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www.sg2.com
Optimising the System of CARE
Using Technology to Optimise Clinical Services
Christopher Farr Senior Fellow, Sg2
May 2012
Changing Landscape of Health Care Delivery
Enabling Multidisciplinary Care
Enabling Subspecialisation
Using Decision Support to Build Standardised Pathways
Building a Network Beyond the Hospital
Reaching the Patient at Home
Developing Your System of CARE
Agenda
Confidential and Proprietary © May 2012 Sg2 3
Traditional Challenges of Hospital Management
Clinician
recruitment
Market
reputation
Relationships
with payers
Case
management
Hospitalists
Work flow
improvement
Staffing levels
Compensation
Overtime,
agency nursing
Consistent
earnings
Cost-effective
credit
Consolidation
LOS = length of stay.
Fill
Beds
Manage
LOS
Control
Labour
Costs
Manage
Balance
Sheet
Confidential and Proprietary © May 2012 Sg2 4
Card
iovascu
lar
Neu
roscie
nces
On
co
log
y
Ort
ho
paed
ics
Ga
str
oin
tes
tin
al
Uro
log
y
Su
rgic
al S
pe
cia
ltie
s
Em
erg
en
cy S
erv
ice
s
Disease-Based Services
Operating Room Services
Digital Information (EMR, CPOE, etc)
Diagnostics = Imaging + Pathology + IT
Patient Services (Monitoring, Nursing, Pharmacy, etc)
Integrative
Services
Fo
un
dati
on
al
Serv
ices
Today’s Hospital Organisational Model Still Looks Inward
IT = information technology; EMR = electronic medical record; CPOE = computerised physician order entry.
Confidential and Proprietary © May 2012 Sg2 5
The Future Is About Building a High-Performance System of Care
Reduce Cost of Care Manage Care Transitions Align Providers
IP = inpatient; SNF = skilled nursing facility; OP = outpatient.
Retail
Pharmacy
Wellness and
Fitness Centre
Diagnostic/
Imaging
Centre
Urgent
Care
Centre
Home
Doctor
Clinics
Ambulatory
Procedure
Centre
IP Rehab
Hospital
Home Care
Acuity
Community-Based
Care
Acute
Care
Post-
Acute
Care
SNF
OP
Rehab
Confidential and Proprietary © May 2012 Sg2 6
Build Foundations to Support an Integrated System
Integrated IT
Systems
Care
Continuum
Clinical
Engagement
IT integrated
across System of
CARE, workforce
Aligned operations
and financial data
Virtual technology
to optimise
coordination
Case management
Remote monitoring
Focus clinical staff
organisation
around your
System of CARE
Confidential and Proprietary © May 2012 Sg2 7
Kaiser Permanente implemented
HealthConnect® in 2004.
EMR that unites documentation
across IP and OP settings
Personal health record
Secure patient-provider messaging
via Web site
Real-time update messages
and records incorporated into patient records
Scheduled telephone visits grew 8-fold from 2004−2007.
Secure email messaging grew nearly 6-fold from
2005−2007.
Electronic Medical Records Will Be a Critical Requirement
Source: Chen C et al. Health Aff (Millwood) 2009;28:323–333.
Confidential and Proprietary © May 2012 Sg2 8
EMR Can Increase Patient Satisfaction While Dramatically Reducing Office Visits
Kaiser Permanente (Cont’d)
Number of patients rating overall
satisfaction at an 8 (out of 10)
or above:
2004: 84%
2007: 87%
Total office visit rate declined 26.2% from 2004 to 2007.
Primary care visits decreased by 25.3%.
Specialty visits decreased by 21.5%.
Even though the setting of care changed dramatically,
patient and member satisfaction still increased.
Confidential and Proprietary © May 2012 Sg2 9
A Strong EMR Allows Innovative Approaches to Service Expansion
Traditional Approach: More Hospitals
Kaiser’s strategy was to build a complete,
self-sustaining hospital in every market
it serves.
Each hospital had ≥50 clinicians, radiology,
pharmacy, lab and other ―one-stop shop‖ services.
