TEMPEST: An Integrative Model For Health Technology Assessment

Health Policy and Technology (]]]]) ], ]]]]]]
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TEMPEST: An integrative model for health technology assessment

Wendy Currie
Editor-in-Chief, Health Policy and Technology, Fellowship of Postgraduate Medicine, London, UK
Abstract
This paper responds to calls for a national forum to track enabling (current) and emerging (future) technologies in healthcare. An integrative model for health technology assessment is developed from prior empirical research, secondary source material and peer review on a range of healthcare technologies: information and communications technology; medical devices, imaging/monitoring technology; personalised medicines; drug discovery and diagnostics. The TEMPEST model is an acronym for technology, economic, market, political, evaluation, social and transformation. These themes are sub-divided into focal areas, where quantitative indicators/metrics are used for comparative analysis. The model provides a conceptual and analytical tool for policy-makers, healthcare professionals IT vendors, citizens and other stakeholders for understanding and evaluating the scale and scope of health technology adoption and implementation at national, regional and local levels. & 2012 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved.
Introduction
The global healthcare industry is changing in three important areas. Firstly, politicians are exploring alternative approaches to fund state-run healthcare systems by introducing market mechanisms in healthcare service delivery [1,2]. Publicprivate partnerships are developing to provide citizens with greater choice in healthcare products and services [3,4]. The impetus behind this is partly because of burgeoning healthcare budgets with OECD countries annually spending anywhere between 5% and 16% of Gross Domestic Product on healthcare, with an average between 8% and 9% [5]. Secondly, while healthcare technology in the European Union is considered a low maturity sector compared with nance and manufacturing, spending on information and communications technology (ICT) is increasing and is
E-mail addresses: wendy.currie@fpm-uk.org
estimated to be between 5% and 8% of GDP [6]. The growing market for ICTs also extends to medical devices and imaging equipment [7] as these technologies are becoming increasingly converged [8]. Thirdly, citizens are encouraged to take greater control over their healthcare choices, moving from traditional medical professionalism to a patient-centred approach. Health tourism is increasing with new products and services supported by a range of enabling and emerging technologies, i.e. telemedicine, mobile devices to alert patients about appointments, prescriptions and test results [9]. Prior research shows that introducing healthcare technologies is high risk where potential and realised benets are difcult to measure [10]. Unintended outcomes are not uncommon, particularly in large-scale publicly funded ICT projects that fail to meet expectations. For example, the National Programme for Information Technology (NPfIT) in England was created to deliver local Information Technology solutions as part of the NHS Care Records Service. England was initially divided into ve geographic areas, each of which would work together to take forward the procurement and
2211-8837/$ - see front matter & 2012 Fellowship of Postgraduate Medicine. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.hlpt.2012.01.004 Please cite this article as: Currie W. TEMPEST: An integrative model for health technology assessment. Health Policy and Technology (2012), doi:10.1016/j.hlpt.2012.01.004
2 implementation of the NHS Care Records Service at a local level. These comprised of the: Eastern, North East, North West and West Midlands, London, and Southern clusters. In 2007, responsibility for local delivery of the NPfIT was devolved to Strategic Health Authorities (SHAs). England was then divided into only three Programme for IT regions each with its own Local Service Provider. In 2011, a decision was again taken to restructure the NPfIT as SHAs were being disbanded. This would allow for more choice and decentralisation of IT services, rather than the original top-down, centralised approached of the previous decade. Following all these changes, the UK coalition government in the autumn of 2011 decided to completely rethink the NPfIT, although this will necessitate a renegotiation of contractual terms with leading IT and management consulting rms. This change of government policy has resulted in media reports that health technology in the NHS is in total disarray, as the aim of providing citizens with full access to their electronic health records remains a vision rather than a reality. By 31 March 2011, total expenditure on the Programme totalled some 6.4 billion [11]. Other cases in Europe, i.e. the European Health Card (EHC) implementation in Germany and the 2012 Hospitals Plan in France aimed at reorganising regional healthcare services, upgrading hospitals to meet safety standards and introducing new IT systems in hospitals have also incurred problems, not only of a technical nature but also politically, organisationally and culturally. Health technology assessment (HTA) is not only a technical issue, but also needs to be understood within a larger, socio-political and economic context, where stakeholders often have different priorities and interests. In recent years, the challenge to transform healthcare due to rising costs and increased demand continues unabated. Health technologies are seen to play a major transformational role [8]. Yet whether they are introduced centrally by government planning, or through regional or local initiatives, i.e. at the hospital level, remains a contentious issue. While the former has advantages of economies of scale (i.e. procurement contracts), standardisation, and interoperability, the latter is more likely to achieve the political buy-in of clinicians, hospital administrators and patients, especially if these groups have been involved in the decision-making process from an early stage. The scientic research agenda should therefore focus on identifying and learning from best practice examples in health technology adoption and diffusion at national, regional and local levels. Scientic research should address the wide ranging interests of stakeholders so that policies and plans for introducing transformational change using technology meets the needs of health professionals, patients and the community at large. The TEMPEST methodology responds to calls to develop an international forum to track emerging and enabling technologies and their potential for diffusion into healthcare environments. This forum is more likely to be effective if it is built on evidence-based research which serves as a resource-base available to multiple stakeholders engaged in the policy, design and implementation of health technologies. Prior research indicates the outcomes of introducing new technologies into healthcare organisations are mixed due to poor policy making, management practice
W. Currie and technical factors [12]. TEMPEST thus adopts a multidimensional and integrative approach to understanding the complexities and challenges of introducing healthcare technologies. It aims to provide a useful HTA tool for policy-makers and communities of practice engaged in health service delivery.
TEMPEST: an integrative model

