Throughout the World there is a strong focus on and movement towards Integrated Healthcare Services (IHS) that put the citizen at the centre. Denmark is a frontrunner when it comes to IHS, however there is still a way to go. Today the focus is on breaking down the silos and building the organisational, financial and technical infrastructures to enable IHS. 2025 will bring an even stronger focus on bringing healthcare closer to the citizens. A cultural change and integration of new enabling technologies is also in the cards.
The challenges for IHS are primarily cultural and financial. Healthcare management have an important role in solving these challenges.
There are definite business opportunities for solutions that can support management, communication, collaboration and coordination across healthcare providers. However, it is important to be aware of the complexity, diversity and fragmentation of stakeholders as well as the barriers for integrating data.
Integrated healthcare services in the future
We are already building the organisational, financial and technical infrastructures to enable Integrated Healthcare Services. The experts give us their bids on how Integrated Healthcare Services will look in the future.
Inspired by The World Health Organisation, we define Integrated Healthcare Services as integration of all healthcare services provided by a collaboration between all public and private stakeholders, through cohesive service management and -delivery across healthcare sectors, departments etc. The cornerstone of the Integrated Healthcare Services is the focus on the needs, preferences, outcome and participation of the citizens, for whom the healthcare services are provided (WHO)WHO. WHO global strategy on people-centred and integrated health services. Retrieved from http://www.who.int/servicedeliverysafety/areas/people-centred-care/global-strategy/en/.
Hal Wolf describes integrated healthcare as bringing together all levels and resources of healthcare to provide cohesive services for the individual:
Without the adoption of an Integrated Healthcare Services approach, healthcare will become increasingly fragmented, inefficient and unsustainable. Improvements in service delivery is necessary to enable people to access high quality healthcare services that meet their needs and expectations. Hal Wolf further argues the relevance of Integrated Healthcare Services in improving accessibility, quality and cost-efficiency:
The emergence of Integrated Healthcare Services is a broad strategic approach that accommodates trends such as individualism, instant gratification, redefined health terminology, Health Consumerism and citizens taking a participatory role in managing own care. These trends call upon a paradigm change, which includes a redesign of the way healthcare services are delivered and managed, towards an integrated healthcare delivery system that is organised around the patient.
The WHO has a ‘Global Strategy on People-Centred and Integrated Health Services’ from 2015, which focuses on “placing people and communities at the centre of health services 2016 – 2026” (WHO)WHO. WHO global strategy on people-centred and integrated health services. Retrieved from http://www.who.int/servicedeliverysafety/areas/people-centred-care/global-strategy/en/.
The strategy acknowledges the need for different paths and interventions towards achieving people-centred and integrated healthcare services, across different countries and healthcare providers. The WHO argue that they should all adhere to a common set of principles and be:
The end goal of Integrated Healthcare Services is that citizens experience relevant and cohesive healthcare services of a high and consistent quality throughout the course of their lives. The movement towards Integrated Healthcare Services is energised by the often fragmented healthcare service offers today, which are often not personalised or integrated into people’s every day lives, as well as by the trend of Health Consumerism.
Peder Jest explains that Integrated Healthcare Services are good and interdependent relations in the healthcare sector between hospitals, GPs, municipalities and citizens, with a special emphasis on patients and citizens:
The healthcare system is changing and it will continue to change into a new paradigm where the citizen will be a much more active co-producer and co-responsible of health in the future. The paradigm change includes a redesign of the way healthcare services are delivered and managed, towards an integrated healthcare delivery system. The end goal is that citizens experience relevant and cohesive healthcare services and journeys of a high and consistent quality throughout their life course.
Integrated Healthcare Services as a concept is influenced by the megatrends of democratisation, increased health focus, urbanisation, digitalisation and the paradigm shift in patient groups.
Healthcare systems around the world currently face major challenges due to the increased life expectancy, cost of chronic diseases and multi-mobidities that the demographic change present. This places a constant pressure on the resources of the healthcare sector.
