Connected Care: Heightened ImperativesRegulatory changes, combined with powerful advances in cloud computing and advanced analytics, create a favorable environment for U.S. healthcare providers, payers and patients to stay connected, and enable anywhere/anytime care via mobile devices and social-media tools and techniques.

• Cognizant Reports

cognizant reports | July 2013

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Executive SummaryThe U.S. healthcare industry’s business landscape is set for drastic changes. Regulatory forces and the availability of new technologies are driving a fragmented landscape towards a connected, collaborative and coherent future focused on quality of care and outcomes. The upcoming era of connected care encourages groups of health-care organizations to collaborate and share patient data, knowledge and insights from day-to-day operations – seamlessly. These groups, known as Accountable Care Organizations (ACOs), repre-sent a move away from quantity to quality of care delivered over a defined period of time across the healthcare continuum. Simply stated, the goal of connected care is to provide the right care at the right place at the right time.

Providers will have to work closely with payers in order to make a connected care system work. The payment model encouraged by the U.S. Patient Protection Affordable Care Act (PPACA) will impact payers and providers alike – requiring them to work out optimal payment models. Key drivers for connected care – such as the value-based purchase (VBP) system that incentivize better outcomes, and meaningful use,1 which encourages the adoption of electronic health records (EHRs) – are prompting healthcare pro-viders to implement operational and process changes to improve accountability and derive maximum benefits. Among the key requirements for providing continuous, connected care is the ability to proactively identify and monitor at-risk populations. To achieve this, patient information must be accessible across care-giving teams and settings. Moreover, connected care requires patients to carry devices that track their health and send realtime data to hospitals. For this to work, the group of care providers need a technology plat-form that is interoperable, and can collate data from all care settings to support shared decision making by care team members and patients. Sev-eral healthcare systems in the U.S. are already taking the first steps toward connected care, and the results look promising.

Technology will play a crucial role in achieving the overall objective of connected care. Care provid-ers will need to securely connect their underly-ing medical systems with health IT systems to improve their chances of making the most of the system being put in place.

We believe the following are key imperatives for care providers in the connected care era:

• Integrate medical systems with longitudinal health records from all providers in all care settings.

• Actively engage patients in their health via timely education about their conditions and treatment options using traditional and online multimedia channels.

• Transform the work culture from an individual-driven to a team-driven model of care.

• Deploy mobile applications for tasks such as making appointments; utilize wearable devices for collecting and sharing data.

• Use big data analytics to understand behavior and improve patient compliance, as well as to ensure treatment effectiveness and efficacy.

• Create a presence on social media to engage with patients.

Drivers and Enablers of Connected Care The Patient Protection Affordable Care Act is a landmark legislation. Driven by objectives such as accountable care, the legislation is a force that mandates collaboration among care provid-ers. However, there are other important reasons that make connected care a necessity for the U.S. The country’s healthcare system has long been plagued by high costs and fragmentation – often resulting in poor medical outcomes and a lack of standardization in medical practices and decision making within and across heathcare systems.

Much of this pivots around IT and process integra-tion, or the lack of it, across teams and depart-ments. A typical Medicare beneficiary usually consults two physicians and five specialists a year, whereas chronically ill patients consult as many as thirteen physicians a year.2 The absence of interoperability among disparate healthcare systems restricts the sharing of patient medical records. Also, the lack of coordination among physicians often results in higher utilization of services and poor care outcomes. The responsi-bility for coordinating these visits and managing the patient often falls on family members, who may not be able to handle it effectively.

A rapidly aging population places a greater cost burden on healthcare providers. In the past decade, the over-65 U.S. population has increased 15%.3 Data shows that healthcare costs rise dramatically for Americans over 65 years as compared with

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The meaningful use standards for electronic health records, which will be adopted in three stages (see Figure 2, next page), are having a positive effect. According to the Office of the National Coordinator for Health IT, hospitals’ adoption of EHR technology to meet meaningful use objectives has resulted in marked improve-ments, with non-federal acute care hospitals recording 32% to 167% increases in their capabil-ity to meet these objectives.7

Beyond this, advances in telecommunication technologies such as smartphones and mobile medical devices – referred to as mHealth – enable remote monitoring of patients, and will also propel the execution of connected care. The use of mobile devices for health purposes has shown encouraging growth. A survey by Pew Internet found that 31% of cell phone owners and 52% of smartphone users have used their devices for col-lecting health-related information.8 For care pro-viders, social media accessed via smartphones, tablets or more conventional computers is a potential tool for encouraging patient engage-ment. This could be through social networks owned by the providers, such as Mayo Clinic’s Connect9 social network, or through other popu-lar sites, such as Facebook.

