Integrating and safeguarding care: The potential role of health information technologies

Abstract

The increasing burden of chronic diseases is one of the greatest challenges healthcare systems globally are facing. Across the world, compelling demands can be found for a fundamental shift in the organisation of health and social care to meet the needs of chronic patients. Integrated care has gathered momentum to overcome fragmentation of care in order to create care systems which are demand-driven, client-centred and cost-conscious. Health information technology – often referred to as eHealth – is usually considered to be an essential building brick of integrated care. Moreover, health information technology is said to hold potential for improving patient safety in chronic care settings. The current perspective paper explores the role of health information technology in integrating and safeguarding care. We argue that health information technology – which supports integrated care – may create optimal conditions to improve patient safety, but only when well-implemented, state-of-the-art technologies are used.

Keywords

Health information technology eHealth electronic health records patient safety integrated care

Introduction

Rapidly aging populations and the related rise in chronic care needs represent major challenges for healthcare systems worldwide. As a consequence, several countries are experimenting with new models of care delivery. Integrated care is seen as an important new approach allowing healthcare systems to cope with the aforementioned challenges and which is aimed at more coordination and continuity of care.¹ Health information technology (HIT) – often referred to as eHealth – is usually considered to be an essential building brick of integrated care as it allows healthcare professionals to better manage and coordinate patient care through the secure use and sharing of health-related information. By making health information electronically available when and where it is needed, HIT may also improve patient safety in chronic care settings. After all, the rising number of chronic patients shifts the balance of care delivery from secondary to primary healthcare.² Poor care transitions at the interface between secondary and primary care may introduce new patient safety risks such as adverse drug events or hospital readmissions.³

The current perspective paper explores the role of HIT in integrating and safeguarding care. The article consists of six sections. The Rising chronic care needs section sets the context of the rising chronic care needs. In Integrated care section, the prospect of integrated care to meet these rising needs is discussed. The Health information technology section discusses the potential role of HIT in integrating and safeguarding chronic care delivery. In The Belgian case section, the potential role is illustrated by discussing HIT initiatives. In Implications for practice section, some implications for practice are formulated based on the previous sections and the paper ends with some concluding remarks.

Rising chronic care needs

In recent decades, tremendous progress has been made in healthcare. The improvement in life-threatening conditions resulted in large falls in death rates for many communicable diseases that includes HIV/AIDS, heart attacks and strokes. The progress in healthcare is worthy of praise, but the future sustainability of healthcare systems is nevertheless jeopardised. Due to an aging population, globalisation and unhealthy lifestyles, the increasing burden of chronic diseases is one of the greatest challenges healthcare systems around the globe are facing. Although overall life expectancy of the world population rose with 10.1 years between 1980 and 2015, healthy life expectancy only gained 6.1 years during the same period, resulting in more years of life with illness and disability. The burden of ill health has shifted from communicable, maternal, neonatal and nutritional disorders (including HIV/AIDS, malaria and lower respiratory infections) to disabling non-communicable diseases such as cancer, ischaemic heart diseases and osteoarthritis.⁴

Chronic care is often complex, both clinically and on the organisational level. It is the sum of different care needs, usually answered by different health and social care professionals and organisations. Chronic care has been developed in ways that have tended to fragment care delivery – within and between healthcare settings – and which is largely built around the long-standing acute and episodic model of care. Yet, chronic patients are in high need of a broad range of professionals and skills from different healthcare settings and practices which are offered as integrated and coordinated services, embedded within a system that promotes patient empowerment. Moreover, a lack of integration and coordination may endanger patient safety in terms of potentially preventable hospitalisation or adverse drug events.^5,6 Hence, fragmentation of care poses a major challenge for chronic care delivery.

Integrated care

Across the world, compelling demands can be found for a fundamental shift in the organisation of health and social care to meet the needs of chronic care patients. For instance, the World Health Organization (WHO) calls for a fundamental shift in the way healthcare services are delivered to ‘integrated people-centred health services that puts the needs of people and communities at the centre of health systems and empowers people to take charge of their own health’.⁷ The Lucian Leape Institute – established by the US National Patient Safety Foundation – identified five concepts as fundamental to endeavour meaningful improvements in care delivery: transparency, patient engagement, restoration of joy and meaning in work, medical education reform and finally care integration.⁸

Integrated care has gathered momentum to overcome fragmentation of care in order to create healthcare systems which are demand-driven, client-centred and cost-conscious. Integrated care is defined by the WHO⁷ as

the management and delivery of health services such that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health system, and according to their needs throughout the life course.

