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E-CareManagement News

October 16, 2006


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 home.

The first 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 technologies.

Hospital at Home -- First Generation

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 U.S.

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 their hands.

However, HAH 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.

The most 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:

The 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.

Click here for more references on HAH.

Hospital at Home -- Next Generation

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.

As these 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.

There are 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.

Pressures to reduce inpatient hospital costs are increasing.  CMS actuaries writing in 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.... much should we be willing to spend to spend provide safe hospital at home care?

Now that's an issue worth talking about.

Vince Kuraitis
Better Health Technologies, LLC


Home Telehealth Reference 2006/2007
Medicare Quality Improvement Community, Fall 2006

Health Plans Partner With Purchasers In Consumerism Drive
Online tools are evolving to better answer cost, quality questions
URAC Issue Brief, August 2006

Few Patients Use or Have Access to Online Services for Communicating with their Doctors, but Most Would Like To
64% of adults would like access to an electronic health record, yet just 2% of adults currently use EHRs
Harris Interactive/The Wall Street Journal Online; September 22, 2006

Pilots Versus Mainstreaming Checklist
Care Services Improvement Partnership Factsheet (UK); Version 1, September 1, 2006

National Survey on Telecare Implementation - early results now available
Care 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
BioMed Central; August 15, 2006

Medical Device Makers Push for Coverage
Medical Device Companies Lobby Congress to Require Medicare Pay Doctors for New Technology
Yahoo Financial News; September 25, 2006

Physicians Slow to Adopt Patient E-mail
Center for Studying Health System Change, September 2006

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 Literature
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
Employers Endorse Consumer-directed Plans, Care Management Programs
Deloitte Center for Health Solutions and Deloitte Consulting LLP, September 2006

How Common Are Electronic Health Records In The United States? A Summary Of The Evidence
Health Affairs; October 11, 2006
Almost 24% 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
A 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
Pew 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
Chapter 2: Care coordination in fee-for-service Medicare
Medicare Payment Advisory Commission (MEDPAC), June 2006

Applicability of the Evidence Regarding Intensive Glycemic Control and Self-Monitored Blood Glucose to Medicare Patients with Type 2 Diabetes
AHRQ Technology Assessment (Draft); August 16, 2006

E-CareManagement News is a complimentary e-newsletter courtesy of Better Health Technologies, LLC <>.

For business and clinical decision makers who are developing innovative approaches to managing chronic diseases and conditions, Better Health Technologies is an eHealth and disease management consulting company that can assist you with strategy/business planning, finding customers, and developing key partnerships.

Disclosure -- no clients are mentioned in this issue.

You may copy, reprint or forward all or part of this newsletter to friends, colleagues or customers, as long as the use is not for resale or profit and the following copyright notice is included intact. Copyright 2006, Better Health Technologies, LLC. All rights reserved

Comments?  Write or call Vince Kuraitis at, (208) 395-1197

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