Around the world, countries and health care organisations are making progress in using health information technology to improve outcomes and access, paving the way for the future of health.
IT might seem that health care systems and challenges are local and unique, but there are more similarities than differences.1 Throughout the world, health care systems struggle with affordability, inequitable health care access, uneven outcomes and increasing demand for services from growing populations with longer life spans.
Health information and digital technologies can help meet these challenges, support population health goals, improve consumer experience and drive insights into health conditions. We found examples of public and private programmes with demonstrated results that offer creative approaches to common problems or lessons for others. In doing so, we begin to see some of the possible features and capabilities for a health system of the future.
Our research found support for Deloitte’s view of the future of health,2 that health care of the future will be different from today in three distinct ways:
We hope the case studies in this report inspire readers to think about what future digitally enabled health care may look like, how organisations should prepare and the role they can play in this future.
Our goal for this research was to create a collection of curated case studies from around the world to:
The assembled case studies are not a comprehensive representation of innovative uses of HIT or countries. They are more of an illustration of how some of the future of health concepts are already here. Figure 1 offers a geographic snapshot of the featured case studies.
Deloitte envisions that health care of the future will be different from today’s in three distinct ways:
Our research lends support to Deloitte’s view of the future of health. We interviewed six world-renowned HIT experts about the characteristics of the future health care system, the technological capabilities needed to achieve that future and nontechnological enablers that should be present. Most of the findings from these interviews align with Deloitte’s perspective (see figure 2).
Experts stressed that the transformation to the health care of the future requires more than just technology, it should include:
Each case study in our research offers elements of the future vision and illustrates how technological and nontechnological enablers contributed to success. We have organised the case studies in three sections, according to the future of health themes that they represent best:
For each case study, we also highlight the nontechnological enablers that contributed to the success.
Initiatives in this section show how digital technologies help improve access to care and well-being for underserved populations.
The ReMiND project in rural India was designed to address deficiencies in an existing community health programme for pregnant women and new mothers. To achieve the project goals, technology developers had to account for users’ low literacy skills and mobile phones without advanced features. However, the biggest contributor to success was change management: modifying meeting formats for programme staff and using data to drive community health workers’ behaviour change so they could accomplish better outcomes.
In the AccuHealth example in Chile, AI helps identify high-risk patients with chronic conditions most likely to benefit from a health-coaching intervention. Remote monitoring enables interventions almost in real time: Health coaches contact monitored patients within one to four hours of an abnormal biometric reading.
In both programmes, digital technology delivers timely prompts and insights to the users, motivating behavioural change, which in turn contributes to saved lives, better health and lower costs.
The Reducing Maternal and Newborn Deaths (ReMiND) programme in India demonstrates how a simple mHealth application can improve care delivery at the community level.
ReMiND’s impact on maternal and infant health is significant:4
In 2006, the Indian government launched the Accredited Social Health Activists (ASHAs) programme to reduce maternal and infant mortality in rural communities. As part of the programme, female community health workers (called ASHAs) visit pregnant women and new mothers to provide services such as nutritional counselling or referrals to hospitals for childbirth.
However, the ASHA programme did not have the same impact in the state of Uttar Pradesh (which has historically high maternal and infant mortality rates)5 as in other parts of the country. To address the deficiencies of the programme in Uttar Pradesh—limited training, inadequate job aid for ASHAs, weak supervision and a lack of role clarity—Catholic Relief Services and its partners launched the ReMiND project.
ReMiND has two key components that strengthen community-level systems around maternal and newborn health:
In the first two years since the launch of ReMiND, 15 per cent more pregnant women received a visit from an ASHA and the percentage of low‑performing ASHAs decreased from 61 to 19 per cent between 2011 and 2013.6 After the introduction of the app, women were 28 per cent more likely to receive a counselling visit from ASHAs on twice as many topics.7
Catholic Relief Services attributes ReMiND’s success to its user-friendly app and structured interpersonal communications that helped ASHAs be more effective. While ReMiND was implemented at the community level, its benefits are potentially replicable at all levels of the health system (community, district, state, or even national).
