Kick-off meeting of the TOWWERS showcase project: 1^st collaborative value-based healthcare anchored on real-world data involving the 5P+

ABSTRACT

The COVID-19 pandemic has highlighted the need to modernize healthcare systems to the reality of the 21st century. The first world-wide Strategic Committee to launch Collaborative Value-Based Healthcare (C-VBHC) anchored on populational Real World Data and structured collaboration, took place in Montreal, via TOWWERS showcase project. The meeting covered a broad range of topics from the perspective of each of the various Real-World healthcare actors, the 5P+: Patient, Prescriber, Producer, Policymaker, Payer, including Data and Research stakeholders. Attended by approximately 20 participants from North America and Europe, the meeting provided a valuable opportunity to unit the 5P+ around common goals and exchanging on solutions. TOWWERS Strategic committee identified key elements required to continue the transformation.

KEYWORDS:

• Market adoption modernization
• care gaps improvement
• populational RWD/RWE
• structured collaboration
• convener
• strategic committee
• value-based healthcare
• COVID-19
• healthcare system transformation
• chronic disorders

1. Introduction

The COVID pandemic has highlighted the need to modernize healthcare systems to the reality of the 21st century. The government of Québec understands the need to move toward a value-based healthcare (VBHC) approach. Also recognized is the importance of collaboration amongst the various healthcare stakeholders (real-world actors) in the goal of modernizing our healthcare system for improving health and wealth of our nation reaching the triple aim. We need RWD to measure results so that we can link therapeutic plans to health goals. We also need to link price to value to address many health economics and outcomes research trends reported by ISPOR regional consortia and network leaders [1]. Champions, including the government, recognize that the TOWWERS system could represent an interesting avenue to reach this goal and thus they endorsed the TOWWERS showcase project. The goal of this kickoff meeting was to officialize the launch of the TOWWERS showcase project and to validate that the committee was aligned to move toward common goals and actions. Specifically, the focus was on taking the first steps toward development of transparent and ethical collaboration guidelines for and with all the healthcare stakeholders in the desired process of healthcare transformation over time.

The kickoff meeting of TOWWERS™ Strategic Committee, convened by Data 4 Actions, took place in Montreal, Canada, in 2021. It represents the first world-wide initiative to convene a Collaborative-Value Based Healthcare anchored on Real World Data (C-VBHC-RWD™). The Strategic Committee has thus initiated the first steps of a global healthcare transformation. The committee members included recognized leaders representing the 5P+^TM: Patients, Payers, Prescribers, Producers, Policymakers, and leaders representing Data and University/Research. Attended by approximately 20 participants (active members and observers), from North America and Europe, the committee provided a valuable opportunity to hear from the various healthcare stakeholders. United around common goals and exchanging on solutions to facilitate the launch of Collaborative Value-Based Healthcare anchored on RWD, the committee identified and endorsed the key elements required to continue the transformation.

The meeting’s goal was to discuss the ongoing process to move toward collaborative C-VBHC-RWE™, and validate the key elements required for this transformation. The strategic committee was chaired by Julie Frappier, a senior health economist with extensive training, over 30 years of global expertise, CEO of Data for Actions and Founder of the TOWWERS™ System. Participants included active members and observers (Appendix 1 & 2), over and above the convener of this initiative.

2. What is TOWWERS?

To solve the complex problem of transforming healthcare paradigms into the reality of the 21^st century, we need to bring key people and specific data together. The healthcare industry is data rich, yet information poor. TOWWERS is a unique system that facilitates the conversion of health and economic populational data into insightful information for the healthcare industry actors via a structured collaboration involving the 5Ps (Figure 1). The structured approach enables the transformation of healthcare paradigms, over time, toward collaborative value-based healthcare anchored on real-word data and the triple aim, in line with OECD’s vision of the next generation of healthcare reforms [2]. This could empower more appropriate evidence-based medical decision-making, yielding more effective interventions and improved patient outcomes over time. The integrated platform enables the tracking of the patient journey over time and improvement in communications among patients and their various health care professionals, thus promoting interdisciplinarity.

Figure 1. A transformation system moving from a sickcare toward collaborative value-based healthcare anchored on RWD.

*RWD composed of economic markers

** RWD composed of economic and health markers customized for specific therapeutic indications

3. Background

Frappier summarized the history leading to the creation of the TOWWERS™ System several years ago. Three of her project submissions were rejected by Health Technology Assessment (HTA) organizations, 2 for medications and 1 for a medical device, in 3 different countries. Reviewers questioned not only the economic assumptions but also clinical relevance, although the products had the potential of generating significant value for the 5Ps. Shortly thereafter, the theme of an ISPOR symposium was [3]: “Patient Centredness, Value, Affordability: Can we have it all? Frappier’s response? ‘Yes, if we modernize our way of collaborating. Yes, if we modernize how we manage data.’