Future Concept: Microclinics
Lease space in strip malls staffed with
2 clinicians and connected to Kaiser’s EMR.
Cover 80% of market needs and transition to
hospitals farther away when needed.
Leverage video conferencing for specialist
consultations when necessary.
Cost 50% less per member compared to hospitals.
Courtesy of Sentara Healthcare.
Source: Capps R. The good enough revolution: when cheap and simple is just fine. Wired Oct 14, 2009.
Confidential and Proprietary © May 2012 Sg2 10
Productivity Software Drives Operational Excellence
Bumrungrad International Hospital, Bangkok, Thailand
3,000 outpatients per day
About 65% of outpatients present without an appointment and
wait 10 minutes on average to see a doctor.
Hospital information system supports short waits and easy access.
Scheduling by demand history analysis:
IT system assigns patients to the doctor with the shortest wait time.
Comprehensive EMR, scheduling, CPOE, PACS/RIS, pharmacy, etc
45
Minutes
PACS = picture archiving and communication system; RIS = radiology information system.
Registration 1
Waiting Room 2
Clinician Exam 3
Routine
Diagnostics 4 Payment 6
Prescription 5
Changing Landscape of Health Care Delivery
Enabling Multidisciplinary Care
Enabling Subspecialisation
Using Decision Support to Build Standardised Pathways
Building a Network Beyond the Hospital
Reaching the Patient at Home
Developing Your System of CARE
Agenda
Confidential and Proprietary © May 2012 Sg2 12
Technology Offers New Opportunities for Coordination and Collaboration
Caregivers must function in multidisciplinary teams supported by
appropriate remuneration incentives.
Eg: Stroke team
Eg: Remote intensive
care unit
Eg: Nursing units
Eg: Telestroke
Eg: Subspecialist
appointments Regional practitioners
Integrated care team
Virtual, integrated team
Virtual, outsourced
services
Coordinated
caregivers
Integrated
Independent
Confidential and Proprietary © May 2012 Sg2 13
Improving Availability of Neurology Services in Northern Ireland, UK
Hub hospital:
Royal Victoria Hospital—part of
the Belfast Health and Social
Care Trust
2 spoke hospitals:
2 rural hospitals—part of the
Western Health and Social Care
Trust
The Challenge: Provide access to a
neurologist for diagnosis and follow-
up with consistent, high-quality care
for both city and country patients
Photo courtesy of Christopher Farr.
Confidential and Proprietary © May 2012 Sg2 14
The Solution: Low-Cost Teleneurology Empowers Remote Patient-Centred Care
Patient Impact Neurologist Impact Operational Impact
Reduced waiting times
Improved speed of
diagnosis
Reduced ALOS
Increased access to
specialists
Reduced travel times
Increased patient
volumes
Improved patient
management
Cost-effective
Easy to set up
Improved resource
allocation
Increased specialist
care
ALOS = average length of stay.
Before Implementing the Teleneurology Program
Only 10% to 11% of inpatients in the rural hospitals were referred to a
neurologist.
After Implementation
40% of inpatients are referred for the teleneurology service.
Service now includes outpatient referrals and patient follow-up visits
Changing Landscape of Health Care Delivery
Enabling Multidisciplinary Care
Enabling Subspecialisation
Using Decision Support to Build Standardised Pathways
Building a Network Beyond the Hospital
Reaching the Patient at Home
Developing Your System of CARE
Agenda
Confidential and Proprietary © May 2012 Sg2 16
Prince Court Medical Centre Kuala Lumpur, Malaysia
Wholly owned by Petronas:
Malaysia’s national petroleum
company
JCI accredited
Facilities: 300 beds, 10 ORs and
63 outpatient suites
Specialties: Heart and lung, oncology,
nephrology, burns, gynecology
The Challenge: How does a 300-bed
facility provide comprehensive, high-end
pathology and radiology services with
subspecialty interpretations?
JCI = Joint Commission International; OR = operating room. Photo courtesy of Christopher Farr.
Confidential and Proprietary © May 2012 Sg2 17
The Solution: A Partnership With the University of Vienna, Austria
Telepathology and teleradiology services
for interpretation, over-reading and
consultations
University of Vienna cytogenetics team reads
for Malaysia and Vienna.
