Day in-the-life endo wide 2 with vid


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Day in-the-life endo wide 2 with vid

  1. 1. For Endo Pharmaceuticals<br />David Voran, MD<br />Medical Director, Innovation Clinic of Heartland Clinic, Platte City, MO<br />July 19, 2011<br />Day-In-The-Life of a Primary Care Physician<br />A Presentation For<br />
  2. 2. Agenda<br />Provide better understanding of clinicians.<br />Foster innovative ideas to improve communication, quality and patient care.<br />Introduce me, where I work and our organization<br />Help you understand my biases<br />Present a PCP’s Day<br />Goal: Try to frame current events to help with your decision making<br />What we know and don’t know<br />Technology in the clinician’s office<br />Impact of current events on healthcare<br />Changing nature of Pharma/Physician relationships<br />Illustrate Pharmaceutical Decision Support in an ePrescribeWorld<br />Emphasize the opportunities that exist<br />List Needs and Possible Solutions<br />Answer further questions<br />
  3. 3. Heartland Health<br />
  4. 4. Heartland Clinic of Platte City<br />Free standing clinic<br />30 miles away from hospital<br />Located in suburb of Kansas City<br />3.5 physician FTE<br />1,000-1,200 visits/month<br />Numerous specialists visit weekly<br />Designated the “Innovation Clinic”<br />Fully digital clinic <br />Most patients connected electronically through web portal<br />Have met or exceeded Meaningful Use Stage 1 criteria<br />
  5. 5. Ambulatory Primary Care Office<br />So What’s a Day Like?<br />
  6. 6. Typical Day<br />20-24 patient visits<br />Mini meetings<br />1-3 procedures<br />Exam room operative or diagnostic<br />1 meeting<br />Staffing, billing, marketing or professional<br />20-40 asynchronous messages<br />Nurses, patients colleagues<br />10-15 interruptions<br />Pharmacies<br />phone calls<br />detail reps<br />
  7. 7. Single EMR<br />7<br />Inpatient: Patient List<br />Ambulatory: Schedule<br />
  8. 8. Integrated HIE<br />
  9. 9. Clinic Visit Note: Where the Action Is<br />Standardized “SOAP” <br />Subjective<br />What the patient says<br />Objective<br />What we see and measure<br />Assessment<br />Diagnosis<br />Plan<br />Prescriptions, orders, education and follow up<br />All in one template-based place<br />Templates provide structure and consistency distribute work to even the patients <br />
  10. 10. Remote access: Productivity Enhancer<br />Through web portals<br />Redundancy<br />Support all browsers<br />All devices<br />PC’s, Macs, iPad, smartphones<br />By all who need access<br />Patients via web portal<br />View their record<br />Message physicians<br />Schedule visits<br />Request medication refills<br />
  11. 11. Real Example<br />Login from home to review lab results<br />Lab Result<br />Patient Summary<br />
  12. 12. Real Example (continued)<br />One click to context aware information resource<br />
  13. 13. Real Example (continued)<br />One click to message the patient<br />
  14. 14. Real Example (continued)<br />One click to active and historical medications<br />
  15. 15. Real Example (continued)<br />One click and begin typing in desired medication<br />
  16. 16. Real Example (continued)<br />Choose a prescription<br />
  17. 17. Real Example (continued)<br />Choosing a pharmacy<br />
  18. 18. Real Example (continued)<br />Checking external pharmacy fill history<br />
  19. 19. Messaging Example<br />Typical Messages from patients<br />
  20. 20. Messaging Example (continued)<br />Needs prescription renewed<br />
  21. 21. Messaging Example (continued)<br />One click to medication list<br />
  22. 22. Messaging Example (continued)<br />Right click and choose “Renew”<br />
  23. 23. Messaging Example (continued)<br />Accept defaults and sign<br />
  24. 24. Decisions, Decisions, Decisions<br />What to ask?<br />What to examine?<br />What to include?<br />What to exclude?<br />Diagnosis<br />~40% uncertainty<br />What tests to order?<br />What to prescribe?<br />Categories<br />Quantity<br />25 - 50 decisions each visit<br />625 - 2,500 a day<br />
  25. 25. Interruptions: The biggest bane<br />Not easy to recover from many of them<br />Interruptions are more than lack of timely decision support<br />Technology has eliminated more than half<br />Patient portal<br />Electronic messaging<br />Many pharmacies still resorting to telephones and faxes<br />Electronic communications preferred<br />Good news is that the industry is slowly catching on<br />Long way to go<br />
  26. 26. ePrescribe … something that is really starting to work well<br />Pharmaceutical Decision Support<br />
