Patient / Consumer Engagement - Key to Successful Population Health Management
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1 Patient / Consumer Engagement - Key to Successful Population Health Management April 12, 2015 Kamahanahokulani Farrar, HHS OCIO Domain Governance Department of Health and Human Services Kristina Sheridan, Associate Department Head, Emerging Technologies The MITRE Corporation DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
2 HIMSS The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number Conflict of Interest Kamahanahokulani Farrar, MRHM Has no real or apparent conflicts of interest to report. Kristina Sheridan, MS Has no real or apparent conflicts of interest to report.
3 Learning Objectives Identify Clinical and Business Intelligence (C&BI) strategies to support patient outreach. Synthesize strategies to manage complex patients that supports multiple providers using shared Electronic Health Record (EHR) resources. Evaluate the use of consumer health informatics (CHI) applications in improving self-management, adherence to prescribed treatment regimens and health behavior. Identify the benefits and incentives in a Patient Centered Medical Home (PCMH) model in providing continuous and coordinated care.
4 A Patient s Story 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
5 Patient, Caregiver, Family Image source: K. Sheridan
6 Data Image source: K. Sheridan
7 Information Image source: K. Sheridan
8 Patient Voice Image source: K. Sheridan
9 Recovery Image source: Kate Sheridan
10 Cultural Shift Current Future Clinical & Passive Patient-Generated Health Data Engaged Patient and Active Patient- Generated Health Data Patient-Provider Partnership Image source: BigStock
11 A Patient s Ecosystem 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
12 Impact and Cost of Chronic Conditions One Chronic Condition Multiple Chronic Condition Caregivers No Chronic Condition Almost 1/3 people in the US manage at least one chronic condition More than 3/4 of US healthcare dollars are spent on their behalf Data extrapolated from 1. Wolff JL, Boult C, Boyd C, Anderson G. Newly reported chronic conditions and onset of functional dependency. J Am Geriatr Soc 2005;53: Bodenheimer, T., Chen E., Bennett, H. Health Affairs 28, no. 1 (2009): 64 74; /hlthaff AARP Public Policy Institute. Insight on the Issues, November 2008: Valuing the Invaluable: The Economic Value of Family Caregiving, 2008 Update 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
13 Reality for Patients and Caregivers 6 Feb 2012 Engaged X Pro-Active Shared Decision-Makers Partners Empowered Images source: K. Sheridan
14 Value to Patients and Caregivers Track - Manage - Share PROCESSES Images source: The MITRE Corporation
15 Value to Providers LONGITUDINAL TREND IN MEDICATION COMPLIANCE LONGITUDINAL TREND IN SYMPTOM SEVERITY USE FOR CLINICAL DECISIONs Source: MITRE Corporation/Heinz College Carnegie Mellon University Fall 2014 Capstone Project
16 A Patient s Value 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
17 Patient Engagement Principles EASY EFFECTIVE PATIENT-CENTRIC 1. IMS Institute for Healthcare Informatics. Patient Apps for Improved Healthcare: From Novelty to Mainstream. Parsippany, NJ: October The MITRE Corporation healthaction Patient Toolkit research
18 Tracking Symptom Severity Images source: The MITRE Corporation
19 Tracking Medications 1. Pharmacy Management Strategies for Improving Drug Adherence. William K. Fleming, PharmD S16 Supplement to Journal of Managed Care Pharmacy JMCP July 2008 Vol. 14, No. 6, S-b 2. Image source: The MITRE Corporation and ONC
20 Managing Day-to-Day Care 1. Checklist Manifesto How To Get Things Right. Atul Gawande. ISBN Image sources MITRE Corporation and BigStock
21 Informing Care Team Decisions Are they developing a new comorbid condition? Let me find out why their mood is so low How did they respond to that new medication? 1. Huba, Nicholas and Yan Zhang. Designing Patient-Centered Personal Health Records (PHRs): Health Care Professionals Perspective on Patient-Generated Data. J Med Syst DOI /s z 2. Image sources: The MITRE Corporation
22 Integrating Patient-Generated Health Data Logical Observation Identifiers Name and Codes (LOINC) Vital Signs Systematized Nomenclature of Medicine--Clinical Terms (SNOMED-CT) Patient/Family History Symptoms RxNorm Medications Procedures Problems Allergies Images sources: Microsoft Clip Art and BigStock
23 Measuring Patient Outcomes Should I check-in with my doctor? Am I really getting better? Is that medication working? 1.. Image sources: The MITRE Corporation
24 Patient-Provider Partnership 1. Electronic Health Records in the Physician Office. McKesson Corporation, Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors Who Are Using With Their Patients: a Qualitative Exploration. J Med Internet Res 2003;5(2):e Cleveland Clinic All Rights Reserved Euclid Avenue, Cleveland, Ohio Image source: The MITRE Corporation
