Clinical and Cost Improvement for Population Health The Roles of HIT/CDS

Transcription

1 Clinical and Cost Improvement for Population Health The Roles of HIT/CDS David Classen MD MS University of Utah and Pascal Metrics This presenter Discloses that he is an employee of pascal metrics a patient safety organization Session Objectives P2 Identify the potential of evidence-based clinical decision support for improving cost and quality outcomes across the continuum of care. Describe the potential role of HIT with clinical decision support in the creation of Accountable Care Organizations (ACOs) and Medical Homes. 1

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3 ACO Context Reimbursement that rewards accountability typically increases the financial risk. Financial Risk CMS ACO Program Full risk (prospective payment) Shared risk (both upside and downside) Shared Savings (upside potential only) Pay for Performance and Quality Incentives Bundled Payments Discounted FFS Traditional Fee For Service Payments are made to providers, in advance, on a per capita basis for a defined population. Providers agree to provide a broad range of potential services for the defined population, and are entitled to any savings (or excess payments). Likewise, providers are at risk if utilization of services in the defined population exceeds expectations. Reimbursement is withheld from ongoing claims payments and used to fund periodic incentive payments to providers that meet clinical, quality, and/or financial performance targets. If targets are not met, the withheld funds are forfeit. Generally combined with a variety of other fee base reimbursement mechanisms (FFS, discounts, per diems, case rates and DRGs). Potential (or budgeted) reimbursement is used to fund periodic incentive payments to providers that meet clinical, quality, and/or finanical performance targets. Generally combined with a variety of other fee base reimbursement mechanisms (FFS, discounts, per diems, case rates and DRGs). Additional reimbursement is earned for achievement of clinical and quality performance targets. Generally combined with a variety of other fee base reimbursement mechanisms (FFS, discounts, per diems, case rates and DRGs) Reimbursement is based on predefined bundles of services or care. Examples include DRG reimbursement, per diems, and case rates. Little or no additional reimbursement is made if the cost of a particular case exceeds the predefined reimbursement level. Providers are reimbursed on the basis of claims submitted for services. Discounts from standard fees are applied and strict cost accounting and controls are required. Providers are reimbursed on the basis of claims submitted for services. Fee schedule is based on costs. Cost accounting is important to ensure that fees and charges are accurate. What is Accountable Care? The concept of Accountable Care highlights the need for physicians, hospitals, other providers, payers, and patients and their caregivers to work collaboratively to ensure and measurably improve appropriate, high-quality, efficient and costeffective delivery of healthcare. 6 3

4 ACO Operational Model Health Care Exchanges Individuals Employers Medicare - Contract/ Shared Savings Managed Care Purchasers Accountable Care Organization Organization that takes responsibility for quality outcomes and cost of care ACO Member Engagement Predictive Modeling & Business Intelligence ACO Risk and Revenue Management ACO Care Delivery Sites Cross Continuum Medical Management IPA PCPs Clinical Information Exchange Urgent Care Patient Centered Medical Home Long Term Care Quality Reporting Hospital Hospital ACO Success Factor requiring HIT/CDS 4

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6 I. ACO Member Engagement ACO HIT/CDS Requirements ACO Maturity Early Developing Mature Episode of care Pre-care intervention; Member outreach Prevention; Lifestyle counseling; Remote monitoring II. Cross Continuum Medical Management Case Management Care Coordination; PCMH Diseasemanagement; Health maintenance III. Clinical Information Exchange Static: Read only access; User-request-based Pushed; CCDs IV. Quality Reporting Manual EHR-based V. Business Intelligence, Predictive Modeling and Analytics VI. ACO Risk & Revenue Management Patient focused; Episode/encounter focused data; Retrospective; Clinical and financial Cost accounting across the continuum of care; Global contracting; Membership data management Population-based; Continuum of care data; Predictive health analytics Provider network management; Allocation of payment Dynamic sharing across venues; Patient access Real-time; Desktop/dashboard; Ad hoc reporting access Social and network data; Behavioral analytics; Real-time Capitation management ACO HIT/CDS Requirements ACO Success Factor: Member Engagement Continuous member connection, including proactive preventive care and self-care support Priority services and support: self-service, including care (e.g. dressing change) and access (e.g. appointment scheduling) educational content reminders wellness programs HIT Solutions: Self service model Patient portals connected to EHR and administrative systems: secure PCP messaging lab results, immunizations, other EHR information access registration, appointment scheduling Call Center support Remote support including automated reminders; smart phone applications, remote device connection (such as scales, blood pressure cuffs) 6

