Developing a cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insi

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Developing a cost model to provide insight

into the economic value of

computer-based patient education for Dutch

endoscopy units

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Developing a cost model to provide insight

into the economic value of

computer-based patient education for Dutch

endoscopy units

Master thesis Medical Informatics

Student Eva Surquin 10187596 e.surquin@amc.uva.nl Mentor Peter Krol

Digital health care strategist Medify BV

Peter.krol@medify.eu

Supervisor Tom Broens Assistant professor

Academic Medical Centre, Dept. of Medical Informatics

t.h.broens@amc.uva.nl SRP location Medify BV Raamplein 1 1016 XK Amsterdam info@medify.eu Period March 2016 – June 2017

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Preface and acknowledgements

This thesis is the final assignment of the Master program Medical Informatics (MI) of the University of Amsterdam, located in the Academic Medical Centre (AMC). The study was conducted at Medify BV., a company specialized in eHealth interventions in the area of computer-based patient education, and supervised by the department of Medical Informatics (KIK) of the AMC. The KIK aims to study, develop and apply methods native to informatics and information sciences in order to better understand and to improve health care and also hosts the MI program.

I wish to express my gratitude to everyone who has helped and supported me throughout the Medical Informatics program and my thesis, starting with my mentor Peter Krol and my supervisor Tom Broens. Both of you have a lot of experience and knowledge in the field and I am really happy that you were willing to share this with me. I am very grateful both of you took a lot of time to bring this thesis to a correct end. If it wasn’t without your feedback, this thesis would not have been at this level. Peter, thank you for your guidance through the complex but amazing area of digital patient counselling, thank you for sharing your vision, your feedback and support. Especially in the last week, you really dragged me through! Tom, thank you for the weekly feedback moments which helped me a lot in the scientific area and for your optimism and enthusiasm which provided me a lot of mental support. Also, thanks for arranging meetings with other persons that helped me to complete this thesis.

There are a number of people who have helped me with valuable input for this thesis. A very special thanks goes to Marieke Sijm for reviewing my model and helping me with structuring my research questions. Moreover, thanks a lot to the managers of the hospitals and eHealth company included in this thesis and Nina Eminovic from the KIK. Thanks to Govert Veldhuijzen for providing a base for this study with the ePACO trial and for the brainstorm sessions, I wish you the best upon completing your PhD.

I want to thank Peter Krol and René Louis for providing me the opportunity to perform my SRP at Medify, while at the same time gaining practical skills in the field.

I would like to thank my niece and best friend Marloes for the endless amount of support and motivation. Furthermore my roomie and ex-roomie Nathalie and Aiah, my MI-friends Charlotte, Esmée, Margie and Liesbeth, my colleagues at Medify and INDG and my sister Laura. You were always a listening ear for me and provided me a great deal of support.

Most important, I’d like to thank my parents, without you I could not have been the person I am today. Thank you for always believing in me and having my back. Thank you for the support throughout my life, this thesis and not to forget the financial support for my studies. Mama, thank you for the sweet cards you sent me over the last period for my studies and thank you for helping me out even when I was initially unwilling to accept it, eventually it gave me a lot of peace ☺.

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Samenvatting

Achtergrond Aandacht voor het kostenaspect van zorg is relatief nieuw. Het uitgangspunt is lange tijd kwaliteit van zorg geweest, ongeacht de kosten. Door de vergrijzing en toename van technologische ontwikkelingen zoals eHealth, is de focus langzamerhand ook verschoven naar het kostenaspect van de zorg voor de patiënt. De kosten moeten immers beheersbaar blijven. Dit brengt verandering in werkproces met zich mee. Zo ook op het gebied van patiëntenvoorlichting, een aspect van het zorgpad wat door zorginstellingen gezien wordt als een tijdrovend en

inefficiënt. Vandaar dat de oplossing in de richting van digitale voorlichting wordt gezocht. Een voorbeeld toepassing van digitale voorlichting is de Medical Experience (MEX). Eerder

marktonderzoek heeft uitgewezen dat middels de MEX er van (een deel van) de populatie het face-to-face voorlichtingsconsult te elimineren valt, en hiermee dus tijd en daarmee kosten bespaard kunnen worden. Voor de onderbouwing van kostenbesparing, wat bijdraagt aan de beslissing voor het investeren in een eHealth oplossing, wordt een business case gemaakt, waarin deze besparingen zijn opgenomen. Het gestandaardiseerde zorgproces en het hoge productie aantal van de voorlichting op de endoscopie afdeling is uitermate geschikt voor digitale

voorlichting. Echter blijkt in de praktijk dat bij ongeveer een kwart van de implementatietrajecten er vragen komen over de realisatie van de kosten-en tijdsbesparingen die in de business case opgesteld zijn. Omdat de realisatie van de business case niet gemonitord wordt, is de

daadwerkelijke kosteninformatie niet beschikbaar in deze trajecten.

Doel Het doel van dit onderzoek is om een kostenmodel te ontwikkelen dat alle componenten betrokken bij het zorgproces bevat. Hiermee kunnen kosten en baten van digitale

patiëntvoorlichting interventies gemonitord worden om zo het ziekenhuismanagement inzicht in kosten en besparingen te geven. We verwachten dat met de inzichten over kosten (efficiëntie) de twijfels over de realisatie van de business case verminderd kunnen worden .

Methoden Voor het ontwikkelen van het model is gebruik gemaakt van verschillende methoden: na het in kaart brengen van de componenten van de huidige business case en processtappen, zijn de componenten van het kostmodel geïdentificeerd en gevalideerd. Hiervoor is literatuur gebruikt en zijn interviews gehouden. Daarna zijn de invoer- en uitkomst variabelen in het daadwerkelijke model gemaakt en gevalideerd. Excel en Microsoft VBA zijn hiervoor gebruikt en wederom zijn er interviews gehouden

Resultaten Invoer variabelen die nodig zijn voor het model zijn gecategoriseerd als

salarisschalen, productie aantallen, processtappen en zorgverleners en tijd die gespendeerd wordt aan deze processtappen. Daarnaast zijn overige kosten zoals No Show opgenomen in het model. Gebaseerd op de invoer zijn kritische proces indicatoren (KPI’s) voor conversie, kostbesparingen en tijdbestedingen gemaakt, wat resulteert in snelle, visuele representaties voor zorgmanagers. Het model kon eenvoudig worden aangepast voor digitale voorlichting voor andere onderzoeken binnen en buiten de endoscopie afdeling. Meer aanpassingen moeten gedaan worden aan het model om voor andere eHealth toepassingen gericht op de thuissituatie geschikt te zijn.

