The Path to Transforming HealthcareProfessor Michael Georgeff CeBIT eHealth Conference 2011
Healthcare Today:Crippled by Knowledge Failures • Error relating to drug therapy reported in 5-20% of all drug administrations • 50% of doctors do not use best practice (evidence-based) care plans • 80% of care plans for chronic disease not followed up • 15-30% of people don’t take prescribed medications • 50% unnecessary acute episodes/hospitalisation from lack of knowledge of patient condition • 50% variation in practice outcomes across regions • 50% of patients with established heart disease are not being targeted with technology that can reduce recurrence by 30% • 180,000 avoidable admissions to Victorian hospitals each year (30 airbuses of people every month)
The Australian PCEHRThe Australian Government is investing $467 million over two years to: Deliver real system change and benefits for consumers and their healthcare providers Establish a national personally controlled electronic health record system Provide people – and the health provider they choose – to access their key health information, online – when and where it is needed Enable people who choose to have a personally controlled electronic health record to register online from July 2012 3
The UK Health RecordProposed benefits: Better care (improved clinical decision-making) Safer care (reduced risk of harm, especially medication errors) More efficient care (e.g., quicker consultations) More equitable care (useful to patients unable to communicate) Reduction in onward referral (e.g., avoidance of hospital admissions) Greater patient satisfaction (by allowing people to state care preferences, receive better care) 5
But does it work? The UK PCR (HealthSpace) was built on the assumption that • a significant proportion of patients will have the motivation and capacity to ‘self manage’ their long term condition using the PCR • this will reduce costs to the NHS • patients’ access to their PCR will contribute substantially to improving data quality The findings show that few people are currently interested in using the PCR to manage their illness It may be time to revisit all these assumptions 6
Key #2: Follow the Internet Road “The dream behind the Web is of a common information space in which we communicate by sharing information. Its universality is essential: the fact that a hypertext link can point to anything, be it personal, local or global, be it draft or highly polished” (Tim Berners-Lee) Designed from the beginning to have no central authority and to operate “while in tatters” Cost the taxpayer little or nothing, as each node was independent and had to manage its own financing and its own technical requirements 9
Context is critical:What kind of future do we want?
Drivers for Reform Not enough • Health promotion • Prevention • Early detection and intervention Lack of • Access • Integration • Coordination Reducing satisfaction • Consumers • providers Increasing costs • Government • Individuals Courtesy ANU Australian Primary Health Care Research Institute
Shifting focus to Primary Health Care Encourage better chronic disease management Support integration & multidisciplinary care Make care more accessible Improve the focus on prevention and early intervention Use technology to support best practice Build the evidence base for effective quality primary health care Courtesy ANU Australian Primary Health Care Research Institute
Case Study: Transforming theManagement of Chronic Disease
Chronic Disease: Big and GrowingMajor burden on the health system:Australia $60 billion; US $1,270 billion per annumDrastic effect on quality of life, morbidity and mortality and a majoreconomic burden in developed and developing economies:GDP Loss (2015): Australia $12B; US: $2,000B, China $75B 14
The Evidence: Chronically Ill Patientsrequire Continuous Collaborative Care The model of care for chronic illness recommended by the Royal Australian College of General Practitioners requires •Longitudinal, planned care •In collaboration with the entire care team •Including the patient •With regular follow up and review Source: http://www.racgp.org.au/guidelines/sharinghealthcare
Why this doesn’t work: What GPs are telling us• Not enough time to handle the added complexity• Too much paperwork and bureaucracy to meet Medicare requirements• Too high a risk of negative Medicare audit• Distracts from patient needs
Barriers to Best Practice CareToo much Annual MBS CDM Items per FWE GP (Australia)paperwork CollaborationMBS CDM Items too time consuming Tracking adherence too Collaboration hard doesn’t happen
How can we change this situation? Provide a means to •Take away the complexity •Make collaboration easy •Remove the administrative overhead •Help support the patient •Ensure high quality, best practice care The only way to achieve these objectives is to automate the end-to-end business processes underlying the management of chronic disease
What are those processes?End to End Disease ManagementReview andMonitoring Follow UpCollaborationPlanning Management Patient Self•• Assure theperformance of control, adherence, Regularly assess subpopulations team and Monitor delivery of effective, efficient across Facilitate care coordination within manage their Identify relevant disease practicefor proactive Empower and prepare patients to and clinicalsystem self-management support and care and organizations careself-management status health and health care•• Provide navigationdistributetheproviders and Ensure the interactions for health team Provideregular reminders to the among team Define rolespatient in assessment, goal-setting, Use planned and throughbytaskscare evidence- Involve timely follow-up support care process care patients members based planning, problem-solving and follow-up action • Embed evidence-based patients and providers Share information with guidelines into daily Organize resources to provide ongoing self- to coordinate support to patients clinical practice management care
To whom do they apply? Kaiser Permanente CAD Trial, 12,000 patients
