As with many aspects of our lives, COVID-19 has drawn into sharper focus how quickly aspects of our health systems that we took for granted can change. Experience from the 46 countries and territories in which KPMG member firm healthcare teams operate show six clear trends as we head towards the new reality. The individual and cumulative effects of these trends are to strengthen the case for better connected healthcare.
1. Digital front doors are here to stay
COVID-19 brought wholesale disruption to our healthcare systems and the global supply chains that support them. It also provided a catalyst for disruption to the traditional channels through which care has been delivered for decades. For example, in order just to maintain access to services, US telemedicine visits surged by 50% in the first month of the pandemic and virtual visits are predicted to top 200 million this year, up sharply from the original prediction of 36 million visits for all of 2020.1
Health systems worldwide have leveraged digital technologies in order to deliver care through new channels, support disease monitoring and contact tracing, and enable more integrated care. The very nature of what healthcare consumers now expect from health systems has changed overnight.
With the pandemic, there has been a proliferation of new companies, technology solutions and virtual services that have rushed to fill the void of healthcare consumer experiences. COVID-19 has created a global opportunity to stress test the business case for a range of digital care modalities. Even in jurisdictions like Canada where healthcare is a covered public service, consumers are paying out-of-pocket for the ability to access care that is timely and convenient.2
2. Redesign of the health system is needed to deliver resilient, patient-centered care
The 2019 KPMGI/Forrester survey revealed that nearly 8 out of 10 healthcare leaders believe they have a good handle on crafting care delivery systems and co-designing care pathways with consumers, but creating a holistic consumer-centric strategy still eludes a significant number of those organizations.3
Being consumer-centered requires a care system designed to support the entire care journey, not just discrete episodes of care within a hospital, clinic, or a doctor’s office. COVID-19 has placed a spotlight on the high levels of fragmentation and poor coordination common in many health systems. It has demonstrated the need for more integrated care systems that span primary, secondary, acute, and community settings, in order to strengthen the resilience of the system overall.
Importantly, this integration is not only about better handovers of patient care. Integration of middle and back-office functions – particularly as they relate to supply-chains, workforce and finance – have been essential to the continuity of services of many health care systems around the world in recent months.
It has also demonstrated that implementing the changes that emerge from this redesign process need not be a generation in the making. Health systems in Australia, the UK, US, Canada, Italy, China, and Singapore (among many others) demonstrated that new care models can be designed and implemented quickly, proving that where there is a will, there is a way.
In many of these jurisdictions, new fever clinics emerged in only a few days, while field hospitals of unprecedented scale with full-scale EMRs were brought to life in a few short weeks.
Health systems that emerge will not only have durability for the coming decades (which may very likely include emergency response systems to address subsequent pandemics) but also provide the flexibility required to accommodate the significant shifts that digital transformation will bring. The length of this planning horizon demands an emphasis on both short and long-term impacts of digital disruption on healthcare.
To deliver more seamless consumer experiences, drive better health outcomes, and reduce cost and harm associated with unwarranted variation in care, healthcare systems around the world have recently been pursuing greater levels of integration. Innovative care systems are also partnering with non-traditional providers such as retail and new digital channels to deliver services which can respond to consumer need more flexibly and cost effectively. COVID-19 has simply accelerated this trend. The emergence of integrated care systems already visible in a range of places will be a powerful enabler of this redesign effort, as shown in the examples below.
| Accountable Care Organizations4,5 (USA) |
Clusters (Saudi Arabia) |
Ontario Health Teams6 (Canada) |
|
| # of covered lives | 32M | 30M | 14M |
|---|---|---|---|
| Unique design feature(s) of integrated care | Stimulates integrated care among provider networks through shared savings incentives with the Medicare program Receives risk-adjusted payments (per patient per month) to deliver a wide array of care types and achieve certain outcomes |
Accountable care organizations consisting of primary, secondary, and specialty care providers
|
Integrated care network with shared governance and accountability amongst providers in a specific geography to enable improved outcomes for the targeted patient populations Coordinated care delivery across a patient’s continuum, including 24/7 patient access to navigation and care coordination |
| Key digital elements | Hospital information systems
|
Integrated personal health records Virtual self-care, education and navigation tools |
A “digital first” approach including:
Jurisdictional longitudinal patient records that integrate the continuum of care, e.g. acute, primary, community, behavioral health, homecare, etc. |
These forms of integration will demand:
- New and different capabilities: There will be a need for new and different capabilities that enable more personalized care, better influence over the technology architecture of the system as a whole, new approaches to intake and referral management, and an ability to more flexibly deploy new channels of care to respond to emerging needs. Though health leaders generally recognize the importance of these capabilities, the KPMGI/Forrester research indicates a majority of healthcare providers identified significant capability gaps as a barrier to implementing better interactions with consumers.7
- Rethinking the architecture of our systems: In many cases, achieving better care integration requires health care leaders to rethink the architecture of their delivery systems, the alignment of incentives toward greater value, and the way in which technology enables information to follow patients across care settings. Until recently, large scale national investments into health technology projects (for example national health records), have all struggled to bridge the gap between the needs of health systems today and those that clinicians and consumers will demand in the future. To respond to COVID-19, jurisdictions around the world have invested in new technologies (for example digital platforms to enable more rapid and effective contact tracing such as the COVID Safe app developed by the Australian Government),8 alongside the treatment of traditionally-expensive platforms (like EMRs) as utility services appropriate for rapid generic deployment.
