Blatt e collaborative himss 2012 final
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Blatt e collaborative himss 2012 final
- 1. Collaborative Care: An Economic Imperative for Care Delivery Systems Mark Blatt MD Worldwide Medical Director Intel Corporation February 2012
- 2. Collaborative Care: An Economic Imperative for Care Delivery Systems Agenda Current Trends The Evidence for Care Coordination Going mobile to Coordinate care • Right Device for Right task • Collaborative workflows • Compute Model matters • Secure Mobile computing Summary 2
- 4. Is Solo Practice a failed Business model ?
- 5. Has Fee for Service meet its Limits?
- 6. Hi-Tech Breach Notification • Mandatory penalties. State AGs sue in civil court – Starting at $100 per violation ($25k/yr) going up to $50,000 repeat violations w/ “willful Neglect” ($1.5M/ yr) Breach Notifications Week of June 1 • Projected PHI is essentially ”encrypted PHI” • Mandatory Reporting with 60 days and publication at HHS Breach site for violations >500 http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/postedbreaches.html 2. HiTech Act, Division A Title XII, Subtitle D Part 1 Sections 13401-11
- 7. Hospital Readmissions (We Don’t Do a Good Job Here) Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days 34.0% were rehospitalized within 90 days 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition About 10% of rehospitalizations were likely to have been planned The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously Authors estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion N Engl J Med 2009;360:1418-28.
- 8. Section 3025 – Hospital Readmissions Beginning October 1, 2012, DRG payments to hospitals who have “excess” readmissions for certain conditions will be reduced. The floor adjustment factor will be 99% for fiscal year 2013, 98% for 2014, and 97% for fiscal year 2015 and thereafter. First three conditions to track AMI, heart failure and pneumonia. October 1, 2014, the list expands COPD (chronic obstructive pulmonary disease), CABG (coronary artery bypass graft), PTCA (percutaneous transluminal coronary angioplasty), and other vascular conditions. 3. The Patient Protection and Affordable Care Act (HR 3590 enrolled: Sec 3025)
- 9. Coordination and Collaborative Workflows The Evidence
- 10. Controlling Costs Starts with Better Management of Chronic Diseases • Medicare beneficiaries with multiple chronic illnesses see an average of 13 different physicians • Fill 50 different prescriptions a year • Account for 76% of all hospital admissions • Account for 88% of all prescriptions filled • Account for 72% of physician visits • And are 100 times more likely to have a preventable hospitalization than someone with no chronic conditions We must improve management of Chronic Diseases through Better Care Coordination Testimony of Gerard F. Anderson, Ph.D., Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, before the Senate Special Committee on Aging, “The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007).
- 11. How Physicians Currently Use Mobile Device(s) “Super-Mobile” Physicians drive higher utilization, demand tablet access to sensitive patient data 11 QuantiaMD* Research Report, “Tablets Set to Change Medical Practice”, June 15, 2011. See www.quantiamd.com/q- qcp/QuantiaMD_Research_TabletsSetToChangeMedicalPractice.pdf
- 12. Patients Report Experiencing Poor Coordination Percent U.S. adults reported in past two years: Your specialist did not receive basic medical 13 information from your primary care doctor Your primary care doctor did not receive a 15 report back from a specialist Test results/medical records were not 19 available at the time of appointment Doctors failed to provide important medical information to other doctors or 21 nurses you think should have it No one contacted you about test results, or 25 you had to call repeatedly to get results Any of the above 47 0 20 40 60 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
- 13. Commonwealth Survey of PCPs How does the US compare with other in communications Percent reporting that they receive information back for “almost all” referrals (80% or more) to Other Doctors/Specialists: 100 82 76 75 75 68 62 61 50 37 25 0 AUS CAN GER NETH NZ UK US Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
- 14. Evidence for Care Coordination 2007 prospective cohort study of 756 patients with “life- limiting illnesses ” in California • In the “patient-centered” group (358): – 38% fewer admissions – 36% fewer inpatient days – 30% fewer ED visits • 26% lower cost Sweeney L, Halpert A, Waranoff J. Patient-Centered Management of Complex Patients Can Reduce Costs Without Shortening Life. Am J Manag Care. 2007;13:84-92.
