University of Fribourg
E-Government Seminar - Autumn semester 2007
Report
E-Health Patient Relationship Management
Prof.: Dr. Andreas Meier Students: Mendimi Gabriella & Eva Stamm
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University of Fribourg
E-Government Seminar - Autumn semester 2007
Table of contents
1. Introduction .................................................................................................................................. 3 1.1 1.2 1.3 1.4 1.5 1.6
The establishment of the internet ................................................................................................. 3 The empowerment of the patient .................................................................................................. 3 The increase in chronical diseases .............................................................................................. 4 Health reforms ............................................................................................................................. 4 The Ljubljana Charter on reforming Health Care....................................................................... 4 Patient relationship management as consequence....................................................................... 5
2. What’s Patient Relationship Management.......................................................................... 5 3. Development of research and current status................................................................... 6 4. CRM versus PRM .......................................................................................................................... 8 4.2 Les différences entre PRM et CRM............................................................................................... 8 5. Les acteurs du système de santé.......................................................................................... 9 6. PRM Méthodologies : a patient oriented approach....................................................... 10 6.1 Integration des données des patients .......................................................................................... 10 6.2 Analyse des données des patients................................................................................................ 11 6.3 Outcomes management ............................................................................................................... 11 7. PRM Strategy .............................................................................................................................. 12 7.1 Analysing phase .......................................................................................................................... 13 7.2 Planning phase............................................................................................................................ 15 7.3 The executing phase .................................................................................................................... 16 7.4 The controlling phase.................................................................................................................. 17 8. 9.
Conclusion and future prospects...................................................................................... 18 Bibliography ............................................................................................................................. 19
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University of Fribourg
E-Government Seminar - Autumn semester 2007
1. Introduction Recent negative trends like the over aging of the society, the increase of the ozone and the steady work pressure lead to a bigger need of medical therapies and towards an overcharge of doctors and hospitals. Concepts of restructuring the health system are overdue. Progresses in technology and information technologies offer the chance to make the relationship between the patient and its providers more efficient. New management approaches recommend focusing on this relationship. This claim comes along with the following changes of the health system. 1.1 The establishment of the internet With the diffusion process of the internet, health knowledge has become accessible around the clock for everyone. Not only doctors are able to inspect the recent results of medical research also laymen can read and partially understand science reports. Patients regularly use the simplified access to medical information. They are able to acquire precisely the knowledge about the action of the doctor, recent developments in the medicine and they take care about preventive treatments. The internet offers also a wide range of contacts such as platforms of other concerned persons and of online doctors. The patient can not only get recommendation and chose a preferential treatment, he will see different prices and offers of doctors, hospitals and pharmaceuticals. For the practicing physician and the pharmaceutical industry this can be a chance to find new clients in a supraregional trading area but in equal measure it conceals the risk of loosing patients to cheaper or more trustworthy providers. Finally the impact of the internet on the transparency in health can be a chance or a threat to everyone. The patient needs help to evaluate and judge the sources, physicians have to accept the internet as assistance instead of denounce it as competitor and industries can either profit of the broad acceptance of their new communication and distribution channel or they will be challenged by those who do it. 1.2 The empowerment of the patient In the last decades the classical role allocation between patient and doctor changed dramatically. Mayer notices that up to the 19th century the relationship was predominantly paternalistic: The doctor made the decision based on the edge in experience while the patient had to follow the instructions. In a humanistic democratic society, where every human takes on responsibility for his own actions this principle becomes anachronistic. 1 A growing number of practitioners as a matter of fact support their patients to look after their health situation. The erstwhile prescription market evolves into a buyers market with mature decision makers. The patient’s movement toward self-government is called the patient empowerment. He calls for co-determination over therapy decisions and enforces his influence on the prescription behaviour of the doctor. The capacity of the doctor or the pharmacist as an opinion leader loses ground. For care providers it remains the task of gaining the trust of the autonomous patient and of transmitting trustful information, but most notably doctors have to get used to take up the inputs of their patients in terms of communication, medication and treatment.
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Mayer, J. Arzt-Patient-Beziehung im Wandel. In: Jähn, Karl; Nagel, E. (Hrsg.): E-health. Springer Verlag, Heidelberg Berlin New York 2004, 320-325.
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University of Fribourg
E-Government Seminar - Autumn semester 2007
1.3 The increase in chronical diseases With the pollution of the environment, bronchial asthma and other chronic illnesses have increased. The World Health Organisation remarks the same development for other careintense diseases like diabetes or overweight - called adipositas in special languages. The world wide balance identifies chronical diseases as by far the leading cause of mortality, representing 60% of deaths. 2 The treatment of all those diseases is sumptuous and patients often relapse when medical attendance is reduced. The health system can not carry an increasing number of expensive therapies. Self-help of the patient might be a chance to reduce costs. 1.4
Health reforms
The involvement of the patient in health care is partially required by law. From the contribution to costs arises the incentive of an efficient use of medical offers. Thus nut only the pattern of expenditure of the patient will be changed. Limits of financial resources of the public health system result in a dissonance between offer and demand of health care goods. Hahn writes that the European Governments struggle since the Eighties to contain the rising costs of health care. 3 For this increase especially the pharmaceutical industry has been denounced. Hence the pressure on the explorative concern grows. The cost-intensive employment of modern technology for the development of new pharmaceuticals, the shortened term of patents as well as the competition toughened, forces the pharmaceutical industry to ensure its existence through successful marketing of existing products. But, to base the marketing solely on the health professionals is not anymore a guarantee for success, instead DTC direct to the consumer – marketing is utilized. But in health care the attempt of market the products directly to the patient is often not facilitated by law. The requirementof prescriptions for certain medicals is only one barrier to direct to patient marketing. Regulations of health insurances intensify this pressure. By far not every medical treatment or substance is accepted by them. This is for understandable reasons: They try to adapt to the new structures as well. The growth of patients due to the inverted age pyramid and to hyper sensibility leads to increased expenses. The insurances react with harder regulations and with the attempt of reducing the costs per head. Patients with chronic illnesses are thus financially not an attractive segment. The risk of discriminating them could be limited by a risk adjustment between the insurances. But this solution requires a transparent classification and central data storage.
