The outline of today’s presentation on encouraging directed innovation in the Healthcare fields.Will help the audienceunderstand the pressures and thought process of Primary Care Physicians, show how Decision Support is actually working in our systems; list shortcomings and needs of both PCP’s and physicians; suggest solutions and answer questions.
Heartland Health is located in St. Joseph, MO (pop. 80,000) about 50 miles north of Kansas City. Composed of Heartland Regional Medical Center and Heartland Clinic. HRMC is a 300 bed hospital and Heartland Clinic is a combination of 30 clinics employing a little over 100 physicians of all specialties.Heartland Health is the proud recipient of last year’s Malcolm Baldridge National Quality Award.
Heartland Clinic of Platte City is one of the 30 Heartland Clinic clinics. It is a free standing clinic located just north of the Kansas City International Airport and 30 miles south of St. Joseph. It faces a totally different environment than other Heartland Clinics in that it is located in a suburb of Kansas City and most patients receive other medical services in 7 different hospitals in the Kansas City area instead of exclusively at HRMC.There 4 physicians (3.5 FTE) 2 Family Practice 1 Pediatric 1 Internal MedicineVarious specialists come down from St. Joseph on most days of the week to have half-day clinics Cardiology Podiatry Surgery Pain Management EndocrinologyWhile we’re not the most advanced users of technology we do push it internally and externally and are leading our organization in exploiting this technology
Having described the environment and technology states what’s a day like today?
Typical day involves a wide range of interactions with patients, staff, administration and colleagues. Fortunately, in our clinic we do have an integrated ambulatory/acute care system the facilitates the bulk of the activities in which we physicians find ourselves engaged.In an ideal environment attention can be focused on leveraging these tools to schedule and choreograph the wide range of daily activities. This whole scenario is relatively fragile and a few interruptions can be immensely disruptive.
Having an integrated system does reduce many of the headaches facing ambulatory primary care physicians.First, it can work to simplify the location of information for the physician.We use a single electronic chart for both Inpatient and Outpatient patient recordsTwo sides of the same coinData entered once is immediately available across the entire spectrum of careShare problem lists, medications, labs, registration, everythingHeartland Health has completed certification for HIMSS Analytics Level 6 Award and is just short of achieving Level 7 status putting us in the top 2% of all health care organizations
Second, having integrated links to a regional HIE (Health Information Exchange) enables us to often know a lot about a “new” patient without have to do de novo data gathering and entering.
Third, having flexible template driven tools enable relatively rapid, seamless ways to document a visit Standardization reduces variability, improves data accuracy, thoroughness and distributes work flow. However, it’s still much more labor intensive compared to what it could be if the patient would be able to be part of the equation from home.
In this set of slides we’ll show how we physicians have leveraged remote access technology combined with asynchronous direct communications with patients to make things easier for us and our staff.In this slide I exploit the large wide-screen computers (iMac and HP All-In-One PC) to load what we call the “organizer” on one side of the screen to review lab results, messages and patient lists while at the same time loading the patient’s medical record on the other half of the screen.In the case shown I have a specific lab result on the left side and with one click load that patient’s summary on the right side of the screen.
It’s not unusual for me to want to make sure of the information I’m about to reply to the patient in interpreting and explaining his/her lab results so I’ll click on “Up-To-Date” a web-based medical textbook that we’ve embedded a link into our EMR. This allows me to search, review the specific plan that I want to take to make sure it’s current and accurate.
One click and a message to the patient opens up and the lab result (or results) are loaded into the body of the message.This then allows me to type (or speak) explanatory sentences or cut-and-paste the on-line literature into the body of the message to the patient. This is something that’s done up to 30% of the time.
If I do want to take action and actually place an order or prescribe a medicine, then one click from the message pulls open the tool that lets me place those orders.In this case I’m looking at the patient’s medication list … both those that I’ve actually prescribed (top half) and those that came in historically from connected but individuals outside our organization.
I’ve decided to add testosterone and one click brings up the new order control and I can begin typing in what I want “testosterone”This produces a list of medications, orders, and tests that contain the word “testosterone” allowing me to prescribe a medication or input a diagnostic or nursing order from one screen.
Choosing a prescription brings up the appropriate fields that will enable me to electronically send the prescription to any pharmacy in the United States.
All pharmacies can be selected by a combination of state, city, zip code or pharmacy name.
If I would like to make sure and check whether the patient has had medications filled by any pharmacy that are not in my system I can do so with one click.Having access to this makes sure that we don’t over prescribe medications, discover patients for whom many medications have been prescribed but have never filled their medications or for those who are getting controlled medications from many physicians.
In this case a patient has run out of a previously prescribed medication. They log into the web portal, choose the medication from their medication list (which is the same one we see) and then request a renewal of the medication, specifying which pharmacy and any other information needed.This resulted in the message on the left side of the screen which can be routed to nurses or directly to the physician (my own personal choice).Taking action on this is very simple. Click on the medication list button …
… brings up the medication. All that I need to do is right click on one or more of the medications ….