The TEMPEST1 methodology leverages its unique framework of 7 themes, 21 sub-themes and 84 (coded) quantitative indicators to deliver evidence-based insights that address scientic and policy issues (see Appendix A). This is reinforced by an inter-disciplinary, multi-dimensional model of health technology assessment (HTA) that allows those applying it to analyse specic health technologies, or related issues, from a market, political, commercial, stakeholder or individual perspective, through a national, regional, local or organisational lens. So far, TEMPEST has been applied to the 27 European Union Member States where data can be compared at the EU and national levels. Incorporating key EU policy priorities, such as encouraging active and healthy ageing, preventive medicine and healthy lifestyles, improving citizens health security, reducing health inequalities, and promoting and disseminating health information [13] TEMPEST offers an integrative approach where data points can be compared and contrasted to show benets and barriers in health technology adoption and diffusion. HTA is a multi-disciplinary process which aims to inform the development of effective health policies that are: (i) patient-focused; (ii) market- and consumer-friendly, and (iii) deliver optimal value and outcomes to all stakeholders invested in public health. As a research approach, it focuses on information about the medical, social, economic and ethical issues related to the use of a health technology, as well as the short- and long-term consequences of its use, in a systematic, transparent, unbiased and robust manner. However, the different academic perceptions and practices of what constitutes HTA raise concerns about the adequacy of evaluation methods. The siloed approach to HTA where studies isolate the economic, organisational or cultural aspects of specic health technologies leads to observations that ythe striking nding from our review (of health technology) is that there has been so little solid evaluation of these (EHR) applications [10]. Others comment that, When technologies are disruptive, operating and nancial impacts are challenging to estimate, which makes it difcult to construct a business case for investmenty disruptive technologies make it difcult to conduct returnon-investment (ROI) analyses [8]. So gathering quantitative and/or qualitative data on selected health technologies without considering the wider socio-political, organisational and ethical issues is a futile exercise [14,15]. It is also
1 This paper introduces the TEMPEST methodology and discusses its rationale in relation to the wider health technology literature. It has currently been applied to 27 EU Member States, although space limitations preclude its further discussion and analysis in this paper. Future issues of Health Policy and Technology will include crosscountry comparisons of TEMPEST data points to give examples of current and potential benets and barriers.
Please cite this article as: Currie W. TEMPEST: An integrative model for health technology assessment. Health Policy and Technology (2012), doi:10.1016/j.hlpt.2012.01.004
TEMPEST: An integrative model for health technology assessment apparent that, while there are serious structural barriers to the use of IT that have nothing to do with technologyylegal and nancial incentives provide little motivation to share information across institutions, which is critical to improving patient outcomes as well as efciency [16]. Scientic research has shown the emphasis in the application of HTA has primarily focused on clinical aspects of health technologies, rather than economic, patientrelated, and organisational aspects. There are some notable exceptions. Danish HTAs, for example, have a wider scope compared with HTAs in other countries, as patient-related and organisational dimensions are included [17]. Evaluating HTA institutions in nine countries (Australia, Canada, Denmark, Netherlands, New Zealand, Norway, Sweden, UK and USA) the authors found that Denmark and Sweden scored highest for including organisational issues, with the USA scoring lowest. In the case of the latter, organisational, economic and patient aspects were given less attention with the inclusion of a limited number of questions. Economic issues were more frequently included than patient issues and this order of priority was fairly consistent for all HTA institutions. Policy recommendations were also usually omitted from HTA reports. Conclusions suggest that reports which omit wider aspects have dubious value for decisionmaking, and there is a vital need for further research [17]. With regard to health technologies, monitoring data should therefore be sufciently robust for HTA to inform optimal use of technology [12]. An evidence-based approach to HTA can offer decision makers data and information about the optimal or sub-optimal use of health technology. Evidence from national or regional studies where organisational and social indicators, for example, are not integrated into HTA, are less likely to provide a robust evaluation of clinical and cost effectiveness. For certain complex technologies (such as ICTs and medical devices), providing evidence about the expected impact of a technology on health system structures, processes, and resources is valuable within the HTA exercise as it can contribute to the development of an effective implementation plan. However, the potential choice of relevant indicators, and the need to harmonise evidence for decision-making, adds further complexity to HTA. A debate is therefore needed to identify key quantitative and qualitative measures, metrics and indicators for HTA, as this is important not only for benchmarking the adoption and use of health technologies, but also for policy-making. Integral to the TEMPEST methodology is a multi-disciplinary, cross-national, and diverse health technology landscape, which utilises and extends prior work on HTA within a structured and themed framework. TEMPEST aggregates health and technology indicators from a wide range of reputable data sources, to contribute to state-of-the-art research by building on prior research that addresses health policy priorities. The pragmatic rationale for TEMPEST is to create a cross-disciplinary, integrative model aimed to bring together disparate academic communities in clinical and social science. For example, academic researchers in health policy, health informatics, health management and health sciences, tend to publish their ndings in specic academic outlets (i.e. academic journals and conference proceedings) which reect disciplinary silos. This offers limited opportunities for knowledge sharing, as dissemination of common issues in health policy and technology needs to be shared with all
relevant stakeholder communities, not least patients and their representative groups. The scale and scope of health technology is a further complexity. ICTs, medical devices, imaging/monitoring technology, personalised medicines, drug discovery and diagnostics, all impact on clinical and non-clinical stakeholder groups. This suggests that a common language needs to be found to enable these diverse groups to communicate with each other. As prior research has shown, the introduction of technologies in healthcare settings has produced mixed results as technologies are in various stages of their maturity life cycle, with untried and untested emerging technologies posing the most risk. Even where technologies are perceived to highly mature, they may not have delivered expected benets, measured by an adequate return-oninvestment. For example, electronic medical records (EMRs) were rst introduced as early as the 1960s, yet their use across the international healthcare landscape is patchy, with many clinicians experiencing problems of inadequate patient data (i.e. missing and/or incorrect). Paper-based records continue to be widespread, as the move to electronic records is fraught with difculties. Recent attempts to introduce electronic patient records (EPRs) and electronic health records (EHRs) have proved equally challenging [18] particularly where the patient is also a user of these systems. Although the reasons for slow adoption of health technologies are often cited as computer problems, clinicians and patients concerns are more commonly focused around ease of use, data integrity, condentiality and patient safety. Another critical issue is around incentives, particularly where perverse incentives highlight the asymmetries of risks and rewards (i.e. the groups which experience the highest risks are not those who experience the rewards from moving to electronic records, for example). Recognising that HTA is a complex task, the TEMPEST methodology rejects ethnocentric perspectives which advocate a one size ts all, towards transforming healthcare. Improvements from health technology in one healthcare environment, may not work in another. For example, a recent study by the OECD2 claimed that Finland has over 100% adoption of EHRs in hospitals and almost the same in primary care. Yet, electronic exchange of key documents (i.e. referrals and discharge letters) between these organisations has been slow. This compares with the UK experience, where the drive to introduce EHRs (i.e. the summary care record) has received signicant investment, although marred by complex problems, a notable one being poor clinical and user engagement [37]. Identifying the contextual reasons why health technologies either succeed or fail in different health environments is a research priority. To assist this endeavour, the TEMPEST methodology aggregates 84 (coded) quantitative indicators from a wide range of robust data sets (WHO, OECD, World Bank, EU, and others), developed from prior empirical research and secondary source material to provide an unbiased, transparent and robust approach to isolating key data points (indicators) to drill-down and compare and
2 OECD (2012) International Workshop: Benchmarking adoption and use of Information and Communications Technologies in the Health Sector, 3031 January, Paris, France.
4 contrast specic themes and sub-themes at the country and regional units of analysis. The benchmarking of selected indicators contributes to a more generic prole and informed understanding of the current health-technology nexus to provide stakeholders (i.e. policy-makers) with a useful template for evaluating the current and potential health technology landscape. TEMPEST thus identies the front-runners, followers and laggards in health policy and technology. However, this does not suggest that the laggards should simply replicate the policies and practices of the front-runners, as contextual factors may point to leapfrogging opportunities which require a tailored health technology policy agenda that may not work across all countries. The following sections introduce the 7 TEMPEST categories to demonstrate the multi-dimensional research agenda of health policy and technology.