7 ACO HIT/CDS Requirements ACO Success Factor: Cross Continuum Medical Management Care Coordination Episodes of care management Evidence based care Alerts Safety surveillance Transitions of care Provider communication Continuum Management Chronic disease management Medication history reconciliation Patient assessments Preventive care HIT Solutions: Care Coordination Clinical decision support On line protocols, order sets, encounter templates Rich evidence content support Provider communication tools Integration Continuum Management Shared care plan management Disease registries Health care maintenance modules e.g. reminders Health risk assessments ACO HIT/CDS Requirements Portal ACO Success Factor: Clinical Information Exchange Care coordination and collaboration will rest on clinical information sharing amongst the members of an Accountable Care Organization Use cases are becoming well defined by the federal and state governments policy and regulatory requirements HIT Solutions: Short Term Medium Term Long Term XXX HIE XX X HIO EHR XX XXX Connected Capabilities Route visit data to other providers and authorized parties Route data in support of care transitions, including referrals Route lab and imaging orders and results Query patient history Route electronic prescriptions Retrieve medication history for medication reconciliation and other medication management Route visit and other data for clinical decision support Route data to patients and enable ownership and management Adjudicate and manage claims and/or patient responsibility Route visit and other data for standardized quality reporting Route visit and other data for standardized public health reporting Route immunization, test result, other clinical information for patient access 7

8 ACO HIT/CDS Requirements ACO Success Factor: Quality Reporting REGULATION IMPROVEMENT Meaningful Use requirements will establish baseline Numerous additional requirements expected Internal use is critical to: track overall performance identify and intercede in time to address anomalies HIT Solutions: EHR systems: quality measure are increasingly based on clinical (not claims) data EHRs enable real-time reporting required for effective intercession Desktop reporting that routes real-time reports to key clinical leader workstations ideally includes access to ad hoc desktop reporting that supports further research ACO-wide reporting requires coordinating data collection (e.g. common terms and formats) and transmitting source data and/or results to a CDR ACO HIT/CDS Requirements ACO Success Factor: Predictive Modeling & B.I. Clinical Clinical Analytics Dashboards Financial Social Data Integration and Rationalization Financial Analytics Behavioral Analytics Reports HIT Solutions: Disease or Process-Specific Solutions Business Intelligence Data Warehouse Predictive Modeling Enterprise-wide Solutions 8

9 ACO HIT/CDS Requirements ACO Success Factor: ACO Risk & Revenue Management Patient/episode focus Billing and Accounts Receivable Patient Registration Payer Contracting Population/ contract term focus Member Registration Provider network contracting and payment Risk management and adjustment Capitation management HIT Solutions: Cost Accounting and tracking (includes funds accounting capability) Billing and Accounts Receivable ADT Applications Contract Management (includes modeling and forecasting capability) Membership Repository Claims processing and payment Dependence upon Business Intelligence, Clinical and Financial Analytics ACO--Disrupting the Status Quo in Healthcare Redesign healthcare around being well and staying healthy, expanding its reach beyond diagnosis and treatment to include wellness monitoring, prevention, and earlier disease detection Fortunately, changes are already in progress. These changes and the enabling technologies are presented in the context of five major trends: E-Power to the Patient The patient is in charge of his or her care management on a daily basis, marked by shared care between patient and provider Earlier Detection Accelerating early diagnosis is crucial to starting treatment for, if not preventing, a problem High-Tech Healing Solutions can improve care and the long-term quality of life Resources: More, but Different Expertise is optimized and spread. Care provider roles change and resources are more available through remote technologies and online communities, for both care/consultation and teaching/training Global Ecosystem More information, more connected, leads to better care and better research CSC March

