Care without walls

A key element of this vision is embedding medical care into everyday life in order to improve patient-centred care. For instance, patients at risk could have their vital signs continuously monitored by wearable devices in order to identify diseases at an early stage and treat them in good time. However, as well as improving remote monitoring or telehealth consultations, the future health care model should rethink all processes along the patient pathway – from the patient’s home and the GP to specialist health care providers and inpatient facilities – and integrate them via new technologies. The transitions between digital and physical settings should be seamless here. Otherwise, a “care without walls” concept cannot improve the patient experience and provide a lasting improvement in clinical outcomes.

The prerequisites for implementing this concept in Switzerland range from the policy and financial frameworks to the technological foundations. On the technology side, the main focus is on a common database for patients and health care providers that gives all stakeholders appropriate access to the requisite data. The revision of the EPR planned in the context of DigiSanté can make a significant contribution here by enabling the provision of the right data in the right place at the right time in a structured, secure manner. The latter two aspects – data structure and data security/protection – are essential conditions with regard to a common health database.

Furthermore, a common database will only be beneficial if it enables a high level of interoperability of content by means of uniform interface standards and a language shared by all stakeholders. This means that everyone involved must speak a “common language” in order to avoid “translations” from one system to the next as much as possible.

Furthermore, a common database will only be possible if data protection and data security are guaranteed. For instance, in all situations, it is necessary to provide clarity as to which stakeholder receives access to data with which rights and for what purpose through the likes of detailed role concepts. If these prerequisites can be fulfilled, “care without walls” can deliver benefits at various levels.

Patients can get on with their lives at home through integrated and technology-based treatment and support, even in the event of diagnoses that currently require inpatient treatment or very frequent appointments with a health care provider. As well as freeing up the infrastructure of health care providers, this also provides benefits for patients’ health support and independence. In addition, it enables people in remote regions to access health care services that are geographically distant from them with fewer difficulties and obstacles. From their first contact with a stakeholder, patients can be referred to the right place to have their issues addressed, meaning that direct emergency admissions and therefore the costs to the population and the health care system as a whole can be reduced.

From a clinical perspective, “care without walls” can add significant value in terms of monitoring, early detection of diseases and simplified collation of all manner of scores or PROMs. The data gathered in the context of “care without walls” forms the basis for new technologies and the implementation of exciting applications such as artificial intelligence for assistance with decision-making, optimisation of triage or virtual interaction of patients via chatbots.

Furthermore, in compliance with data protection and with patient consent, the large volume of structured data gathered can also be used for research, as it is a source of huge potential for clinical research.

“Care without walls” also enables efficiency gains that have become essential in view of demographic trends in Switzerland and on account of the skills shortage. For instance, integrated, end-to-end care can improve interaction between stakeholders, reduce distances or ease the workload via a shared-service approach if health care providers are able to access a shared pool of knowledge and resources. Consistent, integrated care can also deliver efficiency gains in administration.

As things stand, for this wealth of benefits to be used, there is a need for uniform, coordinated management in order to resolve misunderstandings, remove prejudices, define responsibilities and overcome obstacles. One of the most frequently mentioned barriers for patients is the digital affinity of the predominantly elderly patient population. It must be borne in mind here that the longer the older generations use the digital technologies, the more familiar they become with them, and the foundations for the care of today’s young generations are being laid here and now. At any rate, it must be ensured that the individual needs of patients and the socio-economic factors of the people and households concerned (such as level of education and infrastructure) are taken into account. Care must always be extended as well to people who do not use digital technologies. However, in the vision of “care without walls”, these are the exceptional cases, while the standard process is carried out via digital aids.

To increase acceptance of this transformation of health care in Switzerland, it is necessary to avoid a big-bang approach and enable continuous, transparent change so that the population can understand the transition.

Obstacles are also apparent from a technical perspective. For instance, many hospitals are experiencing challenging situations in their dealings with IT software providers, whose strict regulations and requirements are limiting the interoperability and distribution of data.

In particular, suitable conditions for bringing a vision such as “care without walls” to fruition are currently lacking. For instance, there are not enough incentives for integrated care in order to overcome the “compartmentalised approach”. Accordingly, there is a lack of uniform management and clear allocation of responsibilities and leadership at individual, regional, cantonal and national level. In addition, it is necessary to create new financing mechanisms that enable payment for pilot phases and additional materials as well as correctly setting out and charging for virtual medical and nursing services. Along with the policy and financial frameworks, the legal foundations also need further elaboration, particularly with regard to the storage and use of health data.

The numerous examples of projects in various organisations reflect the desire for a transformation towards integrated, digitalised, efficient care despite all the obstacles. For instance, Spitex has conducted a study to find out what services it could perform in the context of a “hospital at home” and where additional specialists would be needed. The canton of Neuchâtel is already working with an overall budget in order to create an incentive for care with cantonal integration. Further projects cover topics such as self-registration on arrival in hospital, making appointments and automated dispensing systems. Many hospitals support projects of this kind, including Baden Cantonal Hospital, which created its innovation hub specifically for this purpose.

Overall, though, it can be said that these many small projects are largely uncoordinated and only come into contact with small demographic and patient groups, so they will only advance integrated care slowly.

Consequently, to accelerate the transformation and build up sound, lasting foundations for technology-based care, it is necessary…

1. … to resolve the issue of responsibility for and leadership of the coordination and integration of many small and large projects and solutions. Clear governance is essential to efficient decision-making on aspects such as financing or standardisation. For political reasons, the cantons should take the lead in each case, as they have ultimate political authority for health care. Furthermore, in the implementation phase, all stakeholders must be involved in discussing the allocation and financing of the patient pathway. The goal should be a holistic strategy for the implementation of a concept of this kind with a clear allocation of responsibilities.
2. … to enable a smooth, “organic” transformation in which projects have sufficient lead times to attain detailed implementation with an optimum user experience.
3. … to raise awareness among all demographic groups, even if they are not in direct contact with an integrated care project. As a result, it should be ensured that the transformation is understood and accepted by the population. Like the organic transformation of health care, this raising of awareness should take place continuously and in different contexts.

However, the prospects are encouraging: Most of the current health care challenges can be countered effectively via the “care without walls” concept. Care without walls is a key factor in the creation of a more sustainable health care system in the future.

This transition does not mean that we will no longer need the physical buildings that we know as “hospitals”. Rather, their role will change, and various services will be delivered outside of their walls – at home, in the workplace and in our communities.

The recent switches to virtual teleconsultations are foretastes of what the future holds. We must re-imagine the hospital of the future, with all the functions that we have developed for our physical hospitals over the centuries.

This article sets out Deloitte’s views, based on interviews with representative stakeholders. We would like to thank the following people for their input:

• Elke Albrecht, CIO of Solothurner Spitäler AG

• Dr Daniel Heller, Chairman of the Board of Directors of Baden Cantonal Hospital

• Marianne Pfister, Co-Managing Director of Spitex Switzerland

• Kristian Schneider, Director and CEO of Biel Hospital Centre

• Thomas von Allmen, Head of the Hospital Care department, Department of Health of Canton Basel Stadt