PowerPoint Presentation › files › 2018 › 04 › 207-Kim... · Gamification is the application of game-design elements and game principles in non-game contexts. • AI (Artificial

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Confidential ©MatrixCare 2017Presentation Name | Presenter’s Name Confidential ©MatrixCare 2018 1

And Presenter’s Name & Date

April 16th, 2018

KIM HICKS, RSM

MatrixCare


COOL STUFF!

https://matrixcare1.sharepoint.com/portals/

hub/_layouts/15/PointPublishing.aspx?app

=video&p=p&chid=40e74843-7832-41a3-

8399-971060dad820&vid=5ec8cef4-316f-

4dca-b3d3-a7fd76881dce

THE FUTURE IS HERE!


TECHNOLOGY WILL NEVER REPLACE HUMAN INTERACTION

NURSES TOOL KIT

Education

Training

Technology

Compassion

Integrity

Technology is a tool to work side by side to improve the quality

of life for America’s seniors AND those who care for them!

https://matrixcare1.sharepoint.com/portals/hub/_layouts/15/PointPublishing.aspx?app=video&p=p&chid=40e74843-7832-41a3-8399-971060dad820&vid=5ec8cef4-316f-4dca-b3d3-a7fd76881dce

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AGENDA

• WHY YOU MUST EMBRACE TECHNOLOGY

• HEALTHCARE BUZZWORDS

• TECHNOLOGY ALREADY AT YOUR FINGERTIPS

• FUTURE TECHNOLOGY


LTPAC HEALTHCARE LANDSCAPE


MORE REGULATORY CHANGES NOW THAN IN THE LAST 25 YEARS!

538 changes to existing

regulations! 18 brand

new

sections of

regulations

New Survey

QAPI

IMPACT Act

Readmission Penalties

Medicaid Cuts

Managed Care

Labor/Staffing Constraints

Increased

requirements

at Medicaid

certified ALs

Data Breaches

Reimbursement Shifts

Value-based Care

21st Century Cures Act

New Survey Process

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WITHOUT DATA FROM TECHNOLOGY…. YOU WON’T SURVIVE

• Compliance

• Increased Revenue

• Managed Care Contracts

• Referrals

• Staff and Resident Satisfaction

• Staff Retention

• Work-flow Efficiency


A BIG… CONFUSING… SWIRL…

THAT CAN BE UNCLEAR AND VAGUELY DEFINDED

OF… ACRONYMS, IDIOMS AND TEXT

HEALTHCARE BUZZWORDS


• Big Data in healthcare refers to electronic health data sets that are too large and complex for traditional software to handle.

• Population Health Management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.

• Interoperability is the ability of a health information system to transmit and receive patient data in a usable manner no matter where or how the data originated. (THIS is part of the IMPACT Act)

• Predictive Analytics is the process of extracting information from existing data set(S) in order to determine patterns and predict future outcomes and trends.

• Machine Learning is an application of artificial intelligence (AI) that provides systems the ability to automatically learn and improve the experience without being programmed. The focus is the development of computer programs that can access data and use it to learn for itself.

• Evidence-Based refers to any concept or strategy derived from objective evidence. SCIENCE

• Gamification is the application of game-design elements and game principles in non-game contexts.

• AI (Artificial Intelligence) is the development of computer systems ability to perform tasks that normally require human intelligence, such as visual perception, speech recognition and decision-making.

• CDS (Clinical Decision Support) is any technology that gives a provider a helping hand with diagnosis or treatment can technically be called a clinical decision support tool. More specifically, these technologies often use big data analytics to suggest the optimal course of treatment, flag allergies or drug interactions, remind providers of missed opportunities, or volunteer suggestions for diagnoses based on available patient information.

• IoT (Internet of Things) is a system of interrelated computing

• devices, mechanical and digital machines, objects, animals or people that are provided with unique identifiers and the ability to transfer data over a network without requiring human-to-human or human-to-computer interaction. IoT can include any device with an internet connection: pill bottles that automatically transmit refill requests, scales with Bluetooth that record weight in the patient’s EHR, smartphone apps that track sleep, diet, and exercise, fitness trackers and smart watches that generate reports, share research data, or deliver alerts, and implantable medical devices like pacemakers that can provide physicians with critical information about vital signs or emerging risks.

BUZZWORDS: A QUICK EXPLANATION

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HEALTHCARE TECHNOLOGY NOW AND COMING SOON!

