Exploring the Business Case for Quality - How Medical Care Can Evolve to Meet Patient Needs

1. Exploring the Business Case for Quality - How Medical Care Can Evolve to Meet Patient Needs Molly Joel Coye, MD, MPH Founder and CEO Health Technology Center www.healthtechcenter.org

2. The need for transformation:IOM Report - “The chassis is broken” • You can’t get there from here: “The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.” Winston Churchill had it right: "The Americans will always do the right thing... after they've exhausted all the alternatives.” www.healthtechcenter.org

3. Aligning environmental forces Four Critical Forces: • Information Technology • Payment - Reimbursement incentives • Clinical knowledge • Professional Workforce www.healthtechcenter.org

4. What didn’t work? • Medical education and continuing medical education • Practice structure: medical groups and Independent Practice Associations • CQI • Accountability: measures and reporting • Information systems and physician profiling • Physician compensation and financial incentives • And why? • US healthcare market organization • leadership and culture • technology capabilities and support • consumer interest and pressure www.healthtechcenter.org

5. CQI: The Intermountain Health System Story Brent James: LDS Hospital, Salt Lake City, Utah • 60 CQI projects over 10 years that were successful: • improved quality outcomes and patient satisfaction • narrowed variation and almost always reduced costs • only 2 were ever disseminated beyond index institutions • Why? - Example of antibiotic use to control pneumonia in hospital • reduced adverse events associated with antibitotic errors by 30%. • reduced mortality of patients treated with antibiotics 27%. • reduced overall antibiotic use by 23%. • reduced antibiotic costs per treated patient by 58%. Chassin, Health Affairs 5/97 www.healthtechcenter.org

6. The IOM Report: Information technology improves quality • Safety Computerized physician order-entry reduced adverse drug events by 55% (Bates, 1998) • Effectiveness Reminder systems and computer assisted diagnosis and management improves compliance with practice guidelines (Durieux, 2000; Evans, 1998) • Patient-Centered Internet can provide access to clinical knowledge, online support groups,customized health education and disease management messages www.healthtechcenter.org

7. The IOM Report: Information technology improves quality • Timeliness mothers receiving computer-generated reminders had 25% higher on-time immunization rate for their infants (Alemi, 1996) • Efficiency 9% of redundant lab tests at a hospital could be eliminated using a computerized system (Bates, 1998) • Equity Internet-based health communication can improve access and provide a broader array of options for interacting with clinicians www.healthtechcenter.org

8. The IOM Report: Information technology strategies • There must be a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education. • This commitment should lead to the elimination of most handwritten clinical data by 2010 www.healthtechcenter.org

9. IOM: What will be required ? Inside healthcare organizations: • Re-organize operations around core clinical processes • E.g., Pregnancy and delivery, diabetes ... • Reflect patient AND provider experience • Align measurement - external reporting as a sub-set of operations data (SEC / FASB) • Integrate ‘pieces’ of care - the patient as hub, not the site of care www.healthtechcenter.org

10. IOM: What will be required ? The external environment = purchasers, regulators • Align payment • budget, not FFS at organization level • option: reflect clinical processes • Align consumer information • Give consumers more discretion • fate of defined contribution??? • Align payment www.healthtechcenter.org

11. IOM: What will be required ? The common denominators are: • consumers and providers (and purchasers) get information that is meaningful for • selection of providers = BUSINESS CASE • improvement = knowledge • payment (price, volume) rewards improved performance for meaningful units of care • budgets for populations • payment to providers for care processes • actuarial versus performance risk • Leapfrog Initiative • volumes/cardiac procedures • Intensive Care staffing • CPOE www.healthtechcenter.org

12. IOM + Quality Forum: Action at the health system level Health Delivery System Steps • Link information systems to clinical processes and financial analyses • build registries • support clinical practice: acute and ambulatory care • adopt new technologies in concert • Focus on variation: • capacity to detect • capacity to assess • capacity to change • Focus on quality waste • Build the internal business case while waiting for the external environment to change www.healthtechcenter.org

