Cambridge Health Network Molly Joel Coye, MD, MPH Founder and CEO Health Technology Center June 22, 2009 Transformation In Chronic Disease Management Through Technology: Improving Productivity And Quality In The Shift From Acute To Home Based Settings

A “Blockbuster” Is Discovered… 72% reduction in HF hospitalizations 63% reduction in cardiac-related hospitalizations 0.51 1.82 0.81 2.20 2.18 2.73 RR=0.28 p=0.03 RR=0.37 p=0.029 RR=0.80 p=NS Heart Failure All Cardiac All Reason for Hospitalization Hospitalizations/Patient-Yr Intervention Control

Frustrated Deployment of a Transformational Technology 72% reduction in HF hospitalizations 63% reduction in cardiac-related hospitalizations SPAN-CHF II: Tufts-New England Medical Center; Lahey Clinic; Beth Israel-Deaconess Medical Center; Rhode Island Hospital. Weintraub et al AHA 2005 0.51 1.82 0.81 2.20 2.18 2.73 RR=0.28 p=0.03 RR=0.37 p=0.029 RR=0.80 p=NS Heart Failure All Cardiac All Reason for Hospitalization Hospitalizations/Patient-Yr Intervention = Remote Patient Management Control

The Medical Mystery The Twenty-Percent Solution And The Seventeen-Year Delay

The Twenty-Percent Solution

And The Seventeen-Year Delay

We Can Make Good Care Far Less Expensive – Relatively Quickly The most pressing task of health policy is to make care effective and affordable, and particularly so in the case of chronic disease. A series of technologies, including in-home monitoring and communications and medication optimization, have been demonstrated to reduce the use of hospitals and skilled nursing facilities by substituting patient self-management and support from lower levels of clinical and nonclinical providers. Large scale deployment has lowered the net cost of care by more than 20%. Presentation: Chronic care: The medical mystery and the 20% solution. The failure of policy to effectively drive implementation of technology-enabled models. Three goals that can be accomplished with modest investment: efficiency, productivity, and satisfaction.

The most pressing task of health policy is to make care effective and affordable, and particularly so in the case of chronic disease.

A series of technologies, including in-home monitoring and communications and medication optimization, have been demonstrated to reduce the use of hospitals and skilled nursing facilities by substituting patient self-management and support from lower levels of clinical and nonclinical providers. Large scale deployment has lowered the net cost of care by more than 20%.

Presentation:

Chronic care: The medical mystery and the 20% solution.

The failure of policy to effectively drive implementation of technology-enabled models.

Three goals that can be accomplished with modest investment: efficiency, productivity, and satisfaction.

Early Trials of a Transformative Technology: Remote Patient Management Home-based Telemedicine for Uninsured, High-risk Diabetic Population Inpatient Admissions  32% Emergency Room Encounters  34% Outpatient Visits  49% (Diabetes Technology & Therapeutics Journal, 2002) Asthma Self-management for High-risk Pediatric Population Activity Limitation  (p = .03) High Peak Flow Readings  (p = .01) Urgent Calls to Hospital  (p = .05) (Arch Pediatr Adolesc Med. 2002) Care Coordination: Hypertension, Heart Failure, COPD, and Diabetes Emergency Room Visits  40% Hospital Admissions  63% Hospital Bed Days of Care  60% Nursing Home Admissions  64% Nursing Home Bed Days of Care  88% (Disease Management, 2002)

Home-based Telemedicine for Uninsured, High-risk Diabetic Population

Inpatient Admissions  32%

Emergency Room Encounters  34%

Outpatient Visits  49%

(Diabetes Technology & Therapeutics Journal, 2002)

Asthma Self-management for High-risk Pediatric Population

Activity Limitation  (p = .03)

High Peak Flow Readings  (p = .01)

Urgent Calls to Hospital  (p = .05)

(Arch Pediatr Adolesc Med. 2002)

Care Coordination: Hypertension, Heart Failure, COPD, and Diabetes

Emergency Room Visits  40%

Hospital Admissions  63%

Hospital Bed Days of Care  60%

Nursing Home Admissions  64%

Nursing Home Bed Days of Care  88%

(Disease Management, 2002)

Why Remote Patient Management Transforms Chronic Care Early intervention – monitoring patients’ physiological, mental, and functional status early enough to detect deterioration and intervene before the need for unscheduled and preventable services Integration of care – exchange of data and communication across multiple co-morbidities, multiple providers, and complex disease states, in contrast to disease management programs that often target a single disease Coaching – motivational interviewing and other techniques to encourage patient behavioral change and self-care Trust – patient reports of satisfaction and feeling of ‘connectedness’ with providers Workforce – shift to lower levels of healthcare workers, including medical assistants, community health workers and social workers for much of the interaction with the patient Productivity – more effective use of provider time at each level of worker None of these can be accomplished by merely connecting a sensing device in the home. All of them require substantial reorganization of systems of care, and financing that rewards discontinuous leaps forward in performance.

