Presented at the Cayman Islands National Healthcare Conference, November 2010

1. Transforming Healthcare The Role of Electronic Medical Records and Information Technology Dale Sanders CIO, Cayman Islands National Health System Healthcare 20/20: Cayman Islands National Healthcare Conference November 2010

2. Can Technology Transform Healthcare? Technology is transformative only if coupled with changes to business and clinical culture & processes Technology alone can do nothing…. But without technology, healthcare cannot transform itself… 2

4. Less attracted to technology, more attracted to business strategy and processes, and the role that information technology can play

6. Agenda Core philosophies, principles and assertions Underlying my style as a CIO Their Effect on Healthcare IT, Past and Future Strategic IT Issues Facing the HSA The unique coincidence of events in history that can launch the Cayman Islands to a new level of influence and prosperity 5

7. Core Business Philosophies and Principles

8. Pure Motives and Intentions Applies personally and professionally Short term gain vs. long term failure How can I always make the best decision? Sustainable long term: Courage, charity, selflessness, love Not sustainable: Fear, shame, greed, vengeance, oppression Is this business motive on solid ground? The Lincoln story From Saving the Union to Abolishing Slavery 7

9. Taking Calculated Risks You cannot transform yourself, your organization, your healthcare, your country… without taking risks Risk = Probability of a Bad Event x Consequences What’s the worst that can happen? What’s the best that can happen? What’s the probability of both? Healthcare is enormously risk averse Careerism : Overly cautious-- be safe-- not progressive Criticism drowns courage Litigation drives fear 8

11. Always more efficient for me to spend the money I earn, than for you to spend the money I earn

12. First Order Economics: I spend the money I earn

13. Second Order Economics: You spend the money I earn

15. Mean Time To Improvement MTTI: The average length of time that expires between improvements in products, services, processes, or personal behavior What’s the cultural MTTI in healthcare? 17 years to adopt the protocol for Community Acquired Pneumonia (CAP) MTTI at Apple? Google? Amazon? HSA? The role of IT in MTTI 11

18. Business Motives for Better Healthcare If you were President of the United States, why would you be motivated to lead a healthy population? What fuels re-election? Jobs and the economy If you were CEO of Dart Enterprises, why would you be motivated to employ a healthy workforce? The elimination of human suffering…maybe PRODUCTIVITY 14

20. Businesses & gov’t services are thriving

21. US hospitals are profitable

22. Businesses & gov’t services are failingWould a US healthcare CEO dream of this in their 25-year Strategic Plan? Would a national healthcare system dream of this?? Yes 15

23. Employers Taking Control 65% of claims and 72% of costs associated with employee lifestyle claims Smoking, drinking, diet/obesity, drug abuse Hewitt Associates; n = 30,000 employees Direct contracting with healthcare providers Innovative financial incentives for participating in healthy lifestyles Financial penalties for failure to participate and show progress “No smokers” hiring policies 16

24. Healthcare Economics Who spends the money? Administrators, Physicians, Nurses, Pharmacists… sometime patients Generally, physicians and nurses don’t know how much the procedures they order or the supplies they consume, cost Who provides the money? Government and employers, sometimes patients At best, 3rd Order Economics 17

25. Business Motives Balancing treatment with wellness Lesson learned at Intermountain Healthcare Our Minister of Health Motivated economically to keep you coming back Motivated economically to keep you healthy 18

26. Commoditization in Healthcare The new “primary care providers” Much of the knowledge and duties formerly associated with General Practitioners should now be delegated to PA’s, nurses, pharmacists, and patients General Practitioners become Chronic Disease Managers Personal Trainers evolve into Personal Health Coaches Working from a Lifetime Health Project Plan Home care and “MinuteClinics” replace ambulatory clinics 19

27. Retail Clinic Metrics 60% of patients who visit retail clinics don’t have a primary care provider…and don’t need one 10 problems account for 90% of visits to retail clinics URI, sinusitis, bronchitis, pharyngitis, immunizations, inner and outer ear infections, conjunctivitis, UTI, BP monitoring, screening labs 20

29. Lower MTTI

31. Justifying the Use of an EMR You can’t justify the use of an EMR based on clinician productivity at the point of care Productivity stays about the same, at best, over time, sometimes permanently decreased The value of an EMR is systemic Downstream benefits of data analysis for process improvement and patient management Remote access, task automation Clinical decision support, sometimes 23

32. EMRs’ Impact on Chronic Disease Mgt 24 Asthma, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), and Diabetes

33. EMRs & Diabetes Management 25

34. 26

35. CAD Discharge Med Management 27 Patient and physician adherence to protocol

36. EMRs Enable Lower MTTI Case study Old clinical protocol Diabetics with no history of CV disease prescribed prophylactic aspirin New evidence Higher risk of GI bleeding and stroke outweigh benefits New protocol More conservative use of aspirin in diabetics with low CV risk New protocol implemented in the EMR order sets at Northwestern 3 day MTTI 28

37. Computerized Medication Order Entry Elimination of hand written prescriptions and orders At 80% adoption Inpatient safety benefits (US) Reduction of 200,000 adverse drug events/year $1B in savings Outpatient safety benefits Reduction of 2,000,000 events/year $3.5B in savings 29

