PHMSlideshare2014

© 2014 Dr. Gordon Jones | Page #1

Curating The Best of

Digital & Population Health

Gordon Jones, DHA, MHSA, PAHM


What is Population Health and Who are the Companies Leading & Enabling It?


Overview of PHM 1. Evolution of Population Health Management (PHM)

2. Why PHM Now

3. Elements of PHM

4. Visualize: Population Health Solution Stack

5. How Technology fits into PHM

6. Patient Outreach Focused PHM

7. Stories of PHM


The Cost Problem


The Payment Problem


“Soon the Web-browser will be as important to the physician as the

stethoscope.”

“Quote by Michael Messer, MD in 1997 for my doctorial research on Physician Adoption

of the Internet”


“Trusty stethoscope faces threat from portable hi-tech.”

“BBC article 2014”


“What the Heck have We been [not] doing the past 15 years?”



“Communication is not only important, but without it, human life would be non-existent. We have to be able to communicate on a personal level, both verbally and non-verbally. If we cannot have a face-to-face encounter, then this requires access to clear audible and visual capabilities enabled by technology.”

It all Begins with Communication


% of 5,000 internet health users surveyed said they would change doctors to one who would communicate with them over the Internet – at the time that translated into…

DHA Research on Health Communication

50 11

$3

%+ Americans not satisfied with the availability of their physicians

Billion primary care dollars


% of patients reported that results or medical

records were not transferred from one place to another in time for an appt

% of patients do not get lab tests, special referrals or follow up care that they need

% of adults report problems with care coordination, notification of test results, and communication among their doctors

20 36 50

Current State of Health Communication




% of doctors say non-critical paperwork has caused them to spend less time with patients

% of doctors feel they are overextended and overwhelmed, not good non-verbally

% of hospital executives said they still gather outcome data by hand, hard to know their patients in a timely manner

63 76 79




“Hello,

I’m your

new

Primary

Care

Physician” “Say ahhh

please”


• Categorized by major domains of healthcare communication.

• Multi-channel approach for client and patient support.

• Connecting patients with the entire healthcare world.




DEVICE SENSOR

GATEWAY MOBILE NETWORK

CLINICAL DECISIONSYSTEM

NURSE CALL CENTER

DOCTOR EMR

PATIENT

PHARMACY LAB

TEC NODES

l i n e a r t h i n k i n g


“Its agreed,

we’ll teach

them how to

grow corn,

A History of Health Communication

but no one

says a word

about how to

get free

healthcare.”


DEVICE SENSOR

GATEWAY

MOBILE NETWORK

CLINICAL DECISION

NURSE

CALL CENTER

PHYSICIAN

EMR

LAB

PHARMACY

Patient-based Communications

PATIENT

PROVIDER


The Rise of the Engaged Patient


Remote Patient Monitoring (RPM)


RPM & Real-time Communications

Note: The marketing term “real time” is currently up for debate. Usually this means near real time (hourly or nightly). EHRs and labs tend to refresh nightly or weekly. However, the overall trend is for faster refresh rates across all data types.


Honesty in Health Communications

I’d Never Admit That to My Doctor; But to a Computer? Sure… Hello Watson!


Stratifying populations by risk

Identifying high-cost conditions

Deploying member engagement strategies around disease management

HMO vs ACO


Defining Population Health Management • Population health management is the process of

proactively monitoring and caring for defined patient groups and includes these components:

• The central role of the primary care provider;

• The patient focus of care coordination provided through wellness, disease and chronic care;

• The critical importance of patient activation, involvement and personal responsibility.


Evolution of PHM • Payers/Employers deployed elements of PHM:

• Hired disease management and HMO firms

• Sponsored wellness and cessation programs

• Health coaching and alerted people to unmet needs

• Obstacles to Success:

• Mistrust of Insurance companies

• Low level of Physician involvement


Evolution of PHM • Health plans embraced vehicles designed to engage

physicians and healthcare organizations:

• Shared savings models, IPA, PHO, MSO

• Patient Center Medical Homes with financial incentives

• Partnering to build Accountable Care Organizations


Why PHM is Needed


Why PHM is Needed • Healthcare reform is driving a change in the way

healthcare is delivered– forcing providers to focus on improving quality and reducing cost (shift from volume to value).

• A plethora of new models:

• Meaningful use [of EMRs] is a “carrot and stick” penalty/incentive program for providers who have Medicare and Medicaid contracts.


Why PHM is Needed • Accountable Care Organizations (ACO) are groups of

doctors and hospitals banding together with payers to assume responsibility (and risk) for a defined POPULATION. The ACO earns rewards when they demonstrate improved quality, lower costs.