W. Currie which relate to economic, social, professional, managerial and technical issues. Other studies on electronic records consider the clinical advantages of introducing electronic records (medical, patient or health). In the United States, electronic health records are seen as one solution for reducing the number of medical errors, which account for 44,000 to 98,000 persons dying in hospitals every year [20]. A national poll found that 4 out of 10 persons believe that quality of care was declining across the health service despite rising healthcare budgets [21]. The US Congressional Budget Ofce predicts that total spending on health care will increase from 16% of the economy in 2007 to 25% in 2025 [22]. Electronic records, with functionality for automated error checking, clinical decision support, and reliable information ow and integration among different individuals and departments involved in patient care, are viewed as an integral part of making healthcare less error prone and more efcient for clinicians and patients. A recent publication shows that, in spite of the potential of electronic records, less than 20% of US physicians are using these systems [23]. Two challenges are identied. One, to develop appropriate clinical and nancial expectations, and two, to build or buy the skills needed for successful implementation [21]. Although these studies are US-centric, the challenge to develop electronic records is being confronted by politicians, professionals and public internationally. Healthcare technology also includes medical devices and imaging systems. The most promising medical device segments within the region pertain to neurology, cardiovascular devices, imaging, in vitro diagnostics, general surgery, orthopaedics, urology and respiratory devices [24]. The annual growth rate of the medical devices market in France, Germany, Italy, Spain and the UK was close to 9%, in an estimated market value of $51 billion. Imaging technologies include picture archiving and communications (PACs) systems and computer tomography (CT) and magnetic resonance imaging (MRI) scanners. Europes medical technology industry is growing steadily with around $5.05bn spent on R&D in 2006. The major European exporting countries of medical technology and their contributions are Germany ($18.6bn), Ireland (8.76bn), France ($8.1bn) and the UK ($7.4bn). Germany, Ireland, the UK, Denmark, Sweden and Finland have medical technology trade surpluses. The medical device market in Germany is expected to increase from $12,863 in 2007 to $16,973 in 2012 [24]. Health technology further includes personalised medicine (genetic diagnosis, testing and therapy), regenerative medicine and remote patient monitoring [7]. The move towards personalised medicine is gaining ground, although its vision and scope needs to be evaluated in terms of its practical application. Part of the impetus for developing personalised medicine technologies is genetic proling for targeting drugs. The Human Genome project has fuelled the drive in the pharmaceutical and biotechnology industries to develop new therapeutic treatments. With almost two million people reported in the USA suffering from adverse drug reactions (ADRs), with tens of thousands leading to fatalities, the need to identify through genetic testing those patients who are likely to have an adverse reaction to a single drug or cocktail of drugs is a key priority. Healthcare technology will further be developed for regenerative medicine. In particular, stem cell research
Technology
Health technology spans inter-disciplinary literature from health informatics, information systems and technology, management and organisations, and clinical decision making [11,12]. The more technically focused literature, particularly from the health informatics or information systems and technology elds is complementary to the broader work on management and organisations, since it considers the technical and engineering challenges of introducing new hardware and software in healthcare settings. The health informatics literature looks at technologies designed and applied to healthcare. Similarly, there is a wealth of literature from information systems and technology that also considers these issues across different geographical, industrial, organisational and operational contexts. Observations from reading this literature suggest that technical challenges faced in banking or manufacturing, for example, are similar to healthcare, albeit the solutions will be different. Complex cultural and organisational factors in healthcare will need to be considered as management consulting solutions, such as, lean thinking (i.e. used in manufacturing) will need to take into account contextual factors (i.e. incentive structures, clinical buy-in, user engagement and risk mitigation). Within the eld of health informatics, there are many studies on how ICT can enhance clinical decision making, particularly as new technologies come on stream. Healthcare IT has been described as an alphabet soup [19] as new acronyms are increasingly introduced. Confusion exists about the acronyms electronic health records (EHRs), electronic medical records (EMRs) and personal health records (PHRs). They are dened respectively as, EHRs provide clinicians with access to patient information and provide evidence-based decision support; EMRs are the electronic version of a legal health record; PHRs are digital health records that are owned, updated and controlled by the consumer [19]. PHRs are also likely to be referred to as electronic patient records (EPRs). Despite the many denitions of electronic health technologies, a common understanding is needed between politicians, healthcare providers, academics and the public more generally, particularly as each type of record implies different access, usage, accountability and responsibility levels, each of
TEMPEST: An integrative model for health technology assessment where restorative medicine aims to culture a persons own cells to create replacement tissues for repairing internal organs damaged by trauma, disease, or aging. Remote patient monitoring will also revolutionise the healthcare technology eld extending from an early forerunner in the form of electrocardiogram (EKG) devices for cardiac monitoring, where readings are transmitted through dedicated telephone lines to cardiac intensivists from remote locations including small rural hospitals [7]. Broadband Internet connectivity has further enabled the remote management of large numbers of intensive care unit (ICU) patients. Remote ICU systems digitally integrate voice, visual images, telemetry data and summary patient history information and allow the monitoring of numerous patients. The TEMPEST methodology identies three important themes relating to technology: enabling/emerging technologies; interoperability of eHealth; and eHealth service delivery model. These themes are not mutually exclusive but are broadly concerned with access and usage of technologies. For example, broadband penetration across the 27 EU Member States varies widely, with Denmark the highest and Slovakia the lowest. Data shows that mobile cellular subscriptions are highest in the EU for Italy and lowest in Malta. Although this indicator provides just one data point, it is extremely important for politicians and industry leaders to bear this in mind when developing mobile eHealth applications. Another example is broadband penetration. Countries which score low on this indicator, will need to develop policies to improve technology diffusion, particularly if citizens are to increase their use of eHealth applications (i.e. government supported sites for seeking information about health). Countries with high mobile cellular subscriptions, and less developed health infrastructures (i.e. Italy) are likely to offer greater opportunities for health application developers using mobile phones. This will provide more efcient and cheaper means of communication for health professionals and citizens (i.e. applications to inform patients about appointments, prescriptions and test results).
Economic
The turbulent economic conditions suggest that governments are seeking additional ways to reduce healthcare budgets while achieving greater economies of scale and scope in healthcare service delivery. Economic environments vary widely across the 27 EU Member States, and healthcare continues to be a major priority for political leaders and citizens alike. Health policy is inextricably linked to economic factors, and it is noteworthy that healthcare spending as a percentage of gross domestic product (GDP) is very low in some countries, but high in others. Across the EU, Member States vary widely in how they pay for healthcare, with the UK having the highest general government expenditure on health as a percentage of total expenditure on health, with Cyprus, the lowest. Conversely, Cyprus has the highest private expenditure on health as a percentage of total expenditure on health, with Denmark, the lowest. These gures are particularly important in relation to health policy and technology, as an under-developed health sector will pose problems for
introducing transformational change. The main drivers of rising healthcare costs in Europe are: ageing populations and the related rise in chronic disease, costly technological advances, patient demand driven by increased knowledge of options and by less healthy lifestyles, legacy priorities and nancing structures that are less relevant for todays society [25]. Along with government expenditure on health, the EU varies enormously in terms of GDP growth and population size. For example, whereas Germany has a population of over 81 millions, Luxembourg and Malta have less than half a million. The leaders in eHealth are typically Denmark, Sweden and Finland, all with relatively low population sizes. In terms of introducing top-down, government-led health IT programmes, this is easier to achieve in smaller countries (with small economic regions), than large countries, where an economic region (i.e. London) is larger than a country. Other country variations include the urban/rural divide among the population, and the labour force segmentation between agriculture, industry and services. These factors are particularly critical for understanding the potential adoption and diffusion of health technologies among diverse populations. For example, countries with a high percentage of the population employed in agriculture (i.e. Romania, 29%) provide very different opportunities for health technology diffusion, than countries with a very low percentage (i.e. Netherlands, 2%, Sweden, 1.1%). This is partly because agricultural workforces are less likely to have access to information technologies than populations employed in industry and services. National, regional and local environments are therefore important as healthcare technologies will need to be developed and targeted to citizens across widely differing economic, population and labour force settings. Recognising these differences, Halamka [26] advocates regional implementation organisations designed to offer an enterprise approach to health technology implementation where they may work with technology service organisations, that help to orchestrate group purchasing plans and model contracts, on behalf of clients. Such an approach is necessary due, in part, to the relatively low maturity of business and IT expertise in healthcare organisations, especially in countries with less developed health and IT sectors. The TEMPEST methodology integrates three economic themes: health funding; performance and population; and labour market segmentation. These areas reect important economic factors including expenditure, population size, labour markets and health infrastructure.
