Beyond EHR      Achieving Operational Efficiency & OptimizationCallum BirDeloitte Consulting SEA
Beyond EHR -    Start Time   End Time   Topic                                            Speaker    8:30         9:00     ...
Benefits for EHR across various Stakeholders      Realizing BenefitsCallum BirDeloitte Consulting SEA
Healthcare Market is experiencing a rapid transition in the clinical needs and  the use of technology for innovation      ...
Some of the Key Questions        Govt Health & Payers                            Providers•How do we make healthcare affor...
A Seemingly Logical “Trendline”                                                                               Community-wi...
It is expected that HIEs help reduce costs and enhance quality by providingphysicians with needed information at the time ...
Fast facts (?)The eHealth Initiative’s (eHI) 2008 survey found that fully operational HIEs are producingresults. The eHI a...
Most direct benefits seem linked to streamlining information exchangeamong HIE participants (Simulated Total)            I...
Benefits for stakeholders groups  The grid illustrates anticipated benefits for a range of potential HIE services across s...
Reducing cost is possible while improving population-based outcomesHIEs are important enablers of the healthcare delivery ...
Healthcare in the future may have very different delivery and reimbursementmodels     Populations                         ...
Consumer Perspectives13
Technology will change lifestyle ofchronic care patient and enable self-care....
What Citizens want?            Interest in online tools and services and in           tools and aids to support self-manag...
Interest varies by generation and country in using a smart phone or PDA tomonitor their health if they are able to access ...
Consumers are highly interested in using a medical device that wouldenable them to check their condition and send informat...
Technology-enabledSelf-Care                                                    self-care                Growth drivers• Co...
Regular follow-up, Mobile Monitoring ,Chronic Care Lifestyle                                                Lifestyle choi...
Personal monitoring device to alertEvidence Based Care                                                      and guide to m...
Provider Perspectives21
It has also well documented quality issue        280,000 people will get the wrong advice today in a doctor’s office     ...
An example of a patient-specific HIE-enabled point of care Clinical Decision    Support - CINA   Patient Specific   Auto...
Diagnoses and Medsare prioritized tohighlight chronic         Goals Not Met areconditions                highlighted for q...
EHRs specifically designed for direct use by physicians such as computerized physician order   entry (CPOE) and physician ...
CPOE (Continued)Encouraging Cost-effective regimens or Less-Costly Drugs                                          Percenta...
Total EHR benefit projections are significantCOST DECREASE FACTORSCost Decrease - 1   Conservative         Medium        A...
Cost Decrease - 5Total benefit projections are significant Record Costs by Reducing Chart Pull Staff, Eliminating Storage ...
Cost Decrease - 9Total benefit projections are significant Materials Management Cost by Reducing Form and Paper Demand    ...
Community Wide     Analytics30
Many Benefits:                                                                                                           ...
3-1                                Screening                              3-1& Early Smoking                              ...
Screening      3-1Trend                              3-1& Early Smoking                                  Adult            ...
3-2 Peer Comparisons                               Screening                                 & Early  Prevention          ...
3.2 Trend                               Screening                                & Early  Prevention                3-2Det...
3-3 Advice to Quit                             Screening                              & Early                          3-3...
3-4 Pharmacotherapy                             Screening                              & Early                          3-...
EHR Technical     Characteristics38
Generic HIE reference architectureThe Generic HIE reference architecture depicts a basic architecture with its variousserv...
HIE sample logical architecture                                  ©2011 Deloitte Touche Tohmatsu Limited
HIE Data Architecture Types         Virtual or Partitioned Centralized Model                                              ...
HIE Data Architecture TakeawaysBelow are key points and takeaways for each architecture types         Federated           ...
Current State of EHRs43
Many EHRs are still in the early deployment phases (estimated allocation)                                              Pha...
Many complex, interrelated characteristics                          STRATEGY &               DETAILED           FEASIBILIT...
Disruptive Innovation        in Healthcare                          Callum Bir                            Director,       ...
Disruptive Innovation                    47   ©2011 Deloitte Touche Tohmatsu Limited
Social NetworkingFacebook drives more traffic online than Google                      48                   ©2011 Deloitte ...
Compare hospitals & doctors?    Percent who compare physicians and hospitals before making a selection and      most trust...
Building fan pages for specific causes,Facebook          organizations or products; sharing                 recreation-ori...
Posting educational videosYouTube              and testimonials          51             ©2011 Deloitte Touche Tohmatsu Lim...
Patients Like MePatientsLikeMe is a data-driven social        PatientsLikeMe                                              ...
Doctors & Citizens accessTwitter        most latest from trusted sources.                        Less is more..           ...
Recruiting talent,Linked-in        announcing staff news            54           ©2011 Deloitte Touche Tohmatsu Limited
Case Studies –     Mobility55
Examples of how Technology is Changing how we may look at EHRs56                                                   ©2011 D...
NSW Emergency Waiting Times Mobile Site57                                        ©2011 Deloitte Touche Tohmatsu Limited
Department of Health and Human Services Tasmaniaimprove the quality of patient care while also increasing organisational e...
Transiting from Patient Oriented Care to     Consumer Model of Care ….
60   ©2011 Deloitte Touche Tohmatsu Limited
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Beyond EHR - Achieving Operational Efficiency

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Callum Bir
IBC Asia 3rd Asia EHR Conference in held in Singapore November 2011
Callum chaired the workshop for the day with guests speakers from Singapore MOHH, HL7, etc.

