Using patient-reported measures to drive change in healthcare: the experience of the digital, continuous and systematic PREMs observatory in Italy

BACKGROUND: The use of Patient Reported Experience Measures (PREMs) has great potential in healthcare service improvement, but a limited use. This paper presents an empirical case of PREMs innovation in Italy, to foster patient data use up to the ward level, by keeping strengths and addressing weaknesses of previous PREMs survey experiences. The paper reports key lessons learned in this ongoing experience of action research, directly involving practitioners. METHODS: The aim of this paper is to present the results of an ongoing action research, encompassing the innovation of PREMs collection, reporting and use, currently adopted by 21 hospitals of two Italian regions. The continuous and systematic PREMs collection has been implemented between 2017 and 2019 and includes: a continuous web-based administration, using web-services; an augmented and positive questionnaire matching standard closed-ended questions with narrative sections; the inclusion and benchmarking of patient data within a shared performance evaluation system; public disclosure of aggregated anonymized data; a multi-level and real-time web-platform for reporting PREMs to professionals. The action research was carried out with practitioners in a real-life and complex context. The authors used multiple data sources and methods: observations, feedback of practitioners, collected during several workshops and meetings, and analysis of preliminary data on the survey implementation. RESULTS: A continuous and systematic PREMs observatory was developed and adopted in two Italian regions. PREMs participation and response rates tend to increase over time, reaching stable percentages after the first months. Narrative feedback provide a 'positive narration' of episodes and behaviours that made the difference to patients and can inform quality improvement actions. Real-time reporting of quantitative and qualitative data is enabling a gratifying process of service improvement and people management at all the hospitals' levels. CONCLUSIONS: The PREMs presented in this paper has been recognized by healthcare professionals and managers as a strategic and positive tool for improving an actual use of PREMs at system and ward levels, by measuring and highlighting positive deviances, such as compassionate behaviours

Public strategies for improving eHealth integration and long-term sustainability in public health care systems: Findings from an Italian case study

eHealth is expected to contribute in tackling challenges for health care systems. However, it also imposes challenges. Financing strategies adopted at national as well regional levels widely affect eHealth long-term sustainability. In a public health care system, the public actor is among the main "buyers" eHealth. However, public interventions have been increasingly focused on cost containment. How to match these 2 aspects? This article explores some central issues, mainly related to financial aspects, in the development of effective and valuable eHealth strategies in a public health care system: How can the public health care system (as a "buyer") improve long-term success and sustainability of eHealth solutions? What levers are available to match in the long period different interests of different stakeholders in the eHealth field? A case study was performed in the Region of Tuscany, Italy. According to our results, win-win strategies should be followed. Investments should take into account the need to long-term finance solutions, for sustaining changes in health care organizations for obtaining benefits. To solve the interoperability issues, the concept of the "platform approach" emerged, based on collaboration within and between organizations. Private sector as well as beneficiaries and final users of the eHealth solutions should participate in their design, provision, and monitoring. For creating value for all, the evidence gap and the financial needs could be addressed with a pull mechanism of funding, aimed at paying according to the outcomes produced by the eHealth solution, on the base of an ongoing monitoring, measurement, and evaluation of the outcomes

Incentivizing ICT in healthcare: A comparative analysis of incentive schemes in Italian Regions

