KEY POINTS IN THE ANALYSIS
We should support the renewal of healthcare services aiming for a model focused on meeting patients' needs, as well as those of healthcare professionals, designing measures to afford added value while optimising the system.
Value-based digital healthcare contributes to reducing the cost and the need for permanent care of patients, improving their overall health and reducing the complexity and progression of diseases requiring greater care in the future.
During this transition we should turn to Big Data for monitoring and gathering data on results and costs. It is also necessary to drive innovation to reach the right perspective and to ensure the sustainability of the health system with the adoption of clear measurement criteria, monitored results and appropriately distributed risks.
Among Spanish citizens, 85% considers it desirable to carry out follow-up and control of patients with new technologies. Furthermore, 92.5% believes that interoperability is essential in the healthcare sector.
1. Digital health and its current context
Population ageing and longer life expectancy, the advent of new technologies, rising healthcare costs and an increasingly discerning and demanding population where health is concerned, are just a few of the issues to be taken into account in re-designing healthcare services in the next few years. In this sense, the healthcare sector has gradually established new practices in the framework of digital health. This area may be understood as a consequence of the technological revolution focused on the use of Information and Communication Technologies (ICT) in health-related processes. According to Statista, in 2020, the digital health industry worldwide reached a total investment of $13,900 million, a figure that is expected to triple by 2025, exceeding $38,000 million 1.
2. Areas of digital health
Digital health has developed in several different areas, including:
- Telemedicine and mobile apps for communication between health professionals and patients.
- Wearables or portable devices used for controlling or monitoring pathologies.
- Electronic Clinical History for the exchange of patient data among healthcare professionals.
- Big Data and data analysis to enhance healthcare processes.
- Artificial Intelligence applied to patient diagnosis and research.
- Virtual reality, augmented reality and mixed reality as instruments supporting surgical processes and training of healthcare professionals.
In fact, among the categories registering the highest investment in digital health worldwide in 2020 are telemedicine ($4267 million), data analysis ($1838 million), health apps ($1391 million), support to clinical decisions ($1165 million) and solutions for administrative and management practices ($837 million), values that reflect the weight of these trends today.2
3. Value-based healthcare
From this context arises the need to provide value-based healthcare (VBHC), one of the latest health-related trends. This relates to the need to support revised healthcare services targeting a model focused on meeting patients' needs, as well as those of healthcare professionals, by means of adopting measures to afford added value while optimising the system. Value is generated through interaction with patients, families and health professionals, and is measured by the results perceived as relevant by patients.
The transformation of the system should thus lead to collaborative patient-oriented practices. The aim of this type of healthcare is to promote the health of the population, patients' experience, health professionals' satisfaction, the efficiency of the health system and the reduction of costs. However, experts agree in pointing out that digital health is a perfect complement to value-based healthcare. This is the ideal mechanism to reach the targets mentioned above, simplifying processes and promoting information exchange.
Having grasped this idea, professionals in this field have coined the term 'Value-based Healthcare’. This trend is associated with cost reduction and enhanced patient quality or satisfaction, although it must be pointed out that despite their great importance these should not be confused with the implication of 'being value-based', which primarily refers to improved outcomes in patients' general health and experience. The diagram below shows an implementation model for a possible example of this system.
To implement a working framework in this field, it is necessary to identify and understand a group of patients whose health-related circumstances give rise to a consistent set of needs. From here, an interdisciplinary group of health professionals design and propose solutions to address such needs. This group measures the outcomes and cost of the services rendered, and analyses this information to continue making improvements to the working system thus structured. It is here that the greatest attention should be paid, given that achieving better outcomes also reduces costs and patients' need for permanent care, thus improving their general health and reducing the complexity and progression of diseases requiring greater levels of healthcare in the future.
4. Types of healthcare systems
There are several types of health systems depending on the provider payment model. The most common is the fee-for-service system, based on the payment of compensation to providers according to the quantity of services rendered. These services include consultations, tests, procedures and other medical treatments. In this model, healthcare providers benefit from each service rendered individually, which may act as an incentive, i.e., to provide more services per patient. However, the value-based model safeguards quality and wellbeing rather than quantity, and focuses on the patient's real needs at all times.
Indeed, according to the World Health Organisation (WHO), around 30% of the resources invested in health worldwide are wasted on avoidable complications, unnecessary treatments and administrative inefficiency4. Awareness of this situation is essential to shifting from a fee-for-service system to a value-based approach. However, while healthcare continues to evolve and providers increasingly adopt value-based care models, significant investment will be necessary in the short term before any reduction in costs is eventually appreciated.
Another challenge posed by Value-Based Digital Health is that the transition from a fee-per-service system to a value-based system has already proved more difficult than expected. Similarly, there is some uncertainty over calculating health outcomes owing to the differences among patients' and health professionals' perspectives on the implications of adding value. Nonetheless, in addressing these challenges, the transition should encompass Big Data for monitoring and gathering data on outcomes and costs. It is, therefore, necessary to pursue innovation to reach the right perspective and to ensure the sustainability of the health system with the adoption of clear measurement criteria, monitored results and appropriately distributed risks.
