1. 2011 Medical Professional Liability Symposium Chicago, IL ~ March 24 & 25, 2011 RISK MITIGATION THROUGH TECHNOLOGY

2. Moderator: Kimberly M. Willis, CPCU, ARM, Senior Vice President, Healthcare Practice, Endurance U.S. Healthcare Panelists: Jordan Dolin, Founder & Vice Chairman, EMMI Solutions Jacques Feldmar, PhD, Chief Executive Officer, OBS Medical Kathryn Eblen Townsend, RN, JD, ARM, CPHRM, Director, Client Insurance Program, PeriGen Larry L. Smith, JD, Vice President Risk Management, MedStar Health

3. Reducing Preventable Medical Injuries: How are we doing? In 1999 the Institute of Medicine reported that medical injuries in US Hospitals accounted for: Up to 98,000 Deaths More than 1,000,000 Injuries Recent Article in NEJM assessed our progress (N.C. Hospitals 2002-2007): Hospitalized Patients had a 1 in 5 chance of harm from care received 13.8% Permanent, Life Threatening or death 63.1% Preventable

4. Root Cause vs Real Cause Root Cause Analysis: Has been ineffective Focus is on the End Result Solutions: more staff education or another new policy Real Cause Analysis: Study of the relationship between individual errors (failings of individual clinicians) and system factors (the interaction of individuals with one another or the work environment) that resulted in the ultimate error

5. Real Cause – Top Common Causes MedStar 5 year Closed Claims Study (134 Claims) Communication Breakdown: Provider to patient; patient to provider; clinician to clinician (24%) Failure to respond to available clinical info (lab results, tests results, patient symptoms) (23%) Failure to monitor or assess patients physiological status (20%) Failure to order diagnostic test in a timely fashion (19%) Failure to follow established policy or protocol (11%) Failure to provide adequate supervision (10%) Failure to obtain consult or referral in a timely fashion (8%)

6. Real Causes Error/Injury Reduction Initiatives

7. OB Risk Reduction Initiative 10 Year retrospective review of MedStars OB claims history: 16% of all claims were OB (Frequency) 31% of all claim dollars were OB (Severity) Board directed goals: Develop system-wide OB care and clinical practice standards against which our staff agree to be held accountable Produce measurable reduction in the number and cost of OB liability claims

8. Initial Results of OB Initiative Using Real Cause Analysis Model, top risks were identified and addressed: Oxytocin Guidelines System-wide Patient Care Standards Established Shortly after implementation and training of staff we experienced one of the worst preventable adverse outcomes we had ever experienced Clear violation of newly established protocol

9. Could Technology Help? While development of system-wide standards was a significant achievement, what was needed was the ability to alert staff to when deviations were about to occur The MedStar OB Leadership sought technology that had the capacity to: Provide real time alerts to providers at the bedside, and Provide OB Leadership with reliable data to monitor staff adherence to established Standards of Care

10. PeriBirth ROI Analysis While OB Leadership was confident that the technological support offered through PeriBirth had the potential to improve care and reduce patient injury, the organization struggled because there were so many other competing requests for funding. Challenge: to prove that the potential long term benefits outweighed the substantial up- front and ongoing annual operating costs, i.e., What was the ROI??

11. Closed Claim Case Simulation Leads to Wider RIO Analysis Clinicians simulated the use of PeriPirth using a closed claim that resulted in a $4M settlement Results of the simulation, particularly the systems decision support responses, were compared to post-event retrospective expert reviews obtained for litigation purposes

12. Closed Claim Case Simulation Leads to Wider RIO Analysis Simulation results mirrored expert reviews both as to the deviations that occurred and the timing of those deviations. Non-reassuring fetal heart rate patterns not responded to timely; inappropriate use of Pitocin; failure to communicate appropriately with physician CONCLUSION: Patient injury and subsequent litigation cost would have been avoided When simulation technique was applied to all OB claims over the previous 10 years, actuary agreed PeriBirth should produce better financial results going forward.

13. Patient Engagement Expertise –Engaging interactive communications platform –Multi-modality approach leading to higher knowledge retention –Innovative technology: trackable, secure –Focus: take an active role in patient health –2.5 million access codes prescribed –Data to support all of our value propositions Who is EMMI?

14. Communication is Critical to Risk Management Efforts Its clear to us, 22 years into this research, that lawsuits are not about bad outcomes… they are about expectations. Linda Crawford, Author When Medial Error Becomes Medical Malpractice: The Victims & the Circumstances. Communication breakdowns are the most common root cause of health care errors that harm patients Paul Schyve, MD, Senior Vice President, Joint Commission According to JAMA, only 3% of malpractice claims involve actual medical negligence

15. It is Also Essential to Patient Satisfaction & Loyalty –Four out of ten HCAHPS tie to communication –According to a recent McKinsey Study: 77% of commercially-insured patients would switch hospitals to one that better informs patients about treatment both during and after visit.