Chronic diseases are responsible for an estimated 41 million deaths worldwide and the cost of chronic disease is enormous. In the United States, for example, caring for individuals with chronic conditions accounts for up to 66 per cent of all national health care expenditures and 98 per cent of total Medicare expenditures.8
In Chile, which has close to 5 million people with chronic conditions,9 AccuHealth (a health management company) uses AI-powered remote monitoring to help in the management of these patients. Unlike traditional disease management companies, AccuHealth performs real-time remote monitoring, as its AI stratifies patients to ensure that health coaches focus on high-risk patients and those in immediate need of intervention.
In Chile, AccuHealth uses two models to work with public and private payers:
One of the biggest learnings has been the importance of human interaction:
AccuHealth’s kits consist of sensors and tablets that guide patients through biometric data collection (blood pressure, glucose levels, weight and other indicators) and quick survey questions. The kits can be customised for different conditions (diabetes, hypertension, chronic obstructive pulmonary disease and even post acute care) and use on-market clinically validated devices.
Trained on deidentified records of 2.4 million Chilean patients,11 AccuHealth’s algorithm segments patients based on health trends and psychological and sociological profiles to identify high-risk patients. This enables health coaches to concentrate on those for whom the impact of monitoring is likely greatest, decreasing the cost and effort involved in managing populations.
To assess clinical impact, AccuHealth conducted a study of 4,000 diabetics using its solution and measured A1c blood sugar and blood pressure levels at study start-up, monthly and after a year. Results showed a 1.5-point reduction in A1c from the sixth month onward. AccuHealth estimates this translates into a 20–40 per cent decrease in medical complications for chronic patients and a 30 per cent decrease in costs over the next 10 years.12
AccuHealth reports its solution has led to a 32 per cent reduction in inpatient and 15 per cent reduction in emergency visits in a payer’s population. Additionally, it has led to a 41 per cent decrease in costs associated with medical leaves, a major expenditure for payers in Chile. On average, private payers see a 35 per cent savings from the AccuHealth solution.13
AccuHealth runs five full-scale and 10 pilot programmes across five provinces and intends to expand its reach to 100,000 Chileans in the medium to long term, by working with more public and private payers.
In this section, we talk about how interoperable data and platforms allow for exchange of health information and analytics that help increase the speed and effectiveness of health interventions. The case studies fall under two categories:
Systemwide digital health platforms. In the future, we expect data to flow seamlessly across platforms, creating new ways for consumers and care providers to proactively collaborate while supporting a system of wellness. Systemwide platforms are huge undertakings, particularly in view of numerous legacy systems that impede interoperability and certain basic capabilities must be in place to create a foundation for data-sharing.
For instance, achieving interoperability requires changes in clinical documentation practices at the organisation and user level, as well as complex interfaces among clinical IT systems, even when standards are in place. Building its e-health system from the ground up, before providers had a chance to invest in their own electronic systems, Estonia may have benefited from early adoption. Australia and the Netherlands represent a more typical scenario where multiple legacy systems, EHR platforms and organisation-specific conventions have evolved as barriers to interoperability. To support interoperability, all three countries have implemented a system of unique IDs for patients, providers and organisations, as well as strict authentication rules.
Typically, a new legal and regulatory framework is required to support digital health efforts. The pace and scale of adoption often hinges on a national decision of opt-in or opt-out for consumers’ participation in data sharing. An opt-out approach has been shown to increase adoption. Estonia has adopted opt-out from the beginning, without much controversy. Australia’s move from opt-in to opt-out was a solid course correction that should lead to higher usage, whereas the Netherlands may see a decline in usage after switching to an opt-in model.14 To gain public and political support for opt-out, legal and technological safeguards of data privacy and security are necessary. All three countries have incorporated these safeguards. Before connecting to a national network, providers must demonstrate that their IT systems meet technical and security requirements. Consumers can authorise and restrict access for certain providers, restrict access to portions of the record and close the record altogether. The systems generate access logs, so consumers know who viewed or contributed to their record.
As is often the case with technology, an if you build it, they will come approach is unlikely to materialise. Achieving a critical mass of users is a common challenge. With providers, incentives and regulatory mandates are common approaches, whereas with consumers, opt-out is a good first step. Ongoing public awareness campaigns serve as reinforcement. But most importantly, technology should deliver value to users; this ensures not just nominal adoption, but actual use.
