Beyond Digitization - Redesign Public Healthcare for Operational Elasticity

 

In-general, the introduction of digital technologies in healthcare services is expected to improve management of healthcare services. In particular, the expectation is to improve management of demand-volatility observed in healthcare service delivery. However, this (introduction of digital technology) alone may not be able to induce required elasticity into the system so that the volatility of demand can be controlled (in any significant way).

It may be noted that to take full advantage of newly introduced technology in any service delivery system, a comprehensive restructuring of the entire service-delivery architecture is required to be done. Similarly, to take mileage out of digitization efforts in healthcare, the healthcare ecosystem may need a thorough re-designing to come to in-tune with newly introduced technology and to be prepared (with build-in flexibility) to accommodate upcoming technologies.

To begin with, let us explore the efforts on digital health going on across the globe. It turns out that in the global landscape, digitization of healthcare-service-provisioning is going on at different levels (refer – APPENDIX – E for further details). If someone considers the following points, one may get some idea on the possible reasons for such a massive thrust for digitization in health sector: -

1. Spending on Healthcare improves Health Indicators (Refer – APPENDIX – A).
2. In the larger part of the world Public Health spending is a significant contributor to Total Health Spending (Refer – APPENDIX – B).
3. Public Health Spending is observed to have been increasing in recent decades across the globe (Refer – APPENDIX – C).
4. Health systems have prepared to support Post-Pandemic (Covid-19) burden and are expected to maintain preparedness for future Pandemics (Williams, B.A., Jones, C.H., Welch, V. et al. Outlook of pandemic preparedness in a post-COVID-19 world. npj Vaccines 8, 178 (2023).).
5. Health systems should take steps to understand how climate change and variability will affect their ability to finance, manage, and protect population and individual health; evaluate the effectiveness of their interventions and systems under diverse climatic conditions and mediated impacts; and identify opportunities to enhance institutional iterative risk management capacity across all levels. (National Library of Medicine, NCBI, USA).
6. It is noteworthy that health and the economy are inextricably linked and there is evidence which, whilst not always apparent or obvious, shows that investing in health and health systems is clearly beneficial for achieving economic objectives. (Ref - eurohealthobservatory.who.int)

Naturally, (in view of above points) public policy makers may have temptation to ‘Maximize the Productivity’ of ‘Public Healthcare System’. Therefore, digitization of Public Healthcare Service Delivery is in-focus across the globe with an intent to increase operational efficiency and gradually reap the benefits of long-term productivity gains. HIMS (Hospital Information Management System) is one of the basic building blocks of healthcare digitization (Refer – APPENDIX – D). HIMS digitizes end-to-end operations of a hospital (or a public health facility). These hospitals or facilities have a hierarchy. Full-fledged public hospitals (or public super specialty hospitals) are at the top of the hierarchy and primary health care centers (or primary health sub-centers) are at the bottom of the hierarchy. The prime objective of these higher-level facilities (at upper levels in the hierarchy) is to provide institutional healthcare (primary, secondary, and tertiary healthcare services). Gradually the objective shifts towards community health as one traverse down the hierarchy of facilities. Those types of facilities that are at the lower levels are mainly responsible for community health care (like for example - RMNCH+A, Preventive Healthcare, Promotive Healthcare).

HIMS is implemented in all the public facilities across the hierarchy (falling within the territory of governance of any government department). It may be understood that these implemented HIMS systems in facilities do not function in silos (exclusively for the individual facility) but are connected to facilitate central monitoring and control through digital means (usually through an integrated command and control center (ICCC) located at the administrative office of governing department). These ICCC make available real time transactional data (data related to day-to-day transactions) and near real time analytical data (analyzed data for trends and indicators of interest). The ICCC data is accessible to facility managers for their respective facilities and to regional officials for their respective regions. The central ICCC has the privilege to access data for all the facilities falling under the territory administered by the department.

