Easing the way in digital therapeutics

Transcription

1 PROVIDENCE Clinical insights from Providence Health & Services July 2017 Easing the way in digital therapeutics Inside: 4 EMG update 5 MACRA clock ticking down 6 Total knee replacement Providence.org/oregon

2 Sunita Mishra, M.D. Internist and medical director of innovation Providence Health & Services 1801 Lind Ave. SW Renton, WA Digital innovation to improve caregiver and patient experience i was brought on board the Providence Digital Innovations Group two years ago to represent the voice of our providers to the team and to help understand how technology could improve caregiver and patient engagement. Our thesis was that we may be able to use technology to connect patients to their caregivers in a meaningful way. Two such technologies that achieve this that I am most excited about are Xealth, a platform developed in-house by our entrepreneurs-in-residence, and Omada, a CMS-approved online diabetes prevention program that is part of our portfolio through Providence Ventures, our venture capital fund established in Xealth Ninety percent of patients say that they would be willing to use health care apps to help manage their chronic condition if the apps were prescribed by their doctor. However, most providers indicate they aren t comfortable recommending digital health products because they have little visibility into a patient s engagement with and adherence to these prescribed solutions. It becomes challenging to follow a patient s progress outside of the electronic medical record. Xealth was developed to solve this problem. With Xealth, clinicians can prescribe and track the use of educational health content, apps for disease management and devices to help monitor care from their EMR charting interface in Epic. Xealth aggregates and filters a variety of content sources in a provider s existing EMR workflow within Epic, which simplifies the ability to create a customized experience for the patient. Clinicians can discuss these digital health tools with their patients during appointments, track usage afterward, and schedule reminders to ensure patients use them. On their end, patients can access these digital health prescriptions online from their health system s secure patient portal, such as Epic s MyChart. The Xealth technology was launched at Providence to support two initial use cases. In primary care, physicians can prescribe educational video content from ACP Decisions to engage patients in the discussion around advance care planning. In women s health, Xealth works with Circle, an app developed by Providence to give moms personalized physician-led support from pregnancy to pediatric care. 2 Providence inscope Providence.org/oregon

3 Omada Omada is a digital health app meant for patients at risk of diabetes, heart disease and other obesity-related chronic conditions. A prescription gives them online access to a robust prevention program that combines digital health tools (such as wireless digital scales and online courses) with Omada s coaches to help older adults improve their health and reduce their risk. Providers are able to follow the patient s activity with the program through dashboards in Epic. Evidence of success Omada and Humana published a study in January in the Journal of Aging and Health that examined outcomes of a Medicare population who participated in the program. The study followed a total of 501 patients with Humana Medicare Advantage insurance and an average age of 68.8 years who were at high risk of developing Type 2 diabetes. Six months after beginning the Omada program, participants lost an average of 8 percent of their body weight. Twelve months after enrolling, participants had lost an average of 7.5 percent of their body weight, which translated to an average of 13 to 14 pounds lost from an average initial weight of 208 pounds. Xealth and apps like Omada are a means of expanding the reach and expertise of the care team in a way that is engaging for patients. Both Xealth and Omada are being launched in Oregon and give our system an opportunity to learn how digital health tools can help us to create better health in our communities. Circle by Providence app for moms and moms-to-be Providence Health & Services offers a free smartphone app for moms and moms-to-be called Circle by Providence. The app provides women with personalized pregnancy and parenting information and convenient access to care and relevant services. by Circle offers: Answers to frequently asked questions about pregnancy and parenting from Providence experts Ability to track more than one child Breastfeeding support via articles, videos and connections to local resources Information about local classes and groups A to-do checklist designed by Providence experts to guide women through every stage of pregnancy and parenting Tracking tools to share with providers during appointments Appointment reminders when patients connect to MyChart through Circle Circle personalizes the information patients see based on their estimated due dates or child s age and insurance type. Feedback from women who use the app suggests they like how the tool helps them find local resources, both from inside the health system and from community partners. Knowing that lactation support is available via video consultation is a key benefit. "It also allows us to build an ongoing relationship with a family as it grows and grows up," says Sunita Mishra, M.D., internist and medical director of innovation for Providence. Circle by Providence is available for iphones and Android devices. Patients can download it by going to the App Store or Google Play. For more information, contact Casey Bass, consumer innovation manager, at Casey.Bass@providence.org. For physician referrals, see page 7. Providence inscope 3