Known worldwide for its e-government services in tax, voting, health care, education and public safety,15 Estonia began to develop e-health infrastructure in the early 2000s and introduced the first e-health services for consumers in 2008.16
Initially, the e-health system had four major components:
Availability of technical expertise, continued commitment from the government and the public’s digital literacy and trust in the government enabled Estonia to realise its e-government vision. An entirely new legal framework was required to support e-health, including mandated use of EHRs by providers, compulsory citizen ID cards, and data security and access requirements.
As of 2015, the total cost of Estonia’s national e-health project was approximately US$3 million.18 This equates to about US$10 per patient record, considerably lower than in other developed countries.19
The security of e-health in Estonia relies on blockchain technology and authentication with ID cards, digital signatures, separation of personal data from medical data, encryption of data and monitoring of actions, allowing users to know who accessed their health data.
Having built a centralised data architecture and secure environment for data exchange, Estonia was well-poised to introduce additional e-health initiatives:
Going forward, connecting the centralised database with other systems presents new opportunities:
Netherlands had an early start with e-health, but faced headwinds along the way. In 2002, the Ministry of Health, Welfare and Sport funded the National Information and Communication Technology Institute for Healthcare (NICTIZ) as a centralised body of expertise on e-health. NICTIZ was tasked with establishing a nationwide digital infrastructure (AORTA) for secure and reliable exchange of medical data among providers.
Completed in 2011, AORTA contained records of one in two Dutch patients.22 However, in response to political pressure, the system moved from patient opt-out to opt-in, the records collected up to that point had to be destroyed and the responsibility for e-health implementation was transferred to the industry.
NICTIZ’s research suggests changes in culture and care processes are needed to accelerate adoption of e-health:23
Despite the setback, as of 2016, 92 per cent of health care providers were connected to AORTA, some 11 million Dutch people (almost two-thirds of the population) opted to having their health data shared among providers and around 150,000 messages were exchanged daily.24
Patient centricity moved to the top of the e-health agenda in 2014, with ambitious goals set for completion by 2019:25
Achieving these goals is taking longer than expected. Access to health information remains complicated for patients, as each health care organisation operates its own patient portal.
The MedMij initiative championed by the ministry aims to accelerate the development of a central personal health record26 by fostering competition among technology developers. Several years from now, a patient should be able to choose one of several MedMij-certified apps to access their longitudinal data in one place and simplify tasks, such as making appointments and viewing test results.
The national rollout of Australia’s My Health Record (MHR) was completed in early 2019 and initial evidence and anecdotal accounts suggest it is on track to deliver on its promise, to ensure that important health information is available when and where it is needed.27
During the disastrous floods in February 2019 in Townsville, MHR proved vital to patients cut off from their regular pharmacies and GPs.28 Patients were showing up at the pharmacies they could manage to get to, without prescriptions and without much knowledge of their medication. But the data in patients’ MHR gave pharmacists all the information necessary. It so happens that Townsville is in a pilot region, North Queensland, where MHR was launched in 2016 and most people in the area have an active and populated health record.29
MHR has considerable public health potential. As all clinicians involved in a person’s care begin to use and contribute data to MHR, it can help them coordinate care and order fewer duplicative tests and services. MHR could also serve as a personal health assistant reminding consumers about age- or condition-appropriate medications or tests (such as pap smears, vaccinations, or the A1c test). And it could even be a platform to document end-of-life wishes.30
MHR started in 2012 as the Personally Controlled Electronic Health Record. It was renamed My Health Record in 2016 and moved from an opt-in to opt-out consumer participation model to increase usage.
MHR does not replace the medical records created by clinical systems at physician practices or hospitals but rather contains a summary of relevant medical information. The Shared Health Summary generated by general practice contains a patient’s diagnoses, medications, allergies, vaccinations, as well as personal information such as age and sex.
Providers can upload to MHR other types of documents too:
This data is automatically saved in the MHR by means of an interoperable data network that requires a high level of standardisation of clinical documentation. Yet, fewer than 25 per cent of health care providers use MHR guidelines for clinical terminology and no national mandates exist to this effect.32
Clinical initiatives by hospital systems. Provider organisations find novel ways to use HIT to tackle inefficiencies and improve quality. Case studies in this section demonstrate how technology augments clinician decision-making and optimises workflows.
