1. The Role of Process Improvement, and Information Technology in Achieving our Nation’s 21 st Century Healthcare Goals C. Martin Harris, M.D. Chief Information Officer, Cleveland Clinic Executive Director, eCleveland Clinic

2. Quality Care Coordination / Prevention Cost Focusing on Healthcare’s 21 st Century Challenges

3. Quality Care Coordination / Prevention Cost Focusing on Healthcare’s 21 st Century Challenges

4. Value Equation Value = Quality Cost

5. % 10 8 6 4 2 0 PrimaryReoperation STS 1.0% CABG Mortality National Benchmark Data

7. Quality of Diabetes Care: Patients Treated by Physicians using EHR vs. Paper Medical Records Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa1102519#t=article * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<0.001 % of Patients Receiving Care A significantly higher proportion of patients being treated by physicians with EHRs received care that aligns with accepted treatment standards* Composite: All Four Recommended Care Processes Measurement of Glycated Hemoglobin Kidney Management Pneumococcal Vaccination Eye Examination 51% 7% 95% 93% 83% 15% 63% 31% 86% 78% EHR PracticesPaper-Based Practices

8. Health Outcomes for Diabetes Patients: Patients Treated by Physicians using EHR vs. Paper Medical Records Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa1102519#t=article * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<0.005 % of Patients Receiving Care A significantly higher proportion of patients being treated by physicians with EHRs obtained better outcomes* LDL Cholesterol < 100mg/dl or Use of Statin Drug Non- Smoker Glycated Hemoglobin <8% BP <140/80mm Hg 44% 16% 87% 82% 71% 48% 56% 39% 66% 52% Composite: At Least Four of Five Outcomes Standards 33% 34% BMI <30 EHR PracticesPaper-Based Practices

9. My Practice : Electronic Medical Record System My Practice : Electronic Medical Record System Dr. Connect : Improved Communication; Improved Care My Practice: ● Community eHealth Services Virtual Visit : Patient/Physician Interaction Globally My Consult : Your First Choice for a Second Opinion My Chart : Your Personal Health Connection My Monitoring : Ongoing Condition Reporting from Home Providers Patients My Practice ● Hospital

10. Cleveland Clinic H H Fairview Hospital Lakewood Hospital H H Lutheran Hospital H H Ashtabula County Medical Center H H Euclid Hospital H H Hillcrest Hospital H H South Pointe Hospital H H Marymount Hospital H H Cleveland Clinic Florida H H Medina Hospital H H Lorain Family Health And Surgery Center FHC Elyria Family Health Center Westlake Family Health Center FHC Lakewood Family Health Center FHC Strongsville Family Health and Surgery Center FHC Brunswick Family Health Center FHC Wooster Family Health Center FHC Independence Family Health Center FHC Solon Family Health Center FHC Chagrin Falls Family Health Center FHC Beachwood Family Health and Surgery Center FHC Willoughby Hills Family Health Center FHC R.E. Jacobs Health Center Lou Ruvo Center for Brain Health Las Vegas, Nevada FHC Cleveland Clinic Toronto FHC S.T.J. Health Center HC Twinsburg Family Health Center FHC

11. My Practice Electronic Medical Record Patients Front Desk Nurses Physicians Schedulers Residents Researchers

12. Physicians:7,043 Residents / Fellows:2,553 Pharmacists: 393 Other End Users:38,776 Patients in the EMR:6,351,317 Encounters:35,591,311 Prescriptions: 70,720,222 Orders:218,125,905 Total Results:703,501,604 Cleveland Clinic User and Encounter Statistics Through September, 2011 My Practice Electronic Medical Record

13. Ambulatory Functionality Messaging Schedule Results Documentation Physician Order Entry Best Practice Alerts My Practice Electronic Medical Record

14. Inpatient Functionality My Practice Electronic Medical Record Inpatient Census All Results Medication Administration Record Vital Signs and I&O Documentation Computerized Physician Order Entry (CPOE)

15. My Practice : Electronic Medical Record System e Research : Research Standardization: Real Data; Real Results Dr. Connect : Improved Communication; Improved Care My Practice ● Community eHealth Services Virtual Visit : Patient/Physician Interaction Globally My Consult : Your First Choice for a Second Opinion My Chart : Your Personal Health Connection My Monitoring : Ongoing Condition Reporting from Home Providers Patients My Chart : Your Personal Health Connection

16. My Chart Patient Services View medical information View health reminders View schedule Prescription renewal request Online appointment scheduling

17. iPhone App: Test Results Messages Appointments Future / Past Preventive Care Health Summary- Meds, Allergies, Problems, Immunizations My Chart 22 33

