CENTER FOR INNOVATION 2013 COMMUNITY HEALTH TRANSFORMATION

Transcription

1 CENTER FOR INNOVATION 2013 COMMUNITY HEALTH TRANSFORMATION Patient-Centered Care Plan

2 COMMUNITY HEALTH TRANSFORMATION The Center for Innovation (CFI) is partnering with the Mayo Clinic Health System (MCHS) and Employee and Community Health (ECH) to create, pilot, and implement a population health model that includes: Optimized Care Team A colocated, multi-disciplinary group that works together to meet the needs of a shared team patient panel. Patient-centered Care Plan A unified tool for patients, caregivers, and clinicians to see, make, and act on care decisions together. Wellness Navigators A volunteer-provided, clinic-embedded service that connects patients with resources to address social determinants of health. Community Engagement A clinic-based coordinator facilitates a self-sustaining, grassroots wellness movement with clinic and community champions. Triple Aim: Improve the health of the population, enhance the patient experience and reduce the per capita cost of care. Guided by the Triple Aim and informed by CFI s human-centered design approach, these projects are contributing to Mayo Clinic s preparations for the radical shift towards pay for value and accountability for the total cost of care. PATIENT-CENTERED CARE PLAN As a patient-driven design, the Patient-centered A combination of cutting-edge app characteristics, Care Plan creates a compelling, interactive clinic system connectivity, and Mayo Clinic s experience for patients to collaborate with their trusted knowledge and expertise is what makes care team. Patients and caregivers have a single Patient-centered Care Plan stand apart. place to communicate their priority concerns, to have meaningful conversations around the plan of Patient-important goals are presented alongside care and to understand all aspects of their health. clinic-recommended actions with the opportunity This tool is connected to the EMR, which means it for patients to ask questions and interact with their is automatically populated with the patient s most care team. Future iterations of Patient-centered up to date medical information. Care Plan will continuously aggregate data allowing care teams to deliver individualized experiences at Patient-centered Care Plan is game-changing in a population scale and proactively understand how the way it allows patients to engage and manage to best focus care delivery resources. their health care information. Other health care organizations and digital health companies offer Beyond improved continuity of care, there are experiences that incorporate personalized goals, financial and competitive benefits to implementing but lack the features and integration that enable care planning tools and processes, including State seamless communication of health information and of MN Health Care Home certification, NCQA collaboration with medical professionals. Patient Centered Medical Home certification, and Stage 2 Meaningful Use requirements. However, following a checklist of these guidelines alone will not necessarily produce an effective patient experience. 2 COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation

3 Built upon existing work in the field, informed by related Mayo Clinic projects, including Patient Online Services, and driven by CFI s iterative, human-centered design approach, Patientcentered Care Plan is being developed to provide a unified tool for patients, caregivers, and clinicians to see, make, and act on care decisions together. CONTRIBUTIONS TO POPULATION HEALTH TRIPLE AIM STRATEGY The Patient-centered Care Plan provides patients with a personalized experience tailored to their conditions, concerns, and priorities and supported by actions to help them manage their individual situation. When used in conjunction with the Optimized Care Team model, this tool enables an entire care team to help them every step of the way by providing ongoing support and guidance for health and lifestyle decisions between clinic visits. Patients are motivated to engage by clinic recommendations based on what is important to them. The Patient-centered Care Plan has potential to improve health outcomes by strengthening the in partnership with patients through personalized actions and the ability to interact with a care team. It is designed to be useful for patients in their daily lives, inviting them to engage around self-care choices and to ask questions when they need help. It provides the interactive decision support patients need to manage their chronic conditions and build healthy habits. The Patient-centered Care Plan can reduce the total cost of care by helping patients make informed, self-care decisions and enhance access to the right care at the right time. It improves access to care without additional clinic visits by providing a communication platform for the Optimized Care Team to remain connected with patients between visits and provide non-visit care within the context of patient-important outcomes. Designed to be as automated as possible and to learn as it is used over time, Patient-centered Care Plan can significantly reduce the labor costs of creating, maintaining, and reporting on plans of care and other quality measures. The Patient-centered Care Plan was developed by the Mayo Clinic Center for Innovation using an iterative, human-centered design process. Primary research interviews with patients and their families were used to test ideas and refine care plan concepts based on what worked and what didn t. I would highly recommend this to a friend or family member. Patient, 45 y/o male COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation 3