EMR, CPOE, RIS and PACS with single
accession number
Shared image server that allows ―instant,‖
simultaneous reading of slides in Malaysia
and Austria
Common laboratory test platforms, imaging
and lab protocols between the 2 institutions
Training and working exchange visits
between institutions
Photo courtesy of Christopher Farr.
Confidential and Proprietary © May 2012 Sg2 18
The Growth Story
Expert interpretation services
provide a unique differentiator
and build referring physician
confidence.
Prince Court builds market
share by offering services not
available elsewhere in Malaysia.
Opportunity exists for Vienna
to ―export‖ its skills—a new
business venture.
After-hours interpretations
available from its Malaysian
partner to support radiology
and pathology in Vienna.
Changing Landscape of Health Care Delivery
Enabling Multidisciplinary Care
Enabling Subspecialisation
Using Decision Support to Build Standardised Pathways
Building a Network Beyond the Hospital
Reaching the Patient at Home
Developing Your System of CARE
Agenda
Confidential and Proprietary © May 2012 Sg2 20
Why Do I Order Diagnostic Exams for My Patients?
Pathology Radiology
Assess risk
Screen for disease
Diagnose disease
Confirm diagnosis
Stage disease
Characterise disease
Monitor disease
Plan treatment
Guide treatment
Monitor treatment
Confidential and Proprietary © May 2012 Sg2 21
Effective Diagnostic Testing Informs Patient Management
Test Ordered (Appropriate?)
Dx Test Performed
Results Analysed and Interpreted
Report Prepared
Patient Management
Communication/Consult With Referring Physician
Computer-Aided Detection
Automation/Cost-Effectiveness
Integrated Structured Reporting
Clinical Decision Support
Community
Diagnostic Associates
IT and Network Integration
Referral
Confidential and Proprietary © May 2012 Sg2 22
The New World: Integrated Reporting
Source: Image adapted from: The Importance of Radiology and Pathology Communication in the Diagnosis and Staging of Cancer:
Mammography as a Case Study. November 2010. http://aspe.hhs.gov/sp/reports/2010/PathRad/index.shtml Accessed January 2012.
Confidential and Proprietary © May 2012 Sg2 23
Standard Approaches Improve Knowledge Sharing, Cut Duplication
Western Australia Department of Health—
Standardised Imaging Pathways
Developed by statewide imaging committee
Web-based tool organised by organ system
Designed to support the work of referrers
and providers of diagnostic imaging services
Education and decision support tool
Reduces inappropriate and increases
appropriate examinations
Each disease has a summary page,
a pathway, images, teaching points,
references and a PDF version
Library of normal anatomy
Image used with permission of the Government of Western Australia Department of Health.
Source: Government of Western Australia Department of Health.
www.imagingpathways.health.wa.gov.au. Accessed March 2010.
Confidential and Proprietary © May 2012 Sg2 24
The Growth Story
Standardised pathways bring
consistent approach to imaging.
Trust that appropriate test is
ordered regardless of site of care
Trust that test is performed using
appropriate protocols
Program exploits statewide PACS
infrastructure.
Single accession number means
all images can be shared across
all public institutions and most
private providers.
Permits over-reads and consults
Expect to save significant costs—
frees up resources for growth
Photo courtesy of Christopher Farr.
Confidential and Proprietary © May 2012 Sg2 25
Minnesota (US) Adopts Imaging Clinical Decision Support Statewide
New statewide initiative:
6 health plans; 60 medical groups
Uses ACR/ACC guidelines for imaging
(avoids precertification requirements)
Advanced studies: MR, CT, PET,
cardiac SPECT
Tool integrated in EMR or accessed
through a Web portal
Data mining tracks and correlates clinical
outcomes from scan interpretations with
ordering physician’s clinical indications.
2007 pilot study estimated 9% reduction
in claims and increase of ―appropriate-
ness‖ from 79% to 89% in just 6 months.
5 medical groups saved $28M.
Estimated total savings is $84M.