Early intervention – monitoring patients’ physiological, mental, and functional status early enough to detect deterioration and intervene before the need for unscheduled and preventable services

Integration of care – exchange of data and communication across multiple co-morbidities, multiple providers, and complex disease states, in contrast to disease management programs that often target a single disease

Coaching – motivational interviewing and other techniques to encourage patient behavioral change and self-care

Trust – patient reports of satisfaction and feeling of ‘connectedness’ with providers

Workforce – shift to lower levels of healthcare workers, including medical assistants, community health workers and social workers for much of the interaction with the patient

Productivity – more effective use of provider time at each level of worker

None of these can be accomplished by merely connecting a sensing device in the home.

All of them require substantial reorganization of systems of care, and financing that rewards discontinuous leaps forward in performance.

The Early Adopter Experience: Veterans Health Administration The VA’s Care Coordination/ Home Telehealth (CCHT) program began in 2001. VHA attributes the rapidity and robustness of its implementation to the “ systems approach ” taken to integrate the elements of the program. Findings from 2006-07 comparative studies: 25% reduction in bed days of care 20% reduction in numbers of admissions 86% mean satisfaction score rating A total of 43,430 patients have been enrolled s ince VHA implemented CCHT in 2003. VHA will increase these services 100% above 2008 levels to reach 110,000 patients by 2011 (only 50% of projected need).

The VA’s Care Coordination/ Home Telehealth (CCHT) program began in 2001.

VHA attributes the rapidity and robustness of its implementation to the “ systems approach ” taken to integrate the elements of the program.

Findings from 2006-07 comparative studies:

25% reduction in bed days of care

20% reduction in numbers of admissions

86% mean satisfaction score rating

A total of 43,430 patients have been enrolled s ince VHA implemented CCHT in 2003. VHA will increase these services 100% above 2008 levels to reach 110,000 patients by 2011 (only 50% of projected need).

Health Buddy Project Lessons Ratan (MKR-A) | 5/12/2009 | © 2009 Robert Bosch LLC and affiliates. All rights reserved. RPM Impact On > 30 Conditions In The VA VA Care Coordination/Home Telehealth Studies 2004-007, in Darkins et al. Telemedicine and e-Health, Dec 2008 Credit: HealthHero Bosch Condition # of Patients % Decrease Utilization Diabetes 8,954 20.4 Hypertension 7,447 30.3 CHF 4,089 25.9 COPD 1,963 20.7 PTSD 129 45.1 Depression 337 56.4 Other Mental Health 653 40.9 Single Condition 10,885 24.8 Multiple Conditions 6,140 26.0

Estimated Savings For Congestive Heart Failure = $6.4 Billion/Y In U.S. Estimated cost savings for all Class III and Class IV heart failure patients: 60% reduction in readmissions vs. standard care 50% reduction vs. disease management without remote monitoring Potential to prevent 460,000 - 627,000 CHF-related hospital readmissions / year New England Healthcare Institute, Research Update: Remote Physiological Monitoringa, 2009 Net savings due to RPM: Vs. disease management = $3,703 / pt / yr Vs. standard care = $5,034 / pt / yr

Estimated cost savings for all Class III and Class IV heart failure patients:

60% reduction in readmissions vs. standard care

50% reduction vs. disease management without remote monitoring

Potential to prevent 460,000 - 627,000 CHF-related hospital readmissions / year

Many Enabling Technologies: Medication Management “ Smart” Pill Bottles Rex Talking Pill Bottle - offered at over 140 N orthern California Kaiser Permanente pharmacies and health care facilities Remote Medication Dispensing Med-eMonitor – improved adherence rates in diverse chronic illnesses from baseline levels of 35-55% to levels in excess of 90% Improved from a baseline of 52% (prior to using device) to over 94% (3-months usage) in patients with schizophrenia Medication Adherence Rates improvement from 40% to over 92% and reduction of HbA1c levels by 18.5% (p=.002) in rural diabetes patients 94% medication compliance rate in CHF VA patients

“ Smart” Pill Bottles

Rex Talking Pill Bottle - offered at over 140 N orthern California Kaiser Permanente pharmacies and health care facilities

Remote Medication Dispensing

Med-eMonitor – improved adherence rates in diverse chronic illnesses from baseline levels of 35-55% to levels in excess of 90%

Improved from a baseline of 52% (prior to using device) to over 94% (3-months usage) in patients with schizophrenia

Medication Adherence Rates improvement from 40% to over 92% and reduction of HbA1c levels by 18.5% (p=.002) in rural diabetes patients

94% medication compliance rate in CHF VA patients

What Are The Transformative Technologies in Chronic Care? Remote patient management Caregiver communication Video interpretation Social networking among patients, caregivers, and health workers Examples: Claims-based decision support systems linked to EBM 19% reduction in hospitalizations, and >50% reduction in total inpatient charges. Physician-patient emails popular, not abused, reduced visits by 25% 2004-2007 in Kaiser Permanente; by 2007, only 66% of visits were in person Medication management Cognitive assessment Remote training and supervision of health workers Data mining

Remote patient management

Caregiver communication

Video interpretation

Social networking among patients, caregivers,

and health workers

Examples:

Claims-based decision support systems linked to EBM 19% reduction in hospitalizations, and >50% reduction in total inpatient charges.