Integrated care is driven by the so-called Triple Aim approach; that is a simultaneous focus on cost-savings, better patient care experiences and improved health outcomes.⁹ Numerous studies have revealed that integrated care indeed has the potential to improve quality of patient care, reduce fragmentation of care and control costs.^10,11 Consequently, care integration is needed to provide chronic care patients with high-quality and efficient care across time and across various healthcare settings involved.

To date, the implementation of integrated care is a challenge for many in daily practice. There is no one-size-fits-all model for successful integrated care, nor is there a firm empirical foundation for specific strategies. Several guidelines and redesign models are available, but few consist of a whole-systems approach.^12–15 In recent years, integrated care literature moved away from disease-specific care integration towards population-based care integration. Policy makers, care organisations, patients and other stakeholders reconfigure care systems on the basis of medical-demographic prognoses for the population within a particular geographic area. Yet, many questions remain regarding the practical organisation of whole-system integrated care and inherently the role of HIT. One can learn not only from guidelines, but also from ongoing experiences to improve healthcare delivery. There has been an increase in initiatives to encourage professional partnerships such as Integrated Care Strategies in Australia,¹⁶ New Care Models and Integrated Care Pioneers in England¹⁷ and Population Health Management Pilots in the Netherlands.¹⁸

Health information technology

As mentioned before, healthcare systems are at risk due to the increasing burden of chronic diseases, spiralling costs, inconsistent quality of care and poorly coordinated care processes. In response, policy makers are constantly searching for suitable strategies, one of which consists of investing in HIT. HIT can be defined as ‘the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of healthcare information, data, and knowledge for communication and decision making’ and has three functionalities: digital storage of data, communication and decision support.¹⁹ Today, the range of possible health information technologies is enormous and changes constantly, making HIT very dynamic. HIT encompasses electronic health records, e-prescriptions, computerised provider order entry systems (i.e. any system in which clinicians directly place orders electronically, directly transmitted to the recipient), picture archiving and communication systems and videoconferencing for doctor appointments. Especially, the use of electronic health records has greatly expanded in recent years.²⁰

There are many barriers to the adoption and implementation of HIT such as the lack of connectivity between healthcare professionals from different settings, the lack of shared goals related to care transitions, misaligned incentives, the challenge of health literacy in engaging patients and their family caregivers and issues of trusts.²¹ Nevertheless, many have high hopes for HIT. Lluch²¹ once stated that:

the advantages of health information technologies over paper records are readily discernible to techno-enthusiasts: i.e., digital environment allows reliable and efficient storage, gathering and exchange of data, thus improving performance and quality of care, especially for patients with multiple chronic conditions.

The following two sections of the present paper will explore this potential role of HIT, first for integrated care and then for patient safety.

HIT and integrated care

Within the rapidly shifting healthcare landscape from acute to chronic illness and the broad spectrum of healthcare services and professionals needed for chronic patients, integrated care is a bedrock principle. After all, care episodes of chronic patients often indicate the involvement of multiple healthcare settings and professionals, with little or no communication between them. Health information technologies have the capacity to assist in improving communication and information sharing throughout the healthcare system; that is beyond the boundaries of a single healthcare setting, institution or professional. The latter is essential in improving care transitions for the chronically ill. A primary benefit of using HIT in delivering healthcare is just the ability to ensure that real-time access to all necessary information is available at all stages in the healthcare process so transition of care is smooth and safe.²² A second benefit of HIT is the facilitation of medication reconciliation. Schnipper et al.²³ demonstrated a reduction in unintentional medication discrepancies using IT in conjunction with a medication reconciliation process redesign compared to no IT support. In addition, several reviews show positive results of health information technologies in integrated care such as declines in hospital admissions, length of hospital stays, emergency department visits and mortality rates.^24–27

A case study across eight different European countries (Denmark, Estonia, Germany, France, Italy, the Netherlands, Spain and the UK) found that health information technologies were strongly in line with developments towards integrated care delivery.²⁸ Moreover, HIT enabled the sharing of relevant health-related information between healthcare professionals which is crucial in closing the gaps between fragmented areas in health and social care. By making information sharing possible along the care continuum, HIT becomes an enabler of integrated care models.²⁹ According to Bauer et al.,³⁰ effective HIT is vital for the delivery of effective integrated care. Health information technologies support patient-centred, evidence-based, measurement-based and accountable care. Moreover, HIT potentially improves health literacy, explains and offers treatments to patients and incorporates them into electronic health records, monitors outcomes systematically and adjusts treatments, tracks a defined population of patients, allows providers to target care towards patients who are in the greatest need and finally aggregates data on clinical processes and patient outcomes to support quality improvements.