Conclusie Het kostmodel geeft het management inzicht in kosten en besparingen van de inzet van digitale patiëntvoorlichting, iets wat tot op heden nog ontbreekt. Het model moet echter wel geoptimaliseerd worden om accuratesse te verhogen. Dit kan in samenspraak met het

management worden gedaan.

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Abstract

Background Attention to the cost aspect of health care is relatively new. Health care has been based on quality of care for a long time, irrespectively of costs. Because of the aging of the population and increase of technological inventions such as eHealth, the focus has slowly shifted to the cost aspect of patient care. After all, costs need to be manageable. This entails a change in work process. Likewise, in the field of patient education. Patient education is an aspect of the care path which is by many healthcare institutions viewed upon as time-consuming and

inefficient. Therefore, the solution has been searched in the direction of computer-based patient education (CBE). An example of an eHealth service in the field of CBE is the Medical

Experience (MEX). Previous market research has shown that the MEX can eliminate (a part of) face-to-face education consultations, thus has potential to save costs. Endoscopy units and their routine pre-colonoscopy processes that have high production numbers are suitable for CBE implementation. However, in practice it turns out that in about a quarter of implementation processes, questions arise about the realization of cost- and time savings that are drafted in the business case. Because the realization of the business case is not monitored, the actual cost information is not available.

Objective This thesis aims to develop a cost model for CBE interventions with all components of the work process involved, to provide insight in costs and savings for hospital management. With these insights, the questions about the realization of the business case should be decreased. Methods For the development of the model, mixed-methods are used. After business case and process flow review of a CBE intervention implemented in an endoscopy unit, components of the cost model were identified and validated. Literature was studied and interviews were held in this phase. After this, the in- and output variables in the actual model were constructed and validated. Excel and Microsoft VBA were used for construction and interviews were held for validation.

Results Input variables required by the model are categorized as salaries, production numbers, process steps and actors and time spent on process steps. Next to this, other monthly costs such as No Show are incorporated in the model. Based on input, key performance indicators (KPIs) for conversion, cost savings and time spent are established, resulting the management to have quick, visual representations of their results. The model could be easily adapted to fit other CBE interventions, more adaptions should be made before the model fits other eHealth services focusing on home-based patient populations.

Conclusion The cost model provides the management with insight in costs and savings of the process integration of a CBE intervention, something that was not available until now. The model however needs to be further optimized. This can be realized together with the managers of departments.

Keywords: computer-based patient education, computer-assisted information, economics, colonoscopy

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Chapter 1 – General introduction and background information

Attention to the cost aspect of health care is relatively new. Health care has been based on quality of care for a long time, irrespectively of costs. Because of the aging of the population and

increase of technological inventions such as eHealth, the focus has slowly shifted to the cost aspect of patient care. After all, costs need to be manageable. Therefore, insight in cost efficiency of eHealth solutions plays an important role in facilitating investment and monitor the

operationalization of these solutions. This also applies to the field of patient education. This research, based on a multicenter case study of computer-based patient education interventions (a type of eHealth solution), offers insights in:

• How a business case for computer-based patient education interventions for Dutch endoscopy units can be established and realized on operational level

• How a cost model for Dutch endoscopy units can be developed and implemented to provide insight into the economic value of computer-based patient education for Dutch endoscopy units

This chapter continues with background information and motivation, followed by aims and research questions of this patient education interventions study.

1.1 Patient education

Patient education is required by the law upfront each examination or intervention. A health care provider has to explain the content of the procedure, its risks, complications, alternatives and prospects after the procedure. Only then, the patient can give informed consent, which is required by the Dutch medical treatment act (WGBO). These patient education tasks are routine tasks that are time-consuming at the health care provider side. Previous research in the US among 350 general practitioners (GPs) indicated that nearly 50% stated that they do no not have enough time for patient education [1].

1.2 Case domain: Computer-based education (CBE)

A solution that has the potential to make obligated routine tasks more cost-effective while simultaneously increasing quality of care, is computer-based education (CBE). CBE is a form of eHealth that educates patients in an interactive way by using multimedia [2]. For health care providers, CBE has the potential for process optimization, resulting in cost reduction. Routine information that is traditionally provided by health care providers can be replaced by a computer program, thus saving care providers’ time. Moreover, CBE has the possibility to include digital questionnaires for the patient to fill in, such as medical condition and informed consent [3]. Reimbursement to the hospital for patient education is part of the Diagnosis Treatment Combination (Diagnose Behandel Combinatie, DBC). For CBE, hospitals receive the same reimbursement as for conventional patient education. Thus, CBE has the potential to be cost saving - as time is saved at the care providers’ side - while receiving the same reimbursement.

1.2.1 State of art of CBE literature

From 1999, four systematic reviews have been performed in the field of CBE [2,4-6]. These reviews mainly focus on clinical outcomes, knowledge, anxiety and satisfaction of patients. All of

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9 the CBE interventions studied in these reviews, had positive or equal outcomes in comparison to conventional patient education. Only in 2005, a review was held by Wofford et al. [6] in which the economic effects of CBE were measured in 20% of the included articles. In the latest review by Fox in 2008 [2], economic effects were mentioned in 40% of the reviewed articles. This indicates an increased awareness of, and focus on, the economic benefits of CBE. However, the results of these economic benefits are in most studies very preliminary. The time- and cost savings to be obtained by CBE are either hypothetical [7-9] or only briefly stated time savings [10]. In two of the articles included in the review by Fox, the economic benefits of CBE were examined extensively. One of these articles found that CBE was more time consuming than conventional consultations, because of additional administrative tasks such as explaining the CBE program. Therefore, this study concluded that CBE was more expensive than conventional patient education [11]. The other article concluded no difference in costs between CBE and conventional patient education [12]. Table 1.1 provides an overview of the design and setting of the studies that examined the economic benefits of CBE.

TABLE 1.1COMPARISON OF STUDIES THAT EXAMINED ECONOMIC BENEFITS IN METHODS AND CONCLUSION

Article Subject Design Setting Conclusion

Green et al. [10] Genetic testing for breast cancer susceptibility Randomized clinical trial, where the CBE program served as

intervention and the CBE program combined with a counseling session as control. Outpatient clinic From several measured patient outcomes it appeared that the CBE program had the potential to serve as standalone, and therefore would save one counseling session (duration

unknown) of a genetic counselor or advanced practice nurse per patient. Martin et al. [11] Colposcopy examination Prospective randomized study, where the CBE program was compared to education by a nurse practitioner. Outpatient clinic CBE took on average 20 minutes longer than the nurse practitioner’s consultation.

Jones et al. [12] Schizophrenia Randomized clinical trial, where (1) a CBE program, A National Health Service (NHS) facility In all three interventions no significant

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10 (2) sessions with a community psychiatric nurse and (3) a combination of (1) and (2) were compared. difference in costs was measured. However, if patients would not have to be

transported to the computer, and the CBE program could be combined with other hospital visits, (1) would have been substantially cheaper.