Government funded public healthcare systems are the backbone of healthcare service delivery in most countries (refer – APPENDIX B). To strengthen this backbone, implementation of HIMS is taken-up. The major outcomes expected from digitization are as under: -

1. Improvement in record keeping of health records – due to management of health records in electronic form (more credible, verifiable, accessible health records).
2. Improvement in productivity of healthcare services – much optimized utilization of resources by the health system for efficient delivery of services.
3. Enhancement in role of data in policy making – closer monitoring of operational data to develop an understanding of ground realities of operations and to frame much more sensible policies for fulfilment of objectives of public healthcare.
4. Improvement in the accessibility of services – easier and faster access to health information and health services through multiple channels available through digital means.

At the same time, digitization enhances the healthcare system operations and is expected to result in: -

1. Increased Speed,
2. Increased Measurability,
3. Increased Accountability,
4. Increased Productivity and
5. Increased Predictability.

With the above-mentioned enhancement to health system operations, the digitized public healthcare system may need to be much more agile in comparison to conventional pre-digitized healthcare provisioning. The agility could be: - 

• ·       Agility to Respond to changing demand (increasing health awareness increases load in facilities).
• ·       Agility to Respond to changing execution dynamics (e.g. shutting down of some facilities may put pressure in other facilities).
• ·       Agility to Respond to sudden spike in certain services due to emergency (say – pandemic, natural calamity in a particular region).

Now, it may be noted that in case of healthcare operations, the conventional demand and supply based analysis may not necessarily hold good (Ref- saylordotog.github.io). Ideally, the supply of public healthcare services should be perfectly elastic to meet the demand for the healthcare services (at any point of time). An inability to adequately or timely meet supply volumes required to meet the demand can have severe consequences related to unfair, unjust and unequal distribution of public health services. It is widely understood that scarce public resources in high demand usually get distributed in society unfairly.

Practically, it may not be possible to make supply possible for all the expected and unexpected changes to demand for healthcare services. But, an agile system stretchable to larger extent is the dream for any organization managing public healthcare system. To this endeavor, digitization can be of little help as it may only do information management for healthcare systems or at the best suggest some trends or predict an upcoming event or eventuality. However, with existing operating tools of available People, Infrastructure and Processes, an administrator at a facility (Hospital Manager) or an administrator at department level (Administrative Officer) may have very little flexibility to take the mileage of information technology to bring changes on ground for improving healthcare services let alone preparing to meet the changing demand for healthcare services.

However, increased accountability and transparency in operations brought about by digitization raises the expectations of dealing with the choppy demand in a much better way. Inability of a public healthcare system to meet the spikes in demand or inability to reduce wastage of public money by timely de-mobilizing deployed resources on shrinking demand could be monitored in real time and in transparent manner through digital means.

It may be mention worthy that administration of public health facilities through centrally controlled bureaucratic mechanism orients the accountability of facilities towards the controlling authority. It turns out that such an authority in a societies with power distance may not remain sensitive to the major beneficiaries of public facilities. This carries risk of health facilities reducing themselves to subordinative role to obey authorities at higher levels in hierarchy. Eventually such a tendency weakens the intricate link of facilities with the community (or citizens). Many times insensitivity of public facilities towards needs of citizens due to weakened link (of facilities towards communities) is seen as an opportunity by the private sector health services providers (who are largely run through payments done by service availing citizens and therefore are little more accountable towards (paying) citizens). All this eventually makes healthcare a commercial service. The problem with commercial healthcare services is the inelasticity of demand (associated with health services) for healthcare services, which carries huge risk of putting the service-provider at position to arbitrarily decide on price of services. Anyhow, more importantly, erosion of needy citizens to seek private health services fails larger missionary intent of the public healthcare provisioning system to provide free service with equality and fairness for a  larger social good.

With the above discussions, let us revisit the point where we started. Institutionalization of technology in true sense means comprehensively redesigning the health service delivery system to be in tune with the technology being implemented. This also means keeping design flexible enough to smoothly accommodate the up-coming technologies as per technology roadmap plan of the organization (or department).