–ACO Types:

»Medicare ACO

»Commercial/Private ACO, or other collaborative


Why PHM is Needed • Medicare ACO requirements and MU requirements

both have specific focus on prevention & wellness and chronic disease management…because:

– 5% of the POPULATION is driving 49% of the cost (focus on the 5%)

– The name of the game here is: keep healthy patient POPULATION healthy and keep the chronically ill patient POPULATION out of expensive ER/hospital stays

– High cost chronic disease management: Hypertension, Diabetes, CHF, COPD, etc.

– Prevention & Wellness: screenings, vaccinations, immunizations…


Maximizing the Value of PHM

Primary Pillars of Population Health Management

Data Aggregation

Combine patient data from disparate

sources to achieve a single view of the

patient

Risk Stratification

Segment population into sub-populations (healthy, chronically

ill) to identify & prioritize

interventions

Care Coordination

Combine prioritized patient lists with

care plans to facilitate the right interventions with the right patients

Patient Engagement & Outreach

Add scale & capacity to care coordination & activate

patients with omni-channel

communications

Data Integration Communication Technology Infrastructure


Elements of PHM


Elements of PHM

Population Stratification and

Segmentation

Propensity to Engage in Health Programs

Enrollment

Consent Preferences

Care Plans and Work Flows

Clinical Care Pathways and Application to Manage Care and

Wellness Workflow around Patients

Progress

Patient Engagement Omni Channel

•Voice •Text •Email •Chat with a Nurse •Talk to a Provider •Remote Sensors •Fitness Devices •Video Consults

Measurement and

Outcomes

Improvements in Efficiencies and Health

Outcomes

Improved Revenue and Cost Reductions

Chronically Ill, Wellness and Prevention

Data Integration and Communication Technology Infrastructure

GREEN: West solutions and services including inbound/outbound IVR, call routing and notifications, services for deployments and integration to all major PHM platforms

Purple: Population healthcare platform functions. (Current partnerships with Healarium, WellCentive, IBM Curam)


Healthcare For


In any given year, about

18% of rising-risk

patients become

high-risk.

Healthcare For


Healthcare For


Evolution of the PHM Affiliated Network


Evolution of the PHM Affiliated Network


PHM’s Affect on Physician Employment


What do Providers Want

Source: Population Health Management 2013, KLAS


Source: Population Health Management 2013, KLAS

Where PHM is Headed


The Power to Understand the Market

Breakdown of the Marketplace


Central Themes of PHM Data Aggregation: Combining patient data from disparate sources Risk Management: Segmenting populations to prioritize interventions Care Coordination: Directing providers’ efforts Patient Outreach: Engaged, informed & connected


Population Health – CITI Overview Citi makes a very early effort in the population health management trend to identify winners and losers (for their investors), where most of the leaders are starting from an advantageous competitive position:

• Cerner - well established and growing footprint in the EMR market, already building out its vision (Cerner Synapse brand) and population health management suite of solutions.

• Allscripts – clear vision for delivering a person-centric population health solution and has started to cobble together an impressive collection of assets. The growth in Population Health Management could prove an important pivot point for the new management team; client retention remain risks.

• McKesson – a smart collection of assets and has a dominant exchange position through RelayHealth. Risks include the company’s ability to retain its EMR and financial systems customers and execution at delivering an integrated solution.

• Optum (UnitedHealth) – amassed an interesting collection of assets and has advanced payer tools, but a cohesive provider strategy remains unclear. Partnerships with large IDNs and ACOs are an advantage.

• Healthagen (Aetna) – assets in exchange and patient engagement, plus in house development and savvy business development initiatives. It remains to be seen if technology will be used to enhance their risk book or if Healthagen can be payer-neutral and sell to ACOs.


Population Health – IDC Overview While a few leaders are identified in the IDC report, the population health management market opportunities are so dynamic that we will likely see new entrants. With the exclusion of just two vendors (Wellcentive and Explorys), the rest of the vendors are owned by companies with multiple healthcare applications or horizontal technology suppliers. As a result, IDC believes consolidation of the market is likely to be slow. Note: PhyTel is not on this list


Population Health – KLAS Overview The most prominent market analysis is provided by KLAS who interviewed 78 providers about their use of 23 vendors. Points of note: • Remains manual • Patient reminders needed • Limited staff for PHM • No consistent communication • EMRs getting into PHM Best of Care Coordination* Strongest Owned Portfolio**