1.5 The Ljubljana Charter on reforming Health Care The charter written in 1996 had the purpose of setting principles for the European Member States of the WHO. It strongly suggests integrating the patient in health decisions. „Health care reforms must address citizens’ needs, taking into account, through the democratic process, their expectations about health and health care. They should ensure that the citizen’s voice and choice decisively influence the way in which health services are designed and operate. Citizens must also share responsibility for their own health. “ 4
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World Health Organization: Chronic Diseases and Health Promotion. 31.10.2007. URL: http://www.who.int/chp. 3 Hahn, Olaf Kilian: Patient Relationship Management. Ein CRM-Ansatz für die pharmazeutische Industrie. Mannheim 2005, p.1. 4 World Health Organization, Regional Office for Europe: The Ljubljana Charter on Reforming Health Care, 1996. 31.10.2007. URL: http://www.euro.who.int/AboutWHO/Policy/20010927_5.
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E-Government Seminar - Autumn semester 2007
1.6 Patient relationship management as consequence
The empowerment of the patient, the enhanced concurrence between the pharmaceutical enterprises, the influence of the internet as information and distribution channel but also as driver of new group structures, and the development of the governmental health economy point at the same direction: Systematic orientation on the patients’ need.
Care provider such as doctors, therapeutist, pharmacies, labours and hospitals, assurances and health care users namely the patients have to rethink their attitudes. The challenge is to manage the new developed autonomy of the patient in a positive manner. Patient Relationship Management can be a way to diagnose and anticipate threats and to recognize and seize chances systematically. To give an overview and to develop a strategy of Patient Relationship Management is the goal of this paper.
2. What’s Patient Relationship Management Obviously when we are talking about PRM we are thinking of it as a form of management. “The linguistic origin of the word management comes from Latin manus, hand, via the Italian maneggiare, which is the training of horses in the manege. Subsequently its meaning was extended to skilful handling in general, like of arms and musical instruments. However the word became associated with the French menage, household, as an equivalent of husbandry in its sense of the art of running a household. The theatre of present-day management contains elements of both manege, and different managers and cultures may use different accents. “ 5 Definitions of different cultures have in common that they concentrate more on the tasks of management today. Thommen writes in his introduction to management that: „Management can be divided in four main elements: planning, deciding, delegation and control.” 6 Those control functions are necessary to enable the core functions of the value chain. The listing of those differs slightly from author to author. Basically R&D, Ressources, Production and Marketing are mentioned. In all departments but remarkably strong in marketing the customer moved into the centre of the efforts. Consequently Customer Relationship Management became a corporate philosophy of adjusting every plan to the consumer needs on one hand and an instrument of marketing on the other hand. 7 Both orientations have in common that they want to tie the customers. Relationship Marketing focuses on long-term business relationships. This means that besides the usual goal of customer acquisition, customer retention and customer recovery is targeted. 8 5
Hofstede, Gert: Cultural constraints in management theories. In: Lane, Henry: International management behavior, Blackwell publishing 2002, reading 1, p. 75.) 6 Thommen, Jean-Paul: Betriebswirtschaft und Management. Gabler 2006, p. 42. 7 Compare: Eggert, Andreas; Fassot, Georg: Elektronisches Kundenbeziehungsmanagement. Schäffer-Pöschel, 2001. p4. 8 Bruhn, Manfred: Relationship Marketing. Management of Customer Relationships.2003.p.13.
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University of Fribourg
E-Government Seminar - Autumn semester 2007
Through the orientation on the customers needs result qualitative advantages, additionally sales and lower costs. 9 This finally leads to a higher ROI. It’s not a surprise that the health system finally wanted to partake in this growth. But here the concept of Relationship Management had to be adapted to the complexity of the system between the patient as customer in a broad sense, the care providers, the government and the assurances. Dr. Stefanie Hornung defines PRM in her book patientology. “PRM is what emerges from the problem of the linkage between the modern patient conscience on one hand and the economical orientated world of the pharmaceutical industry on the other hand.” 10 Most definitions set their focus on this relation. Besides PRM is relies more strongly on the assignment of technology. A definition of the Swiss ICT on the occasion of the user forum “e-Health” thus phrased: “Under the designation Patient Relationship Management, all efforts of maintaining the relationship between health professionals and patients including information and communication technologies can be subsumed” 11 Out of the above-mentioned definitions we deduce a working definition: Patient Relationship management is the • Systematic and skilful • planning, decisioning, delegation and control of tasks, • which serves to maintain the relationship • between patients, hospitals, surgeries, pharmacies, insurances, public health care system and the pharmaceutical industry • with the goal of the best possible supply of the patient • and the efficient use of resources at the same time • supported by information and communication technology.
3. Development of research and current status As we saw Patient Relationship Management emerged from Customer Relationship Marketing. Bruhn sees various origins of relationship marketing. 1. The beginning he finds in the mid-seventies. When marketing activities have been discovered as an exchange process between the seller and the buyer. 2. In the early eighties the question of how the relationships change over time aroused. 3. At the same time research in the field of service marketing has been called explicitly “Relationship marketing”. Upon the new conceptualisation three approaches have been remarked in literature: A tactical approach, which classified RM as marketing tool, a strategic approach, where time bond became more relevant and a philosophical approach, regarding RM as dogma for all corporate operations. 4. Followed by the centre stage of research about the customer retention.