‘Sickcare’ was implemented a half a century ago in developed countries to manage acute medical events. Frappier founded the TOWWERS™ System based on the recognition that the status quo needs to be transformed to adapt to the increasing complexity of the 21st century, including market adoption, prevention and personalized healthcare. Frappier and a team of internal and external collaborators developed a system enabling the transformation of healthcare which strives to achieve the triple aim,¹ in a sustainable manner for and with the 5P+^TM. The system has the ability to respond to an unmet need recognized by the 5P+^TM, and enables the transformation of the OECD vision into results as a first step to initiate this transformation [2].

She explained that in today’s environment in which healthcare represents a significant portion of governmental budgets [4,5], due to the increasing frequency of chronic disorders [6], there is a need for connectedness among the 5Ps™in healthcare delivery and an appreciation of the true value of innovation over time [7,8]. The team believes that a transition toward C-VBHC-RWE™ (Figure 1) is required to transform our current ‘sickcare.’ The collaboration among all the 5Ps™ represents a key ingredient for success since most of the largest challenges have been the result of various groups working in independent silos with different end goals [9]. To optimize the success of such complex collaboration, an additional player is required in this ecosystem: a convener [7], one that must be collaborative, dynamic, independent, transparent, and neutral toward the 5Ps^TM. For this pilot project, the strategic committee endorsed Frappier’s team as a convener to work with and for the 5P+™.

Frappier’s team met with various actors globally representing the 5P+™ to validate the TOWWERS™ vision. Implementing a new process is never without its challenges. A CADTH webinar presented by Dr Renaldo Battista explaining how Health Technology Assessment (HTA) began with small goals and champions and has evolved over time, was a great inspiration to the team in the development of the first strategic committee and implementing the first steps [10] .

4. Strategic committee structure

The members representing the 5P+™ (Appendix 1) were selected based on their reputation as leaders in the health community, their recognized dissatisfaction with status quo, recognition of the need for change and belief in moving from a system of “Sickcare “to ‘Healthcare’ through a C-VBHC-RWE™ approach. The responsibilities of the members of the strategic committee had been previously outlined to them (Appendix 3). The convening of these players, united around a common goal, is a historic event as highlighted by one of the members during the meeting. This virtual meeting was facilitated by Zoom®.

5. Terminology defined

During the meeting, it was essential that the strategic committee first establish a common consensual terminology. Efficacy, effectiveness, and efficiency were differentiated. Efficiency was described as an economic theory comprised of two sub-concepts, both of which respected the efficiency criteria depending on the primary established goal: The Mini-Max and the Maxi-Min. The Mini-Maxi first establishes the allowable budget and then aims to achieve the best possible result with the given funds. Frappier explained that TOWWERS™ seeks to implement the second, the Maxi-Min approach. The initiation point is no longer ‘how much money is available?’ but rather, ‘what is the goal?,’ and with that goal in mind, what are the reasonable resources that are required to achieve that intended goal?, as stated by Berwick [11]. Hence the Maxi-Min economic theory forms the basis of what we currently refer to as VBHC and has been well described by Teisberg [12].

The concept of patient-centeredness represents an evolution from the traditional approach in that the patient is the initiation point of healthcare delivery. Eva Villalba, patient representative and VBHC specialist, explained the application of this concept in the context of a VBHC. ‘First, the patients are the initiation point. A sick or potentially sick patient goes at a doctor’s office with a problem. The healthcare professional then creates a treatment plan based on his patient’s health condition, the patient-specific-environment and individual patient preferences. Patient-centeredness represents one of the components of the triple aim [13], Patient-Centeredness with Value and Affordability, rather than prioritizing only one of these goals. Hence patient-centeredness is not merely about the patients’ desires, but also about adapting the goals and personalized therapeutic plan to the patient, within the context of existing healthcare constraints.’

Frappier continued that the implementation of the Maxi-Min model requires that an information system be put in place that allows for the collection of health and economic data, and only upon collection of the relevant information, can we move gradually toward the Triple Aim [13]. TOWWERS™ is viewed by many stakeholders as the process and tool for change. Allowing the status quo to persist implies the renunciation of change. The creation of a structured collaboration and a platform capable of documenting populational RWE (health & economic) is the first step in the transformation of our system of ‘sickcare’ to one aiming collaborative value-based healthcare.