Market
The drive to develop a market-driven healthcare system is a departure in some European countries from a state-owned and controlled approach, particularly in the light of burgeoning healthcare budgets. As we have seen above, the market for ICTs, devices and imaging technologies is growing considerably. However, other market considerations involve the development of healthcare products and services that run alongside new technologies. Market-driven healthcare includes the development of product and services providers in the EU and beyond which may offer
6 citizens greater choice (i.e. where they source their healthcare requirements). While patients have generally been offered few or even no choice of healthcare provider, particularly in state-run healthcare systems where they have no access to private healthcare, the trend is to widen the market by allowing more competition. In the UK, for example, patients are now able to use primary GP services across the country and also to opt to use secondary healthcare providers (i.e. acute trusts) based on either their own selection of a physician or for convenience of location. This is similar to Belgium, where citizens have greater freedom to visit a GP of their choice, rather than one located in a particular surgery. Moves to develop private healthcare services, either as a supplement or an alternative to state-run healthcare, is controversial, yet inevitable given increasing annual public healthcare budgets [1]. Past healthcare markets have operated on a push strategy where the customer (patient) has been a passive recipient of healthcare delivery. Future markets are expected to balance this with a pull strategy with the public becoming more actively engaged in their healthcare. Evidence of a more customer-driven market approach is witnessed by the growing market for personalised healthcare services, including, the Microsoft HealthVault and Google Health web portals, where citizens can set up their own electronic health/patient record and gain access to a databank of healthcare information resources. In addition, other websites include online pharmacies which sell a range of medicines, with the inevitable problem that some of these sites are selling counterfeit goods with potentially harmful consequences. As the global healthcare market grows, healthcare technologies will gain traction as IT market capabilities and skills mature. As healthcare has been a laggard in technology adoption compared with other industries, it will be necessary for the various stakeholders to gain increased expertise in procuring and managing technology. For example, healthcare organisations, particularly, secondary care providers (hospitals) will need to forge greater links between the various stakeholder groups (i.e. clinicians, managers and users of technology). Different levels of IT maturity exist among healthcare stakeholders. For example, in primary care, it is usual for GPs/physicians/doctors to run their own practices or surgeries. More generally, these individuals are likely to be relatively knowledgeable about the latest ICT, having used patient administration systems for many years. But in secondary care, hospital consultants, nurses, junior doctors, managers and administrators, may be less knowledgeable about clinical and non-clinical uses of technology. Nurses, for example, may not have access to the latest IT software applications, particularly in countries with low IT investment. Notwithstanding the variations in IT capabilities and skills across countries, secondary care is generally perceived as a late mover in health technology adoption, compared with primary care and other industry sectors [27]. For example, Wanless [28] advised the UK government that when comparing the annual spend on IT in a range of business sectors, nancial services spend around 9000 per employee per year on computers, compared with only 1000 per employee in healthcare. This led the UK government to launch the National Programme for Information Technology with an initial pledge to spend over 6bn on
W. Currie transforming healthcare using ICTs (see above). Policymakers therefore need to address the issue of IT market capabilities and skills as this is essential for building new markets in healthcare. The TEMPEST methodology covers three market themes: market-driven healthcare; consumer-driven healthcare; and IT market capabilities and skills. These areas relate to how health professionals engage with technology, how citizens or consumers of health services use health information, and the numbers of health professionals per population.
Political
The business and management literature includes studies on policy and economic issues relating to value creation in public services and redening the healthcare industry. These contributions consider how publicly funded healthcare organisations may adopt methods and practices used in the private sector to create a New Public Management [29] which better serves the public interest. More specically, the global healthcare industry is high on the agenda of international governments as healthcare budgets soar without a commensurate increase in service levels to patients and public [1]. While these studies may not place health technologies at centre stage in their recommendations to modernise the healthcare industry, government funded reports increasingly make a direct link between IT investment and improvement in health service delivery. Most EU countries now produce policy reports on health IT strategy, or eHealth policy. For example, as early as the 1990s, the UK NHS introduced the Resource Management Initiative (RMI) to deploy information systems to connect medical activity to resource usage and to costs [30]. This study showed how IT was used to improve greater communication, planning and control, and even to bring about changes in organisational cultures. Since this period, governments have sought ways to use health technologies with outcomes that go beyond the technical imperative [31]. This has led to observations that, It is impossible to separate technology and policy in networked systemsyStandards in health IT have been likened to construction specications for building the interstate highly system. Yet it turns out that an explicit policy framework is as important as any effort to create technical standards [16]. International governments have developed a health IT or eHealth policy with varying levels of detail. In the US, the Health Information Technology Economic and Clinical Health (HITECH) Act is part of the American Recovery and Reinvestment Act (ARRA) of 2009. ARRA authorises an estimated $20 billion in direct grants and nancial incentives to promote the adoption and meaningful use of electronic health records among health care providers [32]. The entire US health information technology industry had estimated revenues of $27 billion in 2008. Despite political support and extensive investment in health technology, some have expressed caution about the risks of mis-spending this money and having little to show for it later. [26]. In the European Union, all 27 Member States have developed policy statements on healthcare technology investment, adoption and diffusion, which taken as a whole
TEMPEST: An integrative model for health technology assessment is highly fragmented and patchy. This coincides with many challenges, such as, the growth in health tourism [59] which will see increased cross-border trafc in patient data against a backdrop of diverse legal and regulatory systems operating at national and regional levels. This will increase the need for legislation covering data security, condentiality and ownership rights and responsibilities. eHealth policy will need to be integrated with eGovernment policy, particularly as online availability of public services will include health and eHealth. Countries with low access to online government services will therefore need to address these shortcomings, particularly if eHealth is to expand. An example is Austria, with 100% of basic public services for citizens fully available online, against Romania, with at only 8%. Another example is the percentage of the population using e-government services, with Finland at 53% and Bulgaria at 8% [64]. Clearly, unless citizens have both availability and access to government services, progress towards eHealth will be slow. Other important themes include education and training, particularly as a demographic prole with many elderly people and low socio-economic groupings will serve as an inhibitor to eHealth. Many countries have introduced training programmes to help citizens become IT literate by offering publicly available Internet access in libraries. The institutional structure is a key factor in eHealth, particularly as the relationship between politicians and healthcare professionals in policy-making and implementation may either promote or discourage eHealth. For example, research shows that institutional priorities differ across the European Union on a variety of health-related areas. Data shows that establishments with a documented policy, system or action plan on health and safety vary, with the UK at 98% and Greece at 38% [33]. Empirical research has shown that where clinicians and other healthcare professionals (i.e. hospital managers and administrators) reject government policies on health IT, it is unlikely that implementation plans for new systems will be fullled [34,35]. While the literature has many excellent case studies on health IT which focus on a single-site analysis of a particularly application (i.e. EHRs), there are fewer studies on the health policytechnology intersection. While these studies make a good contribution to the eld, policy issues are an important element in health technology. In particular, where health IT policy for large-scale projects is designed at government level, but requires the support at regional and local levels. Health IT is therefore a highly political phenomenon and becomes more so when there is little consensus among politicians, healthcare professionals and patient groups about the benets and risks alongside other important health priorities (i.e. stafng, patient services, access to medicines, etc.). The TEMPEST methodology covers three political themes: eHealth policy; education and training; and institutional structure. The health policytechnology nexus is critical for understanding political priorities for health IT at national, regional and local levels. The next steps for the political agenda should focus on identifying the drivers and barriers for eHealth. While there are many studies that present eHealth data and indicators at the country level, an important research aim of TEMPEST is to identify and measure adoption and use of health IT across countries.