The lack of the expected time savings of CBE, may have been due to the settings in which these studies were conducted. When patients need to come into the hospital for CBE, health care providers are still required to spend time to set up computers and explain the program to patients. Moreover, in two out of three studies a nurse still filled in informed consent forms, which is something that can be done by the patient him or herself. The solution to time savings at health care provider side can potentially be found in computer-based education in the home setting of the patient.

1.2.2 The Medical Experience (MEX)

The CBE case study that is addressed in this thesis is the Medical Experience (MEX), which is a product of Medify BV. The MEX colonoscopy implements computer-based education in the home setting of patients, through a web-based application. The content of the MEX is based on the information provided in conventional paper flyers. The MEX provides step-wise information captured in 3D visualizations, videos, voice-overs and textual elements (Figure 1.1).

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11 FIGURE 1.1–SCREENSHOTS OF ONE OF THE MEX COLONOSCOPY APPLICATIONS

The MEX as a service aims to maximize health care quality while reducing health care costs, according to the Value Based Health Care principle. From a process optimization perspective, visual and interactive CBE is implemented in hospitals’ current work process to improve the information need of both patients and providers. Quality is thus realized through (1) a 3D visualized core, in which the examination or intervention is explained in 3D visualizations to the patient and (2) communication software. The MEX tracks how many and which patients

completed the education within the application (Figure 1.2, left).

FIGURE 1.2–DASHBOARD FOR MONITORING PATIENTS AND QUESTIONNAIRE TRIAGE Hospitals can use this evidence to demonstrate to quality accreditations instances such as the Joint Commission International (JCI) [13] and Dutch Institute Accreditation Healthcare (NIAZ) [14] that patients are educated according to the required components of the WGBO.

Cost reduction for the MEX is demonstrated through a business case. The business plays an important role on decision making as well as on operational level. On decision making level, it is one of the main aspects for decision makers to base an investment decision on [15]. To realize the business case on operational level, the MEX should be implemented and integrated within the existing health care process, so that health care providers’ time can be eliminated or reduced. These eliminations and reductions are realized by questionnaire triage. The patient’s medical condition will be determined based on the answers of a questionnaire implemented in the MEX. Based on the patient’s medical condition, consultations can either be eliminated (green) or reduced in time (orange) (Figure 1.2, right). This elimination is accepted by the NZA [16] and NVMDL [17].

1.2.2.1. The e-Patient Counseling (ePACO) trial

Another study that specifically addresses the MEX is the e-Patient Counseling (ePACO) trial [18]. This is a multicenter randomized clinical trial that studies the impact of electronic patient

counselling on preparation for the examination, anxiety, knowledge, satisfaction and costs from a societal perspective. As the ePACO trial focuses on health care quality aspects of CBE, the study presented in this paper focuses on reducing health care costs from the health care provider’s perspective.

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1.2.3 CBE as a service in Dutch endoscopy units

CBE can be applied on all areas in health care, because every examination or treatment requires patient information by the Dutch law. The health care area in the Netherlands where the MEX is most successful so far is at endoscopy units.

An endoscopy unit is the production unit of the gastroenterology department. In the

Netherlands, an endoscopy unit is located inside each Dutch hospital and next to this there are five outpatient clinic practices (ZBN) that perform colonoscopies. That means that there are 82 endoscopy units in the Netherlands [19]. In these units, a range of examinations and

interventions on the gastro-intestinal tract take place. The most frequent performed examination is a colonoscopy, which is performed around 200,000 times a year in the Netherlands [20]. A colonoscopy is an internal examination of the colon and optionally parts of the large intestines. The examination is performed with an endoscope. This is a flexible tube with a camera at its end [21]. With the camera, the endoscopist can locate potential abnormalities where diagnoses such as Colorectal cancer (CRC) [22] and Inflammatory Bowel Disease (IBD) [23] can be based on and possibly perform minor interventions, such as the removal of polyps (abnormal tissue growth) [24] and collecting tissue for further investigation.

Patients can be referred for a colonoscopy either through a health care provider (when experiencing complaints) or through the Dutch screening program colorectal cancer (when further examination is advised). Table 1.2 summarizes the possible scenarios for colonoscopy referrals.

TABLE 1.2COLONOSCOPY REFERRAL SCENARIOS

(1) Patients experiencing abdominal complaints, such as long episodes of bowel ache, blood or slime loss with their defecation. The GP then refers patients for a colonoscopy.

(2) Patients experiencing abdominal complaints, such as long episodes of bowel ache, blood or slime loss with their defecation. When the GP thinks a second opinion is necessary, patients will be referred to a gastroenterologist. The gastroenterologist eventually decides whether the colonoscopy needs to take place.

(3) Patients that are already under treatment for a condition (gastroenterology related or not) and get complaints or symptoms based on which their specialist decides to perform a colonoscopy. (4) Patients that had a colonoscopy in the past, and were scheduled for a control examination every 1, 2 or 5 years based on the results.

(5) Patients that had a positive result in the first phase of the screening program rectal cancer and decide to undergo a colonoscopy based on this result.

CBE can be a suitable option for endoscopy units, as each patient that needs to undergo an examination or intervention gets an appointment for an education consultation. This is largely a routine process of providing the patient with information about the upcoming research, and obtaining information about the patient’s medical health. During the researcher’s work period at Medify, the following conventional process steps were identified in each hospital:

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13 (1) A patient is referred from (1) a GP, (2 and 3) a physician or a gastroenterologist and the

referral is assessed for scheduling term by the gastroenterologist.

(2) A patient is referred by the Dutch screening program (4), where the hospital has specific places for to schedule. If based on (1), (2), (3), (4), there are places left in the schedule, the hospital will try to fill these spots with patients on the waiting list for a control examination.

(3) The backoffice then schedules the traditional education consultation and colonoscopy. (4) During the conventional education consultation, the patient is educated and fills in

medical condition and informed consent forms. Resulting actions, for example a temporary modification in the medication of the patient around the examination, are executed.

(5) The patient prepares his or her bowels. (6) The examination takes place.

The steps indicated above are displayed in a process flow in Figure 1.3.

FIGURE 1.3–CONVENTIONAL PRE-COLONOSCOPY PROCESS OBSERVED IN 16 HOSPITALS The pre-endoscopy consultation was established because of the two-way need by the patient to receive information of the upcoming examination, and the need from provider side to establish the medical condition of the patient to identify risk factors and safely administer the sedative that is used during most endoscopy examinations. Table 1.3 displays an overview of the aspects of the pre-colonoscopy process, required by the WGBO.