10 E-Power to the Patient Patients take on a larger, more active role in managing health and wellness Not about diminishing the role of the physician but enlarging the role of the patient. Patients are in charge of daily care management, with a shared care relationship with their provider Empowered (e-powered) through the availability of health information, new health and wellness applications and support systems to encourage and monitor progress all available using smart phones or other Internet-enabled technologies Why e-power makes sense: Nearly all healthcare decisions are already made by patients Doctors: 2 hours per year Patients: 8,758 hours per year (Clayton Christensen et al. The Innovator s Prescription: A Disruptive Solution for Health Care, 2009) CSC March E-Power to the Patient Information wherever you are: fitness and health information Source New Leaf Boost Health and Fitness inewleaf makes an iphone a fitness tracker with the addition of its Digifit Connect device and Digifit app suite. During customized, guided workout sessions, the iphone measures heart rate, time in target zones, total calories expended, cadence, speed, distance, power, and zone alerts to change intensity. PedalBrain has a similar attachment and app for cyclists and includes a GPS location function viewable online Source Healthagen Medical Content and First Aid Products like WebMD and itriage provide medical information on demand symptoms, medications, treatment information and basic first aid instructions, specifically targeting consumers by avoiding dense medical jargon. itriage identifies closest treatment locations CSC March

11 E-Power to the Patient Information wherever you are: health monitoring and treatment What if a person s heart rate could be checked regularly by simply wearing a Band-Aid? The U.S. Food and Drug Administration (FDA)-approved Proteus Biomedical s wireless adhesive sensor technology, called Raisin, tracks and records a patient s heart rate, physical activity, body position, and other biometrics Source: Proteus Biomedical Raisin, which is worn like a Band-Aid, then transmits the data via Bluetooth to a PC or mobile device. This eliminates physician office visits to check heart rates, and since they are monitored continuously, adverse events can be spotted right away CSC March E-Power to the Patient Getting patients to change behavior: social networking One key element of behavior change, and one where technology can play a major role, is the ability to connect with others with similar health issues for support and advice One well-known site is PatientsLikeMe.com, which provides information on symptoms and treatments and then links them to known diseases Source PatientsLikeMe.com Dlife.com for diabetics provides recipes, healthy eating recommendations, expert Q&A, diabetic supplies, news, and research in addition to disease information and community support Weight Watchers, Jenny Craig, and many other programs offer Web site options that provide content, customized diets, online coaching, and chat rooms CSC March

12 E-Power to the Aging Patient As people age, technology will play a larger role in the home Home-based sensors installed in walls, floors, toilets, and other locations track and record patient movement, vitals, and adjust lighting and temperature based on time of day (Intelligent Bathroom II, Toto and Daiwa House Industry Co) Toilet sensors: Body weight Frequency Volume Urinalyses Mirror sensors: Body temperature Stress Bed sensors: ECG Pulse Floor sensors: Mobility Falls All the sensor devices will be connected to a special home network. A home-installed computer performs routine data collection and will transmit the data to a medical center, call center, or other authorized organization. Some information can be transferred to family members (Living Lab Center at TRIL, Dublin Ireland, Intel sponsor) CSC March Telemedicine A Key to E-Power Telemedicine is the provision of healthcare services via Information and Communications Technology (ICT) supporting a goal of overcoming geographical separation of patient and/or provider(s) Tele-Visit Use of ICT to conduct provider visits with patients (a.k.a. e-visits) from remote sites Tele-Consult Use of ICT by two or more providers to consult about a patient (with or without the patient present) Tele-Monitoring Use of ICT for the patient to collect and transmit vital clinical data (such as weight, blood pressure, blood sugar levels, and activity) from home or other locations to be viewed as needed by providers 12