And take the appropriate action
Once signed the prescription is sent electronically to the pharmacy and the patient is notified.The reason I prefer to do this instead of routing it to the nurse is that with all of the information about the patient at my fingertips I often may want to alter the dose or change medications. The nurse cannot do this and his/her only choice is to approve it and route it to me for signature. If I want to change things then I have to cancel his/her order and then replace one from scratch … all of this adds more work.
Despite these technologies and other in-place automation the physician is making a thousand decisions a day and at the end of the day all of these little things can add up to leave one exhausted.
Interruptions are still the bane of the day and as mentioned before undermine a well planned day. It’s not surprising that interruptions that are not directly related to patient care are the most intrusive. My own experience is that visits by pharmaceutical detail representatives are the most annoying. This is especially true now that we do not accept samples. There’s very little perceived value-add gained from these interruptions. We do not see pharmaceutical companies being at all creative or innovative with regard to the exploitation of technology in providing value nor has any of these visits helped me get through the day.ePrescribing has exacerbated this as now we know which drugs are on formulary and which ones are not. More often than not we are now gravitating towards those “green” drugs just to avoid a call-back from the pharmacy that the medication we chose “was too expensive” for the patient and “the patient would like a generic.”
So let’s talk about the impact of ePrescribe
ePrescribing has helped many of these decisions and new electronic features are preventing mistakes, call-backs and delays in patients getting the right medication. Still has room for improvement, though.
In addition to having drug-drug and drug-disease interraction checking the real value ePrescribe brings is the formulary and cost information. Many of us consider this “real” decision support as it occurs prior to the decision whereas the other occur after the information.Having this information in advance helps us look intelligent and provides value added services for the patient.What’s very interesting is that many of our patients have more than one illness and even Tier 2 drugs now push that patient’s total monthly out-of-pocket cost over the effective limit of $80-$100 so we are being pressured to choose generics more and more since we don’t offer samples and the voucher systems are not effective (too many, too many restrictions, too many conditions based on 3rd party plans).
As mentioned, most of us are exhausted when we head home …. Only to be called several times during the intervening hours and before the next day starts. Day is never really done.
Picture of courtesy of http://www.datamountain.com/resources/hipaa-hitech-compliance/hipaa-hitech-gap-analysis/
So now on to the doctor’s office. Let’s take a look at my clinic which I think is surfing on the front side of the wave.
First, we started several years ago with hand-held tablet PC’s in the hands of nurses and physicians with the notion that mobility was the most efficient and important way to go digital. It didn’t take us long to figure out that as we went to point-of-care use the computer was as much for the patient as it was for the provider. Hand-held computers were not designed for this.We installed desktop computers on small movable tables and very quickly went from standard 17” to 19” monitors, then installed 21” swivel monitors because some data looked best in landscape and other data in portrait mode (as illustrated above). Then we moved to 23” touch screen all-in-one devices to further reduce the footprint and mobility of the devices as well as begun to involve the patient interacting with the computer (consents, patient education, etc). We now think that we’ll be using 52” or larger interactive wall-mounted touch screens as the price of that technology drops to the $1-2,000 range.As an aside we think the total technology investment per ambulatory exam room suite will continue to hover around $2500. Those that aren’t investing that amount per year per room are probably on the wrong side of the “wave”.
An ever increasing number of devices are being produced that are simple to use, plug into local PC’s and networked devices, inexpensive (an order of magnitude less expensive) than previous specialized diagnostic services.Al of these lower the cost and push formal diagnoses down into the primary care physician’s office enabling just-in-time screening, avoiding costly specialist referrals and speed up the time to treatment.
In addition to the exam room connected devices most of us primary care physicians use a wide variety of applications because the EMR can only tell us current and past data but has very little predictive or what/if capabilities. The reason so many physicians use these is that they can individually purchase them to use because, as a rule, they don’t require back end IT support.Here are several examples of non-intrusive, non-disruptive applications that all have the potential to explode leading to massive disruption.Doximity – provides clinicians with secure physician-to-physician connections by mixing social and public licensing databases together … what’s missing is an embedded secure VOIP functionalityVoalté – enables nurses to parse tasks and keep in touch with patient care while scattered throughout the hospital leveraging texting and location based services with patient informationePocrates – Provides clinicians with concise drug and disease based information at the point of careFooducate – Tool to inform consumers about food choices at the point of purchase
iPadContent and NewsSkyscape suite – mainly Netter’s Atlas and 5MCCMedscapeWebMDMedPagePatient Education ToolsAnatomical slides, videosiPhonePrmarily contact, decision making information and CME (when in car-wash, etc.)ePocratesDoximityBlue BookDragon MedicalCME
Great example of innovation where existing consumer devices that everyone carries are now being married with cases to expand their capabilities.Next up will be ultrasounds and even MRI’s.
