ANDREW BRAUNSTEIN MIT (3 degrees Cmputers / Management) 25 years building Clinical Systems ClinLgica Real-Time Clinical Rule Engine fr Predictive Analytics / Clinical Risk Management HealthWyse handheld / tablet based clud EMR fr Hme health / Hspice / Private Duty Vectis Physician EMR Hewlett-Packard Medical CareVue (ICU / OR / Step-dwn) 6 Patents in Clinical Technlgies Cncurrency in Medical Database updates 5,546,580 Cntext sharing in medical applicatins 6,401,138 RFID based lcatin verificatin 7,477,154/7,978,082 Remte Persnnel tracking 7,664,481 Offline Driving Directins 8,489,320 2
THE FAMILIAR PROBLEM IN THE HEALTH SYSTEM INABILITY TO ACHIEVE THE TRIPLE AIM - Many specific radblcks t achieving the simultaneus pursuit f ppulatin health, enhanced individual care and cntrlled csts. COSTS Avidable $48b - Avidable Admissins $20b - Avidable Readmissins $5b - Adverse Drug Events prblem within the hspital envirnment f which 40 55% are preventable $7b - Other Medical Errrs $20b - Imprve targeting f cstly services POPULATION HEALTH Preventative Pr delivery f preventive services against evidence based guidelines. Unaddressed Patient Cmpliance Ineffectiveness managing diseases in the presence f c-mrbidities / multiple prviders EXPERIENCE OF CARE Inefficiency 0.5% f Medicare Ppulatin causes 32% f all readmissins ($6.4b) Uncrdinated care ($9b) Inefficient peratins ($80b) Reactive versus preventive 3
WHY ARE WE FAILING IN CONTROLLING COSTS / MAXIMIZING OUTCOMES SILOS OF CARE REACTIVE / PROACTIVE PATIENT CHANGES OVER TIME TOO MANY ISSUES TO MANAGE INACCESSIBLE INFORMATION Multiple Specialists Limited knwledge f ther dmains N jint discussin We treat issues as they arise We avid practive treatment withut symptms Fcus needs t be lnger term stability nt just shrt term Mnitr if existing treatment still best chice Other Cnditins Medicatins Preventative Prcedure timeframes PBM Hx/Drug Cmpliance INSURER Hx Prcedures LAB Hx ihealth - Vitals utside visit 4
SHORT-TERM FOCUS OR LONG-TERM FOCUS INSURER SHORT TERM FOCUS Private - Yearly Cntract w/ Emplyers Emplyers shp based n price Little guarantee that cntract renews Public Fcus n yearly budget cycle Payff f lng-term investment is utside budget cycles Likely nt t reap reward f investment in preventin Decisins made with a persnal relatinship PCP LONG-TERM FOCUS Patients rarely switch prviders Have persnal face t face relatinship Lack f preventative care Time mre visits / patient = lwer patient lad Mney lwer share f risk savings 5
PROBLEM: SHIFT TO SHARED RISK CONTRACTS W/O TOOLS TO IDENTIFY AND MANAGE RISK With effective risk tls, ACO s can take n mre f the risk, thus prvider even greater incentives fr high quality care N Risk based industry can survive withut the ability t identify, quantify and manage risk Healthcare rganizatins ptimized t measure carse (aggregate) utcmes and nt practive heath (single patient) status Death Rates Readmissin Rates A new paradigm is needed t achieve the Triple AIM (cst, patient satisfactin and grup health) Integratin f cre Health Data Predictive Analytics Evidence Based Medicine Individualized measures f care quality 6
TWO SIDES OF THE SAME COIN PATIENT CENTERED HOME Radmap fr caring fr cmplex cnditins Cmpliance with NQF best practices Meds Prcedures Labs Preventin f adverse drug events Identificatin f pending clinical tasks/prcedures CLINICAL LOGISTIC OVERSIGHT Prductivity and Cst have n relatinship t medical quality Quality can be measured by: Aggregate scres f patient best practice cmpliance Identificatin f delays in prviding ptimal care 7
HOW MANUFACTURING TRANSFORMED ITSELF W. EDWARDS DEMING Organizatins can increase quality and simultaneusly reduce csts, reducing waste, rewrk, staff attritin and litigatin while increasing [patient satisfactin] When peple and rganizatins fcus primarily n csts Csts tend t rise and quality declines ver time BUT When peple and rganizatins fcus primarily n quality Quality tends t increase and csts fall ver time http://innvatinlabs.cm/summit/summit7/pre/reading_materials/drdeming.pdf 8