  27. 27. Prescribing: A Major Player<br />ePrescribe – Uses CPOE interface<br />Part of the documentation process<br />Launched from the template<br />Actions rendered as text in the note<br />Usually done at the point of care<br />Can get outside information before decisions are made<br />Can tell which meds are on formulary before ordering<br />List of various medications available with generic components<br />Shows alternatives<br />Dramatically reduces interruptions and increases productive time in the exam room<br />
  28. 28. Drug Decision Support<br />
  29. 29. At the end of the day<br />
  30. 30. View from within<br />Pressures facing healthcare<br />
  31. 31. Executives and Decision Makers<br />Vendor “lock”<br />Most organizations locked into long-term HIT contracts<br />Competition rather than cooperation<br />Incapable of sharing services<br />Provider discontent<br />Technology advances<br />High costs of medical technology<br />Security woes<br />Foggy long term vision<br />Workforce shortages, especially primary and nursing care<br />Trajectory of change exceeds bandwidth<br />Conflicting & Changing rules and regulations <br />(federal, states, payers)<br />ARRA impact<br />Who is the customer?<br />Unsustainable of fee-for-service reimbursement<br />Economic downturn<br />
  32. 32. Clinical Pressures<br />Rapidly growing knowledge<br />Changing evidence<br />Uncertainty of diagnosis<br />Increasing disease complexity<br />Lifestyle diseases<br />Solution is life-style changes not medicine<br />Needed information not in your system<br />GIGO<br />Lack of administrative support<br />Pressure to churn patients<br />Average physician needs to bring in $450K per year<br />Need to see >24 pts/day<br />Decreasing time to make medical decisions<br />15 minutes or less to gather, assimilate, diagnose and document<br />Fewer well paying patients<br />3rd party payer intrusions on medical decision making<br />Long hours<br />
  33. 33. Much more than EMR/EHRs<br />“Only 50% of the information needed for the next medical decision can be found in the EMR/EHR”<br />Technology in the Doctor’s Office<br />
  34. 34. POC Technology<br />Push as much technology to the point of care as possible<br />Device is as much for the patient as the provider<br />Used as a “window to the world”<br />Evolution<br /> notebook > tablet > standard workstations > expanded large screen workstations > multi-touch wide-screen devices<br />
  35. 35. Connect everything to the exam room computer<br />Bodelin Proscope<br />Dino-Lite Earscope<br />MIR Winspiro<br />Eye-Fi cards: <br />Enable easyreal-timehands-off transfer of photos into EMR<br />Electronic scales<br />Stadiometers<br />Diagnostic Tools<br />Other Information Tools<br />
  36. 36. Apps: Provide data not in EMRs<br />Doximity<br />connects physicians to physicians securely<br />Helps tie those not sharing same system<br />Voalté<br />connects nurses to nurses to optimize tasks and patient care<br />Borders on unnecessarily tapping IT bandwidth<br />ePocrates<br />drug and disease content optimized for smart phones<br />Fooducate<br />Educates individuals about nutritional content of food by pointing the smart phone at the food label<br />
  37. 37. My own apps and tools<br />iPad applications<br />iPhone Applications<br />
  38. 38. AliveCor<br />Wireless ECG app built on iPhone 4 and specialized case<br />Example of innovation<br />Adding specialized function to consumer products<br />
  39. 39. Fundamental Principle<br />Everything <br />goes <br />to<br /> ground<br />Everything that’s now done in a tertiary hospital will be done in the clinic and eventually be in the hands of the consumer<br />Inescapable and unrelenting mass consumerization of technology<br />Medical diagnostic technology is the next big consumerization opportunity<br />Dramatically lowering the cost and availability of tools<br />Must be willing to use them<br /><br />
  40. 40. … or where the holes are and where Pharma could help<br />What’s Needed<br />
  41. 41. Eliminate “Gotcha” Decision Support<br />Alerts fire after decision instead of before<br />Need indicators that warn of impending alerts<br />Should act like formulary notifications<br />Continue to appear even after overridden many times<br />Why so many physicians use ePocrates, Medscape, and other quick search tools<br />
  42. 42. Improve Product Selection<br />Product status<br />Dither out products that are no longer available<br />Indicate relative prices<br />Diagnostic orders<br />Medications<br />Lack of condition-based prescription recommendations<br />Make a diagnosis > produce a list of orders and medications indicated for this diagnosis<br />Number of these “common” medications no longer available to pharmacies<br />