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Beyond EHR - Achieving Operational Efficiency

  1. 1. Beyond EHR Achieving Operational Efficiency & OptimizationCallum BirDeloitte Consulting SEA
  2. 2. Beyond EHR - Start Time End Time Topic Speaker 8:30 9:00 Registration - 9:00 10:30 Business Case & Benefit Realization for EHR Callum Bir, Deloitte across various stakeholders 10:30 10:45 Morning Coffee - 10:45 12:30 Going Beyond EHR – Opportunities & Operating Callum Bir, Deloitte Models 12:30 13:30 Lunch - 13:30 14:30 Building Foundation going beyond EHR (Case- Victor Chai, MOHH Study) 14:30 15:30 Secondary Uses of Data: Pharmaceutical Shirali Mewara, Deloitte Perspective (Case Study) 15:30 15:45 Afternoon Coffee - 15:45 16:00 Achieving Interoperability & Role of Standards Callum Bir, Deloitte 16:00 16:30 Singapore’s Approach to Standards Yu Chye Cheong, MOHH (Case Study) 16:30 17:00 US’s Approach to Standards (Case Study) Thiam Hwa Lim, HL7 17:00 17:30 Panel Discussion2 ©2011 Deloitte Touche Tohmatsu Limited
  3. 3. Benefits for EHR across various Stakeholders Realizing BenefitsCallum BirDeloitte Consulting SEA
  4. 4. Healthcare Market is experiencing a rapid transition in the clinical needs and the use of technology for innovation Present-day scenario in Healthcare industry Growing Aging Population Innovation through Technology Increasing Healthcare Costs Increasing focus on primary & preventive care Shifting Evolving Increasing Lifestyle diseases Trends Focus Resource Shortage & Medical Tourism Increasing Burden on Provider Emerging Increasing Patient expectation markets Innovative Markets in the SEA region Chronic MedicationHealth Reform Clinical Medical Disease Safety and E Health Effectiveness Tourism Management Management 4 ©2011 Deloitte Touche Tohmatsu Limited
  5. 5. Some of the Key Questions Govt Health & Payers Providers•How do we make healthcare affordable? • How we improve Quality of Care• How do we increase capacity •How do we Improve Patient Safety•How do we improve seamless • How do we improve operational /coordination of care across the health clinical efficiency?care continuum • How do we increase compliance?•How do we keep our population healthy? Patients Life Sc Companies• How do I stay healthy? • How do we accelerate drug discovery,• How do I better manage my disease development, and launch medicinesand improve my lifestyle (Chronic) • How do we increase efficacy, and• How do I share my decision making? safety?• How do I “take-control” of my health • How do we accelerate innovation?better?5 ©2011 Deloitte Touche Tohmatsu Limited
  6. 6. A Seemingly Logical “Trendline” Community-wide Automation Presumed Benefits Enterprise/Integrated Delivery System-wide Automation Extend the Core Hospital-wide Enterprise Automation The Departmental Enterprise Automation Level of Complexity/Involvement6 ©2011 Deloitte Touche Tohmatsu Limited
  7. 7. It is expected that HIEs help reduce costs and enhance quality by providingphysicians with needed information at the time treatment decisions are made HIEs are also envisioned as a way for stakeholders to experiment with new economic models Typical HIE Benefits Potential U.S. net efficiency gain from use of HIEs: >$55B per year or 3% of total healthcare expenditure of Public Health $1.7 T  Improved population health Inpatient EHR $6B  Improved wellness  Improved monitoring and safety Payers and Employers  Reduced costs Outpatient EHR $25B  Reduced MLR  Lower absenteeism  Efficiency Providers  Reduced errors  Improved quality  Efficiency Community Health Information Exchange Other (e.g., Life Sciences) $55B  Faster routes-to-market Sources: Center for Information Technology Leadership, Partners Health Care, Harvard (2004) ©2011 Deloitte Touche Tohmatsu Limited
  8. 8. Fast facts (?)The eHealth Initiative’s (eHI) 2008 survey found that fully operational HIEs are producingresults. The eHI also found in its survey that the HIE results are translating into positivereturns on investment for their stakeholders.The survey results are given below: 69% 52% 69% of the fully operational exchange of fully operational exchange of operational exchange efforts initiatives (29/42) experienced efforts (22/42) report positive (29/42) report a positive financial reductions in health care costs. impacts on health care delivery. return on their investment (ROI) for their participating stakeholders. A majority (69%) of the fully About half (52%) of fully A majority (69%) of operational operational exchange initiatives operational exchange efforts exchange efforts (29/42) report a (29/42) experienced reductions in (22/42) report positive impacts on positive financial return on their health care costs: health care delivery: investment (ROI) for their  19 reduced staff time  16 improved access to test results participating stakeholders:  11 decreased dollars spent on  13 improved quality of practice life  13 reported an ROI for hospitals redundant tests  9 decreased support staff  9 reported an ROI for physicians  5 documented a reduction in patient  8 improved compliance with chronic practices admissions care and prevention guidelines  6 reported an ROI for health plans  5 decreased cost of care for chronic  6 reported better care outcomes for  5 reported an ROI for independent care patients Patients laboratories  4 reported a decrease in prescribing errors  4 increased recognition of disease outbreaks ©2011 Deloitte Touche Tohmatsu Limited
  9. 9. Most direct benefits seem linked to streamlining information exchangeamong HIE participants (Simulated Total) Increased patient safety Electronic receipt/transmission of clinical Administrative savings documentation ( e.g., filing / requesting requests, retrieving patient history, call-in of orders, Duplicate tests call-in of prescriptions ) reduction Substitution to generic drugs Electronic adjudication of orders ©2011 Deloitte Touche Tohmatsu Limited
  10. 10. Benefits for stakeholders groups The grid illustrates anticipated benefits for a range of potential HIE services across stakeholder groups Benefit potential Service Clinical Clinical Care Quality Public health Data Personal results records management reporting reporting aggregation health Stakeholder delivery tools for research records Physicians Hospitals Laboratories Pharmacies Payers Employers Researchers ConsumersAnticipated magnitude of benefits of each service for stakeholder groups. High Medium LowSource: State-level HIE Value & Sustainability Interim Report, AHIMA ©2011 Deloitte Touche Tohmatsu Limited
  11. 11. Reducing cost is possible while improving population-based outcomesHIEs are important enablers of the healthcare delivery ecosystem • Respond to transparency & PC 2.0 - Connected care - Rx reimportation - Medical tourism 4 • PHR (Shared Decision Making) • Incentives - Experience rating & differential Consumerism premiums Focus: Transparency, - Healthy behavior rewards PHRs, Incentives, Value • Complimentary/Alternative Medicine 3 • New medical homes Coordination of Care • Reimbursement realignment • Primary care workforce Focus: Primary Care 2.0 Model • MD led clinical care coordination (The New “Medical Home”) • 3 –7 NMEs per year 2 Comparative Effectiveness / • Center for comparative Evidence-Based Medicine effectiveness • Knowledge management Focus: (1) Personalized Medicine; (2) Comparative Effectiveness; • Prepare for tort reform Episode Based Payments to Acute Organizations • Decreased errors 1 Health Care Information Technology • Decreased care gaps • Reduced malpractice Focus: EHR, HIEs, ICD-10 premiums • Improved efficiency11 ©2011 Deloitte Touche Tohmatsu Limited
  12. 12. Healthcare in the future may have very different delivery and reimbursementmodels Populations Experimentation Period Healthcare Reform Individuals Fee-for-service, individual encounters Bundled payments, performance/ Volume-based payments outcome-based payments, Volume risk proactive health management, patient accountability Performance risk12 ©2011 Deloitte Touche Tohmatsu Limited
  13. 13. Consumer Perspectives13
  14. 14. Technology will change lifestyle ofchronic care patient and enable self-care....