This will provide benchmarking data for policy-making at the regional, national and international level.
Evaluation
One of the issues relating to health technology evaluation is, What is being evaluated? This is a multi-faceted concept with researchers evaluating health technology from a variety of perspectives (i.e. eHealth policy, social and cultural conditions, value for money, benets realisation and risk assessment). Many government sponsored evaluations on health technology, such as the summary care record for the National Programme for IT (NPfIT) in England are ex-post evaluations, which seek to assess what has been achieved at the implementation stage, rather than at the design and development stages [36]. Even at the implementation stage, health technology may only be partially implemented, with an expectation on the part of the sponsor that full implementation will take place at some dened point in the future. The evaluation of the NPfIT focused largely on the social and cultural aspects of an electronic health record, or NHS Summary Care Record, designed to store general health data on 50 million citizens in England. Despite several evaluations of the NPfIT over a ten-year period, this large-scale programme ran into several problems, with the latest recommendation to replace the centrally (top-down) approach with a more decentralised (bottom-up) one, where stakeholders at regional and local levels can dene their own health technology policies to t with their specic requirements [11]. Evaluating health technology is a complex task [38]. Prior studies have identied the importance of understanding ex ante evaluation comparing secondary source data (i.e. health IT strategy/policy documentation) about planned implementation of health technology. This data is often merged with ex-post rationalisations where stakeholders recall what happened following implementation [39]. A common nding is that stakeholder perceptions about the desired outcomes of health technology become confused with actual outcomes, where the initial shopping list of potential benets changes over time [30,40]. Others suggest, we need a new model of health IT that supports value-added, patient-centred processes over individual tasks [41]. Evaluation studies from the health informatics community focus on benets and risks from health technology to the user community, which includes, clinicians, nurses, administrators and patients [4244]. The business and management community focuses more on issues of cost reduction and streamlining operational processes in healthcare. Extending the eld of systematic evaluation of health technology, Rossi et al. [45] identify a number of categories, including: needs assessment, programme theory, process analysis, impact analysis, costbenet and costeffectiveness analysis. A needs assessment examines the nature of the problem the programme is designed to address. This involves identifying stakeholder groups affected by the programme and how/if their working practices are likely to change. The programme theory is the formal description of the concepts and design of the programme. Programme theory delineates the components of the programme and shows anticipated short and long-term
8 effects. It considers how an organisation will achieve desired outcomes as well as unforeseen consequences (both positive and negative). Programme theory drives the hypotheses to be tested in the evaluation. The development of a logic model may further build common understanding among stakeholders. Process analysis and modelling goes beyond the theory of the formal aims and objectives of the programme, and evaluates how the programme is being implemented. Evaluation and implementation are therefore separate focal areas. The impact analysis considers causal effects of the programme. Finally, costbenet or costeffectiveness analysis assesses the efciency, performance and risks of the programme. Evaluations occurring across sites may therefore identify best practice scenarios. Since the late 1980s, new technologies have been increasingly viewed as a means to improve performance management of health service delivery. Many studies have looked at how private sector methods and practices can be transferred to public services, especially healthcare. These initiatives include total quality management techniques [46] business process re-engineering [47,48] knowledge management [49] and more recently, new variants on quality management and lean manufacturing [50]. While these practices may produce variable benets across healthcare services, many writers caution that simply applying management tools and techniques from the private sector into healthcare is not a guarantee for success [48] particularly as each sector is governed by different management philosophies, policies, practices and procedures. Performance measurement and risk assessment are critical factors in conducting a pragmatic evaluation into health technology. Yet studies show that simply gathering quantitative and qualitative data on isolated health technology without considering the wider organisational structural, cultural and managerial issues is seldom useful [14]. Equally, measuring key performance indicators (KPIs) without acting on this information is an exercise in data collection rather than technology evaluation. We therefore concur with the view that, As with medicine, management is and will likely always be a craft that can be learned only through practice and experience [51]. To evaluate health technology, it is important to understand how business processes may change as a result of introducing new technology. Common tools and techniques include value chain analysis [1] process mapping and balanced scorecard [52]. Mixed data collection methods are useful for providing a rich picture of how clinical, non-clinical staff and patients interact with health technology across different settings such as the hospital or in the home. Empirical research into the design and implementation of health technology in the UK NHS has found that poor user engagement is a signicant barrier to adoption [34]. The concept of a national health service is misleading, particularly as health technology policy and implementation reects the federated and fragmented system of the health service, made even more complex by different political priorities in England, Scotland, Northern Ireland and Wales. Health technology evaluation is further complicated by the almost constant policy changes in health, culminating in structural and organisational changes. For example, in some healthcare organisations (i.e. the large teaching hospitals) more money has been invested in developing health
W. Currie technology in specic clinical and non-clinical settings. However, other less well resourced organisations (i.e. small local hospitals) have not been able to embrace the full benets from health technology [27]. Vastly differing levels of health technology maturity therefore exist across the national healthcare environment, and this is an important factor for understanding levels of skills and capabilities of health professionals to procure, implement and use health technologies. Introducing health technology is therefore closely related to the contextual situation and this needs to be factored into any evaluation of health technology [53]. A report by the British Computer Society [54] stressed that health technology projects should be evaluated as business change projects. The report advised that health informatics should consume around 4% of turnover, with project management emphasising a business led as opposed to technology led approach. While this advice is selfevident, others emphasise the disruptive and unpredictable nature of new technology which makes evaluation more difcult. Thus, When technologies are disruptive, operating and nancial impacts are challenging to estimate, which makes it difcult to construct a business case for investmentydisruptive technologies make it difcult to conduct return-on-investment (ROI) analyses [8]. Different stakeholder perceptions and practices of what constitutes health technology evaluation have led to suggestions that current evaluation methods and techniques are inadequate. The piecemeal approach where some studies emphasise organisational and cultural aspects, and others focus on economic factors alone, is too narrow. A recent paper on EHR evaluation found, y.the striking nding from our review is that there has been so little solid evaluation of these applications [10]. Evaluation of health technology should therefore integrate quantitative data with more contextual qualitative approaches from both clinical and social science [7]. For example, one study found the use of computers in European GP practices was 100 per cent for Finland and Estonia, but as little as 57% for Lithuania [55]. This data is interesting and can be further supported by comparative country analysis using other indicators (i.e. GP computing training, etc.). Another example is the Electronic recording and storage of individual administrative patient data, with Hungary at 100% and Latvia at only 26% (www.euphix.org). Quantitative data can therefore be supplemented with contextual data which may involve case studies on specic organisations (i.e. hospitals) to gain a rich picture of the health IT landscape. The TEMPEST methodology covers three evaluation themes: eHealth policy; governance, regulation and compliance; eHealth adoption/user engagement; and performance measurement and benets realisation. Health technology evaluation needs to include both hard and soft indicators where incentives for adoption and implementation are considered alongside perverse incentives for stakeholders.