6. Strategic committee insights

A discussion among the Committee members followed Frappier’s presentation. The major insights are highlighted in Table 1.

Table 1. Thematic summary of stakeholder (5P+) Statements

Theme	Stakeholder Insight
Privacy and Security	Security is a serious issue
Need for Real World Data	There is a clear need for RWD. We must establish a process to overcome this hurdle in order to move forward. This point was endorsed by all committee members. Decisions currently taken based on results of clinical trials could be greatly improved by the availability of RWE via a dashboard detailing the patient’s overall treatment. There are no tools in Quebec presently to collect RWE
Accessibility to Integrated Patient Data	The main weakness of the healthcare system is the difficulty in accessing data. Pharmacists can have access to patient information only within the confines of a GMF (family medicine group). Family physicians have difficulty understanding the reports of specialists. We need to see the data over the long term, rather than the short-term data from demonstration projects. Existing electronic records do not interact with each other [14]. Health practitioners require access to health outcomes to measure the efficacy of their therapeutic plans which involve behavioral interventions as well as prescription medications. A platform accessible to all health professionals, to link their documentation, would be highly beneficial. Pharmacists could assist with documentation of patient compliance Professionals want to monitor the care they are administering as well as their patients’ adherence; if they note that a patient in non-compliant, they recognize that they need to change the treatment plan.
Patient-centredness	Patient-centeredness must be applied in the context of a VBHC system We must identify the needs of patient to determine value. Developing partnerships with the patients would allow health care professionals and the system to become more patient-centered
Interdisciplinary Effective Healthcare Team	There is little evidence of concrete interdisciplinarity. Team members are unaware of the responsibilities of the other members [8]. The Quadruple Aim [15,16] which includes Care Team well-being as a key component to a quality healthcare system, as reflected in personnel shortages during Covid-19 which reduced patient access to care.
Value Based Healthcare and Innovation	The practical application of VBHC will demonstrate its value. We must measure costs in the trajectory and identify an optimal healthcare pathway. Quebec is in a good position for transition as it has a culture of measuring and gaining a clear vision, underlining the importance of evidence-based data. Resistance to measurement is based on a perceived sense of judgment by some practitioners and is not understood as continuous quality improvement. We are working in silos [8,14] and that there is much work to be done. Costs are currently considered in silos and not in relation with the value of each innovation and that this culture needs to change

The TOWWERS™ System, which has evolved through multiple discussions with multiple stakeholders over the years, locally and internationally, has reached its current level of readiness for launch.

7. Transforming the OECD’s vision into results

In January 2017, the OECD held a ministerial meeting to propose the Next Generation of Health Reforms [2]. One of the goals of the TOWWERS™ System is to enable the transformation of the recommendations of this recognized organization that involved multiple countries into results.

The OECD proposition’s primary elements included patient-centredness, high-value health systems, innovation – technology, collaboration, RWE, and big data. This would yield an improvement in health system performance, health system governance, patient accountability, populational health, knowledge, informed decisions, and reduction in duplication. However, no action plan as to how to move from a vision to concrete results was offered. Frappier and her team believe that for the OECD health reform recommendations to be transformed into reality, a structured collaboration with/by the 5Ps™ is required as well as a modernized data system, as provided by the TOWWERS™ System.

8. Ingredients for success for C-VBHC-RWE™

Multiple meeting participants requested that a platform such as myTOWWERS™ be implemented. According to Drucker [17], ‘What gets measured gets managed.’ This is particularly pertinent during a pandemic in which the only information collected thus far, has been the number of deaths, hospitalizations, and new cases. The question was raised by Frappier and her team ‘is this really enough?,’ referring to access to more Real-World Data (RWD), a structured collaboration with and for the 5Ps™, endorsed common goals & KPIs, a clear understanding that the process is dynamic, and ultimately, that in time we will be able to adapt our thinking to not ‘how much’ but to ‘what is the goal?’ and thereafter questioning ‘did we reached the goal’? If not, ‘what are the next steps’ with and for the 5Ps?

The first necessary step for sustainable C-VBHC-RWE™ to be achieved is the endorsement by government. Subsequently, a new actor, a convener [7], with and for the 5Ps™, must be added to the ecosystem. This convener must be transparent to ensure that clear goals, roles, and regulations are adopted. This essential structured collaboration with and for the 5Ps™ will be monitored, maintained, and ensured by the Strategic Committee representatives of the 5P+™. A new vision in which the inversion from a Maxi-Min- to a Mini-Max- based approach⁷ as standard of care should take shape from that point going forward.