  43. 43. Improve Pharmacy Selection<br />Many pharmacies identified by number<br />Lack of maps<br />Fuzzy zip code<br />Need to show nearby pharmacies when zip codes are entered<br />Need selection choices similar to what we have on our mobile phones<br />Our expectations are so much higher now that we’re using mobile tools<br />
  44. 44. What do we see and, more importantly, what are the boundaries with which we can confidently operate?<br />Framing the “picture”<br />
  45. 45. From my point of view<br />In a period of change<br />Reimbursement, Rules, Relationships<br />Increased accountability, transparency<br />Democratization of Medical Knowledge <br />Patients participation, access and control<br />Accountability?<br />Increased role of Healthcare IT<br />No longer can be ignored<br />Traditional Healthcare “bubble” bursting<br />Extreme personalization <br />Based on genetics<br />Unique medications<br />Move towards Social Media paradigms in Healthcare IT<br />Virtualization of Healthcare<br />Hospitals and Clinics too costly<br />Most care delivered directly to the patient at home, office virtually<br />What we know<br />What we think is going to happen<br />
  46. 46. Innovation – Looking thru the Windshield<br />Law of accelerating returns<br />Key events happening at ever rates<br />PC’s will match the power of the human brain around 2020<br />Approaching singularity<br />Culminate in the merger of biology and technology<br />Transcend limitations of our biological bodies and brains<br />No distinction between human and machine or between physical and virtual reality<br />
  47. 47. Interesting healthcare predictions<br />“Physics of the Future”<br />Information technology<br />High temperature superconductors<br />Nanotechnology<br />Applications to Healthcare:<br />Healthcare diagnostic instruments and information moving out of the hospital to clinics, homes and individuals<br />Significant future care will be virtual, multimedia and come to the patient<br />Medicine will become personal<br />Control our genetics<br />Dr. MichioKaku: Professor of Theoretical Physics at the City University of New York<br />
  48. 48. What’s driving change?<br />Computing power doubles every 18 months<br />Pn = Po x 2n<br />Pn = computer processing power in future years<br />Po = computer processing power in the beginning year<br />n = number of years to develop a new microprocessor divided by 2 (i.e., every 2 years)<br />Power of a network is proportional to the square of the number of nodes (users)<br />NetUse = k * N2<br />Applies to everything<br />Power of an EMR is proportional to the number of medical facilitiesusing it<br />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 <br />Moore’s Law<br />Metcalf’s Law<br />
  49. 49. Technology Drivers (Illustrated)<br />Metcalf’s Law<br />Moore’s Law<br />
  50. 50. From web to apps<br /><br /><br />
  51. 51. Mobility enables integration<br />Explosion of mobile users<br />Exponential growth over previous computers<br />Enables massive integration at the person level<br />Ubiquitous computing<br />Affordable<br />Faster access<br />Personal<br />Fun to use<br />Measureable real-world activation<br />Real time reward/influence<br />
  52. 52. Result: High Tech Everywhere<br />Chips to manufacture custom-made DNA segments.<br />Biosensors build into cars to monitor blood glucose, location based pollen and cloud based health info<br />Apps to help with complex decision making. <br />Nanoworms for real time monitoring.<br />Advanced medical robotics<br />Mental manipulation of computers<br />
  53. 53. Tangible reward for Innovation<br />Beam me up doctor<br />The X PRIZE Foundation<br />$10 million prize for the public to develop a mobile application<br /> Must diagnose patients "better than or equal to a panel of board certified physicians<br />“Tricorder” Prize<br />
  54. 54. …targeted at all roles throughout healthcare and integrated with existing services<br />Huge opportunity for Innovation<br />
  55. 55. Data Mining Opportunities<br />Study existing EMR databases<br />Clinicians don’t have the time nor are paid to datamine<br />Need for cooperative innovation<br />Pharm<br />Academic Medicine<br />
  56. 56. Past Proposal – Before it’s time?<br />March 2007<br />Open up EMR to Pharma Scientific Divisions via subscription<br />Goals<br />Mine data<br />Communicate with providers and patients<br />Locate potential candidates for further diagnostics and/or early intervention<br />Ideas rejected<br />Too risky<br />