  15. 15. What Citizens want? Interest in online tools and services and in tools and aids to support self-managed care 15 ©2011 Deloitte Touche Tohmatsu Limited
  16. 16. Interest varies by generation and country in using a smart phone or PDA tomonitor their health if they are able to access medical records and downloadinformation about their medical condition and treatments. ©2011 Deloitte Touche Tohmatsu Limited
  17. 17. Consumers are highly interested in using a medical device that wouldenable them to check their condition and send information to their doctorelectronically through a computer or cell phone via the Internet17 Deloitte ©2011 Deloitte Touche Tohmatsu Limited
  18. 18. Technology-enabledSelf-Care self-care Growth drivers• Consumerism• Increased Expectation from patients and more importantly, care givers• Ubiquitous computing Barriers• Lack of awareness of benefits• Data Governance, Ownership, and regulatory frameworks still needs to be worked out• Lack of Sustainable business models• Still in early stages of development 18 ©2011 Deloitte Touche Tohmatsu Limited
  19. 19. Regular follow-up, Mobile Monitoring ,Chronic Care Lifestyle Lifestyle choices for chronic patients Growth drivers• Increased access to healthcare and health- related information, particularly for hard-to- reach populations• Increase mobile (voice) coverage and adoption Barriers• Relatively untapped market• Limitation on care delivery on phone http://www.youtube.com/user/ProjectHealthDesign#p/u/16/VNdkgOuui00 19 ©2011 Deloitte Touche Tohmatsu Limited
  20. 20. Personal monitoring device to alertEvidence Based Care and guide to make improvements in health or treat a condition. Growth drivers• Significant innovation in Med Tech industry• Rapidly growing Chronic Disease patients in Asia• Improved ability to diagnose and track diseases Barriers• Lack of complete end-to-end operator service• Largely Silo approach till date http://www.youtube.com/user/ProjectHealthDesign#p/u/12/rYkuswN8wMY 20 ©2011 Deloitte Touche Tohmatsu Limited
  21. 21. Provider Perspectives21
  22. 22. It has also well documented quality issue  280,000 people will get the wrong advice today in a doctor’s office  2,800 people will be harmed today by a medication error  Over 98,000 people will die this year in hospitals from a preventable medical mistake Estimated Deaths Due to Medical Errors Leading Causes of Death1 Deaths in Hospitals 1 Heart Disease 727,000 2 Cancer 540,000 3 Strokes 160,000 4 COPD 109,000 5 Accidents/Adverse Effects 97,000 High (98,000) 6 Pneumonia 86,000 7 Diabetes 63,000 8 Motor Vehicles 43,000 Low (44,000) 9 Firearms 32,000 10 Suicide 31,000 … To Err is Human’ - Selected Strategies to 14 AIDS 17,000 Improve Medication Safety 1 National Vital Statistics Report. Center for Disease Control and Prevention (CDC). Deaths Final Data for 1997. Volume 47, number 19. P. 1 - 105. June 30, 1999.  20% of labs and x-rays are done because prior results are unavailable  1 in 7 hospitalizations occur because information about patient is not available  On average. Americans receive the care recommended for their conditions only 54.9% of the time  Translation of medical research into practice is slow—average of 17 years. For instance, nearly one- third of patients with congestive heart failure are discharged from the hospital without ACE inhibitors, even though it has been known for a decade that these drugs provide life-saving benefits22 ©2011 Deloitte Touche Tohmatsu Limited
  23. 23. An example of a patient-specific HIE-enabled point of care Clinical Decision Support - CINA Patient Specific Automated Produced for every patient, at every visit, regardless of the Reason for Visit ©2011 Deloitte Touche Tohmatsu Limited
  24. 24. Diagnoses and Medsare prioritized tohighlight chronic Goals Not Met areconditions highlighted for quick reference and visibility Targeted reminders for nursing staff allow better leverage of provider time and more efficient workflow Labs, Calculations and Diagnostic Procedures pertinent to the Action Items are displayed for easy reference ©2011 Deloitte Touche Tohmatsu Limited
  25. 25. EHRs specifically designed for direct use by physicians such as computerized physician order entry (CPOE) and physician documentation are critical to enhance patient safety and care qualityBuilding a Stronger Safety Net Non-intercepted serious medication Preventable Adverse Drug Events errors per 1,000 patient days per 1,000 patient days 86% decline 62% decline 7.6 2.9 1.1 1.1 Before CPOE After CPOE Before CPOE After CPOEPrompting Best Clinical Practice Percentage of Eligible Patients Percentage of Eligible Patients Receiving Pneumococcal Vaccination Receiving Subcutaneous Heparin 36% 32% 18.9% 0.8% No CPOE CPOE No CPOE CPOE Reminder Reminder Reminder Reminder ©2011 Deloitte Touche Tohmatsu Limited Source: Clinical Advisory Board
  26. 26. CPOE (Continued)Encouraging Cost-effective regimens or Less-Costly Drugs Percentage of Oral H2-Blocker Orders Using Nizatidine CPOE alert to preferred H2 blocker introduced Estimated annual Savings: $75,000 80% 68% 83% 90% 18% 12% 1.120% 1.1 Weeks 1 2 3 5 7 9 11Reducing Time to Deliver Care Physician Order to Receipt by Pharmacy Physician Order to Delivery to Patient Care Areas 3.4 4.6 32% hours hours 0.5 hour 1.4 hour Before CPOE After CPOE Before CPOE After CPOE ©2011 Deloitte Touche Tohmatsu Limited Source: Clinical Advisory Board