Sources: (Bornholms Hospital)Bornholms Hospital. De otte hovedområder i Udviklingshospital Bornholm. Retrieved from https://www.bornholmshospital.dk/udviklingshospital-bornholm/om-udviklingshospital-bornholm/de-8-delprojekter/sider/default.aspx & (KORA)KORA. KORA evaluerer forsøg med værdibaseret styring på ’Udviklingshospital Bornholm’ – KORA. Retrieved from http://www.kora.dk/aktuelt/undersoegelser-i-gang/projekt/i14043/kora-evaluerer-forsoeg-med-vaerdibaseret-styring-paa-’udviklingshospital-bornholm’
Under the name ’Udviklingshospital Bornholm’ the Capital Region of Denmark have exempted Bornholm Hospital from the region’s rate management model from 2016 to 2018. The purpose is to gain experiences with new management- and funding models. The theory of ‘Valuebased Healthcare’ forms the basis.
In valuebased healthcare the management is focused on the value for patients rather than e.g. activity-based results. The hospital organises itself with a point of departure in the patient needs and coordinated patient journeys.
Bornholm Hospital focuses on eight initiatives:
Bornholm Hospital will gain experience and document the effect of new management and funding models, which the Capital Region can use in potentially scaling these new ways of managing healthcare throughout the region.
Integrating healthcare services across sectors and departments demands a strong collaboration between all stakeholders across sectors. John Christiansen employs an engine analogy to describe this collaboration:
In a similar way, Kevin Dean compares Integrated Healthcare Services to a:
Hal Wolf explains that in order to collaborate as a joint system the diverse individual healthcare providers will need to think and work differently:
Denmark is consciously aiming for and working towards Integrated Healthcare Services and is a frontrunner internationally. The focus is on bringing down the silos, creating enabling organisational, financial and technical infrastructure and personalising healthcare to the benefit of the citizens.
At their core, Integrated Healthcare Services are focused on more cohesion and collaboration to provide coordinated, people-centered, end-to-end healthcare services. According to Hal Wolf Denmark is well on its way and well ahead of other countries:
Hal Wolf underlines the importance of innovation and the use of technology in order to achieve integration of healthcare services. In his opinion Denmark has the strength of a collective focus on innovation, information and integration:
Although Denmark might be in front when it comes to the integration of healthcare services, Peder Jest underlines that we still have quite a way to go:
Peder Jest recommends that the Danish Healthcare Sector finds inspiration in the rest of the World and combines the best practice into our healthcare system (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.
The healthcare sector today is characterised by multiple stakeholders, which are on the one hand independent of each other and on the other interdependent on each other. Cross-sectorial cohesion and collaboration is a much-debated topic and expressions like ‘breaking down the silos’ and ‘bridging the gaps’ are all but infrequent in healthcare debates.
The silos refer to the notion that as a general rule each sector, each organisation, each department etc. manage their own self-contained healthcare field and –services independently from other sectors, organisations and departments. The responsibility for what happens in “the gaps” between healthcare providers is as such not assigned to anyone, except the citizens/patients who are in transition. The silo thinking is a result of the way the sectors are managed, in a hierarchical structure, with management tools and financial models that do not account for the need to collaborate across sectors, but rather enforce fragmented healthcare services.
Erik Jylling is not alone in pointing out the fragmented healthcare services in Denmark. In mandagmorgen’s investigation of ‘the healthcare system according to Danes’, where 6,000 Danes were asked about their opinion on the Danish Healthcare Sector, mandagmorgen conclude that the key issue for Danes (66 %) is cooperation between hospitals, General Practitioners and municipal care (Mandag Morgen & TrygFonden, 2016)Mandag Morgen. & TrygFonden. (2016). Sundhedsvæsenet – ifølge danskerne. Retrieved from http://www.mm.dk/artikel/sundhedsvaesenet-ifoelge-danskerne-2.
Providing healthcare services that fulfill the expectations of the citizens/patients will therefore require increased integration of services through collaboration and cohesiveness between healthcare sectors. In order to fully achieve Integrated Healthcare Services, it is essential that the silos will be brought down in the long term.
So what does it take to bridge the gaps and eventually break down the silos? According to Hal Wolf and Peder Jest, consolidating an integrated healthcare ecosystem is dependent on building an infrastructure. This infrastructure will need to be multidimensional and include organisational, financial and IT aspects [id references=”599″] and ((Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark).