25 A Patient s Care Model 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
26 Patient Centered Medical Home (PCMH) Scenario: John and Mary 26 John, 75 year old diabetic with comorbidities Mary, 45, daughter and caregiver Dr. Jones, General Practitioner Dr. Smith, Psychiatrist Dr. Brown, Physical Therapist Nurse Practitioner Davis NP John Mary GP Psychiatrist NP PT
27 Patient-Centered Access 27 Patient- Facing Tools GP Mary John Empowering Caregivers Empowering Patients Online Access Download Record Secure Messaging Two-Way Communication Schedule Appointments Extrapolated from PCMH 2011-PCMH 2014 Crosswalk,
28 Team-Based Care Team Meetings Patient and Caregiver Engagement 28 John GP Mary Behavioral Health Language Support Psychiatrist PT Self Management Support Extrapolated from PCMH 2011-PCMH 2014 Crosswalk, NP Continuity of Care
29 Population Health Management 29 Complete Patient Information Evidence-based Decision Support John Mary Clinical Data Proactive Population Management GP NP Psychiatrist PT Comprehensive Health Assessment Extrapolated from PCMH 2011-PCMH 2014 Crosswalk,
30 Care Management and Support 30 Care Planning Self Care Support NP Psychiatrist PT GP John Mary John Medication Management Mary Identify Patients for Care Management Extrapolated from PCMH 2011-PCMH 2014 Crosswalk,
31 Care Coordination and Care Transitions 31 John Mary Psychiatrist NP Tracking Data and Follow-Up Coordinating Care Transitions GP Referrals NP Extrapolated from PCMH 2011-PCMH 2014 Crosswalk,
32 Performance Measurement and Quality Improvement Improved Outcomes 32 Patient & Caregiver Engagement John Mary Patient- Generated Health Measures 911 Reduced Hospitalizations Extrapolated from PCMH 2011-PCMH 2014 Crosswalk, Image sources: The MITRE Corporation and Microsoft Clip Art
33 Patient Engagement Strategy 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
34 Patient Centered Medical Home Strategies Demonstrate active engagement of patients and families in patient care and quality Improvement activities Use payment strategies to support the active engagement of patients as partners in their own care and in practice-level quality improvement Support practices with technical assistance, tools, and shared resources to engage patients Require health information technology standards to recognize and promote patient engagement Require meaningful patient input in the design, implementation, and evaluation of medical home programs Support additional research on the feasibility and impact of patientengagement strategies. Source: The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care, Feb 2011, AHRQ {publication No. AHRQ
35 Patient Engagement Policy/Standards 2015 The MITRE Corporation. All rights reserved. Approved for public release. Distribution unlimited. Case number
36 Meaningful Use Stage 3 25 percent of a provider's patients must access their records through View/Download/Transmit or an ONC-certified app 35 percent of patients must receive a clinically relevant secure message Providers must incorporate information from patients on "non-clinical" settings from 15 percent of their patients. Source: John D. Halamka, March 25, 2015, :
37 IMPACT Act The Improving Medicare Post-Acute Care Transformation Act of 2014 IMPACT Act of 2014 Standardized Patient Assessment Data to enable Assessment and quality measure uniformity Quality care and improved outcomes Comparison of quality across PAC settings Improve discharge planning Interoperability Facilitate care coordination Extrapolated from: CMS.gov: and-cross-setting-measures.html :
38 Care Coordination Services Reimbursement Supports Chronic Care Coordination Reimbursement of $42 for the service which applies to "chronic care management services furnished to patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline." Extrapolated from: CMS.gov: P.html :
39 Summary Including Patient-Generated Health Data in Clinical and Business Intelligence (C&BI) strategies improves outcomes Providing patient-facing tools to manage complex conditions and integrating Patient-Generated Health Data (PGHD) into Electronic Health Record (EHR) resources enhances coordination between multiple providers Designing tools and processes to support Patient and Caregiver needs can significantly improve self-management, adherence to prescribed treatment regimens and health behavior Patient Centered Medical Homes (PCMH) provide continuous and coordinated care and benefit from including patients and caregivers as valued partners The combination of patient-centric strategy, policy, tools and processes will enable patient engagement and lead to successful population health management
40 Questions Thank You If you have questions please contact: Kamahanahokulani Farrar
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