six weeks, Hospital 3
Lab tests 4 days before, at Hospital 3 lab
7 Hematologist Twice a year, Hospital 3
Lab tests 4 days before, at Hospital 3 lab
8 Neurologist Once a year, Hospital 3
Cognitive test Same day, Hospital 3
SUM 30-40 appointments/year
9 Home nurse Three times a day

For Jon –
the appointment
is
the care process
For Olav –
the appointment
is an element in
the care processes
Jon
Olav,
and Nora

The Danish experiences
Jan Petersen, Chief Consultant
MedCom, Denmark
Exploring healthcare inefficiencies:
the case of health care appointments

17
What is MedCom?
• MedCom is established in 1994.
• The Regions, Local Government and
the National government decided to
make MedCom permanent, with the
following aims:
• “MedCom shall contribute to the
development, testing, dissemination
and quality assurance of electronic
communication and information in the
health sector with a view to
supporting good practice in patient
care.”
– MedCom is financed by:
– The Ministry of Health
– The Danish Regions
– Local Government
Denmark/Municipalities

18
Prerequisites for eHealth and standardization in Denmark
• Unique Person ID - life-long and multi-purpose since 1968
• National registration of hospital contacts since1976
• Legal authorization registry for health care professionals
• Health provider/organization registry since 2006
• National security services
• National health service – tax financed
• National it-strategies
• National classifications and terminology
• - and a multi-vendor policy within eHealth
• Combination unique to Denmark

19
• A lot of work already done by international experts
• Open the Danish market for international vendors
• Make opportunities for the Danish vendors on the international market
• Maintaining a dynamic market – following new trends
Why international standards?

20
Danish HL7 CDA-Ver 2 profiles – one of many

21
The Danish Health Data Network
• Exchange of data:
• Messaging
– One-to-one
– One data provider - One data
consumer
• Web service
– One-to-many
– One data provider – Many data
consumers
• Index lookup
– Many data provider – Many data
consumers

22
Complex / Simple patient’s appointments –
support for planning
• The cross-sector overview of patient
appointments will leverage:
– Quality of care – increased co-ordination
– Limit duplication of procedures
– Gain a rapid overview of the patient’s
appointments
– Patient can keep track of appointments
– Existing bookings can be seen in planning new
appointments
– Provides a rough overview regarding past and
planned health care services in the patient’s
care plan
• Appointments will be a part of the National
EHR overview for citizens and health care
professionals on The national Health Portal
sundhed.dk
https://sundhedsdatastyrelsen.dk/-/media/sds/filer/rammer-og-retningslinjer/digitaliseringsstrategi/digitally-support-complex-crosssector-patient-pathways.pdf?la=da
https://www.sundhed.dk/borger/service/om-sundheddk/ehealth-in-denmark/

23
Multi-vendor > interoperability
• Interoperability – how to secure it in a multi-vendor
environment
– Common interfaces – standards – profiles
– Robust Internationale standards
– National consensus – including clinical and technical
co-operation in national profiling
– Testing and Certification of al vendor products
– Robust testing and certification operation (ISO 9001)
– Monitoring the use of MedCom approved standards
– Publishing which vendor passes the certification

24
• Think small – disseminate big
• Only one challenge at a time
• Standardization by demand
• If you cannot explain your strategies/plans in
plain language – it will probably never work in
the real world
• Building the infrastructure along the way
• Define problem – choose the right tool
• There is no silver bullet!
Lessons learned

Exploring healthcare inefficiencies:
The case of health care appointments
Profiling international standards
Morten Bruun-Rasmussen
mbr@mediq.dk
MEDIQMEDINFO 2017. Hangzhou, China. August 24 2017.

Profile definition
MEDIQ
• A profile is a selection of definitions and
options from standards or other
specifications.
• Profiles provide developers a clear
implementation path.
• Profiles give purchasers a tool that
reduces the complexity and cost of
implementing interoperable systems.