On the opposite, several studies show negative consequences of HIT. Steventon et al.³¹ found that telecare did not lead to significant reductions in service use compared to regular care in the UK. Chaudhry et al.³² concluded that telemonitoring did not improve outcomes such as hospitalisation and mortality for patients with heart failure.

HIT and patient safety

Since 2000, it has often been claimed by policy makers that HIT may address many quality and safety concerns in today’s healthcare.³³ Nevertheless, there still remains a large gap between the theoretical and empirical benefits of HIT applications.^34–36 Electronic prescribing is able to reduce the number of medication errors by half in acute settings and electronic health records are associated with lower mortality rates in hospitals.^37,38 In addition, HIT systems have the potential to reduce delayed, missed or incorrect diagnoses.³⁹ However, the rapid uptake of health information technologies may result in unintended consequences. New types of errors may result from computerised provider order entry, alarm fatigue arising from proliferation of well-intended safety alerts and problems with poor interoperability of different health record systems.⁴⁰ HIT has the potential to improve patient safety, but only if technology-specific risks can be minimised. Technology-related errors occur when health information technologies are unavailable for use, malfunctions during use, are used incorrectly, or when they interact with another system which may result in data being lost or incorrectly entered, displayed or transmitted. These errors significantly increase organisational inefficiencies and the risk of patient harm.⁴¹

In conclusion, the effect of HIT in integrated care has not been shown unequivocally and a number of questions still remain regarding the impact on patient safety in healthcare delivery. As explained earlier, the care system in which health information technologies are implemented is likely to be characterised by care fragmentation for which integrated care is being advanced as a possible solution, hopefully leading to improved health outcomes and patient safety. In conclusion, HIT is not a stand-alone solution. There are other important preconditions for organising care integration such as legislation (e.g. responsibilities of healthcare professionals), financial incentives (e.g. pay for coordination) and developing competence (e.g. healthcare professionals become skilled in multidisciplinary working).

The Belgian case

The federal state of Belgium encompasses three Regions (Flanders, Wallonia and Brussels) and three Communities (the Flemish, French and German-speaking Community). Since 1980, parts of the responsibilities for health policy have gradually moved from the federal government to these sub-national authorities. In Belgium, over one quarter of the population (27.2%) reports to have a chronic disease, mainly back pain (17.7%), allergies (13.0%), joint diseases (12.7%), hypertension (12.7%), neck pain (9.4%), headaches (8.1%) and respiratory disorders (7.9%). Unfortunately, these chronically ill patients often suffer from multimorbidity as well: 50% to 70% of individuals over the age of 70 have at least two chronic conditions.⁴² Moreover, the increasing prevalence of chronic patients places a high financial burden on the healthcare system. In 2015, Belgium devoted 10.4% of the gross domestic product to healthcare which is higher than the OECD average of 9%.⁴³

Belgium carries out considerable actions to reform the health technological landscape. In 2012, it launched the project eGezondheid (in English eHealth) that includes several actions to facilitate HIT by 2019.⁴⁴ These actions include the development or improvement of a summarised electronic health record, electronic patient records in hospitals, medication schedules, electronic prescribing, Resident Assessment Instrument (BEL-RAI), legal frameworks and financial incentives, personal health records, eHealth education, national taxonomy and a governance structure. Recently, the federal government invested €3.50 million in 24 pilot projects. The aim of the funding is to test the use of applications and mobile devices in practice.

Furthermore, numerous HIT applications have already been developed and implemented, both on the federal and on the regional level.⁴⁵ At the federal level, eHealth Platform, Hubs & Metahubs, eHealth Box, eHealth Consent, Recip-e and MyCareNet were launched. The eHealth Platform – founded in 2008 – is a federal public service which provides an electronic platform devoted to data exchange between all stakeholders in healthcare, including professionals, facilities and patients. The ultimate goal of the platform is to improve the quality and continuity of care, simplify administration and contribute to healthcare policy. It is a federal health network that respects medical confidentiality and guarantees information security and privacy protection. The eHealth Platform is not a central data storage, but it implies a controlled access to decentralised databases and uses encrypted personal data. Furthermore, a hub is a central system in which hospitals can collect patient information. Metahubs connect these individual hubs. The eHealth Box is an electronic mailbox for all actors in healthcare. Patients are not able to send messages to healthcare professionals, but can receive all relevant documents. Through eHealth Consent, patients are able to give their informed consent for the electronic exchange of their health-related information. The application Recip-e provides electronic prescribing and MyCareNet facilitates digital communication with healthcare insurance. In addition to these federal initiatives, each of the three regions in Belgium also developed a digital platform to facilitate communication and information exchange between healthcare actors: Vitalink (Flemish region), Inter-Med (Walloon region) and BruSafe (Brussel-Capital region).