In relation to the organisational infrastructure Peder Jest argues that:
At the same time, he acknowledges that the organisational infrastructure between General Practitioners, the municipalities and the hospitals, however, still has room for improvement:
The organisational infrastructure concerns designing a cost-efficient integrated service delivery system, which provides high quality healthcare services focused on the needs and preferences of the citizens/patients. In the welcome speech at the WHINN (Week of Health Innovation) Hospital+Innovation Conference 2017, Stephanie Lose, President of the Regional Council of Southern Denmark, stated that “the patient service comes first!”. The design of a patient-centred and integrated service delivery system includes cohesive patient journeys through coordinated workflows, pathways and transitions. Citizens should not need to navigate between sectors and departments, healthcare professionals should instead improve their ability to collaborate. This will require each healthcare provider to offer flexible services that are naturally integrated in the entire coordinated patient journey, e.g. move the delivery of services to the patients in their home or at other external locations like GP’s or local health centers.
According to John Christiansen and Peder Jest organisational structural changes include designing the future integrated service delivery and establishing an infrastructure that will support the collaborative care services across sectors, as well as preparing the healthcare personnel for their new roles and responsibilities, as task may be allocated differently between healthcare providers than today. These changes will entail a need for cultural changes and competency development, which is supported by management through dedicated resources and openness to cooperation, collaboration, patient-centered focus and change (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark and (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.
As previously mentioned, promoting Integrated Healthcare Services will require a management-anchored alignment of incentives and payment structures to support a collaborative joint responsibility across healthcare providers. The new financial structure will need to encourage integration of services centred around the patient/citizen and support the changes in roles and responsibilities.
When it comes to financial management in the healthcare sector, it is important to mention that the Danish Healthcare Sector is currently experimenting with other ways of organising and financing healthcare. For example, the potential of valuebased healthcare is being investigated in Bornholm Hospital (‘KORA evaluerer forsøg med værdibaseret styring på ’Udviklingshospital Bornholm’ – KORA’).
In connection with valuebased healthcare, John Christiansen argues that the Danish healthcare sector of the future will focus on quality:
The aim of the technical infrastructure is to form the platforms that allow for relevant realtime access to information across healthcare stakeholders. The focus is increasingly on open platforms and interoperability as well as ensuring transparency, meanwhile ensuring data security. Hal Wolf sees potential in collaborative technologies that make information available and actionable for the relevant stakeholders (Data Analytics). He underlines the importance of achieving a complete integration of data and information:
Healthcare services are not isolated services detached from each other or from the everyday life of a patient. The increasing people-centred focus in healthcare includes personalising the healthcare service delivery to the personal needs and preferences of the person, as a patient and as a private person, through a holistic approach. At the same time patients are assigned an active and collaborative role, in which the healthcare providers support them in self-managing their illness. The relationship between healthcare providers and citizens/patients is increasingly characterised by co-production, in that all parties have an active role and a shared commitment and responsibility for managing the health of the citizen (Health Consumerism).
Hal Wolf argues that there is a clear focus on the patients as health consumers and improving the services for the patient:
John Christiansen also acknowledges this focus in the Danish Healthcare Sector:
Erik Jylling believes that over the next ten years we will move closer to more systematic integrated healthcare:
In 2025 the Danish Healthcare Sector is expected to be focused on more person-centred healthcare in the local environment of the citizen. This change will demand a cultural change and employing relevant new technologies to enable treatment and healthcare at a distance. Prevention is expected to be more in focus in 2025 as well.
Erik Jylling from Danish Regions believes that the future will bring a more person-centred healthcare system:
This is in line with the trend of Health Consumerism, which forces the healthcare sector to center around the users/patients. Erik Jylling also believes that the Danish Healthcare system will be completely digitalised in 2025, in line with the trend of Data Analytics.
Erik Jylling’s predictions are backed by John Christiansen who already sees an attempt to make a plan pointing forward where both the region and municipalities will have different parts to play than they had 10 years ago in providing service and nursing to those citizens who have a specific need but also in relation to health promotion and prevention (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark. John Christiansen predicts that in the future the different healthcare actors will work together in integrated collaborations around the patients and thereby create coherence and integrated care. He argues that there will be less silo-thinking and the first atempts to try to bring down the silos are already taking place in e.g. Esbjerg FAM and Esbjerg municipality, in the outpatient psychiatry or in childrens diabetes care being handled in the patients own home (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.
