The Digital Revolution in Health

Jerome Beranger, Roland Rizoulieres

• Publisher: Wiley-ISTE
• Year: 2021
• Print ISBN: 9781786306951
• eBook ISBN: 9781119842460
• Edition: 1
• Topic: Business
• Subtopic: Management
• Index: Business

What sort of health system do we want to implement in the face of the imminent arrival of artificial intelligence and robotics in medical practices? The Covid-19 health crisis has demonstrated the importance of digital technologies in the care of patients and their families, as imperative attention was called to ethics and relational practice.

This book analyzes numerous sources of feedback to reveal the multiple facets of this so-called Medicine 4.0. It reveals the extent to which digital medicine requires new forms of organization and new approaches to co-conception, in a logic that is resolutely collaborative with patients. The book concludes with legal and ethical points of view in order to challenge the reader on their duty to truly be an "actor" of their health care.

PART 1
The Health System and Digital Technology: Challenges, Issues, and Transformations

Introduction to Part 1

As financers and builders of standards, public authorities and the private sector (particularly insurance and mutual insurance companies) must support the creativity and development of digital innovations in health, and provide a framework and encouragement for this movement. For too long, good ideas and innovations have remained confined to the services, institutions, or local networks that gave rise to them, generating compartmentalization and operational incompatibilities. Our healthcare system needs these technological innovations to overcome the difficulties of coordination between professionals, to deal with the growing proportion of elderly people in homes and institutions and patients with chronic diseases. Digital technology must also help citizens and patients to be more involved in their healthcare.

At different territorial scales and in particular to manage the city-hospital link, healthcare professionals have many digital tools and services at their disposal in their daily medical practices, whether for patient care or administrative management. However, these tools are offered by various institutional and private players on geographical scales that are sometimes inconsistent with patients’ health and life paths. Above all, however, practice comes up against fragmented and often poorly interoperable application frameworks. Depending on the history of each organization, a tool often corresponds to each use, which greatly complicates daily professional practice. This phenomenon leads to the most basic expectations and needs of healthcare professionals (medical and paramedical) not being met or being met in too fragmented a manner: exchanges and sharing of information between caregivers around a patient, coordination of professionals, completeness of information available on care pathways, simplification of administrative procedures, etc.

We analyze the challenges, issues, and transformations of the healthcare system through digital technology from three perspectives. The first component deals with the digital integration of health territories from an organizational analysis perspective. The second part develops the digital experience within the city-hospital journey of cancer patients, with an organizational and ethical analysis. Finally, the last section looks at the experience of a tool for coordinating players, a connected health record, from a sociological and organizational perspective.

1. Introduction written by Roland RIZOULIÈRES.

1
Digital Integration and Healthcare Pathways in the Territories

1.1. Introduction

At the beginning of March 2018, French ministry work on the “digital” project of the Stratégie de transformation du système de santé (STSS), on the theme “Accelerating the digital shift”, aimed to produce by the end of June 2018 an operational roadmap covering the 2018–2022 period and aimed at strengthening the digital shift in the health system. In the long term, however, digital technology is responding to two strong but unfinished challenges: better integration of healthcare and better coordination of care.

The management of patients is becoming more complex, in particular due to the increasing prevalence of chronic pathologies, the accumulation of co-morbidities, psychosocial problems, and the aging of the population (Perone et al. 2014; Huard 2018). The difficulty in applying the recommendations of practice guidelines for such complex patients has been shown; in fact, by combining health, social, and environmental issues, they have specific properties (Wilson et al. 2001; Waldvogel et al. 2012). Complex patients are complicated not only because of their multiple pathologies but also when their different problems intertwine and interact, creating a new situation that is more difficult to manage. It becomes a unique case for which interventions must be rethought (Boyd et al. 2012) and adapted not only to the specificities of the pathologies and above all to the priorities and resources of patients and their environment.

Patient management in this context of epidemiological transition has been the subject of various conceptualizations, including the Chronic Care Model (CCM; Figure 1.1) proposed by Wagner et al. (1998) and Bodenheimer et al. (2002a, 2002b). In order to respond to the diversity of problems and the multiple skills required, these models recommend individualized care, requiring on the one hand an adapted healthcare system (Bodenheimer et al. 2009) and, on the other hand, a coordinated interdisciplinary approach (Schibli 2012; Gittel 2014).