Basic building block for monitoring of elasticity of demand in public facilities can be two primary indicators Capacity and Throughput (for details refer – APPENDIX F) of a service for a facility. Capacity of a Hospital (or facility) is defined as the maximum number of service seekers (patients, citizens) that can be served per unit of time. Throughput of a Hospital is number of service seekers (patients, citizens) served per unit time. Any observed deviation or any suggested prediction on operations going beyond operating limits of Capacity or Throughput be considered as an alarm and response team be suitably alerted to start preparations within a tentatively available response time.

Clearly to have an agile and responsive healthcare system, a compatible healthcare service delivery design is mandatory to take the benefits of on-going digitization. This means a re-redesign of prevailing healthcare system be considered along with the digitization efforts. Unless this is done, the likelihood of both a) technology getting adopted into the system would be less and also, b) ability of technology to increase operational excellence would be less.

Rethinking a healthcare system design in the light of introduction of emerging technology is a huge, complex, and subjective task. For the sake of getting a very broad idea, we may consider listing some of the points. We consider a public healthcare service delivery system as a system of Processes, which uses human resources (People) and non-human resources (Infrastructure) to deliver services. Thus, going on these lines, the important points to consider at broad level are as under: -

1.      People

a.      Skills (Management)

                                                              i.      Clinical

                                                            ii.      Non-Clinical

b.      Skill Assessment

c.      Recruitment

d.      Knowledge (Management)

e.      Continuous Learning & Capacity Building

2.      Infrastructure and Auxiliary Services

a.      Space

                                                              i.      Buildings

                                                            ii.      Open Spaces

                                                          iii.      Sheds / Parking

b.      Equipped Facilities – e.g.: -

                                                              i.      IPD / OPD / OT Areas

                                                            ii.      Blood Bank

                                                          iii.      Pharmacy

                                                           iv.      Store

                                                            v.      Restaurant

                                                           vi.      Administration

                                                         vii.      Waiting Area

c.      Supply-Chain Backbone

d.      Transportation Services

e.      Security Services

3.      Processes (BPR - Business Process Re-engineering)

a.      Information Design and Workflow

b.      Work-Flow Design and Workflow

c.      Facility Administration Manual

d.      Procedures

e.      Guidelines

f.        Regulations

In the healthcare system redesign, resource optimization for BPR (Business Process Re-engineering) may be an interesting point to further elaborate on some of the possibilities to consider (while doing healthcare service redesign): -

1.      Breakdown the Services to micro-services for increased flexibility to manage Service Delivery: -

a.      Healthcare services can be broken down into logical microservices, so that Hospital Mangers may have greater flexibility to manage processes at much more granular level.

2.      Prepare to overcome bottlenecks in processes: -

a.      A bottleneck is a point of congestion in a health service delivery process. Special attention to bottlenecks in processes can improve process flow: 

                                                                 i.      Identify bottlenecks.

                                                                ii.       Strategize to reduce impact of bottlenecks.

3.      Resource Optimization for Increased Capacity: -

a.      Time Optimization – Regulation of Facility Working Hours:

                                                           i.      Provision to regulate working hours of human resources with suitable reward and recognition for additional services to existing employees:

        1.      Provision for Over Time (additional shifts).

        2.      Provision for Working during Holidays.

b.      Space Optimization:

                                                              i.      Provision to acquire use other facilities to work as temporary hospitals so that space can be increased or decreased.

        1.      Provision to procure and prepare near-by facilities to serve as extended hospital premises (with minimal paperwork). Regular drills to simulate this contingency (just like fire-drills).