According to Danish Regions, Danish healthcare will gradually move in the direction of person-centred and integrated healthcare services. In their “Direction for the ‘Citizens’ Healthcare System’” from June 2015 it is argued, among other things, that there is a need for cultural change and for involving the users, citizens as well as healthcare personnel. The point of departure should be the needs and preferences of the citizen as well as their experiences, and they should be given the opportunity to manage as much of their own journey as they can and want to. In the end, citizens should experience holisticness and cohesiveness in their healthcare services across departments, organisations and sectors, and they should receive the support they need. (plan for borgernes sundhedsvæsen, Danske Regioner, Juni 2015).
In line with Danish Regions, Peder Jest argues that there is a need for a cultural change, and there is a need to employ Smart Health technologies to relieve the pressure on the healthcare personnel:
John Christiansen agrees with Peder Jest in bringing in smart health technologies to support the healthcare personnel, and he adds that we already see a tendency where citizens push new technology on the professionals and that this trend will become even more dominant in the future:
Erik Jylling also argues that new solutions, e.g. technologies, and digitalisation will be necessary components in integrating Danish healthcare:
There is an increasing willingness in the public sector to engage in open collaboration with private companies and other partners to solve the challenges of the healthcare sector together.
Erik Jylling believes first and foremost that the patient’s diagnostic, prehab and rehab will take place in or near people’s own home. Secondarily, he believes that the more specialised hospital services and healthcare services will have a more supporting set up than today. And that the patients will have more abilities and possibilities to interact with the system. He argues that we will see a system that is much more differentiated and supports strong and less strong patients accordingly (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark.
Peder Jest backs this forecast of treatment locally:
Peder Jest underlines the active role and responsibility of the citizens in:
In this connection he also argues that citizens need to be educated in managing their own health.
Josep Roca advocates a stronger focus on prevention, due to the potential for really generating cost-efficiency (Roca, 2017)Roca, J. (2017, January 12). Josep Roca. Interview performed by Health Innovation Centre of Southern Denmark. Erik Jylling agrees:
The challenges for Integrated Healthcare Services are related to culture, financial structures and financial pressure due to the changing demography. And facing these challenges will demand a management focus in the healthcare sector.
Erik Jylling from Danish Regions believes that our primary challenge for organising healthcare in Denmark is creating a joint focus across different healthcare providers and ensuring a continuum of care for the patient, through sharing more data across sectors, upgrading competencies and supporting prevention (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark. And in this connection he sees both cultural and financial barriers:
Peder Jest adds a need for more respect to the equation:
John Christiansen supports this sentiment about the need for solving the tasks in collaboration and respecting each other’s contributions and he adds that in order to achieve this the separate parties need to actually meet and understand what each party does (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark. He also underlines:
When identifying the primary challenges for Denmark in achieving Integrated Healthcare Services, Hal Wolf adds to the cultural and financial aspects. He identifies four main challenges, which are general for most countries; 1) integration and exchange of information, 2) integration of processes and technology, 3) coherence between new facilities (e.g. hospitals) and the “silver tsunami” needs, and 4) the funding model. (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.
John Christiansen from Danish Nurses Organization supports Hal Wolf’s challenge in relation to the “silver tsunami” and explains:
John Christiansen believes that the challenge will be to create coherence and integration in a situation of:
In the light of this impending financial pressure, which will potentially also be affected by increasing costs due to new treatment possibilities, John Christiansen argues that the healthcare sector will be under pressure due to the numbers and compentencies of healthcare personnel and:
Technology will particularly be relevant when the distances increase due to the centralisation of e.g. hospitals.
He argues that health promotion and prevention will be an important focus:
Peder Jest underlines that the changes in the healthcare system are dependent on the mindset of the management:
The Integrated Healthcare Services trend in the Danish Healthcare Sector may offer opportunities for companies developing solutions that can support:
There are, however also som barriers for integrated solutions to overcome:
When developing solutions for healthcare, particularly solutions that handle personal data, the following aspects will be relevant to consider.