GAPS LEAD TO MISTAKES PCP wns patient- 70y w/ DM, HTN, Chrnic Liver Disease T high risk t cntinue taking metaxalne. N Hep-A vaccine N ASA Hspitalized fr MI Intended t give prescriptin fr Beta-blcker. SNF fr stabilizatin. Osteprsis dcumented Did nt Schedule Eye check, nr Bne Density as rdered N biphsphate prescribed Hme Care versight Nt mnitring SCr Self Nt mnitring Weight Nt Mnitring Glucse 9
NATIONAL QUALITY FORUM MEASURES The Natinal Quality Frum (NQF) is a nt-frprfit, nnpartisan, membership-based rganizatin that wrks t catalyze imprvements in healthcare Cnvenes wrking grups t fster quality imprvement in bth public- and private-sectrs Endrses cnsensus standards fr perfrmance measurement NQF-endrsed measures are evidence-based predicative NQF endrsement is the gld standard fr healthcare quality. 10
DISEASE MANAGEMENT EXAMPLE: NATIONAL VOLUNTARY CONSENSUS STANDARDS FOR AMBULATORY CARE Bne and Jint Cnditins Hydrxychlrquine annual eye exam Rheumatid arthritis new DMARD baseline serum creatinine Rheumatid arthritis new DMARD baseline liver functin test Rheumatid arthritis new DMARD baseline CBC Rheumatid arthritis annual ESR r CRP Methtrexate: LFT within 12 weeks Methtrexate: CBC within 12 weeks Methtrexate: creatinine within 12 weeks New rheumatid arthritis baseline ESR r CRP within three mnths Sterid use steprsis screening Ostepenia and chrnic sterid use treatment t prevent steprsis Osteprsis use f pharmaclgical treatment Cardivascular Disease Deep vein thrmbsis anticagulatin 3 mnths Stent drug-eluting clpidgrel Pulmnary emblism anticagulatin 3 mnths Pst MI: ACE inhibitr r ARB therapy New atrial fibrillatin: thyrid functin test Patients that had a serum creatinine in the last 12 reprted mnths Heart failure use f ACE inhibitr (ACEI) r angitensin receptr blcker (ARB) therapy MI use f beta blcker therapy Heart failure use f beta blcker therapy Atrial fibrillatin warfarin therapy Male smkers r family histry f abdminal artic aneurysm (AAA) cnsider screening fr AAA Secndary preventin f cardivascular events--use f aspirin r antiplatelet therapy Chrnic Kidney Disease Chrnic kidney disease: mnitring phsphrus Chrnic kidney disease: mnitring parathyrid hrmne (PTH) Chrnic kidney disease: mnitring calcium Nn-diabetic nephrpathy use f ACE inhibitr r ARB therapy Chrnic kidney disease lipid prfile mnitring Chrnic kidney disease with LDL 130 use f a lipid lwering agent Diabetes Cmprehensive diabetes care: HbA1c cntrl (<8.0%) Adults(s) taking insulin with evidence f self-mnitring bld glucse testing Adult(s) with diabetes mellitus that had a serum creatinine in the last 12 reprted mnths Diabetes with LDL >100 use f a lipid lwering agent Diabetes with hypertensin r prteinuria use f an ACE inhibitr r ARB Diabetes and elevated HbA1c use f diabetes medicatins Primary preventin f cardivascular events in diabetics (lder than 40 years) use f aspirin r antiplatelet therapy Hyperlipidemia and Athersclersis Adherence t lipid-lwering medicatin Dyslipidemia new med 12-week lipid test Hyperlipidemia (primary preventin) lifestyle changes and/r lipid lwering therapy Athersclertic disease lipid panel mnitring Athersclertic disease and LDL >100 use f a lipid lwering agent 11
MANAGE MULTIPLE TYPES OF RISK Risks are patient specific Age Sex Cnditins Change ver time Have Cmplex interactins Identify inflectin pints 12
ADVERSE DRUG EVENTS ADE Breakdwn Drug-related mrbidity and mrtality csts $177 billin 82% f American adults take at least ne medicatin and 29% take five r mre Serius preventable medicatin errrs ccur in: 3.8 millin inpatient admissins 2 3.3 millin utpatient visits 3 Mrtality frm preventable medicatin errrs: 7,000 deaths each year 4 At least 40% f csts f ambulatry (nn-hspital settings) ADEs are estimated t be preventable At least tw studies attribute 42-60 percent f ADEs t excessive drug dsage fr the patient's age, weight, underlying cnditin, and renal functin. Drug Interactin Allergy (Drug) Allergy (Categry, Class, Crss-Reactivity) Duplicatin Dsing C-Mrbidity Impact 13