18. Cleveland Clinic H H Fairview Hospital Lakewood Hospital H H Lutheran Hospital H H Ashtabula County Medical Center H H Euclid Hospital H H Hillcrest Hospital H H South Pointe Hospital H H Marymount Hospital H H Cleveland Clinic Florida H H Medina Hospital H H Lorain Family Health And Surgery Center FHC Elyria Family Health Center Westlake Family Health Center FHC Lakewood Family Health Center FHC Strongsville Family Health and Surgery Center FHC Brunswick Family Health Center FHC Wooster Family Health Center FHC Independence Family Health Center FHC Solon Family Health Center FHC Chagrin Falls Family Health Center FHC Beachwood Family Health and Surgery Center FHC Willoughby Hills Family Health Center FHC R.E. Jacobs Health Center Lou Ruvo Center for Brain Health Las Vegas, Nevada FHC Cleveland Clinic Toronto FHC S.T.J. Health Center HC Twinsburg Family Health Center FHC................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. My Chart Patients: 371,903

19. Near Real-Time Management Information Challenges: Beyond Technology

20. Supply CategorySurgeon 1Surgeon 2Surgeon 3Surgeon 4Surgeon 5 Implants$3,818$3,048$3,844$4,065$4,002 OR Time364377432360357 Misc. Supplies258225948158200 Blades & Knives791237995138 Sutures2127292127 Others580740647602650 Total$5,120$4,540$5,979$5,301$5,374 Within the surgical services resource area, surgical supplies are categorized into several functional categories Challenges: Beyond Technology Near Real-Time Management Information

21. Blade Type Surgeon 1Surgeon 2Surgeon 3Surgeon 4Surgeon 5 BLADE,STRYKER 277-96-250 RECIPROCATING 1.85 BLADE,STRYKER 277-96-275 RECIPROCATING 1.859.42 BLADE,STRYKER 277-96-300 RECIPROCATING 9.8012.025.16 BLADE, STRYKER 2108-156 34.5339.0237.1133.78 BLADE, STRYKER, 2108-182 0.9946.77 BLADE,5627-10-500, DEPUY 45.947.89 BLADE,5627-11-500, PFC SIGMA 61.5913.81 SAWBLADE, STABLECUT, 506076 9.88 BLADE SAGITTAL, 2108107004 0.50 BLADE,STRYKER,2108-189 34.0539.6137.1130.13 Total 78.88123.2578.6394.51137.53 Average cost per Encounter Cost variation for one type of blade reflects frequency of use Challenges: Beyond Technology

22. Near Real-Time Management Information Context-Based Training Challenges: Beyond Technology

24. Near Real-Time Management Information Context-Based Training Shared Goals and Incentives Challenges: Beyond Technology

25. Cleveland Clinic Community Physician Partnership, Medical Mutual Explore Innovative Relationship to Enhance Coordination and Quality of Care First of its kind in Ohio, program will reward superior quality and efficient care, promote move toward performance-based payment 11/9/10 Cleveland Clinic Community Physician Partnership (CPP) and Medical Mutual of Ohio have signed an agreement to form an innovative relationship to enhance coordination and quality of care across northeast Ohio. “This proposed affiliation with the Cleveland Clinic Community Physician Partnership will enhance provider collaboration and build a delivery model that puts the patient at the center of the care continuum,” said Delos M. Cosgrove, MD, CEO and President of Cleveland Clinic. “This type of coordination encourages communication between patient, provider and insurer with the goal of ultimately improving outcomes and building accountability for a higher level of care for our patients.”

26. Quality Care Coordination / Prevention Cost Focusing on Healthcare’s 21 st Century Challenges

27. Quality Care Coordination / Prevention Cost Focusing on Healthcare’s 21 st Century Challenges

28. Nearly Half of Americans Have One or More Chronic Diseases Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000 45% 133 Million Americans

29. Centers for Disease Control and Prevention. Chronic Disease Overview page. http://www.cdc.gov/nccdphp/overview.htm. April 6, 2007 U.S. Patients with One or More Chronic Conditions Account for Three in Four Healthcare Dollars Spent Chronic Disease Healthcare Costs = ~$1.58 trillion U.S. Healthcare Spending (2006) = $2.1 trillion 25% 75%

30. Online Care Coordination and Diabetic Management Cost (Financial and Human) Time Diabetics, particularly those with multiple co- conditions, spend 2.3 times more on healthcare than non-diabetics Preventive Activities Patient Responsibility (Episodic Physician Supervision) Problem-Related Hypertension / Heart Interventions Reduced Health Maintenance Compliance Vision / Coronary Complications (Increase Likelihood) Hospitalizations Patient-Driven Scheduling

31. My Practice : Electronic Medical Record System Dr. Connect : Improved Communication; Improved Care My Practice: ● Community eHealth Services Virtual Visit : Patient/Physician Interaction Globally My Consult : Your First Choice for a Second Opinion My Chart : Your Personal Health Connection My Monitoring : Ongoing Condition Reporting from Home Providers Patients My Practice ● Hospital My Monitoring : Ongoing Condition Reporting from Home

32. My Monitoring

34. Health Information Exchange Public / Private

35. My Practice: Physician Results View Patient Flowsheet Data

36. My Monitoring My Chart Health Information Exchange Public / Private

37. Dear Patient, You are managing your blood sugars well. Keep up the good work. Continue watching what you eat and doing your moderate, daily exercise. Please schedule your next office appointment for 120 days from now. Message me if you have additional questions.