cdmNet: managing the full cycle of care A web-based (“cloud”) service supporting collaboration across the entire care team• Extracts patient data from GP desktop• Creates electronic, personalised, best- practice care plan• Shares care plan and Care Team health record with care GP team and patient• Monitors and updates care plan and health record• Automates follow-up and review• Supports patient self management• Manages Medicare compliance Hospital Patient
Team Progress Notes GP alters meds in response Diab Ed advises meds, non conformance, need to see GP Optician advises resultsCDMS Notes Shared across Care Team Diab Ed advises medications(example taken over 6 month period) Diab Ed notes non-conformance Diab Ed notes non-attendance Podiatrist requests plan change Diab Ed advises medication GP initiates
The Trials:Barwon South Western (Vic) Eastern Goldfields (WA)
Making Care Planning Work • 88-205% increase in GPMPs Annual MBS CDM Items per FWE GP (Australia) • 80-201% increase in TCAsAutomation of Team Care care plans – Arrangements • 310-595%with one click in GPMP Reviews increase easier than No more faxing – templates • 220-358% increase in TCA Reviews reviews are now easy • PLUS all plans are best practice TCA reviews with one click Results from Barwon South Western (Vic) and Eastern Goldfields (WA) trials (n = 13, t-test, p < 0.01)
• 103% increase in patients receiving HbA1c tests • 66% increase in microalbumin tests Care Delivering Best Practice • 80% increase in HDL tests% GPMP Patients Receiving Service • 1595% increase in dietician services • 253% increase in podiatry services • 498% increase in medications review services Results from Barwon South Western (Vic) trial (n = 99)
Practice Benefits• Saves time: cdmNet increases productivity by 250%• Eliminates paperwork: cdmNet automates all documentation• Simplifies collaboration and review: cdmNet removes the overhead of collaboration, monitoring and review• Improves safety and quality of care: cdmNet improves adherence to best practice guidelines• Increases net revenues: regular users increase annual CDM revenues by over $35,000 per GP• Reduces risk: cdmNet tracks patient care and facilitates Medicare compliance• Maximises flexibility: cdmNet works in any practice environment
Economic BenefitsOver 10 years, diabetes alone, 50% uptake• Benefits to Health System – GP MBS CDM Items: $680 million for increased services – Allied Health MBS CDM Items: $580 million – Hospital Productivity Savings: $600 million from reduced separations – Patients: $4.8 billion from increased workforce participation• Cost to the Commonwealth Government – $1,260 million for MBS CDM Items – $2,280 million for PBS medicines• Compensated by increased tax revenues – $2,930 million from taxes on individuals and their consequential higher workforce participation rate – $370 million from taxes on payments to healthcare professionals.
Nothing will work alone• Need to educate healthcare professionals of the benefits of collaborative care• Need to adopt more effective practice processes• Need to adopt proven change management principles across the entire system• Need to measure benefits to drive uptake• Incentives are key!!
Medicare Support MBS Item Rebate FrequencyGP Management Plan $133.65 1-2 yearsTeam Care Arrangement $105.90 1-2 yearsGPMP Review $66.80 Every 3-6 monthsTCA Review $66.80 Every 3-6 monthsCycle of Care (SIP) $40/$100 12 monthsDiabetes PIP $20 all Pt Calendar yearPractice Nurse Item 10997 $10.60 5 per yearAllied Health Incentives $50.95 5 per year
The Dilemma of Medicare Incentives• Process improvement requires aligned incentives• In CDM, Medicare provides special item numbers to encourage the key elements of the process• But to access these adds further complexity and more processes• Need effective IT support to “make the right thing to do the easy thing to do”• And the incentives must properly align with desired outcomes! (careful market design)
Re-Designing the Model• Need to consider alternative incentive schemes that reward practices and the care team for the providing the COMPLETE cycle of care, not just parts of it• Need to gather the evidence to demonstrate quality of life and economic benefits• Need to feed this back into policy and model design• Proposed Coordinated Care for Diabetes Pilot a game changing opportunity – but only if built on world-best infrastructure and business processes
Establish the Basic Infrastructure • Connectivity via standards (but flexible, lightweight, future-proof) • Healthcare Provider Directories • Individual Healthcare Identifiers • National Authentication Service • Privacy legislation • PCEHR Infrastructure – distributed, not driven by the acute sector • Work with NeHTA foundations – they are moving in the right direction
Convince Providers it is Time to Change “Many health care providers believe themselves to already be doing “planned” visits. They note that their patients with chronic conditions come back at defined intervals. Upon closer inspection, however, these visits may look a lot like acute care.” “The deficiencies of this approach include: •Rushed practitioners not following established practice guidelines •Lack of care coordination •Lack of active follow-up to ensure the best outcomes •Patients inadequately trained to manage their illnesses Overcoming these deficiencies will require nothing less than a transformation of health care”The Chronic Care Model, MacColl Institute for Healthcare Innovation, Group Health Research Institute.
Forrester says “$34 B Market for Healthcare Unbound Technologies by 2015” 80% is Chronic Care $US (billions)ADL/elder $0.35 $0.37 $0.47 $0.59 $0.73 $0.98 $1.2 $1.6 $2.0 $2.4 $3.0 $3.7 Chronic $0.10 $0.13 $0.22 $0.38 $0.65 $1.2 $3.8 $12.1 $23.1 $26.3 $25.7 $26.7 Acute $0.00 $0.00 $0.00 $0.00 $0.01 $0.02 $0.65 $2.0 $3.6 $3.5 $3.0 $3.2 Total $0.45 $0.50 $0.69 $0.97 $1.4 $2.1 $5.7 $15.7 $28.7 $32.3 $31.7 $33.6 (Numbers have been rounded)
The Path Forward The PCEHR is only a part of the solution Solutions are more important Remember the internet 51
Contact and AcknowledgementsProfessor Michael GeorgeffDepartment of General Practice, Monash UniversityCEO, Precedence Health CareEmail: email@example.comPhone: +613 9023 0800This work is supported by funding from the AustralianGovernment under the Digital Regions Initiative and by the Victorian Department of Innovation, Industry and Regional Development under the Victorian Science Agenda program.