PATIENT SPECIFIC MEDICATION QUALITY CHECKS Cnditin Med Requirements Evidence based Prtcls Add (by med r class) D/C Benchmarking ability t successfully cntrl cnditins Med Impacting Cnditin Mitigate Impact with Dsing Restrictins Labs t mnitr high risk areas Identify Bdy System Risk (i.e. Pulmnary Functins, Cardiac Functins) Adverse Drug Events Allergies Drug / Drug Interactin Checking FDA Meds OTC Meds Drug / Fd Interactin Checking Medical Errrs Identificatin f Therapeutic Duplicatin Dse Range Checking (high / lw) Age / Sex / Weight Diagnses (including Renal / Liver / Smking) Rute 14
PATIENT SPECIFIC LAB QUALITY CHECKS Driven by Evidence Based Standards Disease / cnditin based Age based Maintenance mnitring Outside visit cycle Therapeutic Drug Mnitring Fllw up n related lab results Triggered by dse changes 15
FUTURE OF MED MONITORING GROUP HEALTH COOPERATIVE Agreed upn list f drugs fr mnitring, with lab tests and time intervals Fr example - patients taking adalimumab (Humira) fr rheumatid arthritis have cmplete bld cunt, creatinine, and alanine transaminase tests every 2 mnths. Dse change in ne med may trigger mnitring in ther meds Mnthly reprt f patients taking ne r mre f the medicatins n the list. Patient Labs scheduled and Mnitred Patients verdue fr lab tests receive a letter If a patient des nt cmply they receive anther reminder As a nte paced in patient s pharmacy prfile, the pharmacist can remind during any refill As a last resrt, patients get a persnal call frm a clinical pharmacist r anther member f the care team. Overall, patients are very cmpliant with [TDM]. Within 30 days f sending a reminder letter ut, we see abut 70% f thse peple cme in and get their lab wrk, and within 100 days, we get up t 80%, 16
PROCEDURE/TESTING QUALITY CHECKS Driven by Evidence Based Standards Disease Cnditin Maintenance mnitring Outside visit cycle Triggered by age / sex 17
DIFFERENT EMRS ONE PATIENT AUGMENTED DATA COLLECTION/RISK ANALYSIS ACO s OWN PATIENT ACROSS THE CONTINUUM Cmmunity Outpatient / Primary Care Hspital Rehab/SNF Hme Health Changes in Risk reprted t verseer Supprt Self Care Med Cmpliance Educatin Self Directed Labs 306 NQF Prtcls 33 fr SSP 7 are satisfactin Disease Oversight Med Mgmt Effectiveness TDM / Labs Dsing Changes Care Crdinatin mnitring 300 NQF Prtcls Pre/Pst cnsistency Mnitring f fllw-up care Real-Time risk Sepsis Bleeding Strke 91 NQF Prtcls Hspitalizatin Risk Missed D/C rders Mnitring f fllw-up care Real-Time risk Sepsis Bleeding Strke 60 NQF Prtcls Hspitalizatin Risk Missed D/C rders Med Mgmt Effectiveness TDM / Labs Dsing Changes 18
PATIENT ENGAGEMENT CONDITION BASED INTERACTIVE DATA GATHERING Cllect/Analyze BP, Glucse, ther self mnitred vitals/labs Reminders fr taking medicine based n infrmatin gathered frm PBM / Insurance claims As patient changes utside visit - need t have utreach t review Meds/ Labs and initiate suggestins fr changes. Targeted patient specific Self Care educatin/tracking via Electrnic delivery 19
MANAGE MULTIPLE FACILITIES USE QUALITY MEASURES TO IDENTIFY PRACTICE ISSUES Lwer Risk implies fcus n quality Deming et. al. Cmpare facilities by quality f care, nt just prductivity Veterans Administratin Identify best practices within an rganizatin while islating pr prcesses Quickly measure the effect f changes Allws rders f magnitude imprvement in breadth f clinical prcess imprvements 20
CLINLOGICA MANAGES RISK FOR SUCCESS BEYOND FEE FOR SERVICE At each step crss check all ther stages Preventin is cheaper than rewrk Cllect and analyze data alng all parts f a prcess Identify utliers Increases in quality simultaneusly reduces cst reduces waste, rewrk, staff attritin and litigatin while increasing patient satisfactin Triple AIM Quality benchmarked external t the prcess Mdeled after W. Edwards Deming s revlutin in manufacturing 21
Quality Of Care Analytics Minding The Gap