Cloud computing, combined with big data analytics, will be the backbone of a connected care platform. Effective cloud deployments will enable care providers to store data from various sources – including wireless remote monitoring devices and applications connected to the care system – as well as update and share medical records across venues and health populations. Insights gleaned from advanced

The Growing Burden of Chronic Disease

Figure 1

Source: The Impact of Chronic Disease on U.S. Health and Prosperity: A Collection of Statistics and Commentary, Partnership to Fight Chronic Disease, 2009.

29%

31%

39%

41%

53%

54%

62%

Stroke

Pulmonary conditions

Hypertension

Heart disease

Diabetes

Mental disorders

Cancers

Projected rise in cases of seven of the most common chronic diseases, 2003-2023

their counterparts in countries such as Spain and Sweden.4

The high incidence of chronic illnesses and their projected growth is another source of concern for care providers. Cases of cancer, diabetes and five other major chronic conditions are expected to increase by more than 50% by 20235 (see Figure 1). Containing these chronic diseases could help save billions of dollars in direct healthcare expenditures.

Hospitals are also bracing for a shortage of trained medical staff, especially nurses. The projected short-age is expected to be between 800,000 and one million by 2020.6 This will put additional pressure on hospitals already overcrowded with patients.

The solution to these problems lies in a para-digm shift in the way care is delivered. Care pro-viders are realizing that connected care, with its focus on continuous care, disease prevention and remote monitoring, offers the best way forward. Fortunately, the underly-ing technologies that will support connected care are evolving rapidly. These

include remote monitoring devices, mobile appli-cations, big data analytics and cloud comput-ing. The growing adoption of electronic medical records and the increase in health-related infor-mation exchanges also bode well for the future of connected care.

Care providers are realizing that connected care–with its focus on continuous care,

disease prevention and remote

monitoring–offers the best way

forward.

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munity care providers spread across settings, a connected care system will need to ensure that data related to patient outcomes is shared seamlessly and securely among all team mem-bers. Widespread adoption of EHRs by physicians and hospitals will also be crucial. The benefits of meaningful use – namely complete and accurate information, better access to information and patient empowerment – can only be realized if the adoption levels for EHRs increase significantly.

For example, although the cumulative use of elec-tronic health records has recorded a substantial increase over the past two years (see Figure 3, next page), the total number of health profes-sionals who attested to meaningful use under the Medicare program as of May 2012 was 62,226, which represents only 12.2% of the total eligible physicians in the U.S.10 In order to avoid penal-ties that come into effect in 2015, this number, as well as the resulting increase in meaningful use, will need to increase rapidly. The goals of each of the successive stages of meaningful use (see Figure 2) are progressively harder to achieve. Therefore, greater adoption of EHRs for clinical decision making is crucial for the overall effec-tiveness of the meaningful use program.

analytics will drive better decision making for individual patients, as well as patient populations. Importantly, cloud storage can bridge the data gap among physicians at different locations, which will ultimately create a virtuous loop of secure data flow that can drive more informed decision making and result in better outcomes for patients.

Connected Care for Providers Connected care focuses on providing appropriate care intervention at the right time, in the right setting, and with the right providers.

To derive the most from value-based purchas-ing, or VBP, care providers must shift their focus from sick care to well care (i.e., early intervention to avoid hospital admissions and readmissions). Since incentives are structured to discourage cost-ly, inappropriate care, hospitals will need to work on prevention, which includes educating patients on self-care, constant monitoring, and keeping track of population health statistics to understand patterns and devise appropriate strategies.

Given that care providers will share account-ability for outcomes, and with multi-disciplinary care teams involving physicians, faculty and com-

The Evolution of Meaningful Use

To achieve meaningful use, eligible providers and hospitals must adopt certified EHR technology and use it to achieve specific objectives. Getting there involves the following three stages:

Stage 1 2011-2012

Data capture and sharing

Stage 2 2014

Advance clinical processes

Stage 3 2016

Improve outcomes

Stage 1: Meaningful use criteria focus on:

Stage 2: Meaningful use criteria focus on:

Stage 3: Meaningful use criteria focus on:

Electronically capturing health information in a standardized format.

More rigorous health information exchange (HIE).

Improving quality, safety and efficiency, leading to improved health outcomes.