Analytics coupled with clinician education has played a major role in transforming pain management at Geisinger in the United States. At the Sheba Medical Centre in Israel, efficiencies created by AI support quality improvement by prioritising critical cases in the radiologists’ workflow, reducing time to treatment and improving outcomes for patients with critical pathologies.
For both organisations, several important factors contributed to success: an integrated data and analytics infrastructure already in place; clearly defined goals a new solution would meet; culture that supports innovation and data-driven decision-making; and change management—such as user engagement, education and feedback—to help achieve desired behaviour change.
With 140 deaths per day from drug overdoses, the US Health and Human Services declared the opioid epidemic a public health emergency in 2017.33 In the years that led up to it, it had become increasingly apparent that prescription opioids played a big role.34 In 2012, the Geisinger health system, serving more than 1.5 million patients in Pennsylvania and New Jersey, decided to take a close look at the prescribing patterns of its own physicians.
Using its robust health information system, which captures longitudinal electronic health records and medical and prescription claims, Geisinger’s IT team built a controlled-substance monitoring dashboard that allowed population-level views and patient-level drilldown.35 Until they saw the data, high prescribers had no idea they were outliers.
It took one or two years of clinician education for things to start changing. A strong physician-led culture and a commitment to care quality ensured that all physicians embraced the feedback and reevaluated their prescribing behaviour.
Today, Geisinger’s holistic pain management programme includes physical therapy, mindfulness and meditation, exercise, acupuncture, diet and nutrition, and behavioural therapy.36
The cost benefit of Geisinger’s opioid prescribing programme is hard to measure. In the short term, treating pain holistically may be more expensive than prescribing medications, but the risk of addiction is greatly reduced, and the outcomes and patient experience are improved. Geisinger may be in a better position than others to absorb the added cost, as most of its patients are customers for life and 40 per cent are also insured through Geisinger.
With physician education aimed to encourage pain management approaches that do not rely heavily on opioids,37 opioid prescriptions fell from 60,000 per month in 2014 to 31,000 in 2017 and to under 22,000 in 2019.38 This would not have been possible without the organisation’s dashboard obsession, powered by cradle-to-grave health data and the ability to turn that data into usable information.
Now, EHR integration with the state’s Prescription Drug Monitoring Programme makes it possible to know if a patient has received or sought opioid prescriptions elsewhere. The EHR also limits the quantities and doses for new opioid prescriptions.39
With controls in place to minimise the risks for new addictions, the focus is shifting to treatment, which may prove the biggest challenge yet. Treatment is demanding, the risk of relapse is high and many patients simply refuse treatment. Here, technology may once again serve as an enabler: A health information exchange that can ensure secure communications among the state’s treatment facilities is nearing completion.
Exponential growth of medical imaging in routine diagnostic practice, without a corresponding increase in the number of radiologists, has increased radiologists’ workloads: One US study estimates it increased from three images per minute per radiologist in 1999 to 16 in 2010.40
The growing demands on radiologists were acutely felt at Sheba Medical Centre, Israel’s largest hospital campus. With 75 per cent of patient care involving imaging and a conventional first-in-first-out workflow, radiology became the bottleneck, delaying diagnosis and treatment.41
The medical centre looked to AI to improve efficiency. With Aidoc, a technology startup, the team focussed on time-sensitive and potentially life-threatening conditions that can benefit from a quicker diagnosis.42 They started with brain imaging. When AI detects bleeding in the brain, that image pops up on a radiologist’s screen, pushing that case to the top of the work list so that the radiologist can review and confirm the diagnosis and return the results to the ordering physician, who can initiate immediate treatment.
Sheba’s radiologists welcomed the new tool and pushed for the development of AI solutions for other time-sensitive pathologies: pulmonary embolisms, lung nodules, fractures and abdominal air. The software helps not only prioritise and reduce time to treatment, but also improves diagnostic accuracy, ensuring that no cases of life-threatening pathologies are missed.
Software developers spent weeks shadowing radiologists to understand their work, pain points and communication flows. Several key insights informed the design of the tool:
Due to advanced IT and data security capabilities, Sheba was able to quickly roll out the solution to all radiologists and its innovation-led culture contributed to physician engagement with Aidoc’s software developers and quick adoption of the technology.