  27. 27. Total EHR benefit projections are significantCOST DECREASE FACTORSCost Decrease - 1 Conservative Medium Aggressive Reduce Medication Error by implementing Physician Order Entry 124,564 124,564 124,564 A Total Adjusted Admissions 0.37 0.37 0.37 B Medication Error per 100 Admissions$ 2,262 $ 2,262 $ 2,262 C Clinical Cost per Medication Error 3.08% 3.08% 3.08% D % of Medication Errors with Associated Litigation Costs$ 50,105 $ 50,105 $ 50,105 E Litigation and Damages cost per Medication Error Resulting in Litigation 50.00% 60.00% 85.00% F Percent Decrease in Medication Error per 100 admissions $ 876,536 $ 1,051,843 $ 1,490,111 Additional Annual Cost Savings = (AxB/100xCXF)+(AxB/100xDxExF)Cost Decrease - 2 Conservative Medium Aggressive Reduce Duplicate Lab and Radiology Orders through on line order entry and results availability$ 3,943 $ 3,943 $ 3,943 A Laboratory Cost per Adjusted Admission$ 2,854 $ 2,854 $ 2,854 B Radiology Cost per Adjusted Admission 124,564 124,564 124,564 C Total Adjusted Admissions 10.00% 15.00% 20.00% D % Reduction in Lab Expense by Decreasing Duplicate Lab Orders 10.00% 15.00% 20.00% E % Reduction in Radiology Expense by Decreasing Duplicate Radiology Orders $84,666,151 $126,999,226 $169,332,302 Additional Annual Cost Savings Benefit = (AxCxD)+(BxCxE)Cost Decrease - 3 Conservative Medium Aggressive Reduce Transcription Costs by Automating Transcription through direct entry into the CIS $1,318,712.00 $1,318,712.00 $1,318,712.00 A Current Transcription Costs (Medical Records and departmental) 30.00% 50.00% 75.00% B % Reduction in Transcription Costs $395,614 $659,356 $989,034 Additional Annual Cost Savings Benefit = AxBCost Decrease - 4 Conservative Medium Aggressive Reduce Average Expense per Adjusted Admission 124,564 124,564 124,564 A Total Adjusted Admissions$ 17,081 $ 17,081 $ 17,081 B Average Expense per Adjusted Admission 2.00% 3.00% 4.00% C % Decrease in Average Expense per Adjusted Admission $42,554,179 $63,831,269 $85,108,358 Additional Annual Cost Savings = AxBxC ©2011 Deloitte Touche Tohmatsu Limited
  28. 28. Cost Decrease - 5Total benefit projections are significant Record Costs by Reducing Chart Pull Staff, Eliminating Storage and Supply Conservative Medium Aggressive Reduce Medical Cost.22.40 22.40 22.40 A Total Medical Records Chart Pull FTEs$ 31,355 $ 31,355 $ 31,355 B Average Salary per Medical Record Chart Pull FTE 26% 26% 26% C Average Benefit Load per Medical Record Chart Pull FTE54.00 54.00 54.00 D # Medical Records per Square Foot272,722.00 272,722.00 272,722.00 E # Medical Records$ 51.54 $ 51.54 $ 51.54 F Annual Cost per Square Foot$ 498,697.00 $ 498,697.00 $ 498,697.00 G Annual Cost for Medical Record Forms, Folders, and Other Miscellaneous Supplies 40.00% 60.00% 75.00% H Reduction in Chart Pulls $1,112,980 $1,289,973 $1,422,718 Additional Annual Cost Savings = [AxHxBX(1+C)]+(E/DxF)+GCost Decrease - 6 Conservative Medium Aggressive Reduce Pharmacy Costs through Generic Substitutions and Changes to Dosages and Forms$ 2,854.00 $ 2,854.00 $ 2,854.00 A Pharmacy Expense per Adjusted Admission124,564.00 124,564.00 124,564.00 B Total Adjusted Admissions % Reduction in Pharmacy Expense per Admission due to Generic Substitutions and changes to 6.00% 10.00% 15.00% C dosages and forms $21,330,339 $35,550,566 $53,325,848 Additional Annual Cost Savings Benefit = AxBxCCost Decrease - 7 Conservative Medium Aggressive Reduce Nursing Overtime Expense by Increasing Productivity123,250 123,250 123,250 A Annual Nurse Overtime Hours$ 53.00 $ 53.00 $ 53.00 B Average Cost per Nurse Overtime Hour 5.00% 8.00% 10.00% C Productivity Increase $326,613 $522,580 $653,225 Additional Annual Cost Savings Benefit =AXBXCCost Decrease - 8 Conservative Medium Aggressive Reduce Labor Costs Through Revenue Cycle Efficiencies.175.90 175.90 175.90 A Total Revenue Cycle FTEs43,710 43,710 43,710 B Average Revenue Cycle FTE Salary 28% 28% 28% C Revenue Cycle FTE Benefit Load 5.00% 10.00% 20.00% D % Decrease in Revenue Cycle FTEs$ 490,148 $ 980,295 $ 1,960,590 Additional Annual Cost Savings Benefit = AxBx(1+C)xD ©2011 Deloitte Touche Tohmatsu Limited
  29. 29. Cost Decrease - 9Total benefit projections are significant Materials Management Cost by Reducing Form and Paper Demand Conservative Medium Aggressive Reduction in 1,000,000.00 1,000,000.00 1,000,000.00 A Total Paper, Forms, and Other Materials Management Cost 20.00% 30.00% 40.00% B % Materials Management Cost Reduction $200,000 $300,000 $400,000 Additional Annual Cost Savings = AxBREVENUE INCREASE FACTORSRevenue Increase - 1 Conservative Medium Aggressive Increase Net Revenue through Decrease in Untimely Filings2,954,388,312 2,954,388,312 2,954,388,312 A Total Annual Inpatient Gross Revenue992,024,075 992,024,075 992,024,075 B Total Annual Inpatient Net Revenue6,933,919 6,933,919 6,933,919 C Annual Untimely Claims Gross Write-Offs ($) 20.00% 40.00% 60.00% D % Decrease in Untimely Claims Filings $465,654 $931,308 $1,396,962 Additional Annual Revenue Benefit =(B/A)xCxDRevenue Increase - 2 Conservative Medium Aggressive Increase Net Revenue through Increase in Gross Revenue Charge Capture$ 2,954,388,312 $ 2,954,388,312 $2,954,388,312 A Total Annual Inpatient Gross Revenue$ 992,024,075 $ 992,024,075 $ 992,024,075 B Total Annual Inpatient Net Revenue 0.40% 0.50% 0.90% C % increase in Gross Revenue Capture $ 3,968,096 $4,960,120 $8,928,217 Additional Annual Net Revenue Benefit =AxCxB/AOne Time Revenue Increase - 3 Conservative Medium Aggressive One Time Increase in Cash Collections by Decreasing Discharged-Not-Final-Billed AR$ 992,024,075 $ 992,024,075 $ 992,024,075 A Total Annual Inpatient Net Revenue72 72 72 B Current Days in Net AR 2.00% 5.00% 6.00% C % Decrease in Days in Net AR $3,919,175 $9,797,936 $11,757,524 Additional One Time Cash Benefit = A/365xBxCRevenue increase - 4 Increase in Net Revenue by reducing denied days and rebilling due to better Conservative Medium Aggressive coding/documentation 6,231.00 6,231.00 6,231.00 A Total Annual Denied Days 19,724,726.00 19,724,726.00 19,724,726.00 B Estimated Annual Dollars associated with denied days 15.00% 20.00% 30.00% C % Decrease in Denied Days ©2011 Deloitte Touche Tohmatsu Limited $2,958,709 $3,944,945 $5,917,418 Additional Annual Net Revenue = B/AxAxC