**PHYTEL **MCKESSON (MEDVENTIVE)

*/**I2I SYSTEMS **HEALTHAGEN

**PREMIER **WELLCENTIVE

*EXPLORYS OPTUM: HUMEDICA

THE ADVISORY BOARD COMPANY CONIFER HEALTH SOLUTIONS

OPTUM: CARE SUITE & IMPACT

ECLINICALWORKS VALENCE HEALTH

ALLSCRIPTS (DB MOTION) COVISINT

*FORWARD HEALTH GROUP TRUVEN HEALTH

VERISK HEALTH ATHENAHEALTH

EPIC NEXTGEN

CARADIGM CERNER

EARLY LEADERS

PROVEN POTENTIAL

EMERGING STORIES


Aetna

Aetna

Optum

Advisory Board

Humana

Humana

CareFX

Medtronic

Axolotl

Care Coordination and Patient Outreach Formation & Advisory

Data Aggregation and Intelligence Risk Management & Clinical Analytics

End-to-End

Population Health – End-to-End Overview

http://www.xghealth.com/

http://www.healthcatalyst.com/


Electronic Medical Record & PMS


Data Analytics and Stratification


Care Coordination


Healthcare Communications


mHealth, tHealth & Remote Monitoring


Wellness, Rewards and Gamification


Transparency Cost and Quality


“Without automation, PHM is an

impossible dream.”

Quote of the Day


The Power to Understand the Market

Health Information Exchanges Understand the Market


ONC HIE Program


Private HIE Venders

KLAS Report Leaders: • EPIC Care Everywhere • Orion Health Collaborative Care • Siemens MobileMD • Covisint • Cerner • eClinicalWorks

• RelayHealth • Medicity • Optum HIE • Dell


Apple HealthKit & Health |Touch ID


Apple & IBM

Mobility Big Data Analytics

Personalized Healthcare


Google Fit


Consumer Data for PHM


Consumer Buying Habits for PHM

Frequent credit card purchases at pizza shops and fast-food outlets

Cigarette purchases at grocery stores by consumers with bronchial problems

Frequent purchases of large amounts of alcoholic beverages

No vehicle ownership registration on file

May need advice on weight control or diabetes and high blood pressure risks

Increased chance of visiting an ER to an asthma attack

Possibly a sign of depression or alcoholism

Could presage difficulty in reaching schedule care appointments

Fallout in the frequency of drug refills shown on a charge card

May require a reminder notification from the PHM or a call from a nurse

The Data The Analysis


Hospitals Are Mining Patients' Credit Card Data to Predict Who Will Get Sick No need in trying to hide anything from me, I know

about your 2am Papa John’s deliveries

Predicting Patient Health Risks for PHM


The Power to Engage the Right Authority

The Power to Ask the Right Question


Patient Stratification for PHM


Investment for PHM


Market Segments for PHM •Hospitals and Medical Centers •Health Plans/Insurance Companies •Home Healthcare •Disease Management/Care Coordination •Pharmacy and Pharma •Accountable Care Organizations •HMO | PHO| IPA | CIN | AN


Executives to Engage about PHM •CEO | CFO | CMO •Chief Medical Officer •Chief Information/Technology Officer •Chief Transformation Officer •Chief Nursing Officer •Director of Patient Discharge •Director of Case Management •Office of Patient Outreach


Some questions to ask on PHM •What does it mean to you to engage a

population? •Who in your market is responsible for

managing the population? •How are you looking to use PHM to promote

your corporate strategy, it’s scalability and sustainability of the system expansion?


Some questions to ask on PHM •How will you be using PHM to improve

coordination and information exchange across all sites of care?

•Are you planning to use PHM to drive process improvement, better patient outcomes, minimize cost growth, stabilize existing costs structures while improving efficiency of the health system?


Technology Strategies for PHM 1.Have a comprehensive technology Vision and Strategy; 2.One Size Does Not Fit All: A single method of physician-

patient communication will miss a lot of patients; 3.Leverage Technology for Provider Efficiency: Providing a

comprehensive view of all patients and efficient tools to manage the care each population needs;

4.Workflow Integration: Align People, Process, and Technology;

5.Security and Compliance Risk Mitigation: Manage liabilities with the right security framework.


Now You Know Me


You’re Showing Me You Know Me

Now You Know Me


You’re Showing Me You Know Me

Now You Know Me

You’re Showing Me You Care


All Populations

Healthcare For


The Power to be Prepared Now

For The Coming Tide Don’t let Patient Engagement…


Don’t Be Your Hospital’s Global Warmer


Defining Patient Engagement • Patient engagement is the process by

which patients become invested in their own health. Health systems with effective patient engagement programs provide patients with the information and tools needed to take control of their care.