- 15. ED Visits by Source of Care and Income http://www.aafp.org/afp/2009/0115/p94.html
- 16. Evidence for Care Coordination Geisinger Health System in Pennsylvania • 36 primary care practices with NCQA Level 3 PCMH certification vs. control practices • Positive results: – 40% reduction in 30-day readmissions – 20% reduction in (total) admissions – 7% lower costs Arvantes, J. Geisinger Health System Reports That PCMH Model Improves Quality, Lowers Costs. AAFP News Now. May 26, 2010.
- 17. New West Physicians (Denver, CO) 76 Providers (41 FP, 17 IM, 8 Hospitalist, 10 mid levels) Level 1 PCMH NCQA (pending) • Extended Hour and After hrs Access (24x7) • EMR is all offices connected to hospital, labs, path • EPrescribing and electronic prescription delivery • Quality improvement CDM programs • $4.4M cumulative HIT investment ($11M incr. rev „07-‟09) • Centralized coordinated Post discharge and follow up with 24 hrs (including we deliver your meds) • Daily team meetings: 30 minute review of the day RESULT: 1% 30 day readmit rate (usual 6-18%+) American Hosp Association Jan 2011 ACO Case Study: New Physicians West
- 18. Collaborative Workflows Example Use Cases
- 19. To Support Care Coordination for Better Outcomes, Mobilized Data is Critical Gather & Store Data EMPOWER citizens Share the Data Mobilize Data
- 20. End-To-End Story Care Coordination Across the Continuum Mobile Data is Critical Health Clinical Decision Support Emergency Checkup Personal Health Record Self Check & Control Data Data Exchange Patient-Centric Care Exchange Clinic Electronic Health Record Data Repository Home Community Hospital Visiting Remote Care Diagnostic Academic Hospital Pharmacy Long term Research Care
- 21. Right Form Factor/Capabilities for the JobIn Hand Usage USER EXPERIENCE Table Top Usage Frequent/ Short Sessions Fewer/Longer Sessions Content Significant data creation, Portable Disinfectable, sealed, entry, medium collaboration rugged, Barcode, data collection/ manageability, RFID, Handwriting viewing, media image editing Medium forms, data collection/ viewing, media SIZE Simple forms, data Notebooks collection/viewing, MCA+ Netbooks Ultrabooks small media Tablets Pocketable Smartphones and Handhelds Some Convergence Multi-Function FUNCTIONALITY Basic/Medium Internet Immersive/Visual Internet +MCAs have a variety of processors from Atom to Core i5 & i7 vPro
- 22. What Real time Collaboration Might look like
- 23. Possible Collaborative Workflows • EMS: Treat in place: EMT/ doc / homecare nurse/ community care worker • ED Discharge to home : doc/ homecare nurse/ community care worker • ED Admit: ED nurse / floor nurse / transportation • Consults Acute inpatient: doc/doc/therapists/ pharmacist/ etc) • Consults Chronic Disease outpatient: doc/ doc/ therapists/ homecare nurse / community care worker/ etc • Homecare: doc/ homecare nurse/ community care worker
- 24. Healthcare Security & Privacy Across Desktop Virtualization Options Application Virtual Virtual OS Image Terminal Virtualiz- Hosted Container Streaming Services ation Desktop Client Client PHI at Rest Server Server Server or Server or Server Risk Isolation Virtual Virtual App Client / Client / Client / Strategy Containers Isolation Server Server Server Able to Work Offline Yes Yes No No No Manage and Patch Centralized Centralized Centralized Centralized Centralized User Session Data Sync Data Sync Session on Session on Session on Availability with Server with Server Server Server Server 2nd Generation Intel® Core™ vPro™ Processor Family Based PCs Support ALL Desktop Virtualization Models 24
- 25. The Case For MMR (Multimedia Redirect) (2) VDI Cloud Svc Queries (1) User Requests Device Media, GFx, Network Capabilities Virtual Desktop 2 (3) If High End Client Enterprise VDI and Cloud Low BW connection, then render/decode locally on client Local App Redirected (4) If Low End Client & Media (MMR) High BW connection then render/decode in DC Low Server and stream bitmap Client Side Server Side Utilization (1%) Central Data
- 26. Streaming and Virtual Hosted Desktop Study: Phase 2 IT@Intel White Paper, Intel Information Technology Computing Models, April 2010 26
- 27. Secure Mobile Computing (MPOC) and Care Collaboration 27
- 28. Mobility Drives Higher Need for Protection Frequent 2M laptops/year are reported as stolen and 97% are never found23 78% of US organizations have some type of encryption strategy in 2009, Costly up from 66 percent in 200726 The average cost of a lost laptop is $49,24624 >59% of respondents say it is very important Often from the inside to encrypt employee’s 70% of all reported security mobile devices26 breaches were due to insiders25 23 Source: Processor, May19,2006. http://www.processor.com/editorial/article.asp?article=articles/P2820/30p20/30p20.asp&guid=024E96876DB944D89AA42906DB9FFE84; 24 Source: Ponemon Institute , April 2009 , http://communities.intel.com/docs/DOC-3076 ; 25 Source: CNET News.com, from Ponemon Institute Survey (163 F1000 companies) ,January 2005, http://forums.cnet.com/5208-6132_102-0.html?threadID=56566 ; 26 Source: Symantec Global Internet Security Threat Report Trends for 2008,Volume XIV, Symantec, April 2009 http://eval.symantec.com/mktginfo/enterprise/white_papers/b-whitepaper_internet_security_threat_report_xiv_04-2009.en-us.pdf