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14 TABLE 1.3–ELEMENTS OF THE PRE-ENDOSCOPY PROCESS EXPLAINED

Aspect Explanation

(1) Education Explaining the patient the purpose and content of the examination, its risks, possible

complications, alternatives and future perspective.

(2) Anamnesis Establishing the patient’s medical condition because of the sedation that will be

administered during the examination. (3) Informed consent Based on (1), the patient has to agree with

undergoing the examination. The informed consent is currently registered by a care provider in the EHR.

The routine tasks and the large production number divided over locations spread all over the Netherlands, meaning that it is an applicable solution within the Netherlands. Moreover, the production number of colonoscopies is even growing because of the screening program colorectal cancer. The National Institute for Public Health (RIVM) introduced this national screening program for early detection of bowel cancer to reduce the high mortality rate [25] and improve treatment options. Hospitals have a number of motivations to participate in the screening program rectal cancer. First of all, it contributes to the quality of care. With the

screening program, colorectal cancer or precancerous stadia can be detected early on. The patient will have more treatment options that are less invasive, thus quality of life is improved. Apart from this, early diagnosis also means reduced treatment costs for the institution. Also, from production side, the screening program is attractive for hospitals: the DBC for a screening program colonoscopy is between 600 to 1200 euros, while for a regular colonoscopy this is 200 to 400 euros [26].

Concluding, the large production number of endoscopy units, the visible savings by eliminating or reducing consultations for the same reimbursement or even higher reimbursement from the screening program, make endoscopy units and their processes a suitable health care area for implementation of CBE such as the MEX.

The facts and figures of this section of colonoscopy relevant in this thesis are presented in Table 1.4.

TABLE 1.4-FACTS AND FIGURES OF ENDOSCOPY UNITS AND COLONOSCOPY IN THE NETHERLANDS

Number of colonoscopy procedures 200,000 [20]

Number of endoscopy units 82 (77 hospitals and five ZBN that perform a colonoscopy)

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15 obstipation, long episodes of bowel

complaints, weight loss, positive test result phase 1 screening program.

Possible diagnoses based on a colonoscopy - Inflammatory Bowel disease (IBD) – incidence 2,500 and prevalence 82,000 [23]

- Colo-rectal cancer (CRC) – incidence 15,427, prevalence 103,000 and mortality 5000 [27]

- A precancerous form of CRC. Possible interventions during a colonoscopy Polypectomy and collecting tissue Number of additional colonoscopies after full

implementation screening program bowel cancer

72,000 [25]

1.3 Problem analysis

Resulting from the previous sections, the problem identified that will be addressed in this thesis is the lack of insight in costs and benefits, and the lack of evidence of economic effectiveness of CBE interventions. In the following paragraph, we elaborate on these problems in relation to this research.

1.3.1 The lack of insight in costs and the lack of economic benefits of CBE

From the latest systematic review on CBE from Fox in 2008 [2] can be concluded that there is a lack of information about CBE interventions that are actually integrated in the health care process. Most interventions are an alternative to current education methods, for example placing information on the hospital website [2]. Moreover, from the state of art of CBE literature can be concluded that the results of the few articles that discuss cost information are ambiguous on the economic benefits of CBE: some of them indicate it saves costs while others claim that it is more expensive. Apart from theoretical perspective, the need of cost information for eHealth

interventions in Dutch health care is also present in practice: two often observed bottlenecks before and after eHealth implementation are (1) absence of a solid business case or added value of the eHealth intervention, and (2) the real substitution of existing health care is not managed, because of incorrect or incomplete implementation, resulting in increased costs instead of decreased costs [28].

For the MEX colonoscopy, the current business case that is provided in an early stage of contact provides an overview in expected cost savings (for example see Section 2.3.1). If the MEX colonoscopy is implemented in the process correctly, the process should become more efficient. However, during the researcher’s work period at Medify BV. it was observed that after

implementation, in four out of sixteen hospitals a number of questions arises about whether these cost savings are actually feasible and how the process should be modified in order to obtain these savings. This problem could not be immediately solved, because it has not been monitored in any of the sixteen hospitals whether the targets of the business case were obtained.

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16 1.4 Objective and research questions

To obtain insight in potential time- and cost savings of the MEX colonoscopy, first the elements of costs should be determined. The costs can then be presented through a cost model. The main goal of the study is therefore to develop a cost model for predicting costs and benefits, based on the MEX colonoscopy.

In order to reach this goal, we strived to answer the following research question and sub questions:

How can a cost model for patient education for endoscopy units in Dutch hospitals be constructed and what value does it add?

1. How is the current business case for endoscopy units in Dutch hospitals constructed on decision making level and realized on operational level of endoscopy units in Dutch hospitals?

2. What are the differences in education processes before and after implementation of the MEX colonoscopy?

3. Which factors determine costs and benefits of the MEX colonoscopy for a hospital? 4. How can the cost model be implemented and presented to the hospital management? 5. What is the applicability of the cost model for the MEX colonoscopy on other eHealth

solutions?

1.5 Scope

This thesis focuses on process optimization with the use of cost indicators and monitoring these cost indicators of a CBE intervention implemented in pre-colonoscopy processes of endoscopy units in the Netherlands.

Because of the ePACO trial, clinical and other patient outcome measurements are outside the scope of this study. The majority of patients that will undergo a colonoscopy is referred via the GP, physician or screening program to the outpatient setting, as also patients from the inpatient clinic sometimes need a colonoscopy. This thesis only focuses on the outpatient group, because patients from the inpatient clinic are already in the hospital. This means that the time- and cost savings will be of less significance, because there is no possibility for CBE in the home setting. It is however possible to educate inpatient clinic patients with for example an iPad, but this process is not as much rolled out yet as the outpatient clinic process.

During this project, IT governance decision making was also studied to gain insight in decision making for investment in eHealth solutions. An important result from the eHealth monitor in the Netherlands [29], is that policy makers are reluctant towards efficiency gains and cost savings. They call for more insight in mechanisms where eHealth can really lead to cost savings. Conditions during implementation to make an eHealth solution successful that are mentioned are: clear targets, a good business case, attention for support and change management and attention to technical and organizational conditions. This stakeholder and business model oriented vision is supported in several other articles [30, 31]. Because of the importance of a good business case, efficiency gains and cost savings, the effect of these components on decision

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17 making for investment in the MEX colonoscopy was strived to be studied. Unfortunately, these results did eventually not fit in this overall study. As this research does provide valuable insights in the decision making of eHealth investment in Dutch hospitals, this part of the study is enclosed in Appendix A.

1.6 Outline

The remainder of this thesis is organized in the following manner:

• In Chapter 2, the components and realization of the business case and the process before and after implementation of the MEX colonoscopy will be analyzed.