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Compare: Eberl, Markus; Zinnbauer, Markus: Measuring Customer Relationship Management Performance: A Consumer-Centric Approach. In: Journal of Marketing Channels, Vol.12, No.3, pp 79-104. 10 Hornung, Stefanie: Patientologie. Börm Bruckmeier 2005. 11 Swiss ICT. Information and communication association. Programm for the Forum 2006. URL: http://www.ehealthcenter.ch/files/Forum2006eHealthSwissICT.pdf. 31.10.2007.
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University of Fribourg
E-Government Seminar - Autumn semester 2007
5. Around 1990 attributes of networking and interaction became the subject of further research. 6. In the mid-nineties RM has been related to consumer goods under the keyword brand relationships. 7. Additionally diverse constructs of RM such as commitment, trust and service quality shifted into the science agendas. 8. Nowadays research deals with mainly with the third stage of RM: The recovery or termination of customer relationships. 12 Health care showed its interest in Relationship Management around the turn of the millennium. There were approaches from medical practitioners of describing the doctorpatient relationship before, which implied implicit a systematic management. An example was the research of Dr. Dawson in the field of the therapy of borderline syndromes. 13 An attempt of describing the new role of the patient made later on Smith. He focussed on the communication between patient and doctor and interrogated the patients about their attitudes. 14 The year 2001 was a golden year of PRM research. Now, for the first time the concept of CRM was applied on Life science and Health Management. 15 Meanwhile the broad intersection of internet and health has been researched copiously. Possibilities of E-Health and the consequences of web based information on the patient behaviour have been two studies which emerged from that. 16 Recent research concentrates on specific questions of PRM. Hahn for example examined the influence of additional services on the retention of diabetics. The management approach he used is based on CRM and adopted to the requirements of chronic ill patients. 17 Hombug and Dreist conceived the first study on the subject of the patients majority. 18 Wetterman had a deeper look at case studies of realizing PRM and she tried to find out where the application in hospitals shipwrecked. 19 Other thesis such as the one of Holgrate Catherine focus on the effect of PRM on Pharmaceutical industry. 20
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Compare Bruhn p.7,8. Compare Dawson, David: Relationship Management of the borderline Patient. Brunner/Mazel 1993. 14 Compare James Monroe Smith: Producing Patient Centered Health Care: Patient Perspective about health and illness and the Physican/ Patient Relationship. Auburn house 1999. 15 Compare: - Badenhoop, Rolf: Patient Relationship Management: CRM in der Life Sciences Industrie. Gabler 2001 - Leppi, Udo: Auf dem Weg zum individuellen Gesundheitsmanagement. Trends aus einer Studie. In: Pharma-Marketing Journal(PMJ). 25 Jg, Nr2, S.62. 2001. - Cap Gemini, Ernst and Young: Patient Relationship Management: Die Rolle des Patienten in der Life Sciences Industrie. Studie 2001. URL: http://www.img.unibayreuth.de/index.php?option=com_weblinks&task=view&catid=72&id=349 - Ryf, Balz: Studie Patient Relationship Management: Res und Herausforderungen für die Zukunft Artikel in Badenhoop. 2001 16 Compare: - Jähn, Karl; Nagel, Eckhard: E-Health. 2003. - Murray, E.; Burns, J.; Tai See, S.; Nazareth, I.: Interactive Health Communication Applications for people with chronic disease. The cochrace database of systematic reviews. Issue 4, 2005 17 Compare: Hahn, Olaf Kilian: PRM 2005 18 Compare: Hombug Christian; Dietz Beatrix: Patientenmündigkeit. Universität Mannheim 2005. 19 Compare: Wettermann, Rebecca: Driving CRM value in healthcare: Deploying intuitive CRM options can produce greater ROI and enhanced patient and caregiver experience. Article in Health management Technology, Vol 28, Issue 9, S 48. 1 Sept 2007. 20 Compare: Holgrate Catherine: Die Zukunft des deutschenGesundheitsmarktes. PRM als strategische Option für die pharmazeutische Industrie. 13
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University of Fribourg
E-Government Seminar - Autumn semester 2007
The national institute for health care management collects studies about recent research in health care: pharmaceutical management issues amongst others. 21 Those examples are just a small part of the recent research achieved in the field of PRM. But still there is necessity of research especially in relation with strategies and management topics.
4. CRM versus PRM Le patient Relationship management (PRM) s’inspire du Customer Relationship management (CRM) et s’applique au domaine de la santé. De ce fait il y’a beaucoup de points communs entre le CRM et le PRM mais également des différences : 4.1. Les similitudes entre PRM et CRM Le PRM et le CRM ont des similitudes en ce qui concerne les méthodologies de travail :
Par exemple la collecte des données sur le patient ou le client et leur interprétation, la différence ici est que les données médicales sont plus sensibles que les données client dans le domaine du Customer Relationship Management.
Les relations one-to-one mais le concept de la personnalisation des relations clients existe déjà dans le domaine de la santé avant l’introduction du PRM.
