Cambridge Health Network   Molly Joel Coye, MD, MPH Founder and CEO Health Technology Center   June 22, 2009 Transformatio...
A “Blockbuster” Is Discovered… 72% reduction in HF hospitalizations 63% reduction in cardiac-related hospitalizations 0.51...
Frustrated Deployment of a Transformational Technology 72% reduction in HF hospitalizations 63% reduction in cardiac-relat...
The Medical Mystery <ul><li>The Twenty-Percent Solution </li></ul><ul><li>And The Seventeen-Year Delay   </li></ul>
We Can Make Good Care Far Less Expensive – Relatively Quickly  <ul><li>The most pressing task of health policy is to make ...
Early Trials of a Transformative Technology: Remote Patient Management <ul><ul><li>Home-based Telemedicine for Uninsured, ...
Why Remote Patient Management Transforms Chronic Care <ul><li>Early intervention –  monitoring patients’ physiological, me...
The Early Adopter Experience: Veterans Health Administration <ul><li>The VA’s Care Coordination/ Home Telehealth (CCHT) pr...
Health Buddy Project Lessons Ratan (MKR-A) | 5/12/2009 | © 2009 Robert Bosch LLC and affiliates. All rights reserved. RPM ...
Estimated Savings For Congestive Heart Failure = $6.4 Billion/Y In U.S. <ul><li>Estimated cost savings for all Class III a...
Many Enabling Technologies:  Medication Management <ul><li>“ Smart” Pill Bottles  </li></ul><ul><ul><li>Rex Talking Pill B...
What Are The Transformative Technologies in Chronic Care? <ul><ul><li>Remote patient management </li></ul></ul><ul><ul><li...
February 2009:  The State Of The Union And Budget Proposal “…  Hospitals with high rates of readmission will be paid less ...
Policy Levers On The Near Horizon In The U.S. <ul><li>Reimbursement alignment </li></ul><ul><ul><li>Reduce or eliminate pa...
Policies That Would Be Required For Successful Implementation  <ul><li>Clear statement of goals and expectations </li></ul...
Molly Joel Coye, MD, MPH Founder and CEO 415.537.6960 phone 415.537.6969 fax [email_address] Health Technology Center 524 ...
HealthTech: Technology and Transformation  <ul><li>A non-profit research organization and expert network that develops for...
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Transformation In Chronic Disease Management Through Technology: Improving Productivity And Quality In The Shift From Acute To Home Based Settings

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June 22, 2009 presentation to Cambridge Health Network at King's Fund by Molly Joel Coye, MD, MPH, Founder and CEO Health Technology Center

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  • SPAN-CHF II: Tufts-New England Medical Center, Lahey Clinic, Beth Israel-Deaconess Medical Center; Rhode Island Hospital. Weintraub et al AHA 2005 Dozens of small hospital-sponsored demonstrations around the country have proven that coordinated care can improve quality and drastically cut ED use, hospitalizations, and SNF days. But nowhere has this been taken to scale – that is, used to produce substantial decreases in expenditures for large populations. This is the kind of impact that will be needed to reliably reduce estimates for future hospital capacity requirements.
  • SPAN-CHF II: Tufts-New England Medical Center, Lahey Clinic, Beth Israel-Deaconess Medical Center; Rhode Island Hospital. Weintraub et al AHA 2005 Dozens of small hospital-sponsored demonstrations around the country have proven that coordinated care can improve quality and drastically cut ED use, hospitalizations, and SNF days. But nowhere has this been taken to scale – that is, used to produce substantial decreases in expenditures for large populations. This is the kind of impact that will be needed to reliably reduce estimates for future hospital capacity requirements.
  • Scale of the impact. Visicu – 20-40% improvement in mortality, 30% drop in LOS and costs CHF Solutions – elimination of ICU charges, decrease ED charges for one of the largest and most expensive patient groups currently utilizing hospital services.
  • VHA CCHT (Care Coordination/Home Telehealth) program involves the use of health informatics, disease management and home telehealth technologies to provide routine non-institutional care (NIC) and chronic care management services to veteran patients with diabetes, congestive heart failure, hypertension, posttraumatic stress disorder, chronic obstructive pulmonary disease and depression. The majority (85%) of technology utilized was messaging/monitoring services, 11% video-telemonitors and 3% videophones.
  • Smart Pill MedivoxRx. Wizzard Software, MedivoxRx Technologies Announces Plans to Further Enhance Rex-The Talking Bottle and Rex Pharmacy System, Other Recent Events. Press Release August 16, 2006. http://www.wizzardsoftware.com/pr/show_news.php?misc=search&amp;subaction=showfull&amp;id=1155732273&amp;archive=1159802122 Remote Medical Dispensing Schizophrenia Trial - Dr. Dawn Velligan, PHD and Dr. Alec Miller, MD; UTHSCSA (University of Texas Health Center in San Antonio). http://www.informedix.com/professional/results/schizophrenia1.pdf Diabetes Trial - Underserved Diabetes population – St. Vincent Healthcare, Billings, Montana. http://www.informedix.com/professional/results/diabetes.pdf CHF - CHF in VA Population – Wayne State http://www.informedix.com/professional/results/chf_va.pdf
  • Barbara Harvath, Steve DeMello and Andrew Broderick are continuing work in this area for us, and they’d welcome questions and comments.