Physician-patient emails popular, not abused, reduced visits by 25% 2004-2007 in Kaiser Permanente; by 2007, only 66% of visits were in person

Medication management

Cognitive assessment

Remote training and supervision of health workers

Data mining

February 2009: The State Of The Union And Budget Proposal “… Hospitals with high rates of readmission will be paid less if patients are re-admitted to the hospital within the same 30-day period… saving roughly $26 billion of wasted money over 10 years .”

Policy Levers On The Near Horizon In The U.S. Reimbursement alignment Reduce or eliminate payment for hospital readmissions Bundled payments for: Episodes of care Chronic care management Investment in Electronic Medical Records Much of “20% solution” gains made in absence of full EMR - no reason to wait for integration Full EMR boosts power of RPM systems Redistribution of risk Gain-sharing Accountable Care Organizations (allow physicians and hospitals to conspire, accept risk) Medicare HMO subset: Special Needs Plans (SNIPs) focus on 20% most severe home-bound Pause for chaos… Comparative Effectiveness Research The specter of NICE

Reimbursement alignment

Reduce or eliminate payment for hospital readmissions

Bundled payments for:

Episodes of care

Chronic care management

Investment in Electronic Medical Records

Much of “20% solution” gains made in absence of full EMR - no reason to wait for integration

Full EMR boosts power of RPM systems

Redistribution of risk

Gain-sharing

Accountable Care Organizations (allow physicians and hospitals to conspire, accept risk)

Medicare HMO subset: Special Needs Plans (SNIPs) focus on 20% most severe home-bound

Pause for chaos…

Comparative Effectiveness Research

The specter of NICE

Policies That Would Be Required For Successful Implementation Clear statement of goals and expectations “ A national drive to reduce ED and hospital use for CHF, pneumonia and AMI patients by 20% in 3-5 years” Redirect investments in professional education – shift resources to re-training and re-deployment Investment in workforce training Create a new workforce of home health and community health workers – 16-24 week training, remote supervision, consultation and continuing education Invest in social services to prevent deterioration Build networked “hubs” for monitoring and responding to patients enabled with RPM National coordinating center – predictive modeling, patient segmentation and other policies Protocols for staff training, patient management and education Test adaptations to local needs and disseminate successful models Technology investment and on-going field R&D as new capabilities emerge Do not let EMR implementation and integration challenges distract from cost-reduction goals Remember – innovation should target successful adoptions that have rapid cycle impacts on costs and the independence of patients

Clear statement of goals and expectations

“ A national drive to reduce ED and hospital use for CHF, pneumonia and AMI patients by 20% in 3-5 years”

Redirect investments in professional education – shift resources to re-training and re-deployment

Investment in workforce training

Create a new workforce of home health and community health workers – 16-24 week training, remote supervision, consultation and continuing education

Invest in social services to prevent deterioration

Build networked “hubs” for monitoring and responding to patients enabled with RPM

National coordinating center – predictive modeling, patient segmentation and other policies

Protocols for staff training, patient management and education

Test adaptations to local needs and disseminate successful models

Technology investment and on-going field R&D as new capabilities emerge

Do not let EMR implementation and integration challenges distract from cost-reduction goals

Remember – innovation should target successful adoptions that have rapid cycle impacts on costs and the independence of patients

Molly Joel Coye, MD, MPH Founder and CEO 415.537.6960 phone 415.537.6969 fax [email_address] Health Technology Center 524 Second Street, 2 nd floor San Francisco, CA 94107 www.healthtech.org

HealthTech: Technology and Transformation A non-profit research organization and expert network that develops forecasts and planning tools for emerging technologies in healthcare, and works with a broad range of stakeholders to advance their adoption. Represents approximately 20% of hospital capacity in the U.S. Created in response to the IOM Crossing The Quality Chasm report: an average of 17 years elapses between demonstration that a new technology represents a significant advance and the widespread adoption of that technology. Our Vision: Innovations and technologies are adopted rapidly across the industry to make healthcare better and reduce the cost of care Our Mission: To make healthcare better, safer, more satisfying and more affordable – by building partnerships across the industry to research and accelerate the adoption of transformative technologies In 2009, HealthTech will move into the public domain, and merge with the Public Health Institute, based in Oakland, California.

A non-profit research organization and expert network that develops forecasts and planning tools for emerging technologies in healthcare, and works with a broad range of stakeholders to advance their adoption. Represents approximately 20% of hospital capacity in the U.S.

Created in response to the IOM Crossing The Quality Chasm report: an average of 17 years elapses between demonstration that a new technology represents a significant advance and the widespread adoption of that technology.

Our Vision:

Innovations and technologies are adopted rapidly across the industry to make healthcare better and reduce the cost of care

Our Mission:

To make healthcare better, safer, more satisfying and more affordable – by building partnerships across the industry to research and accelerate the adoption of transformative technologies

In 2009, HealthTech will move into the public domain, and merge with the Public Health Institute, based in Oakland, California.