  30. 30. Community Wide Analytics30
  31. 31. Many Benefits:  Improved quality of care/patientThe HIE is also a tool for community-wide analytics safety  Cost reduction (e.g., redundant tests) Screening & Early Diagnosis &  Enhanced operational efficiencies (pulling information, reporting, Prevention Detection Staging Treatment & Palliation etc.)  Population ManagementAdult Breast Cancer Timely Breast Participation in Cancer Deaths  Community-wide diseaseSmoking Rate Screening Rate Cancer Biopsy Clinical Trials managementIn HospiceAdolescent Colorectal Cancer Needle Biopsy for  Disease Hospice Inappropriate Hormonal surveillance  Etc.Smoking Rate Screening Rate Breast Cancer Therapy - Prostatectomy Length of StayAdvice to Early Stage Breast Clean Margins Breast Appropriate EBRT Breast CancerQuit Smoking Cancer Diagnosis Conserving Surgery Prostate Cancer Survival RatePharmacotherapy to Advanced Stage Breast Hist. Assessment EBRT/Hormone Therapy Colorectal CancerQuit Smoking Cancer Diagnosis Breast Cancer Prostate Cancer Survival RateAdult Obesity Advanced Stage Hist. Assessment Adjuvant Radiation Lung CancerRate Colorectal Cancer Dx Colorectal Cancer Breast Consv. Surgery Survival RateCancer Incidence Rate Path Compliance Adjuvant Hormone Ther Prostate CancerAll Sites For Specimens Invasive Breast Cancer Survival RateBreast Cancer Pathology Reports for Adjuvant Chemotherapy Breast CancerIncidence Rate Breast Cancer Breast Cancer Mortality RateColorectal Cancer Pathology Reports for Adjuvant Chemotherapy Colorectal CancerIncidence Rate Colorectal Cancer Colorectal Cancer Mortality RateLung Cancer Pathology Reports for Mammography After Lung CancerIncidence Rate Lung Cancer Treatment Mortality RateProstate Cancer Pathology Reports for Colonoscopy Prostate CancerIncidence Rate Prostate Cancer After Treatment Mortality Rate Breast Cancer Staged Cancer Pain All Cancers Before Treatment Assessment Mortality RateKey: Better than National rate/Target Colorectal Ca. Staged Prevalence of Pain Equal to or slightly worse than National Before Treatment Among Cancer Patients rate/Target Significantly worse than National Lung Cancer Staged rate/Target Before Treatment Improving Prostate Cancer Staged Steady Declining Before Treatment ©2011 Deloitte Touche Tohmatsu Limited
  32. 32. 3-1 Screening 3-1& Early Smoking Adult Rate Prevention Detection Diagnosis Treatment & PalliationAdult Breast Cancer Timely Breast Participation in Cancer DeathsSmoking Rate Screening Rate Cancer Biopsy Clinical Trials In HospiceAdolescent Colorectal Cancer 20.00% Needle Biopsy for 22.2% Inappropriate Hormonal HospiceSmoking Rate Screening Rate 20.0% Breast Cancer Therapy - Prostatectomy Length of Stay 19.9%Advice to Early Stage Clean Margins Appropriate EBRT Breast CancerQuit Smoking Breast Cancer Dx 15.00% Breast Consv. Surgery Prostate Cancer Survival RatePharmacotherapy to Advanced Stage Hist. Assessment EBRT/Hormone Therapy Colorectal CancerQuit Smoking Breast Cancer Dx Breast Cancer Prostate Cancer Survival RateAdult Obesity 10.00% Advanced Stage Hist. Assessment 12.0% Adjuvant Radiation Lung CancerRate Colorectal Cancer Dx Colorectal Cancer Breast Consv. Surgery Survival RateCancer Incidence Rate Path Compliance Adjuvant Hormone Ther Prostate CancerAll Sites 5.00% For Specimens Invasive Breast Cancer Survival RateBreast Cancer Pathology Reports for Adjuvant Chemotherapy Breast CancerIncidence Rate Breast Cancer Breast Cancer Mortality Rate 0.00%Colorectal Cancer US Pathology Reports for GA Exchange Healthy Chemotherapy Adjuvant Colorectal CancerIncidence Rate Colorectal Cancer Colorectal Cancer People 2010 Mortality RateLung Cancer Pathology Reports for Target Mammography After Lung CancerIncidence Rate Lung Cancer Treatment Mortality RateProstate Cancer Pathology Reports for Colonoscopy Prostate CancerIncidence Rate Prostate Cancer After Treatment Mortality Rate Source: Behavioral Risk Factor Breast Cancer Staged Surveillance Survey, 2006 Cancer Pain All Cancers Before Treatment Assessment Mortality Rate Colorectal Ca. Staged Prevalence of Pain Home Next Before Treatment Among Cancer Patients Lung Cancer Staged Before Treatment More Prostate Cancer StagedProprietary and confidential Before Treatment ©2011 Deloitte Touche Tohmatsu Limited
  33. 33. Screening 3-1Trend 3-1& Early Smoking Adult Rate Prevention Detection Diagnosis Treatment & PalliationAdult Breast Cancer Timely Breast Participation in Cancer DeathsSmoking Rate Screening Rate 26% Cancer Biopsy Clinical Trials In HospiceAdolescent Colorectal Cancer Needle Biopsy for Inappropriate Hormonal HospiceSmoking Rate 24% Screening Rate Breast Cancer Therapy - Prostatectomy Length of StayAdvice to Early Stage 22% Clean Margins Appropriate EBRT Breast CancerQuit Smoking Breast Cancer Dx Breast Consv. Surgery Prostate Cancer Survival RatePharmacotherapy to 20% Advanced Stage Hist. Assessment EBRT/Hormone Therapy Colorectal CancerQuit Smoking Breast Cancer Dx Breast Cancer Prostate Cancer Survival Rate 18%Adult Obesity Advanced Stage Hist. Assessment Adjuvant Radiation Lung CancerRate Colorectal Cancer Dx 16% Healthy Colorectal Cancer Breast Consv. Surgery Survival Rate US GA ExchangeCancer Incidence Rate People 2010 Path Compliance Adjuvant Hormone Ther Prostate CancerAll Sites 14% Target For Specimens Invasive Breast Cancer Survival RateBreast Cancer 12% Pathology Reports for Adjuvant