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Integrated Healthcare Services


Organising healthcare services for the 21st century

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Summary


it fundamentally brings the resources, a multidisciplinary approach, utilising its best case scenario, individual patient records so that a healthcare system can look at the individual at an individual basis across the care continuum
Hal Wolf

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.

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Short definition

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/.

What are Integrated Healthcare Services?

Hal WolfHal Wolf
CEO and Director
describes integrated healthcare as bringing together all levels and resources of healthcare to provide cohesive services for the individual:

“Integrated healthcare can be done at the institutional level, it can be done at the national level, or it can be done within an individual office, but it fundamentally brings the resources, a multidisciplinary approach, utilising its best case scenario, individual patient records so that a healthcare system can look at the individual at an individual basis across the care continuum, from primary care and prevention to secondary prevention to acute care, to chronic disease management” (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.

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 WolfHal Wolf
CEO and Director
further argues the relevance of Integrated Healthcare Services in improving accessibility, quality and cost-efficiency:

“This is fundamentally the goal we see in system after system. It is causing changes in the way we offer care, it is causing changes in the way we access and utilise information, we are learning from it, we are learning how to do it more efficiently but the fundamental outcomes that we hope to achieve and continue to achieve with integrated care is simply better outcomes, lower costs, better access, and more efficiency that is built into the system overall” (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.

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:

  • Comprehensive
  • Equitable
  • Sustainable
  • Coordinated
  • Continuous
  • Holistic
  • Preventive
  • Empowering
  • Goal-oriented
  • Respectful
  • Collaborative
  • Co-produced
  • Endowed with rights and responsibilities
  • Governed through shared accountability
  • Evidence informed
  • Led by whole-system thinking
  • Ethical
(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/pp: 10-11.

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 JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
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:

it is first the patients and the citizens, then it is the GPs and municipalities, and then if they need us it is the hospital systems. And Integrated Healthcare Services is; are you working together around the patient and using the same data, having the same way of looking at the results and the solutions and to be sure that you are all thinking in the same direction and that it is what the patients and the citizens want. That is integrated healthcare” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

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.

Why are Integrated Healthcare Services Relevant?

Integrated Healthcare Services as a concept is influenced by the megatrends of urbanisation, technological advances, change in healthcare burden, polarisation, individualization and democratisation, amongst others.

Healthcare systems around the world currently face major challenges due to the increased life expectancy, cost of chronic diseases and multi-morbidities that the demographic shifts present. This places a constant pressure on the resources of the healthcare sector.

CASE:

Developing Hospital Bornholm

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:

  • Better use of diagnostics
  • Better overviews for the patients
  • Use of the patients’ own health information (PRO)
  • Joint responsibility for admission and discharge of elderly patients between hospitals, municipalities and GPs
  • Joint and flexible outpatient clinics
  • Following patient preferences towards the end of their lives
  • Culture, frames and competencies
  • New types of visitation for acute patients

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.

How are Integrated Healthcare Services Achieved?


A symbiotic relationships where things matter to each other and help optimise one another. So, things that fit together like gears in a machine.
John Christiansen

Integrating healthcare services across sectors and departments demands a strong collaboration between all stakeholders across sectors. John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
employs an engine analogy to describe this collaboration:

“I see it as a simple principle. I see it as an engine where parts must fit together, have meaning for each other without every part being able to handle or matter on its own (…) A symbiotic relationships where things matter to each other and help optimise one another. So, things that fit together like gears in a machine.” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark
[Translated from danish]
.

a 20 layer cake which only tastes good when all of those layers have been cooked properly and put well together.
Kevin Dean

In a similar way, Kevin DeanKevin Dean
Honorary Professor, The Maersk Mc-Kinney Moller Institute, SDU Health Informatics, Patient@Home Advisory Board
compares Integrated Healthcare Services to a:

a 20 layer cake which only tastes good when all of those layers have been cooked properly and put well together” (Dean, 2018)Dean, K. (2018, January 4). Kevin Dean. Interview performed by Health Innovation Centre of Southern Denmark.

