Medical Informatics Update: Analytics and Tools for Care Coordination IBM Thomas J Watson Research Center October 16th, 2013 The 2013 edition of the Medical Informatics Update is a joint effort between IBM Research and the Columbia University Center for Advanced Information Management. The general chairs for this workshop are Dr. Shahram Ebadollahi and Dr. Georges Hripcsak.

1. Improving Care Coordination with
Big Data, Analytics and Technology
Paul Contino
Corporate Chief Technology Officer
New York City Health & Hospitals Corporation
Medical Informatics Update
Analytics and Tools for Care Coordination
IBM Thomas J Watson Research Center
October 16th
, 2013

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Introduction – A Little About HHC
Care Coordination at HHC
Care Coordination + Patient Engagement
Analytics and Big Data
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HHC at a Glance:
Largest municipal healthcare organization in the U.S.
$6.7 billion integrated healthcare delivery system
Serve 1.4 million New Yorkers every year, including 475,000 uninsured
Facilities:
• 11 acute care hospitals, 4 skilled nursing facilities, 6 large
diagnostic and treatment centers
• Health and Home Care (in-home services)
• More than 70 community health clinics
• 420,000 member health plan (MetroPlus)
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New York City Health & Hospitals Corporation

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New York City Health & Hospitals Corporation

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HHC at a Glance:
Care statistics (2012)
• Staffed Beds: 7,554 (4500 acute, 3000 LTC)
• Clinic Visits: 4,876,259
• ER Visits: 1,190,413
• Discharges: 221,372
• Births: 20,744
HHC Acute Care Hospitals
37% of all uninsured inpatient discharges
43% of uninsured ED visits
67% of uninsured clinic visits
$698 million in uncompensated care annually at HHC
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New York City Health & Hospitals Corporation

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“Care coordination is the deliberate organization of
patient care activities between two or more participants
(including the patient) involved in a patient's care to
facilitate the appropriate delivery of health care
services. Organizing care involves the marshalling of
personnel and other resources needed to carry out all
required patient care activities, and is often managed by
the exchange of information among participants
responsible for different aspects of care.”
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Care Coordination Defined

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EMR – since 1993, implementing Epic over next 4-5 years
CIDP – Chronic Illness Demonstration Project
Health Home – Medicaid high utilizers of healthcare services
HEAL 17 – InFocus (Behavioral Health / Schizophrenia)
HHC Advantage – Referral Management
PAMS - Panel Management System
PCMH – Patient Centered Medical Home
H-MH - Hospital Medical Homes Demonstration Program
CPMS - Care Plan Management System
Interboro RHIO – SHIN-NY
HHC ACO Inc. – Accountable Care Organization MSSP
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Care Coordination Activities at HHC

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Creating an Effective Care Team
Account for
Socioeconomic &
Cultural Factors
The Extended
Care Team -
•Friends
•Family
•Community
•Social Services
Family

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 To better serve patient populations
with complex medical and behavioral
needs.
 To improve patient outcomes through
improved care plan management and
care coordination.
 To reduce inappropriate healthcare
utilization (ED and Inpatient visits) by
coordinating and providing access to
needed services.
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Care Coordination Goals at HHC

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PCMH
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Care Coordination + Patient Engagement
Care Coordination ePatient = Engaged, Empowered
EMR
CIDP
Health
Home
Chronic Disease Registries
Population Health
HHC
Advantage
HIE
ACO
PHR
Telemedicin
e Remote
Home
Monitoring
mHealth
Mobile
Personalized Health & Wellness
Patient Generated DataProvider Generated Data Analytics
CPMS
Care Plan

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 Comply with safety and quality reporting requirements
 Predict and prevent adverse events and readmissions
 Identify new effective treatments and care plans
 Measure and effectively communicate results to consumers
 Identify and manage a defined population of patients
 Coordinate care among care team members
 Manage wellness and diseases instead of treating illnesses
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Using Collaboration and Analytics in Healthcare

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Care Coordination
“Patient Engagement
is the Blockbuster
Drug of the Century”
- Leonard Kish
Health IT strategy consultant

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Home Monitoring & Personal Health Dashboards

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Volume – Velocity – Variety
Volume - The amount of patient data has grown exponentially over
the last five years. (EHR adoption, medical imaging, ‘omics’ data)
Velocity – we will create more data in the next five years than all
the digital data created to date.
Variety – 20% structured / 80% unstructured: social media (search,
txts, blogs, tweets, facebook updates), imagery (satellite, video,
photos), sensors (optical, thermal, chemical, acoustic)
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Big Data in Healthcare

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Next Generation Medical Sensor Technology
Electronic Sensors Printed on Skin “Skintronics”

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Gartner 2013
In 2009, there were roughly 2.5 billion connected devices in the
world and 900 million sensors.
By 2020, predicting that there will be 37.3 billion connected device
and 30 billion sensors.
HP Labs estimate that by 2030, 1 trillion sensors will be in use
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Big Data in Healthcare

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Big Data in Healthcare

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Global Spending on Healthcare
Bradley et al., BMJ Qual and Safety 2011

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Total Healthcare Investment
Bradley et al., BMJ Qual and Safety 2011

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Questions & Answers