Chemotherapy Breast CancerIncidence Rate Breast Cancer Breast Cancer Mortality Rate 10%Colorectal Cancer Pathology Reports for Adjuvant Chemotherapy Colorectal CancerIncidence Rate Colorectal Cancer Colorectal Cancer Mortality Rate 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20Lung Cancer Pathology Reports for Mammography After Lung CancerIncidence Rate Lung Cancer Treatment Mortality RateProstate Cancer Pathology Reports for Colonoscopy Prostate CancerIncidence Rate Prostate Cancer After Treatment Mortality Rate Source: Behavioral Risk Factor Breast Cancer Staged Surveillance Survey, 2006 Cancer Pain All Cancers Before Treatment Assessment Mortality Rate Less Colorectal Ca. Staged Prevalence of Pain Before Treatment Among Cancer Patients Back Home Next Lung Cancer Staged Before Treatment Proprietary and confidential Prostate Cancer Staged Before Treatment ©2011 Deloitte Touche Tohmatsu Limited
  34. 34. 3-2 Peer Comparisons Screening & Early Prevention 3-2 Adolescent Detection Smoking Rate: percent of youthsTreatment & Palliation Diagnosis ageAdult 13-17 who currently smoke Breast Cancer Timely Breast Participation in Cancer DeathsSmoking Rate Screening Rate Cancer Biopsy Clinical Trials In Hospice 25%Adolescent Colorectal Cancer Needle Biopsy for Inappropriate Hormonal HospiceSmoking Rate Screening Rate Breast Cancer Therapy - Prostatectomy Length of Stay 23.0%Advice to Early Stage 20% Clean Margins Appropriate EBRT Breast CancerQuit Smoking Breast Cancer Dx Breast Consv. Surgery Prostate Cancer Survival RatePharmacotherapy to Advanced Stage Hist. Assessment EBRT/Hormone Therapy Colorectal CancerQuit Smoking 15% Breast Cancer Dx Breast17.2% Cancer Prostate Cancer 16.0% Survival RateAdult Obesity Advanced Stage 14.4% Hist. Assessment Adjuvant Radiation Lung CancerRate Colorectal Cancer Dx Colorectal Cancer Breast Consv. Surgery Survival Rate 10%Cancer Incidence Rate Path Compliance Adjuvant Hormone Ther Prostate CancerAll Sites For Specimens Invasive Breast Cancer Survival RateBreast Cancer 5% Pathology Reports for Adjuvant Chemotherapy Breast CancerIncidence Rate Breast Cancer Breast Cancer Mortality RateColorectal Cancer Pathology Reports for Adjuvant Chemotherapy Colorectal CancerIncidence Rate 0% Colorectal Cancer Colorectal Cancer Mortality RateLung Cancer Exchange Georgia U.S. Average Pathology Reports for Healthy Mammography After Lung CancerIncidence Rate Lung Cancer People 2010 Treatment Mortality RateProstate Cancer Pathology Reports for Target Colonoscopy Prostate CancerIncidence Rate Prostate Cancer After Treatment Mortality Rate Source: (Georgia, US) YBRSS Breast Cancer Staged survey, 2005 Cancer Pain All Cancers Before Treatment Assessment Mortality Rate Colorectal Ca. Staged Prevalence of Pain Back Home Next Before Treatment Among Cancer Patients Lung Cancer Staged Before Treatment More Prostate Cancer StagedProprietary and confidential Before Treatment ©2011 Deloitte Touche Tohmatsu Limited
  35. 35. 3.2 Trend Screening & Early Prevention 3-2Detection Adolescent Smoking Rate: percent of youths age 13- & Palliation Diagnosis TreatmentAdult 17 who currently Timely Breast Breast Cancer smoke Participation in Cancer DeathsSmoking Rate Screening Rate Cancer Biopsy Clinical Trials In HospiceAdolescent 40% Colorectal Cancer Needle Biopsy for Inappropriate Hormonal HospiceSmoking Rate Screening Rate Breast Cancer Therapy - Prostatectomy Length of Stay 35%Advice to Early Stage Clean Margins Appropriate EBRT Breast CancerQuit Smoking Breast Cancer Dx 30% Breast Consv. Surgery Prostate Cancer Survival RatePharmacotherapy to Advanced Stage Hist. Assessment EBRT/Hormone Therapy Colorectal CancerQuit Smoking 25% Breast Cancer Dx Breast Cancer Prostate Cancer Survival RateAdult Obesity Advanced Stage Hist. Assessment Adjuvant Radiation Lung CancerRate 20% Colorectal Cancer Dx Colorectal Cancer Breast Consv. Surgery Survival RateCancer Incidence Rate 15% Path Compliance Adjuvant Hormone Ther Prostate CancerAll Sites For Specimens Invasive Breast Cancer Survival RateBreast Cancer 10% Pathology Reports for Adjuvant Chemotherapy Breast CancerIncidence Rate U.S. Breast Cancer Georgia Cancer Breast Mortality Rate 5%Colorectal Cancer Exchange Pathology Reports for Healthy people 2010 Adjuvant Chemotherapy Colorectal CancerIncidence Rate 0% Colorectal Cancer Colorectal Cancer Mortality RateLung Cancer Pathology Reports for Mammography After Lung Cancer 91 93 95 97 99 01 03 05 07Incidence Rate Lung Cancer Treatment Mortality Rate 19 19 19 19 19 20 20 20 20Prostate Cancer Pathology Reports for Colonoscopy Prostate CancerIncidence Rate Prostate Cancer After Treatment Mortality Rate Source: YBRSS survey, 2005 Breast Cancer Staged Cancer Pain All Cancers Before Treatment Assessment Mortality Rate Less Colorectal Ca. Staged Prevalence of Pain Before Treatment Among Cancer Patients Back Home Next Lung Cancer Staged Before Treatment Prostate Cancer StagedProprietary and confidential Before Treatment ©2011 Deloitte Touche Tohmatsu Limited
