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ANDREW BRAUNSTEIN
o MIT (3 degrees – Computers / Management)
o 25 years building Clinical Systems
o ClinLogica – Real-Time Clinical Rule Engine for Predictive Analytics / Clinical Risk Management
o HealthWyse – handheld / tablet based cloud EMR for Home health / Hospice / Private Duty
o Vectis – Physician EMR
o Hewlett-Packard Medical – CareVue (ICU / OR / Step-down)
o 6 Patents in Clinical Technologieso Concurrency in Medical Database updates 5,546,580
o Context sharing in medical applications 6,401,138
o RFID based location verification 7,477,154/7,978,082
o Remote Personnel tracking 7,664,481
o Offline Driving Directions 8,489,320
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THE FAMILIAR PROBLEM IN THE HEALTH SYSTEM
COSTS
Avoidable
• $48b - Avoidable Admissions
• $20b - Avoidable Readmissions
• $5b - Adverse Drug Events problem within the hospital environment of which 40 –55% are preventable
• $7b - Other Medical Errors
• $20b - Improve targeting of costly services
POPULATION HEALTH
Preventative
• Poor delivery of preventive services against evidence based guidelines.
• Unaddressed Patient Compliance
• Ineffectiveness managing diseases in the presence of co-morbidities / multiple providers
EXPERIENCE OF CARE
Inefficiency
• 0.5% of Medicare Population causes 32% of all readmissions ($6.4b)
• Uncoordinated care ($9b)
• Inefficient operations ($80b)
• Reactive versus preventive
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INABILITY TO ACHIEVE THE TRIPLE AIM - Many specific roadblocks to achieving the simultaneous pursuit of population health, enhanced individual care and controlled costs.
WHY ARE WE FAILING IN CONTROLLING COSTS / MAXIMIZING OUTCOMES
SILOS OF CAREPATIENT CHANGES OVER TIME
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o Focus needs to be longer term stability – not just short term
o Monitor if existing treatment still best choice
o Other Conditions
o Medications
o Preventative Procedure timeframes
o We treat issues as they arise
o We avoid proactive treatment without symptoms
o Multiple Specialists
o Limited knowledge of other domains
o No joint discussion
REACTIVE / PROACTIVE
TOO MANY ISSUES TO MANAGE
o PBM – Hx/Drug Compliance
o INSURER – HxProcedures
o LAB – Hx
o iHEALTH - Vitals outside visit
INACCESSIBLE INFORMATION
SHORT-TERM FOCUS OR LONG-TERM FOCUS
INSURER – SHORT TERM FOCUS
o Private - Yearly Contract w/ Employers
o Employers shop based on price
o Little guarantee that contract renews
o Public – Focus on yearly budget cycle
o Payoff of long-term investment is outside budget cycles
o Likely not to reap reward of investment in prevention
o Decisions made with a personal relationship
PCP – LONG-TERM FOCUS
o Patients rarely switch providers
o Have personal face to face relationship
o Lack of preventative care
o Time
o more visits / patient = lower patient load
o Money
o lower share of risk savings
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PROBLEM: SHIFT TO SHARED RISK CONTRACTS W/O TOOLS TO IDENTIFY AND MANAGE RISK
o With effective risk tools, ACO’s can take on more of the risk, thus provider even greater incentives for high quality care
o No Risk based industry can survive without the ability to identify, quantify and manage risk
o Healthcare organizations optimized to measure coarse (aggregate) outcomes and not proactive heath (single patient) status
o Death Rates
o Readmission Rates
o A new paradigm is needed to achieve the Triple AIM (cost, patient satisfaction and group health)
o Integration of core Health Data
o Predictive Analytics
o Evidence Based Medicine
o Individualized measures of care quality
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TWO SIDES OF THE SAME COIN
PATIENT CENTERED HOME
o Roadmap for caring for complex conditions
o Compliance with NQF best practices
o Meds
o Procedures
o Labs
o Prevention of adverse drug events
o Identification of pending clinical tasks/procedures
CLINICAL LOGISTIC OVERSIGHT
o Productivity and Cost have no relationship to medical quality
o Quality can be measured by:
o Aggregate scores of patient best practice compliance
o Identification of delays in providing optimal care
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HOW MANUFACTURING TRANSFORMED ITSELFW. EDWARDS DEMING
“Organizations can increase quality and simultaneously reduce costs, reducing waste, rework, staff attrition and litigation while increasing [patient satisfaction]”
When people and organizations focus primarily on costs Costs tend to rise and quality declines over time
BUT…
When people and organizations focus primarily on quality Quality tends to increase and costs fall over time
http://innovationlabs.com/summit/summit7/pre/reading_materials/DrDeming.pdf
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GAPS LEAD TO MISTAKES
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PCP owns patient- 70yo w/ DM, HTN, Chronic Liver Disease
Too high risk to continue taking metaxalone.
