Evidence-based health care connectivity- putting the promise back into technology

• Abstract
• 1. Introduction
• 2. Methodology: put clinicians and patients at the centre of new networks of service
• 3. Results – demonstrate the impact for patients and clinicians
• 4. Discussion – extrapolate from the results to discover the impact on the wider organisation and build a business case for the health care sector
  • 4.1 The promise of health connectivity
  • 4.2 Generalising cost savings to the hospital
  • 4.3 Application to the NZ health care sector
  • 4.4 Impact on quality of care
• 5. References
• Appendix: Cost, Benefits and Economic Evaluation of the Permanent Use of Wireless Technology at CHW
  • Cost of Applying Wireless Technology at CHW
  • Benefits of Applying Wireless Technology at CHW
  • Economic Evaluation of Using Wireless Technology at CHW

Abstract
This paper presents a structured approach for conceiving and implementing evidence-based health care connectivity solutions. The key elements are to put clinicians and patients at the centre of new networks of service, knowledge, trust and accountability, focus on connecting individuals rather than connected infrastructure, demonstrate the benefits and measure results, and robustly analyse the validity and generalisation of the results to the wider healthcare sector. The methodology is illustrated with recent studies reporting on Royal Prince Alfred Hospital and Children’s Hospital Westmead in Australia and discusses the applicability of these studies to New Zealand health care organisations and to the New Zealand health sector.
 

1. Introduction
There is all too often an undercurrent of under-delivery or uncertainty of realised value running through health care information technology [IT] connectivity projects and this is often accompanied by an uneasy feeling the sector may be "re-inventing the wheel". This is in sharp contrast to the well-established evidence-based approach for therapeutics and other clinical interventions.

This paper presents a structured approach for building the evidence-base for efficacious health care connectivity solutions:

1. Methodology: put clinicians and patients at the centre of new networks of service, knowledge, trust and accountability. The paper reports on the Cloud 9 Study at Sydney’s Royal Prince Alfred Hospital.
2. Results: demonstrate the impact for patients and clinicians. This paper reports the results from a recent study at Sydney’s Children’s Hospital at Westmead (CHW).
3. Discussion: extrapolate from the results to discover the impact on the wider organisation and to build a business case for the health care sector. This paper reports on the broadening out from the Westmead pilot to the rest of CHW and to the wider Australian and New Zealand health care sector.

2. Methodology - put clinicians and patients at the centre of new networks of service
Connectivity within health care is usually located in the context of connected infrastructure – IT vendors tend to automatically put the connectivity technology "cloud" in the centre and build the infrastructure around this. However, this paradigm needs to be shifted to one of connecting individuals rather than infrastructure – putting patients and clinicians at the centre of new models of connectivity for improved communication and collaboration.

Clinicians are also often overlooked in conceiving and implementing health connectivity initiatives, so it is not surprising, therefore, that these projects often have a poor value prognosis. The health care sector and IT industry needs to collaborate to study and demonstrate health care information and communication technology (ICT) value to clinicians and better health outcomes for both patients and the health care sector. While clinicians are rightly sceptical of new technology, they will strongly evangelise where the value is demonstrated and widely useful.

The Cloud 9 Study^[1] a the Royal Prince Alfred Hospital in Sydney, Australia, was sponsored by Cisco and Intel to test the utility of the methodology of putting patients and clinicians at the centre of networks of service, knowledge, trust and accountability to develop new health connectivity solutions. The Royal Prince Alfred is the principal teaching hospital of the University of Sydney.

The objectives were:

1. To develop a deep understanding of the requirements of key "customers" of connectivity technology in health care.
2. To create compelling reasons for health providers to innovate – driven by the clinicians within the hospital.
3. To develop a methodology that could be replicated across the sector.

In-depth interviews were held with the hospital CEO, CFO, CIO and with six individuals in roles with high needs for communication and collaboration: the Director of Intensive Care, the Director of Emergency, a neurology registrar, a cardiac physician, a ward clerk, and a senior physician.