  36. 36. 3-3 Advice to Quit Screening & Early 3-3 Smokers who receive advice to quit Prevention Detection Diagnosis Treatment & PalliationAdult Breast Cancer Timely Breast Participation in Cancer DeathsSmoking Rate Screening Rate Cancer Biopsy Clinical Trials In HospiceAdolescent Colorectal Cancer 100% Needle Biopsy for Inappropriate Hormonal HospiceSmoking Rate Screening Rate Breast Cancer Therapy - Prostatectomy Length of StayAdvice to Early Stage 100% Margins Clean Appropriate EBRT Breast CancerQuit Smoking Breast Cancer Dx 95% Breast Consv. Surgery Prostate Cancer Survival RatePharmacotherapy to Advanced Stage Hist. Assessment EBRT/Hormone Therapy Colorectal CancerQuit Smoking Breast Cancer Dx Breast Cancer Prostate Cancer Survival RateAdult Obesity Advanced Stage 90% Hist. Assessment Adjuvant Radiation Lung CancerRate Colorectal Cancer Dx Colorectal Cancer Breast Consv. Surgery Survival RateCancer Incidence Rate Path Compliance Adjuvant Hormone Ther Prostate CancerAll Sites 85% For Specimens Invasive Breast Cancer Survival RateBreast Cancer Pathology Reports for Adjuvant Chemotherapy Breast CancerIncidence Rate Breast Cancer 85% Cancer Breast Mortality RateColorectal Cancer 80% Pathology Reports for Adjuvant Chemotherapy Colorectal CancerIncidence Rate Colorectal Cancer Colorectal Cancer Mortality RateLung Cancer Pathology Reports for Mammography After Lung CancerIncidence Rate 75% Lung Cancer Treatment Mortality RateProstate Cancer Exchange Healthy People 2010 Target Pathology Reports for Colonoscopy Prostate CancerIncidence Rate Prostate Cancer After Treatment Mortality Rate Breast Cancer Staged Cancer Pain All Cancers Before Treatment Assessment Mortality Rate Colorectal Ca. Staged Prevalence of Pain Before Treatment Among Cancer Patients Back Home Next Lung Cancer Staged Before Treatment Prostate Cancer StagedProprietary and confidential Before Treatment ©2011 Deloitte Touche Tohmatsu Limited
  37. 37. 3-4 Pharmacotherapy Screening & Early 3-4 Smokers who are recommended pharmacotherapy to Prevention Detection Diagnosis Treatment & Palliation assist in quitting smokingAdult Breast Cancer Timely Breast Participation in Cancer DeathsSmoking Rate Screening Rate Cancer Biopsy Clinical Trials In HospiceAdolescent Colorectal Cancer Needle Biopsy for Inappropriate Hormonal HospiceSmoking Rate Screening Rate 90% Breast Cancer Therapy - Prostatectomy Length of StayAdvice to Early Stage Clean Margins Appropriate EBRT Breast CancerQuit Smoking 80% Breast Cancer Dx Breast Consv. Surgery Prostate Cancer Survival Rate 88.7%Pharmacotherapy to 70% Advanced Stage Hist. Assessment EBRT/Hormone Therapy Colorectal CancerQuit Smoking Breast Cancer Dx Breast Cancer Prostate Cancer Survival Rate 60%Adult Obesity Advanced Stage Hist. Assessment Adjuvant Radiation Lung CancerRate Colorectal Cancer Dx 50% Colorectal Cancer Breast Consv. Surgery Survival RateCancer Incidence Rate Path Compliance Adjuvant Hormone Ther Prostate CancerAll Sites 40% For Specimens Invasive Breast Cancer Survival RateBreast Cancer 30% Pathology Reports for Adjuvant Chemotherapy Breast CancerIncidence Rate Breast Cancer Breast Cancer Mortality RateColorectal Cancer 20% Pathology Reports for Adjuvant Chemotherapy Colorectal CancerIncidence Rate Colorectal Cancer Colorectal Cancer Mortality Rate 10%Lung Cancer Pathology Reports for Mammography After Lung CancerIncidence Rate 0% Lung Cancer Treatment Mortality RateProstate Cancer Exchange Pathology Reports for Colonoscopy Prostate CancerIncidence Rate Prostate Cancer After Treatment Mortality Rate Breast Cancer Staged Cancer Pain All Cancers Before Treatment Assessment Mortality Rate Colorectal Ca. Staged Prevalence of Pain Before Treatment Among Cancer Patients Back Home Next Lung Cancer Staged Before Treatment Prostate Cancer StagedProprietary and confidential Before Treatment ©2011 Deloitte Touche Tohmatsu Limited
  38. 38. EHR Technical Characteristics38
  39. 39. Generic HIE reference architectureThe Generic HIE reference architecture depicts a basic architecture with its variousservices and security components that make up the HIE. Channels Business services Stakeholders e-Prescribing and Lab Demographics Immunizations medications orders/Results Web/HTTP (Portal) Hospitals Disease Admit/Visit/ Allergies Radiology management Discharge notes Clinics Interactive voice response (IVR) Diagnostic Imaging Scheduling Labs Fax Distributed services Enterprise master Electronic medical Patients Consent management Alerts patient index (EMPI) record (EMR) Electronic Data interchange (EDI) Record locator Terminology Identity management EMR Lite service (RLS) Payers File transfer protocol (FTP) Data services Centers for Medicare Data warehouse Business intelligence Audit/Logging data and Medicaid Services (CMS) Web service Decision support Messaging data Medical management State Agencies/Programs (Medicaid, Pharmacy Infrastructure services Benefits Management, Eligibility, Child Welfare, Call center Audit logging Monitoring Business rules Foster Care, etc.) Security management Messaging Exception handling ©2011 Deloitte Touche Tohmatsu Limited
  40. 40. HIE sample logical architecture ©2011 Deloitte Touche Tohmatsu Limited
  41. 41. HIE Data Architecture Types Virtual or Partitioned Centralized Model Federated/decentralized Model No centralized data repository. Each stakeholder keeps its own data within its walls and queries Each stakeholder sends its agreed upon data to a central data repository where data is “cleansed” assemble data on the fly. It is an easy model for stakeholders to accept…with major issues and normalized. Yet, this central data repository is virtual or the physical central repository is related to presenting the data in a normalized, significant way and with acceptable performance partitioned in such a way that a given stakeholder controls its own data partition and could easily take it back if required. Central but partitioned data repository 1 Stakeholder A 4 Stakeholder C Stakeholder B Stakeholder A Operational Database Stakeholder C Stakeholder B Federated Hybrid Model Each stakeholder sets up a mirrored database on the facility’s edges Centralized Model 2 where data can be cleansed and normalized per the exchange’s standards. It is this database that is used to query data from the 3 Exchange.Each stakeholder sends its agreed upon data to a central data repository where datais “cleansed” and normalized. Typically, analytical software sits on top of the central 4data repository for longitudinal analysis. Hybrid Model Each stakeholder sends an agreed upon subset of patient data to a Stakeholder A central data repository where data is “cleansed” and normalized. Part of Central data repository the patient data remains decentralized with record locator service/centralized metadata indicating where these decentralized components are. Central subset data repository Operational Database Edge Database Stakeholder A Stakeholder C Stakeholder A Stakeholder B Stakeholder B Stakeholder C Stakeholder B Stakeholder C ©2011 Deloitte Touche Tohmatsu Limited