- Activation of consumers and patients: Perhaps the most challenging frontier for better integration however lies in better mobilizing the most important resource available to health systems: consumers. Improved activation of technology-literate consumers and their healthy behaviors are critical ingredients for digitally-enabled population health management.9 Smart devices (like phones or wearables) now touch almost every part of our life and healthcare is not immune. Though hundreds of thousands of applications are available to consumers and health professionals, the evidence for behavior change and improved population-level outcomes through scale implementation of digital health solutions (in particular mobile solutions) remains limited.10,11 COVID-19, and the widespread adoption of digital platforms to enable contact tracing, monitoring, and consumer education provide an unprecedented opportunity for large-scale evaluation of digitally-enabled public health programs in order to inform future policy.
3. Insight-driven decisions are better decisions, every time
Photo credit: AdventHealth Mission Control (Orlando, USA) - developed and implemented in partnership with GE Healthcare Command Centers (pre-COVID-19 image)
The global pandemic response has demonstrated another priority: the importance of insight in driving strategy and supporting every decision. As health systems have grappled with wholesale disruption to global supply chains, raced to manage capacity within facilities and across networks, and tried to predict and control the spread of a virulent pathogen, they have returned time and again to one critical enabler: data.
While 71 percent of healthcare leaders said that data and analytics will remain an investment priority over the next three years, less than one half believe that they have the ability to execute on their desire to have more actionable and timely insights.12 Improving access to more timely data has been critical for many providers in the search for greater speed to insight, reflected by the increasing prevalence of command centers in healthcare over recent years.13
Perhaps the most critical change for payers, providers, and policy makers to emerge from the COVID-19 crisis is the mission-criticality of data: not just in responding to the pandemic, but in looking forward to a new reality.
The integrated care systems and digital front doors outlined previously can only function effectively, and create sustained value, if the data they create lead to more timely decisions that improve system outcomes. While platforms for better integrated decision making – such as command centers – will play an important role in managing more complex systems and the greater number of channels they will employ, influencing clinical performance requires information to be available much closer to where clinical decisions are made. Indicators of operational performance (for example emergency department waiting times) are ultimately aggregates of hundreds of thousands (or millions) of decisions being made each minute by clinicians and managers. Along with presenting the data in a visually compelling manner, however, substantial effort must focus on changing the underlying ways of working to embed an evidence-based operational management system at the core of a healthcare delivery system.14
Ambulance Victoria
In Australia’s second-most populous state, Ambulance Victoria’s mission is to provide high quality pre-hospital care and medical transport.
To support this mission and drive performance improvement on the front-line, data is used in day-to-day operations through the organization’s descriptive, predictive, and prescriptive data and analytics capabilities. Actionable data insights are made available to staff at all levels, from the CEO to junior-level paramedics. This system gives paramedics a view on their own performance and team management can better understand the root causes of issues and predict future outcomes.
4. Consumer-centricity will be a key driver of how care is delivered
Despite the fact that most healthcare organizations reflect “consumer or patient centeredness” in their strategies, many of them have designed their service delivery models, operational processes and technology solutions to meet the needs and preferences of funders, policy makers and clinicians, rather than patients. For many consumers, particularly those living with chronic diseases, COVID-19 has brought both uncertainty and long awaited change to the way that they access services.
New, technology-enabled service delivery models have emerged in a variety of care settings: virtual access to primary and secondary care consultations, virtual and remote mental health services, app-based self-assessments for COVID-19 (including on globally available platforms like Babylon and Ada Health) to name a few. These changes have occurred at remarkable speed and, in many cases, have enhanced access and experience for consumers. In large part, this is because the focus of the technology-enablement was on delivering value (even if only through reduced risk) to consumers, rather than to the health system.