Using that information to track key clinical conditions.

Increased requirements for e-prescribing and incorporating lab results.

Decision support for national high-priority conditions.

Communicating that information for care coordination processes.

Electronic transmission of patient care summaries across multiple settings.

Patient access to self-management tools.

Initiating the reporting of clinical quality measures and public health information.

More patient-controlled data. Access to comprehensive patient data through patient-centered HIE.

Using information to engage patients and their families in their care.

Improving population health.

Source: HealthIT.govFigure 2

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dollars spent, but also in the quality of care deliv-ered. Several care systems have developed their own versions of ACOs, and are taking first steps toward a connected care future. These ACOs, such as the Arizona Connected Care, Accountable Care Alliance and NewHealth Collaborative, are trying out payment models, taking into consideration the upside (cost savings) and downside risks (penal-ties for missing payment targets). They are also con-tracting private and public payers under various risk arrangements.

Although these are early days, the benefits of coor-dinated care are already evident. A survey of seven ACOs by the Commonwealth Fund11 found cost benefits derived by reducing hospitalization, lowering the costs of care and lessening emer-gency room use.

With greater technological integration between health IT and mHealth, plus advanced analytics and data storage technologies such as cloud com-puting, the benefits of a coordinated care system will be wide-ranging. mHealth alone, for example, will create cost savings for U.S. care providers by allowing doctors to reach patients beyond hospital premises – reducing the burden on hos-pital staff, and empowering patients regarding self-care. According to Juniper Research, the global cost savings from mHealth will be between

Meaningful Use of Electronic Health Records

Figure 3

Cumulative attestations of meaningful use of electronic health records by primary care physicians and specialists increased substantially during the period from April 2011 through May 2012.

Source: Early Results of the Meaningful Use Program for Electronic Health Records, The New England Journal of Medicine, February 2013.

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Under the bundled payment model introduced by the PPACA, a single payment will be made to the participating group of institutions for a defined episode of care. For such a payment model to work, information about the service provided (including associated costs) by each institution/physician at different stages of care will have to be made available. Under a value-based care model, accountable care organizations (ACOs) will be encouraged to devise strategies and agree upon performance benchmarks with all the play-ers, especially payers (see sidebar next page). The new model encourages hospitals to improve their remote monitoring efforts so that they can more optimally time patient admissions. Hospitals will also need to work out ways to integrate disparate sources of data – ranging from clinical and finan-cial data to standard costing – in order to derive insights that can drive improvements in processes and care. This requires a robust, secure, clinically integrated and interoperable IT infrastructure.

Even as care providers put in place the tech-nologies to enable connected care, they need to understand that the center of the connected care universe will be the patient. Decisions made at each stage of the patient’s journey will need to consider their needs and preferences.

System-wide Benefits of Connected CareWith its ability to improve coordination within the currently fragmented care system, connected care is perhaps an inevitable next step. The costs of uncoordinated care are too high – not just in

Sharing data freely is at the heart of a connected care implementation – and this is where the challenges begin.

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reside primarily in silos – making it hard to com-municate across disparate systems. At the same time, HIE interoperability is a key requirement of future payment systems. It is therefore critical that healthcare players agree on standards, and work to make their IT systems and processes compliant with these standards.

Standardization is also criti-cal for measuring and mon-itoring the quality of care provided under the value-based purchasing system. While ACOs continue to develop metrics to measure performance, they experi-ence a considerable time lag in accessing reports on cost savings and qual-ity improvement.14 This makes it crucial for care providers to ensure the quality and reliability of the data collected, as this will have a direct bear-ing on the quality of metrics created based on the data.

Apart from these broad technological challenges, caregivers will face significant challenges at the organizational level. The most prominent will be generating physician and staff buy-in to coordinate with other care providers. Physicians, who are used to making care decisions based on personal evaluation and judgment, may find it

HIE interoperability is a key requirement of future payment systems. It is therefore critical that healthcare players agree on standards, and work to make their IT systems and processes compliant with these standards.

US$1.96 billion and US$5.83 billion by 2014,12 with U.S. and Canada among the top beneficiaries.

Widespread connected care will also see the cre-ation of a feedback loop among various stake-holders in the care cycle, including physicians, patients and payers. Such a virtuous cycle can be leveraged for better decision making at a broader level. Advanced analysis of cross-sectional data can support effective management of chronic diseases, public health monitoring and quality of life. The types of emerging analytics approaches include predictive, prescriptive and comparative analytics.13 Sharing of data on outcomes among care professionals and researchers creates the opportunity to reduce medical errors.