• In Chapter 3, the construction and validation of a cost model for patient education for endoscopy units in Dutch hospitals will be presented, its features and generalizability will be discussed.

• In Chapter 4, the overall main findings will be discussed and recommendations for future work will be provided.

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Chapter 2 – The business case in practice and the role of costs on

operational and governance level in endoscopy units

2.1 Introduction

To identify the root cause of the questions that arise about the economic benefits of the MEX colonoscopy, more insight in the delivered business case and the actual use in practice of the targets set in the business case should be obtained. Although the doubts on efficiency arise on operational level, the business case already starts playing a role on decision making level. A relevant result from the eHealth monitor in the Netherlands [29], is that policy makers are reluctant regarding efficiency gains and cost savings. They call for more insight in mechanisms where eHealth can really lead to cost savings. A solid base for cost reduction that will be realized after implementation, needs to be clear to the decision makers [31].

This chapter presents a case of one hospital that aims to identify the gap between the business case and practice, by reviewing the business case and its actual use on operational level. Furthermore, the processes before and after implementation of the MEX will be discussed.

2.2 Methods

Of one of the hospitals that indicated to have problems with their work process after

implementing the MEX, the business case and actual use in practice were reviewed. This was realized by:

(1) analyzing the components and outcomes of the business case.

(2) comparing the process flow before implementation of the MEX colonoscopy to the process after implementation of the MEX colonoscopy.

2.3 Results

The hospital that was used as a case study for business case and process flow review was a top clinical hospital that executes 3,500 colonoscopies per year.

2.3.1. The business case

The review of the business case for the hospital resulted in identification of the following aspects:

Input (based on Figure 2.1)

- The salary of a nurse, based on workweeks a year and workhours per week - The number of procedures

- The current time a physician or nurse is spending on education and anamnesis during a consultation

- The time savings per consultation

- Expected number to be eliminated during consultation - Expected number of short consultation

- Traditional consultation - Initial & license costs

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19 FIGURE 2.1– FILLED INPUT VALUES BUSINESS CASE FOR THE HOSPITAL

Outcome (based on Figure 2.2) - Time savings per year in hours - Time savings in FTE

- Savings in euros

- Time of Return on Investment (ROI)

FIGURE 2.2– FILLED OUTPUT VALUES BUSINESS CASE FOR THE HOSPITAL

Values Specific hospital

values to fill in

Work hours of an endoscopy nurse per

week 36

Work weeks of an endoscopy nurse per

year 45

Salary € 45.500

Number of colonoscopies per year 3500

Intial costs € 10.000

License costs € 2.340

Number of gastroenterologists 5

Numer of license years 3

PROCESS TABLE Conventional education CBE (MEX)

Component of education Explanation per component Minutes per component Minutes per component Establishment of the differences in time spent on components

Component 1 Indication 5 5 Remains

Component 2

Medical condition, anamnesis

15 10

A part is elimininated by the patient filling in the information in the home-based situation

Component 3 Education 10 0 Eliminated

Total educational time 30 15

Timesavings per intake 15

Timesavings

Procedure Number per year Timesavings per patient Timesavings per year in hours Timesavings in FTE Costsavings in euros Colonoscopy 3500 15 875 0,54 € 24.576

Savings based on full license period

Requested total investment

Number of license years

Savings based on five years license

Return on investment time in years

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20 The business case displayed in Figure 2.1 and 2.2 indicated (highlighted in Figure 2.2) that there were:

- 875 hours of expected time savings, which is 0,54 FTE. - Expected cost savings of 24.576 euros.

2.3.2 The conventional pre-colonoscopy process

The conventional process of the hospital used for this case was similar to the process displayed in Figure 1.3. The patient was approached for the appointments of the consultation and

examination by mail. The duration of the nurse education (step 3) was 45 minutes. The information on the medical condition of the patient was sometimes pre-filled by the patient at home on paper. The questionnaires had to be typed in the EHR manually. When necessary, the nurse could discuss aspects of the patient’s medical condition with a resident gastroenterology, who was supervising the pre-endoscopy process. Patients were provided with information flyers to take home at the end of the consultation. Figure 2.4 displays the described process in the hospital used for this case.

FIGURE 2.4CONVENTIONAL PRE-COLONOSCOPY PROCESS IN THE CASE HOSPITAL

2.3.3 Pre-colonoscopy process after implementation of the MEX Colonoscopy

The MEX colonoscopy is offered to patients referred by the GP or that or on the waiting list (1) through their email. Gastroenterologists still assess the referral. Some patients’ e-mail addresses are known EHR. When this is not the case, the e-mail address should be obtained through a phone call (3,4). Each patient then receives a unique link (5), because at the end of the

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21 application, patients have to fill in a questionnaire about their medical condition and give their informed consent for the examination (7). Based on triage of the answers of the patient (8), the hospital decides to either schedule the patient immediately for the colonoscopy, or schedule and invite the patient for a short additional intake in the hospital (9). To obtain a constant

throughput, patients are asked to fill in the questionnaire within a certain time frame (e.g., three days). The hospital has a tool to monitor the status of a patient within the application, thus when the questionnaire is not returned within the requested term, they can call the patient to remind or help (6). The patients still prepare their bowels prior to the examination (11). The patients that do not have an email address available are going through the conventional process. The process and technical architecture of the MEX colonoscopy are displayed in Figure 2.5 and 2.6

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22 FIGURE 2.5–PROCESS FLOW OF THE PRE-COLONOSCOPY PROCESS IN THE CASE

HOSPITAL AFTER IMPLEMENTATION OF THE MEX COLONOSCOPY

The process steps are now as follows:

(1) A patient is referred from (1) a GP, (2 and 3) a physician or a gastroenterologist and the referral is assessed for scheduling term by the gastroenterologist.

(2) A patient is referred by the Dutch screening program (4), where the hospital has specific places for to schedule. If based on (1), (2), (3), (4), there are places left in the schedule, the hospital will try to fill these spots with patients on the waiting list for a control examination.

(3) The backoffice calls the patient to inform about the CBE module. (4) The backoffice checks if the patient has an email address available.

(5) If the answer to (4) is yes, the backoffice creates a link for the patient. If the answer to (4) is no, the backoffice schedules a traditional education consultation and the

colonoscopy.

(6) The hospital monitors the progress of the patient that has CBE in the Medify dashboard.

(7) The patient walks through the CBE module at home, or has a traditional intake with a nurse at the hospital.

(8) The answers of the patients that have had CBE at home are coming back to the hospital. The backoffice sees if there is need for action (red or orange questionnaire) or that the patient can be directly scheduled for the examination.

(9) The colonoscopy is scheduled (green) or the colonoscopy is scheduled together with an additional consultation (orange or red questionnaire).