Figure 1.1. Long-term chronic care model

(Source: Perone et al. 2014). For a color version of this figure, see www.iste.co.uk/beranger/health.zip

The consequence of this integrated and coordinated approach is the need for digital tools on the territory to ensure exchanges between professionals and patients/caregivers. It is precisely on this point that our reflection focuses. However, while the digital revolution brings great changes, digital tools are primarily based on organizational changes and often reveal organizational difficulties rather than representing the “Holy Grail” for all our problems.

Integration of care can be defined as a set of techniques and organizational models implemented to enable the transmission of information, the adoption of common operating modes, and collaboration between the health, medical, and social sectors. It can intervene at the level of financing, the administrative organization of the territory, and the functioning of healthcare structures.

The immediate goal of integration is to reduce the fragmentation of medical and social services in order to facilitate patient access to services that meet their needs. Its longer-term goal is to enable better care outcomes and better use of health resources.

The Chronic Care Model (Wagner 1998) conceptualizes the totality of conditions that influence the quality of care for a chronically ill person: funding, policies, laws, training, communication systems, information, resources, etc. This model postulates that changes in these different areas will have an impact on the practice of caregivers and on the care of sick people.

It also suggests that changing practices at the caregiver level requires action at the overall health system level. It may thus prove relevant to act on the legislation surrounding the methods and conditions for financing services, on the communication systems available to enable caregivers to communicate with patients, on the organization of training systems, on the recognition of the usefulness of support structures offered to patients, etc. The report also suggests that, in order to change practices at the caregiver level, action must be taken at the global level of the health system. Furthermore, this model shows the importance of proactive and interdisciplinary teamwork.

It is part of a clearly collaborative perspective in which the person being cared for participates actively in their care.

Integration alone does not improve care outcomes. It must be combined with “case management” procedures, that is, the explicit identification with an individual, or a group, of coordination activities whose flexibility and workload are beyond the capacity of primary healthcare professionals in their daily practice.

We will look at how digital healthcare is helping to improve the health and life course of patients and their caregivers, while raising the organizational issues inherent in our historically siloed healthcare model.

1.2. What lessons can be learned from integrated American and Swiss models?

In general, the study of internationally integrated health systems is situated from the perspective of organizational critical analysis in the management of chronic diseases. Issues of efficiency and cost-effectiveness (cost containment) are the two main drivers. The digital issue generally remains in the background. However, as Christian Bourret (2003) points out, “in the United States, 30% of medical errors are said to be due to problems related to information processing, in particular patient identifiers. This shows the importance of health information and the extent to which its control, optimal use, and quality of data are at the heart of the evolution of health systems and the improvement of the quality of care.”

Jane Grimson et al. (2000) identify “the inability to share information across healthcare systems and organizations as one of the major barriers to care coordination and cost containment.” Some of the reasons for the limited or non-implementation of information technology in the health sector are the complexity of medical data, data entry problems, security and privacy issues, the lack of a unique national patient identifier in many countries, and a general lack of awareness of the benefits of information technology. Many models are experiencing these difficulties. Obviously, we cannot analyze them all in this chapter. We will focus on two of them: the HMO (Health Maintenance Organization) in the United States and the Swiss model of the Delta network (Huard and Schaller 2010a, 2010b, 2011a, 2011b). The HMO was chosen for its historical character and the Swiss model for its effectiveness in chronic disease management (Huard 2019).

1.2.1. The cradle: the United States

The United States has been experimenting with integrated systems at least since the 1950s and has seen a significant evolution in the organization of its most familiar model, the HMO, since the 1990s. However, the HMO is not the only model in the United States. Since the country has not historically had compulsory health insurance, it is the private sector that has strongly structured the health system. Obamacare has only partially changed this dominant state of affairs.

The other interesting model in the United States concerns the territorial structuring of medical homes in town medicine, the PCMH (...

Table of contents

• Cover
• Table of Contents
• Title Page
• Copyright Page
• Foreword: Advocacy for a European Reference Framework for Digital Ethics
• Acknowledgements
• Introduction
• PART 1: The Health System and Digital Technology: Challenges, Issues, and Transformations
• PART 2: Digital Technology and Transformations in the Relationships between Professionals and Patients
• PART 3: Supporting Digital Healthcare
• List of Authors
• Index
• End User License Agreement