- 29. BIG QUESTION: PHI (CHI) on the Client? As data is more portable it is more susceptible to being lost or stolen. NO PHI on Client/ Thin only PHI on Client/ Rich compute Improved Security Flexible compute models Central Manageability Online/Offline data access Fast Provisioning Remote access Network Security and Reliability Cost of Downtime / Data Loss Bandwidth Requirements Security Regulatory requirements Placing PHI on Client requires Balancing Multiple Tensions
- 30. Data Breaches In Georgia 30 http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html
- 31. Protecting Mobile PHI Intel Hardware Enabled Security Technologies • SSD (Solid State Drive) with AES: high performance, low power, robust, encrypted solid state drives • AES-NI (Advanced Encryption Standard – New Instructions): high performance encryption of PHI at rest, in use, in transit IPT (Identity Protection Health Technology): strong 2-factor authentication Info Exchange • Anti-Theft: mitigating loss or theft of client with PHI • vPro AMT (Active Management Technology): improving manageability and compliance • VT/TXT (Virtualization and Trusted Execution Technologies): protecting server confidentiality and SSL/TLS integrity in a virtualized / cloud environment or IPSec EHR Client EHR Server SSD AES- IPT Anti- vPro SSL/TLS AES- IPT VT / (AES) NI Client Theft AMT or IPSec NI Server TXT 31
- 32. Intel® Anti-Theft Technology Protection: Tamper-resistant security feature in laptop hardware that detects potential theft and disables itself. Non-Destructive: When returned, the laptop can be easily reactivated without harming laptop or data. Owner Recovery Message: Disabled laptop can display unique recovery message and contact information to return laptop to its owner Track, Manage & Recover laptops Enhanced Data Encryption solutions for Business 32
- 33. SUMMARY Mobile computing is more than simple data look up. Different devices for different tasks Data consumption/ creation at the point of care are a good start Collaborative workflows are where you want to go Security when going mobile is paramount. Encryption and two factor authentication are good starts Balanced compute models that take advantage of central server manageability and security with client side execution, lowers IT costs, and can improve the end-user experience GATHER SHARE MOBILZE EMPOWER 33
Editor's Notes
- Non USA for chronic disease .for some locations
- Tablet Adoption by Physicians May Soon Exceed 50%Years of Practice Not a Barrier to Mobile AdoptionMobile Devices Support Core Physician ActivitiesIn professional settings, physicians most often use their mobile devices to access drug and treatment reference information. Also high on the list is obtaining new information about treatments and research, and making decisions about patient treatment and diagnosis. Emerging areas of use include medical testing decisions, patient education materials, and accessing patient records and information Access online resources: research drugs (73%), treatments (50%), clinical research (50%), patient diagnosis (44%)When asked how they would prefer to use their mobile devices for peer-to-peer activities, physicians’ top interest is access to EMR data. They also prioritize receiving treatment protocols alerts, and sharing and discussing cases with other physicians. For physician-to-patient activities, physicians value “e-prescribing,” sharing patient education materials, getting paid for time devoted to email and chats with patients, and receiving alerts when patients need follow-up treatment Among barriers that may impede use of mobile devices, physicians are most concerned about patient privacy and physician liability, and lack of financial reimbursement for physician time and investment in using this technology. Physicians also cite limited institutional support for peer-to-peer engagement using mobile technology. Concerns about patient privacy and liability also feature as physician-patient barriers. Interestingly, though, just 37% of physicians cite lack of technology among patients as a barrier. This would have been much higher just a year ago Twenty-five percent of physicians in our survey report using both smartphones and tablet devices for their work. These “Super Mobile” physicians are using online resources at significantly higher rates than physicians who use either a smartphone or a tablet alone. Among the top professional activities for these very mobile physicians are searches for drug and treatment reference materials, learning about new treatments and research, and diagnosing and choosing treatment for patients. While these activities are similar to those pursued by other physicians who are online, “Super Mobile” physician are using online resources much more frequently across a broad range of core professional activities, pushing physician online usage upward. One notable impact of tablets is that physicians are much more interested in accessing patient data and records via a mobile device with a tablet than with their smartphone.QuantiaMD® Research Report, “Tablets Set to Change Medical Practice”, June 15, 2011. See www.quantiamd.com/q-qcp/QuantiaMD_Research_TabletsSetToChangeMedicalPractice.pdf