  • Transformation In Chronic Disease Management Through Technology: Improving Productivity And Quality In The Shift From Acute To Home Based Settings

    1. 1. 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
    2. 2. 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
    3. 3. 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
    4. 4. The Medical Mystery <ul><li>The Twenty-Percent Solution </li></ul><ul><li>And The Seventeen-Year Delay </li></ul>
    5. 5. We Can Make Good Care Far Less Expensive – Relatively Quickly <ul><li>The most pressing task of health policy is to make care effective and affordable, and particularly so in the case of chronic disease. </li></ul><ul><li>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%. </li></ul><ul><li>Presentation: </li></ul><ul><li>Chronic care: The medical mystery and the 20% solution. </li></ul><ul><li>The failure of policy to effectively drive implementation of technology-enabled models. </li></ul><ul><li>Three goals that can be accomplished with modest investment: efficiency, productivity, and satisfaction. </li></ul>
    6. 6. Early Trials of a Transformative Technology: Remote Patient Management <ul><ul><li>Home-based Telemedicine for Uninsured, High-risk Diabetic Population </li></ul></ul><ul><ul><li>Inpatient Admissions  32% </li></ul></ul><ul><ul><li>Emergency Room Encounters  34% </li></ul></ul><ul><ul><li>Outpatient Visits  49% </li></ul></ul><ul><ul><li> (Diabetes Technology & Therapeutics Journal, 2002) </li></ul></ul><ul><li>Asthma Self-management for High-risk Pediatric Population </li></ul><ul><li>Activity Limitation  (p = .03) </li></ul><ul><ul><ul><li>High Peak Flow Readings  (p = .01) </li></ul></ul></ul><ul><ul><ul><li>Urgent Calls to Hospital  (p = .05) </li></ul></ul></ul><ul><ul><ul><li> (Arch Pediatr Adolesc Med. 2002) </li></ul></ul></ul><ul><li>Care Coordination: Hypertension, Heart Failure, COPD, and Diabetes </li></ul><ul><ul><ul><li>Emergency Room Visits  40% </li></ul></ul></ul><ul><ul><ul><li>Hospital Admissions  63% </li></ul></ul></ul><ul><ul><ul><li>Hospital Bed Days of Care  60% </li></ul></ul></ul><ul><ul><ul><li>Nursing Home Admissions  64% </li></ul></ul></ul><ul><ul><ul><li>Nursing Home Bed Days of Care  88% </li></ul></ul></ul><ul><li>(Disease Management, 2002) </li></ul>
    7. 7. Why Remote Patient Management Transforms Chronic Care <ul><li>Early intervention – monitoring patients’ physiological, mental, and functional status early enough to detect deterioration and intervene before the need for unscheduled and preventable services </li></ul><ul><li>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 </li></ul><ul><li>Coaching – motivational interviewing and other techniques to encourage patient behavioral change and self-care </li></ul><ul><li>Trust – patient reports of satisfaction and feeling of ‘connectedness’ with providers </li></ul><ul><li>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 </li></ul><ul><li>Productivity – more effective use of provider time at each level of worker </li></ul><ul><li>None of these can be accomplished by merely connecting a sensing device in the home. </li></ul><ul><li>All of them require substantial reorganization of systems of care, and financing that rewards discontinuous leaps forward in performance. </li></ul>
    8. 8. The Early Adopter Experience: Veterans Health Administration <ul><li>The VA’s Care Coordination/ Home Telehealth (CCHT) program began in 2001. </li></ul><ul><li>VHA attributes the rapidity and robustness of its implementation to the “ systems approach ” taken to integrate the elements of the program. </li></ul><ul><li>Findings from 2006-07 comparative studies: </li></ul><ul><ul><ul><li>25% reduction in bed days of care </li></ul></ul></ul><ul><ul><ul><li>20% reduction in numbers of admissions </li></ul></ul></ul><ul><ul><ul><li>86% mean satisfaction score rating </li></ul></ul></ul><ul><ul><li>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). </li></ul></ul>
    9. 9. 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
    10. 10. Estimated Savings For Congestive Heart Failure = $6.4 Billion/Y In U.S. <ul><li>Estimated cost savings for all Class III and Class IV heart failure patients: </li></ul><ul><ul><li>60% reduction in readmissions vs. standard care </li></ul></ul><ul><ul><li>50% reduction vs. disease management without remote monitoring </li></ul></ul><ul><ul><li>Potential to prevent 460,000 - 627,000 CHF-related hospital readmissions / year </li></ul></ul>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