16. Poor Communication Impact Both the Top and Bottom Line Hospitals need to implement programs to both educate patients and set clear expectations –Provide patients with clear, focused information –Involve patients in their care –Facilitate patient-physician dialogue –Deliver appropriate, consistent information –Involve family or circle of care –Leverage technology – most cost-effective vehicle

17. Enterprise Risk Solutions Must Support Broad Business Goals Hospitals can leverage technology to take a proactive, executive supported approach that blends risk management efforts with the Hospitals business objectives: –Patient safety programs –Quality initiatives –Patient satisfaction & HCAHPS scores –Enhancing operational efficiencies –Reducing cancellations –Reducing length of stay –AND proactive claim avoidance

18. Surgical Procedure Foreseeable Complication Satisfied Patient Lawsuit Filed Lawsuit Avoided Continuum of Care Traditional Risk Management Process Enterprise Risk Management Process Improving Quality & Safety Managing Expectations Enhancing Communications Mediation Fails Risk Management Gets Involved Complaint Filed True Enterprise Risk Solutions

19. Proof Statements & Studies We Conducted With Our Clients We seek to measure the impact of our programs whenever the opportunity presents itself. Below are a few examples of what we have documented to date. –Improved Press Ganey Scores at The Methodist Hospital in Houston –Improved HCAHPS scores at Banner Estrella in Arizona –Reduced average length of stay at UPMC –Reduced surgical cancelation rates at Beaumont in Michigan –Improved patient flow at Grady Memorial –Increased procedure attendance rates at University of Chicago –Secured reinsurance discounts for multiple clients –Our clients have claims rates well under the national average

20. Can Vital Signs Monitoring Help? Unexpected cardiac arrest: vital sign abnormalities observed 8 hours beforehand in >60% of cases Long term consequences depend on intervention time 86% of patient monitors alerts are false alerts UK National Patient Safety Agency Recommendation: to identify patients who are deteriorating and act early

21. MEWS: Not a Solution Nurses do not have time Clinicians do need not trust the system Not enough information for communication

22. Visensia Software: Patient Physiological Risk Index Calls medical staff as needed when needed Takes into account vital signs correlations and trends HR RR BP SpO2 Temp

23. Clinical Results Clinical Results 95 % of Visensia alerts are true alerts Mean advanced detection time: 6.33 hours 58% reduction patients become seriously unstable 60% reduction in the crisis duration critically unstable In the 24 months to date no patient on the Visensia monitor had an unexpected fatal cardiac event

24. Vital Sign Monitoring Can Reduce Risk and Cost Deterioration can be identified early False alerts can be suppressed Hospital workflow and communication can be improved Nurse staffing can be optimized Difficult to track and communicate multiple changing variables Constant reaction to clinical crisis 86% false alarms Risk Index

25. Technology solutions developed specifically for Obstetrics: Clinical decision support and risk management tools designed to improve outcomes and patient care Include a robust suite of OB performance measurements and reports Designed to help address the common findings in med/mal claims: Communication errors Inadequate documentation of actions Improper actions – Both omission and commission Actions inconsistent with established protocols / workflow Employ physicians, midwives, and OB nurses; serving clients in the U.S. and Canada Risk Reduction in Obstetrics

26. Fetal Monitoring Program with Clinical Decision Support Real-time FHR tracings analysis; using powerful automated pattern recognition software following NICHD definitions Providing continuous feedback on contraction frequency; alerts when excessive contraction rates occur and persist

27. OB-Specific EMR with Clinical Decision Support Real-time, advanced clinical decision support Multi-disciplinary, highly structured documentation system Evidence-based practice protocols for care providers EMR w/Clinical Decision Support

28. Documented Reduction in Med/Mal Costs Multi-Hospital System

29. Shoulder Dystocia Risk Reduction Program Used in Physician Offices / Hospital Clinics / Hospital Triage Personalized Estimate of Risk of Shoulder Dystocia w/Injury Identifies 4 to 5 times More than Current Methods Clinician Protections: – Documented Risk Assessment Results – Patient Decision Participation – Informed Consent Documentation

30. Decreased Rates of Shoulder Dystocia with Risk Reduction Technology Prospective Hospital Study (2010) Shoulder Dystocia incidence decreased 50% Primary Cesarean rate remained stable YEAR 1YEAR 2YEAR 3 (YTD) P Value for Trend A LL B IRTHS 272123721414 T OTAL CS % 37.2%39.3%39.5%0.095 P RIMARY CS % 21.0%22.5%18.7%0.224 R EPEAT CS % 16.2%16.8%20.8%<0.001 % OF SD IN ALL B IRTHS 1.8%1.7%0.9%0.056 % OF B IRTHS T ESTED 7.9%17.2%17.5%

31. Target Market for Technology Solutions And, Potential Decision-Makers

32. QUESTIONS?

33. RISK MITIGATION THROUGH TECHNOLOGY Moderator: Kimberly M. Willis, CPCU, ARM, Senior Vice President, Healthcare Practice, Endurance U.S. Healthcare Panelists: Jordan Dolin, Founder & Vice Chairman, EMMI Solutions Jacques Feldmar, PhD, Chief Executive Officer, OBS Medical Kathryn Eblen Townsend, RN, JD, ARM, CPHRM, Director, Client Insurance Program, PeriGen Larry L. Smith, JD, Vice President Risk Management, MedStar Health