        2.      Provision to prepare tent-based cottage (or ither such temporary arrangements) to extend the facility with temporary work rooms / waiting rooms.

c.      Human Resource Optimization:

                                                              i.      Promote, generate, authorize and use volunteers to support human resources requirements to supply additional serves; this includes:

    1.      Non-Clinical Volunteers.

    2.      Clinical Volunteers.

d.      Physical Resource Optimization:

                                                              i.      Physical resources including clinical equipment be optimized within the facility to absorb changes to healthcare service demand:

    1.      Required redundancy of physical resources.

    2.      Store policies to manage storage of resources with greater flexibility.

    3.      Procurement policy mandating vendors to be ready to supply additional resources on demand within a SLN (Service Level Norms) based response time.

In my opinion, if some organization (say - a consulting firm or an NGO) approaches a government department (specially in developing countries) with a proposal on assessing and improving preparedness of public health to meet the needs of changing demand, such a proposal be given due considerations. 

APPENDIX – A

1.      The link between spending on healthcare and improvement in health indicators is well established. This is evident from the following graphs taken from ourworld.org:

a.      Health Expenditure and Life Expectancy (Country Wise)

a.      Health Expenditure and Health Access and Quality (Country Wise)

APPENDIX – B

1.      Public spending on healthcare remains significant contributor to healthcare expenditure (McMahon, R. & Pence, Diana & Bressler, Linda & Bressler, Martin. (2016). New tactics in fighting financial crimes: Moving beyond the fraud triangle. 19. 16-25.).

a.      Country Wise Public and Private Spending in Healthcare Sector

APPENDIX – C

1.      Accordingly, government health spending is observed to have been increasing in recent decades across the globe. Following graphs from ourworld.org could be a good illustration to support this:

a.      Country Wise Government Health Expenditure as Share of GDP

APPENDIX – D

a.      HIMS (Hospital Information Management System) or Hospital Management System (HMS) is an integrated information system for managing all aspects of a hospital’s operations such as medical, financial, administrative, legal, and compliance. Hospital management system includes electronic health records, business intelligence and revenue cycle management. (Ref- HealthMed)

b.      HIS (Health Information System) serve multiple users and a wide array of purposes that can be summarized as the "generation of information to enable decision-makers at all levels of the health system to identify problems and needs, make evidence-based decisions on health policy and allocate scarce resources optimally" (Ref- WHO Health Information Systems. Toolkit on monitoring health systems strengthening, 2008)

c.      Relation between HIMS and HIS - Usually, implementation of HIMS is amongst the building blocks of digitization process in healthcare sector. Data collected through operationalization of HIMS becomes basis for holistic digitization of ecosystem. HIMS can be considered as initial and essential part of the larger Health Information Systems (HIS).

APPENDIX – E

Many governments are attempting to leverage digitization of public health system for enhanced operational productivity. However, the on-going efforts are at different stages for different countries. This is evident from the report – “The State of Digital Health 2023” published by Digital Health Monitor ( digitalhealthmonitor.org ). A high proportion of countries are at Phase 2 or Phase 3 (out of total 5 phases defined in the report). Most countries (40%) are at Phase 3 in overall digital health maturity, followed by 33% at Phase 2 and 22% at Phase 4. Only, three of the participating countries (4%) are in Phase 5 (Portugal, Saudi Arabia, and the United Arab Emirates). This means these three countries have matured the digital health ecosystem and have a provision for embedded digital health in preservice training of health professionals, such that over 75% of health professionals receive this training.  No country is at Phase 1. The report findings indicate that majority of countries are in the process of implementing digital transformation in healthcare sector.

 APPENDIX – F

‘Operational Elasticity’ is defined as the capacity to dynamically reconfigure space, staff, and resources to increase point capacity (Ref – Ozzie Paez Research).

Demand for public health services rendering services to majority of population in any country should be (near) perfect inelastic (w.r.t. demand assuming no (significant) price is charged by public facilities). In delivery of public services, a promised QoS (Quality of Services) standards must be maintained in the interest of fairness, equality and in the interest of commitment to provision public good (certain aspects of healthcare has characteristics of public good) to all the beneficiaries.