Institute for Clinical
Systems Improvement (ICSI)
“Ensure Minnesotans only
receive medically appropriate
imaging tests…”
ACC = American College of Cardiology; ACR = American College of Radiology;
CT = computed tomography; MR = magnetic resonance; PET = positron emission
tomography; SPECT = single-photon emission computed tomography.
Source: ICSI. www.icsi.org. Accessed May 2011.
Changing Landscape of Health Care Delivery
Enabling Multidisciplinary Care
Enabling Subspecialisation
Using Decision Support to Build Standardised Pathways
Building a Network Beyond the Hospital
Reaching the Patient at Home
Developing Your System of CARE
Agenda
Confidential and Proprietary © May 2012 Sg2 27
Calgary Health Region—Alberta Provincial Stroke Strategy, Canada
Health promotion and disease prevention
Stroke algorithms and vascular risk reduction
programme
Emergency services and acute care
Stroke screening and diversion strategy
A&E protocol, TIA triage, 24/7 brain
attack team
Foothills Medical Centre
(stroke nurse, TCD, CT, MR, tPA protocol,
stroke unit)
Rehabilitation and community integration
Inpatient and tertiary neuro rehabilitation
Outpatient rehabilitation, physiatrist stroke follow-up,
swallowing programme, community accessible rehabilitation
Stroke Recovery Association, Brain Injury Coalition of Calgary
Best-in-Class Stroke Care Requires Teamwork
Calgary
A&E = accident and emergency; TIA = transient ischaemic attack; TCD = transcranial Doppler; tPA = tissue plasminogen activator.
Source: www.hsf.sk.ca/siss/documents/SaskCHRAPSSpresentationMarch07.ppt. Accessed March 2009.
UNIVERSITY OF
CALGARY
Calgary Stroke Program
Confidential and Proprietary © May 2012 Sg2 28
Regional Leadership and Community Stakeholders Drive Coordinated Care
Programme established by Professor
Alastair Buchan, University of Oxford
Provincial Government—
Alberta Health and Wellness
Heart and Stroke Foundation
of Alberta, NWT and Nunavut
Leadership from each of 9 health regions
City of Calgary Fire Department
Stroke Recovery Association/Young
Stroke Survivors
University of Calgary, Foothills Medical
Centre
Sources: University of Oxford. News release.
www.ox.ac.uk/media/news_releases_for_journalists/071217.html. Published
December 17, 2007. Accessed August 2010; Alberta Provincial Stroke Strategy.
www.strokestrategy.ab.ca/about-APSS.html. Accessed August 2010.
Fort McMurray
Grande Prairie
Hinton
Cold Lake
Edmonton
Camrose
Lloyd-
minister
Wetaskiwin
Medicine
Hat
Lethbridge
Calgary
Red Deer
Key
Comprehensive
Stroke Centres
Other Primary
Stroke Sites
Regional Hospital
Primary Stroke
Centres
Calgary Stroke Program
Confidential and Proprietary © May 2012 Sg2 29
Partnering With Ambulance Services Helps Improve Door-to-Needle Time
Wake Forest University Baptist Medical
Center, Winston-Salem, NC, US
Objective
Clear need to accelerate the 90-minute
door-to-needle time for stroke patients;
improve blood draw delays
Plan
Worked with ambulance service providers
to develop a process to draw blood en route
to the ED
Assembled lab draw kits distributed to ambulance
services free of charge; cost of lab kits <$1 (USD)
Results
35-minute reduction in door-to-needle time
Increased frequency of ED ―stroke‖ notification
by ambulance services
EMS = emergency medical services; ED = emergency department. Source: Wake Forest University Baptist Medical Center, 2010.
Changing Landscape of Health Care Delivery
Enabling Multidisciplinary Care
Enabling Subspecialisation
Using Decision Support to Build Standardised Pathways
Building a Network Beyond the Hospital
Reaching the Patient at Home
Developing Your System of CARE
Agenda
Confidential and Proprietary © May 2012 Sg2 31
Effective Care Cannot Occur Without Engaged Patients
Acute
Care
Support to Engage Patients
Transition Out of
Hospital
Transition to In-
Hospital Care
Patient Outcome
Text Reminders
Colored Magnets
Health Coaches
Online Medical Learning
Confidential and Proprietary © May 2012 Sg2 32
Patient-Area Network Is the Key to Supporting Patients at Home
The delivery, facilitation and communication of health-related
information via mobile telecommunication and multimedia
technologies—including cell phones, tablet devices, PDAs and
wireless infrastructure in general
There’s a difference between data and actionable information.