• Population Health Management• Patient/Resident/Family Portal

• EHR

• IoT

• TELEHEALTH

• CDS (Clinical Decision Support)

• Analytics• Analytics vs. Reports

• Predictive

• Machine Learning


• Medication and chronic condition management

example:

• Users set the times when medications should be taken, and

the app reminds them. It also provides information about the

medications and warns about drug interactions and side

effects. By taking the medications properly, users earn points towards gift cards or charitable donations in raffles held

weekly.

• Physical therapy and rehabilitation example:

• A Canadian company, GestureTek Health develops applications specific to health, disability, and rehabilitation. Its

VR exercise programs enable patients to have fun while

stretching their physical and cognitive

capabilities. MindMaze created devices, which use virtual

reality, brain imaging and gaming technologies to retrain the brain in stroke victims. It also works on solutions for spinal

cord injury and amputee patients.

GAMIFICATION…

http://medicalfuturist.com/top-examples-of-gamification-in-

healthcare/


POPULATION HEALTH MANAGEMENT

Population Health Management is the

aggregation of patient data across multiple

health information technology resources,

the analysis of that data into a single,

actionable patient record, and the actions

through which care providers can improve

both clinical and financial outcomes.

http://www.gesturetekhealth.com/

https://www.mindmaze.com/

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CARE COORDINATION WITH BOUNDARIES

SYNERGISM


PORTAL

HyperCloud

CARE COORDINATION WITHOUT BOUNDARIES

• SNF EHR

• Hospital EMR

• Labs

• Pharmacy

• Physician’s EMR

• AND MORE!


PORTAL – Connected Devices!

HyperCloud

TELEHEALTH

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LTPAC Population Care Management

and Care Coordination Platform

https://player.vimeo.com/video/208363182

THE FUTURE IS ALREADY HAPPENING!


CDS (CLINICAL DECISION SUPPORT)LIMITLESS POSSIBILITIES

CDS (Clinical Decision Support) is any

technology that gives a provider a helping

hand with diagnosis or treatment can

technically be called a clinical decision

support tool. More specifically,

these technologies often use big data

analytics to suggest the optimal course of

treatment, flag allergies or drug

interactions, remind providers of missed

opportunities, or volunteer suggestions for

diagnoses based on available patient

information.


ILLUSTRATION OF ENTERPRISE CLINICAL DECISION SUPPORT

ECDS

A shared service model leveraged across

MatrixCare

(ENTERPRISE SOLUTION)

Delivers Evidence Based

knowledge/information

Supports interoperability thru

consistent and standard content

including codifying data

Data utilized includes: assessments, lab data, medication lists, Point

of Care data, etc.

Clinical Coach™

Uses Evidence Based

guidelines to

Enhance Decision Making

Clinical Guardian™

Use of data analytics along with intelligent rules:

• Identification of a resident at risk for an adverse event or gaps in care

Leverage Machine Learning to improve

care and reduce costs

https://player.vimeo.com/video/208363182

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The 5 Rights of an Effective CDS system

1. …the right information✓ evidence-based, actionable…. [what]

2. …to the right people✓ clinicians, physicians, residents…. [who]

3. …in the right format✓ documentation tools, order sets, alerts, warnings…. [how]

4. …through the right channels✓ EHR, portals, smartphone, …. [where]

5. …at the right times✓ Key decision/action, speed matters…. [when]


Clinical Guardian™

• Assist in identifying Residents/Patients that may be at risk for an adverse event.

• Enhanced management of chronic conditions, ie. Wound healing

• Potential identification of gaps in care


Enterprise Clinical Decision Support

Clinical Coach™

• Provide evidence based information and knowledge that enhances the

decision making process.

– Alerts to identify the potential need for a high priority intervention

– Messages to assist in care coordination

– Recommendations in care planning, order additions or changes, etc.

– Reference Information like facility protocols, federal regulations, etc.


Peak into the future at what ECDS can offer….

Risk Identification: Re-hospitalization avoidedSequence of Events

1. Betty receiving HH care (CCRC LLC)

2. Outpatient Surgery - TKR

3. Betty admitted to SNF (CCRC LLC)

4. 30 days post-surgery admit SL (CCRC LLC)

5. 60 days post-op Home (HH)

6. 90 days post-op Betty signs of

possible respiratory infection

Ms. Betty BACKGROUND:

• Dx = COPD; DM; HTN

• Pt of Home Health Services

• CareCommunity Portal Subscriber

• Requires Total Knee Replacement• CCRC Client – multiple Care

settings

• Betty feeling ill

• HH visit next week

• Betty reports SS via CC

• Mobile device O2 stats

down• Negative Lab trend

CC & Device data

SL

SNF

Data analysis

care setting agnostic

ECDS Rule Triggered – CC

SS/Dx and Post Op >60 days

HH Alert – MD Visit

recommended

CC message – Betty

schedule MD visit

Mobile Message –

daughter MD visit

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Care Monitoring Facility Level - to identify need for intervention

Mr. Bertram

BACKGROUND:

• Dx = DM without complications

• Resident of SL facility

• Care Assist used to chart cares

• CNA Lisa is assigned to provide care to Mr.