The study process is outlined in figure 1 below.

Figure 1: Cloud 9 Study Methodology

The Royal Prince Alfred Hospital has embraced the Cloud 9 Study methodology, and the study’s detailed findings and recommendations were launched in a book and video^[1] at the international Medinfo 2007 conference in Brisbane, Australia.

The Cloud 9 Study epitomised the first step in conceiving effective solutions for health connectivity. However, the second step (demonstrating benefits) and the final step (use of general principles to develop the business case) are critical to converting this information into robust evidence for the benefit of the health care sector.
 

3. Results – demonstrate the impact for patients and clinicians
This section looks at the results from a study at CHW that followed from the Cloud 9 Study. One of the key finding of the Cloud 9 Study was that the need for mobility of and delivery of information at the point of care was unmet, and the Westmead pilot set out to study the impact of mobile care on efficiency and quality of care.

This independent study^[2] allowed for the first time in Australia a systematic, qualitative and quantitative comparison to be conducted of communications efficiencies in an Emergency Department (ED) once a mobile wireless network was deployed. The "before and after" study measured the impact of the new communication technologies on the daily work of ED clinicians and nurses.

CHW was selected for the pilot study because it was already operating with an electronic medical record (EMR) system, a document-imaging system, and an electronic admission and scheduling system. This hospital is the largest paediatric centre in New South Wales. It has 3,000 staff in 150 departments and provides care for children from New South Wales and across Australia and the Pacific Rim.

The trial started with observations made before the wireless IT was installed in March 2006. Further research was undertaken in June 2006 to record any changes in behaviour that occurred following the introduction of the wireless capabilities. The study aimed to identify the extent to which such technology could improve the quality and capacity of health care compared to the fixed line PABX and pager systems and desktop PCs currently used by clinical staff.

The trial was conducted between 15 April and 1 June 2006 and involved 80 staff including registrars, medical officers, visiting medical officers and nurses. The trial consisted of the deployment of: 

• Wireless infrastructure in the ED, operating theatres and the surgical ward 
• Forty wireless, hands-free communication devices (WHFCDs) in the ED
• Ten "computers on wheels"
• Six handheld computers.

The mobile computing devices gave clinical staff real-time access to patient information anywhere in the ward and patient observations could also be entered at the bedside, avoiding inaccurate transcription and making those observations immediately available to all.

The trial was funded by various private sector sponsors including Cisco Systems, IBM, Vocera, Intel, Dimension Data and Dell. The costs of the trial included the purchase and application of technology used; training of medical staff in using the chosen technology for maximum benefit; and implementation of a system to monitor, identify, record and assess trial results, including surveys of medical staff. The NTF Group, which specialises in observation and modelling studies, was engaged to collect and analyse the trial results, and consulting firms Aegis Group and Applied Economics were engaged to collate and present the results in a report to the New South Wales government.

The main findings for the evaluation period included:

1. Clinical staff reported a very high level of satisfaction with the way the technology supported their delivery of care.
2. Twenty hours of staff time was saved per day, which equates to 7,439 hours per year. If these time savings were extrapolated across all hospital departments, potential time savings from the use of wireless technologies would be around 122,000 hours per year. The monetary value of those savings, calculated on the basis of current average salary levels across the hospital, would be more than AUD $7 million a year.
3. The probability of a fast or very fast triage response increased from 38 percent to 46 percent. The probability of a slow or very slow triage response decreased from 42 percent to 34 percent (refer figure 2).

Figure 2: Impact on triage times

4. Discussion – extrapolate from the results to discover the impact on the wider organisation and build a business case for the health care sector
 

4.1 The promise of health connectivity
This trial was a formative step towards the potential transformation of CHW into a digital hospital, where networked ICT, especially new mobility capability through robust, secure wireless technologies, would enable clinicians to quickly access patient information and clinical data and communicate with each other at any time and anywhere in the hospital.

