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

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Title: 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

2
The 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.

3
Aligning environmental forces
  • Four Critical Forces
  • Information Technology
  • Payment - Reimbursement incentives
  • Clinical knowledge
  • Professional Workforce

4
What 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

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

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

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

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

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

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

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

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

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?

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

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

16
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
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.
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
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

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
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

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."

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

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

24
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
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

26
Strategy 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

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
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
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
30
Two 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
31
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 CareScie
nce Markle Foundation HRET Mills-Peninsula
Health System ECRI Sequoia Healthcare
District Parkview Health Milbank
Foundation The California Endowment
32
Just give us the tools
The future is here. It's just not widely
distributed yet.
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