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Community Based Personal Health Management as presented by Mark Pierson, MD; Vice ...

Community Based Personal Health Management as presented by Mark Pierson, MD; Vice
President for Quality and Clinical Information, Peace Health St. Joseph Medical Center at the 2010 Personalized Health Care National Conference at Ohio State.

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  • Ed Wagner working with Group Health Cooperative and Robert Wood Johnson created from the literature and their experience a coherent model for chronic care delivery. We are trying to bring this to life in our community: Supporting patients with diabetes and congestive heart failure then all chronic diseases to become informed and effective in their own health. We have provided clinical information systems with registries, reminders, measurement, feedback and patient accessible information for self management.

Community Based Personal Health Management Community Based Personal Health Management Presentation Transcript

  • COMMUNITY An Optimum Perspective for a Health Ecosystem (From Paternalism toward Whole Community Health) Marc Pierson MD V.P. PeaceHealth, St. Joseph Medical Center Bellingham, WA
  • Place People History Perspective Shifts Over 20 Years
  • WHATCOM COMMUNITY
  • BELLINGHAM, WASHINGTON
  •  
  • It Takes a Community
  • OUR FUTURE How to get upstream of illness?
  • 114 yrs of MISSION, VISION, VALUES
    • MISSION ELEMENTS
      • … Personal and Community Health
    • VALUE ELEMENTS
      • Respect, Stewardship, Collaboration, & Social Justice
    • VISION
      • Every patient will have safe, evidence based, compassionate care, every touch, every time.
  • EARLY HISTORY
    • WA State Mandate for 100% Managed Care, 1993-95 =>
      • Whatcom Integrated Delivery System (WIDS) 1993-97
      • Community Health Record (CHR) 1995-Present
      • Whatcom Health Information Network (WIDS) 1 993-95
    • Whatcom Community Health Improvement Consortium (CHIC) 1997-2001 =>
      • Community diabetes registry and collaborative
      • Immunization registry
      • Mammography collaborative
      • Tobacco cessation
  • PATIENTS AT THE CENTER Whatcom County, WA 1995 Patient Patient's Home Hospital Physician's Office Payer Pharmacy Home Health Physician Home SNF E D & EMS OP Surg . Radiation etc.
  • MIDDLE HISTORY
    • RWJF Pursuing Perfection 2001-2005 =>
      • Patients in leadership and improvement roles
      • Patient request #1: “Navigator-Coach” Role
      • Patient request # 2: Decision support and Patient Activation Measure
      • Patient request # 3: Patient Centric, Community-wide, Personal Health Management Platform (Shared Care Plan)
  • A Patient Centric Approximation
  • RECENT HISTORY
    • Congral’s Shared Care Plan software & Microsoft HealthVault (2006-Present) =>
      • Interoperable computing with patient managed data
      • Building the value & capacity for widespread adoption
        • Mobile devices, home devices, social network capability, provider integration
    • WA State HIIAB Health Record Banks (2007-Present)
      • Stimulus for state-wide, person centric, access to personal health data and information (four pilots)
    • CMS 9 th Scope of Work, Transitions of Care with Qualis Health (QIO)
      • Congral’s Care Manager Dashboard, patient and provider community-wide work flow tools (go-live 2/’11)
      • MS HealthVault Community Connect (go-live 2/’11)
  • Coordination Rules, Analytics, Messages EMR 1 - N PAYER CLAIMS DATA 1 - N LAB 1 - N IMAGING ENTERPRISE 1 - N PHARMACY DATA DEVICES 1 - N Patients Providers DEVICES 1 - N DEVICES 1 - N DEVICES 1 - N HV Ecosystem Applications
  • FUTURE
    • VERY friendly cloud based tools for family management of personal health
      • Natural Language Processing
      • Computer assisted decision support enabled by NLP
    • Analysis and signal processing on whole community databases (HIE)
    • Social software (twye, ect.)
      • Conversations and the key to behavior change
    • Genomics/Proteomics widely available to population
  • THE HUMAN STACK (A Socio-Technical Perspective) Information Data New Behaviors Commitments Conversations Communication Practices (habits)
  • A Future of Socio-Technical Innovation For and Within Communities Thank You