Background: The use of Information and Communication Technologies (ICTs) in healthcare has been presented as a potential solution to the current challenges that healthcare systems have to face. The introduction of ICTs may need initial investments and, moreover, may produce changes in the routine practice of the healthcare system. Financial incentives are expected to be an effective managerial tool to communicate a strategic vision and a mandate, to improve the adherence to the strategy and to promote a consistent individual behaviour. In this perspective, financial incentives are assumed to accelerate the ICTs adoption and use in healthcare. The aim of this study was to investigate whether and how Italian Regional healthcare systems use the Chief Executive Officers’ (CEOs) reward scheme to stimuli the implementation of ICT in healthcare. Materials and methods: A content analysis was conducted on the Italian Regional acts on healthcare CEOs incentive schemes, that were approved in the period 2010–2012 and with a legal validity that ranged from 1 to 4 years (until 2014). The acts cover around 60% of the Italian Regions. ICT goals were identified, categorized, and compared using descriptive statistics. Results: This study identified two areas on which financial incentives related to ICTs were mainly focused: (i) ICT infrastructure and architecture; (ii) flows and processing of economic and financial data. The use of technology to better store and process medical data (i.e. EHR-like systems) were only marginally present. Use of e-Health and mHealth solutions for providing healthcare services, valorization of ‘health big data’ in a community care perspective, more advanced applications of technology for monitoring or preventing diseases were not incentivized for CEOs in Italy. Conclusion: The use of ICTs in healthcare appears to be of general interest in Italy: a great number of Italian Regions introduced specific goals into CEOs financial schemes. Efforts in this field seem to be not linked to the objectives of better care at sustainable cost, while it appears important to ensure a better and wider presence of enabling environments and to implement ICT-based control systems. Keywords: ICT, Financial incentives, Incentive scheme, Healthcare CEO, Italy, Region

Basic ICT adoption and use by general practitioners: an analysis of primary care systems in 31 European countries

There is general consensus that appropriate development and use of information and communication technologies (ICT) are crucial in the delivery of effective primary care (PC). Several countries are defining policies to support and promote a structural change of the health care system through the introduction of ICT. This study analyses the state of development of basic ICT in PC systems of 31 European countries with the aim to describe the extent of, and main purposes for, computer use by General Practitioners (GPs) across Europe. Additionally, trends over time have been analysed

E-patient (r)evolution: quando è il paziente a coinvolgere il medico.

Lo scopo di questo studio è fornire un contribuito al framework teorico di riferimento, con evidenze sui comportamenti di scelta della popolazione della Regione Toscana riguardo l’uso di internet quale strumento per reperire informazioni sulla salute. Dai risultati emerge che sono i più giovani e istruiti, con una insoddisfazione del sistema sanitario e con cattive esperienze con le Asl in termini di burocrazia e prontezza del front-office a consultare più internet, ma coloro i quali hanno un buon rapporto con il proprio medico di famiglia sono più propensi a condividere tali informazioni derivanti dalla rete con il medico stesso

A m-health intervention in the maternal care pathway: protocol for the impact evaluation of hAPPyMamma (Preprint)

Background: M-health has a great potentiality in both improving quality and efficiency of care, and in increasing health literacy and empowerment of patients-users. There are several studies related to the introduction on m-health tools for supporting pregnancy and the post-natal period, with promising but not still rigorously evaluated impacts. This article contributes to the literature, by presenting an m-health intervention (the mobile app called “hAPPyMamma”) applied in the maternal and child care of a high-income country (in a pilot area of Tuscany Region, Italy) and the methods adopted for evaluating its impact. Objective: The final aim of the introduction of this m-health app in the maternal care pathway is to promote the health of pregnant women and of their children and to improve their experience of care. Methods: This study is based on a quasi-experimental design that compares two groups: women who use the app (intervention group) and women who do not use the app (control group). The data concerning the measures of the maternal health literacy and the empowerment are collected prospectively in order to be able to perform a difference in difference analysis. In the post-partum period also data on women’s experience in the maternal care pathway are collected from both groups and data on the experience of the hAPPyMamma use are collected only within the intervention group. The organisational impact is evaluated through a quantitative and qualitative survey addressing professionals and managers of the maternal care pathway involved in the intervention. Results: The recruitment of the two samples was carried out with the same procedure in 2017, and was subsequent: first, the control group, and after some months, the intervention group. 177 women were enrolled in the control group; out of them, 170 answered to the first web questionnaire and 114 to second one. 150 women were enrolled in the intervention group; out of them, 100 women answered the first web questionnaire and 90 the second one. Data collection was completed in April 2018. Data analysis is underway. Conclusions: This study evaluates the implementation of the m-health intervention hAPPyMamma and describes its impact at individual and organisational level, in terms of the improvement of maternal health literacy, the access to and the utilisation of healthcare services during the maternal care pathway. This study contributes to define the potential role of this m-health tool in maternal care pathway in Tuscany Region and consequently in the Italian context, and the possible extension of its implementation