Therefore, funding (fiscal capacity) and supply of healthcare services (operational capacity) must be stretched to meet the fluctuating demand (for health services) in such a way that operational efficiency does not get compromised. This can only be achieved by increasing operational elasticity of the system to the maximum possible extent so that all the contingencies are met without any compromise to the QoS.

Designing a public health ecosystem to support judicious use of public money to meet the commitments of public healthcare services is a challenging task. To discuss on these challenging tasks, it may be useful to understand following terminologies: -

1.      Capacity of a Hospital – Capacity of a Hospital is defined as the maximum number of customers (patients, citizens) that can be served per unit of time. (Ref - Terwiesch C, et al.: Working with capacity limitations: operations management in critical care. Critical Care 2011, 15:308)

 

2.      Throughput of a Hospital - Throughput of a Hospital is number of customers (patients, citizens) served per unit time. (Ref - Terwiesch C, et al.: Working with capacity limitations: operations management in critical care. Critical Care 2011, 15:308)

a.      The throughput of a finite-capacity queueing system is the mean number of clients served during a time interval.

Elastic is a term used in economics to describe a change in the behavior of buyers and sellers in response to a single variable like a change in price or other variables for a good or service. (Ref – Investopedia)

The ‘Operational Elasticity’ of a Hospital (healthcare facility) can be considered as the capacity to dynamically reconfigure synchronized efforts of human resources, clinical tools and infrastructure (includes all other supporting infrastructure – Building, Open Space, Facilities, IT Hardware, Internet Connection and other such things) to provide agreed QoS (Quality of Service) to beneficiaries. It may be advisable to calculate operational elasticity for a particular service available in the facility.

In view of the above, it is reasonable to assume that operational elasticity (of a healthcare facility) is (its) ability to change capacity with changing load of beneficiaries visiting the facility (to avail a given service). With all other things remaining constant (like (say) QoS- Quality of Service, clinical tools, facility infrastructure), throughput can be representative of load.

So, we will analyze the two entities throughput and capacity from the perspective of a hospital manager managing a healthcare facility for OPD service (for simplicity).

 

Assumptions: -

• 1.      The diagram above illustrates OPD Operation of a given Facility (F).
• 2.      On changing the throughput, the capacity requirement changes linearly following the line O – CT2. O – CT2 is at an angle CT2-O-T2.
• 3.      The time for which the facility operates during a working day is fixed.
• 4.      Resources available at the facility to conduct OPD Operations are fixed.
• 5.      QoS (Quality of Service) can not be reduced at any cost.
• 6.      Private healthcare facilities are not available to beneficiaries of the given facility to take the load off by attracting visitors with capacity to pay fee at a private facility.
• 7.      Band U – L is the operational threshold showing upper limit and lower limit of the threshold.

 

Operation -

• 1.      The OPD at the facility operates within the band U-L using built-in redundancy and contingency provisions in the operational design of the facility.
• 2.      The Hospital Manager (HM) has got some further flexibility to manage minor fluctuations in throughput by resorting to following arrangements (resulting in resource pulling): -
• a.      Promote multitasking wherever possible.
• b.      Selectively extend duty hours of the staff by an hour at the expense of OT (Over Time) fee to the staff.
• 3.      However, for a larger spike in demand with throughput T2, the capacity may need sudden upgrade to C2 taking operations to CT2 Level. And once the spike phase gets over, the system may need to get back to original operational level of CT1.
• 4.      To take the OPD operations of a facility from CT1 to CT2 and back, the Hospital Manager may need an ecosystem ready to supply resources at the point of delivery within the response time(s).
• 5.      Normal operations of public facilities do not support such an elasticity to quickly scale-up and scale-down on demand fluctuations.
• 6.      Therefore, there is a need to redesign the Contingency-Ready system. Assessment of Preparedness and identification of gaps could be a starting point for such an endeavor.

 

 

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