4.2 Les différences entre PRM et CRM Les principales différences entre le PRM et CRM concernent les objectifs à atteindre : Le CRM essaie de fidéliser le client afin de l’amener à dépenser le maximum d’argent sur des produits ou des services vendus par l’entreprise. Le PRM a pour objectifs de donner au patient toutes les informations dont il a besoin pour mieux choisir ses soins de santé et aussi réduire les coûts de santé. Avec le PRM, hôpitaux se focalisent sur leurs patients tandis que le CRM vise le marché entier. Dans le CRM et le PRM, les bénéfices sont les mêmes : meilleure anticipation des besoins des clients (patients), amélioration des canaux de communications entre les patients et les médecins pour le PRM, donner une information crédible au client (patient). L’idée héritée du CRM est que « Lorsqu’un besoin nait chez le patient, le médecin est là pour le satisfaire »
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URL: http://www.nihcm.org/research/pharmaceuticals_issues
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University of Fribourg
E-Government Seminar - Autumn semester 2007
5. Les acteurs du système de santé Dans le domaine du PRM, il y’ a 3 acteurs principaux qui représentent une triade:
Le patient
C’est un individu qui a une altération dans son état de santé (maladies, blessures…). Pour remédier à cette altération, il va généralement voir un médecin qui lui prodigue des soins. Le patient attend du médecin qu’il lui qu’il lui fournisse des informations exactes et complètes sur son état de santé et un traitement adéquat. Aujourd’hui, les patients ne tolèrent pas la moindre erreur médicale de la part des médecins car ils supposent qu’un médecin doit maitriser leur dossier avant de poser un diagnostic. Les médecins sont souvent attaqués en justice par des patients pour erreur médicale. Le patient est en général assuré contre certaines maladies chez un assureur à qui il verse une prime d’assurance. Généralement les dépenses de santé ne sont pas prises en charge totalement par les compagnies d’assurance. Le patient doit alors payer un complément de sa poche.
Le médecin
Un médecin est une personne qui a un diplôme de docteur en médecine. Il est un professionnel de la santé qui exerce la médecine en se chargeant de guérir et soigner les maladies, pathologies, et blessures de ses patients. Le médecin est souvent pris en tenaille entre les intérêts du patient pour qui il doit tout mettre en œuvre en vue de la guérison et ceux des assurances maladies qui font pression sur lui afin qu’il réduise les coûts de traitement au minimum.
Les assureurs
Les assureurs sont des assurances publiques (France) ou privées (Suisse), en fonction du système de santé des pays. Ce sont les payeurs de cette triade. Ce sont eux qui remboursent tout ou partie des dépenses engagées pour soigner un patient. Ils offrent une assurance-maladie à leur client contre le versement par le client d’une prime. Ainsi, Lorsqu’un client est malade, ses dépenses de santé sont en partie ou totalement couvertes par cette assurance. Les assureurs exercent une pression à la fois sur les médecins et sur les patients pour réduire les dépenses de santé. Par exemple en France, l’Etat qui gère la sécurité sociale a demandé aux médecins de préférer la prescription de médicaments dits génériques qui sont beaucoup moins chers que les médicaments brevetés. Ceci afin de réduire le déficit de la sécurité sociale. En Suisse les prescriptions des médecins sont également suivies de près par les assureurs (contrôle d’économicité) : Les procédures d’économicité ont avant tout un rôle préventif. Les fournisseurs de prestations (médecins,…) dont les coûts sont élevés sont invités à revoir leurs structures de coûts. Dans les pays d’Europe, il existe en généralement deux façons de financer le système de santé: Le financement par l’impôt ou assurance publique: c’est le cas de la France et de l’Allemagne. Mais voila, le système de santé en France est déficitaire, alors une manière de réduire se déficit est de réduire les dépenses de santé. Le financement par l’assurance-maladie obligatoire : C’est le cas de la Suisse. Son modèle est basé sur une assurance obligatoire gouvernée par le marché et assumée par des caisses travaillant en concurrence. Un catalogue de prestations minimales est imposé à tous les assurés. Dans les deux cas, les assureurs publics ou privés mettent en œuvre des stratégies pour réduire les dépenses de santé de leurs adhérents.
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E-Government Seminar - Autumn semester 2007
Dans les deux cas, le Patient Relationship Management (PRM) peut contribuer à réduire ces dépenses de santé. La figure 1 illustre les relations entre ces différents acteurs des systèmes de santé.
INSURER
PATIENT
PROVIDER
money flow service flow
Figure 1: The medical triad
6. PRM Methodologies: a patient oriented approach Avant d’être une technologie, le PRM doit etre une stratégie. Quelles sont ses méthodologies ? 6.1 Intégration des données des patients D’après des statistiques, un patient sur dix n’est pas correctement identifié par l’hôpital. Quand on parle d’identification du patient, on ne parle seulement de savoir son nom, son prénom et son adresse. L’identification est surtout son historique médicale : ses visites, ses maladies précédentes, tous les médecins qui l’ont auscultés, les médicaments qui lui ont été prescrits, les opérations chirurgicales subies, ses allergies… Le dossier médical complet du patient permet au médecin d’avoir une bonne information sur le patient afin de poser un diagnostic fiable et de fournir au patient le traitement et les informations adéquates. Problème : Le plus souvent, le médecin a une vue partielle du dossier médical du patient parce que les informations se trouvent dans des systèmes hétérogènes.