Profiling process
MEDIQ
International
standard
International
profile
National
profile
• Broad coverage
• Not specific
• Not useful for implementation
• Not useful for daily operation
• For a specific use case
• Constrains are done
• Can be implemented
• Not useful for daily operation
• For a specific use case
• Further constrains are done
• Useful for implementation
• Useful for daily operation

Communication
Application
level
Logical
level
Technical
level
presentation
clinical content
model
format & storage
transmission
Semantic
interoperability
Technical
interoperability
terminology
functionality
presentation
clinical content
model
format & storage
transmission
terminology
functionality
Clinical
Interoperability
Continuity and
quality
Organisational
level
Interoperability and the ALT-model

Defining content is challenging
MEDIQ

Appointment data to be shared
MEDIQ
The data are discussed
and agreed in a group
with 20-25 people form
hospitals, municipalities,
general practitioner and
vendors

 Appointment identification code
 An unique appointment code, generated by the filler system
 Patient
 The person, who are booked for a health care service
 Appointment requester
 The organization/person who have ordered the appointment via the placer system
 Appointment registrant
 The organization/person who have booked the appointment via the filler system
 Start date and time
 Start date and time when the appointment is to take place
 End date and time
 End date and time when the appointment is to conclude
 Health care organization
 The responsible health care organization/person for the appointment
 Location
 The visit address for the appointment
 Reason
 The reason why the appointment is scheduled
 Status
 The status for the appointment (booked or deleted)
Appointment content
MEDIQ

1. The profile can be implemented (in DK)
2. The profile are a constrain of the standards (no addition)
3. The original standard shall be used where possible
4. The used language shall be the same as the standard (English)
5. Datatypes in the standard shall be carried on in the profile
6. Danish agreed national coding shall be used in the profile
7. Mandatory data element in the standard shall also be
mandatory in the profile
8. Optional data elements in the standard shall be avoided in the
profile
9. Optional data in the standard can be mandatory in the profile
10. The use of an optional data element shall be well defined
11. The profile shall include a description of the intended use
12. The profile shall include information for future maintenance
Profiling: 10 commandments
MEDIQ

Anne Moen,
Faculty of Medicine, University of Oslo
Exploring health care inefficiencies:
the case of health care appointments
Collaboration – Coordination

Episodic encounter
• Defined problem – (sub) acute situation
– Clear start – stop
Series of interdependent encounters
• Interacting problems – co-morbidities,
– Team approach; activities – expertise – resources – services
• Activities to manage chronic condition(s)
– Monitor the disease – regular follow up by specialist(s)
– Trajectory of treatment and supported self – care
Appointment is either

Data elements - “appointments”
• Scheduled appointment ≠ used appointment
– Were the patient seen ?
– What happened in an appointment ?
• Type of appointment
– f2f consultation (traditional)
– Tests; prepare for f2f consultation
– eVisits – teleconsultation
• Time to appointment – access to care
– Urgency, maximum wait time

Coordination – Collaboration
• for citizen
– Coordination – self serve re. appointments
• Booking – single or multiple resources in encounter
• Overview of history and future plans
– Collaboration
• for health providers
– Coordination of resources
• Overview, continuity
– Collaboration – team approach
• Mobilizing resources, expertise & experience, tests

Appointment overview for ..
• Coordination of information
– Integrated data view or search in multiple screens
– Scheduled appointment ≠ used appointment
• Collaboration – sharing information
– Easy – to – use; complete/comprehensive information
– Granularity of information relative to logistic / clinical use
– Policy for cancellation – changes
• Coordination of care
– Benefit and beneficiaries
– Planning – seeing same team & resources ?

Exploring healthcare
inefficiencies: the case of health
care appointments
Catherine Chronaki
euoffice@HL7.org
Funded under
H2020-72745

39
Patient summaries: our navigator in the
health and social care ecosystem
“Bring the Power of Platforms to Health Care” using data to drive:
[Bush & Fox, HBR November 2016]
administrative automation
networked knowledge
resource orchestration
Elements to consider: appointments, technology, and productivity
 virtual and f2f just-in-time appointments
Context: Patient summary as a window to a person’s health or
personal dashboard:
Medications, allergies, vaccinations
problems and procedures, labs, diagnostic imaging
recent or planned Encounters, implantable devices
advance directives
Exploring healthcare inefficiencies: the case of health care appointments
eStandards need to
• help build trust
• unlock the power of health data
• facilitate decision support
• navigate the health system
August 24, 2017, Hangzhou, China

40
Connected Care in the US
and the Patient Summary promise
August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments
http://surescripts.com/connectedpatient/default.html

41
Connected Care and the Patient
experience: organization coordination
For any two organizations to meaningfully coordinate care
on behalf of a patient, they must
know which patients they should be coordinating care for
know which providers those patients see
have procedures in place to determine when, how and
what patient information to communicate with each other
have the tools, processes, and technology to be able to
transfer and effectively use that information.
August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments
http://go.surescripts.com/hubfs/Whitepaper-all-healthcare-is-not-local-1.pdf

42
eStandards –
eHealth Standards and Profiles in Action for Europe & Beyond
Vision of the global eHealth
ecosystem
 people have navigation tools for
safe and informed health care
 interoperability assets fuel
creativity, entrepreneurship, and
innovation
eStandards will:
 nurture digital health innovation
 strengthen Europe’s voice & impact
 enable co-creation and trusted
provider-user relationships
Base Standards
Use Case based
Standards Sets
Assurance and
Testing
Live
Deployment
Feedback and
Maintenance
Tooling and
Education
Forums and
Monitoring
eStandards
Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China

43
Innovation is where standards are most needed:
to unlock data for trust & flow
Today:
Massive health data accumulated in silo EHR systems serving documentation
purposes. We need to move from passive documentation to active use of
information and knowledge creation: activation!
Patient summaries defined at the macro level: cross-border exchange for emergency
or unplanned care at a national level. Need to address communities and individuals!
Standards and profiles address a predefined exchange of information. Need flexible
use of available content and structure, recognizing national, regional or local
jurisdictions trust & flow!
Shaping the future: Focus on the top level: systems of innovation!
Systems of record – documentation systems -EHRs
Systems of differentiation – profile based data exchange
Systems of innovation – unlock data and user experience
+
+
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e
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e
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a
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e
Exploring healthcare inefficiencies: the case of health care appointments
August 24, 2017, Hangzhou, China

44
What do we need to make digital health work with
standards and interoperability?
Co-create
to make it real using
standards
Governance
to make it scale for
large-scale deployment
Alignment
to make it flourish in a
sustainable way
Exploring healthcare inefficiencies: the case of health care appointments August 24, 2017, Hangzhou, China

45
HL7 FHIR appointment v3.0.1
https://www.hl7.org/fhir/appointment.html
August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments

46
FHIR Appointment has Maturity level 3
Conditions:
(level 0)
FHIR resource or profile (artifact) has been published on the current build.
(level 1) the artifact produces
no warnings during the build process and
the responsible WG has indicated that they consider the artifact substantially complete
and ready for implementation
(level 2) the artifact has been
tested and successfully exchanged between at least three independently developed
systems leveraging at least 80% of the core data elements using semi-realistic data &
scenarios based on at least one of the declared scopes of the resource e.g. connectathon.
These interoperability results must have been reported to and accepted by the FMG
(level 3) the artifact has been
verified by the work group as meeting the Trial Use Quality Guidelines
subject to a round of formal balloting
has at least 10 implementer comments in the tracker from at least
3 organizations resulting in at least one substantive change
August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments

47
Recommendations from
health market collaborative
Make explicit what each player is bringing to the effort
Establish shared aim
Don’t reinvent the wheel
Make it flexible
Prioritize on the basis of impact and difficulty
Expenditures and impact on patients
Level of complication and risk
Ease of standardization
Benefit to the health systems
Choose simple metrics and goals
Better, faster, more affordable care
Use one improvement methodology
Fix the business side
Source: The employer-led revolution, Big Idea, HBR July 2015 August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments

48
Six Forces That Can Drive
Innovation—Or Kill It.
Players The friends and foes lurking in the health care system that can
destroy or bolster an innovation’s chance of success.
Funding The processes for generating revenue and acquiring capital, both of
which differ from those in most other industries.
Policy The regulations that pervade the industry, because incompetent or
fraudulent suppliers can do irreversible human damage.
Technology The foundation for advances in treatment and for innovations
that can make health care delivery more efficient and convenient.
Customers The increasingly engaged consumers of health care, for whom
the passive term “patient” seems outdated.
Accountability The demand from vigilant consumers and cost-pressured
payers that innovative health care products be not only safe and effective
but also cost-effective relative to competing products.
Source: HBR May 2006: Why innovation in health care is so hard
August 24, 2017, Hangzhou, ChinaExploring healthcare inefficiencies: the case of health care appointments

Exploring healthcare inefficiencies:
the case of health care appointments
Discussion

Exploring healthcare inefficiencies: the case of appointments 50

Exploring healthcare inefficiencies: the case of appointments 51

Exploring healthcare inefficiencies: the case of appointments 52