  42. 42. HIE Data Architecture TakeawaysBelow are key points and takeaways for each architecture types Federated Centralized Hybrid Participating organization  HIE entity has control of  Variable types and level retains control of their the healthcare information of connectivity healthcare information  Stakeholders decide the  Stakeholders decide the Stakeholders retain patient data to share patient data to share control over the patient  Data security is more  Data security is more data complex complex than Federated Data security is  Not a preferred option for  A preferred option as it considered to be less stakeholders as they don’t allows leveraging existing complex have control of the data HIOs Generally uses a form of (Co-Mingling of data)  Data analytics is easier Record Location Service  Data analytics is easier (RLS) ©2011 Deloitte Touche Tohmatsu Limited
  43. 43. Current State of EHRs43
  44. 44. Many EHRs are still in the early deployment phases (estimated allocation) Phase 1: 2: Phase 2: 3: Phase 3: 4: Phase 0: 1: Phase 4: 5: STRATEGY DETAILED IMPLEMEN- FEASIBILITY & PLANNING DESIGN TATION OPERATIONSNo broad community supportNo clear objectiveNo self-sustainable business modelPrivacy concernsNo clear value for physicians PROGRESSION OF PHASES 44 ©2011 Deloitte Touche Tohmatsu Limited
  45. 45. Many complex, interrelated characteristics STRATEGY & DETAILED FEASIBILITY PLANNING DESIGN IMPLEMENTATION OPERATIONS How the Exchange is structured, how decisions are made, and the rules GOVERNANCE: that guide relationships among stakeholders, between old and new participants, the governance model it will follow Definition of an agreed upon vision, definition of core features and FUNCTIONAL: functions that constitute HIE, definition of strong value propositions for each key stakeholder type… How is the Exchange architected, how it deals with standards, the set of TECHNOLOGY: services it must incorporate, etc… How will privacy/data access be defined, how will secure data exchange PRIVACY/SECURITY: be implemented, definition of patient consent policies, etc… Definition of a self-sustainable financial model, definition of a balance FINANCIAL: ROI among stakeholders, definition of mechanisms to counter first mover disadvantage, etc.…45 ©2011 Deloitte Touche Tohmatsu Limited
  46. 46. Disruptive Innovation in Healthcare Callum Bir Director, Life Sciences & Healthcare
  47. 47. Disruptive Innovation 47 ©2011 Deloitte Touche Tohmatsu Limited
  48. 48. Social NetworkingFacebook drives more traffic online than Google 48 ©2011 Deloitte Touche Tohmatsu Limited
  49. 49. Compare hospitals & doctors? Percent who compare physicians and hospitals before making a selection and most trusted sources of medical information compared to other sources 49 ©2011 Deloitte Touche Tohmatsu Limited
  50. 50. Building fan pages for specific causes,Facebook organizations or products; sharing recreation-oriented campaigns 50 ©2011 Deloitte Touche Tohmatsu Limited
  51. 51. Posting educational videosYouTube and testimonials 51 ©2011 Deloitte Touche Tohmatsu Limited
  52. 52. Patients Like MePatientsLikeMe is a data-driven social PatientsLikeMe Type Privatenetworking health site that enables its Founded 2004members to share condition, treatment, Headquarters Cambridge,and symptom information in order to Massachusetts,USA Key people Ben Heywood, Co-Founder,monitor their health over time and learn Presidentfrom real-world outcomes. Members are James Heywood, Co-Founder, Chairmanable to find and connect with patients like David S. Williams III, Chief Marketing Officer, Head ofthem, gain social support, and learn first- Business Development Robert Palladino, Chiefhand about ways to cope and manage. Financial Officer Paul Wicks, PhD., R&DPatientsLikeMe aims to help patients Directoranswer the question: "Given my status, Slogan "Patients Helping Patients Livewhat is the best outcome I can hope to Better Every Day" Website patientslikeme.comachieve, and how do I get there?" Type of site social networking Launched October 10, 2005 Current status Active52 ©2011 Deloitte Touche Tohmatsu Limited
  53. 53. Doctors & Citizens accessTwitter most latest from trusted sources. Less is more.. . 53 ©2011 Deloitte Touche Tohmatsu Limited
  54. 54. Recruiting talent,Linked-in announcing staff news 54 ©2011 Deloitte Touche Tohmatsu Limited
  55. 55. Case Studies – Mobility55
  56. 56. Examples of how Technology is Changing how we may look at EHRs56 ©2011 Deloitte Touche Tohmatsu Limited
  57. 57. NSW Emergency Waiting Times Mobile Site57 ©2011 Deloitte Touche Tohmatsu Limited
  58. 58. Department of Health and Human Services Tasmaniaimprove the quality of patient care while also increasing organisational efficiency intheir hospitals.58 ©2011 Deloitte Touche Tohmatsu Limited
  59. 59. Transiting from Patient Oriented Care to Consumer Model of Care ….
  60. 60. 60 ©2011 Deloitte Touche Tohmatsu Limited
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