Pretty self explanatory and coherent with general technology advancements in the last decade.
So what kind of things are needed and what do I, as a physician, think Pharma could help
Back to decision support. While the information systems we use help us avoid making mistakes with regard to drug plans, formularies and cost to the patient they do nothing to help us choose the right drug. Instead most alerts will only fire AFTER a drug is selected. We need a similar list of drugs approved for a given condition and the ability to search for drugs by class or condition based on the previously entered documentation.Fortunately most of us physicians carry a number of mobile tools to use for this but reaching for them and then selecting them adds time to reach a proper decision and time is of the essence to physicians whether they are in the ambulatory or acute care venues.
In addition to pre-selecting those products most appropriate for the condition we find that ePrescribing tools now used carry forward the entire product catalogues including drugs that are not available on the market or not available commonly. The reason is that most advanced systems need to have all of the existing products in order to do reverse allergy checking and quickly find patients that may ever have taken a given product.We’re hoping that while these features would continue to be available at least the products that have been removed from current markets and/or are not being sent to most pharmacies would be dithered. Ideally we’d like this filter to be connected to the local pharmacies inventory in real time.
Finally, the current method of locating pharmacies is a far cry from what it could be. Most of the time neither the patient nor the physician know the address nor the zip code of the pharmacy and even if we put in the patient’s zip code nearby or nearest zip codes do not show. Need something like “pharmacies nearest to zip code”
We know for certain that we’re in a world of change. There is general recognition that the current system is unsustainable yet most are paralyzed into leading the way into new paradigms of health care. What we know is thatReimbursement mechanisms are on the verge of collapseSustainable Growth Formula has been ignored too long to implementNot enough resources to fund current systemsEveryone is looking at increasing transparency and accountabilityRoute out fraud and abuseShift from volume to quality based reimbursementInternet has given the masses access to healthcare knowledge and removed barriers to research and dataPatients are increasingly armed with knowledgeHave much more time to learn about their illness than a physician who needs to keep up-to-date on a much larger volume of knowledgePatients wanting to participate in decisionsFinancial incentivesAvoidance of side-effects and adverse effects of medical careStill not willing to accept accountability for their decisions, thoughNo longer can an office or group stay in a paper world and survive without suffering (unlike recent times when the cost of digitalizing was greater than the benefit).Benefit now exceeds costsCannot participate in ACO’s and new integrative models without converting to digital environmentsWhile there are many ideas about what’s coming there is huge uncertainty. Nevertheless what we think is going to happen includes:Bursting of the current healthcare bubble. The race to the bottom is beginning for the large majority of healthcare providers. As more and more of the financial decision making is pushed to the individual patient it’s becoming painfully obvious that we’ve priced ourselves out the free market. Lead by cost-cutting frenzy Medicaid and Medicare reimbursements are going to deflate and 3rd party payers will be eager to follow in order to sustain their medical loss ratios. We, as a nation, cannot continue to pay as much for the services we’re getting.Genomics is showing us that many of our pharmacologic treatments are ineffective in certain populations. As testing becomes more prevalent we will be able to identify those for whom standard medications will not work and will be required to select medications appropriate for their genetics. In the future these same tools will allow us to design medications specifically for individuals that shouldn’t require the current extremely expensive triple phase testing required as we’ll know in advance these drugs will work in those for whom they are designed as well as know for whom they will not work. However, the state of these advancements is still early as a recent failure of gene detection usage fails at Duke “How Bright Promise in Cancer Testing Fell Apart”(http://www.nytimes.com/2011/07/08/health/research/08genes.html?_r=1&nl=todaysheadlines&emc=tha2)Disease and medical care is social. Bacteria, viruses follow social dynamics. In order to get return on our investments Healthcare IT will need to be aligned with bugs and people … become social.Hospitals are dangerous places if for no other reasons that we’re bringing sick people close together and having fewer and fewer individuals with less and less training move room to room (acting as vectors for disease). Often the safest place for recovering from elective procedures is rapid discharge to home. Advances in technology are going to help make virtual care viable for many conditions. These include leveraging systems like Microsoft’s Kinect to actually be virtual therapists. This, combined with advancing robotics may enable us to provide virtual care even within hospital settings minimizing spread of iatrogenic diseases (i.e., in-room robotic nurses).
What, then, is the Singularity? It’s a future period during which the pace of technological change will be so rapid, its impact so deep, that human life will be irreversibly transformed. Kurzweil, Ray (2005). The Singularity Is Near: When Humans Transcend Biology (Kindle Locations 361-362). Penguin. Kindle Edition. Culminate in the merger of biology and technologyTranscend limitations of our biological bodies and brainsNo distinction between human and machine or between physical and virtual reality
For companies to survive the near term they must understand Moore’s and Metcalf’s law and try to incorporate them into their day-to-day business decisions.Moore’s LawPn = future computing powerPo = current computer powern = # of years required to develop new process divided by 2Metcalf’s LawApplies to just about anything and especially to social systemsThe key principles are that these forces are like waves and timing is everything. It’s important to be on the front side of the wave but not in the trough in order to gain the most momentum. So a company should be recycling it’s hardware and software every 18-24 months. A 36 month cycle puts one on the backside of the wave.Secondly, the more connections a company has to other entities the more powerful their information systems are. With regard to pharmaceuticals my own take is that the more physicians and patients a company connects to the more they will be able to profit.
