The Affordable Care Act, better known as “Obamacare”, begins enrollment next week. In this context, Bloomberg’s World Healthcare Efficiency Index, released last month, makes for interesting reading.  Among 48 countries worldwide, the US ranked 46th. The top four (Hong Kong, Singapore, Japan and Israel), emphasize the role of Government. Israel is unique in that digital healthcare, an area heavily incentivized by Obamacare, is a key factor. The eHealth suite example of Clalit, Israel’s largest HMO, is an interesting case for developed countries like the US, and is one of the digital health case studies to be featured at the upcoming mHealth Israel Conference.   




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Clalit Health Services is Israel’s largest HMO (4.2 million members), second in size globally to Kaiser Permanente. This includes 14 hospitals, 1400 clinics and 7,500 physicians. Five years ago, Clalit launched an e-Health suite that now has nearly two million monthly users. According to Dr. Yossi Bahagon, a family physician and e-Health, m-Health and Tele-Care expert, "Clalit''s e-Health activity has created a dramatic change both at the patient and national levels, with proven outcomes in clinical quality, efficiency, accessibility and financial aspects". He estimates an ROI for Clalit during this period of 415%.


While there is plenty of hype (and some good old fashioned chicanery) around mobile health applications, real change will come from system-wide deployments. In most countries, these efforts have failed to reach nation-scale. After some trial and error, Clalit has found success in Israel through what Dr. Bahagon describes as a five layer approach:



 



1.      Personal health Record Layer (what the patient SEES): Medical history, diagnoses, allergies, vaccinations, laboratory results, hospital discharge letters etc. All medical terms are accompanied by explanations with suggestions, called an information prescription (Ix). Each Ix is reviewed by 2 different experts and "translated" into layman''s language by a medical linguistic editor.



2.      Personal Knowledge Layer (what the patient KNOWS): Personally tailored preventive medicine and health recommendations, such as mammography and lipid profile screening recommendations, based on sex, age, medical history and previous medical tests. Recommendations are in textual, visual and interactive formats to increase patient engagement. Compliance of users exposed to this layer was 63% higher than for patients informed by traditional means.



3.      Personal Health Services Layer (what the patient DOES): Patients carry out their own administrative and clinical self-service, giving patients the ability to refill chronic prescriptions, get medication and refill reminders. Preliminary studies have shown that using mobile medication reminders improves adherence rates by 80-85%. Patients can e-consult a physician or other medical professional either via 1-on-1 asynchronous platform or for pediatrics, by means of real-time video conference. Currently more than 8,000 synchronous e-Visits are done per month, from more than 900 locations, reducing unnecessary ER visits by 47%.



4.      Remote Patient Monitoring Layer (personal metrics the patient MONITORS). This layer takes a proactive approach to health promotion and chronic disease management. Sensor infrastructure, paired with mobile apps and wearable bio-sensors, allow remote physical examination, monitoring and broadcasting of various physiological measurements such as physical activity, food intake and sleep patterns.



5.      Hybrid Layer (Integrating offline and on-line care). The Hybrid layer brings more medical services to patients in their homes. Some examples:



a.      Wireless, vital-sign sensors, transmitting patient data for professional interpretation



b.      Home-lab offering comprehensive lab services (such as blood & urine) at the patient''s home



c.      Interactive digital pillbox, addressing the issue of non-adherence



At Clalit, applying this Hybrid-Health holistic approach yielded a reduction of more than 15,000 hospitalizations days per year (YOY) in a population of 74,000 patients aged 65-85 years old. The direct financial ROI for this layer was around 350%.



The United States has colossal challenges facing its healthcare system. Obamacare provides explicit incentives for health providers to offer eHealth services. Israel’s experience in digital healthcare can be a valuable reference. 


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