4 Electrodiagnostic services update Steven Day, M.D. Neurologist Providence Neurological Specialties-West 9135 SW Barnes Road, Suite 461 Portland, OR A number of investments have been made recently to enhance electrodiagnostic services in the form of physician expertise, facilities and equipment. We now have 10 neurologists and two physiatrists performing electromyography (EMG) as part of their practices in the Portland area. With this expansion in physician availability, additional equipment was purchased for several neurology and physiatry clinics. Epically easier In addition, we are spearheading two projects to improve the processes around ordering an EMG and receiving the report. The first is a new order in the Epic electronic health record, which allows ordering clinicians to request an EMG just as they may order a radiographic study. A separate referral will no longer be necessary, and location preference can be indicated. This order will be sent directly to Providence Brain and Spine Institute clinic staff, significantly streamlining the ordering process and reducing delays for patient scheduling. The second project is a direct software interface between the EMG machines and Epic, which will allow direct importation of an EMG report into a patient s chart and automatic routing to the Epic inbox of an ordering clinician. This solution will eliminate steps that delay reporting or result in misdirected or lost reports. Accreditation Lastly, the outpatient neurologists located in our west neurology clinic are piloting a project to form an accredited EMG laboratory with the goals of improved and consistent service to patients and referring physicians. Accreditation of laboratories is relatively new in electrodiagnostics. Accreditation by the American Association of Neuromuscular & Electrodiagnostic Medicine will provide an independent endorsement of the diagnostic excellence of EMG services at Providence Brain and Spine Institute to patients and clinicians as they make decisions about where to receive care. Advantages of EMG Electromyography is an essential tool in the diagnostic of peripheral neurological disorders. The exam is composed of two subtests, which allow for a diagnostic conclusion when they are analyzed together: A nerve conduction study involves electrically stimulating a nerve and recording its response or that of the muscle it innervates. A needle electrode examination involves placing a small needle directly into muscles and recording the electrical activity generated by the muscle at rest and with voluntary activation. An EMG is a helpful diagnostic adjunct when there is concern about mononeuropathy (carpal tunnel syndrome, wrist drop, foot drop); polyneuropathies; radiculopathies (when MRI does not identify clear nerve root compression); disorders of the neuromuscular junction (myasthenia gravis); and myopathies or muscular dystrophies. The new EMG order in Epic will go live this summer. When ordering an EMG, it is important to specify the clinical syndrome of concern and the limb to be studied (e.g., carpal tunnel syndrome, right arm). It is also helpful to briefly review the test with the patient so they know what to expect, given that some people find it uncomfortable. If it is not clear that an EMG would help, a neurological consultation can always be requested instead. To contact EMG services, call Providence Brain and Spine Institute at Providence inscope Providence.org/oregon

5 The MACRA clock is ticking down We are half way through the first MACRA performance year. While some practitioners may qualify under an Advanced Payment model, most will find themselves in the Merit-based Incentive Payment System. MACRA applies to any practitioner who bills Medicare, including advanced practice nurses. In 2019, Medicare payments will be adjusted based on this year s performance in three categories: Quality, clinical practice improvement and advancing the use of health information. Although cost is a fourth category under MIPS, it will not count for 2019 payment. Meeting quality performance goals counts for 60 percent of the overall score. The practice improvement goal counts for 15 percent, and advancing health information, similar to meaningful use requirements, counts for 25 percent. Remember, MIPS scoring is based on median performance of all clinicians. So, by definition, half of all providers will be eligible for a 4 percent bonus, while the other half will realize a decrease in payment rate in If you have been participating since the beginning of the year, you re probably in good shape. If not, you still have a chance to fully participate. For this initial performance year, CMS modified the proposed rules to allow practitioners to participate for a partial year. The minimum requirement for full participation is 90 consecutive days of data. If you submit less than 90 days of data, CMS has indicated it will not penalize practices, but if you do not submit any data, you will automatically be penalized 4 percent. There is still plenty of time to meet requirements for this performance year. CMS gave practitioners a break this year in an effort to smooth the implementation and help all of us participate. Act now before time runs out! James Tuchschmidt, M.D., chief executive, Providence Clinical Programs and Physician Strategy Resources For easy-to-understand documents on preparing for MACRA, visit cms.gov and enter MACRA as the search term. For questions related to Providence, please contact: Laura Butcher, Medicare strategy leader, Population Health Division, at Laura.Butcher@providence.org Ray Manahan, director of government programs, Providence Population Health Division, at Ray.Manahan@providence.org Merit-based Incentive Payment System (MIPS) timeline Incentive paid for 2017 MIPS performance +/- 4% Incentive paid for 2018 MIPS performance +/- 5% Incentive paid for 2019 MIPS performance +/- 7% Incentive paid for 2020 MIPS performance +/- 9% year for 2019 year for 2020 year for 2021 year for 2022 year for 2023 year for 2024 Source: American Academy of Dermatology For physician referrals, see page 7. Providence inscope 5