Intervene (advice, support,
therapy)
Notify (patients, clinicians,
caregivers, EMS)
Evaluate Transmit
Data
Collect
Health Data
PDA = personal digital assistant.
Source: Center for Technology and Aging. Technologies for Remote Patient Monitoring for Older Adults. Published April 2010.
Confidential and Proprietary © May 2012 Sg2 33
Mobile and Smartphones Bring the Exam Room to the Patient
Telemedicine
as a Channel
Telemedicine as an
Active Partner
Telemedicine as a
Decision-Support Tool
Mobile Phones Tele-ICU Automated
Tele-ophthalmology
Diagnosis Smartphones
© Image from BigStockPhoto.com.
ICU = intensive care unit.
Confidential and Proprietary © May 2012 Sg2 34
Time and Place Dependencies Are Eliminated
Current Model Patient-Area Network Model
Low Frequency Visits High Touch
Acute Care Focused Right Treatment
Appointment Driven When They Need It
Location Centric Where They Are
High Cost Lower Cost
Confidential and Proprietary © May 2012 Sg2 35
Blood Pressure Spirometer
Printed with permission
of Microlife USA.
Many Devices Can Be Integrated Into the Patient-Area Network
Wi-Fi Scale
Pulse Oximeter
Physical Activity Blood Glucose
Confidential and Proprietary © May 2012 Sg2 36
The Spectrum of Remote Monitoring Opportunities Is Broad
Market
Segmentation
Wellness
and
Prevention
Chronic
Disease
Management
Acute Care Post-Acute
Care and
Rehabilitation
Aging at
Home
Focusing on: Prevention
and early
maintenance
Avoiding
critical events
Keeping
patients out
of hospital
Staying
on track
Avoiding move
to long-term
care
Generally
Includes:
Weight
measure
Exercise
Calories
consumed
Basic SMS
reminders
Diabetes
CHF
Hypertension
COPD
Medication
adherence
Secure SMS
test results
Crisis
management
Ensuring that
discharge
instructions
are followed
Improved and
managed
elective
admissions
Staying on
protocol
Monitoring
home therapy
Preventing
readmissions
Medication
optimisation
Remote
monitoring
of vital signs
and daily
activity
Assistive
technologies
There are many opportunities to create value and lower costs.
SMS = simple messaging service; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.
Changing Landscape of Health Care Delivery
Enabling Multidisciplinary Care
Enabling Subspecialisation
Using Decision Support to Build Standardised Pathways
Building a Network Beyond the Hospital
Reaching the Patient at Home
Developing Your System of CARE
Agenda
Confidential and Proprietary © May 2012 Sg2 38
6 Steps to Building Your System of CARE
1 Vision: Establish a vision by disease
for the patient journey from home to
home along the System of CARE.
4 Information Technology: Identify the IT
services needed to effectively coordinate care
across all providers along the clinical pathway.
2 Clinical Pathway: Identify the specific
services and resources available to
support the patient journey.
5 Navigation: How does the patient move across
the System of CARE? What support services
are required to allow the patient to navigate the
System of CARE easily?
3 Pain Points: Identify where other
providers could better serve the
patient—and determine the best way
of working with them.
6 Work Flow: Identify how current processes,
practices and work flow need to change to
reduce duplication and waste.
Retail
Pharmacy
Wellness and
Fitness Centre
Diagnostic/
Imaging Centre
Urgent
Care
Centre
Hospital
Acuity
Community-Based Care Acute
Care
Post-
Acute
Care
Doctor
Clinics
Ambulatory
Procedure Centre
OP
Rehab
IP Rehab
SNF
Home Care Home
Confidential and Proprietary © May 2012 Sg2 39
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