These objectives are being pursued at CHW because international experience has already demonstrated that the speed with which medical staff can access information and communicate with each other in emergency and other situations is critical to the quality of patient care and the capacity of hospitals to meet demand for care. In the United States hospital system, eg, information technology is often viewed as an enabler, with the value of an ICT project being measured in the resulting improvement in the clinical or operational process. The improvements can be in the form of fewer tasks in the process, better information at decision points, fewer handoffs, quicker cycle times or better availability of information. They all translate into higher quality and more efficient patient care.

The improved patient care and demand management outcomes that the use of appropriate ICT can enable reduces the need for capital investment in beds and other infrastructure capacity, particularly where clinicians optimise the functionality and applications of the ICT tools. While clinicians may tend to seek more infrastructure spending rather than targeting process efficiency and reliability to improve demand management, the trial sought to introduce ICT systems that clinicians could benefit from in terms of convenience, work speed, time savings and quality of care. In establishing the trial CHW considered that ICT systems that could deliver these outcomes for clinicians would maximise their acceptability to medical staff.
 

4.2 Generalising cost savings to the hospital
The savings in costs generated by time savings in the delivery of care were assessed by the independent economic consulting firm, Applied Economics, as part of its economic evaluation of the demonstrable benefits of the trial.

The trial demonstrated that, as a minimum, the use of wireless technology in the ED saved 20 hours and 23 minutes per day or 7,439 hours per year of labour by the FTE 83 clinicians in that department.

CHW considers that, as the ED is highly representative of all other departments in the hospital, these minimum time savings could be applied to the hospital as a whole. Based on this assumption, Applied Economics has calculated that the use of wireless technology across all departments in CHW would save a potential 122,000 clinical hours. Using 2005/06 prices this is estimated as a potential saving to CHW of AUD $7.4 million per year. The calculation of these savings is described in more detail in the economic evaluation by Applied Economics shown in the Appendix to this paper
 

4.3 Application to the NZ health care sector
CHW confronts many of the same challenges for reform confronting hospitals and health care sites around New Zealand. The findings of this study and others must be assessed for their relevance to the New Zealand and used to inform a more robust debate about the return on investment of health care connectivity in New Zealand. However, the smaller size of most health provider organisations in New Zealand, relative underinvestment in ICT infrastructure, and an uncertain appetite for embracing the "digital hospital" concept means the business case needs to be revisited for relevance to New Zealand.

Approaching deep and sustained health care reform is difficult, and the healthy scepticism of clinicians and nurses to technology initiatives is justified. Effective health care reform relies on a systemic approach to change at multiple levels – changes within the wider health care system, changes at a regional level and changes within health providers themselves. The Ministry of Health’s formative Connected Health programme and the regional co-operative initiatives for health connectivity can serve as leading initiatives in the systematic development and deployment of evidence for effective health care connectivity in New Zealand.
 

4.4 Impact on quality of care
The results of the wireless technology trial at CHW discussed in this paper affirm the international evidence that ICT systems that improve access to patient and clinical information and speed up communication between clinicians can provide real savings in treatment time and accuracy. This has a direct benefit on the quality and safety of patient care, process efficiency and reliability.

Based on international evidence, other benefits can accrue from the use of wireless technology, including safer and higher quality patient care, when it is combined with, and used to accelerate, the adoption of new clinical applications and fundamental business process and workflow reform. However, given the length of the trial undertaken at CHW it has not been feasible to measure this and other related benefits as part of the economic evaluation.
 

5. References
 

1. Tobias J, Stewart-Weeks M, eds. Cloud 9: connecting clinicians for better healthcare. Sydney, Australia: Cisco Systems and Intel Corporation; 2007.
2. Aegis Consulting Australia. Accelerating mobile access by clinicians to key clinical services and applications to improve the safety, cost-effectiveness and quality of patient care. Sydney, Australia; 2006.

Appendix: Cost, Benefits and Economic Evaluation of the Permanent Use of Wireless Technology at CHW
The economic evaluation of the trial results at CHW has been undertaken by Applied Economics, an independent economic consultancy. A summary of its final report2 is provided below.
 