The launch of a system such as TOWWERS™, could ultimately transform our ‘sick-care’ system toward a true ‘healthcare’ system, a value-based healthcare system aiming the triple aim. Linking dynamic clinico-economic RWD, health and economic, to all the following parameters is a crucial step to ensure its progress. Connecting diagnoses, therapeutic plans, health results and risk factors over time will provide greater insight into the underlying relevance of the RWD and will facilitate more meaningful decision-making and help determine a more realistic action plan for the future.

9. Conclusion

TOWWERS’ Strategic Committee, including the government, endorsed that structured collaboration and RWD must be modernized to today’ reality. A critical step for the Strategic Committee is the development of transparent and ethical collaboration guidelines and assure that they are respectful of the 5P+s over time. We need a system facilitating more meaningful, modern, decision-making that can have an impact to build actions plans, with and for the 5P+, rather than a largely government centric approach. Finally, we must keep in mind that collaborative VBHC aiming for the triple aim is not a destination but a journey.

We are privileged and extremely pleased to implement this showcase project with the support of our champions, members of the Strategic Committee. The evolution of this complex yet exciting venture should trigger a process leaving behind the status quo and moving toward the next generation of health reform outlined by OECD.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Declaration of interest

M Frappier and J Frappier confirm that they are shareholders of Data 4Actions, the organization that has created and implemented the TOWWERS system. M Huard was a student working for Data 4 Actions during the process leading to the strategic committee and the publication. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Acknowledgments

Over and above the contribution of our authors during the process leading to this kick-off meeting and this publication, we would like to acknowledge the significant contribution of these experts for participating in the various milestones leading to the creation of the strategic committee, the kick-off meeting and all the next steps for transforming a vision into results: Eve Blanchet (Boehringher Ingelheim), Marc Pesant (CIUSSS du Nord-de-l’Île-de-Montréal), Alain Bakayoko (PME MTL), Stéphane Barakat (AbbVie), Julie Savage-Fournier (JSF Optimisation), Paul L’Archevesque (Bureau de l’Innovation), Dr Claude Guimond (FMOQ), Dr Anouck Taster (CISSS des Laurentides), Carolyne Roy (Clinique chiropratique le carrefour), Hawa Sangho (CUISSS-MCQ), Anne Lee (NHS National Services Scotland, Scottish Medicines Consortium).

Additional information

Funding

This paper was not funded.

Notes

1. Patient-centeredness, Value and Affordability.

APPENDIX 1

– Strategic Committee – Active Members Representing the 5P+™

1. Patients: Eva Villalba (Coalition Priorité Cancer Québec)

2. Prescribers: Dr Pierre Martin (Groupe de Médecin de Famille du Cap)

3. Policymakers : Nadia Nour (By interim, Bureau de l’Innovation, April 9th 2021)

4. Payers : Jacques L’Espérance (J. L’Espéreance Actuariat Conseil)

5. Producers : Anie Perrault (BioQuébec)

6. Data : Barbara Decelle (IVADO)

7. University-Research: Anne-Marie Larose (Ex-Aligo)

APPENDIX 2

– Strategic Committee – List of Observers

1. Alain Bakayoko (PME Montréal)

2. Ève Blanchet (Boehringher-Ingelheim)

3. Isabelle Fauchon (Hackordage, Communicangel, HEC Paris, Paris, France)

4. Marilyn Krelenbaum (Consultant to the healthcare industry)

5. Marc Pesant (CIRTES)

6. Valérie Viau (Synchronicité)

7. Richard Fahey (Appeco)

8. Stéphane Barakat (AbbVie)

9. Manon Frappier (Data 4 Actions)

APPENDIX 3

– RESPONSIBILITIES OF STRATEGIC COMMITTEE

1. To work together collaboratively

2. To participate in the transformation and modernization of the healthcare system via a process of Collaborative Value-based healthcare based on real world evidence in order to improve the health and wealth of the nation, in which all the actors will win by participating in this transformation (Pareto-optimal Optic).

3. To represent the vision and mission of the stakeholder group of which they are a part.

4. To collaborate objectively in order to identify solutions to advance the cause (transformation to a Collaborative-Value-based healthcare system based on RWE)

5. To propose financial and non-financial partner of success to optimizer the success of this showcase initiative

6. To advise on solutions when faced with issues that could pose obstacles to the cause

7. To actively participate in discussions in order to achieve excellence and a consensus among members

8. To direct the committee toward a collegial, respectful and collaborative process and to work with the team, while at the same time, demonstrating the courage and desire to offer independent opinions and advice.