In May 2018 the General Data Protection Directive from EU (GDPR) will enter into force in the EU (European Council, 2016)European Council. (2016). The General Data Protection Regulation. Retrieved from http://www.consilium.europa.eu/da/policies/data-protection-reform/data-protection-regulation/. The purpose of the directive is to strengthen citizens’ fundamental rights when it comes to data, privacy and digitalisation – but also to simplify rules for companies and thereby facilitate growth. Some of the more noteworthy changes enforced by the directive are the possibilities of issuing fines amounting to up to 4% of a company’s annual turnover.
In order to adhere to the GDPR, companies may look at the Guidelines for Cybersecurity (ISO 27032).
The regulation regarding data subject consent has been further strengthened and clarified. Consent must be explicit and the citizen must be clearly informed of the precise and defined purpose of data collection. Furthermore the citizen has the right to revoke consent. If consent is revoked the data must be deleted and proof that it has taken place presented to the citizen. This will affect all companies handling data pertaining to the citizen’s health.
Data portability is a new topic introduced by the GDPR. With GDPR the citizen will have the right to data portability. This means that if you collect personal data the citizen has the right to receive the personal data concerning him or her in a structured, commonly used and machine-readable format. They also have the right to transmit those data to another organisation that collects data about the citizen. The purpose of this obligation is to limit the number of times citizens have to answer questions about the same subject matter, e.g. age, height, gender etc.
This is particularly interesting from a healthcare perspective because data might be required to be shared across different organisations in the healthcare sector to a much greater extent than they are today. This might also prove a new business opportunity for companies, since there may be a whole new market emerging for solutions to support data portability, e.g. by providing system integration or sharing information between different IT systems.
In addition to the more general GDPR directive, an updated directive on Medical Devices will enter into force in the spring of 2020 and 2022. The two directives (EU) 2017/745 “MDR” & EU 2017/746 “IVDR” – (European Parliament & European Council, 2017a)European Parliament. & European Council. (2017a). (EU) 2017/745. Retrieved from http://data.europa.eu/eli/reg/2017/745/oj/eng and (European Parliament & European Council, 2017b)European Parliament. & European Council. (2017b). (EU) 2017/746. Retrieved from http://data.europa.eu/eli/reg/2017/746/oj/eng heavily regulate what is defined as medical devices, and how such devices can be tested and used within the boundaries of the EU. This is central for especially Data Analytics and Smart Health Technologies. ‘Medical purpose’ is defined as any type of diagnosis, prevention, monitoring or treatment or alleviation of disease or disability. The vast majority of devices which collect health information are likely to be considered medical devices, even if they do not process or analyse the data. Companies operating within the domain of health should proactively investigate compliance with these regulations and adjust development processes accordingly.
Bringing technology into the sphere of healthcare services brings with it relevant ethical considerations. The Health Innovation Centre of Southern Denmark has developed two videos that illustrate the expectations and challenges that may arise when new technology meets the healthcare sector. The videos focus on the perspectives of the patients at home and the clinicians working across sectors, respectively. Companies may consider these ethical aspects in their development process.
Companies developing solutions for Integrated Healthcare Services in the Danish healthcare sector of 2025 should particularly consider the following:
Adapt to Changes in Tasks and Responsibilities
The movement towards Integrated Health Services includes that primary and secondary care becomes more integrated; this implies that tasks will move between municipalities and regions, but also that new tasks and responsibilities emerge. Erik Jylling argues that:
These changes may lead to a need for different solutions/products. It is therefore important that companies are aware that solutions developed for the Danish healthcare sector of 2018 may not automatically apply in a 2025 context.
Design for the Support System around the Patient
When looking at health consumers, they usually have a large support system surrounding them; families, friends, neighbours, people they meet in their everyday lives, all of whom are often overlooked and not drawn into the value chain for healthcare. Companies can include these actors as well as the community aspect in their design process to empower not only the health consumer but also the health consumer support system, e.g. through connecting people digitally.
Integrated Healthcare Services may add value for the citizens, healthcare personnel, healthcare sector and society as a whole in relation to:
Potential risks to consider: