The Fully Integrated Hospital – Realistic Aims or Overambitious Dreams?
By Christian Holz, author of the recently published study on ‘The HBS/HINE European eHospital Census – An Assessment of Current Healthcare IT Application Profiles and the Future Outlook in Europe’
In the Client Forum of the March 2004 edition of the HBSQuarterly Mr Murray Bywater, representing the Health Information Network Europe (HINE) was interviewed. His interview highlighted the cooperation between HINE and HBS Consulting which has now resulted in the completion of the landmark European eHospital Survey. This study assesses the current situation and some future outlooks of the Healthcare IT sector in Europe. It is timely and therefore appropriate to use this issue of the HBSQuarterly to review some of the outcomes of this research.
Obviously a summary of 13 reports dealing with individual country chapters each of about 160 to 190 pages in length goes beyond the scope of a journal article. For that reason only one of a number of exciting findings of the study has been selected. As an extremely important issue in current healthcare IT development “integration” is frequently mentioned in the study. Sometimes it even seems that integration is the most important amongst the current topics.
There is an observable trend amongst Healthcare IT suppliers to expand their own product portfolio by means of mergers or strategic partnerships with or acquisition of other companies to enable the offering of a range of products. These products look to cover the spectrum of requirements for IT in Healthcare and to offer solutions which are adjusted to and integrated with each other.
In the hospitals it seems that every Healthcare IT system has to be integrated with every other system in the hospital or even with organisations, institutions and other health service providers in the wider healthcare community. IT managers and CIOs in hospitals all over Europe dream of the fully integrated hospital. This is understandable since a number of the new Healthcare IT applications like ePrescribing or advanced Workflow Management Systems to enable clinical pathways are only imaginable on a certain level of integration of different hospital IT systems. Furthermore the introduction of DRG- based hospital payment systems sets another external pressure to increase the integration of different modules and systems across the hospital.
The drive toward integration is quite a U-turn compared with former preferences. In comments from interviewees and from analysis of quantitative data, HBS Consulting found that in recent years, solutions have been preferred which ideally meet the requirements of one department. CIOs and IT managers preferred rather isolated applications which represented the best possible solution for the task in question.
The current study uncovers evidence for the move to integrated healthcare IT solutions and an example can be found when comparing the suppliers of different modules of patient administration applications. Due to the inconsistency in use and understanding of terms like Patient Administration System and Hospital Information System, HBS Consulting surveyed different functions of these systems separately. The three major functions are hereby (i) systems for Admission, Discharges and Transfers (ADT), (ii) systems for scheduling of critical resources (SCR) and (iii) systems for collecting and coding of information for financial and reporting purposes (CCI).
Table 1 very precisely shows the trend towards purchase of the different above- outlined types of patient administration applications from the same supplier. Out of the 577 hospitals in the eHospital Census sample which had all three types of systems, far less than half of the hospitals which installed the first of these systems before 1990, decided to purchase all three modules from the same supplier. This share rapidly grows over the following time. In the case that the first of these three application types has been installed in year 2000 or later, nearly two third of the hospitals have chosen the same supplier for all three functions.
Table 1: Change of Supplier Consistency over Time (PAS functions)
Source: HBS Consulting – eHospital Census
Although there are quite considerable differences1 between the European countries focused upon by the study, a general trend towards integrated systems can be stated. This assumption is also supported by the outcome of another question which has been asked during the investigation. Here the CIOs and IT managers interviewed during the survey programme were asked to assess their current level of integration and the level of integration which they expect to be in function in their hospital in five years time.
Most interestingly and very consistent across all European countries is the significant expected shift towards fully integrated systems within the next five years. This ranges from 72.7% in France up to 97.4% in the U.K. and Ireland but also in the Scandinavian countries nearly 95% of the hospitals expect to be fully integrated in five years time. Besides Spain (76.2%) and Austria (74.3%) in all other countries this share is between 80% and 90% – the European figure2 is 83.7%. About two third to three quarter of the hospitals with full integration in five years even expect to be connected externally to other locations in their own organisation or other institutions in the wider health care community (only Austria is somewhat an outlier here with only half of the hospitals with full integration in five years expecting external connection as well).
This uniformity in the expected situation in five years is extremely surprising when comparing the current level of integration across Europe. Here the predominant setting on European level is LAN based separate systems – only very loose connections between several automated systems in the hospital. In some countries, especially in France and in Italy, many hospitals are not even on this level of integration and still use systems which only meet the needs of one department.
Figure 2 shows the migration pattern between the current level of integration and the expected level of integration in five years. The numbers in the chart show how many hospitals out of a thousand hospitals migrate between one and the other integration level. Most interestingly many of the hospitals with lower levels of integration plan or expect respectively to change straight to fully integrated solutions by skipping one or more intermediate levels.
Obviously the question arises whether these ambitious efforts to implement fully integrated hospital IT solutions within the next five years in a total of more than 2,000 acute hospitals in the countries focused upon by this study3 can be considered to be realistic.
Some of the data gathered for the eHospital Census suggests some doubt about the feasibility of these aims. Only about one third of those hospitals which plan to implement fully integration in the next five years indicated having an agreed and documented formal integration strategy.
Interestingly this share is significantly higher in continental Europe and lower in Scandinavia and on the British Isles. Further support for doubts on implementing full integration in the next five years can be found in financial figures obtained by the Census. Especially in countries in which the difference between the current share of fully integrated hospitals and hospitals planning to be fully integrated within five years is particularly large (i.e. France and Italy but also Belgium and the Netherlands and Spain) the budget of the IT department is particularly small. In 62.9% of the Italian hospitals for example, only less than 1% of the total hospital budget is assigned to IT expenditure and in 85.5% of the hospitals less than 2%. In France this latter share is 84.3% which is in both cases very much higher than the overall European figure. Additionally, in these countries the share of CIOs and IT managers expecting the IT budget of their hospital not to grow (i.e. to stay stable or even to shrink) is remarkably higher than in the other countries.
So it can be stated that particularly those countries which still have the longest way to go to achieve the ambitious aim of fully integrated hospitals give their IT departments the least financial power to reach this aim. These factors support the lack of confidence in whether the highly ambitious plans can be realised with this insufficient financial strength.
However, fully integrated hospitals are on the top of the agenda since this is simply inevitable for advanced healthcare IT applications and DRG clearing. HBS Consulting, with its network of contacts within the major European hospitals is perfectly placed to gauge the reality of this transformation and to assess the time frames within which the trend to integration outlined can indeed be achieved.
1) Including the finding that in the Netherlands and in Belgium the described trend seems to be reverse: In both countries, newer installations rather tend to be isolated applications by different suppliers. On the other hand the described trend is especially strong in Germany and in the U.K. and Ireland.
2) That is the overall figure for all countries focused by the eHospital Census: Germany, France, U.K. and Ireland, Italy, Spain, Belgium, the Netherlands, Austria, Switzerland, Denmark, Sweden, Norway and Sweden.
3) Please note, that for methodological reasons in Germany, France, the U.K. and Ireland, Italy, Spain, Belgium, Austria and the Netherlands all hospitals with less than 100 beds and in Switzerland with less than 75 beds have been excluded from the base population of the eHospital Census. Furthermore the Census focused only on acute hospitals rather than all (including long-term stay, geriatric, psychiatric etc.) hospitals.