6 Focus on: Total knee replacement Yaser Metwally, M.D., FRCS Orthopedic surgeon Providence Medford Medical Center Advance Joint Replacement Center of Southern Oregon 707 Murphy Road Medford, OR Total knee replacement constitutes two-thirds of all lower extremity joint replacement in the United States. Mako robotic-arm assisted surgery was introduced for partial knee replacement in 2007, for total hip replacement in 2011 and last year for total knee replacement. The technology is a major advancement in accuracy and precision in bone perpetration and implant positioning. Mako robotic-arm assisted total knee replacement overcomes limitations in instrumentation design and the human imprecision in implementing the preoperative plan. It allows us to execute the desired plan to within one degree for each patient. The Mako total knee replacement represents an exciting technological advance that helps precisely execute the preoperative plan and will hopefully result in higher rates of patient satisfaction. A surgeon s tool When you hear robotic-arm assisted technology, it s important to understand that the Mako robotic arm doesn t actually perform the surgery. The surgery is performed by the orthopedic surgeon, who uses the Mako System software to pre-plan the patient s surgery. The surgeon guides the Mako robotic arm to remove diseased bone and cartilage and then insert the total knee implant. The Mako technology was designed to help surgeons provide patients with a personalized surgical experience based on their specific diagnosis and anatomy. -Here s how it works Step 1: Before surgery It begins with a CT scan of the patient s knee joint, which is used to generate a 3-D virtual model of the patient s unique anatomy. This virtual model is loaded into the Mako system software and is used by the surgeon to create the patient s personalized preoperative plan. Step 2: In the operating room As the bone is prepared for the implant, the surgeon guides the robotic arm within the area defined in the patient s preoperative plan. The Mako system helps the surgeon stay within the planned boundaries. This protects any soft tissue from unintentional injury. Step 3: After surgery After surgery, the surgeon, nurses and physical therapists will set goals for the patient according to postoperative total knee replacement protocols. They will also closely monitor the patient s condition and progress. Manual vs. Mako In a recent study comparing Mako robotic-arm assisted total knee replacement versus traditional manual total knee replacement, Mako demonstrated on average cuts that were four times more accurate and implant placement that was three times more accurate. Degree Manual A (I/E) A (F/E) AC (V/V) AC (F/E) D (V/V) D (F/E) PC (V/V) PC (F/E) P (I/E) P (F/E) T (V/V) T (A/P) F-I (V/V) F-I (F/E) MTKA (n=6) MTKA (n=3) RATKA (n=6) RATKA (n=3) Reference: Robotic-arm assisted total knee arthroplasty demonstrated greater accuracy to plan compared to manual technique. E. Hampp, L. Scholl, et al. The Core Institute, Phoenix, Ariz.; The Cleveland Clinic, Cleveland, Ohio. 6 Providence inscope Providence.org/oregon F-I (I/E) T-I (V/V) T-I (A/P) Degree Mako A (I/E) A (F/E) AC (V/V) AC (F/E) D (V/V) D (F/E) PC (V/V) PC (F/E) P (I/E) P (F/E) T (V/V) T (A/P) F-I (V/V) F-I (F/E) F-I (I/E) T-I (V/V) T-I (A/P)

7 noteworthy New website eases access to trials With thousands of active clinical trials and research studies available throughout Providence, finding the right study can be overwhelming. The Providence Research and Clinical Trials website is a one-stop resource aimed at making it easier for both patients and providers to learn about, access and participate in a wide range of clinical trials and groundbreaking therapies. The site pulls together studies available across our regions and partner organizations, drawing data from the standardized Velos Clinical Trials System. Users can search for open and enrolling clinical trials by geographic location, keyword or clinical areas. They may also contact the Patient and Provider Engagement Center (PEC), which has a dedicated team to help patients and providers find a study, navigate the process, and connect with appropriate research experts. To visit the site, go to Research.Providence.org. To reach the PEC, call Providence Bridge Pedal is Aug. 13 On one pedal-friendly Sunday morning each summer, cars are sidelined as thousands of people on bicycles take over Portland s Willamette River bridges. This popular event attracts riders of all ages, abilities and bicycle styles. The 22nd Providence Bridge Pedal features multiple rides, from the free Kids Pedal to the 30-mile Marquam Express, which crosses nine spans from the Sellwood to the Fremont. There s also a 7.5 mile walk that crosses both the Marquam and Fremont bridges. To learn more and to register, visit ProvidenceBridgePedal.org. Referral resources When your patients need advanced care, our specialists are right at your fingertips. Call toll-free 844-ASK-PROV ( ) for: Nonurgent consults and referrals, 8 a.m. to 4:30 p.m., Monday-Friday More resources General information Integrative medicine East Portland: West Portland: Home medical equipment Home services Hospice Neurodiagnostic services Regional lab services Rehabilitation services Providence.org/oregon Providence executive advisory board Doug Koekkoek, M.D., chief executive, Providence Clinical Services, Providence Medical Group Tom Lorish, M.D., chief executive, Providence Outreach James Tuchschmidt, M.D., chief executive, Providence Clinical Programs and Physician Strategy Contact Providence InScope Holly Young, editorial director, Will Morton, editor, Subscribe to our CLINICAL newsletters ProvidenceOregon.org/clinicalnews Providence inscope 7

8 4805 NE Glisan St. Portland, OR NONPROFIT US postage PAID PORTLAND or PERMIT no 5510 Prescribe a visit to Basecamp Basecamp is an innovative new space at Providence Heart Institute on the Providence St. Vincent Medical Center campus. Our name reflects the starting point where great adventures and great achievements begin in heart disease prevention and wellness. Basecamp offers cardiac rehabilitation and diagnostic services, educational information, cooking demonstrations and exercise classes both for patients undergoing cardiac rehabilitation and for members of the public who simply want to get healthier. Make a referral at WelcomeToBasecamp.org