- Sweeney,L., Halpert,A., Waranoff,J. (2007). Patient-centered management of complex patients can reduce costs without shortening life. The American Journal Of Managed Care, 13 (2), 84-92.OBJECTIVE: To determine the effect of intensive patient-centered management (PCM) on service utilization and survival. STUDY DESIGN: Prospective cohort study of 756 patients in California who had a life-limiting diagnosis with multiple comorbid conditions (75% were oncology patients) and who were covered by a large commercial health maintenance organization from February 2003 through December 2004. METHODS: Group membership determined assignment to the PCM cohort versus the usual-management cohort after blindly screening for clinical complexity. Both cohorts accessed the same delivery system, utilization management practices, and benefits. Intervention was intensive PCM, involving education, home visits, frequent contact, and goal-oriented care plans. RESULTS: Roughly half (358) of the 756 patients received PCM. Fewer PCM oncology patients elected either chemotherapy or radiation (42% increase over usual-management oncology patients). PCM patients had reductions in inpatient diagnoses indicative of uncoordinated care: nausea (-44%), anemia (-33%), and dehydration (-17%). PCM patients had utilization reductions: -38% inpatient admissions (95% confidence interval [CI] = -37%, -38%), -36% inpatient hospital days (95% CI = -35%, -37%), and -30% emergency department visits (95% CI = -29%, -31%). PCM patients had utilization increases: 22% more home care days (95% CI = 20%, 23%) and 62% more hospice days (95% CI = 56%, 67%). Overall costs were reduced by 26% (95% CI = 25%, 27%). Patients' lives were not shortened (26% of PCM patients died vs 28% of patients who received usual management) (P = .80). CONCLUSION: Comprehensive PCM can sharply reduce utilization and costs over usual management without shortening life. (Source: PubMed)
- Geisinger Health System Reports That PCMH Model Improves Quality, Lowers CostsBy James ArvantesPosted: 5/26/2010, 2:30 p.m. -- As pilot projects of the patient-centered medical home, or PCMH, model continue to roll out, some early adopters of the model are beginning to report the results of their PCMH pilots. One such early adopter is Geisinger Health System in Pennsylvania, a physician-led health care system that covers 43 counties. The company recently reported that its investment in the PCMH model has resulted in improved quality, lower costs, and greater physician and patient satisfaction rates.Geisinger started rolling out the PCMH model in 2007, using it to drive sustained changes in its integrated health care delivery system. The result was the Geisinger ProvenHealth Navigator model, which now encompasses 31 Geisinger primary care practice sites and five non-Geisinger practices. According to Thomas Graf, M.D., chair of the Geisinger Community Practice Service Line, during the past three years, Geisinger practices testing the ProvenHealth Navigator model saw a 40 percent reduction in hospital 30-day readmissions and a 20 percent reduction in overall hospital admissions when compared to a control group that did not use the system. In addition, the cost of care for patients in the test group was 7 percent less than the cost of care for the patients in the control group, Graf said.At the same time, said Graf, physician, staff member and patient satisfaction rates among the medical home sites were far greater than the satisfaction rates among the control sites, based on surveys conducted by Geisinger. "The patient-centered medical home allows you to do primary care the way you would want to do it," said Graf. "From our perspective, it is really the way we do business now. It is about knowing who all of the patients in your entire populations are, where they are, what is going on with them and then being proactive about managing them."Geisinger has data on 85,000 patients covered by the ProvenHealth Navigator model and, thus, is able to compare cost and quality data for these patients with 150,000 patients who are enrolled in nonmedical home practices that contract with the Geisinger Health Plan. The health care system is now in the process of expanding ProvenHealth Navigator to other practices it contracts with, as well as to the remaining six Geisinger practices. ProvenHealth Navigator "is our way of delivering care going forward," said Graf.Measuring QualityAccording to Graf, the goal of the ProvenHealth Navigator system is to provide physician-directed, team-based