Social
Social aspects in the development and diffusion of health technology relate to issues about inclusion and access for citizens to health services and products. Politicians are
TEMPEST: An integrative model for health technology assessment aware that the digital divide where inequalities of access and usage of health technologies is a serious impediment to the further growth in eHealth. Factors like population size, race, ethnicity, age, disability, life expectancy, national income per capita, and access to healthcare, are all important in the drive to promote increased use of health technology. The EU, however, faces serious challenges over the coming years as the population across the 27 EU Member States is projected to increase from 501 million in 2010 to 525 million in 2035, peaking at 526 million around 2040. A gradual decline to 517 million is forecast for 2060. Coupled with population growth, the EU population is expected to continue to grow older, with the share of the population aged 65 years and over rising from 17% in 2010 to 30% in 2060, and those aged 80 and over rising from 5% to 12% over the same period [56] (Eurostat, 2010). Ageing populations and declining birth rates put pressure on labour markets with reduced economic output as labour forces decrease with more people retiring. This increases the burden on the existing workforce. By 2020, Hungary will have the highest old-age dependency ratio in emerging market economies (EMEs) of 30.1%, up from 24.0% in 2010. Other countries with an old-age dependency ratio over 20.0% in 2020 include Poland and Romania. A decreasing workforce means there will be a smaller working-age population paying taxes resulting in lower government revenues and lesser potential for public spending. Pension spending will have to rise in order to accommodate for more elderly who will have increased health care needs. This will increase the cost of healthcare systems as they will need to be upgraded [57]. Efforts to move from established approaches to health service delivery, where the patient enters the healthcare system, either following a visit to a GP or a hospital, and is then diagnosed and treated, to one which emphasises prevention and wellbeing, will require a signicant cultural change [13]. To meet this challenge, EU27 politicians are keen to promote social inclusion schemes to develop health initiatives which measure patient outcomes rather than simply meeting xed targets. Fostering health literacy, where citizens take an active role in their health and wellbeing is about social change, as the health care system is currently built on the presumption of medical professionalism (i.e. the clinical judgement of the professional) rather than on consumerism (i.e. the patients right to choose). Changing these embedded cultural traditions will not occur over-night as citizens (patients) have traditionally acted as passive recipients of the health system, and not active consumers of health services. Increasing public awareness about prevention and wellbeing by governments will need to be stepped up, but the growth in global health tourism will fuel this goal, particularly as health professionals and patients seek cheaper and more efcient solutions to health problems. Recent gures show that approximately 4 million international patients per year seek health solutions outside their country, with a worldwide market worth between US $20 and US $40 billion [58]. Medical tourism is further estimated to account for around 5% of total tourism worldwide [59]. As health technology products and services continue to enter the marketplace, this will encourage the growth of patient-centred healthcare, where citizens increasingly use online and mobile devices to manage their health needs.
Across the EU, large and small companies are developing hardware and software applications for clinical and patient uses. These include, mobile phone applications to book GP/ physician and hospital appointments, receive prescriptions and test results, access to an online electronic health record, participation in health blogs/chat rooms and other online health applications. Studies show the availability and use of health technology products and services is increasing. However, the differing demographic proles across the EU will mean that governments will need to target and tailor health technology offerings to meet the needs of the vast majority. For example, the percentage of the population aged over 65 in the EU in 2010 shows Germany has 20.6% compared with Ireland at only 11.3% and Slovakia at only 12.3%. This suggests that governments and companies need to consider age demographics with health technologies targeted at the elderly population in Germany, which may include, online monitoring of chronic conditions using ICT and medical devices. For Ireland and Slovakia, these technologies will be less relevant, as the demographics show a much larger proportion of the population under 65 years. Health and wellbeing programmes facilitated by health technologies will be more usefully targeted at middle-aged people and younger. Market segmentation for health technology products and services will thus need to consider variations in social factors. The TEMPEST methodology covers three social themes: social inclusion/access to IT; patient-centred healthcare; and demographics. The adoption and diffusion of health technologies will continue to be patchy as a result of differing access/inclusion and demographic proles both across and within EU Member States. In addition, the drive to make healthcare more patient-centred will occur if health literacy increases, encouraged not only by government campaigns on prevention and wellbeing, but also through the emerging international market in health tourism.
Transformation
The transformation of healthcare focuses on the macro- and micro-levels. Across the EU, politicians have increasingly looked at health technology as a means to transform healthcare. For the past few decades, ICT, medical devices and monitoring technologies have been perceived as a magic bullet to drive change in the healthcare industry. All EU Member States have developed eHealth policy, but the relationship between policy formation and implementation is uncertain. The technology sector is also looking to develop new products and services to improve health service delivery. Important questions include: How can technology be used to transform healthcare? What are the best practice examples? The TEMPEST data on 27 EU Member States points to vast differences in the health systems of individual countries and their eHealth status. Politicians, industrialists and academics, alike, continue to promote the potential of health technology to transform the health sector for the benet of all citizens. A key goal is to create an integrated or seamless healthcare system where patients receive cradle to grave services, which are meticulously documented and stored on
10 electronic or personal health records. Yet healthcare systems across EU Member States are fragmented, with a mixture of public and private sector providers and payers. This detracts from an integrated approach since patient data is recorded across multiple systems, owned and controlled by many different healthcare organisations. Even within the same system, i.e. a national healthcare system, patient records are patchy as health events (i.e. visits to different healthcare professionals for general appointments (i.e. GP check-ups) and specic treatments (i.e. diagnosis, testing, treatment) will capture data from many different sources. As patient data is located and stored in many different physical environments, it is likely that the contextual nature of the data and how it is used by professionals also varies [60]. While health technology has the potential to improve health service delivery, policymakers and professionals working in this eld need to reduce the barriers, which include: implementation problems from immature/untested health technologies (i.e. EHRs), perverse nancial incentives for providers/payers, resistance from health executives/clinicians/patients, lack of resources, fears about privacy/security/condentiality (of patient data), inertia, lack of IT capabilities and skills, under-developed health infrastructures, resource constraints, and many others. To understand the potential of how technology will transform healthcare, the TEMPEST methodology calls for a wider debate which does not simply advocate reinventing the wheel (i.e. investing in more studies on health IT) to reproduce existing ndings, but to support a research agenda that encourages the cross fertilisation of academic and practitioner communities of practice involving multiple stakeholders. One study reported the ndings from a literature review of 4,683 titles on health IT between 20042007. This research found that many studies focused on patient-focused applications with little formal evaluation, descriptions of commercial EHRs and health IT systems designed to run independently from EHRs, and fewer studies from health IT leaders. The authors claim, We found that although predictive analysis suggest that health IT has the potential to enable a dramatic transformation in health care delivery, the empirical research evidence base supporting its benets is limited [10] The authors call for more publicprivate partnerships and policies which address the mis-alignment of incentives to accelerate the adoption of health IT, and for a more robust evidence base for IT implementation. The TEMPEST methodology covers three transformational themes: education and training; the reform agenda; and eHealth strategy and implementation. Politicians are currently preoccupied with transforming healthcare with much emphasis on health technology as an enabler in this process. However, the TEMPEST methodology, which aggregates data sets and material from a wide variety of academic, government and professional sources, suggests that transforming current healthcare systems needs to take into consideration wider socio-economic and political factors which go far beyond the technical imperative. For example, the increasing calls to move from diagnosis and treatment to prevention and well-being cannot be achieved through technical change alone but a cultural and behavioural shift in attitudes and lifestyle. Government campaigns on health
