• Affordability
  • Brazil looks set to expand telemedicine

    Market research report on Brazil’s telemedicine shows it’s likely to increase from $495.3 million in 2015 to $743.8 million in 2017. That’s about a 50% increase in two years. Research and Markets published its findings and also found that the country’s mHealth market revenue look set to grow from $446.8 million to $1.43 billion over the two years, more than three times its 2015 spend.

    Brazil’s teleradiology takes a huge market share, 98%. The remaining 2% is for specialist consultations and distance learning and education. mHealth is a different market. Its range’s broad, and includes some apps for telemedicine.

    Despite mHealth’s gigantic growth forecast, there are several investment barriers. Short life-cycles is one. Both wearable and apps, and across vital signs remote monitoring and chronic disease management, mHealth’s rapidly and constantly transforming its ecosystem with new value proposition and solutions. Dealing with these obsolescence costs creates affordability challenges.

    World Bank data shows Brazil’s Gross Domestic Product (GDP) per head as about US$8,539. An average for Africa’s about US$5,666. The extra 50% can make a big difference to eHealth affordability. Even so, Brazil’s forecast expansion’s huge, so Africa’s health systems may be able to see some significant growth.

  • Healthcare analytics can be affordable

    Healthcare analytics promises massive rewards by improving hospitals efficiency. For Africa, the drawback’s that countries don’t have millions of dollars to spend on ICT upgrades and developments. An article in Healthcare IT News shows that hospitals don’t need a staff of 50 and a US$3 million budget to achieve valuable investment returns from healthcare analytics.

    Karen Reff, manager of decision support at Union General Hospital, a small facility in Georgia with 45 beds, invested US$50,000 and launched an analytics programme that freed staff from time-consuming data-crunching. It enabled clinicians to spend more time on delivering care and uncovering best practices to help reduce readmissions and pinpoint the best location for an outpatient clinic for Chronic Obstructive Pulimnary Disease COPD and Congestive Heart Failure (CHF) patients.

    “It all started with our CEO finally crossing his pain threshold for what he could tolerate when it came to trying to manage and mine data in Excel, having everyone working from the same page,” Reff explained. “From there it was a very organic process. I read tons of literature, including Gartner’s magic quadrant reports, and other information online to see what other organizations were doing. I investigated quite a few vendors, narrowed it down to six, and asked for RFPs.”

    After several months, the hospital found a vendor that met its needs within the hospital’s budget and price range. Reff said the analytics programme has helped to reduce readmissions substantially. “In the past, 30-day readmissions were reviewed and reported quarterly due to the time-intensive process required to gather the information needed for analysis,” Reff said. “Now the information is reviewed and considered on a monthly basis by the case management team to identify opportunities to reduce readmissions. Additionally, since readmission information is now available to case managers in real time, interventions can be implemented in a more timely manner.”

    African countries with tight budgets can learn from Union General Hospital. Implementing an analytics programme can be modest investment with more chance of sustainability. Good research into what’s available and a good understanding of needs and budgets, it’s possible to set up an affordable service that delivers real value. It should find a place in Africa’s eHealth strategies.

  • Is affordability the big challenge for eHealth and UHC?

    Tennis might not have much to do with healthcare, but Arthur Ashe extracted a universal concept. “Success is a journey, not a destination. The doing is often more important than the outcome.” It’s important for realistic plans for Africa’s long-term goals for Universal Health Coverage (UHC).

    It’s impossible to argue sensibly against the goal of UHC. For Africa, affording it, and its eHealth component’s a huge challenge. WHO says UHC’s goal “is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them. This requires:

    a strong, efficient, well-run health system; a system for financing health services; access to essential medicines and technologies; a sufficient capacity of well-trained, motivated health workers.” 

    Achieving UHC needs an emphasis on people and an increase in healthcare spending for each person. It’s obvious and understandable that Africa doesn’t spend enough on healthcare. Affordability’s been a long-standing constraint, but spending numbers from the World Bank shows how healthcare spending’s changing.