(10) The additional consultation takes place. (11) The patient prepares his or her bowels. (12) The examination takes place.

FIGURE 2.6TECHNICAL ARCHITECTURE OF THE POST-IMPLEMENTATION PRE -COLONOSCOPY PROCESS

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23 The technical architecture of the MEX is as follows: the patient is invited by a back office

employee via a dashboard. Through this dashboard, they can also monitor the progress of the patient within the MEX. The unique link reaches the patient through his or her email address. The unique link leads to the MEX colonoscopy, where the patient answers the questionnaire. The answers are generated in a PDF file which can be uploaded using the multimedia function. From Figure 2.5 and 2.6 can be derived that:

(1) There are five additional tasks at backoffice side, which are (1) Calling the patient to inform about the CBE module. (2) Checking if the patient has an email address available. (3) Creating a link for the patient.

(4) Progress monitoring in the Medify dashboard. (5) Questionnaire triage

(2) There are two new computer systems involved in the process.

Medify’s business case aims to include all referral scenarios so that (1) the hospital has one standardized work process and (2) obtains maximized savings.

Based on the review of the process, it turned out that this hospital only included scenario 1 and 4 in the CBE process, which results in the following outcomes if we re-fill the current business case:

FIGURE 2.7ADJUSTED BUSINESS CASE

- 613 hours of time savings, which is 0,38 FTE. - It would save the hospital 17.203 euros.

During the researchers work period at Medify it was found that the reason the hospital only included scenario 1 and 4, was because according to them it was inefficient to include patients referred by a specialist (scenario 2 and 3), because the specialist already asks the patient about his or her health during the anamnesis. These questions partially overlap with the questionnaire included in the CBE. Moreover, the screening program currently does not allow eliminating face-to-face contact with patients. This is preventing hospitals to guide screening program patients through the CBE process.

2.4 Conclusion

The conclusion of this chapter is as follows: Timesavings

Savings based on full license period Requested total

investment

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24 - The business case of the MEX for the hospital studied as a case did not include

administrative tasks resulting from the post-implementation processes, such as the lack of EHR integration, which generates more administrative tasks.

- Based on the review of the process, it turned out that the hospital only included GP referrals and waiting list patients in the CBE process. Therefore, they were unable to determine how much they actually benefit or lose in terms of FTEs and costs. From the preliminary calculations in this chapter, we found that they can save up to 0.38 FTEs and 17,203 euros at maximum. This is 0.16 FTEs and 7,373 euros less than originally

estimated.

Deriving from the comparison of the conventional pre-colonoscopy process (Figure 2.4) and the MEX colonoscopy pre-colonoscopy process (Figure 2.5) we hypothesize that the moderation and extension of the work processes, the shifting of tasks between staff members and the use of additional computer systems causes questions at the department about the feasibility of the cost savings. To confirm this hypothesis, more insight into the pre-colonoscopy process and its costs is required.

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25

Chapter 3 – The cost model

3.1 Introduction

As can be derived from the previous chapter of this thesis, the pre-colonoscopy process after implementing CBE becomes more complex for care providers because (1) there are tasks added and (2) there is a task shifting from education time to administrative time. Hence, it is

hypothesized there is a need for management to obtain insight in the end-to-end cost impact of implementing CBE interventions such as the MEX colonoscopy. A way of helping managers with substituting existing health care, while at the same time monitoring their costs, is through the use of key performance indicators (KPIs). KPIs are specific and measurable elements, in health care often used for quality and safety reporting and monitoring [32], such as number of complications after treatment or incidents. KPIs can also be used for financial monitoring and reporting [32], think of mean costs per treatment and net income per employee [33]. The construction of a cost related KPI measurement and monitoring tool can be achieved by developing a cost model that exists of mathematical equations of components and the relation among these components. In this chapter we develop a cost model to predict the costs and benefits of the MEX colonoscopy. Furthermore, we develop a tool for hospital management with an overview of results that are obtained after implementation of the MEX colonoscopy.

This chapter aims to determine the cost and benefit factors for the MEX colonoscopy,

implement these costs and benefits in a model and make this model presentable to the hospital management. Moreover, we strived to test the generalizability of this model. This chapter is structured as follows: first, aspects that could play a role in the cost model for CBE are presented, then the construction of the model and its validation are discussed. Finally, the generalizability of the model will be discussed.

3.2 Methods

Mixed methods were used to construct and validate the cost model. Overall, the construction of the model can be divided in three main phases:

(1) the identification and validation of the input variables.

(2) the construction and validation of the in- and output variables in the actual model and (3) the adjustment of the model to test its generalizability.

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26 FIGURE 3.1– PROCESS FLOW OF THE APPLIED METHODS FOR THE CONSTRUCTION AND VALIDATION OF THE COST MODEL

Phase 1 – Identification and validation of components

1.1 Generalizing components from process flows (16 hospitals involved) 1.2 Identifying other components from literature

1.3 Identifying other components from a checklist from a cost model expert 1.4 Reusing input variables from the existing business case

Initial set up

1.5 Validation by cost model expert

1.6 Validation by endoscopy unit manager (1 hospital involved)

Phase 2 – Construction and validation of the in- and output variables in the actual model 2.1 Selecting tool

2.2 Dataset production endoscopy units for validation of values output variables (2 hospitals involved)

2.3 Brainstorm session representation of the model

Second set up model

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27 2.5 Validation output variables by endoscopy unit manager (1 hospital involved)

Final set up model for four hospitals

2.6 Validation output variables values by endoscopy unit managers (3 hospitals involved)

Phase 3 – Adjustment of the model to test its generalizability

3.1 Adjustment model for cardiology decision making setting (1 hospital involved) 3.2 Adjustment model for other eHealth solution (1 company involved)

Table 3.1 relates the different phases to the involved hospitals and company.

TABLE 3.1– INSTITUTIONS RELATED TO THE DIFFERENT PHASES

The following paragraphs will discuss each phase of the construction and validation of the cost model.

3.2.1 Identification and initial validation of cost model components

Initial components of the cost model were based on analyzing and generalizing components from process flows (phase 1.1), identifying other components from literature (phase 1.2), a checklist from a cost model expert (phase 1.3) and reusing components from the existing business case of Medify (phase 1.4). For the literature review, snowball sampling was used from the results of the CBE literature review in Chapter 1. After the initial construction of the cost model, the cost-model expert was consulted for intermediate validation (phase 1.5). The cost-cost-model expert recommended to perform validation on the components of the cost model. Thus, a semi-structured interview was conducted to achieve validation (phase 1.6). The components of the interview were perspective on costs and benefits realized through the MEX and desired management information. The validation interview was held with two unit managers of a

gastroenterology department in a top clinical hospital. One of them was involved before and after implementation of the MEX eHealth service, and the other one only after implementation.