13. Churchill also said, "Give us the tools and we will finish the job." • Now we have new tools - technologies - with which to make these changes • IOM Committee on Quality of Healthcare in America: technology is no longer an option - it is an imperative • Healthcare leaders feel the pressure to change (Leapfrog) - • pipeline of technologies overwhelming • strategy options not easily apparent • and traditional methods of technology adoption no longer work • So..which tools? Which technologies? www.healthtechcenter.org

14. Which tools, which technologies? • Information Technology • ICU in a gurney • Devices • Hepatic dialysis • Polymers • Pharmaceuticals • Inhaled insulin • Biotechnology www.healthtechcenter.org

15. Technology as strategy • A tool is not a strategy • Strategies involve disruptive technologies • radical disruption of business models and customer experience • make care radically better and cheaper for the consumer • The puzzle of the open market in healthcare: • ‘orphan technologies’ - NAS/IOM study • emerging business case for quality • emerging business case for cost reduction • learn from the developing world - employ technology for intentional change www.healthtechcenter.org

16. Strategies for intentional changein the US • Current pace of innovation and adoption so slow that • National Academies’ Board on Science, Technology and Economic Policy and • IOM Board on HealthCare Services • convened special project to identify public policies needed to “stimulate the development, adoption, and diffusion of high-value medical innovation.” (June 2001) www.healthtechcenter.org

17. Intentional, disruptive change - which tools for chronic disease? MD receives alert reports, adjusts Rx, revises surveys or initiates a visit. Substantial savings in emergency visits and hospitalizations. Sam’s nurse reviews symptoms, provides assistance or notifies Sam’s MD. Sam steps onto scale. “Good Morning, Sam.” Scale reports weight, sends over web, reports progress & gives tailored Yes/No survey. Takes ~20 seconds www.healthtechcenter.org

18. But tools are not strategy • Strategy speaks to how we will • select tools • finance them • learn to use them • and why • Sensible strategies in the face of overwhelming possiblities involve collaboration - • turn fragmentation into a virtue • health systems form a national network of laboratories \ • need systematic harvesting and dissemination of learnings www.healthtechcenter.org

19. Strategy I: Check each technology against the IOM six aims for quality improvement • Safe • Effective • Patient-centered (who defines…) • Heart Scan • Fully half of all adults polled interested in genetic test for a very serious disease even if there was no known treatment or a way to prevent it. • Would spend $300-400 for testing if treatment was available • Timely • Efficient • Equitable IT cost Clinical technologies = the ringer diffusion www.healthtechcenter.org

20. Strategy II: Check each technology against the ‘three-legged stool’ • Quality • orphan technologies • chronic disease monitoring and remote patient management • Intensive Care staffing - Visicu.com • Cost • Where quality improvement • narrows variation, • eliminates error and • decreases process time • Access • and the fourth leg: consumer demand www.healthtechcenter.org

21. Strategy III: Check for drag • Barriers - and solutions - are cross-industry • The checklist: • Culture • Guild • Lack of Toyotas • Quality hazards of implementation • Contradictory reimbursement schemes • Capital - human and financial • Leadership • Uncertainty - (Churchill again) "True genius resides in the capacity for evaluation of uncertain, hazardous and conflicting information." www.healthtechcenter.org

22. Strategy IV: Build national leadership • Urgency stressed by the NAS - IOM project • Value underscored by research on the value of innovation • Industry-wide strategies: • Provider systems and health plans • Leadership • Standards • Toyotas • Professional commitment • Collaboration in learning networks • Developers • Strategies • Crash projects for development to solve industry problems • Government strategies – • Standards • Coverage, reimbursement, conditions of participation • Financing - new investment strategies www.healthtechcenter.org

23. Strategy VI: Develop forecasting information for delivery system leaders Strategic information, from a new non-profit - The Health Technology Center • Nature of scientific advances • Clinical program impacts • Probable products and services • Potential impact on delivery systems: clinical programs, facilities, workforce and market strategy • Potential impact on insurers: cost, coverage and reimbursement • Staging: timeline, promoters and inhibitors, sentinel events, wild cards • Leading companies developing technology, potential partners • Strategic assessment: options, migration pathways www.healthtechcenter.org