Here are visual examples of Metcalf’s and Moore’s Laws.Metcalf’s is obvious but less obvious is the time to mass adoption of technology (see inserts) which is based on Metcalf’s LawMoore’s LawThe five paradigms of exponential growth of computing: Each time one paradigm has run out of steam, another has picked up the pace. ElectromechanicalRelay switchesVacuum tubesTransistorsIntegrated CircuitsKurzweil, Ray (2005). The Singularity Is Near: When Humans Transcend Biology (Kindle Location 1293). Penguin. Kindle Edition.
Although the Internet entered the mainstream a mere 15 years ago, life without it today is nearly incomprehensible. And our use of the web has rapidly changed as well. In simple terms, it has evolved from online directories (Yahoo!) to search engines (Google) and now to social media (Facebook). Built on the desktop and notebook PC platform, the web’s popularity is significant.Today, however, a new platform shift is taking place. In 2011, for the first time, smartphone and tablet shipments exceed those of desktop and notebook shipments (source: Mary Meeker, KPCB, see slide 7). This move means a new generation of consumers expects their smartphones and tablets to come with instant broadband connectively so they, too, can connect to the Internet.In this report, Flurry compares how daily interactive consumption has changed over the last 12 months between the web (both desktop and mobile web) and mobile native apps. For Internet consumption, we built a model using publicly available data from comScore and Alexa. For mobile application usage, we used Flurry Analytics data, now exceeding 500 million aggregated, anonymous use sessions per day across more than 85,000 applications. We estimate this accounts for approximately one third of all mobile application activity, which we scaled-up accordingly for this analysis.Our analysis shows that, for the first time ever, daily time spent in mobile apps surpasses desktop and mobile web consumption. This stat is even more remarkable if you consider that it took less than three years for native mobile apps to achieve this level of usage, driven primarily by the popularity of iOS and Android platforms. Let’s take a look at the numbers.
This miniaturization without sacrificing power and performance is pushing all technology to the mobile individual.As technology is driven towards the individual mass integration is enabled as the cost of data entry and interfacing activity is distributed widely rather than born centrally.
Medical innovation is being pushed towards the individual in many ways but the announcement of a $10 million dollar prize for hand-held accurate diagnostic device is adding serious fuel to the fire. Think this is impossible? Recall that MichioKaku talks about high temperature superconductors being able to enable hand-held MRIs that will be common in a few years.
All of these problems present a huge opportunity for innovationMust understand principles of innovation and natural evolution of innovation in order to create true innovation
Hospitals, Clinics and Physicians have been inputting years of data into Electronic Records and much of this is structured and normalized enough to be mined to produce information that would improve patient’s health.Current study designs, privacy rules and regulations and human subject protocols are stumbling blocks to this type of nation-wide data mining but can be over come, especially if directed by the patients whose data is ostensibly available to them and the methodologies as well as results are transparent.Need to avoid commerical pitfalls that could backfire.
An attempted was made (by me) to bring together Pharma’s Scientific Affairs and our front line physicians to streamline the process of information sharing.Pharma was paying physicians to abstract clinical information and enter it into their systems via a web-based portal ($150 - $300). Resulted in very inefficient manual translation of data from one electronic system to another.At the same time Heartland Health’s IT department was inundated with requests by clinicians to provide unique data extraction queries to meet clinical, research and other needs while staffed only enough to complete the EMR roll-out. Estimate at the time was that a demand existed for up to 3 data extraction and management specialists with no plan for data analysts until after the completion of the roll-out (2-3 years in the future).Project would turn the EMR into a revenue source rather than a cost center by working closely with outside entities focused on improving patient care.