1.1 – g enera lizin g proc ess f low com pone nts 1.6 – V alida tion com pone nts m odel 2.2 – D atase t prod uctio n end oscop y units 2.5 – V alida tion o utpu t varia bles 2.6 – V alida tion o utpu t varia ble va lues 3.1 – A djustm ent mod el for card iology decisi on m akin g 3.2 - A djustm ent mod el for othe r eHea lth so lutio n Hospital A ● Hospital B ● Hospital C ● Hospital D ● Hospital E ● ● Hospital F ● Hospital G ● ● ● ● ● Hospital H ● Hospital I ● ● ● Hospital J ● Hospital K ● Hospital L ● Hospital M ● Hospital N ● Hospital O ● ●

Tele rehabilitation and

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28

3.2.2 Construction and validation of the in- and output variables in the actual model

There is a number of tools available that are beneficial for constructing the cost model and presenting it to end-users, but since to our knowledge, hospitals are facing problems with

opening non-standard software on their computers, we used Excel [34] as a pragmatic tool (phase 2.1). Because of its easy accessibility and comprehensibility, we expect it to be suitable for the majority of the target group. Additionally, it meets our requirement to enable re-use of data entry, transform and consolidate data and hide data for simplicity for end-users. Apart from this, Excel features the extension Visual Basic Application [35] that can be used to automate storage of data.

Output variables’ values were calculated with the help of provided production datasets of two gastroenterology departments (phase 2.2). For the representation of the model, a finance

controller of a medium sized commercial company was consulted. A brainstorm session was held on how to present input variables, output variables and KPIs (phase 2.3). One of the unit

managers helped validating the output variables and KPIs. For the actual representation, the real values of a department were filled in the model and displayed over the next few months. The unit manager was asked questions upon (1) the completeness of the input and output variables/KPIs and (2) the frequency of use of the model (phase 2.4). For the final set up of our model, the model was adjusted to the situation of four hospitals and provided to its endoscopy unit manager.

3.2.3 Adjustment of the model to test its generalizabilityIn order to test the generalizability of our model on other (sub)domains, two unstructured interviews were held with (1) the unit manager of a cardiology department of an urban hospital and (2) the general manager of a small-sized eHealth company specialized in telemonitoring for heart failure patients and tele rehabilitation for patients who had a recent treatment for their heart disease. Questions about operations before and after implementation of the eHealth service were asked.

3.3 Results

3.3.1 Process flow review

The process flow review resulted in a number of steps that could be generalized for all hospitals. The generalization is based on the process steps of Section 2.3.3, Table 3.2 provides a short schematic overview of the generalized differences in process steps between the MEX colonoscopy processes.

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29 TABLE 3.2SCHEMATIC OVERVIEW OF GENERALIZED PROCESS STEPS IN HOSPITAL

Based on this review, steps 1-10 from Table 3.1 were included in the model.

3.3.2 Literature review

The literature review resulted in three new articles [9, 30, 34], that introduced next to the savings during education, medical condition and informed consent also the components reduced number of phone calls, reduced numbers of clinical mistakes, reduced number of no-shows and reduced number of re-colonoscopies. The components were mapped to the components of the

classification model of the expert, that is available upon request at the author. In Table 3.3, the components are mapped to the classification model of the expert and explained.

TABLE 3.3-IDENTIFICATION OF POTENTIAL COST SAVINGS THROUGH ELECTRONIC PATIENT EDUCATION

Component with reference

Group Translation to

pre-colonoscopy tract Model reference (Mapped to Figure 3.3 ) 1 Patient education [9] Employee Labor Saved, Avoided or Productivity Increase (time savings)

The time that is spent on education on colonoscopy of a staff member. Item 11 and 33 2 Anamnesis [9] Employee Labor Saved, Avoided or Productivity Increase (time

The time that is spent on asking the patient on anamnesis, for example medical history and medication. Item 11 and 33 Hosp ital A Hosp ital B Hosp ital C Hosp ital D Hosp ital E Hosp ital F Hosp ital G Hosp ital H Hosp ital I Hosp ital J Hosp ital K Hosp ital L Hosp ital M Hosp ital N Hosp ital O

(1) and (2) referral available ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(3) and (4) call to inform about

CBE and check mail address ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(5a) create link in MEX ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(5b) Schedule traditional

consultation and examination ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(6) Monitor CBE progress in

dashboard ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(7) Patients walks through CBE or has a conventional

education consultation ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(8) Triage answers and

uploading PDF file in EHR ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(9) The colonoscopy is scheduled (green) or the colonoscopy is scheduled together with an additional consultation (orange or red

questionnaire) ● ● ● ● ● ● ● ● ● ● ● ● ●

(10) The additional

consultation takes place ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(11) Schedule pre-operative

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30 savings) 3 Informed consent [9] Employee Labor Saved, Avoided or Productivity Increase (time savings)

The time that is spent on asking the patient his or her informed consent for the colonoscopy examination. Item 11 and 33 4 Reduced number of phone calls [34] Employee Labor Saved, Avoided or Productivity Increase (time savings)

The time that is spent on answering phone calls with questions from patients on the examination. Item 37 5 Reduced number of clinical mistakes [30]

Marketing Lack of medical information, lack of informed consent.

- 6 Reduced number of no shows [34] Other monthly cost savings

Because of personal contact and preference day for examination.

Item 35 and 36 7 Reduced number of re-colonoscopies [18] Other monthly cost savings

Because it is said that only a small part of information that is provided during a physical intake is remembered, it can be hypothesized that the number of patients that will have to undergo a re-examination will be smaller for CBE than for traditional education

consultations.

Item 38

The reduced number of clinical mistakes (item 5 in Table 3.3) was not included in the eventual model, because hospitals do not always register these mistakes and are also not transparent about these to protect their image. However, this aspect is important, because when a patient undergoes the examination without having all risk factors for the examination identified and/or without informed consent, the hospital might receive fines Health Care Inspectorate (Inspectie

Gezondheidszorg, IGZ). Additionally, when hospitals lack the evidence required by quality

accreditations, they might damage their image, which could result in loss of production as patients do not want to come to the hospital anymore because of clinical mistakes. It is hypothesized that the MEX prevents clinical mistakes. This is because the hospital can only schedule the examination for patients once their medical condition and informed consent is known. In the conventional process the patient might not show up at the education consultation and it could be more easily accidentally missed that the patients risk identification and informed consent is not known. Therefore, the MEX is expected to be cost saving for reducing the number of clinical mistakes.