Patient Engagement Framework


Myth #1: It’s Next Year’s Problem


Myth #2: It’s an IT issue


Myth #3: It’s Expensive

A 5% reduction in admissions, readmissions and ER visits can drive an additional $25M in shared savings in a patient-population of 100,000.

http://axialexchange.com/blog/article/how-patient-engagement-pays-for-pcps

http://axialexchange.com/blog/article/how-patient-engagement-pays-for-pcps


Myth #4: People don’t like engaging

Patient channel preferences (Frequency per year)

Not at all

1 time

2 times

3 - 4 times

>4 times


Myth #5: Only the young use Digital

Digital interaction with Payor or Health System (at least 1 interaction)

today

future


Myth #6: Mobile is the Game Changer


Myth #7: Patients want features Ranking of criteria for success of online/mobile proposition


Myth #8: A comprehensive offerings

© 2014 Dr. Gordon Jones | Page #90 Continuum of Communication – Chronically Ill & Healthy

TEC for Hypertension™

TEC for Diabetes™

TEC for CHF™

TEC for CAD™

TEC for Wellness™

Protocols in Health Communications 1. Cloud-based communications platform that leverages evidence-based clinical protocols

to manage care across patient populations using omni-channel, bi-directional communications.

2. Suites of condition-focused, patient engagement and outreach applications that span the patient care continuum– from prevention and wellness to chronic illness.

3. Supporting communication infrastructure and expertise required for effective and modernized patient engagement and outreach across the enterprise.


TEC for Hypertension™

Capture patient’s communication preferences.

Automated outbound call surveys patient on hospital discharge experience.

Patient calls daily to record BP & Pulse in the automated system.

System sends SMS reminder to patient if miss calling in their BP & Pulse.

Patient is priority routed to care coordinator when BP is elevated.

Patient gets email survey to assess how med change is working.

Patient gets a “well done” message via SMS to encourage them.

Automated outbound call reminds patient to make an appointment.

Hypertension Micro-Protocol


The Power to Understand the Problems

PHM Stories


This is René Brunét Jr. the 92-year-old owner of New Orleans’ oldest operating movie theater which is where he sits in this photo. As you can see, he is fragile and on oxygen. How mobile do you think he is?


New Orleans EMA Office & CHS


In the winter of 2014 when a rare ice storm threatened New Orleans, Mr. Brunét and other residents were contacted, either by phone or actual visit, from a city emergency management officer who had gained access to their private medical information. The city wanted to make sure that the kidney dialysis patients in their jurisdiction were advised to seek early treatment because clinics would be closing. Others, like Mr. Brunet who rely on breathing machines at home, were told how they could find help if the power went out.

So, how was the EMO able to do this on such notice?

Those warnings resulted from a search of vast volumes of government data, in this case Medicare health insurance claims, enabling them to identify potentially vulnerable people and share their names with local public health authorities for outreach during emergencies and disaster drills.

What would you call this – Big Brother, govt invasion of privacy, or would you call this Population Health.

New Orleans EMA Office & CHS


Automating Patient Care Coordination

year project to Automate Patient Care Coordination outside hospitals

5 100 thousand at full-risk

3 million patient population 40 hospital 4 state affiliated health network


% Increase in outpatient clinic visits due to increased engagement

Interactive Voice Response Interventions

30 54 % Reduction in hospital admissions and costs

among IVR program patients

Higher satisfaction ratings among patients and clinicians


% of mobile device owners use text messaging.

Driving Text Adoption with Patients

79 41 % of US households are wireless only,

meaning they only us mobile at home.

% increase in appointment confirmations by patients who prefer to receive text reminders.

83


1,323 patients diagnosed with cardiovascular & pulmonary disease

66 % reduction in cost of readmits 67 % reduction in readmissions 68 % reduction in bed days

VIDANT HEALTH SYSTEM

Remote Monitoring & Health Mgt


VIDANT HEALTH SYSTEM

Remote Monitoring & Health Mgt

$9 Million In annual savings in direct costs;

$6,923 in per Patient savings;

Does not include reducing liability

of readmit liability penalties.


Multi-channel Video Care Coordination

DOD contractor enabling live two-way video counseling between certified counselors and active duty military, National Guard, Coast Guard

Unv. of New Mexico training platform for rural providers, and connect to specialist for chronic disease management.

UMTRC created a sustainable business model using video collaboration to support health providers to reduce readmission rates

Health


For More Information, please contact:

Dr. Gordon Jones Curator of the Best in

Digital & Population Health Strategy [email protected]

706-383-3776

Documents

PHMSlideshare2014