39. All of these options are evidence based

41. Personal Health Records Should be assigned to EVERY patient Whether they use it or not At Northwestern, 2009 25,000 patients actively using a PHR Patient satisfaction: 8.7 out of 10 Lab results, secure messaging/email with providers, medication refills, BMI and glucose management 0.3 email messages/patient/month 32

42. The Downside to PHRs 600+ PHRs on the market now My PHR at Northwestern is tightly coupled to Northwestern’s EMR system No reasonable portability of my data We need the equivalent of www.mint.com Integrates your personal financial records from multiple sources into a single perspective 33

43. Transformational Technology Precision diagnostic technology increases More investment and reward for precise diagnosis, less reward for broad brush therapeutics Evidence based medicine captured in software Precise diagnosis, precise treatment Low cost, ubiquitous telemedicine Every home, every care provider Smart phones Protocols, orders, status communication Financial transactions Centralized “command center” patient monitoring and healthcare management 34

44. Commoditize Innovation Google-like search ability for EMRs New feature in Cerner Facebook: 550 million people can’t all be wrong Patients supporting one another in disease management Health coaches as Friends Already happening with obesity and diabetes Concepts from Amazon Other physicians also ordered these medications and procedures What are the reviews on these medications? Building a “shopping cart” of orders for procedures and medications, with expenses 35

45. Text Messages and HIV Management 5,300 patients in Kenya on AR therapy; U of British Columbia; 2007-2009 Weekly text msgs from nurse managers Mambo? (are you ok?) Sawa or shida (or > 48 hrs no response) If shida, phone call follow-up 9% improvement in drop of blood virus levels One nurse per 1,000 patients 33 phone calls per week 36

46. Commoditized IT Apple store has 7,000+ applications written to support health care on the iPad and iPhone Android-based phones are the fastest growing Physicians: Epocrates, WebSphere MD Patients: Diet, exercise, diabetes and depression management 15% of respondents 18-29 years used a healthcare related application on their mobile phone Healthcare providers needs to start endorsing and “prescribing” the use of these tools 37

47. Strategic Implications for the Health Services Authority

48. Evolution of Electronic Medical Records The vendor market for EMRs is in-between the 3rd and 4th Generation of EMRs The future of healthcare– which is now-- demands a 5th Generation product The Speed of Software is at play here and the future is uncertain 39

50. HITECH

51. Healthcare Reform

53. Fee for Quality

54. Capitation

55. Direct contracting with employers

56. Medicare

57. Encounter-based billing

58. CPT billing

60. Athena

64. Epic40

65. Commodity Pricing? Average of US $80,000 per bed to implement an enterprise Clinical Information System Expensive and lacking agility… This has to change 41

67. Economics of care42

68. Motives Behind 5G EMRs Clinician efficiency Evidence based medicine Diagnosis, capitated billing Supporting the Medical Home Economics of care Portability of data Patient engagement in their own care Shareholder in the financial risk and benefit Natural consequences Defendable medicine Simplified billing 43

69. The US Influence on EMRs HITECH Funding Initiative in the US At least $20B in incentives to physicians and hospitals to stimulate the adoption of EMRs in healthcare Something is wrong with this picture… Did the iPod or iPhone require government incentives to stimulate adoption? What will be the impact on EMR products and market? Where’s the motivation to innovate if the consumer is forced to buy your product? 44

70. Current Vendor Landscape 45 *KLAS 2010

71. What’s Going to Happen? HITECH funding stimulates the wrong kind of adoption Rush to invest in 3G and 4G EMRs No residual vendor incentive to innovate Hospitals and clinics: No money or will power left to invest again for another 10-15 years Will 5th Generation EMRs Emerge? Yes, in about 2 years, which benefits late adopters 46

72. HSA IT Adoption Remarkably well for a relatively small system But still, very problematic 4.6% of operating revenue on IT 85% of that on the Total Cost of Ownership of our core Cerner clinical information system Leaving 15% for everything else Materials Management, Pharmacy, Human Resources, GL, Web presence, email, telephones, and many others… 47

73. Critical Questions Can HSA and Cerner evolve together to meet HSA’s needs? Can we afford Cerner– are the benefits worth the expense? $40,000 per employed physician per year Total Cost of Ownership 85% of the total HSA IT budget Cerner contract expires in June 2013 We have less than three years to make a 15-year decision 48

74. Other HSA Strategic IT Needs Real Time Claims Adjudication and Eligibility Verification Supply Chain and Materials Management Outpatient Pharmacy Management Outpatient EMR, including Specialty Modules Extending the EMR to private physicians Electronic prescribing to all private pharmacies Modern Telephone System Dental EMR 49

75. Summary of Thoughts HSA is facing a big decision regarding its EMR and core clinical information system IT alone is not enough for transformation Must be accompanied with cultural change, patients and providers We are Homo Economicus not Homo Sapiens Half joking, full truth  EMRs and IT have a proven and positive return on investment, if invested properly 50

77. Culturally risk tolerant

78. Financially capable and astute

79. Legislatively agileNext year at this conference, the rest of the world will be paying to watch 