Exemple : Un patient qui lors de ses visites successives dans un hôpital consulte un généraliste, un cardiologue, un rhumatologue, un ORL, un gastro-entérologue…. Souvent chaque médecin consigne les informations du patient dans un système qui lui est propre et n’a accès qu’aux informations qui concernent sont domaine. Le cardiologue prescrit un traitement au patient qui contient un certain produit. Or dans la partie du
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E-Government Seminar - Autumn semester 2007
dossier du patient vue par le généraliste et qui est enregistré dans un autre système informatique, il est marqué que le patient est justement allergique à ce médicament. La prescription du cardiologue peut mettre en danger la vie du patient et aboutir à une erreur médicale. Or si le cardiologue avait su que le patient était allergique à ce produit, tout cela aurait été évité. Dans ce cas on parle de fragmentation du système de santé. En langage informatique défragmenter veut dire réorganiser la disposition de l’information sur un support de stockage afin de réduire les temps d’accès et donc d’augmenter les performances. Pour rendre le système de santé plus performant, il faut donc une intégration des données du client. Cette intégration consiste à combiner les données du patient stockées dans différentes répertoires, systèmes et mêmes différentes organisations de santé afin de fournir à l’utilisateur qui est le médecin une vue homogène et complète de ces données du patient. Le problème est que ces données proviennent de sources hétérogènes qui n’ont pas forcément le même schéma de données. Cela nécessite donc l’utilisation d’une application EII (Enterprise information integration) qui est une application qui permet l’intégration de données provenant de sources hétérogènes dans une base de données centralisée et unique. Ainsi les médecins peuvent avoir une vue à 360 degrés des informations du patient quelque soit son point d’entrée. 6.2 Analyse des données des patients Une fois les données du patient intégrées divers outils permettent de les analyser : La méthode de la modélisation prédictive - «predictive modeling » permet notamment de faire cette analyse. Un modèle prédictif permet la prévision d’un événement futur à partir des éléments du passé. Le modèle est crée à partir de plusieurs facteurs ou prédicats (âge du patient, les maladies diagnostiquées,…) qui auront une influence sur le résultat. Une formule est ensuite créé utilisant des statistiques techniques, les prédictions sont calculées et le modèle résultant est testé et validé avec des données supplémentaires. Pour résumer, la modélisation prédictive permet de : a.
Prédire quel patient présentant certaines conditions possède un risque élevé de développer une certaine maladie. Exemple : quel est le risque pour un patient avec une tension élevée (high blood pressure) de développer un Glaucome ? b. Pour les patients déjà diagnostiqués quels sont ceux qui peuvent développer des complications ? Exemple : quel est le risque pour un individu malade du diabète de développer une maladie du cœur. De cette façon, le médecin peut prescrire un traitement préventif au patient pour éviter les complications de la maladie qui pourraient entrainer une augmentation des dépenses de santé. Typiquement, une complication de la maladie du patient peut entrainer une opération chirurgicale lourde. Le « predictive modeling » a beaucoup d’avantages, il permet:
des interventions de prévention au lieu d’un traitement couteux sur quelqu’un qui est déjà malade. de découvrir des maladies plus tôt. En général plus une maladie est découverte tôt, plus facilement on la guérit. C’est le cas pour beaucoup de cancers Une meilleure communication avec le patient.
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Tout ceci contribue à baisser les couts de santé. 6.3 Outcomes management Une fois les prédictions faites, le médecin peut communiquer les résultats au patient, discuter avec celui-ci toutes les possibilités d’intervention. Ainsi le patient qui est bien informé peut choisir le traitement qu’il préfère. Le patient contribue avec le médecin à l’amélioration de son état de santé. Le patient peut instantanément avoir toutes les informations concernant son état de santé notamment par l’accès à une application web. Le médecin peut communiquer au patient ces informations à travers ses canaux de communication préférés : directement, par courrier, par email, site web, téléphone, fax… Un patient qui est bien informé sur son état de santé est un patient moins anxieux, qui suit mieux son traitement et qui a donc de meilleures chances de guérison. Car un autre facteur d’augmentation des dépenses de santé vient des patients qui ne suivent pas les traitements jusqu’au bout et qui donc des rechutes. Un médecin qui a une vue complète de toutes les données du patient, peut mieux diagnostiquer la maladie dont souffre le patient. Le médecin fait donc moins d’erreurs médicales. Le résultat est une relation entre le patient et le médecin plus personnalisée et donc la diminution des erreurs médicales et la baisse des couts du système de santé. On voit donc qu’avec ces méthodologies du PRM, le système de santé est moins fragmenté, le patient est complètement identifié avec son historique médicale, le médecin a une vue à 360° du patient et il peut mieux le soigner. Dans beaucoup d’hôpitaux, les processus sont centrés sur l’hôpital. Avec l’introduction du PRM, l’approche est plutôt orientée patient. Cette dernière approche a plus d’efficacité. Voici quelques exemples qui illustrent les avantages des méthodologies du PRM :
Exemple 1: Prévenir la douleur chez l’enfant. Au Children Memorial Hospital à Chicago, le Docteur Eric Bremer qui est directeur de recherche sur les tumeurs du cerveau utilise une combinaison de modélisation prédictive et de datamining. Les tumeurs du cerveau possèdent un taux de mortalités très élevé. La clé du traitement est de savoir quel genre de tumeur le patient a et le stade d’évolution de cette tumeur. Ainsi, on peut adapter son traitement car il est nécessaire de donner la bonne dose la chimiothérapie afin que non seulement le patient ne souffre pas beaucoup mais aussi qu’il ait moins de dommages corporels. L’utilisation de la modélisation prédictive et du datamining permet de déterminer le type de tumeur du cerveau que le patient a et son stade d’évolution. Exemple 2 : améliorer le Chronic Desease Management (CDM) avec le PRM. En Ontario au Canada, le programme de recherche COMPETE qui associe le PRM et CDM contient des algorithmes individualisés pour chaque patient, basés sur le passé médical du patient, les médicaments qu’il prend actuellement, ses allergies, ses risques vasculaires. L’algorithme génère des objectifs adaptés à ce patient et des recommandations.