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31 No Show (item 6 in Table 3.3) means that the patient does not show up at an appointment. In the pre-colonoscopy process, this can be either during the conventional education consultation or at the examination itself. No Show can be viewed upon as a waste of health care, because the reserved time from a health care provider cannot be used effectively [35, 36]. Therefore, No Show can be considered as a cost component for the model, because No Show is a costly aspect in the pre-endoscopy process. Moreover, CBE has the potential to decrease these costs by:

(1) Eliminating a number of pre-colonoscopy consultations.

(2) Scheduling the examination only when the patient completes the CBE.

(3) Decreasing anxiety, as this is one of the of No Show at the colonoscopy examination [35]. If the ePACO trial concludes that CBE decreases anxiety, then CBE might be cost saving by decreasing No Show at the examination itself as well.

3.3.4. Business case

As last aspect, various existing business cases of Medify were reviewed for input for the cost model. The example business case from the hospital studied as case in Chapter 2 can be found in Figure 3.2 below.

Values Specific hospital

values to fill in

Work hours of an endoscopy nurse per

week 36

Work weeks of an endoscopy nurse per

year 45

Salary € 45.500

Number of colonoscopies per year 3500

Intial costs € 10.000

License costs € 2.340

Number of gastroenterologists 5

Numer of license years 3

Timesavings

Savings based on full license period

Requested total investment

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32 All aspects of the business case were used for input (Figure 3.3), which are:

- Salary (Item 2-7)

- Time spent on the intake (Item 11 and 33) - Proportions traditional and digital (Item 24) - Proportions additional (Item 32)

- License and initial costs (output / representation sheet) - Cost savings (output / representation sheet)

- FTEs (output / representation sheet)

3.3.5 Validation interview

In Table 3.4, an overview of the retrieved aspects from the validation interview that are cost-related can be found. No new aspects for cost model input were retrieved from the validation interview, but a number of input variables were identified during the interview.

TABLE 3.4-LIST OF CODES DERIVED FROM THE VALIDATION INTERVIEW

Code Description Model reference Figure

3.3)

Benchmarking Desire to see how other

hospitals are organizing their processes, to find out if they can work more time- and cost efficient.

-

Costs vs. benefits, willingness-to-pay

The belief that benefits have to outweigh the costs to pay the initial and license costs.

-

Integration The belief that CBE has to be

integrated with the EHR to obtain efficiency.

Item 30 – uploading PDF file

Obtaining mail addresses, monitoring patients

One of the perceived bottlenecks in the post-implementation process in terms of efficiency.

Components invitation education and monitoring (items 24 – 29)

Benefits – less pressure on physical intake

The belief that CBE causes less pressure on intake in hospital.

-

Costs - rescopies Mentioned as one of the most undesired events in terms of efficiency.

Item 38

Costs – No Show Mentioned as one of the most undesired events in terms of efficiency.

Item 35 and 36

Management info – average waiting time

The wish to see how much time patients take on average to complete the CBE as

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33 management information.

Management info – questionnaire triage

The wish to see how many patients need to come for additional consultation.

Output / KPI

representation tab (figure 3.8)

Costs – additional intake Acknowledging that it matters in terms of costs which actor does the additional consultation with patients.

Item 34

Gastroenterologists and patient education

The belief that

gastroenterologists have too little time to educate patients in a sufficient way.

-

3.3.6 Implementation in selected tool

Based on the input of phase 1, 38 input variables were constructed in Excel. These variables are required for the most complete output and KPIs. The brainstorm session on the representation of the model resulted in the advice to separate input from output and make graphical

representations. Figure 3.3 and 3.4 display the input variables of the model and an example input sheet. In the input sheet, users can fill in values which they can either store as target values (left bottom button) or actual values (right bottom button). The output sheet will be later represented to the endoscopy unit managers in the form of KPIs. A schematic overview of the input variables of the model and the equations for the output variables can be found in Appendix C and D.

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34 FIGURE 3.3AN EXAMPLE INPUT SHEET CONTAINING ALL INPUT VARIABLES

1. Input variables - Questions applicable to both processes Input values

1. How many colonoscopy examinations are there on yearly basis? 4408

2. What is the monthly salary of a back office employee? 35.10

3. What is the monthly salary of a nurse? 45.6

4. What is the monthly salary of a resident gastroenterology? 60.7

5. What is the monthly salary of a gastroenterologist? 80.17

6. What is the monthly salary of a physician assistant? 20.5

7. What is the monthly salary of a nurse practitioner? 60.12

2. Input variables - Conventional education process (How was the process organized before implementation of CBE?)

8. How did you reach out to a patient before and after the education consultation and examination

appointment? Regular mail

9. Who did this? Backoffice

10. How much time did you spend on this per patient in minutes? 20

11. What was the duration of an education consultation? 5

12. Who did this? Nurse, nurse practitioner and resident

3. Input variables - CBE process

13. Of what percentage of patients is the emailaddress know in the EHR? 20%

GP referrals

14. What percentage of patients is referred by the GP? 35%

15. Does the GP inform the patients about the CBE process? Yes

16. What percentage? 50%

17. Does the GP include the patient's emailaddress in the referral? Yes

Referrals from other specialisms

19. What percentage of patients is referred by other specialims? 35%

20. Do other specialisms inform the patients about the CBE process? Yes

22. Do other specialisms enter the patient's emailaddress in the EHR if the email is unknown? Yes

Gastroenterologists referral

Calculated percentage: 30%

CBE in home-based education

24. What percentage of patients do you expect that will use CBE in the home-based situation? 20%

Patient invitation for CBE

25. Who is going to call the patients? Backoffice

26. How much time do you spend on this per patient in minutes? 5

Monitoring

27. Who is going to monitor patients in the dashboard and call them? Backoffice

29. What percentage of patients needs to be reminded by phone call? 20%

Medical condition and informed consent answers patient

30. Who schedules the examination, potential additional consultation and uploads the PDF file with

answers in the EHR? Backoffice

Additional consultation

32. What percentage of patients still needs to come to the hospital for an additional consultation? 20%

33. How long does this consultation take per patient in minutes? 20

34. Who does this? Nurse, nurse practitioner and resident

4. Other costs

35. What was the no-show percentage for the educational consulation? 15%

36. What was the no-show percentage for the colonoscopy examination? 6%

37. How many phone calls with questions on the examination or the preparation of the examination did

you receive? 40

38. How many times did a re-colonoscopy occur due to inadequate bowel preparation? 0

Current reporting Set targets

Developing a cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insight cost model to provide insi

Developing a cost model to provide insight

into the economic value of

computer-based patient education for Dutch

endoscopy units

Developing a cost model to provide insight

into the economic value of

computer-based patient education for Dutch

endoscopy units

Preface and acknowledgements

Table of contents

Samenvatting

Abstract

Chapter 1 – General introduction and background information

Chapter 2 – The business case in practice and the role of costs on

operational and governance level in endoscopy units

Chapter 3 – The cost model