Challenges Facing Connected Care A connected care environment requires disparate and mutually exclusive sets of players to work together. These include care providers, payers, network operators, mobile and medical device manufacturers, and health information exchanges (HIEs). Given the current state of fragmentation in the U.S. healthcare system, creating such an environment requires overcoming wide-ranging cultural and technological obstacles.

Sharing data freely is at the heart of a connected care implementation – and this is where the chal-lenges begin. Sharing electronic health records across care settings is now considered a neces-sity by most industry players. However, due to a lack of open standards, this is difficult to imple-ment. Currently, healthcare data and processes

Quick Take

Payer Interoperability

Payers will have a key role to play in a connected care setup as well as the process of healthcare reform. At the heart of this partnership will be the sharing of data between payers and providers (i.e., payer interoperability).

Lately, payers have taken active interest in HIEs as seen in Aetna's acquisition of HIE provider Medcity. This means that going forward payers will be able to access data related to clinical outcomes, risk and population management. This in turn will enhance their ability to utilize providers' services and track the appropriate metrics for reimbursements such as reduced readmission rates.

For a connected care system to work, payers and providers should be able to agree upon clinical and cost goals and share resources. It is, therefore, important that ACOs approach payers early on and develop reasonable performance benchmarks. This will also enable ACOs to get the best out of the VBP system and also meet meaningful use goals.

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difficult to consider input derived from analysis of large chunks of data or the opinions of their counterparts in other hospitals/clinics. A survey of 13,500 physicians by Merritt Hawkins on behalf of the Physicians Foundation found that 62% of physicians believed the ACO model of care is unlikely to increase the quality of care or decrease cost.15 Given these perceptions, top management will play a key role in clinical and cultural change man-agement. Clinical change management revolves around realigning existing processes to coordi-nate with a larger group of physicians across care settings. Fine-tuning these processes will involve creating clear channels of communication and sharing clinical data among settings. Challenges will also arise on the data-sharing front as various stakeholders, including device manufacturers, network operators, insurance companies and patients, will want a say in who owns the data. Solving this issue upfront will be critical for a coordinated care deployment to be successful.

Transforming Care A patient-centered connected care model will require hospitals to bring about drastic changes in their operating models. From increas-ing the adoption of EHRs, to improving the shar-ing of related data, to encouraging physicians and patients to base their care decisions on the insights derived from that data requires top leadership to drive organization-wide cultural changes, especially toward fact-based decision making. As caregivers move to provide more care remotely, they will need to improve their levels of engagement with the patient community by deploying technologies that enable this to hap-pen. We believe the following points should be the top priorities for care providers as they prepare for a connected care future:

• All about patient data: When it comes to sharing data, hospitals need to design their medical records so that users are not over-whelmed by the sheer volume of information. Patient records shared with physicians should have role-based permissions to ensure the right information is presented to them and that the patient data is appropriately protected. Moreover, the terminology used in

these records should be standardized across the board to ensure there are no discrepancies. Hospitals should also implement tools that will allow collection of patient data and transmit the data necessary to calculate population health metrics.

• Embracing analytics and big data: New-age data analytics offer powerful tools for making sense of the deluge of data that hospitals deal with today. In a connected care environment, these tools will help hospitals aggregate clini-cal, administrative, socio-economic and patient-generated data — improv-ing their understanding of processes and care outcomes. Hospitals can combine this knowledge with principles of behav-ioral economics to gain insights into patient com-pliance, risk stratification and the design of appro-priate interventions.

• Automation and inte-gration: Care providers in an ACO set up will need to integrate their existing health informatics with medical pro-cesses. Automation of care processes needs to be accompanied by the integration of these processes, which are currently uncoordinated and exist in silos of data. This will be crucial for deploying a connected care strategy that produces insights generated on a daily basis. These insights can be used to improve out-comes at all the connected care settings.

• Patient education: Health systems need to adopt a fresh approach to patient education. This will include providing various tools that will help proactive patients and/or their family members gather the health information they need. These tools include Web sites and mobile apps that provide treatment options and educational materials. This will ensure engagement at the very beginning of the care cycle. As the patient moves through the care continuum, tools such as mobile apps for scheduling physician appointments should be made available.

Patient records shared with physicians should have role-based permissions to ensure the right information is presented to them and that the patient data is appropriately protected.