W. Currie and wellness can be targeted to citizens using the Internet and other mobile technologies, but this needs to be accompanied by incentives, nancial or otherwise. Education and training thus plays an essential role in transforming healthcare, and goes far beyond simple instruction on how to use technology. The TEMPEST data identies indicators which measure government expenditure on prevention and wellbeing, but this will only make an impact if combined with large-scale investment to change behaviour and habits (i.e. healthy eating and exercise). The reform agenda in healthcare further considers changes to business models [1]. As governments look towards reducing health costs by treating more patients at home rather than at hospital, R&D expenditure on new products and services will be crucial in changing the way healthcare is delivered. Citizens are now exposed to the exponential growth in social media sites for health products and services, most of which is currently unregulated. In conjunction with the large companies offering technologyenabled healthcare (i.e. online EHRs from Microsoft and Google), smaller technology rms will increasingly enter the market with new systems and applications. So far, the success of centrally-imposed government policy to introduce health technology has seen mixed results. Prior research suggests the relationship between eHealth strategy and implementation will also need to be more closely coupled [61,62] since top-down policy decisions often result in poor implementation and unexpected outcomes [63]. The TEMPEST methodology thus aims to track health technologies from policy decisions through to strategy and implementation to give stakeholders a wider understanding of the factors that both encourage or inhibit best practice in healthcare settings. So an important indicator in this process is to consider not only the extent of technology diffusion, but also its deployment and use by health professionals and patients.
Conclusion
Following an extensive review of the health policy and technology literature (which is not exhaustive in this paper) the TEMPEST methodology which combines 7 core categories, 21 themes and 84 indicators/metrics, is developed on the premise that, a one-size-ts-all approach to transforming healthcare using technology is misguided. This paper has introduced the core thinking behind the TEMPEST methodology, giving some examples of key differences between EU Member States. To determine what will work in one country, as opposed to another, it is important to gain a deeper understanding of the contextual factors that may enhance or inhibit the adoption and diffusion of health technology. While the technical imperative is overstated in much of the health technology literature, other factors play a large part in determining success and failure scenarios. These include: differences in health expenditure; demographic conditions; health infrastructure; ICT skill levels; health literacy; clinical and patient engagement; and many other factors. Understanding key differences within and across EU Member States is therefore critical to policymakers and other health and health technology stakeholders [65]. For example, while Denmark, Finland and Sweden are
TEMPEST: An integrative model for health technology assessment considered front-runners in eHealth, they all benet from a relatively low population size and a mature social and health infrastructure. These countries are the same size as many regions in larger countries. Germany, the UK and France, with well developed social and health infrastructures have much larger population sizes, where centrally-imposed health and eHealth policies are more difcult to implement. The TEMPEST methodology thus offers a useful tool for comparative country analysis of EU Member States, using cross-disciplinary indicators for benchmarking to assist policy-makers in their decision-making. The limitations of this approach, however, are not insignicant as the relative paucity of reliable and robust data sets is a major barrier. This is recognised by bodies such as the OECD, who are keen to identify key indicators for benchmarking eHealth. We therefore conclude with a call to increase and enhance the quantity and quality of data to support policy-making to improve health service delivery and outcomes in the 21st century.
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particular, John Vassallo, Elena Bonglioi, Thaima Samman and Ray Pinto. Thanks also go to Bruna Guimaraes and Rochelle Eng. I would like to thank Professor Dan Hamilton of the Johns Hopkins University for his excellent coordination and management of the research programme. Thanks also go to Dr. David Finnegan, for his work on the earlier phases of TEMPEST study. I recognise the help and support of all the above individuals and look forward to continuing to work with these colleagues.
Appendix A.
The TEMPEST methodology
Acknowledgements
I would like to take this opportunity to thank all those who have supported the study. They include in alphabetical order, Jos Aarts, Erasmus University Rotterdam, Margunn Aanestad, University of Oslo, Nicola Bedlington, European Patients Forum, David Bevan, European Academy of Business in Society, Nicole Denjoy, COCIR, Jens Dibbern, University of Bern, Gilbert Lenssen, EABIS, Thomas Knothe, Fraunhofer Institute, Tina Blegind-Jensen, Copenhagen Business School, Patrick Oliver, Accenture, Cristina Vela Marimon, Telefonica, Simon Pickard, EABIS, Nancy Pouloudi, Athens University of Economics and Business, M Rajarajan, City University, Loic Sadoulet, INSEAD Centre for Social Innovation, Donald Singer, University of Warwick Medical School/Fellowship of Postgraduate Medicine, Karl Stroetmann, Empirica, Sinan Tumer, SAP, and Vishanth Weerakkody, Brunel University. I would also like to thank the sponsors, Microsoft colleagues for spearheading the Information Technology (IT) to Enabling Technology (ET) research initiative. In
The TEMPEST Health methodology (see Appendix A) is developed by Professor Wendy Currie, Editor-in-Chief of Health Policy and Technology, and is a research-based decision-making tool to help health stakeholders identify the opportunities and barriers to transforming healthcare with enabling technologies. TEMPEST Health is sponsored by the Enabling Technology Coalition, a collaborative grouping of business, non-governmental organisations and other stakeholders, initiated by Microsoft and facilitated by Johns Hopkins University. The Enabling Technology Coalition promotes research on the potential for enabling technologies in facilitating European economic growth in four areas: health; low-carbon economy; education; and governance. The research is supported by a coalition of partners, including, Accenture, COCIR, The European Academy of Business in Society and GE Healthcare. Microsoft leads the coalition on the IT to ET Enabling Technology programme, which supports other scientic studies co-ordinated by The Johns Hopkins University. The TEMPEST concept was initially developed as a prototype with quantitative and qualitative indicators (see: http:// www.enablingtechnology.eu/ehealth/academic_study). Since this initial study, TEMPEST has been extensively revised and now contains 84 quantitative indicators to provide a more robust and reliable means for comparative country analysis on health technology assessment. Professor Currie is working with the coalition of partners to apply the methodology to 27 EU Member States (Table A1).
Table A1 TEMPEST Technology Theme Enabling/emerging technologies Indicator/metric T1a: Broadband penetration (as % of total population) T1b: Speed% of broadband subscription above 2 Mbps T1c: % of households with an internet connection T1d: % of households with a broadband connection T2a: % of individuals using a mobile phone via UMTs (3G) to access the Internet T2b: % of individuals using a laptop via wireless connection away from home/ work to access the Internet T2c: Obtaining patient consent for data storage and transfer: Oral/Written consent T2d: Obtaining patient consent for data storage and transfer: No specic consent
Interoperability of eHealth
12
Table A1 (continued ) TEMPEST Theme eHealth service delivery model Indicator/metric
W. Currie
T3a: Mobile cellular subscriptions (per 100 people) 2008 T3b: Fixed Internet Subscribers (per 100 people) 2008 T3c: % of population who are regular Internet users (using the Internet at least once a week) T3d: % of population who are frequent Internet users (using the Internet every day or almost every day) E1a: Total health expenditure as a % of GDP E1b: General government expenditure on health as a % of total expenditure on health E1c: Private expenditure on health as a % of total expenditure on health E1d: General government expenditure on health as a % of total government expenditure E2a: GDP growth E2b: GDP per capita ($) E2c: Country population E2d: Urban population (% of total) E3a: Labour forceAgriculture (%) E3b: Labour forceIndustry (%) E3c: Labour forceServices (%) E3d: Telephone lines (per 100 people) 2008 M1a: % Practices having websites M1b: GP practices receiving professional IT support M1c: Population covered by mobile cellular network (%) M1d: Personal computer (per 100 people) M2a: % of Population seeking health information on injury, disease or nutrition M2b: Electronic storage of individual medical patient data M2c: Density of physicians (per 10,000 population) M2d: Practising physicians per 100,000 inhabitants M3a: Density of nursing and midwifery personnel (per 10,000 population) M3b: Density of densitry personnel (per 10,000 population) M3c: Density of pharmaceutical personnel (per 10,000 population) M3d: % GPs facing interoperability problems in data exchange P1a: % basic public services for citizens fully available online P1b: % basic public services for enterprises fully available online P1c: % population using e-government services P1d: % enterprises using e-government services P2a: Per capita total expenditure on health at average exchange rate (US$) P2b: Per capita total expenditure on health (PPP int. $) P2c: Per capita government expenditure on health at average exchange rate (US$) P2d: Per capita government expenditure on health (PPP int. $) P3a: Establishments with documented policy, system or action plan P3b: Hospital beds (per 10,000 population) P3c: Radiotherapy units (per 1,000,000 population) P3d: Take-up of Internet services: looking for information about goods and services (% of population) Ev1a: E-Government web measure index Ev1b: Workers answering very well informed to regarding the health and safety risks related to your job, how well informed would you say you are? Ev1c: Euro Health Consumer Index (Patient Rights and information, eHealth, Waiting time for treatment, outcomes, Range and reach of services provided, Pharmaceuticals) Total Score and Rank Ev1d: Bang for the buck score in Euro Health Consumer Index 2009
Economic
Healthcare funding
Performance and population
Labour market segmentation
Market
Market-driven healthcare
Consumer-driven healthcare
IT market capabilities and skills Policy eHealth policy
Education and training
Institutional structure
Evaluation
Governance, regulation and compliance