Hal WolfHal Wolf
CEO and Director
explains that in order to collaborate as a joint system the diverse individual healthcare providers will need to think and work differently:


How do we get an entire system looking simultaneously and integrate its approach to care, at the individual level? So that an individual is not going from one place to another but that the physicians, the clinicians, the family are all integrated in focusing on the individual from a care standpoint.
Hal Wolf
“… How do we get an entire system looking simultaneously and integrate its approach to care, at the individual level? So that an individual is not going from one place to another but that the physicians, the clinicians, the family are all integrated in focusing on the individual from a care standpoint. So we are beginning to see this recognition across all healthcare systems, that in order to reduce waits, to get to faster conclusions, to provide better care to the individual, we need to think and look collectively, against all of our different disciplines and try to do so in a simultaneous way, for when we are called upon in order to contribute, be able to have the benefit of the information about that person that has gone from discipline to discipline, have care pathways that are designed to cut across the multi-disciplines of care, and also have the tool sets that are available for continuity of care to exist” (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.

Integrated Healthcare Services in the Danish Healthcare Sector

Today

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 WolfHal Wolf
CEO and Director
Denmark is well on its way and well ahead of other countries:

“In the rest of the globe I think the patterns are the same it is just the difference of timing. Where Denmark started this journey 7, 8, 10 years ago, and is now in full swing towards those levels of innovation and investment, by the government and by the individual hospitals as well as the primary sector that is involved … How do we utilise the systems that are in front of us, reduce our bed days per thousand, utilise sensors that are around us, utilise innovation, begin to understand the use of EMRs at a better level, barcoding, whatever the technology may be, and then the workforce development that comes behind it, the process change etc.” (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.

So I would say when you think about the consciousness of the healthcare system in Denmark, the thing that distinguishes it, maybe more so than any other system, that is the collective focus on innovation, the collective focus on the improvement and the use of information, which has always stood behind it, the focus on continuing to improve the integration of care.
Hal Wolf

Hal WolfHal Wolf
CEO and Director
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:

“So I would say when you think about the consciousness of the healthcare system in Denmark, the thing that distinguishes it, maybe more so than any other system, that is the collective focus on innovation, the collective focus on the improvement and the use of information, which has always stood behind it, the focus on continuing to improve the integration of care. This really is one of the world-leading healthcare systems in terms of thinking about how to innovate, how to improve, versus almost anywhere else on the globe. There are certainly pockets that also exist but it is very impressive, very impressive in Denmark” (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.

Although Denmark might be in front when it comes to the integration of healthcare services, Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
underlines that we still have quite a way to go:

”When we are abroad we are very proud of talking about the Danish model. I am not so convinced that it is correct that it is really good all the way. We have the possibilities but we still have some problems” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
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.


Our healthcare system today in Denmark is very silo-based in its way of organising things. Different authorities. We have a centralisation, we have a subspecialisation. So it is rather fragmented.
Erik Jylling

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.

“Our healthcare system today in Denmark is very silo-based in its way of organising things. Different authorities. We have a centralisation, we have a subspecialisation. So it is rather fragmented” (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark.

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 JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
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 WolfHal Wolf
CEO and Director
and Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
, 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 JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
argues that:

“The hospitals also have a very good connection with the GPs because the GPs are the gatekeepers, they are the only people that can deliver patients to the hospital. They decide. And that is a good system, I think. Not everyone can just go to the hospital, of course they can in accidents and so on but I think it is a good thing with a gatekeeper; one clever person that can decide, do you need to go to the hospital or could we use another method for this” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

The connection between the GPs, the municipalities and the hospitals, still needs to be better. We still have some problems that we do not have very good solutions for … So we need to think differently! And we try to think differently!
Peder Jest

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 connection between the GPs, the municipalities and the hospitals, still needs to be better. We still have some problems that we do not have very good solutions for. And also giving messages back to the GP from the hospitals, they are, alone in our region, more than 650 small entities of GPs, and it is small companies in fact, and how should we deliver the same message to all these people? So we need to think differently! And we try to think differently! But I think we really have good ideas of how to work in a different way” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

“the patient service comes first!”
Stephanie Lose

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 ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
and Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
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’).


So a change of focus, from producing a lot to producing the right things, at the right time, with the right outcome.
John Christiansen

In connection with valuebased healthcare, John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
argues that the Danish healthcare sector of the future will focus on quality:

”So a change of focus, from producing a lot to producing the right things, at the right time, with the right outcome. And there has been a tendency that the incentives, which have been poured down over us, have more gone in the direction of speed and increased production. Where the future will, and this is already happening, the future will bring a larger focus on delivering quality” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

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 WolfHal Wolf
CEO and Director
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:

Denmark has not fully achieved complete integration of data and information yet but it is working on it very tightly, so there are pockets of integrated care” (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.

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 WolfHal Wolf
CEO and Director
argues that there is a clear focus on the patients as health consumers and improving the services for the patient:

“without question I am seeing municipalities working regions, the individual hospitals, the national focus on innovation. All of this has a lot to do with integrating services, which are being brought forward for the embetterment of the citizen, for the embetterment of the consumers or the embetterment of the patient. So in Denmark in particular as I see the changes in funding mechanisms, as I see the national focus on integration and improving and facilities, behind every conversation I have heard is recognition of the expectation on the consumer level and the need of the institutions to change for the embetterment and the usability at the patient level and the consumer- and the citizen level. It is well and alive inside Denmark, and it is what gives everyone a lot of parts (to play) and moving in that direction” (Wolf, 2018)Wolf, H. (2018, January 3). Hal Wolf. Interview performed by Health Innovation Centre of Southern Denmark.

I now see a plan that actually indicates the possibility of creating more integration between the systems we have in the healthcare sector today, both between the municipal and the regional levels as well as the state level. A system where the patient is viewed as a significant contributor and co-responsible for managing their own health, and where we as emloyees (nurses) come into play in different ways.
John Christiansen

John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
also acknowledges this focus in the Danish Healthcare Sector:

”I now see a plan that actually indicates the possibility of creating more integration between the systems we have in the healthcare sector today, both between the municipal and the regional levels as well as the state level. A system where the patient is viewed as a significant contributor and co-responsible for managing their own health, and where we as emloyees (nurses) come into play in different ways” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

In 2025

Erik JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
believes that over the next ten years we will move closer to more systematic integrated healthcare:

“I think we see small signs of doing this, interactions and interventions today but not as a system, not as a whole system, not as a well-planned and scheduled performance but much more like different initiatives taking place here and there. But I think what will happen from now and the next ten years is that we much more convene and standardise those services so it is much more like a system” (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark.

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.


I think we will see a much more person- or patient-centered healthcare system in 2025. I think we will see a healthcare system which much more takes its point from the patient’s view, and where the patient is a much more interactive agent in his or her own personal record.
Erik Jylling

Erik JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
from Danish Regions believes that the future will bring a more person-centred healthcare system:

“I think we will see a much more person- or patient-centered healthcare system in 2025. I think we will see a healthcare system which much more takes its point from the patient’s view, and where the patient is a much more interactive agent in his or her own personal record” (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark.

This is in line with the trend of Health Consumerism, which forces the healthcare sector to center around the users/patients. Erik JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
also believes that the Danish Healthcare system will be completely digitalised in 2025, in line with the trend of Data Analytics.

Erik JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
’s predictions are backed by John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
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 ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
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).


I have to say we need to have a cultural change, perhaps a cultural revolution aimed at the employees at the hospitals … And I think a lot of things will happen in five years. And a lot of new expectations in the next generations will show up and we have to educate the people, our employees, much more in thinking different. Making a cultural change.
Peder Jest

In line with Danish Regions, Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
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:

“I have to say we need to have a cultural change, perhaps a cultural revolution aimed at the employees at the hospitals. Because they are working very hard today and they are very busy, and there are a lot of patients (…). And that is why these smart health technologies have to be used by the employees in the future . They (red. the personnel) dont expect it. I expect that 70% of the employees they are not thinking about the future, they are thinking about what is happening here today and they even can’t imagine how it will be in 5 years from now( …) And I think a lot of things will happen in five years. And a lot of new expectations in the next generations will show up and we have to educate the people, our employees, much more in thinking different. Making a cultural change” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

we will see that patients of their own accord choose to bring in new technology (Smart Health Technology) that we as professionels are not familiar with. So, everything will happen much faster and the citizens will assume more responsibility by themselves before they even meet the healthcare sector.
John Christiansen

John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
agrees with Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
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:

”we will see that patients of their own accord choose to bring in new technology (Smart Health Technology) that we as professionals are not familiar with. So, everything will happen much faster and the citizens will assume more responsibility by themselves before they even meet the healthcare sector. I think this will be a new player in the market (Health Consumerism). We already see strong tendencies in this direction today” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

… it gives us the challenge that we have to use all the solutions that are out there and we have to put up demands for what kind of solutions we need and challenge companies to build those solutions for us.
Erik Jylling

Erik JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
also argues that new solutions, e.g. technologies, and digitalisation will be necessary components in integrating Danish healthcare:

“I see a very great future for the healthcare system, many challenges but also many solutions in the upcoming years. But it gives us the challenge that we have to use all the solutions that are out there and we have to put up demands for what kind of solutions we need and challenge companies to build those solutions for us. But I am very optimistic that it will happen and that we have the ability to digitalise the healthcare system to that extent that we could fulfill those basic goals we have for the healthcare system” (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark.

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 JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
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 JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
backs this forecast of treatment locally:

“The primary trends, and perhaps not everyone will like what I say now, will be that a lot of people do not have to go to the hospital, they have to be treated at the GPs, perhaps together with some physicians from the hospitals, but they have to be treated away from the hospital … but feel that they have the hospital near them. And a lot of people, healthy young people, have to treat themselves” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

managing (their) own health, taking measurements. And treating yourself to some extent will be routine within the next five years.
Peder Jest

Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
underlines the active role and responsibility of the citizens in:

“managing (their) own health, taking measurements. And treating yourself to some extent will be routine within the next five years” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

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 JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
agrees:

“We need to help people take care of themselves and support the majority of patients through prevention and support” (Erik Jylling, 2017)Erik Jylling. (2017). WHINN Hospital+Innovation, “The Future Role of the Hospital”, Erik Jylling. .

Challenges for Integrated Healthcare Services

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.


it has a lot to do with economical barriers, with cultural barriers, and another way of organising public healthcare services, integrated with social services and the labour market services so that we can get the buck for the dollar.
Erik Jylling

Erik JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
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:

“The challenges are if we can overcome our traditional way of planning things. It is concerning our economy, the incentives, the way we subsidise the right service and not the service that is favourable for the single element in the system. That we can overcome our traditional way of cultural thinking concerning how we deliver service, what we define as patients’ needs instead of asking the patient what they need … So it has a lot to do with economical barriers, with cultural barriers, and another way of organising public healthcare services, integrated with social services and the labour market services so that we can get the buck for the dollar” (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark.

The primary challenges are how to work very close together and understand each other and respect each other, whether you are a GP, a hospital physician, a hospital system or a municipality.
Peder Jest

Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
adds a need for more respect to the equation:

“The primary challenges are how to work very close together and understand each other and respect each other, whether you are a GP, a hospital physician, a hospital system or a municipality. And I think we need a little more respect for the different ways we have to think and work” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

I see a need for us to somehow have an eye for how we can optimise each other rather than thinking about what the economic incentive should be.
John Christiansen

John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
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:

“I see a need for us to somehow have an eye for how we can optimise each other rather than thinking about what the economic incentive should be” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

When identifying the primary challenges for Denmark in achieving Integrated Healthcare Services, Hal WolfHal Wolf
CEO and Director
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.


We may think that in the future we will be really healthy elderly citizens, the truth is probably that we will be active elderly citizens but probably not as healthy as we imagine.
John Christiansen

John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
from Danish Nurses Organization supports Hal WolfHal Wolf
CEO and Director
’s challenge in relation to the “silver tsunami” and explains:


…likely shortage of personnel resources, likely shortage of finances, likely shortage of political will to reprioritise and invest further in the public healthcare system.
John Christiansen
“I think this is an exciting time when we are in the process of building hospitals that do not match the needs of the population but instead the population will probably need to adjust to the highly specialised hospitals that are being built, and the citizens can do more themselves in a shorter time. And it makes sense. At the same time we know that the demography will put us under pressure due to the ageing society. We may think that in the future we will be really healthy elderly citizens, the truth is probably that we will be active elderly citizens but probably not as healthy as we imagine. We will probably have more chronically ill, more multi-morbidities and everything else. And I think, especially the hospitals as a sector has neglected much of this in the way they organise their services today” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
believes that the challenge will be to create coherence and integration in a situation of:

”likely shortage of personnel resources, likely shortage of finances, likely shortage of political will to reprioritise and invest further in the public healthcare system” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

we need to work smarter … and utilise the technological possibilities and involve the citizens and their families in the healthcare task.
John Christiansen

In the light of this impending financial pressure, which will potentially also be affected by increasing costs due to new treatment possibilities, John ChristiansenJohn Christiansen
District Chair, Danish Nurses Organization
argues that the healthcare sector will be under pressure due to the numbers and compentencies of healthcare personnel and:

we need to work smarter … and utilise the technological possibilities and involve the citizens and their families in the healthcare task.(Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

Technology will particularly be relevant when the distances increase due to the centralisation of e.g. hospitals.