No Hep-A vaccine
No ASA
Hospitalized for MI
Intended to give prescription for Beta-blocker.
SNF for stabilization. Osteoporosis documented
Did not Schedule Eye check, nor Bone Density as ordered
No biphosphateprescribed
Home Care – oversight
Not monitoring SCr
Self
Not monitoring Weight
Not Monitoring Glucose
NATIONAL QUALITY FORUM MEASURESo The National Quality Forum (NQF) is a not-for-
profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare
o Convenes working groups to foster quality improvement in both public- and private-sectors
o Endorses consensus standards for performance measurement
o NQF-endorsed measures are
o evidence-based
o predicative
o NQF endorsement is the gold standard for healthcare quality.
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DISEASE MANAGEMENTEXAMPLE: NATIONAL VOLUNTARY CONSENSUS STANDARDS FOR AMBULATORY CARE
Bone and Joint Conditions Hydroxychloroquine annual eye exam Rheumatoid arthritis new DMARD baseline serum creatinine Rheumatoid arthritis new DMARD baseline liver function test Rheumatoid arthritis new DMARD baseline CBC Rheumatoid arthritis annual ESR or CRP Methotrexate: LFT within 12 weeks Methotrexate: CBC within 12 weeks Methotrexate: creatinine within 12 weeks New rheumatoid arthritis baseline ESR or CRP within three months Steroid use—
osteoporosis screening Osteopenia and chronic steroid use—treatment to prevent osteoporosis
Osteoporosis—use of pharmacological treatment
Cardiovascular Disease Deep vein thrombosis anticoagulation ≥3 months Stent drug-eluting clopidogrel Pulmonary embolism anticoagulation ≥3 months Post MI: ACE inhibitor or ARB therapy New atrial fibrillation: thyroid function test Patients that had a serum creatinine in the last 12 reported months Heart failure—use of ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB)
therapy MI—use of beta blocker therapy Heart failure—use of beta blocker therapy Atrial fibrillation—warfarin therapy Male smokers or family history of abdominal aortic aneurysm (AAA)— consider
screening for AAA Secondary prevention of cardiovascular events--use of aspirin or antiplatelet therapy
Chronic Kidney Disease Chronic kidney disease: monitoring phosphorous Chronic kidney disease: monitoring parathyroid hormone (PTH) Chronic kidney disease: monitoring calcium Non-diabetic nephropathy–use of ACE inhibitor or ARB therapy Chronic kidney disease–lipid profile monitoring Chronic kidney disease with LDL ≥130–use of a lipid lowering agent
Diabetes Comprehensive diabetes care: HbA1c control (<8.0%) Adults(s) taking insulin with evidence of self-monitoring blood glucose testing Adult(s) with diabetes mellitus that had a serum creatinine in the last 12 reported months Diabetes with LDL >100—use of a lipid lowering agent Diabetes with hypertension or proteinuria—use of an ACE inhibitor or ARB Diabetes and elevated HbA1c—use of diabetes medications Primary prevention of cardiovascular events in diabetics (older than 40 years)— use of
aspirin or antiplatelet therapy
Hyperlipidemia and Atherosclerosis Adherence to lipid-lowering medication Dyslipidemia new med 12-week lipid test Hyperlipidemia (primary prevention)—lifestyle changes and/or lipid lowering therapy Atherosclerotic disease—lipid panel monitoring Atherosclerotic disease and LDL >100—use of a lipid lowering agent
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MANAGE MULTIPLE TYPES OF RISK
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o Risks are patient specific
o Age
o Sex
o Conditions
o Change over time
o Have Complex interactions
o Identify inflection points
ADVERSE DRUG EVENTSo Drug-related morbidity and mortality costs $177 billion
o 82% of American adults take at least one medication and 29% take five or more
o Serious preventable medication errors occur in:o 3.8 million inpatient admissions2
o 3.3 million outpatient visits3
o Mortality from preventable medication errors:o 7,000 deaths each year4
o At least 40% of costs of ambulatory (non-hospital settings) ADEs are estimated to be preventable
o At least two studies attribute 42-60 percent of ADEs to excessive drug dosage for the patient's age, weight, underlying condition, and renal function.