Despite these considerable efforts, critical comments are formulated regarding the rather slow transformation of the eHealth project (suggesting that 2030 would be a more realistic time limit for the reform rather than 2019), the limited role of patients in eHealth applications, the absence of explicit procedures for sanctions in case of unauthorised access, the number of healthcare professionals in minority and the absence of patients’ representatives in the eHealth Board.^45,46 Furthermore, one could argue that HIT initiatives are generally not firmly embedded in broader efforts to realise effectively integrated care. The initiatives listed above not only show potential overlap, but to a certain extent also seem to take the current highly fragmented care delivery system as a given. There are a plethora of HIT initiatives in Belgium that lack coordination in terms of their design and operation. A policy framework is therefore essential, especially in the context of more hospital collaborations in Belgium where different electronic health records are still being used. This also occurs in other healthcare systems around the globe as HIT initiatives are often developed through the succession of uncoordinated projects that are not harmonised with the public health system.⁴⁷

Implications for practice

Recent healthcare policies encourage the adoption of HIT as it may improve processes of care and patient outcomes. Indeed, evidence – such as the Chronic Care Model of Wagner et al.⁴⁸ – emphasises the use of HIT as a wider strategy to overcome inconsistent quality and fragmentation of care. A comprehensive and integrated care delivery approach is required in which HIT operates as a building brick and where special attention is given to the quality and safety of care as well as to the quality of working life of healthcare professionals. HIT can facilitate better coordination between healthcare professionals and the patient, resulting in more integrated care and thus less fragmentation. Following, improved access to care is an important benefit of HIT, especially for countries with chronic shortages of healthcare professionals which tackle the challenge of providing patient care to people over a broad geographical area.⁴⁷ HIT should be implemented in a way that supports integrated care by giving care teams more autonomy and stimulating self-management of the patient. Furthermore, HIT-supported integrated care models may create optimal conditions to improve patient safety by integrating safety-related competences and responsibilities in the healthcare team. However, this reasoning only applies when well-implemented, state-of-the-art health information technologies are used.

For example, healthcare professionals have not fully embraced HIT due to barriers such as the structure of the healthcare organisational system (with often strong hierarchical traditions, lack of cooperation and teamwork in care delivery, cultural barriers and autonomy issues), tasks definitions (i.e. still largely traditional, task-focused and provider-centred care), people policies (including lack of training, IT literacy, time, support, trust and legal frameworks), incentives (e.g. lack of adequate funding) and information and decision processes (including workload concerns).²¹ In addition, patients mention as barriers the lack of additional benefits, the conviction that only regular care is efficient, technological difficulties and the high degree of dependency of ICT.⁴⁹ With these barriers in mind, it is of great importance to refine high-functioning and interoperable HIT initiatives. Moreover, empowering healthcare professionals and patients with the knowledge and skills to use health information technologies and sharing examples of best practices may increase the use of HIT.

A second example are the security risks that may also curb the dissemination of HIT. The level of trust patients and professionals have in these technologies can significantly be reduced due to technical software failures, professionals having unauthorised access to electronic health records of all patients, hackers invading the IT-system, vulnerable authentication and database matching.¹ Initiatives to improve the protection of health-related information are needed. Several guidelines and new frameworks – for example the SAFER guidelines and the Health IT Safety framework – can provide conceptual foundation for HIT-related patient safety measurement, monitoring and improvement.^33,50 In particular, the WHO National eHealth Strategy Toolkit is a practical guide that provides governments and stakeholders with a solid foundation and method for developing and implementing a national eHealth strategy in three stages; that is developing a national eHealth vision that responds to health and development goals, defining a roadmap that reflects country priorities and the eHealth context and establishing a plan to monitor implementation and to manage associated risks.⁵¹

Conclusions

Managing the increasing prevalence of chronic care needs is one of the most important challenges healthcare systems are facing. HIT is often considered efficacious for integrating and safeguarding care. Worldwide, large budgets are being invested and the number of reviews and meta-analyses on HIT has increased considerably in recent years. Indeed, HIT which supports integrated care may create optimal conditions to improve patient safety. However, this reasoning only applies when well-implemented and state-of-the-art health information technologies are used.

Footnotes

Acknowledgements

MD and DV drafted the manuscript. SM and ED revised the manuscript for important intellectual content. All authors approved the final version to be published.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This work is supported by the Agentschap Innoveren & Ondernemen (Belgium).

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