Piloting a web-based systematic collection and reporting of patient-reported outcome measures and patient-reported experience measures in chronic heart failure

OBJECTIVES: To evaluate the feasibility of a digital and continuous collection and reporting of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) for chronic heart failure (CHF). DESIGN: A single-site pilot study was settled for evaluating the feasibility of the intervention, both using qualitative and quantitative data (ie, workshop, surveys). SETTING: The pilot has been implemented in a Tuscan specialised hospital (Italy). PARTICIPANTS: 162 patients were involved. Inclusion criteria were: a previous diagnosis of HF, age ≥18 years, absence of cognitive impairment or active tumours, ability to provide informed consent to study participation. INTERVENTION: The continuous collection and reporting of PROMs and PREMs has been designed and implemented in 2018. PREMs questionnaires for patients were developed, while Kansas City Cardiomyopathy Questionnaire-12 was used for assessing PROMs. Questionnaires are administered at specific time points: discharge; 30 days, 7 and 12 months after the discharge. Enrolment of patients, administration and real-time reporting of questionnaires are carried on through a digital platform. OUTCOME MEASURES: Enrolment, response and drop-out rates were considered to assess the feasibility of the intervention. Qualitative data were collected during meetings and workshops with health workers. The representativeness of the recruited sample with respect to the population characteristics was also evaluated. RESULTS: The system has been successfully implemented during 2018. Response rates have been consistently above 50%, demonstrating patients' transversal willingness to participate. All the involved stakeholders acknowledged the feasibility of the design. The recruited sample is significantly different in terms of age and educational level compared with the overall population characteristics. CONCLUSION: It is possible to run a web-based systematic collection and reporting system for CHF patient-reported data. Systematic collection and reporting of PROMs and PREMs data allows professionals to increasingly assume CHF patient perspective in their daily work. Limitations will be used to improve the system

Including patient-reported measures in performance evaluation systems: Patient contribution in assessing and improving the healthcare systems

In healthcare, the introduction of quality standards and indicators to assess performance triggered the development of multidimensional Performance Management Systems (PMSs). The concept of performance in healthcare has recently evolved and broadened its scope. One of the current challenges of PMSs is measuring and integrating the patient perspective into traditional measures. In the regional healthcare system of Tuscany (Italy), a PMS has been implemented and used since 2005. The PMS counts on the systematic involvement of clinicians and managers. Furthermore, the PMS also includes patients' perspective. Moreover, Tuscany has recently implemented the first regional permanent Patient-Reported Outcome and Experience Measures (PROMs and PREMs) Observatory in Italy. This paper presents the results of an action research aimed at analysing the integration of patient-reported outcome and experience indicators into a consolidated PMS. The study describes the process of identifying and discussing of patient-reported indicators with practitioners and categorising findings into three domains: design of patient-reported indicators, integration process into the PMS, and goal of adoption of the patient-related indicators. The paper also describes facilitators, challenges, and lessons learnt with respect to organisational, methodological, cultural, and responsibility-linked factors. The study discusses the ability to agree on how to transform patient data, especially PROMs, into effective performance indicators. The integration of patient-reported indicators into the PMS poses two main challenges: one in terms of sustainability of the performance system itself, and another regarding the attribution of the responsibility for patient outcomes between care settings and providers. This paper provides initial insights on how the integration of patient-reported indicators can make PMSs more inclusive and focussed on the patient-centred perspective