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University of Fribourg
E-Government Seminar - Autumn semester 2007
Exemple 3 : Informer les parents en temps réel sur les soins reçus par leur enfant. En 2005, le service de néo-natalité de la Royal Infirmary d’Edinbourg en Ecosse a inauguré un site web qui permet aux parents de nouveau-nés, en particulier les prématurés de voir en temps réel l’état de santé de l’enfant et les traitements qui lui sont administrés. Le site permet également aux médecins de noter tous les médicaments administrés aux enfants. L’hôpital entend ainsi améliorer la communication entre les médecins qui s’occupent des enfants d’une part et d’autre part entre les médecins et les parents de nouveau-nés. Le site www.patientsite.org fournit en démonstration une application du même type mais destinée à tous les patients en général. Pour résumer cette partie, nous pouvons dire que Le Patient Relationship Management avant d’être un ensemble de technologies mises ensemble est d’abord une stratégie. C’est la raison pour laquelle les processus au sein de l’hôpital doivent également être adaptés. Sans cela en fait la technologie mise en place ne sera d’aucune utilité. 7. PRM Strategy Strategies – known from military or sport games – are more or less plans designed to achieve particular goals. In our case it should be a help for relationship managers for the skilful handling of the tasks planning, deciding, delegation and control. Before planning a phase of analysis should be integrated in the concept. Whilst the steps deciding and delegation can be resumed in the phase execution. So far we have four steps of systematic patient relationship management: analysing, planning, execution and control. This order once more reminds of the customer relationship marketing process. But still it has to be adapted to the particularities of the health market and it is notably supported by ICT. We will exemplify the process for a gynaecologist trying to reform its patient relationship management. We are conscious, that PRM is nowadays most often used in pharmaceutical industry. But since the process there is more simular to the CRM – except the specialities of the prescription market – we chose the more uncommon example of the doctor adapting to the new behaviour of the patients. Special weight will be given to the analysing phase because we already heard about general planning of PRM methods and because analysing is a very important phase to the whole process. The steps of execution and control are very practically tasks and thus will be very roughly explained in this paper.
7.1 Analysing phase The analysing phase has the goal of giving an overview over the general situation of the health care institution. Its indispensable for solving patient relationship problems. It involves analysing the environmental influences such as the health market in general and the competitors. For this purpose we accomplish a SWOT-analysis. It can be divided in the categories: 1. External analysis of opportunities and threats for the patient relationship. 2. Internal analysis of strengths and weaknesses for the patient relationship. The external influences can not be influenced by the gynaecologist himself. The analysis should cover the following areas: Health market developments, Technologies, political and social environment, patients, suppliers of pharmaceuticals, suppliers of professional infrastructure, competitors. The gynaecologist discovers after analysing external data the following threats:
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E-Government Seminar - Autumn semester 2007
Society: Demographic Change and ageing: decline in birth rate Society: Income inequalities Competitors: Trend for group practices Environment: Ecological health threats such as pollution Politics: Limit of practitioners Patient: Rising patient expectations to the knowledge of the doctor Pharmaceutical industry: Direct to Patient – Marketing Suppliers: Expensive Swiss quality products (Image price?) Competition: Many up-to date successors fresh from university Competition: Many female graduates often preferred by female patients And he discovers the following opportunities 22 : Internationalisation: Free movement of goods, services, labour Society: Technological developments: Society: Increase of medical know how and high investment in product development Society: 2nd age of enlightenment: transparency on diseases such as aids, hepatitis et al., sexually education in school. Environment: Ecological health threats Politics: Limit of practitioners Market: Non-saturated market Patient: Empowerment of the patient Pharmaceutical industry: Generic products available Human Resources: qualified graduates as assistants available The findings highlight some possibilities in relationship marketing. In reality the analysis can be done for every unit of the medical offer and it should also be done very detailed. The analysis done here serves just as an idea of how it could work. An internal analysis helps to weigh which activities make sense to undertake for the gynaecologist and which chances are not relevant because he can not seize them. The gynaecologist thus thinks about: his financial situation, the quality of his personal and of his own service, practice marketing, communication, relationships to patients, location, premises and infrastructure. He finds out the following weaknesses:
• • • • • • • • • • • • • • • • • • •
Unsatisfactory payment behaviour of young patients No quality certificate (e.g. Swiss pep) No advanced training Lack of marketing and management skills Lack of IT skills No systematic complaints management High rate of young patients loss Poor linkage with insurances Old fashioned equipment But he also knows about his strengths: Available capital Motivated medical assistant Loyalty of lifelong patients Trust of patients in family practice Good retention of older patients – regular patients Wife and father are retired doctors High verbal feedback Amortised equipment Complete database back to the Seventies 24 hours emergency attendance 22
Some external factors may be a threat and a opportunity
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University of Fribourg
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E-Government Seminar - Autumn semester 2007
Enough parking places Close bus station After having created the internal and external analysis a matrix can be made which links opportunities and threats with the most important weaknesses and strengths. E.g: Opportunity Strength
Weakn.