Cost of Applying Wireless Technology at CHW
The cost of applying medical grade wireless technology in all departments at CHW on a permanent basis consists of both capital and recurrent expenditure. The incremental costs have been calculated over a nine year period allowing for capital spending in 2006/07, recurrent spending from 2006/07 to 2014/15 and recapitalisation of equipment in operational year 4 (2010/11). Over the nine-year period estimated incremental expenditure consists of:

• AUD $4.05 million in 2006/07 for the capital cost of a wireless ICT system
• A recurrent cost of AUD $100 000 each year from 20007/08 for the licence fee to use WHFCDs. 
• A recurrent cost of AUD $275 000 every two years from 2007/08 to replace batteries for the mobile computing devices.
• A recurrent cost of AUD $843 000 in 2010/11 for the recapitalisation of equipment.

Over the four-year budget cycle from 2006/07 to 2009/10 the funding required to implement medical grade wireless technology across CHW is estimated to be AUD $4.625 million consisting of:

• AUD $4.05 million in 2006/07 for the capital cost of a wireless ICT system
• AUD $575 000 in 2007/08 – 2009/10 for the recurrent costs of operating the system.

If the funding already provided by private donors for the trial (about AUD $765 000) is taken into account the total capital cost for the project in 2006/07 is AUD $4.8 million.


 

Benefits of Applying Wireless Technology at CHW
The international evidence identifies that ICT systems that improve access to patient and clinical information and speed up communication between clinicians provide real savings in treatment time and accuracy. This has a direct benefit on the quality and safety of patient care, process efficiency and reliability. The results of the wireless technology trial at CHW affirm the international evidence that advanced ICT systems save clinical treatment time for staff and patients.

Savings in clinical treatment time lead to direct savings in health care costs because labour is used more effectively. The labour costs at CHW represent 70 percent of the hospital’s operating costs. Of total labour costs, clinical labour costs represent 68 percent. Substantial time savings in clinical treatment can therefore represent significant cost savings. The cost savings that result from applying wireless technology to all departments in CHW is estimated to be about AUD $7.4 million per year (based on constant 2005/06 prices).

This estimated cost saving is considered to be conservative given that it is based on constant year to year prices and because it ignores the reality that greater time savings would accrue in outgoing years as medical staff become more familiar with wireless technology applications and functions.

Based on international evidence, other benefits can accrue from the use of wireless technology, including safer and higher quality patient care, when it is combined with, and used to accelerate, the adoption of new clinical applications and fundamental business process and workflow reform. Given the length of the trial undertaken at CHW is has not been feasible to measure this and other related benefits as part of the economic evaluation.


 

Economic Evaluation of Using Wireless Technology at CHW
The estimated benefit of the project is reflected by the net present value (NPV). The NPV is the sum of the net benefit for each year of the project over its nine year life. The NPV calculation is applied to the sum of net benefits whether based on the incremental cost (which does not include the trial capital costs already funded) or the total cost (which considers the entire capital cost). The table below illustrates the net benefit for each year of the project based on incremental and total costs.

Table 4 - Summary of costs and benefit, Wireless Infrastructure, CHW, constant 2005/06 prices, AUD $000s

As recommended by NSW Treasury, the NPV can be assessed by discounting the sum of net benefits by 4 percent, 7 percent or 10 percent to reflect varying sensitivities. The economic assessment of the trial results applies all these discount rates to assess the NPV in varying scenarios. Based on a central 7 percent discount the NPV for the project based on incremental costs is AUD $33.2 million and the NPV based on total costs is AUD $35 million.

It should be recognised that even if the benefits were only half of the amount estimated in the economic evaluation, the benefits of the incremental and total project would be substantially higher than the costs.

Accordingly, the economic assessment concludes that the investment by NSW Health in the implementation of wireless technology across all departments in CHW is a worthwhile allocation of funds.