Julie Miller’s interview with Dr. Lonny Reisman, Chief Medical Officer of Aetnahttp://managedhealthcareexecutive.modernmedicine.com/mhe/Thought+Leadership/Aetna-manages-cancer-care/ArticleStandard/Article/detail/728450As is often the case, more care or more costly care did not provide improvement. Outcomes for patients in the evidence-based group were similar to the control group.According to Dr. Reisman, the cooperative model of care that patients and providers want also offers an opportunity for payers to drive the kind of care quality that saves money."What's changed particularly as it relates our role, is that there is a much more collaborative relationship between the doctor and the patient with regard to how care is rendered," he says. "Contrast that to the model where basically a patient goes to a qualified doctor who would diagnose, stage and treat in a way that he or she deemed appropriate, and then we would basically pay for those services.”Health information technology is layered over the clinical elements to give physicians electronic access to these protocols and other decision-support resources at the point of care."We would like to see providers working closely with patients to improve health outcomes and lower medical costs," Dr. Reisman says. "We can advance outcome-oriented practices by providing both health information technology and care management support.”Payers can play a pivotal role by introducing the technology providers need to deliver quality care. Increasingly, payers are also changing provider reimbursement structures to skew them toward service quality instead of quantity.Patients, too, can be encouraged to follow their own path toward better outcomes by adhering to doctors' orders and by taking advantage of added support from care managers. Aetna's strategy puts some financial backing behind both efforts, aiming for a return on investment based on total medical costs for a population.Specifically, Aetna's pharmacy benefit for certain members deliberately offers low or zero copays to encourage them to fill their prescriptions and maintain their care plans. Such value-based benefit design is an emerging trend, most commonly applied to drug benefits.Dr. Reisman says in addition to the reduced co-pays, Aetna has also started using other more creative incentives to encourage adherence, such as social media and text messaging. One program offers members a chance to win money in a lottery that they can participate in only if they remain adherent with their medication regimens.An analysis released in May by Avalere Health showed that 10% of cancer patients don't even fill their first prescription for their oral oncology drugs. The abandonment was primarily attributed to high cost sharing levels and the number of concurrent prescriptions.
Cutting costs in a hospital system does not have to mean rationing care if executives embrace changes in system design, Maureen Bisognano said in her keynote address kicking off the Healthcare Financial Management Association's annual conference.Read more: Embrace change to find savings: IHI chief - Healthcare business news, research, information and opinions | Modern Healthcare http://www.modernhealthcare.com/article/20110627/NEWS/306279935#ixzz1QWXe39gJ ?trk=tynt
Keeping in mind that time is of the essence for physicians and also understanding the power of processes similar to the Lean workflows and approaches being used so successfully in many industries what’s needed is real-time, just-in-time dynamic connections that are embedded into our critical systems. This will take a concentrated collaborative approach that links doctors, patients, 3rd party payers, pharma and ancillary support services. This is a dream and a world towards which we are headed but are a long way from achieving.Nowhere do I see the need for this more than in chronic pain management for us Primary Care Physicians who are saddled with having to deal with pharmacologic management of pain because (in my opinion) the refusal of pain centers to manage pain in favor of procedures.
In my opinion pharmaceuticals should be engaging the physicians through the existing applications the physicians trust but in an interactive way. First, they could provide content and materials in a “Pull” fashion (ePocrates example). Second they could have pull links embedded in other informative tools where more practical information could be provided. They could also connect physicians directly with Scientific Affairs teams to answer specific questions instead of having to go through less knowledgeable detail representatives.Pharma and products need to have Social Media Presence but much more interactive, up front and straightforward and avoid misrepresentation like the plague. People are and will use social media tools to interact directly with manufacturers (we do this all the time on our ice makers and other household products).I also feel the bigger opportunity is to develop product management applications for consumers. Many of our problems with ambulatory medications is lack of knowledge about drug specifics that we physicians either forget or don’t have the time to educate patients on (how, when and conditions to take medications and what to do if doses are missed or accidentally doubled) or that if instructed patients will forget. People should be able to whip out their mobile phones and have an app with all of their current medication products with FAQ’s, interactive alarm tools, drug counts, automatic sending of refills requests to pharmacies as their counts get low … the possibility goes on and on.If pharmaceutical companies would form direct relationships with consumers of their products at the product level then brand loyalty would be increased. If consumers had access to Scientific Affairs to answer questions their doctors and pharmacists can’t or don’t have the time to then it reduces the likely they would switch to generics or request brand names as there would be a value add that can’t be provided by generic manufacturers.
Example of several stand-alone apps that layer on by feeding on the same information providing and closed loop process to improve one’s game by delivering meaningful information and allowing the individual to share their progress.In this example I use a GPS application on my iPhone that not only lets me know the yardages and details about the whole I’m playing and my current position (within 1-2 yards) but also enables me to keep track of my scores. When the round is finished the application automatically uploads it to the product’s web site and gives me the opportunity to share my round via several social media sites of my choosing. The application then calculates and maintains detailed statistics based on the simple information entered as I play each hole and then offers me iPhone and iPad applications that deliver customized interactive lessons that I can work on to improve those areas in which I’m weak. This includes newer applications that make it very easy to capture a video of your own swing and compare it to professional golfers that can be synchronized and stepped through in detail both on the iPhone and also on the web site where the videos can be enlarged and scrutinized more effectively.There is nothing preventing companies with medical products in creating, delivering and benefiting from similar array of consumer and physician directed products that would go a long way towards improving the efficiency and safety of medical care in this country (well, actually the world).