The power of electronic prescribing
In Australia, the Department of Health has partnered with the Australian Digital Health Agency to deliver on the 2018-19 budget measure supporting a national electronic prescribing system. Legislative changes, together with a co-design process with the health sector, has led to development of a technical framework to help clinical software systems create, collect and store electronic prescriptions. Electronic prescribing will change the way that consumers will interact with their prescriptions – recognizing an electronic prescription as an alternative legal form by which medicines are supplied.
While the initial rollout was planned to happen over the course of 12 months, the Australian Government’s COVID-19 National Health Plan accelerated the electronic prescribing rollout so that people could obtain medicines without physically going to doctors’ offices or pharmacies (if their pharmacies offer home delivery).
The project has successfully enabled the first Australian electronic prescription, which was transmitted in Anglesea, in the State of Victoria in mid-May 2020. One prescription is expected to become 100 million in the next 12 months, and upwards of 400 million within two years, demonstrating how rapidly digital transformation can change the lives of consumers and the role of care systems.
Globally mental health disorders affected more than one billion people in 2016 and contributed 19 percent of all life-years-lived with disability.15 While one in two people will experience a mental health disorder in their lifetime, eighty percent of those with common disorder, and up to 50 percent of those with a severe disorder won’t seek or receive treatment.16 In many cases, historical technology investments provide a platform to record that a patient has a condition and information about the process of care. To date, they have had little role in addressing either the primary diagnosis or its deeper social determinants: vulnerability, loneliness, and social isolation to name a few.
This is rapidly changing however, with thousands of mobile digital solutions now available to help respond to mental and addictive health needs. With the burst of consumer-centered digital disruption that COVID-19 has brought-on however comes with uncertainty.17 How should consumers or healthcare providers determine the efficacy or effectiveness of these platforms? How, if at all, should they be integrated into mainstream technology platforms like EMRs or EHRs as we move toward a new reality? What are the clinical, operational and technology governance considerations associated with their implementation? How should consumer choice be balanced with the need for standardization in a health system and reductions in unwarranted variation? How will safety regulators keep up?
The challenge for healthcare providers is in how ‘enablers’ such as digital and analytical tools can be brought together in a connected way to better respond to the needs and preferences of consumers, while at the same time improving outcomes at a population level in a financially sustainable way. This is at the heart of being ‘patient-centered by design’. Stepping toward a new reality will require health systems to leave their current ways of working behind, to think holistically about the needs of consumers and then retooling the care system, workforce, and use of data, operations, and digital enablement to align to those needs.
5. Enterprise-wide innovation is required to meet the evolving demands of health systems
The understandable focus of health systems on diagnosis and treatment often occurs at the expense of innovation in traditional middle and back-office settings, as digital investment is directed toward clinical enablement and front line services. Yet this long-term underinvestment in innovative approaches to operational and support functions has left many healthcare organizations with ageing systems and processes that have not kept pace with the productivity improvements realized in other sectors.
Furthermore, the ability of organizations to safely incubate the capability to leverage new, productivity-improving technologies (for example robotic process automation and augmented intelligence more broadly) before scaling them into front-line environments has been stifled. However, the more mature a healthcare provider, the easier these barriers are to overcome, since these organizations are equipped with better capabilities to enable innovation, as demonstrated by the KPMGI/Forrester research.18
Global shortages of critical supplies (including personal protective equipment (PPE) and medical equipment) arising from the disruption of supply chains and extraordinary growth in demand as a result of COVID-19 have revealed startling levels of fragility in the resilience of our health systems. These vulnerabilities have greater implications however: COVID-19 has demonstrated the importance of health systems in the economic and security interests of countries and territories. More simply, health is a critical and too-often overlooked determinant of wealth and national security.
Shaping a new reality to respond to the issues identified above will not be achieved through a focus on middle or back-office functions like procurement, or supply chain, alone. While these functions can be instrumental in bridging gaps in the supply chain, doing so without connecting them into the delivery of care, and the demand for supplies that care creates, will be fraught. Healthcare providers will fail to realize the enormous benefits available through the application of emerging technologies core to the transformation of middle and back-office functions (for example the use of autonomous vehicles for non-emergency patient transport, or AI chat bots responding to queries from patients or carers), unless they are able to take a more connected approach. The new, digitally-enabled reality that emerges from COVID-19 will only be enabled through the development and sustainment of new capabilities within the workforce.
6. The new workforce is agile and digitally empowered
Shortages in front-line care workers have been a common feature of health systems, with the World Health Organization (WHO) estimating a shortfall of over 18 million by 2030 if no action is taken.19 A trend towards more long-term conditions, coupled with the pace of technological change, mean the skills required of those health workers are also changing. Simply training more workers is no longer sufficient, nor is it sustainable.