ADE Breakdown
Drug Interaction
Allergy (Drug)
Allergy (Category, Class, Cross-Reactivity)
Duplication
Dosing
Co-Morbidity Impact
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PATIENT SPECIFIC MEDICATION QUALITY CHECKS
Condition Med Requirements
•Evidence based Protocols
•Add (by med or class)
•D/C
•Benchmarking ability to successfully control conditions
Med Impacting Condition
•Mitigate Impact with
•Dosing Restrictions
•Labs to monitor high risk areas
•Identify Body System Risk (i.e. Pulmonary Functions, Cardiac Functions)
Adverse Drug Events
•Allergies
•Drug / Drug Interaction Checking
•FDA Meds
•OTC Meds
•Drug / Food Interaction Checking
Medical Errors
•Identification of Therapeutic Duplication
•Dose Range Checking (high / low)
•Age / Sex / Weight
•Diagnoses (including Renal / Liver / Smoking)
•Route
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PATIENT SPECIFIC LAB QUALITY CHECKS
Driven by Evidence Based Standards
•Disease / condition based
•Age based
Therapeutic Drug Monitoring
•Follow up on related lab results
•Triggered by dose changes
Maintenance monitoring
•Outside visit cycle
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FUTURE OF MED MONITORINGGROUP HEALTH COOPERATIVE
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o Agreed upon list of drugs for monitoring, with lab tests and time intervalso For example - patients taking adalimumab (Humira) for rheumatoid arthritis have complete blood count,
creatinine, and alanine transaminase tests every 2 months.
o Dose change in one med may trigger monitoring in other meds
o Monthly report of patients taking one or more of the medications on the list.
o Patient Labs scheduled and Monitoredo Patients overdue for lab tests receive a letter
o If a patient does not comply they receive another reminder
o As a note paced in patient’s pharmacy profile , the pharmacist can remind during any refill
o As a last resort, patients get a personal call from a clinical pharmacist or another member of the care team.
Overall, patients are very compliant with [TDM]. “Within 30 days of sending a reminder letter out, we see about 70% of those people come in and get their lab work, and within 100 days, we get up to 80%,”
PROCEDURE/TESTING QUALITY CHECKS
• Disease
• Condition
Driven by Evidence Based
Standards
• Outside visit cycle
• Triggered by age / sex
Maintenance monitoring
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DIFFERENT EMRS ONE PATIENTAUGMENTED DATA COLLECTION/RISK ANALYSIS
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Community Outpatient / Primary Care Hospital Rehab/SNF Home Health
o Changes in Risk reported to overseer
o Support Self Careo Med Complianceo Educationo Self Directed Labs
o 306 NQF Protocolso 33 for SSPo 7 are satisfaction
o Disease Oversighto Med Mgmt
o Effectivenesso TDM / Labso Dosing Changes
o Care Coordinationmonitoring
o 300 NQF Protocols
o Pre/Post consistency
o Monitoring of follow-up care
o Real-Time risko Sepsiso Bleedingo Stroke
o 91 NQF Protocolso Hospitalization Risko Missed D/C orderso Monitoring of
follow-up careo Real-Time risk
o Sepsiso Bleedingo Stroke
o 60 NQF Protocolso Hospitalization Risk o Missed D/C orderso Med Mgmt
o Effectivenesso TDM / Labso Dosing Changes
ACO’s OWN PATIENT ACROSS THE CONTINUUM
PATIENT ENGAGEMENTCONDITION BASED INTERACTIVE DATA GATHERING
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o Collect/Analyze BP, Glucose, other self monitored vitals/labs
o Reminders for taking medicine based on information gathered from PBM / Insurance claims
o As patient changes – outside visit - need to have outreach to review Meds/ Labs and initiate suggestions for changes.
o Targeted patient specific Self Care education/tracking via Electronic delivery
MANAGE MULTIPLE FACILITIESUSE QUALITY MEASURES TO IDENTIFY PRACTICE ISSUES
o Lower Risk implies focus on quality
o Deming et. al.
o Compare facilities by quality of care, not just productivity
o Veterans Administration
o Identify best practices within an organization while isolating poor processes
o Quickly measure the effect of changes
o Allows orders of magnitude improvement in breadth of clinical process improvements
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CLINLOGICA MANAGES RISKFOR SUCCESS BEYOND FEE FOR SERVICE
Triple AIM
• Quality benchmarked external to the process
• Modeled after W. Edwards Deming’s revolution in manufacturing
Increases in quality simultaneously reduces cost• reduces waste, rework,
staff attrition and litigation while increasing patient satisfaction
At each step cross check all other stages• Prevention is cheaper than
rework
Collect and analyze data along all parts of a process• Identify outliers
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Quality Of Care AnalyticsMinding The Gap