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• Feedback loops: Virtuous loops of informa-tion flowing among hospital-based physicians, nurses, ambulance services and patients can significantly empower care providers by allow-ing them to provide just-in-time interventions. A feedback loop for a chronic condition such as heart disease could consist of daily weight information that triggers just-in-time interven-tion over the phone, reducing hospitalization and improving patient self-care – ultimately resulting in cost reductions for the health system.

• Going mobile: Mobile phones and mobile health devices are crucial for remote monitoring and self-care. Therefore, it is critical for a health system to have a mobile strategy in place that addresses these requirements. mHealth, though it is in the nascent stages, holds tre-mendous promise for improving patient care and reducing costs. Care systems should pro-actively integrate this into their strategy.16

• Getting social: In a connected care future, social media will act as a key component in engaging patients and the community in general. Rich content is the key to a strong social media pres-ence. There are plenty of examples of hospitals

using social media to not only connect with patients, but also under-stand what kind of infor-mation the patient com-munity seeks. On Mayo Clinic’s Connect social network, for example, patients connect and share their experiences, physicians and research-ers share stories about their research, and spe-cialists discuss patient care, innovations and new treatments.

Competing in the post-reform era will require pro-viders to effectively reduce the total cost of care while improving quality and patient/member satisfaction. Technologies such as mobile, big data analytics and cloud computing will play a key role in patient-centered, connected care and will help providers reduce costs and improve patient engagement, as well as elevate quality and outcomes.

A feedback loop for a chronic condition such as heart disease could consist of daily weight information that triggers just-in-time intervention over the phone, reducing hospitalization and improving patient self-care – ultimately resulting in cost reductions for the health system.

Footnotes1 Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS)

Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria.

2 “The Fragmentation of U.S. Health Care – Causes and Solutions.” Oxford Press.

3 “65-and-Older Population Soars.” USNews.com, January, 2012.

4 2012 - The Year In Healthcare Charts, Forbes.com, December 30, 2012.

5 “The Impact of Chronic Disease on U.S. Health and Prosperity: A Collection of Statistics and Commen-tary.” Partnership to Fight Chronic Disease, 2009.

6 “America’s Nursing Shortage by the Numbers.” soliant.com, September, 2009.

7 “Hospital Adoption of Electronic Health Record Technology to Meet Meaningful Use Objectives: 2008-2012.” The Office of the National Coordinator for Health IT, March, 2013.

8 “Mobile health has found its market: smartphone owners.” Pewinternet.org, November, 2012.

9 http://connect.mayoclinic.org/.

About Cognizant

Cognizant (NASDAQ: CTSH) is a leading provider of information technology, consulting, and business process outsourcing services, dedicated to helping the world’s leading companies build stronger businesses. Headquartered in Teaneck, New Jersey (U.S.), Cognizant combines a passion for client satisfaction, technology innovation, deep industry and business process expertise, and a global, collaborative workforce that embodies the future of work. With over 50 delivery centers worldwide and approximately 162,700 employees as of March 31, 2013, Cognizant is a member of the NASDAQ-100, the S&P 500, the Forbes Global 2000, and the Fortune 500, and is ranked among the top performing and fastest growing companies in the world.

Visit us online at www.cognizant.com for more information.

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10 “Early Results of the Meaningful Use Program for Electronic Health Records.” The New England Journal of Medicine, February, 2013.

11 “Early Adopters of the Accountable Care Model - A Field Report On Improvements In Health Care Delivery.” The Commonwealth Fund. March, 2013.

12 Juniper Research: “Mobile health monitoring services to save healthcare providers between $1.9 and $5.8 billion globally by 2014.” May, 2010.

13 “Four types of data analytics that providers are using to improve population health.” Mecitynews.com, March, 2013.

14 “Early Adopters of The Accountable Care Model - A Field Report on Improvements In Health Care Delivery.” The Commonwealth Fund, March, 2013.

15 “A Survey of America’s Physicians: Practice Patterns and Perspectives.” The Physicians Foundation. September, 2012.

16 “20 Hospitals with Inspiring Social Media Strategies.” medicalbillingandcoding.org, January, 2012.

Credits

Author and AnalystAkhil Tandulwadikar, Senior Research Associate, Cognizant Research Centerr

Subject Matter ExpertsSashi Padarthy, Practice Leader, Cognizant Business Consulting’s Healthcare Provider Practice

DesignHarleen Bhatia, Design Team LeadMeenakshi Sundaram Thambusamy, Designer