What’s needed short term are those innovations that don’t further paralyze executives, clinicians and aren’t disruptive or tax IT’s bandwidth. These should be focused on individuals and augment the systems they are using.With regard to life-style interventions, pharma (from my perspective), is probably in a stronger position to influence these changes than clinicians
Long term innovation will integrate the millions of apps that are used by executives, clinicians, patients and technicians and return information to those needing medical decisions. The flow of data should be aligned with people, bacteria and viruses and provide (finally) tools that will enable to predict and let individuals avoid disease states while improving their health.
Unfortunately many of our own innovations have either been thwarted or delayed because of local, regional and national rules that lag innovation by several years if not decades.
Unfortunately the biggest innovations may need to be political and legal as politics and law are linear process in a world that is geometric.According to a New York Times article published on June 26 (http://www.nytimes.com/2011/06/27/technology/internet/27iht-internet27.html?_r=1&nl=technology&emc=techupdateema3) , at a meeting held on last month in Paris a spirited discussion was held regarding the inability of current regulations to deal with global activity on the internet that is illegal in most of the countries. The problem is, as was eloquently put by Mr. Paltrege of the OECD (Organization for Economic Co-operation and Development) is that “There is a realization that Internet governance wouldn’t work under a traditional treaty model. If you do this via a treaty, are you putting a straitjacket on innovation?” He went on to point out that“We're trying to get the message across that if you hamper the flow of information, you are shooting yourself in the foot in terms of the economic benefits of the Internet,” said Sam Paltridge, an official in the O.E.C.D.’s directorate for science, technology and industry. “If someone comes along and threatens that openness, that’s a real problem for economic growth.”
For Endo Pharmaceuticals David Voran, MD Medical Director, Innovation Clinic of Heartland Clinic, Platte City, MO July 19, 2011 Day-In-The-Life of a Primary Care Physician A Presentation For
Agenda Provide better understanding of clinicians. Foster innovative ideas to improve communication, quality and patient care. Introduce me, where I work and our organization Help you understand my biases Present a PCP’s Day Goal: Try to frame current events to help with your decision making What we know and don’t know Technology in the clinician’s office Impact of current events on healthcare Changing nature of Pharma/Physician relationships Illustrate Pharmaceutical Decision Support in an ePrescribeWorld Emphasize the opportunities that exist List Needs and Possible Solutions Answer further questions
Heartland Clinic of Platte City Free standing clinic 30 miles away from hospital Located in suburb of Kansas City 3.5 physician FTE 1,000-1,200 visits/month Numerous specialists visit weekly Designated the “Innovation Clinic” Fully digital clinic Most patients connected electronically through web portal Have met or exceeded Meaningful Use Stage 1 criteria
Ambulatory Primary Care Office So What’s a Day Like?
Typical Day 20-24 patient visits Mini meetings 1-3 procedures Exam room operative or diagnostic 1 meeting Staffing, billing, marketing or professional 20-40 asynchronous messages Nurses, patients colleagues 10-15 interruptions Pharmacies phone calls detail reps
Single EMR 7 Inpatient: Patient List Ambulatory: Schedule
Clinic Visit Note: Where the Action Is Standardized “SOAP” Subjective What the patient says Objective What we see and measure Assessment Diagnosis Plan Prescriptions, orders, education and follow up All in one template-based place Templates provide structure and consistency distribute work to even the patients
Remote access: Productivity Enhancer Through web portals Redundancy Support all browsers All devices PC’s, Macs, iPad, smartphones By all who need access Patients via web portal View their record Message physicians Schedule visits Request medication refills
Real Example Login from home to review lab results Lab Result Patient Summary
Real Example (continued) One click to context aware information resource
Real Example (continued) One click to message the patient
Real Example (continued) One click to active and historical medications
Real Example (continued) One click and begin typing in desired medication
Real Example (continued) Choose a prescription
Real Example (continued) Checking external pharmacy fill history
Messaging Example Typical Messages from patients
Messaging Example (continued) Needs prescription renewed
Messaging Example (continued) One click to medication list
Messaging Example (continued) Right click and choose “Renew”
Messaging Example (continued) Accept defaults and sign
Decisions, Decisions, Decisions What to ask? What to examine? What to include? What to exclude? Diagnosis ~40% uncertainty What tests to order? What to prescribe? Categories Quantity 25 - 50 decisions each visit 625 - 2,500 a day
Interruptions: The biggest bane Not easy to recover from many of them Interruptions are more than lack of timely decision support Technology has eliminated more than half Patient portal Electronic messaging Many pharmacies still resorting to telephones and faxes Electronic communications preferred Good news is that the industry is slowly catching on Long way to go
ePrescribe … something that is really starting to work well Pharmaceutical Decision Support
Prescribing: A Major Player ePrescribe – Uses CPOE interface Part of the documentation process Launched from the template Actions rendered as text in the note Usually done at the point of care Can get outside information before decisions are made Can tell which meds are on formulary before ordering List of various medications available with generic components Shows alternatives Dramatically reduces interruptions and increases productive time in the exam room