Table A1 (continued ) TEMPEST Theme eHealth adoption/ user engagement Indicator/metric Ev2a: Use of computers in European GP practices Ev2b: Electronic recording and storage of individual adm. patient data Ev2c: Computer in consultation room Ev2d: Use of a computer during consultations Ev3a: Internet Users (per 100 people) Ev3b: % of population who have never used the Internet Ev3c: Use of the Internet in European GP practices Ev3d: Use of broadband in European GP practices S1a: People/sq. mile S1b: Life expectancy at birth, all population, years S1c: Proportion of the population assessing their health as good or very good S1d: Health life years at age 65 S2a: Connecting to different types of health actors (other GPs) S2b: Connecting to different types of health actors (hospitals) S2c: Connecting to different types of health actors (health authorities) S2d: Connecting to different types of health actors (pharmacies) S3a: Adult mortality rate (probability of dying between 15 and 60 years per 1000 population) S3b: Population aged over 60 (%) S3c: Annual population growth rate S3d: Gross national income per capita (PPP itn. $) Tr1a: Prevention and Public Health Services (% current health exp.) Tr1b: Provision and adm. of public health programs (% current health exp.) Tr1c: % of persons employed with ICT user skills Tr1d: % of persons employed with ICT specialist skills Tr2a: R&D intensity (R&D expenditure as a % of GDP) Tr2b: R&D expenditure in EUR million by sector of performance Tr2c: Business enterprise R&D expenditure on manufacturing as a percentage of total Tr2d: Business enterprise R&D expenditure on services as a percentage of total Tr3a: Business enterprise R&D expenditure in EUR millions as a percentage of total Tr3b: Increase range of goods or services during 20062008 as a percentage of innovative enterprises Tr3c: Electronic exchange of patient data for at least one purpose Tr3d: Electronic exchange of patient data (Lab results from laboratories)
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Performance measurement and benets realisation Social Social inclusion/ access to it
Patient-centred healthcare
Demographics
Transformation
Education and training
Reform agenda
eHealth strategy and implementation
References
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TEMPEST: An Integrative Model For Health Technology Assessment

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TEMPEST: An integrative model for health technology assessment

E-mail addresses: wendy.currie@fpm-uk.org

TEMPEST: an integrative model

The TEMPEST methodology

Performance and population

Labour market segmentation

IT market capabilities and skills Policy eHealth policy

Education and training

Governance, regulation and compliance

TEMPEST: An integrative model for health technology assessment

Performance measurement and benets realisation Social Social inclusion/ access to it

Education and training

eHealth strategy and implementation

[39] [40] [41]

[45] [46] [47]

[52] [53] [54]

TEMPEST: An integrative model for health technology assessment

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