While COVID-19 has thrown workforce shortages into sharp relief, it has also accelerated the pace of change. We have seen widespread reforms to scope of practice legislation as well as professional regulation and flexibility. There has been a sharp uptick in the use of technologically enhanced models of care, and we have seen widespread deployment of volunteer staff to assist with health delivery – changes that have been widely accepted by both patients and staff. And though the pressure on staff has been great, it seems to have generated a much greater appreciation of the importance of staff wellbeing, including the need for more flexible and remote working.
There is a strong desire to maintain the progress that’s been made since COVID-19, and not to fall back into old, unproductive ways of working. Equally, any future developments to the healthcare workforce should be considered and coordinated to deliver an aligned and empowered workforce.
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Footnote:
- CNBC (April 4 2020). Telehealth visits are booming as doctors and patients embrace distancing amid the coronavirus crisis: https://www.cnbc.com/2020/04/03/telehealth-visits-could-top-1-billion-in-2020-amid-the-coronavirus-crisis.html
- Globe and Mail (March 18 2020). Telemedicine companies see soaring demand for online health consultations: https://www.theglobeandmail.com/business/article-telemedicine-companies-see-soaring-demand-for-online-health/
- Forrester Consulting. (2019). Healthcare Providers Data Review. Internal KPMG report: unpublished.
- Gonzalez-Smith, J., Bleser, W., Muhlestein, D., Richards, R., McClellan, M., Saunders. R. (2018). Medicare ACO Results for 2018: More Downside Risk Adoption, More Savings, and All ACO Types Now Averaging Savings. Health Affairs: https://www.healthaffairs.org/do/10.1377/hblog20191024.65681/full/
- Centers for Medicaid and Medicaid Services. (2020). About the Program: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about
- Ontario Ministry of Health and Long-Term Care. (2020). Become an Ontario Health Team. Ontario Ministry of Health and Long-Term Care website: http://health.gov.on.ca/en/pro/programs/connectedcare/oht/#OHT
- Forrester Consulting. (2019). Healthcare Providers Data Review. Internal KPMG report: unpublished.
- Australian Government, Department of Health, (2020). COVIDSafe app: https://www.health.gov.au/resources/apps-and-%20tools/covidsafe-app
- Britnell, M., Ambres. C., Thomas, H. (2016). What works: Creating new value with patients, caregivers and communities. KPMG International: https://assets.kpmg/content/dam/kpmg/pdf/2016/04/creating-new-value-with-patients.pdf (PDF 1 MB)
- Murray, E., Hekler, E. B., Andersson, G., Collins, L. M., Doherty, A., Hollis, C., Rivera, D. E., West, R., & Wyatt, J. C. (2016). Evaluating Digital Health Interventions: Key Questions and Approaches. American journal of preventive medicine, 51(5), 843–851: https://doi.org/10.1016/j.amepre.2016.06.008
- Safavi, K., Mathews, S.C, Bates, David W., Dorsey, E.R. & Cohen, A.B. (2019). Top-funded digital health companies and their impact on high-burden, high-cost conditions. Health Affairs, 38(1).
- Forrester Consulting. (2019). Healthcare Providers Data Review. Internal KPMG report: unpublished.
- World Economic Forum. (2019). 4 ways data is improving healthcare. World Economic Forum website: https://www.weforum.org/agenda/2019/12/four-ways-data-is-improving-healthcare/
- Burrill, G., Parker, J., & Fitzgerald, E., (April 2019). Creating a culture of excellence: how healthcare leaders can build and sustain continuous improvement, KPMG International: https://assets.kpmg/content/dam/kpmg%20/xx/pdf/2019/03%20/creating-a-culture-of-continuous-improvement-kpmg-global-healthcare.pdf (PDF 1 MB)
- Rehm, J., Shield, K.D. (2019). Global Burden of Disease and the Impact of Mental and Addictive Disorders. Curr Psychiatry Rep 21(10): https://doi.org/10.1007/s11920-019-0997-0
- Organization for Economic Co-operation and Development (OECD). (2019). Mental health. OCED website: https://www.oecd.org/health/mental-health.htm
- National Institute of Mental Health. (September 2019). Technology and the future of mental health treatment. National Institute of Mental Health website. https://www.nimh.nih.gov/health/topics/ technology-and-the-future-of-mental-health-treatment/index.shtml
- Forrester Consulting. (2019). Healthcare Providers Data Review. Internal KPMG report: unpublished.
- Cometto, G et al. (2016). Health workforce needs, demand and shortages to 2030: an overview of forecasted trends in the global health labor market. World Health Organization website. https://www.who.int/hrh/com-heeg/Needs_demands_shortages.pdf (PDF 711 KB)