[Abstract] How to secure better outcomes for everybody in asthma management: the international-medicines use review health technology assessment (international-MUR HTA)

Aims: This project is looking at the development and application of the novel tool (International–Medicines-Use-Review-Health-Technology-Assessment; International-MUR HTA) in community practice that for the first time is able to meet better asthma control and secure added value service in asthma management. More specifically it allows to: evaluate the quality of care delivered in terms of economic impact (for patient-provider-society), health outcomes and patient benefits; collect real-world evidence and evaluate longterm effect of care; provide different stakeholders with evidence-based information that would help formulate health policies in community practice that are safe, effective, patient-focused and cost-effective, balancing access to innovation and cost containment. Crucially, the tool can also support the delivery of a cost-effective and cost-saving intervention for asthma patients based on the success of the Italian-Medicines-Use-Review (I-MUR) trial [1]. Methods: Evidence from the Italian-Medicine-Use-Review (I-MUR) trial showed that the I-MUR intervention provided by the community pharmacists in asthma is effective, cost-saving and cost-effective.1 The trial allowed to model a novel framework (International-MUR-HTA) that would enable to routinely deliver the intervention, but also collect and analyse patient relevant data on its clinical-effectiveness, quality-of-life and cost-effectiveness. I-MUR-HTA was discussed within three expert-panel discussions including policy-makers, commissioners, academics, healthcare-professionals and patientrepresentatives in Italy,2 UK3 and Brussels/Europe.4 The current plan includes testing the use of the tool in RW environment across European regions. Results: Evidence collected from the expert discussions confirmed that International-MUR-HTA information is relevant to meet current NICE target for cost-effective service delivery and this is what is needed to support the evaluation of innovative effective and cost-effective health policies and promote their implementation across nations. Its implementation is underway and real-world pilots are planned to take place in different European regions. Conclusion: the International-MUR-HTA appears to be an innovative tool to promote active patient involvement into policy-decision-making and community service implementation

An Exploration in Accountable Care Organization Structure, Contingency and Performance, 2015-2017

The Patient Protection and Affordable Care Act of 2010 enacted one of the most significant reforms seen in the United States healthcare landscape. The Center for Medicare and Medicaid (CMS) led transformation efforts in regulatory reform and coverage expansion across the U.S. population. Since 2010, care delivery systems have been shifting from episodic, decentralized and fee-for-service models to value-based population health models, like accountable care organizations (ACO). ACOs have been specifically primed for local response to improve the health of their communities. ACO research has traditionally focused on performance measures like mortality, readmissions, quality outcomes and savings. ACO organizational characteristics analyzed in the literature have focused on provider composition, health information technology, leadership structures and provider access. According to CMS, readmissions account for one of the greatest contributors in healthcare spend, and studies by The Commonwealth Fund detail the top percentile of the population as high need, high cost (HNHC) patients who further contribute to the majority of healthcare spend. Opportunity exists to explore the diversity among ACO structures, their relationship to local environments and influence on top contributors to healthcare spend, like readmissions and high need, high cost populations. The objectives of this study are to better understand existing ACO structures, explore relationships among ACO organizational structures, their local environment in which they operate and directional impact on performance, with emphasis on at risk patients like high need, high cost populations. Theoretically, this study applies Structural Contingency Theory (SCT) for its empirical analyses, specifically a multiple contingency approach. In the extant literature, SCT has not been commonly applied due to its longitudinal nature and limited public access to ACO organizational data. The study sample consists of 45 ACOs that entered into the Medicare Shared Savings Program under Track 1 for the entire term from 2015 to 2017. ACO performance is represented by total shared savings, change in rate of readmissions and change in rate of inpatient psychiatric admissions. Four contingency-structure relationships are analyzed from the National Survey of Accountable Care Organizations and CMS Public Use Files, 1) ACO governance structure and strategy alignment, 2) Interdependency from complex coordination and formalized provider agreement types, 3) interdependency from complex coordination and formalized relationships with mental and behavioral health specialists, and 4) complex coordination and health IT integration and interoperability. Regression analyses were used to analyzed potential misfit and directional impact on performance and the contingency-structure pairs. Results indicate that wide variety exists among ACO structures, that conventional investments in provider agreements and fully integrated health IT do not clearly present positive performance effect. Future research opportunities exist to further examine the impact ACO programs have on meeting community needs and populations. This study offers the theoretical application of a multiple contingency approach from Structural Contingency Theory and a practical exploration of ACO structure, its contextual operations and performance on high need, high cost populations

What is eHealth?

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Organizing the U.S. Health Care Delivery System for High Performance

Analyzes the fragmentation of the healthcare delivery system and makes policy recommendations -- including payment reform, regulatory changes, and infrastructure -- for creating mechanisms to coordinate care across providers and settings

How Will Comparative Effectiveness Research Affect the Quality of Health Care?