    11. 11. Many Enabling Technologies: Medication Management <ul><li>“ Smart” Pill Bottles </li></ul><ul><ul><li>Rex Talking Pill Bottle - offered at over 140 N orthern California Kaiser Permanente pharmacies and health care facilities </li></ul></ul><ul><li>Remote Medication Dispensing </li></ul><ul><ul><li>Med-eMonitor – improved adherence rates in diverse chronic illnesses from baseline levels of 35-55% to levels in excess of 90% </li></ul></ul><ul><ul><ul><li>Improved from a baseline of 52% (prior to using device) to over 94% (3-months usage) in patients with schizophrenia </li></ul></ul></ul><ul><ul><ul><li>Medication Adherence Rates improvement from 40% to over 92% and reduction of HbA1c levels by 18.5% (p=.002) in rural diabetes patients </li></ul></ul></ul><ul><ul><ul><li>94% medication compliance rate in CHF VA patients </li></ul></ul></ul>
    12. 12. What Are The Transformative Technologies in Chronic Care? <ul><ul><li>Remote patient management </li></ul></ul><ul><ul><li>Caregiver communication </li></ul></ul><ul><ul><li>Video interpretation </li></ul></ul><ul><ul><li>Social networking among patients, caregivers, </li></ul></ul><ul><ul><li>and health workers </li></ul></ul><ul><ul><li>Examples: </li></ul></ul><ul><ul><li>Claims-based decision support systems linked to EBM 19% reduction in hospitalizations, and >50% reduction in total inpatient charges. </li></ul></ul><ul><ul><li>Physician-patient emails popular, not abused, reduced visits by 25% 2004-2007 in Kaiser Permanente; by 2007, only 66% of visits were in person </li></ul></ul><ul><ul><li>Medication management </li></ul></ul><ul><ul><li>Cognitive assessment </li></ul></ul><ul><ul><li>Remote training and supervision of health workers </li></ul></ul><ul><ul><li>Data mining </li></ul></ul>
    13. 13. 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 .”
    14. 14. Policy Levers On The Near Horizon In The U.S. <ul><li>Reimbursement alignment </li></ul><ul><ul><li>Reduce or eliminate payment for hospital readmissions </li></ul></ul><ul><ul><li>Bundled payments for: </li></ul></ul><ul><ul><ul><li>Episodes of care </li></ul></ul></ul><ul><ul><ul><li>Chronic care management </li></ul></ul></ul><ul><li>Investment in Electronic Medical Records </li></ul><ul><ul><li>Much of “20% solution” gains made in absence of full EMR - no reason to wait for integration </li></ul></ul><ul><ul><li>Full EMR boosts power of RPM systems </li></ul></ul><ul><li>Redistribution of risk </li></ul><ul><ul><li>Gain-sharing </li></ul></ul><ul><ul><li>Accountable Care Organizations (allow physicians and hospitals to conspire, accept risk) </li></ul></ul><ul><ul><li>Medicare HMO subset: Special Needs Plans (SNIPs) focus on 20% most severe home-bound </li></ul></ul><ul><li>Pause for chaos… </li></ul><ul><li>Comparative Effectiveness Research </li></ul><ul><ul><li>The specter of NICE </li></ul></ul>
    15. 15. Policies That Would Be Required For Successful Implementation <ul><li>Clear statement of goals and expectations </li></ul><ul><ul><li>“ A national drive to reduce ED and hospital use for CHF, pneumonia and AMI patients by 20% in 3-5 years” </li></ul></ul><ul><ul><li>Redirect investments in professional education – shift resources to re-training and re-deployment </li></ul></ul><ul><li>Investment in workforce training </li></ul><ul><ul><li>Create a new workforce of home health and community health workers – 16-24 week training, remote supervision, consultation and continuing education </li></ul></ul><ul><ul><li>Invest in social services to prevent deterioration </li></ul></ul><ul><li>Build networked “hubs” for monitoring and responding to patients enabled with RPM </li></ul><ul><ul><li>National coordinating center – predictive modeling, patient segmentation and other policies </li></ul></ul><ul><ul><li>Protocols for staff training, patient management and education </li></ul></ul><ul><ul><li>Test adaptations to local needs and disseminate successful models </li></ul></ul><ul><li>Technology investment and on-going field R&D as new capabilities emerge </li></ul><ul><ul><li>Do not let EMR implementation and integration challenges distract from cost-reduction goals </li></ul></ul><ul><ul><li>Remember – innovation should target successful adoptions that have rapid cycle impacts on costs and the independence of patients </li></ul></ul>
    16. 16. 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
    17. 17. HealthTech: Technology and Transformation <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Our Vision: </li></ul><ul><ul><li>Innovations and technologies are adopted rapidly across the industry to make healthcare better and reduce the cost of care </li></ul></ul><ul><li>Our Mission: </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>In 2009, HealthTech will move into the public domain, and merge with the Public Health Institute, based in Oakland, California. </li></ul>

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