Threat
Patient empowerment
Ageing
High Feedback
Old patient structure
New technologies& know how
Not updatet
Old equipment
Expensive swiss equipment
The finding of the Swot analysis form the basis for target planning within patient relationship management. Targets of patient relationship management for our case could be: o o o o o
Improvement of management and marketing skills Receive a quality certificate Improvement of service quality through specialisation Improvement of average patient retention Stronger patient orientation: Collect patient satisfaction, patient history, patient suggestions data For each and every target a value can be defined and a time horizon can be set. As a next step a segmentation of customers can be made in terms of demographic criteria (e.g. age), frequency of consultation, socio-economic criteria (e.g. income level), consternation, health insurance company and so on. The segments are then described and finally the profitable relationships are identified. The gynaecologist could decide to focus on the segment of older patients for example spending may be more money in health. Besides: If he improves the relationship with his aged patients he seizes the chance of changing society structures and he uses his strength of having high retention of older patients. 7.2 Planning phase For the chosen segment(s) we can now begin to plan strategies for patient acquisition, patient retention and patient recovery. Those three strategies can also be seen as three options and it is not necessary to plan all of them contemporaneously. We will further shortly deal with all three options for our case. 1.) Acquisition strategy: The primary aim of patient acquisition strategy is to acquire new patients by having the practices direct its marketing activities accordingly. In our case the goals of improving marketing skills and service quality could be a reason to focus on acquisition. There are two kinds of strategies: The persuasive and the stimulating. The first possibility is to convince new patients f.e. through free trial consultations and through quality guarantees. The second wants to get the attention of the patients with help of advertisement, image and special offers. In our case a mixed strategy might be right. After deciding the strategy type instruments can be chosen. We can make use of the marketing mix. Price instruments: We can offer free starting consultations
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University of Fribourg
E-Government Seminar - Autumn semester 2007
Promotion: We can advertise in “55 plus” and in “Seniortip”, the two leading internet magazines for seniors. And we might even help older people handle the computer. As a consequence we can introduce a patient forum integrated in an own homepage to enable patients discussions about our service. Product: We can offer product packages such as mobile attendance and psychological support for women in menopause. Place: We can provide home consultations of our medical assistant for seniors or bus schedules. 2.) Retention strategy: The key of patient retention strategy is to retain the maximum number of patients who are profitable. There are two possibilities how to reach a high retention. Solidarity strategies strive for patient retention by means of psychological determinants such as patient satisfaction. Dependence strategies in contrast set up barriers for the patient to switch to another doctor. In our case a mix of both themed “To be an indispensable partner to the patient” can be profitable. Solidarity elements: Patients are cared by a small intimate team of the gynaecologist and his assistant. Father and wife are the well-known voices who do call centre services. The family practice evokes a atmosphere of trust. Dependence elements: The complete database of the gynaecologist is an advantage since patient files are an element of dependence. However, if the patient switches nevertheless to another gynaecologist patient data must be committed to his new confidant. 3.) Recovery strategy: A recovery strategy includes regaining the trust of lost patients. This can be profitable because those patients might show a higher loyalty than before. The recovery can either make amends or improvements to address the problems. In our case as we have seen we have a high retention of older patients. That means automatically that there is no further need to invest in a recovery strategy for our current patients. Anyway, we can establish a complaint management just to make sure we have an instrument to find out where we lack of fulfilling the patients needs and then – as long as they are controllable - try to change reasons for rotations. For the three options or phases of patient acquisition, retention and recovery strategy we developed very roughly some single inferior tasks. They mark just examples and not a complete management instruction. 7.3 The executing phase Any concept is worthless without implementation. To ensure that the patient relationship management succeeds all employees must be involved. Major changes may be required in internal operational processes. For the implementation it is necessary to first set down the implementation targets. The focus in bigger practices, in hospitals and pharmaceutical industries is on achieving acceptance and on informing involved persons. After instructing the employees the goal is to work out measures to improve the patient orientation and to fix specific responsibilities. For our gynaecologist this means he first has to sit together with his assistant and his involved family members to make the PRM concept understood. His goal must be to achieve a high level of enthusiasm. This first step is followed by the very important phase of adjusting the infrastructure to the new concept. Here its necessary to introduce the new databank for setting up the complaint management, for placing satisfaction questionnaires, for integrating the communication between the patients and for collecting the patient disease histories. While implementing the PRM strategy an eye has always to be kept on cost and time effects. One aspect for our gynaecologist could be the possible advantage of engaging an external consultant especially for IT implementation since cost advantage is bigger if every specialist works efficient in his domain.
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E-Government Seminar - Autumn semester 2007
Theoretically we can differ between a radical restructure of our health service and permanent small improvements. We will have to combine both elements since our major changes such as the web performance will be visible at once, but the small team has to start utilising the IT before and to make progresses in working with it in small steps. 7.4 The controlling phase A PRM strategy can only be successful if the impacts of the efforts on our goals are continuously controlled. Those impacts are either non-economic or economic variables, but in case of medical care providers the focus is on non–economic criteria. Non-economic controls are aimed at verifying relationship managements non-economic targets. Thus it is necessary to conduct various construct measurements. These include the doctor-patient-relationship assessment (Relationship quality, quality of health service, perceived value of consultation), the psychological consequences (patient satisfaction, patient commitment) and the behaviour (patient retention). There are different ideas of how to measure non-economic variables. The gynaecologist choses to evaluate the quality of health service with the measurement of single attributes because he assumes that psychological and relationship constructs are the sum of specific estimates of different elements. He constructs a patient questionnaire to collect the data. In customer relationship marketing an instrument is used which can be easily transformed to patient relationship management: The Servqual questionnaire 23 in our case used to evaluate the quality of health service. According to this method service quality in PRM is measured on the basis of attributes in categories. Tangibles: Modern equipment, visually appealing facilities, professionalism of employees, visually appealing materials Reliability: Service as promised, dependability in terms of patients problems, performing service right the first time, providing health around the clock, maintaining error-free patient files. Responsiveness: keeping patient informed, no long time in waiting room, willingness to help begins at the reception of patient, readiness of doctor to respond to patients input. • Assurance: employees instil confidence, feelings of safety, employees are courteous, employees answer to patients questions. • Empathy: individual patient attention, dealing with patient in a caring way, having patients interest at heart, understanding of patients needs, convenient consulting hours. The patient can now either give grades or answer on a scale ranging from absolutely to non existent. - Doctor-patient relationship quality can be measured only by dimensions of familiarity and trust. Indicated by the variable groups personal understanding, personal awareness, professional awareness for the first dimension and harmony, acceptance and participation simplicity for the second. - Patient satisfaction measurement begins directly by verbally asking: “How satisfied are you with your consultation?” Afterwards more detailed question about the reasons for satisfaction or non-satisfaction can be asked. - Perceived value of the consultation can be found out be asking questions about the price such as: “Treatment X is fairly priced”, “Treatment X has an unpayable value” - Commitment of the patient is higher when then patient feels as a part of the medical institution: “I am concerned about the long term existence of this practice”, “I am very loyal to this practice”. - The patient retention can be measured by future patients behaviour in terms of: 1.) Likelihood of repeat consultations: “I will repeat my consultation” 2.) Intention of making use of other medical services: “I will do my injections here” 3.) Intention to make recommendations: “I will introduce my children/ my friends to this practice”.