Because if we continue to extrapolate the expenses that we have now the money will run out and the workforce will run out. So, again we come back to the need for a bigger health promotion and prevention effort. And to work smarter with the people who become ill, not just acutely but perhaps particularly the chronically ill.
John Christiansen

He argues that health promotion and prevention will be an important focus:

“Because if we continue to extrapolate the expenses that we have now the money will run out and the workforce will run out. So, again we come back to the need for a bigger health promotion and prevention effort. And to work smarter with the people who become ill, not just acutely but perhaps particularly the chronically ill” (Christiansen, 2017)Christiansen, J. (2017, December 5). John Christiansen. Interview performed by Health Innovation Centre of Southern Denmark.

And I think the leadership from the healthcare sector really have to think differently from what they are doing today. They are oldfashioned too
Peder Jest

Peder JestPeder Jest
Executive Director, Odense University Hospital, Patient@home Executive Board
underlines that the changes in the healthcare system are dependent on the mindset of the management:

“And I think the leadership from the healthcare sector really have to think differently from what they are doing today. They are oldfashioned too, they are thinking of the next year’s budget and how to reach the black lines and not red lines so we can keep our jobs and so on but I think they have to act quite differently, in fact I think we need a revolution in the healthcare sector!” (Jest, 2018)Jest, P. (2018, January 2). Peder Jest. Interview performed by Health Innovation Centre of Southern Denmark.

Opportunities and Barriers

The Integrated Healthcare Services trend in the Danish Healthcare Sector may offer opportunities for companies developing solutions that can support:

  • communication
  • collaboration
  • coordination
  • management and business intelligence across sectors, organisations and departments.

There are, however also som barriers for integrated solutions to overcome:

  • the complexity, diversity and fragmentation of stakeholders
  • individual budgets and the related motivation, involvement and ownership
  • data integration and -sharing

Considerations for companies

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.

 

Advice for companies

Companies developing solutions for Integrated Healthcare Services in the Danish healthcare sector of 2025 should particularly consider the following:


we have to share much more data than we do today, across sectors. And we have to upgrade competencies in different places in the healthcare system, especially in the municipality area, so that we can discover patients before they become patients, when they decline in their social status or social ability to take care of themselves.
Erik Jylling

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 JyllingErik Jylling
Executive Vice President of Health Politics at Danish Regions
argues that:

“we have to share much more data than we do today, across sectors. And we have to upgrade competencies in different places in the healthcare system, especially in the municipality area, so that we can discover patients before they become patients, when they decline in their social status or social ability to take care of themselves” (Jylling, 2017)Jylling, E. (2017, December 13). Erik Jylling. Interview performed by Health Innovation Southern Denmark.

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.


I know that [the relatives] are critical. And I think support groups, caregivers and families are crucial in care (…) and they are very unsupported. There is no real systematic mechanism to help them, so I think their role is critical.
Peter Watts

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.

“I know that [the relatives] are critical. And I think support groups, caregivers and families are crucial in care (…) and they are very unsupported. There is no real systematic mechanism to help them, so I think their role is critical. If you look at the 8 minutes that the practitioner gets, and maybe the 10 minutes that the nurse navigator gets, the family gets the other 23 hours. And their role is around the clock, it’s 3 o’clock in the morning, it’s midday, it’s a constant issue. So they are a critical path. And very overlooked as well, I think, and very misunderstood” (Watts, 2017)Watts, P. (2017, December 19). Peter C. Watts. Interview performed by Health Innovation Centre of Southern Denmark.

Values and Risks of Integrated Healthcare Services

Integrated Healthcare Services may add value for the citizens, healthcare personnel, healthcare sector and society as a whole in relation to:

  • More cohesion
  • Efficient and appropriate treatment
  • Reliability
  • Transparency, information and coordination
  • Flexibility

Potential risks to consider:

  • The worklife balance for healthcare personnel due to increased accessibility
  • The resources that creating these fundamental changes in healthcare will demand

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