    Africa compared to global

    In 2013, Africa spent an average of about US$150 per person on healthcare. Globally, spending was almost US$1,140, so a huge gap for Africa to close, and it’s widening. The spending range has increased by about 17% over the previous five years, but this may not represent Africa’s progress. It’s spending since 2008’s increased by about 30%. Globally, the increase’s about 11%. Africa’s making progress, but it may be challenging to sustain. Average spending in 2013 dipped by about 3% over 2012. Despite this, Africa’s healthcare spending overall’s made considerable progress.

    Africa’s not all the same

    The picture across Africa’s a bit different. The high average growth rate of 30% over five years reflects a narrowing spending range. The difference between top and bottom’s a reduction of about 10% since 2008. It shows that overall, countries are moving in the right direction, but, there are some important details. Some countries are the very bottom of the spending league table may be stuck. Some at the very top may be reducing spending per person.

    This may be partly due to increasing and changing populations. Africa has the world’s fastest growing population. An eHNA post summarised these. It directly affects the healthcare spending per person numbers and trends, giving African countries two UHC challenges:

    Catching up the rest of the world Keeping up with its increasing number of citizens and patients and their needs and demands.

    What’s eHealth’s role? 

    When UHC was set up in developed countries, such as the UK’s NHS, eHealth wasn’t part of the landscape. Now, it offers an increasingly wide range of opportunities to run health services more efficiently, provide health professionals with clinical data they need and to use analytics to improve healthcare’s effectiveness.

    eHNA’s post on WHO’s 2015 global eHealth survey shows Africa lagging behind globally. With little in the way of legacy systems, Africa can take advantage of eHealth’s growing potential. The growth in healthcare’s finances should have a sustained allocation for eHealth as an essential resource to help to make a bigger difference as new types of eHealth come on stream in the future. It needs integrating with the steady recruitment, training, development and retention of the extra health workers needed to move towards UHC.

    Affordability constraints mean that a set of slow burn eHealth investments is the core option. This isn’t easier than big bang. It brings its own set of challenges, such as architecture, interoperability (IoP) and cyber-security weaknesses at interfaces as new initiatives, such as the Internet of Things (IoT), genomic databases and eHealth that hasn’t been imagined yet.

    Patience is needed for these to come to fruition with UHC. Eduardo Galeano, the Uruguayan writer offers an appropriate strategy. “Utopia is on the horizon. I move two steps closer; it moves two steps further away. I walk another ten steps and the horizon runs ten steps further away. As much as I may walk, I'll never reach it. So what's the point of utopia? The point is this: to keep walking.” If requires eHealth strategies build on long-term eHealth visions. No visions = short term fixes.

  • How's Africa's eHealth doing? WHO has some answers

    Africa’s healthcare’s tight financial constraints mean that eHealth investment’s slower than the rest of the worlds. WHO’s eHealth Survey 2015 has information from 33 African countries, about 61%, and provides some important insights.

    Africa’s eHealth finances are not sufficient to sustain its programmes. Globally, countries have an average of about 56%, including Africa’s numbers, of its eHealth finance sources in place. Africa has about 40%. It implies that Africa’s eHealth finance needs to improve its financial planning to improve its eHealth sustainability. The flow of funds from these diminished resources may be about 30% of requirements, revealing an even tighter constraint. 

    With this financial gap, it’s inevitable that eHealth will trail the global performance. 

    About 37% of African countries have a range of policies and strategies in place, lower than the global average of 55%About 56% invest in eHealth capacity building compared to 77% globallyeHealth legislation coverage is about 21%, about half the global rate of 42%About 7% have diagnostic, prescribing and vaccination alerts in place compared to 24% globally, more than a third downUsing eHealth for billing, HR and supply chain management’s at 62%, the same as the global rateAbout 32% use eLearning compare to about 43% globally, with both rates being slightly higher for health professionals than for health professionalsFor social media, 49% of African healthcare organisations are users, compared with 66% globally; for individuals and communities, the figures are 58% compared with 61%, so not much differenceFor Big Data, Africa is trailing by 2% to 13%. 

    These findings say nothing about the effectiveness or sophistication of the eHealth programmes. If there are limitations in Africa’s eHealth, these may be resolved by investing to catch up. While it’s demanding, some African countries are closer than others. eHNA’ll show the league table in the next few days.

    The next update’ll include WHOs 2016 eHealth survey. It’s expected in the summer. It’ll be good to see what it finds about the Internet of Things (IoT). It wasn’t a question in the 2015 survey.

  • eHealth problems can cost healthcare millions

    eHealth’s risky. When they set in, it shows how risk’s a cost. A report on DigitalHealth.net says booking and reporting patient activity at Sheffield Teaching Hospitals NHS Foundation Trust using CSC’s Lorenzo is contributing to major activity under-performance. A Trust report in February 2016 says it’s cost it nearly £12m, $17m, so far. It’s almost 1.2% of the Trust’s income. Looked at another way, if eHealth spending should be about 4% a year, it’s more than 25% of the cost, and another valuable, salutary eHealth lesson for African countries that goes alongside eHNA’s eHealth lessons learned eBook.

    It attributes the cause mainly to financial losses from elective activity, out-patients, critical care and a larger than expected deduction for emergency readmissions within 30 days. It indicates that some of this is because of eHealth problems of data issues in the new Lorenzo system towards the end of September that are creating challenges in reporting complete and accurate income figures.

    A bigger issue is the operational impact of the new system on booking and scheduling processes, particularly in outpatients. Some have been more time consuming. Lorenzo experts are visiting outpatient areas to assess the issues and recommending processes changes. Resolving the issues is critical to regaining high levels of operational performance.

    As Africa’s health systems expand their EHR adoption, it’s vital they implement a rigorous risk mitigation plan effectively and fully. Risk management has a cost, but it’s much less than the cost of risk that Africa’s health systems can do without.

  • A study in Tanzania sets out mHealth financing models

    mHealth affordability’s an essential part of its sustainability. An article in PLOS sets out a sustainable cost models for mHealth at scale. It’s derived from Mobile for Reproductive Health Project (m4RH) in Tanzania. One goal for the study is that most mHealth programmes in developing countries fail to reach scale, with a common cause likely to be the challenge of creating sustainable finances. The study explores strategies for mHealth program sustainability and cost-recovery models.

    Three strategies for cost-recovery were identified:

    User pay-for-service SMS cost reduction Strategic partnerships.

    These were used to develop four different cost-recovery scenarios. Each one leveraged strategic partnerships to reduce SMS costs and create SMS revenue. The team assessed the effects using break-even and uncertainty analyses for 125,320 users. 

    For three of the four scenarios, costs exceeded revenue by $94,596, $34,443, and $84,571. Not good on the face of it, but these costs represented large reductions, 54%, 83%, and 58%, respectively, from the programme costs of $203,475. They represent notional losses of between 17% and 46%. Scenario 4 had a profit of $5,660, a modest, approximate 3% profit, so affordable. Break-even points were driven by user volume, not changes in programme costs.

    Breaking even was only probable when all SMS costs were transferred to users and the lowest per-SMS cost was negotiated with telecom partners. This is fine for mHealth funders’ and investors’ affordability and sustainability, but it may adversely affect the economic gains. People too poor to pay may not be able to afford the health information they need, restricting the programme’s reach and impact.

    Like all studies there are a few caveats. Perhaps the most important one that the team identifies is the lack of cost and cost-effectiveness data on these types of programmes. If it was available, it would allow direct comparisons of economic Value for Money (VFM) with affordability. In mHealth business cases, these are two vital trade-offs. How much VFM do health systems need and how much can they afford is perennial, with affordability often a major constraint in decisions. Without reliable estimates of VFM, decision takers can’t make rigorous evidence-based choices between mHealth programmes competing for scarce finance.

    Despite this, the study’s findings offer a structured array of financing choices. It’s an important step forward for Africa’s mHealth.

  • UPMC and Health Catalyst aim to reduce healthcare costs

    Costing healthcare’s not easy. Patient costing in hospitals is easier than in primary care, but still has many challenges. One’s limited data. Another’s the large proportion of healthcare costs that are overheads relying on apportionment formulae that can inadvertently skew results. It can also be hard to define patients and the aggregation of their episodes of care, especially patients with long-term conditions.

    An initiative by University of Pittsburgh Medical Center (UPM) might help. It’s announced a strategic link with Health Catalyst, a data warehouse firm for a healthcare costing project. Their chosen methodology’s an Activity Based Costing (ABC) model. 

    UPMC’s well placed to tackle this. Its healthcare provision extends across hospital and primary care, so it can include wider care episodes. It also uses an ABC costing methodology that it deployed in 2014 “To blend quality data with physician- and patient-specific cost data.” Significant changes in clinicians’ behaviour have been achieved, leading to better care at lower costs.

    ABC’s not a new technique. Johnson and Kaplan proposed it in 1987 in their book Relevance Lost The Rise and Fall of Management Accounting. It proposed an improved definition of units for costing and a better cost centre structure for apportionments. Each cost centre needs: 

    A clear definition of its boundaries A time estimate for completing measurable inputs and outputs An understanding of cost drivers that explain cost variation.

    Their approach set out the need to extend costing to activity beyond fixed assets, such as hospitals. It also proposed that ABC numbers be dealt with in a performance management context that includes non-financial data. 

    While Johnson and Kaplan suggested ABC is not new, it can be seen as a better way to use the longstanding methodology of Total Absorption Costing (TAC). Both ABC and TAC allocate direct costs and apportion indirect costs to units of output. 

    This method means that it can’t be used to identify marginal costs. There are two types, variable and semi-variable. Identifying most variable costs isn’t too difficult. They change with each change in workload of an individual patient. In healthcare, it’s mainly drugs and some resources that aren’t material, such as a hospital inpatient’s food. Semi-variable costs, sometimes called stepped costs are the most challenging because they change with chunks of workload. These can depend on current spare capacity, productivity and time needed, so can be different wards, units and healthcare professionals. These variable costs are needed to manage short-term costs and fine-tuning operational activity. Johnson and Kaplan recognised that ABC doesn’t do it, implying that both ABC and variable costing are needed together. This is the model used by the UK’s NHS. 

    Reliable costs are needed for Diagnosis Related Group (DRG) and equivalent financing models for hospital services. Precise costs are largely unattainable when apportionments are used, however robust the apportionment methodology. It’s important to refer to a cost, not the cost. There may be more than one.

    As Africa’s health systems contemplate better unit costs, such as South Africa’s work on DRG’s for its NHI that eHNA covered, it’s essential to remember their two components. First is units, so data on workloads are needed. Second is costs, so a methodology that draws data from annual expenditure records is needed. It’s vital to improve these while simultaneously developing the costing methodologies.

  • Can Africa afford EHR cost overruns?

    eHealth affordability’s a big challenge for Africa’s health systems. Finding the finance for an EHR project is often the biggest part of an eHealth project’s budget. While this is tough enough, finding the finance cost overruns when a project’s already underway.

    STAT News has found that EHR cost overruns in the USA can be substantial. It identifies four examples, three in Massachusetts, USA and one in England:

    Brigham and Women Hospital in Boston overran its EHR budget by $27 million Southcoast Health of New Bedford struggled with the costs of its EHR in its four community hospitals Lahey Health in Burlington said the cost of switching its EHR resulted in extra training and support costs Cambridge University Hospitals in England lost its CEO and chief finance officer (CFO) as part of an investigation into its eHospital programme.

    All the EHR cost overruns created extra financial stress and losses on the organisations’ overall financial performance. They’re important, and alarming, examples of the financial risks of EHRs that can also apply partly to all eHealth.

    For African health systems that have found the finances for EHRs and other eHealth projects, can they provide the finance for equivalent risks? Important measures that can help include:

    Don’t provide eHealth finance that’s too tight and unrealistic, so will inevitably overrun Keep eHealth finances and projects under frequent and regular review to respond to cost increase as they’re about to happen rather than as an emergency or crisis response after they’ve happened Include a generous contingency provision in each eHealth project as part of the business case to test their high-end costs for sustainability Always have an option to abort eHealth projects if their costs start to look like they’re out of control 

    STAT News’s report shows that eHealth finance isn’t just about finding the money for eHealth, it’s about firm financial and risk management of eHealth projects. The bigger the scale, the firmer the financial and risk management requirements. These are even more important in Africa where health systems start from a much more constrained base.

  • EHR projects in USA hospitals have lessons for Africa

    Just because more hospitals use EHRs doesn’t mean EHRs are overcoming all their limitations. A US research team from Illinois, Massachusetts, Washington and the Office of the National Coordinator (ONC) has found that the challenges persist. Their research is published in Health Affairs. It found that in 2014, 75% of US hospitals had implemented at least a basic EHR, compared to 59% in 2013. It’s mainly small and rural hospitals that haven’t.

    Despite this substantial progress, many hospitals reported unresolved challenges. They include:

    Over half said up front and recurring costs reported challenges related to financial costs (up front and ongoing) Gaining cooperation from physicians, sometimes resistance Finding adequate ICT support.

    Small hospitals were more likely to report challenges. In addition, most hospitals might not be able to meet a more advanced stage of readiness, referred to as stage 2 core objectives. Unsurprisingly, hospitals that are not yet equipped to meet the readiness criteria were more likely to say they’re facing challenges. The financial implications are a critical challenge, and effective affordability strategies are needed.

    Small hospitals and EHR and eHealth affordability are prevalent challenges on Africa’s eHealth landscape. The USA’s experience shows that stepping up the scale isn’t enough. Engagement with health professionals, eHealth usability, utilisation, affordability and realising benefits are vital too. These are more challenging than implementing EHRs as systems.

  • England's not releasing eHealth savings estimates

    The need for evidence for eHealth benefits is vital in making better eHealth decisions. eHNA has numerous reports on a range of findings from the USA. Some of it’s positive, some shows the need for change and show limited gains in efficiency and cost savings. A report in Digital Health News (DHN), a UK-based online media services, says England’s NHS isn’t sharing details of estimated savings. The Department of Health has turned down DHN’s Freedom of Information request to see the report that DHN claims is the source of the estimates: Modelling the potential of digitally enabled processes, transparency and participation in the NHS by McKinsey.

    Estimated savings of between £8.3 billion and £`13.7 billion by 2020 have already been referred to in the public domain by officials. It’s not clear if these are potential savings, probable savings, cash savings, redeployable resources, or exceed the costs of achieving them. The numbers are significant, about half the £22 billion in annual efficiency gains that NHS England’s aiming for by 2020 to help fill a £30 billion gap between funding and demand. The report has been superseded by new plans, so the status of its estimated savings isn’t clear.

    It’s also about 1% of NHS England’s total spending. If extra eHealth spending takes its share of total spending up by about 1%, the eHealth savings may not be a net gain. This very simple comparison excludes the extra costs of risks in trying to realise the benefits. 

    In Exploiting the information revolution: call for independent evaluation of the latest English national experiment in the UK’s Chartered Institute for IT’s Journal of Innovation in Health Informatics, Dr Philip Scott says NHS England’s eHealth framework has “Many laudable and common sense ambitions,” but it’s “Light on evidence to support its aspirations, or plans for its evaluation.” An example is that it doesn’t include findings from the evaluation studies of the later stages of the abandoned National Programme for IT, and claims the unpublished McKinsey report was commissioned specifically to support the framework, raising “Questions about its objectivity.”

    An important lesson for African health systems is to ensure transparency about their eHealth plans. Engaging stakeholders effectively helps to produce better, sustainable business cases, plans and results. Sharing all the information is essential. eHealth plans are hardly state secrets.