Executives and Decision Makers Vendor “lock” Most organizations locked into long-term HIT contracts Competition rather than cooperation Incapable of sharing services Provider discontent Technology advances High costs of medical technology Security woes Foggy long term vision Workforce shortages, especially primary and nursing care Trajectory of change exceeds bandwidth Conflicting & Changing rules and regulations (federal, states, payers) ARRA impact Who is the customer? Unsustainable of fee-for-service reimbursement Economic downturn
Clinical Pressures Rapidly growing knowledge Changing evidence Uncertainty of diagnosis Increasing disease complexity Lifestyle diseases Solution is life-style changes not medicine Needed information not in your system GIGO Lack of administrative support Pressure to churn patients Average physician needs to bring in $450K per year Need to see >24 pts/day Decreasing time to make medical decisions 15 minutes or less to gather, assimilate, diagnose and document Fewer well paying patients 3rd party payer intrusions on medical decision making Long hours
Much more than EMR/EHRs “Only 50% of the information needed for the next medical decision can be found in the EMR/EHR” Technology in the Doctor’s Office
POC Technology Push as much technology to the point of care as possible Device is as much for the patient as the provider Used as a “window to the world” Evolution notebook > tablet > standard workstations > expanded large screen workstations > multi-touch wide-screen devices
Connect everything to the exam room computer Bodelin Proscope Dino-Lite Earscope MIR Winspiro Eye-Fi cards: Enable easyreal-timehands-off transfer of photos into EMR Electronic scales Stadiometers Diagnostic Tools Other Information Tools
Apps: Provide data not in EMRs Doximity connects physicians to physicians securely Helps tie those not sharing same system Voalté connects nurses to nurses to optimize tasks and patient care Borders on unnecessarily tapping IT bandwidth ePocrates drug and disease content optimized for smart phones Fooducate Educates individuals about nutritional content of food by pointing the smart phone at the food label
My own apps and tools iPad applications iPhone Applications
AliveCor Wireless ECG app built on iPhone 4 and specialized case Example of innovation Adding specialized function to consumer products
Fundamental Principle Everything goes to ground Everything that’s now done in a tertiary hospital will be done in the clinic and eventually be in the hands of the consumer Inescapable and unrelenting mass consumerization of technology Medical diagnostic technology is the next big consumerization opportunity Dramatically lowering the cost and availability of tools Must be willing to use them
… or where the holes are and where Pharma could help What’s Needed
Eliminate “Gotcha” Decision Support Alerts fire after decision instead of before Need indicators that warn of impending alerts Should act like formulary notifications Continue to appear even after overridden many times Why so many physicians use ePocrates, Medscape, and other quick search tools
Improve Product Selection Product status Dither out products that are no longer available Indicate relative prices Diagnostic orders Medications Lack of condition-based prescription recommendations Make a diagnosis > produce a list of orders and medications indicated for this diagnosis Number of these “common” medications no longer available to pharmacies
Improve Pharmacy Selection Many pharmacies identified by number Lack of maps Fuzzy zip code Need to show nearby pharmacies when zip codes are entered Need selection choices similar to what we have on our mobile phones Our expectations are so much higher now that we’re using mobile tools
What do we see and, more importantly, what are the boundaries with which we can confidently operate? Framing the “picture”
From my point of view In a period of change Reimbursement, Rules, Relationships Increased accountability, transparency Democratization of Medical Knowledge Patients participation, access and control Accountability? Increased role of Healthcare IT No longer can be ignored Traditional Healthcare “bubble” bursting Extreme personalization Based on genetics Unique medications Move towards Social Media paradigms in Healthcare IT Virtualization of Healthcare Hospitals and Clinics too costly Most care delivered directly to the patient at home, office virtually What we know What we think is going to happen
Innovation – Looking thru the Windshield Law of accelerating returns Key events happening at ever rates PC’s will match the power of the human brain around 2020 Approaching singularity Culminate in the merger of biology and technology Transcend limitations of our biological bodies and brains No distinction between human and machine or between physical and virtual reality
Interesting healthcare predictions “Physics of the Future” Information technology High temperature superconductors Nanotechnology Applications to Healthcare: Healthcare diagnostic instruments and information moving out of the hospital to clinics, homes and individuals Significant future care will be virtual, multimedia and come to the patient Medicine will become personal Control our genetics Dr. MichioKaku: Professor of Theoretical Physics at the City University of New York
What’s driving change? Computing power doubles every 18 months Pn = Po x 2n Pn = computer processing power in future years Po = computer processing power in the beginning year n = number of years to develop a new microprocessor divided by 2 (i.e., every 2 years) Power of a network is proportional to the square of the number of nodes (users) NetUse = k * N2 Applies to everything Power of an EMR is proportional to the number of medical facilitiesusing it Right now, medicine is still a mom & pop shop but is on the verge of migrating into much larger entities that will leverage Metcalf’s law Moore’s Law Metcalf’s Law