  57. 57. What some others are doing now<br />Managing Cancer Care <br />Backing physicians with decision support tools at their fingertips”<br />Communicating directly with members via SM and Text Messages<br />Offering chances to win money in a lottery based on adherence to treatment protocols<br />Dynamic pharmacy benefits designed to encourage members to fill prescriptions<br />Value-based benefit designs<br />Providing follow-through patient tracking for clinicians<br />Embedding care managers in practices<br />Enveloping evidence base protocols in provider’s EMRs<br />Collaborative Cancer Care Program<br />No reason Pharmaceutical companies can’t play<br />
  58. 58. Focus on the smallest entity<br />Focusing on the smallest component (the patient) provides the most leverage<br />Enables massive change rapidly<br />May offer the best long term solutions<br />Again, no reason pharma can’t also play this game<br />
  59. 59. Enable Real-time Connections<br />Work with vendors to create dynamic links during the prescribing process for both the physician and the patient<br />Just-in-time offers<br />Coupons, Vouchers, Access to resources, Enable connection to researchers<br />Could automate after market data collection directly from consumer<br />Physician and patient would be notified in real-time of additional resources and information<br />ePrescribe Pt Receives Mobile Invitation or Notification from Pharmacy that script is ready and vouchers accepted<br />Embed independent care managers for patients<br />Both real and virtual, manual and automated<br />
  60. 60. Leveraging mobile apps<br />Embed in existing apps<br />Have aSocial MediaPresence<br />But be careful<br />Have to be honest and up front<br />Huge opportunities<br />Physicians and patients need more help than they are currently getting<br />Would push patients to content and management apps<br />“Pull” processes<br />Consumer directed content<br />
  61. 61. Example of Integration between Apps<br />Golfshot<br />Golfplan<br />Golfscape<br />TW My Swing<br />Thru and thru integration<br />Playing<br />Keeps score and stats<br />GPS graphic range finder<br />Practicing<br />Customized video lessons<br />Upload your swing, compareagainst Tiger with feedback<br />All connected providing complete golfing experience<br />Buit in FB and Twitter feeds<br />
  62. 62. …places where innovative technology can have immediate and long-lasting, transformative impact<br />Short and Long Term Needs<br />
  63. 63. Short Term Needs<br />Non disruptive technologies and applications to help with current day processes<br />Anything to reduce intrusive interruptions (read office hour detail rep visits)<br />Tools to help data transfer<br />Currently everyone uses fax but need CCD and CCR formats<br />Tools to facilitate communication between competing systems<br />HIE’s are just not being accepted<br />PHRs (like Google Health) have failed … actually pulled from market<br />Will join but not do the hard work of porting information<br />Technology to convert data to information<br />Secure mobile patient/physician communication tools<br />Anonymous monitoring of lab test results nationwide<br />Map of what diseases are occurring where<br />Weatherbug for medicine<br />Life-style change management tools at the individual level<br />
  64. 64. Long Term Needs<br />Get me to the Church on time!<br />Social umbrella over multiple EHRs<br />All health and disease is social<br />Viruses and Bacteria follow social connections<br />Information systems must align with People, Bacteria and Viruses<br />Real-time suite of apps for providers and patients<br />Connected monitoring tools controlled by individuals<br />Management of patients in their homes and work place<br />Must work to keep them out of the clinics and hospitals<br />Virtual Personal Health Records<br />Connect and integrate personal data by linking multiple disparate systems in real-time<br />
  65. 65. Rules May be Biggest Barrier<br />Legal, political and organizational inertia are the biggest impediments to innovation today<br />Policies, procedures and laws are all 20th century based<br />Instruments, diagnostics, information technology are all 21st century tools<br />Surrounded by global tools but constrained by parochial applications<br />
  66. 66. Doing the splits<br />Exponential growth of technology<br />Linear growth of policies and politics<br />Existing rules and policies aren’t keeping up with technological advances and in danger of loosing not only their meaning but efficacy<br />The real innovation needed might be a new paradigm for regulation, perhaps from the bottom up instead of top-down (an app?).<br />
  67. 67. …. Or extending the discussion<br />Q & A<br />
  68. 68. Widescreen Test Pattern (16:9)<br />Aspect Ratio Test<br />(Should appear circular)<br />4x3<br />16x9<br />