With 96 per cent accuracy, Aidoc’s solution has been shown to reduce turnaround time by 32 per cent for critical cases.43 Studies are ongoing to evaluate the impact on overall length of stay, diagnostic accuracy and turnaround time.
Going forward, Sheba and Aidoc are exploring the use of AI in:
Many countries are exploring AI’s potential in diagnostic imaging.
Initiatives in this section are early experiments that target large segments of the population and demonstrate the potential of mobile technologies to meet population health goals, by actively engaging and empowering consumers.
In Canada, parents responsible for tracking their children’s immunisations have a new tool to help with the manual process. The CANImmunize app is designed to increase immunisation rates and accuracy of immunisation records in a fragmented system by giving individuals control of their records and equipping them with evidence-based information. It also created a foundation for data exchange and vaccine surveillance at a national level.
In emergencies, rapid information can be the difference between life and death. The MyMDA case study from Israel demonstrates that making individuals a part of the care team can increase the quality and efficiency of the emergency response. By making it easier for consumers to share their medical history and nature of the emergency, the app helps make the emergency response team faster and better prepared.
The SPARX mobile game from New Zealand reveals how youth engagement can drive improvement in mental health. By gamifying the intervention designed specifically for teenagers with depression, the e-therapy mobile app has been successful at improving emotional resilience and increasing requests for face-to-face counselling, particularly among underserved indigenous youth. Health questionnaires included in the game generate evidence of effectiveness as the app is used.
In Canada, parents are often the custodians of their kids’ immunisation records. But the system doesn’t make it easy. For one, it is possible to get vaccines at multiple types of providers (pharmacists, doctors, emergency departments) who might not share information with each other. Furthermore, immunisation schedules differ across provinces: For instance, Quebec recommends the second dose of the measles, mumps and rubella vaccine at 18 months, while Ontario does so at four to six years.48 And the system is problematic for national public health reporting too, due to different data standards in provincial immunisation registries.
CANImmunize, a mobile app and web platform to help families manage immunisation records, was born out of a chance conversation in 2011 between a mum and a public health researcher. After its initial launch in Ontario, the app was rolled out nationally in 2014, with support from the Public Health Agency of Canada. Today, the app counts 55,000 users of the cloud-based platform and 300,000 mobile downloads.49Available in French and English, the app enables users to:
Efforts are underway to scale up the app by enabling:
A pilot programme in Ontario to access the provincial immunisation registry through the app has shown promise and is a step towards moving immunisation records digitally between provinces.50 Digital scanning of vaccine product barcodes, useful for product recalls and adverse event reporting, has been shown to be technically feasible.51
The Canadian Vaccine Catalogue (CVC) is the byproduct of the data science that went into developing the CANImmunize app. The CVC is a standardised vaccine terminology and regularly updated database of all vaccine products in Canada that can translate vaccine information for EHRs and information systems used by different provinces. The CVC helps achieve Canada’s vision of a national network of immunisation registries and improve vaccine surveillance.
Collaboration with school districts helps increase public awareness about the app: When schools send out suspension letters for failing to provide up-to-date immunisation records, usage spikes.52 Ottawa, Toronto and Kingston schools accept immunisation record submission through the app and other counties plan to do so soon.
In the future, CANImmunize has the potential to improve vaccination rates and surveillance among adults and serve as a digital immunisation passport. Digital technology can also address the vaccination needs of niche groups, such as bone marrow transplant recipients and cancer patients.
Timely emergency medical response is often hampered by a lack of critical information, such as the precise location of the emergency, the patient’s medical history and a clear understanding of the nature of the emergency. Emergency medical teams (EMT) across the world spend considerable time—a crucial resource in emergency situations—to gather this information, which leads to a delay in emergency response.53
Magen David Adom (MDA), Israel’s national emergency service, built a mobile app known as MyMDA to increase its efficiency in emergency responses. The consumer app is available in multiple languages and enables users to:54
The MyMDA app is part of a suite of mobile apps that not only creates connexions and data exchange between EMTs, first responders, ICU teams at hospitals and consumers in emergencies, but also enables peer-to-peer sharing of resources:55
With the data from the consumer and the first responder apps, the MDA technology can automatically call the five nearest first responders to the emergency scene. Trained as paramedics and first-aids,56 first responders use their own transport and typically take less than five minutes to arrive, which is several minutes before the ambulance.57
MDA can identify other MyMDA users carrying emergency medicines (such as EpiPens or insulin). If needed, the app can locate the closest user in possession of these medicines and ask them to bring the medicine to the site of the emergency. Upon arrival, the EMT team replaces their medicine.