Technology Drivers (Illustrated) Metcalf’s Law Moore’s Law
From web to apps http://blog.flurry.com/bid/63907/Mobile-Apps-Put-the-Web-in-Their-Rear-view-Mirror http://www.slideshare.net/kleinerperkins/kpcb-top-10-mobile-trends-feb-2011
Mobility enables integration Explosion of mobile users Exponential growth over previous computers Enables massive integration at the person level Ubiquitous computing Affordable Faster access Personal Fun to use Measureable real-world activation Real time reward/influence
Result: High Tech Everywhere Chips to manufacture custom-made DNA segments. Biosensors build into cars to monitor blood glucose, location based pollen and cloud based health info Apps to help with complex decision making. Nanoworms for real time monitoring. Advanced medical robotics Mental manipulation of computers
Tangible reward for Innovation Beam me up doctor The X PRIZE Foundation $10 million prize for the public to develop a mobile application Must diagnose patients "better than or equal to a panel of board certified physicians “Tricorder” Prize
…targeted at all roles throughout healthcare and integrated with existing services Huge opportunity for Innovation
Data Mining Opportunities Study existing EMR databases Clinicians don’t have the time nor are paid to datamine Need for cooperative innovation Pharm Academic Medicine
Past Proposal – Before it’s time? March 2007 Open up EMR to Pharma Scientific Divisions via subscription Goals Mine data Communicate with providers and patients Locate potential candidates for further diagnostics and/or early intervention Ideas rejected Too risky
What some others are doing now Managing Cancer Care Backing physicians with decision support tools at their fingertips” Communicating directly with members via SM and Text Messages Offering chances to win money in a lottery based on adherence to treatment protocols Dynamic pharmacy benefits designed to encourage members to fill prescriptions Value-based benefit designs Providing follow-through patient tracking for clinicians Embedding care managers in practices Enveloping evidence base protocols in provider’s EMRs Collaborative Cancer Care Program No reason Pharmaceutical companies can’t play
Focus on the smallest entity Focusing on the smallest component (the patient) provides the most leverage Enables massive change rapidly May offer the best long term solutions Again, no reason pharma can’t also play this game
Enable Real-time Connections Work with vendors to create dynamic links during the prescribing process for both the physician and the patient Just-in-time offers Coupons, Vouchers, Access to resources, Enable connection to researchers Could automate after market data collection directly from consumer Physician and patient would be notified in real-time of additional resources and information ePrescribe Pt Receives Mobile Invitation or Notification from Pharmacy that script is ready and vouchers accepted Embed independent care managers for patients Both real and virtual, manual and automated
Leveraging mobile apps Embed in existing apps Have aSocial MediaPresence But be careful Have to be honest and up front Huge opportunities Physicians and patients need more help than they are currently getting Would push patients to content and management apps “Pull” processes Consumer directed content
Example of Integration between Apps Golfshot Golfplan Golfscape TW My Swing Thru and thru integration Playing Keeps score and stats GPS graphic range finder Practicing Customized video lessons Upload your swing, compareagainst Tiger with feedback All connected providing complete golfing experience Buit in FB and Twitter feeds
…places where innovative technology can have immediate and long-lasting, transformative impact Short and Long Term Needs
Short Term Needs Non disruptive technologies and applications to help with current day processes Anything to reduce intrusive interruptions (read office hour detail rep visits) Tools to help data transfer Currently everyone uses fax but need CCD and CCR formats Tools to facilitate communication between competing systems HIE’s are just not being accepted PHRs (like Google Health) have failed … actually pulled from market Will join but not do the hard work of porting information Technology to convert data to information Secure mobile patient/physician communication tools Anonymous monitoring of lab test results nationwide Map of what diseases are occurring where Weatherbug for medicine Life-style change management tools at the individual level
Long Term Needs Get me to the Church on time! Social umbrella over multiple EHRs All health and disease is social Viruses and Bacteria follow social connections Information systems must align with People, Bacteria and Viruses Real-time suite of apps for providers and patients Connected monitoring tools controlled by individuals Management of patients in their homes and work place Must work to keep them out of the clinics and hospitals Virtual Personal Health Records Connect and integrate personal data by linking multiple disparate systems in real-time
Rules May be Biggest Barrier Legal, political and organizational inertia are the biggest impediments to innovation today Policies, procedures and laws are all 20th century based Instruments, diagnostics, information technology are all 21st century tools Surrounded by global tools but constrained by parochial applications
Doing the splits Exponential growth of technology Linear growth of policies and politics Existing rules and policies aren’t keeping up with technological advances and in danger of loosing not only their meaning but efficacy The real innovation needed might be a new paradigm for regulation, perhaps from the bottom up instead of top-down (an app?).