Outlines how the use of comparative effectiveness research on the relative merits of a healthcare intervention compared with others could improve quality of care and outcomes. Presents challenges in enhancing CE research and expanding its adoption

Measuring the 'success' of telehealth interventions

Despite substantial investment over recent years in telehealth there appears to be little consensus regarding what a successful implementation should achieve. However, defining success is often controversial and complex due to differing views from the large number of stakeholders involved, the local environment where telehealth is deployed and the scope, or size, of any planned initiative. Nevertheless, a number of generic measures are proposed in this paper which then provides a framework for the measurement of success. The local context can then be applied to determine the exact emphasis on specific measures, but it is proposed that all of the measures should be included in the holistic measurement of success. Having considered what constitutes success attention is then given to how success should be quantified. Robust evaluation is fundamental and there is much debate as to whether the �gold standard� Randomised Control Trial (RCT) is the most appropriate methodology for telehealth. If the intervention, technology and system, can be maintained in a stable state then the RCT may well provide the most authoritative evidence for decision makers. However, ensuring such stability, in what is still a novel combination of technology and service, is difficult and consequently other approaches may be more appropriate when stability is unlikely to be maintained

Towards an interoperable healthcare information infrastructure - working from the bottom up

Historically, the healthcare system has not made effective use of information technology. On the face of things, it would seem to provide a natural and richly varied domain in which to target benefit from IT solutions. But history shows that it is one of the most difficult domains in which to bring them to fruition. This paper provides an overview of the changing context and information requirements of healthcare that help to explain these characteristics.First and foremost, the disciplines and professions that healthcare encompasses have immense complexity and diversity to deal with, in structuring knowledge about what medicine and healthcare are, how they function, and what differentiates good practice and good performance. The need to maintain macro-economic stability of the health service, faced with this and many other uncertainties, means that management bottom lines predominate over choices and decisions that have to be made within everyday individual patient services. Individual practice and care, the bedrock of healthcare, is, for this and other reasons, more and more subject to professional and managerial control and regulation.One characteristic of organisations shown to be good at making effective use of IT is their capacity to devolve decisions within the organisation to where they can be best made, for the purpose of meeting their customers' needs. IT should, in this context, contribute as an enabler and not as an enforcer of good information services. The information infrastructure must work effectively, both top down and bottom up, to accommodate these countervailing pressures. This issue is explored in the context of infrastructure to support electronic health records.Because of the diverse and changing requirements of the huge healthcare sector, and the need to sustain health records over many decades, standardised systems must concentrate on doing the easier things well and as simply as possible, while accommodating immense diversity of requirements and practice. The manner in which the healthcare information infrastructure can be formulated and implemented to meet useful practical goals is explored, in the context of two case studies of research in CHIME at UCL and their user communities.Healthcare has severe problems both as a provider of information and as a purchaser of information systems. This has an impact on both its customer and its supplier relationships. Healthcare needs to become a better purchaser, more aware and realistic about what technology can and cannot do and where research is needed. Industry needs a greater awareness of the complexity of the healthcare domain, and the subtle ways in which information is part of the basic contract between healthcare professionals and patients, and the trust and understanding that must exist between them. It is an ideal domain for deeper collaboration between academic institutions and industry

Wireless technology and clinical influences in healthcare setting: an Indian case study

This chapter argues that current techniques used in the domain of Information Systems is not adequate for establishing determinants of wireless technology in a clinical setting. Using data collected from India, this chapter conducted a first order regrssion modeling (factor analysis) and then a second order regression modeling (SEM) to establish the determinants of clinical influences as a result of using wireless technology in healthcare settings. As information systems professionals, the authors conducted a qualitative data collection to understand the domain prior to employing a quantitative technique, thus providing rigour as well as personal relevance. The outcomes of this study has clearly established that there are a number of influences such as the organisational factors in determining the technology acceptance and provides evidence that trivial factors such as perceived ease of use and perceived usefulness are no longer acceptable as the factors of technology acceptance

Addressing the Health Needs of an Aging America: New Opportunities for Evidence-Based Policy Solutions

This report systematically maps research findings to policy proposals intended to improve the health of the elderly. The study identified promising evidence-based policies, like those supporting prevention and care coordination, as well as areas where the research evidence is strong but policy activity is low, such as patient self-management and palliative care. Future work of the Stern Center will focus on these topics as well as long-term care financing, the health care workforce, and the role of family caregivers

Co-innovation: the future of telemedicine in developing countries

Telemedicine which has been widely adopted in developed countries to reach all its citizens irrespective of their location is only being used for education purposes or disaster relief in developing countries. Since developing countries already suffer inadequate healthcare provision especially in remote areas, it would be essential to implement telemedicine practices for daily clinical uses rather than education use. This research argues that to understand the future of telemedicine in developing countries, both well-established technology innovations adoption factors as well as co-innovation factors should be addressed. In the context of healthcare provision, we propose a conceptual framework that integrates the healthcare resources and the organisational affiliations in co-innovation