5. The ecosystem of Value-Based Healthcare
Value-Based Healthcare (VBHC) is an ecosystem comprising several actors, for each of which specific benefits apply. Among these, we may mention the following:
Since the term was first used by Michael Porter and Elizabeth Olmsted in 2006, some countries have set in motion projects to promote the expansion of health systems based on patients' needs and the creation of value, with Sweden among the pioneers and world leaders in this field. This Scandinavian country has implemented Value-Based Digital Health systems in 21 regions for knee, waist and spinal column therapies, achieving a 20% reduction in complications and 17% reduction in expenditure per patient as compared with the former fee-for-service system6.
Furthermore, healthcare centres in territories such as the Netherlands, Norway, United Kingdom, United States, Germany, Australia and India have also gradually brought in practices based on this approach. For instance, South East Wales implemented practices focused on patients with asthma and chronic pulmonary obstruction, achieving a cost reduction of 1.3 GBP6. It should be noted, however, that some of the initiatives set in motion, despite including aspects that to some extent fit in with the premises of Value-Based Digital Health, were not necessarily established with the intention of creating value or with this particular model in mind.
Overall, there is still a long road ahead before achieving consolidated models, given the recent appearance of this approach and the lack of consensus among some experts regarding its implementation. There is still debate on the scope of Value-Based Digital Health, the difficulty in establishing standardised measurements of outcomes and value, the real and immediate impact on costs, the need to avail of robust infrastructures for data processing and some health professionals’ reluctance to change established practices6.
Despite this, in the European context, programmes have been set in motion to promote the transformation of healthcare systems following the Value-Based Digital Health approach. The most notable among these is led by the EU Innovative Health Initiative that is currently developing a large-scale ecosystem, open to participation by stakeholders, to incorporate results reported by patients and measures to enhance patient participation and value generation. This project known as H20 (Health Outcomes Observatory), is a public-private consortium in which patients, family members, health professionals, healthcare providers, researchers, academics, scientists, health sciences executives, pharmacists and manufacturers of medical devices contribute to reaching its aims.
In Spain the degree of adoption is still at an earlier stage than in Europe and worldwide. Nevertheless, according to a survey by Fundación IDIS, 84.9% of Spanish citizens consider it desirable to carry out follow-up and control of patients with new technologies. Furthermore, 92.5% believe interoperability is a key factor in the healthcare sector5. However Spain is still a long way from these objectives, considering that Value-Based Digital Health is currently in its design stage, and only a small number of projects implementing this approach have been launched in recent years. All the same, groups of academics and professionals in the sector have pooled their ideas to evaluate the possibility of addressing the transformation of Spain's healthcare system in this direction. For instance, value based healthcare was the central topic at the VII Forum on Healthcare Transformation organised by Deusto Business School8.
6. Successful cases
Martini-Klinik (Germany). This clinic set up a digital platform compiling clinically reported outcomes and measures (CROMs) and measures of the experience reported by patients (PROMs) at Hamburg University Hospital in order to improve healthcare outcomes, especially those related to prostate cancer 9. The information compiled by the database allows health professionals in various different specialities to access patients' clinical histories. It is reported that thanks to this system, participating health professionals can judge which of the surgical techniques used deliver the most effective results, thus increasing the hospital's mean positive outcomes with regard to the rest of the country and the world10.
Diabeter (The Netherlands). This project built the digital platform Vcare that interprets real-time glucose data in patients with diabetes mellitus type 1. This system loads the data directly from the patient's insulin pump or glucose meter to a server, registering in real time the patient's health status while recording CROMs. Next, this data is processed within the system and sent to the patient with information regarding trend, aims, possible treatment and follow-up. Should any deviation be appreciated in the patient's data, a warning is sent to a healthcare professional who will take any necessary action. Diabeter has achieved an improvement in the healthcare system without the need for increased costs9.
NHS Wales (United Kingdom). The NHS Wales established a national programme focused on the compilation and analysis of data on the Welsh National Data Resource (NDR) for providing services to 3.1 million Welsh citizens. The NDR works as an interoperability centre with an open API linked to a group of servers distributed over the territory that incorporate the data generated at healthcare centres, facilitating reports, research and clinical support throughout Wales. The programme bridges data gaps, giving rise to a more connected collaborative and coordinated system that has been successfully tried and tested in scenarios related to COVID-19, cancer and ambulance services11.
Group of Hospitals in the Autonomous Region of Madrid (Spain). Four hospital centres in the Autonomous Region of Madrid (Hospital Universitario General de Villalba, Fundación Jiménez Díaz, Hospital Rey Juan Carlos and Hospital Infanta Elena), together with Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz, developed CSalud, a project for implementing Big Data encompassing nearly half a million inhabitants. Its approach is data analysis for the enhancement of healthcare on three fronts: prevention, early detection and personalised treatment, covering eight aspects of care (cardiovascular and nephrology, neurology and mental health, chronic respiratory diseases, age-related pathologies, oncology and hematology, public health and infectious diseases, bone and joint pathologies and, lastly, surgical complications and critical care). This initiative seeks to shift from a reactive to a proactive model in which the prevailing aims are patients' needs and reducing disease complexity and progression 12.
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5. Inclusive of medical centres and payers
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