38. Cost Reduction Medicare spending per patient UCLA MedicalJohns Hopkins MassachusettsCleveland Clinic Mayo Clinic during last two years of life Center Hospital General Hospital Foundation (St. Mary’s Hospital) Total Medicare spending $93,842 $85,729 $78,666 $55,333 $53,432 Inpatient site of care $63,900 $63,079 $43,058 $34,437 $34,372 Outpatient site of care $14,125 $13,404 $11,509 $8,906 $7,557 Skilled nursing/long-term care facility $6,891 $3,287 $15,149 $5,101 $7,114 Other sectors of care $8,926 $5,959 $8,951 $6,889 $4,389 Executive Summary, April 2008

39. Service Line Cost Management Cost Management Initiative Standardize materials and services to improve consistency (predictable outcomes) and reduce unnecessary costs Sustainable Way of Working 1. 1. Create a standard approach to Service Line Cost Management - - Definitions - - Roles and Responsibilities - - Data Analysis & Interpretation - - Improvement Implementation 2. 2. Educate & develop the ongoing organizational capability within Cleveland Clinic Health System - sustain an environment that continually scrutinizes costs Cost Reduction

40. Driven by multi-disciplinary team -Liver Transplant Surgeons -Infectious Disease -OR Nurse Managers -Transplant Coordinators -Pharmacy -Continuous Improvement -Supply Chain -Finance Analyze cost across continuum of care -Reviewed costs from all resource areas Focus on factors the team can control -The Institute has identified opportunities to reduce costs in the OR Cost Reduction Liver Transplant Cost Management Team

41. Excluding acquisition costs, direct cost per encounter decreased from $47,834 to $43,588 Cost Reduction:$4,245 9% Cost Reduction

42. Technical Direct Cost per Encounter YTD June 2010 & YTD June 2011 (Adjusted for LOS outliers) Cost Reduction Knee Replacement (DRG 470) Cost Reduction:$507 6%

43. Online Care Coordination and Diabetic Management Cost (Financial and Human) Time $ Online Scheduling Online Care Coordination Online, Physician-Supervised GlucoseTracking Patient-Driven Scheduling Preventive Activities Patient Responsibility (Episodic Physician Supervision) Problem-Related Hypertension / Heart Interventions Reduced Health Maintenance Compliance Vision / Coronary Complications (Increase Likelihood) Hospitalizations Diabetics, particularly those with multiple co- conditions, spend 2.3 times more on healthcare than non-diabetics Health Maintenance Compliance Ongoing Education

44. Quality Care Coordination / Prevention Cost Focusing on Healthcare’s 21 st Century Challenges

45. Quality Care Coordination / Prevention Cost Focusing on Healthcare’s 21 st Century Challenges

46. My Practice : Electronic Medical Record System Dr. Connect : Improved Communication; Improved Care My Practice ● Community eHealth Services Virtual Visit : Patient/Physician Interaction Globally My Consult : Your First Choice for a Second Opinion My Chart : Your Personal Health Connection My Monitoring : Ongoing Condition Reporting from Home Providers Patients Public / Private Sector Connectivity My Practice ● Hospital

47. Cleveland Clinic Pilots Microsoft HealthVault CLEVELAND, Nov. 10, 2008 / PRNewswire via COMTEX / — Cleveland Clinic, a World-class academic medical institution and leader in health information technology, today announced collaboration with Microsoft Corp., a worldwide leader in software, to pilot the patient-controlled data exchange between Microsoft ® HealthVault TM, a Web-based personal health platform; a suite of widely-used digital medical devices; and e Cleveland Clinic My Chart ®, Cleveland Clinic’s electronic personal health record (PHR) system. Today, more than 150,000 Cleveland Clinic patients use eCleveland Clinic My Chart ®. The short-term pilot, begun on Monday, Nov. 3, is the first pilot in the country to follow multiple diseases in the clinical delivery setting using multiple at-home devices such as glucometers, heart rate monitors, weight scales and blood pressure monitors.

