1. www.healthtechcenter.org1 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

2. www.healthtechcenter.org2 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.”

3. www.healthtechcenter.org3 Aligning environmental forces Four Critical Forces: Information Technology Payment - Reimbursement incentives Clinical knowledge Professional Workforce

4. www.healthtechcenter.org4 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

5. www.healthtechcenter.org5 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

6. www.healthtechcenter.org6 The IOM Report: Information technology improves quality Safety Computerized physician order-entry reduced adverse drug events by 55% (Bates, 1998) EffectivenessReminder systems and computer assisted diagnosis and management improves compliance with practice guidelines (Durieux, 2000; Evans, 1998) Patient-CenteredInternet can provide access to clinical knowledge, online support groups,customized health education and disease management messages

7. www.healthtechcenter.org7 The IOM Report: Information technology improves quality Timelinessmothers receiving computer-generated reminders had 25% higher on-time immunization rate for their infants (Alemi, 1996) Efficiency9% of redundant lab tests at a hospital could be eliminated using a computerized system (Bates, 1998) EquityInternet-based health communication can improve access and provide a broader array of options for interacting with clinicians

8. www.healthtechcenter.org8 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

9. www.healthtechcenter.org9 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

10. www.healthtechcenter.org10 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

11. www.healthtechcenter.org11 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

12. www.healthtechcenter.org12 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

13. www.healthtechcenter.org13 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?

14. www.healthtechcenter.org14 Which tools, which technologies? Information Technology –ICU in a gurney Devices –Hepatic dialysis –Polymers Pharmaceuticals –Inhaled insulin Biotechnology

15. www.healthtechcenter.org15 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

16. www.healthtechcenter.org16 Strategies for intentional change in 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)

17. www.healthtechcenter.org17 Intentional, disruptive change - which tools for chronic disease? Sam steps onto scale. “Good Morning, Sam.” Scale reports weight, sends over web, reports progress & gives tailored Yes/No survey. Takes ~20 seconds Sam’s nurse reviews symptoms, provides assistance or notifies Sam’s MD. MD receives alert reports, adjusts Rx, revises surveys or initiates a visit. Substantial savings in emergency visits and hospitalizations.

18. www.healthtechcenter.org18 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

19. www.healthtechcenter.org19 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 = the ringer cost diffusion IT Clinical technologies

20. www.healthtechcenter.org20 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

21. www.healthtechcenter.org21 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."

22. www.healthtechcenter.org22 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

23. www.healthtechcenter.org23 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

24. www.healthtechcenter.org24 HealthTech Reports 2001-2002 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

25. www.healthtechcenter.org25 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 changeLeapfrog, HCFA, health plan negotiations –remove barriers reimbursement incentives, technology investment –build the ‘escape hatch’ practical options: migration paths to quality –definitely unpredictablewho would have thought the VA would lead? –potentially explosivephysician reaction, lawsuits, legislation

26. www.healthtechcenter.org26 Strategy VII: Build migration pathways 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 year migration pathway 5 yrs10 yrs Quality healthcare: from vision to reality in a decade strategic objectives visionary goals tactical choices

27. www.healthtechcenter.org27 A new architecture for healthcare: Axis 1 = the IOM six aims for quality Safe 5 yrs10 yrs Effective 5 yrs10 yrs Patient-centered 5 yrs10 yrs Timely Efficient Equitable hand-held prescription lookup; phamacy screening CPOEambulatory prescriptions electronic entry clinical processes defined, patient registries built 15 chronic disease programs implemented ambulatory/in-home chronic disease monitoring

28. www.healthtechcenter.org28 A new architecture for healthcare: Axis 1 = the IOM six aims for quality Safe 5 yrs10 yrs Effective 5 yrs10 yrs Patient-centered 5 yrs10 yrs Timely Efficient Equitable hand-held prescription lookup; phamacy screening CPOEambulatory prescriptions electronic entry clinical processes defined, patient registries built 15 chronic disease programs implemented ambulatory/in-home chronic disease monitoring IT STRATEGY - investments - workforce - leadership

29. www.healthtechcenter.org29 A new architecture for healthcare: Axis 2 = clinical processes Pregnancy and Delivery 5 yrs10 yrs Cardiac Care 5 yrs10 yrs Diabetes 5 yrs10 yrs IOM 15 priority chronic conditions + 80-20 rule for your institutions, populations C/S rate, variation genetic testing genetic therapy cardiac registries established endovascular surgery certification achieved ambulatory and in-home monitoring; angiogenics XYpancreatic transplants, stem cell

30. www.healthtechcenter.org30 Noninvasive continuous glucose monitor FDA approved Two Sensor Applications: Technology Timeline 199920002001200220032004200520062007200820092010 Noninvasive continuous glucose monitor developed Noninvasive continuous glucose monitor becomes community standard Smart clothes FDA approved Smart clothes become “accepted therapeutic choice” Cygnus’ GlucoWatch Biographer Smart clothes developed Long-term implantable glucose monitor developed Long-term implantable glucose monitor FDA approved Long-term implantable glucose monitor becomes community standard Sensatex’s Smart Shirt ChipRx’s Schematic of a Self-Regulating Responsive Therapeutic System

31. www.healthtechcenter.org31 The Vision Advance the use of new technologies to make people healthier Strategic Partners Sutter HealthProvidence Health Kaiser PermanenteCarolinas Health Group Health of Puget SoundPeace Health VHA Inc.California Public Hospitals Ascension HealthInstitute for the Future Premier, Inc.Wellpoint Health Networks HCACareScience Markle FoundationHRET Mills-Peninsula Health SystemECRI Sequoia Healthcare DistrictParkview Health Milbank FoundationThe California Endowment

32. www.healthtechcenter.org32 Just give us the tools… The future is here. It's just not widely distributed yet.