4 INSIGHTS One of my concerns is lack of communication between the various locations within Mayo. If they had one spot where they could make decisions about me, I wouldn t have to repeat myself as often as I do. Patient, 63 y/o male CURRENT CHALLENGES CFI developed the Patient-centered Care Plan through an iterative, human-centered design process. We tested concepts and learned what worked and didn t work through primary research with patients and their families. The objective was to craft an experience that would delight patients and help them meet their health and well-being goals. Patients perspectives, rather than the clinical perspective, were the primary driver. In our research, we found several key reasons why current care plans fall short of delivering information in a way that is meaningful and engaging for patients. There is no unified tool or process to deliver a single, overall plan of care + + Multiple plans of care exist today, created at the individual department level. + + These plans of care tend to focus on only a single facet of the patient s overall context and may contain conflicting instructions or not actually address the patient s priority concerns. Creating an individualized, unified care plan currently has a high labor cost. + + The current system requires a great deal of manual entry of redundant data to create and maintain a plan of care, often by licensed roles. This approach is not sustainable across our entire population of patients. + + Some data can be automatically populated today, but not all of the necessary information exists in the current documentation of patient care (e.g. patient-important goals, patient actions, and what to do ifs ). Current plans are often based on the assumption that patient goals are the same as clinic goals. + + Most plans of care, including the Impression Report Plan (IRP) section of clinical notes, are intended for clinician-to-clinician communication and focus on goals related to biometrics and medical status. + + Encouraging patients to follow their plan of care is not only about providing them with viewing access, but also about including their voice patient-important goals and concerns and an opportunity to interact with their care team through the care plan to achieve their personal goals. With current technology and processes, it typically takes an ECH Care Coordinator up to 2 hours to establish a Plan of Care for a newly enrolled patient. VALUES AND PERCEIVED BENEFITS: PATIENT ONLINE SERVICES SURVEY AUGUST 2012 Work with my health care provider Percentage of respondents (n=1014) Manage my health issues Stay in contact w/my provider(s) Issue very imporant POS very helpful in this area Understand my condition better Feel more in control of my health Listed in order by highest amount of gap Save me time 80% were not Mayo employees Included AZ, FL/GA, and Midwest patients Manage my health at a distance Prepare for upcoming appts Survey questions were customized for each portal (GE and Cerner) Share info with family/friends 0% 10% 20% 30% 40% 50% Conducted prior to broad roll-out of Secure Messaging 4 COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation

5 CHT: PATIENT-CENTERED CARE PLAN Digital care plans currently replicate paper-based forms, missing the opportunity to be built for the web and incorporate interactive features. + + By replicating paper forms intended for clinic use, these digital care plan documents often contain superfluous information that obscures elements that are important and useful to patients. + + This static documentation approach, rather than an interactive, living information approach, misses the opportunity to create collaborative experience for patients around their plan of care. The current online care delivery experience was created to display information rather than designed to be a collaborative, interactive experience for patients. + + Patient Online Services the patient portal and mobile app has established an important foundation for displaying health information in an open and transparent way, including clinic notes, secure messaging, and lab results. Patients have valued the access and convenience of the current features and continuous improvement of the experience. + + Currently, we are only scratching the surface of online care delivery and significant opportunities remain to deliver a compelling experience for patients that they return to again and again. Patients want to actively collaborate with Mayo Clinic s services to address the issues that are important to them - understand my condition better, manage my health issues, work with my health care provider, and prepare for upcoming appointments. CARE PLAN DESIGN PROCESS 25 Stakeholders 5 Workshops 13 Care plan insights Understanding user needs What is a Care Plan? A shared reality we create together with people. What is needed? A unified tool for people inside and outside of Mayo Clinic to see, make, and act on care decisions together. PATIENT-CENTERED CARE PLAN DESIGN AND DEVELOPMENT PROCESS Patient-centered Care Plan aims to provide a simple, elegant solution that brings focus to the content that is most important to patients. The user is brought directly into the content and can quickly access the information they need by scrolling through the page or using the menu. The front-end user design and back-end intelligence enables content to be displayed and delivered dynamically, based on what is relevant to that individual patient at that moment in time. Testing a range of ideas 1 Information map 6 Framework concepts 11 Patient interviews ECH Adult Care Coordination and Charter House Oct 2011 Jan 2012 Fall/Winter 2012 Spring 2013 Summer/Fall 2013 During early rounds of user interviews, patients provided rich feedback regarding the composition, design and aesthetics. However, as we began to delve deeper into the design, it became more difficult for users to provide input based on generic care plan information. To alleviate this problem and ensure high quality feedback, we created a functional mock-ups and shadowed patient visits. We populated the Patient-centered Care Plan concept with the patient s individual care plan information, which allowed them reflect more personally on how they might use it and provide us with deeper feedback on the design. Testing a single, refined idea 1 Concept mockup 13 Patient interviews Usability Lab and Home Visits 21 Provider and AH staff interviews Rapid prototyping enabled by existing IT web services 1 Care Plan prototype 2 Future Care Team tests 50 Patients to participate COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation 5

6 DESIGNING A CARE PLAN FOR PATIENTS Patient-centered Care Plan evolves based on collaborations between patients and their care teams, including their informal caregivers. The look and feel of the experience plays an important role in setting the tone for these interactions, establishing a warm aesthetic and sense of emotional connection throughout the design. Our aim was to create a patient-centered experience that would be inviting, enjoyable, and attractive. In response to being shown a Patientcentered Care Plan mock-up populated with their own Priority Concerns following a provider visit, patients interviewed said they felt that we were truly listening. Positive comments were made about simplicity of the single-page layout presented by the interactive mock-up. A theme from the interviews was the intimate, individualized experience it created, including a comment that for the first time they felt connected to their health care in a way they hadn t been before. I would buy a computer just to use care plan. Patient, 54 y/o female Patients prefer to have conversations based on their priorities. They do not want to be dictated to or instructed in generic ways that do not align with their greatest concerns. Understanding this, it was important that Patient-centered Care Plan represent the patient s voice and deliver content in a usable, patient-friendly way. Patient-centered Care Plan is meaningful to patients because presents information in a way that speaks to the realities of their daily life and individual situation. How can care teams care for a large, diverse panel of patients and still deliver highly personalized experiences? Each patient s care plan is comprised of discreet data elements managed by relational databases, which can automatically populate information and provide clinical decision support. As Patient-centered Care Plan is adopted and used by care teams to collaborate with thousands of patients, it presents a powerful opportunity to learn what works for different patient groups, continuously build knowledge to inform best practices, and use automation to deliver individualized, high-touch experiences at a population scale. Priority Concerns Nearly everyone has areas of their overall health they would like to improve. The Priority Concerns section focuses specifically on that the area in which the patient wants to see change or improvement - as a key motivator for patients. This is the focal point of the Patient-centered Care Plan experience. The implication of the word goal varies greatly among clinicians and between patients and providers. We found that Priority Concern was the preferred term for effectively expressing and capturing patient-important goals. Actions Patients can update and learn how to address their Priority Concerns through Patient Actions recommended by their care team. Actions are presented in a way that invites patients to ask questions and interact with their care team for support and guidance. This provides a framework that is relevant across a population, whether a patient s concerns are related to the complications of a serious illness or a desire to establish healthy habits. 6 COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation

7 What does the word goal mean to you? What to Do If In the reality of daily life, patients sometimes guess at or ignore provider guidance. They may not know what is normal to experience with their condition or, without realizing the implications, might skip a medication or not follow care advice when other factors in their life get in the way. Something you re looking forward to doing. Patient working with ECH Care Coordination Patient-centered Care Plan provides the What to Do If section to help patients make informed decisions based upon common occurrences associated with that patient s combination of diagnosis, concerns and medications. While these questions are sometimes part of a visit discussion, the information is only occasionally captured, often as handwritten instructions on the patient s visit sheet. Patients, their caregivers, and care coordinators identified What to Do If information as very important and highly useful, particularly when managing chronic conditions or navigating the experience of a serious illness. COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation 7

8 Recent Clinical Notes We found that patients Priority Concerns were not always directly related to their medical diagnosis. Providers in different practice areas have different perceptions regarding priorities and goals. What patients felt was most important often did not align with the problem list in their medical record. While secondary in importance to patients Priority Concerns, problem list information still provides important context for patient and caregiver decision-making. We identified the Impression Report Plan (IRP) section within a clinical notes as currently the best available information related to patient diagnosis, symptoms, and provider notes for management. Messages Patient-centered Care Plan creates a collaborative experience between patients and their care team. Messages provide a way of communicating and making decisions together between visits. Patientcentered Care Plan provides the opportunity to ask a question at any time via the link on the right hand side of the experience. The Messages section is the patient s overarching communication inbox that curates all incoming and outgoing communication between patients and care team. Whether it originates from a section of the Patient-centered Care Plan, is a message exchange or photo sent from the patient via mobile app, or is a note documenting a phone call with the patients it can be found here. Patient interviews indicated that the ability to message their care team provided a sense of security and support for patients. Knowing that an answer would be available when they needed it was reassuring and contributed to patients confidence when faced with health challenges. 8 COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation

9 Medications Patients felt that integrating their medication list into their care plan experience was very useful; particularly when displayed in a way that included how and when to take it, how much to take, and what it was being taken for. Patient-centered Care Plan improves on the current medication list by enhancing readability and providing an opportunity for greater collaboration between patient and care team. Patients can ask questions, report how effectively a medication is addressing their symptoms, and answer questions that gauge their understanding of their medications. By inviting greater patient engagement, this interactive medication list has the potential to support decision-making and remain more up-to-date between visits. Calendar In early concepts, a timeline-driven approach resonated with patients who wanted to interact with their information based on where they ve been, where they are, and where they re going. This was particularly useful for patients who had frequent appointments and rechecks as well as for caregivers who were helping coordinate and keep track of someone s care and condition history (e.g. previous hospitalizations or medications that had been tried and didn t work). The calendar section displays upcoming visits, milestones, and recommendations for preventive services. It has the flexibility to display an itinerary for patients who have multiple appointments within a day as well as a longitudinal view for patients with infrequent clinic appointment or preventive service needs. Appointment information is automatically populated and patients can add other appointments, establish milestones for goal, or synch to their preferred calendar service. COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation 9

10 Optimized Care Team A colocated, multidisciplinary group that works together to meet the needs of a shared team patient panel. My Care Team Patients want to be connected with their care team and for that connection to feel welcoming and familiar. Easy-to-find contact information and photos help connect patients with their team. Patient-centered Care Plan comes to life when it is used in conjunction with the Optimized Care Team model because it enables the team to provide more non-visit care and ongoing communication with patients. By using Patient-centered Care Plan to collaborate with their team, patients feel that their care team knows who they are and cares about their concerns. The Care Team section of Patient-centered Care Plan supports an integrated, collaborative union of forces approach to care by: + + Allowing patients to invite others to be part of their broader care team and use the tool with them - family, friends, or other providers. + + Acknowledging the important role that informal caregivers play to help patients manage their conditions. + + Including specialists who patients and their care team can tap into for additional opinions and recommendations. + + Connecting patients and care teams with the day-to-day support of caregivers and the expert knowledge of specialists. 10 COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation

11 Profile Patients can help their care team deliver care more effectively by providing contextual information about themselves and their preferences. They can update their personal information (demographics, power of attorney, advanced directives), download printable or -ready versions of their care plan, and view their labs and vitals. Often, these are documents and information that are important for clinical care continuity, but less important in the daily experience of patients. Patients find biometric information useful for knowing if they are within the recommended clinical norms and for making decisions based on biometric data. However, as a motivator for actively engaging in everyday self-care and lifestyle changes, biometric data alone plays a less important role than patient priority concerns. DESIGNING PATIENT-CENTERED CARE PLAN FOR THE CLINIC The clinic-facing view of Patient-centered Care Plan can streamline information for decisionmaking and reduce clerical burden by putting everything the care team needs to know about that patient in one centralized location. When patients interact with Patient-centered Care Plan, updates and notifications are displayed in real-time on the clinic-facing view. This allows the care team to interact with their patients within a holistic context with content ranging from patient concerns and preferences to their latest labs and clinical notes. COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation 11

12 Care Plan Summary Tab This provides the overall visual landscape of a patient s care plan content. The care team can see what their patient s priority concerns are, view the latest clinical notes or problem list, and update actions or communicate with the patient. The Top 5 Things You Need to Know support patient-centered care and decision-making. These reference points might range from the patient s fear of needles to their reliance on a family member for transportation to the fact that their spouse recently passed away. It is information input by the care team, not typically captured or easily found within the EMR. Patients shown a mockup with their information felt they would use the Patient-centered Care Plan 2-3 times a month. Patients who expressed interest in connecting third-party monitoring products (Fitbit, Nike+, etc) felt they would interact with the tool on a daily basis. Care plan is great, but if I could incorporate my Fitbit, track calories and such, that would be fantastic! Patient, 52 y/o female Opportunities PATIENT ACTIVATION By testing a working Patient-centered Care Plan prototype with patients over a period several months, we can begin to learn whether this interactive experience will have an impact on patient engagement. In addition to patient-reported behaviors, health outcomes, and satisfaction, we will look at the frequency with which patients communicate with their care team, provide status updates on their actions, or update content. Ultimately, we would expect clinical outcomes vitals, labs, and quality metrics to be positively impacted, but in early, limited experiments we will primarily focus on tracking patient and care team interactions and gathering feedback from patients and staff about the experience of using the tool. MOTIVATE ACTIVATE SUPPORT A TOOL FOR OPTIMIZED CARE TEAMS The Optimized Care Team model establishes the practice changes that can bring Patient-centered Care Plan to life. It will be important to test Patient-centered Care Plan in conjunction with this model, which supports increased non-visit care and emphasizes the importance of addressing all of a patient s concerns with the right care, in the right way, at the right time. We will test the potential for the Patient-centered Care Plan tool to increase the Optimized Care Team s capacity to care for a growing number of patients with chronic conditions and comorbidities. We will observe how care team members use the clinic-facing view to improve continuity for patients and share work as a team. We will test the hypothesis that this view will reduce the amount of time the team spends looking through the various notes and pages within the record to find a patient s information and understand their situation. Driven by patients own priority concerns, attitudes, and beliefs Recommended actions are based on individual patients priority concerns and personal context Communication with formal and informal care team members provides what is needed along the way - encouragement, guidance, information. The functional prototype can also serve as a testing ground for deploying standardized and required assessments making it possible to deliver and track this information more effectively with reduced clerical burden. 12 COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation

13 OPPORTUNITY FOR NON-VISIT CARE 16% could have been an RN visit 18% could have been non-visit care 66% needed an NP / PA / MD visit Q Optimized Care Team experiments showed potential for increased non-visit care and RN visits, which could be supported by the features of the Patientcentered Care Plan tool. Establishing a Patient-centered Care Plan for a patient will require discussing their Priority Concerns, Patient Actions, and What to Do Ifs with them and inputting these into the tool. We will test the process of capturing patient priority concerns by using a simple walk-through that includes prompts based on motivational interviewing techniques. This could occur during the rooming process or as part of a visit with a provider or nurse. As a care team uses Patient-centered Care Plan over several months, we will also gain insight into our hypothesis that, if linked to a relational database and meta-tags, Priority Concerns, Patient Actions, What to Do Ifs, and other manually entered fields can begin to provide automated suggestions for providers based on the contextual information of that patient or similar patients. 36% would have benefited from an integrated team care as part of the visit (e.g. pharmacist) A PORTABLE MAYO EXPERIENCE The use of the Patient-centered Care Plan doesn t have to start and stop at Mayo Clinic. Just as this tool will support seamless interactions for patients seeing multiple Mayo Clinic clinicians across our departments and campuses, it can also enable care in partnership with outside medical professionals, caregivers, and patients. Patients experience with an integrated approach to care no longer needs to be constrained by geography. With Patient-centered Care Plan, anyone will be able to collaborate with their local providers, social workers, therapists, or other health care professionals, including those at Mayo Clinic and in the Mayo Clinic Care Network. Even within the limitations of early prototypes, we can begin testing the My Care Team feature that allows patients to invite others to use Patientcentered Care Plan with them. Patients caregivers, particularly the adult children of aging parents and parents of seriously ill adolescents, benefit from knowing their loved one s What to Do Ifs, clinic-recommended actions, and having a way to communicate with the patient and their care team together. Patients were shown cards labeled with different categories of information and were asked to identify what was most important to them. (Pointing to card friends and family involved in my care ) These are very good... friends and family. Because our daughter-in-law does all our checks and pays the bills and the other one does the medications. Patient and caregiver for her husband, both working with ECH Care Coordination With more study, we will learn the impact of this interaction on health outcomes as well as patient preferences related to managing permissions and access to their Patient-centered Care Plan. COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation 13

14 Diffusion Clinical Systems Terms Synthesis: A viewer used widely within Mayo Clinic Rochester. Cerner: EMR used in the Mayo Clinic Health System (MCHS), Arizona, and Florida. Centricity: EMR used at Mayo Clinic Rochester Amalga: A data aggregator that pulls from multiple sources and enables a population view of patient information. Currently used In Mayo Clinic Rochester and being piloted in MCHS. BUILDING A FOUNDATION TODAY TO ENABLE TOMORROW S TECHNOLOGY LEAP Patient Online Services Clinical Systems Patient-centered Care Plan was developed to be The Patient-centered Care Plan is an EMRagnostic an interactive, patient-driven experience. The platform. The current prototype pulls from interface contains many existing elements within existing data sources and is delivered embedded in the Patient Online Services portal and Mayo Patient the care team s current digital experience - the App - Secure Messaging, Medications, Labs, and Synthesis viewer. As the application framework for Clinical Notes but brings them together in a web services, business logic, and data sources different way. continues to become more robust at Mayo Clinic, it presents the opportunity for a more flexible, rapid The Patient-centered Care Plan invites patients approach to user experience innovation than to interact, focuses the information on patients previously possible. personal goals, and reinforces a connection with a care team of clinicians and caregivers. Patientimportant Many of the components of the Patient-centered elements have been added as the Care Plan exist in clinic databases today, which primary information - Priority Concerns, Actions, has enabled a fairly comprehensive prototype. and What to Do Ifs. Elements that are not consistently documented in a retrievable way - Priority Concerns, Actions, and By conducting research with the Patient-centered What to Do Ifs, and indications for medications Care Plan prototype, we can understand where to are managed in a secure, temporary CFI database invest in next-generation capabilities and inform for research purposes. A more permanent data future functional requirements to deliver management solution and production-level unparallelled online experiences for our patients. programming will be required for a final product. FUTURE VISION: AN INTELLIGENT ADAPTABLE SYSTEM During our prototype build, we have learned that user interfaces like the Patient-centered Care Plan can be developed, delivered, and improved upon more rapidly within an integrated application framework that includes robust business logic and data access layers. Flexible & Responsive Delivered as people need it. Patient Interface Invited Caregiver & Provider Interface Care Team & Clinic Interface Presentation Layer User Interface (UI) UI process components What users - patients and staff - need to be able to see and do. Electronic data capture Assessments and reports Dashboards and task lists Manage panels / populations Decision support information Communicate contextually Business Layer Application facade Business workflow Business components Business entities Intelligently assists workflow Knows context of presentation layer and credentials / needs of person accessing it Has situational awareness Knows location, active patients, condition status, care pathways, resource availability, today s tasks / team, etc Data Access Layer Data acess components Data helpers / utilites Service Agents Performance standards UI standards Defines best configuration for presenting the data from the trusted data source. External access governed and supported for federal reporting, scholarly comparison, clinical pathways, data validation to a source system ACROSS ALL LAYERS: Security Operational management Communication Data Services Web services / Interfaces Big data and Analytics Data Storage Layer Oracle TRC Electronic Data Trust Clinical Data Repository Optum / Humedica Decision Support Sys 14 COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation

15 FUTURE VISION: PATIENT-CENTERED CARE PLAN DEVELOPMENT AND IMPACT Patient-centered Care Plan is an element within the OPHM initiatives. Mayo Clinic ehealth and the Office of Information and Knowledge Management will also be key development partners. It is a tool that will support the Triple Aim across Mayo s primary care panels. It has the potential to play a significant role in delivering Mayo Clinic knowledge and decision-making support to 200 million. Proof of Concept Experiment Production Development and Testing Pop Health Production Release System-wide Roll Out for Population Health Develop and Expand Features for Subspecialty Practice and External Licensing 2 ECH Care Teams 4-6 Optimized Care Teams OPHM Pilots: 4-6 Clinic Sites OPHM DIffusion: Across All Sites Future potential partners: Project Mars Practice Redesign Center for Connected Care Center for Individualized Medicine Mayo Clinic Care Network Lives touched 50 26% U.S. adults with multiple chronic conditions - National Health Interview Survey, 2010 Care Team panel size of 6,000 From total weighted primary care panels Destination practice only 6,200 to 9,300 25,000 to 56, ,000+ 1,000,000+ Research and Patient Experience The clinic-facing view of Patient-centered Care Plan has the potential to function as a customer relationship management (CRM) tool, helping care teams understand how to best meet the individual needs of the patients they serve. From Prototype to Production The successful development and diffusion of Patient-centered Care Plan is dependent upon new clinic workflow processes and practice changes that support increased non-visit care - like the Optimized Care Team model - to bring it to life. Combining clinic-provided information alongside patient-reported outcomes has the potential to build knowledge for research and clinical decision support when aggregated across thousands of interactions with different patients across the Mayo Clinic enterprise. As a platform, it anticipates the new roles and tasks required of care teams in a pay-for-value environment. As a tool, it can support and reinforce the rapid practice changes that will be necessary to re-center the system on patient needs - clinical and non-medical. This intelligent, predictive clinical decision support holds the potential to reduce the amount of time spent manually entering redundant data, contribute to enterprise-wide practice standardization, and ultimately support the creation of an individualized, interactive care plan for every Mayo Clinic patient based on what we ve learned works best for patients similar to them. Ultimately, Patient-centered Care Plan presents a broad-reaching opportunity to not only touch the lives of Mayo Clinic patients, but to also be available for anyone who seeks Mayo Clinic knowledge and decision support to optimize their health and well-being. COMMUNITY HEALTH TRANSFORMATION Mayo Clinic Center for Innovation 15

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