48. True Value of Health Data Exchange to Cleveland Clinic Patients All data available to Cleveland Clinic treating physicians Patient transfers data from all physicians, hospitals, retail pharmacies, commercial laboratories and digital devices. PhysiciansHospitals Com. Laboratories Retail Pharmacies Home Devices Patient transfers data to Cleveland Clinic My Practice My Practice Electronic Medical Record System NHIN State HIE

49. In three days Mr. Jones receives his second opinion verifying that he needs surgery, but Cleveland Clinic specialist recommends valve repair instead of replacement. Mr. Jones fills out online medical questionnaires and sends required scans and test results to Cleveland Clinic. After being diagnosed with a heart condition requiring surgery by his doctor at home in Arizona, Mr. Jones goes online to request a My Consult remote second opinion from a cardiology specialist at The Cleveland Clinic

50. Because Cleveland Clinic is considered a national center of excellence for heart surgery, Mr. Jones schedules his surgery and flies to Cleveland. Before he leaves, he signs up for the Microsoft Health Vault personal health information management service, and imports all the information related to the care he has received in Arizona—this includes his laboratory tests, hospitalizations and medication history. Because Cleveland Clinic is considered a national center of excellence for heart surgery, Mr. Jones schedules his surgery and flies to Cleveland. Before he leaves, he signs up for the Microsoft Health Vault personal health information management service, and imports all the information related to the care he has received in Arizona—this includes his laboratory tests, hospitalizations and medication history. In three days Mr. Jones receives his second opinion verifying that he needs surgery, but Cleveland Clinic specialist recommends valve repair instead of replacement.

53. What Cleveland Clinic knows about Mr. Jones prior to his arrival. Mr. Jones chooses to share his health history with his Cleveland Clinic specialist and, by simply selecting “send to Cleveland Clinic,” ensures that everything his surgical care team needs to know about him is in his eCleveland Clinic My Practice electronic medical record before he ever leaves Arizona.

54. All of Mr. Jones’ care is documented in the eCleveland Clinic My Practice electronic medical record system. Mr. Jones travels to Cleveland Clinic, for mitral valve repair surgery, confident that his care team on both sides of the United States is virtually working together to deliver the best care possible.

55. All of Mr. Jones’ care is documented in the eCleveland Clinic My Practice electronic medical record system. Before he is discharged, Mr. Jones signs up for My Chart so that he can securely connect to his own personal health information and receive messages from his care team anywhere there is an Internet connection. Then he travels to Florida to spend a month with his sister while he recuperates. And because his physician at home signed up for Cleveland Clinic’s Dr Connect service, every aspect of Mr. Jones’ treatment progress is securely available to his primary care doctor.

56. Then he travels to Florida to spend a month with his sister while he recuperates. While he is in Florida, Mr. Jones uses Microsoft HealthVault to utilize Cleveland Clinic’s My Monitoring services. Through a secure Internet connection, he downloads daily information from his digital scale and blood pressure monitoring device into HealthVault, which then sends it to Cleveland Clinic’s electronic medical record system and My Chart so that he and his physicians can work together to keep him on the right track..

57. Now fully recovered, Mr. Jones returns home to Arizona where he receives his ongoing follow-up care from his own physician while staying connected to his Cleveland Clinic care team through My Chart, My Monitoring, and Dr Connect for his local physician. He also knows that all the other Cleveland Clinic eHealth services are still available to him should the need ever again arise.

58. My Chart Dr Connect My Consult Monitoring My Practice And because Microsoft HealthVault is interfaced with the Cleveland Clinic My Practice electronic medical record system, he can assemble and store a comprehensive history of all the treatment he received from any healthcare provider which will be available to him and the providers he chooses in the future.

59. My Chart Dr Connect My Consult Monitoring Virtual Visit My Practice Confident, Empowered Patient Security, Access and Control And because Google Health and Microsoft HealthVault are interfaced with the Cleveland Clinic My Practice electronic medical record system, he can assemble and store a comprehensive history of all the treatment he received from any healthcare provider which will be available to him and the providers he chooses in the future.

60. Online Care Coordination and Diabetic Management Cost (Financial and Human) Time $ Online Care Coordination Online Scheduling Online, Physician-Supervised GlucoseTracking Patient-Driven Scheduling Preventive Activities Patient Responsibility (Episodic Physician Supervision) Problem-Related Hypertension / Heart Interventions Reduced Health Maintenance Compliance Vision / Coronary Complications (Increase Likelihood) Hospitalizations Diabetics, particularly those with multiple co- conditions, spend 2.3 times more on healthcare than non-diabetics $ Health Maintenance Compliance Ongoing Education CoachingHealth Maintenance Ongoing Education

61. Value-Based U.S. Healthcare System Quality Care Coordination / Prevention Cost Focusing on Healthcare’s 21 st Century Challenges