care based on core concepts, such as proactive outreach to patients and chronic disease management. "Each person on the team has a specific function independent of the others, with the physician directing and referring the care," said Graf.These core concepts, in turn, are coupled with 10 quality metrics that serve as guides for Geisinger's primary care system and that slowly evolve, according to Graf. Last year, for example, one of the metrics called for all ProvenHealth Navigator sites to achieve level-three PCMH recognition from the National Committee for Quality Assurance -- a goal that was met.Other quality metrics address the entire spectrum of care, from office visits to electronic communications to case management. The Future of MedicineRonald Paulus, M.D., M.B.A., EVP for clinical operations and chief innovation officer for the Geisinger Health System, is convinced that the medical home represents the future of medicine if it is implemented and supported properly. He pointed out that the PCMH has been in the medical literature since the 1960s, but the concept has not "really taken off" because insurers and other entities are reluctant to pay for it.Geisinger has addressed that problem by changing the payment structure to support the medical home. The health care system continues to pay physicians on a fee-for-service basis, but it also provides advanced practitioner stipends and staff bonuses and has directly increased the compensation of physicians by 10 to 15 percent. Geisinger also furnishes practices with additional funds to help them carry out PCMH functions. The goal is to move from a volume-based to a value-based system, according to Graf. The company employs a gain-sharing program that gives the medical home sites the opportunity to earn bonuses if they meet certain cost goals and achieve quality standards. "If the practices hit 100 percent of their quality measures, and they save money, then they receive 50 percent of their savings," said Paulus. "If they hit 70 percent of their quality metrics and save money, they receive 70 percent of the 50 percent." Paulus stressed that the medical home practices must save money and meet the quality goals to qualify for the bonus payments.
- Why is it essential?Meaningful use (review) What does it take to be successful?ID HospitalBuilding data exchangesData at the point of care – in the clinical settingData at the point of care – wherever the patient isWorking together as an industry
- Bring Your Own Tablet / SmartphoneDriving a rapid increase diversity of client types, presenting manageability challenges in prevention (patching) and recovery (remediation of malware)User expectation is to also do personal apps such as social media, web browsing, emailing, which are all high risk activitiesApps downloaded through app stores are a major malware propagation vector into mobile devicesSolution: separate ePHI from risk by partitioning healthcare apps and ePHI from unsecure clients, personal activities and unsecured appsMove ePHI to backend storage, ie VDI modelSecure client eg with sandboxing technologyDesktop Virtualization (Virtual Containers) with TXTDesktop virtualizationand cloud computingVM full lifecycle security with Intel®Virtualization Technology and Trusted Execution TechnologiesPartitioning applicationsacross VM’s based on riskKeep higher risk activities such as browsing away from most sensitive data including PHI
- As part of the story, point out that many of these tension points aren’t new to the cloud but are extended into the cloud and in some case amplified.Security needs little introduction. We are reminded daily from the news stories about the negative impacts of security breeches. The challenge is balancing security requirements with the needs of the datacenter. The Cloud is not immune from the security challenges. It brings many of the same downsides from a conventional build out: The recent growth of security breeches driven by the ever evolving hacker software base and the criminalization of the hacking community. The cost of downtime caused by a security breech and from the data loss itself, not to mention the huge negative impact to a company’s brand image when a breech occurs. And the compliance and regulatory issues. These are all the same, but they get amplified in cloud. The concentration of assets and multi-tenancy aspect of cloud brings the constant tug-of-war between operational efficiency and security to a higher tension. Beyond consolidation, the additional concentration of data assets in a cloud deployment makes it a very high-value target for attack. And the added complexity of a multi-tenancy and relative immaturity of the tools makes securing the different clients security needs more challenging the standard deployment. Having a major breech during the infancy of a cloud deployment could be a significant blow to the image and future business. The challenge is balancing all the potential benefits of cloud technology with a sound approach to security.