24. Completed Reports Minimally Invasive Surgery Drug Delivery Devices Sensors for Monitoring Organ Assistance and Substitution Stem Cells Genetic Testing Imaging Tissue and Fluid Bioengineering PACS and CAD Point of Care: Mobile Computing Networking Cancer Pharmaceuticals and Biologics Now Underway: Robotics Remote Patient Management Security Technologies Cardiovascular Pharmaceuticals Anti-infectives HealthTech Reports 2001-2002 www.healthtechcenter.org

25. Clocking the strategy - vision and tactics The vision is: To achieve a threshold change in the quality of healthcare within this decade; major change within 5 years. The change model is mostly hydraulic: • increase the pressure to change Leapfrog, HCFA, health plan negotiations • remove barriers reimbursement incentives, technology investment • build the ‘escape hatch’ practical options: migration paths to quality • definitely unpredictable who would have thought the VA would lead? • potentially explosive physician reaction, lawsuits, legislation www.healthtechcenter.org

26. strategic objectives visionary goals tactical choices Strategy VII: Build migration pathways Quality healthcare: from vision to reality in a decade • Operating visions will span • quality aims • clinical processes • infrastructure • leadership and organization • Multiple pathways for each vision • segment by relevant differentiation among shareholders • tactical choices understood in context • tactical choices supported by relevant VHA analyses 5 yrs 10 yrs 5 year migration pathway www.healthtechcenter.org

27. A new architecture for healthcare: Axis 1 = the IOM six aims for quality 5 yrs 10 yrs Safe hand-held prescription lookup; phamacy screening CPOE ambulatory prescriptions electronic entry 5 yrs 10 yrs Effective clinical processes defined, patient registries built 15 chronic disease programs implemented ambulatory/in-home chronic disease monitoring 5 yrs 10 yrs Patient-centered Timely Efficient Equitable www.healthtechcenter.org

28. A new architecture for healthcare: Axis 1 = the IOM six aims for quality 5 yrs 10 yrs Safe hand-held prescription lookup; phamacy screening CPOE ambulatory prescriptions electronic entry 5 yrs 10 yrs Effective clinical processes defined, patient registries built 15 chronic disease programs implemented ambulatory/in-home chronic disease monitoring 5 yrs 10 yrs Patient-centered IT STRATEGY - investments - workforce - leadership Timely Efficient Equitable www.healthtechcenter.org

29. A new architecture for healthcare: Axis 2 = clinical processes 5 yrs 10 yrs Pregnancy and Delivery C/S rate, variation genetic testing genetic therapy 5 yrs 10 yrs Cardiac Care cardiac registries established endovascular surgery certification achieved ambulatory and in-home monitoring; angiogenics 5 yrs 10 yrs Diabetes X Y pancreatic transplants, stem cell IOM 15 priority chronic conditions + 80-20 rule for your institutions, populations www.healthtechcenter.org

30. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Two Sensor Applications: Technology Timeline ChipRx’s Schematic of a Self-Regulating Responsive Therapeutic System Sensatex’s Smart Shirt Long-term implantable glucose monitor developed Long-term implantable glucose monitor becomes community standard Long-term implantable glucose monitor FDA approved Smart clothes developed Noninvasive continuous glucose monitor developed Noninvasive continuous glucose monitor FDA approved Noninvasive continuous glucose monitor becomes community standard Smart clothes become “accepted therapeutic choice” Smart clothes FDA approved Cygnus’ GlucoWatch Biographer www.healthtechcenter.org

31. The Vision Advance the use of new technologies to make people healthier Strategic Partners Sutter Health Providence Health Kaiser Permanente Carolinas Health Group Health of Puget Sound Peace Health VHA Inc. California Public Hospitals Ascension Health Institute for the Future Premier, Inc. Wellpoint Health Networks HCA CareScience Markle Foundation HRET Mills-Peninsula Health System ECRI Sequoia Healthcare District Parkview Health Milbank Foundation The California Endowment www.healthtechcenter.org

32. Just give us the tools… The future is here. It's just not widely distributed yet. www.healthtechcenter.org