Since its launch in 2016, the app has been downloaded more than 150,000 times and the emergency response time has been cut by 35 seconds.58
Early adopters were people with medical conditions anticipating the need for emergency care. Adoption by healthy people has been slower.
The next version of the app will give users the option to take advantage of all the extended features or just the basic ones. This way, people unwilling to provide their personal health information and national ID number can still use the app for calling, location sharing and sending video feeds.
MDA executives have a vision for a new approach to emergencies:
With one of the highest teenage suicide rates globally59 and a shortage of counselling services, New Zealand harnessed an innovative e-therapy solution to reduce the impact of teenage depression.
Funded by the Prime Minister’s National Youth Mental Health Initiative, the SPARX app uses cognitive behavioural therapy to assist teenagers with mild to moderate depression and anxiety. Teenagers sign up and play as avatars exploring a 3D world to complete quests, meet new characters, play mini-games and solve puzzles. Virtual guides instruct players on how to apply these new learnings to feel better and solve problems in real life.
Initially, mental health professionals were sceptical about SPARX’s effectiveness. But several studies have shown SPARX to be as effective as face-to-face counselling.60 For instance, in a 2012 comparative study (n=187) measuring the effectiveness of SPARX versus traditional counselling, SPARX helped more kids aged 12–19 recover from depression. Additionally, 43.7 per cent achieved remission, compared to the 26.4 per cent receiving traditional counselling.61
The app tracks user progress by administering a patient health questionnaire, PHQ-9 (a validated mental health assessment tool), as the player progresses through game levels. The ongoing assessment measures app effectiveness at the population and individual level by ensuring the app does not cause harm or create an opportunity cost (e.g., by keeping patients from seeking further help while they participate in an intervention that isn’t working). If scores remain low, the app prompts the player to use SPARX’s telephonic or text messaging service or seek face-to-face counselling.
The SPARX marketing efforts target counsellors, school nurses and physicians, as well as parents and teenagers using a multichannel approach: events (e.g., annual polyfest) and traditional and social media. Due to the generational nature of the SPARX user base, the marketing approach needs to keep up with teenagers’ evolving media preferences.
As of May 2019, the app had more than 20,000 registered users in New Zealand. The SPARX initiative has resulted in multiple successes.
The SPARX team also described some of the challenges:
The team is in the process of building SPARX 2.0. New features could include direct connexion for face-to-face services, data exchange with national databases (health care services and social security and education databases), APIs that will connect other apps onto the SPARX platform and capabilities to conduct randomised clinical trials through the app.
Health information and digital technologies are helping to create the necessary foundation for the future of health. Technology can help organisations improve their existing business and reinvent themselves once they decide what roles they want to play in the future. Together with other organisational capabilities, technology can help improve behaviours, augment our thinking and optimise processes, leading to better health and lower costs.
Some of the lessons learnt from our case studies are:
We hope this report inspires readers to continue to think about what the future of digitally-enabled health care may look like, how organisations should prepare for it and the role they will play in this future.
We have used a multimethod approach to address the goals of this research, in three workstreams.
Workstream 1: Interviews with HIT experts
Workstream 2: Environmental scan to identify promising case examples
Workstream 3: Further research on selected case examples
Deloitte health care and technology specialists see technology as much more than hardware and software or tablets and smart phones. Deloitte sees a way to assist you in transforming your health care organisation to meet your business objectives, gain a competitive advantage, improve clinical efficiencies and raise the standards of patient care. The understanding of your business, clinical and patient needs, and the role technology can play in meeting them is a foundation of Deloitte’s enterprise health systems work. Deloitte provides strategic advice, offers insight from heath care subject matter professionals and helps make certain that you not only select the right technology for you, but that it’s implemented and managed in the most efficient and effective way possible.