23
Compare Bruhn p. 197 ff
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For the final analyze the answers must be converted into absolut numbers and finally with the help of statistic programms such as PLS dependencies between the categories can be determined and total satisfaction or relationship quality can be found out. 8.
Conclusion and future prospects As we have seen there are various reasons why changes in health are overdue. PRM is the way to generate a win-win situation out of the problem - or in other words - the chance of making profit of this necessity. There is an advantage for everyone using it. The patient profits from a better communication with the doctor, of an individualized offer and of a diminution of medical errors due to the integration of all medical facts (former consultations and treatments, allergies..) in one patient file and also due to the diminution of misapprehensions because of illegible files . The health care system profits of the commitment of the patient and of the application of PRM to fight chronic diseases. Finally the doctor profits not only in a empathic way – namely of being able to be a bigger help to the patient. But he also profits in economic terms. With adapting his working processes to PRM all practice tasks can be made with the same software, data has to be collected just once and can be shared with other health providers. Money and time can be saved. Since the PRM approach is new there is just a small part of research done. Most of the research either concerns the economic side and leans thus strongly on CRM or it emphasizes more the advantages of PRM for the patient. Approaches which relate both perspectives are still rare. It has to be said that PRM is not just a technical system which can be bought and used immediately. Integrating a PRM system means to make major changes in the whole organization of medical providers. Instead of focussing ona smooth work flow the patient must be in centre. Since PRM handles with high confidential data, data protection will be an important subject to treat in future. More even than in other fields health care needs international regulations for handling data because it is often needed in urgent circumstances or even in life-threatening situations. Accomplish those claims is necessary to reduce the scepticism of the patients. A secure transmission, storage and administration is thanks to todays technic possibilities throughout feasible.
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9. Bibliography • • • • • • • • • • • • • • • •
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Mayer J. : Arzt-Patient-Beziehung im Wandel. In: Jähn, Karl.; Nagel, Eckhard. (Hrsg.): E-health. Springer Verlag, Heidelberg Berlin New York 2003. World Health Organization: Chronic Diseases and Health Promotion. URL: http://www.who.int/chp. (31.10.2007). Hahn, Olaf Kilian: Patient Relationship Management. Ein CRM-Ansatz für die pharmazeutische Industrie. Mannheim 2005. World Health Organization, Regional Office for Europe: The Ljubljana Charter on Reforming Health Care, 1996. URL: http://www.euro.who.int/AboutWHO/Policy/20010927_5. (31.10.2007). Hofstede, Gert: Cultural constraints in management theories. In: Lane, Henry: International management behavior, Blackwell publishing 2002. Thommen, Jean-Paul: Betriebswirtschaft und Management. Gabler 2006, p. 42. Eggert, Andreas; Fassot, Georg: Elektronisches Kundenbeziehungsmanagement. Schäffer-Pöschel, 2001. Bruhn, Manfred: Relationship Marketing. Management of Customer Relationships. Prentice Hall, 2003. Eberl, Markus; Zinnbauer, Markus: Measuring Customer Relationship Management Performance: A Consumer-Centric Approach. In: Journal of Marketing Channels, Vol.12, No.3. Hornung, Stefanie: Patientologie. Börm Bruckmeier 2005. Swiss ICT. Information and communication association. Programm for the Forum 2006. URL: http://www.ehealthcenter.ch/files/Forum2006eHealthSwissICT.pdf. (31.10.2007). Dawson, David: Relationship Management of the borderline Patient, Brunner/Mazel 1993. Smith, James Monroe: Producing Patient Centered Health Care: Patient Perspective about health and illness and the Physican/ Patient Relationship. Auburn house 1999. Badenhoop, Rolf: Patient Relationship Management: CRM in der Life Sciences Industrie. Gabler 2001. Leppi, Udo: Auf dem Weg zum individuellen Gesundheitsmanagement. Trends aus einer Studie. In: Pharma-Marketing Journal(PMJ). 25 Jg, Nr2, 2001. Cap Gemini, Ernst and Young: Patient Relationship Management: Die Rolle des Patienten in der Life Sciences Industrie. Studie 2001. URL: http://www.img.unibayreuth.de/index.php?option=com_weblinks&task=view&cati d=72&id=349. (31.10.2007) Ryf, Balz: Studie Patient Relationship Management: Res und Herausforderungen für die Zukunft Artikel in Badenhoop 2001 (see above). Murray, E.; Burns, J.; Tai See, S.; Nazareth, I.: Interactive Health Communication Applications for people with chronic disease. The cochrace database of systematic reviews. Issue 4, 2005. Hombug, Christian; Dietz, Beatrix: Patientenmündigkeit. Universität Mannheim 2005. Wettermann, Rebecca: Driving CRM value in healthcare: Deploying intuitive CRM options can produce greater ROI and enhanced patient and caregiver experience. Article in: Health management Technology, Vol 28, Issue 9, S 48. 1 Sept 2007. Holgrate, Catherine: Die Zukunft des deutschen Gesundheitsmarktes. PRM als strategische Option für die pharmazeutische Industrie. URL: http://www.nihcm.org/research/pharmaceuticals_issues. (31.10.07)
Website demonstrations: • http://www.connectingforhealth.nhs.uk/newsroom/worldview/protti11 • http://www.healthcareitnews.com/story.cms?id=740 • http://www.babylink.info/edinburgh/NeonatalUnit/Welcome1.aspx • https://www.patientsite.org
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