Bertram

• Lisa documents her tasks in Care Assist

• Over the last week there have been 5 different CNA

Caregivers• Today - Lisa proceeded to assist Mr. Bertram with

Dressing

• Mr. Bertram Refused the care and did not get

dressed

• The Facility has implemented a procedure to

review and intervene cases in which a resident

refuses care 3 or more times within a 5 day period.

ECDS Rule: 3 Refusal

Alert sent to Care

Director

Due to the number of caregivers the 3rd

refusal might have been missed without leveraging ECDS



Gap in Care Identification (ECDS &

Analytics)

Abe Abraham

BACKGROUND:

• Dx = DM without complications

• Resident of Skilled Nursing Facility

• Care Assist implemented - eMAR

• Abe has a prescription for NovoLog

• QAPI Manger worked with DON to implement a

number of ECDS Rules related to identifying Gaps

in Care.

• Rule implemented to identify the appropriate

frequency and timing of an A1c (potential to identify frequency by resident based on how well DM is

being managed. Quality Assurance

Process Improvement

Manager

ECDS Rule: A1c

Monitoring Rule triggered

Alert: sent to QAPI and DON

from Facility level identifying Gaps. Alert: sent specific to Abe

indicating his last A1c Lab was completed 2 months ago but

His BG levels have been out of

range for 50% of the time

during this period. ECDS

recommendation – test at 2 months.

Note: A1c completed 2 – 3 months

but due to less than desirable BG

values test recommended to be

run every 2 months.


ARE YOUR USING ANALYTICS?

• Power BI (business intelligence) tools• Third-party vendors

• All inclusive

• Cost

• Access to Data

• Real-time Data vs. Historical Data

• Pre-built AND customizable

• Clinical AND Financial

• Predictive


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• Reporting is the process of organizing collected data

into structured summaries to monitor different areas of

your business including both clinical and financial.

• Analysis is the process of exploring your data and

reports to obtain meaningful insights to be used to better

understand and improve both clinical and financial

performance.

• Reporting reveals what is happening and analysis

explains why it is happening and what you can do about

it.

• Data and reports become useless with a tool to

analyze them.

REPORTS VS. ANALYTICS

Reports and Analytics are not interchangeable terms. They both pull from the same

data, but are different in terms of purpose and value.


Operational Focus

Highly detailed

Snapshots

Tables, printed pages

Scheduled delivery

Parameterized

Reporting


Analytics

Strategic Focus

Summarized data

Interactive Discovery

Trends, Patterns, slice / dice

Visualizations, conditional styles

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PREDICTIVE ANALYTIC REQUIREMENTS

ALL AVAILABLE

DATA

LEVERAGE MACHINE LEARNING

ACHIEVE CLINICAL OR

FINACIAL EFFICACY

PROVE IMPACTABILITY THROUGH CONTINUOUS MEASUREMENT


• The team used Azure Machine Learning to

build and train a model based on several

years of falls data.

• Data was unstructured

• The model was integrated into the

MatrixCare application.

• When a clinician enters a note, an

algorithm determines whether it was a fall.

• If it is determined to be a fall, appropriate

care plan is recommended.

MACHINE LEARNING- IT’S HAPPENING IN LTPAC NOW

MATRIXCARE 24-HOUR HACKERTHON

FANTASTIC EXAMPLE OF USING UNSTRUCTURED DATA FROM THOUSANDS OF RESIDENTS TO

RECOMMEND THE APPROPRIATE COURSE OF ACTION FOR A CURRENT RESIDENT EPISODE!


FINAL THOUGHTS

BIG DATA

CDS

PREDICTIVE ANALITCS

POPULATION HEALTH MANAGEMENT

MACHINE LEARNING

RESIDENT PORTAL

The mission is to leverage technology

to improve the quality of life for

America’s seniors and for those who

care for them!

Documents

PowerPoint Presentation › files › 2018 › 04 › 207-Kim... · Gamification is the application of game-design elements and game principles in non-game contexts. • AI (Artificial