13 Acuity Types of Care/ Challenges Addressed Level (Telemedicine Solution) Cost of Care Care Quality High Moderate Telemedicine Addresses Many Care Needs and Challenges Telemedicine pilots have provided evidence they can solve a broad array of healthcare challenges 1) Intensivist coverage (Tele-ICU) 2) Inpatient rounding coverage (tele-rounding, rounding robots) 3) Emergency care services (Mobile tele-consults) 4) Post-acute care monitoring (tele-monitoring with tele-visits) 5) Provider collaborations that may include the patient (Tele-consults that can include data and image sharing) 6) Non-office visits (Tele-visits, tele-consults) 7) Patient self-monitoring and support, especially for chronic conditions Increasing Care Demand Provider Shortage Patient Satisfaction * (For rural areas) Lower (tele-monitoring with mhealth options, tele-visits, tele-consults) 8) Aged care monitoring and support (Tele-monitoring with intelligent home monitoring options, tele-visits) Legend: Positively addresses challenges Significantly addresses challenges Intensivist Coverage Many community and rural hospitals cannot provide intensivist coverage 24 hours a day for their ICUs. They solve the problem by using tele-icu solutions The University of Massachusetts Medical Center reported a 20% decline in patient deaths at the Medical Center during its trial period of tele- ICU, and a 36% decrease in the severity-adjusted mortality rate at a participating community hospital Loyola University Medical Center in Maywood, Illinois, compared telemedicine costs to alternatives and determined that telemedicine capital equipment costs were one-thirteenth (1/13) compared to the alternatives Meta-analysis of 13 studies conducted between 2004 and 2010 in the United States indicated that telemedicine reduced ICU mortality by 20% and shortened length of stay (LOS) by 1.26 days An Australian trial with video conferencing and live telemetrics equipped for trauma allowed specialists in Melbourne to provide advice to primary treating physicians 20% DECREASE IN ICU MORTALITY Debra Woods, RN, Medical Connectivity: Tele-ICU Saves Money as well as Lives, Telemedicine and e-health, March 2011, p 64. T 13

14 Inpatient Rounding Coverage Physicians can conduct daily inpatient rounds without leaving their office by using tele-rounding solutions on mobile carts or remote-care robots Patients are comfortable with the technology: 67% agreed that they would prefer tele-rounding with their physician than to be treated by a partner 76% felt comfortable with tele-rounding daily 86% felt that they could easily communicate with their doctor during tele-rounding Physicians are aware of tele-rounding benefits. One study showed: 71% agreed it accelerated hospital discharges 95% agreed it saved physician time 97% agreed they learned more about their patients Off-hours robotic visits were three times more efficient than in-person visits Emergency Care Services Effective emergency care is about quick diagnosis and immediate treatment. Reported improvements in patient care using telemedicine are significant TeleECG provides real-time support for EMTS while they respond to calls in the patient s home or while transporting them. Ambulances capture and transmit ECG images that are analyzed by cardiologists who recommend an immediate course of action In Norway, outcomes improved by 15-20% likely due to the fact that approximately 50% of cardio patients now are administered antithrombolytic treatment by EMTs before arriving at the Emergency Room In the U.S., smartphones are used to transmit ECGs. Patients with confirmed heart attacks are brought directly to the lab where staff are waiting. This has reduced patient time to treatment of up to 131 minutes T 14

15 Post-Acute Care Monitoring Many newly-discharged patients need close monitoring to ensure continued health progress and high-quality outcomes, and to avoid re-admissions. Telemedicine is a proven winning solution A 2010 Catalan Remote Management Evaluation (CARME) study in Spain reported a 62% increase in care quality and a 68% decrease in hospitalizations in a one-year period COPD patient studies have shown a 33% reduction of Emergency Room visits and a 46% reduction in hospital costs due to reduced inpatient days. Sixty-three percent (63%) of patients who would otherwise be in nursing homes can now stay in their homes using telemedicine and home care The U.S. Veterans Health Administration investigated the use of automated home monitoring along with the nurse-run disease management program for CHF patients post-discharge. The combined solution decreased readmissions by 72%, 20% more than traditional disease management programs alone T Provider Collaborations Telemedicine-enabled care overcomes care practice and complexity barriers to support truly collaborative care Pediatric specialists within the Department of Defense Health System provided 300 remote consults to family medication physicians and physician extenders in In 74% of the cases, the treatment plan was modified after the consult. In 60%, physicians were able to resolve the patients primary problems Radiologist coverage and consultation is an established form of tele-consults, especially for after-hours and weekend coverage. Images are sent to the teleradiologists who perform preliminary readings that are made available to the local physicians via a secure Web site At Lake Forest Hospital in the United States, teleradiology consults have a 30-minute turnaround in urgent cases The Telestroke Programme run by the Scottish Centre for Telehealth has been providing 24x7 telemedicine links from Dr Garys Hospital to the stoke unit in Aberdeen Royal Infirmary with very positive results 60% OF CONSULT CASES RESOLVED PATIENTS PRIMARY PROBLEMS Department of Defense Study Finds Telehealth Cuts Pediatric Costs, ihealthbeat, February 10, T 15

