THE NEXT BIG THING -- HOSPITAL AT HOME
I hereby predict
the Next Big Thing is hospital at home (HAH).
How do I know
this? My primary source is my wife, Jill. Both of our children --
now age 18 and 21 -- were born by C-section during the golden era of
indemnity insurance. I remember Jill practically begging her doctor
to get the insurance company to authorize a few extra days in the
hospital so that she could rest and recover.
I asked her how she
would handle that today -- would she want to spend the extra time in
the hospital? "No way!" she said.
Today many people
would prefer to receive medical treatment in their homes. Emergency
room and inpatient hospital care is expensive, and patients are
paying more out-of-pocket. People are fearful of medical errors and
hospital acquired infections. They want the comfort of their own
surroundings. Advancing technology will allow for safer care in the
generation of hospital at home has been around for 40 years, but the
coming revolution in HAH will truly be able to build on the
convergence of a wide range of new eHealth and consumer
Hospital at Home --
Hospital at home is
a concept that dates back to the 1960s. Don't feel bad if you're not
familiar with the term -- it hasn't received much airtime in the
While speaking at
the at the recent
Healthcare Unbound conference, I asked the audience of 300
people whether they were familiar with HAH. Only about 20% raised
advancements have occurred in many other countries -- including
Australia, the UK, Canada, France, Israel, Greece and others. There
is a significant research and literature base about HAH, but
curiously, almost none of it is from the U.S.
There are many HAH
models: early discharge of elderly medical patients, early discharge
of patients following elective surgery, and inpatient hospital
admission avoidance initiatives.
In its purest form,
HAH is voluntary. Patients are given a choice -- hospital or HAH?
Equipment and people are brought to the patient's home.
In 2005 a
Cochrane review examining studies of first generation HAH was
published. Drawing from an initial list of over 80 studies, the
review focused on 22 randomized trials of hospital at home care
compared with acute hospital inpatient care.
The findings of the
Cochrane review of first generation HAH are inconclusive and mixed:
Patients admitted to hospital at home did not generally have
significantly different outcomes than those treated in hospital.
While there is some evidence that patient satisfaction may be higher
at home, the burden on carers can also be greater and there is
little evidence of cost savings to the health service.
significant HAH project in the U.S. is being conducted as a
collaborative project among Johns Hopkins Medicine, Johns Hopkins
Bloomberg School of Public Health, and The John A. Hartford
Foundation. Initial results were published in a recent issue of the
Annals of Internal Medicine:
hospital-at-home care model is feasible, safe, and efficacious for
certain older patients with selected acute medical illnesses who
require acute hospital-level care.
for more references on HAH.
Hospital at Home --
While the original
concept of HAH is not rooted in technology, the next
generation of HAH will be dramatically enhanced by technology.
The ground work is
being laid today with a wide range of independent eHealth and
consumer technologies, including: electronic health records,
personal health records, digital home networks, broadband, remote
patient monitoring, secure electronic messaging between patients and
physicians, mobile technologies, ePrescribing, medical call centers,
interactive health portals, and others.
technologies converge, a next generation of HAH will become
possible. Advanced technologies will allow a wider range of patient
conditions to be treated safely at home. As an approach that builds
on and synergizes multiple emerging eHealth technologies, HAH could
be highly disruptive to traditional health care delivery.
Care Level Management is one early example of a company offering
HAH services. Care Level Management focuses on the frail elderly.
significant concerns and barriers. There is a potential to
over-burden caregivers at home. HAH could become viewed as a
reincarnation of the negatives of managed care -- "We won't pay for
you to be in the hospital; good luck recovering at home.” Physician
workflow is not yet structured to accommodate HAH. The models to
provide appropriate reimbursement for HAH are not yet developed, and
the business models for HAH are not mature.
reduce inpatient hospital costs are increasing. CMS actuaries
Health Affairs project that that hospital spending in the U.S.
will exceed $1 Trillion (yes, with a "T") in 2015.
If we can plan
to spend $1 Trillion to care for people in buildings where there's a
high risk of medical errors and infection, where the cost of care is
higher than anywhere else, where people would rather not be....
should we be willing to spend to spend provide safe hospital at home
Now that's an
issue worth talking about.
Health Technologies, LLC
TECHNOLOGY & CARE MANAGEMENT
Home Telehealth Reference
Medicare Quality Improvement Community, Fall 2006
Health Plans Partner With Purchasers
In Consumerism Drive
Online tools are evolving to better answer cost,
URAC Issue Brief, August 2006
Few Patients Use or Have Access to
Online Services for Communicating with their Doctors, but Most Would
of adults would
like access to an electronic health record, yet just 2% of adults
currently use EHRs
Interactive/The Wall Street Journal Online; September 22, 2006
Services Improvement Partnership Factsheet (UK); Version 1,
September 1, 2006
National Survey on
Telecare Implementation - early results now available
Services Improvement Partnership (UK); September 16, 2006
Diagnosis, Access And
Outcomes: Update Of A Systematic Review Of Telemedicine Services
Journal of Telemedicine and Telecare, September 2006,
Wikis, Blogs And Podcasts: A New
Generation Of Web-Based Tools For Virtual Collaborative Clinical
Practice And Education
August 15, 2006
Medical Device Makers Push for
Medical Device Companies Lobby Congress to
Require Medicare Pay Doctors for New Technology
Yahoo Financial News; September 25, 2006
Physicians Slow to Adopt Patient
Center for Studying Health System Change,
Remote Control for Health Care
The New York Times; September 9, 2006
A Systematic Review Of The Literature On Home Monitoring For
Patients With Heart Failure
Journal of Telemedicine and Telecare, July 2006
Why Are Health Care Interventions
Delivered Over the Internet? A Systematic Review of the Published
Journal of Medical Internet Research; June 23, 2006
Anticipation Grows For At-Home Tech
Healthcare IT News; August 1, 2006
Reducing Corporate Health Care Costs: Refocusing the Strategy
Endorse Consumer-directed Plans, Care Management Programs
Center for Health Solutions and Deloitte Consulting LLP, September
How Common Are Electronic Health Records In The United States? A
Summary Of The Evidence
Health Affairs; October 11, 2006
of physicians used an EHR but only 9% used systems with at least 4
key functionalities identified by the Institute of Medicine
The Future of the Internet II
survey of technology thinkers and stakeholders shows they believe
the internet will continue to spread in a "flattening"and improving
world. There are many, though, who think major problems will
accompany technology advances by 2020
Internet & American Life Project; September 24, 2006
Thought Leadership Survey: Physician Alignment through IT
Harris Interactive (sponsored by McKesson); August 2006
The Rise In Spending Among Medicare Beneficiaries: The Role Of
Chronic Disease Prevalence And Changes In Treatment Intensity
Health Affairs; August 22, 2006
Report to the
Congress: Increasing the Value of Medicare
Applicability of the Evidence Regarding Intensive Glycemic Control
and Self-Monitored Blood Glucose to Medicare Patients with Type 2
Technology Assessment (Draft); August 16, 2006
E-CareManagement News is a
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