Title: Exploring the Business Case for Quality How Medical Care Can Evolve to Meet Patient Needs
1Exploring 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
2The need for transformationIOM Report - The
chassis is broken
- You cant 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.
3Aligning environmental forces
- Four Critical Forces
- Information Technology
- Payment - Reimbursement incentives
- Clinical knowledge
- Professional Workforce
4What didnt 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
5CQI 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
6The 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
7The 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
8The 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
9IOM 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
10IOM 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
11IOM 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
12IOM 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
13Churchill 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?
14Which tools, which technologies?
- Information Technology
- ICU in a gurney
- Devices
- Hepatic dialysis
- Polymers
- Pharmaceuticals
- Inhaled insulin
- Biotechnology
15Technology 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
16Strategies 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)
17Intentional, 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.
Sams nurse reviews symptoms, provides assistance
or notifies Sams MD.
Sam steps onto scale. Good Morning, Sam.
Scale reports weight, sends over web, reports
progress gives tailored Yes/No survey. Takes
20 seconds
18But 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
19Strategy 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
20Strategy 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
21Strategy 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."
22Strategy 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
23Strategy 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
24HealthTech 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
25Clocking 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
26Strategy VII Build migration pathways
Quality healthcare from vision to reality in a
decade
5 year migration pathway
5 yrs
10 yrs
- 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
27A 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
28A 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
29A 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
30Two Sensor Applications Technology Timeline
ChipRxs Schematic of a Self-Regulating
Responsive Therapeutic System
Sensatexs 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
31Advance 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 CareScie
nce Markle Foundation HRET Mills-Peninsula
Health System ECRI Sequoia Healthcare
District Parkview Health Milbank
Foundation The California Endowment
32Just give us the tools
The future is here. It's just not widely
distributed yet.