16 Non-Office Visits Patients need to interact with their care providers for a wide range of health issues. Many do not require an office visit and can be addressed using telemedicine solutions Online provider-patient consultations called e-visits can range from s regarding minor health issues or medical questions to Webcam online visits Using online communications offers physicians a unique way to control their schedule. They can work from home, work in the evenings, or fill in an office visit cancellation with an e-visit. It keeps face-to-face visits open for patients who really need to see the physician in person University of Minnesota Medical Center has 36 physicians who take shifts to provide e-visit coverage seven days a week with very positive patient feedback A Los Angeles physician uses e-visits for the Fresno Clinic when the weather makes it impossible to travel. It saves visits annually that would have had to be re-booked A Brisbane, Australia program screens children for hearing and visual difficulties. Thirty-five percent (35%) had hearing problems and 12% had visual abnormalities T Remote Patient Self-Monitoring and Support Patients with chronic conditions need to continually monitor their health by keeping track of key health metrics Internet-enabled telemedicine solutions are ideal for remote patient selfmonitoring both at home and for mobile use At home, a laptop or workstation can be connected to a variety of medical devices that record and send the readings to the home station. The health app is used to store the daily metrics and reminds the patient when to take medications and record vital signs For patients needing a mobile solution, the smartphone can be that personal care assistant providing immediate alerts, reminders, education and care coaching There are many examples of how telemedicine supports patient-self monitoring In a Kaiser study for hypertensive patients, those using the remote monitoring readers had a 50% increase in the likelihood of blood pressure control In a randomized study in the U.S., diabetic patients using a mobile telemedicine solution reduced their A1C levels by nearly two points A home-based solution for CHF patients showed a 26.7% reduction in outpatient claims, a 40.9% reduction in inpatient claims and a 22.2% reduction in LOS A trial in the United Kingdom reported a 91% decrease in hospitalizations for chronic bronchitis and emphysema patients 16

17 Aged Care Monitoring and Support Baby boomers will become the largest contributors to the increasing demand for care. They also desire to live independently, at home Telemedicine, supporting boomer healthcare and lifestyle needs, is multi-faceted: Teleconferencing equipment enables remote visits and other interactions that help maintain relationships between these patients and their providers Specialized remote devices including cameras, motion sensors, and bed sensors monitor patient behavior as well as vital signs, with little or no patient intervention Living labs using interdisciplinary teams of ethnographers, designers and engineers design the best technology for optimal adoption A 2010 study comparing annual costs showed that home care using telemedicine costs $4,623 a significant savings compared to nursing home care at $33,800 or inpatient care at $142,188 ACO Resources: More, but Different Solving the healthcare resource puzzle requires new players and new care models Three trends are developing in labs, pilot projects, and local care practices that bring to light potential approaches to fix the current strained system by combining new resources, different processes, and emerging technologies Redesigned care team that blends skills and technology to optimize resources and care delivery Next-generation training and ongoing education to support the new care team New care models inside and outside office walls CSC March

18 ACO The Changing Face of Health Resources Redesigned Care Teams: Team includes doctors, nurses, dieticians, chronic care coaches, physician assistants, and medical assistants and even robots Primary care physician plays central role; each team member plays a supporting role depending on level of expertise or training Team members work together to execute care plan Allows primary care physician more time to focus on complex cases 35 Changing Face of Health Resources Technology solutions are care team members, too Huggable Teddy: Packed with electronic sensors and sensitive skin technologies to distinguish between cuddling for comfort and agitation. Can also be fitted with audio and video to assist care team in monitoring children MIT Media Lab s Huggable Teddy Kompai R&D: Provides at-home assistance to minimize the need for personal care assistants WellDoc s patient coach provides realtime coaching over mobile phones, including immediate actionable information to help patients stay motivated to improve their health Kompai R&D WellDoc s Patient Coach 36 18

19 Changing Face of Health Training Technology trains care team: RNotes: App provides a collection of clinically useful information for work and exam preparation for nurses MedPage Today: App supports continuing education and offers breaking medical news PULSE!!: Simulation video gaming software allows team to train on 3-D video patients and includes ordering tests, examining physical features, determining diagnosis, and recommending treatment RNotes App Procedures Consult Mobile: App allows physicians and residents to review procedures 22 PULSE!! 37 This person discloses that he works for pascalmetricsa patient safety organization Questions? Comments 19