Collaborative Care:
An Economic Imperative for Care
Delivery Systems
Mark Blatt MDWorldwide Medical DirectorIntel Corporation February 2012
Collaborative Care: An Economic Imperative for Care Delivery SystemsAgenda
Current Trends
The Evidence for Care Coordination
Going mobile to Coordinate care• Right Device for Right task• Collaborative workflows• Compute Model matters• Secure Mobile computing
Summary
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The Current Environment
Is Solo Practice a failed Business model ?
Has Fee for Service meet its Limits?
• Mandatory penalties. State AGs sue in civil court– Starting at $100 per violation
($25k/yr) going up to $50,000 repeat violations w/ “willful Neglect” ($1.5M/ yr)
• Projected PHI is essentially ”encrypted PHI”
• Mandatory Reporting with 60 days and publication at HHS Breach site for violations >500
Hi-Tech Breach Notification
2. HiTech Act, Division A Title XII, Subtitle D Part 1 Sections 13401-11
http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/postedbreaches.html
Breach Notifications Week of June 1
Hospital Readmissions(We Don’t Do a Good Job Here)
Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days
34.0% were rehospitalized within 90 days50.2% of the patients who were rehospitalized within 30 days
after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization
Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition
About 10% of rehospitalizations were likely to have been plannedThe average stay of rehospitalized patients was 0.6 day longer than
that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously
Authors estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion
N Engl J Med 2009;360:1418-28.
Beginning October 1, 2012, DRG payments to hospitals who have “excess” readmissions for certain conditions will be reduced.
The floor adjustment factor will be 99% for fiscal year 2013, 98% for 2014, and 97% for fiscal year 2015 and thereafter.
First three conditions to track AMI, heart failure and pneumonia.
October 1, 2014, the list expandsCOPD (chronic obstructive pulmonary disease), CABG (coronary artery bypass graft),PTCA (percutaneous transluminal coronary angioplasty), and other vascular conditions.
Section 3025 – Hospital Readmissions
3. The Patient Protection and Affordable Care Act (HR 3590 enrolled: Sec 3025)
Coordination and Collaborative
Workflows
The Evidence
Controlling Costs Starts with Better Management of Chronic Diseases
• Medicare beneficiaries with multiple chronic illnesses see an average of 13 different physicians• Fill 50 different prescriptions a year• Account for 76% of all hospital admissions• Account for 88% of all prescriptions filled• Account for 72% of physician visits• And are 100 times more likely to have a preventable hospitalization
than someone with no chronic conditions
Testimony of Gerard F. Anderson, Ph.D., Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, before the Senate Special Committee on Aging, “The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007).
We must improve management of Chronic Diseases through
Better Care Coordination
How Physicians Currently Use Mobile Device(s)
11 QuantiaMD* Research Report, “Tablets Set to Change Medical Practice”, June 15, 2011. See www.quantiamd.com/q-qcp/QuantiaMD_Research_TabletsSetToChangeMedicalPractice.pdf
“Super-Mobile” Physicians drive higher utilization,demand tablet access to sensitive patient data
Patients Report Experiencing Poor Coordination
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
Percent U.S. adults reported in past two years:
No one contacted you about test results, or you had to call repeatedly to get results
Test results/medical records were not available at the time of appointment
Your primary care doctor did not receive a report back from a specialist
Any of the above
25
21
19
15
13
47
0 20 40 60
Doctors failed to provide important medical information to other doctors or nurses you think should have it
Your specialist did not receive basic medical information from your primary care doctor
37
7582
6168
62
76
0
25
50
75
100
AUS CAN GER NETH NZ UK US
Commonwealth Survey of PCPsHow does the US compare with other in communications
Percent reporting that they receive information back for “almost all” referrals (80% or more) to Other Doctors/Specialists:
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Evidence for Care Coordination
2007 prospective cohort study of 756 patients with “life-limiting illnesses ” in California• In the “patient-centered” group (358):
– 38% fewer admissions– 36% fewer inpatient days– 30% fewer ED visits
• 26% lower cost
Sweeney L, Halpert A, Waranoff J. Patient-Centered Management of Complex Patients Can Reduce Costs Without Shortening Life. Am J Manag Care. 2007;13:84-92.
ED Visits by Source of Care and Income
http://www.aafp.org/afp/2009/0115/p94.html
Evidence for Care Coordination
Geisinger Health System in Pennsylvania• 36 primary care practices with NCQA
Level 3
PCMH certification vs. control practices• Positive results:
– 40% reduction in 30-day readmissions– 20% reduction in (total) admissions– 7% lower costs
Arvantes, J. Geisinger Health System Reports That PCMH Model Improves Quality, Lowers Costs. AAFP
News Now. May 26, 2010.
New West Physicians (Denver, CO)
76 Providers (41 FP, 17 IM, 8 Hospitalist, 10 mid levels)Level 1 PCMH NCQA (pending) • Extended Hour and After hrs Access (24x7)• EMR is all offices connected to hospital, labs, path• EPrescribing and electronic prescription delivery • Quality improvement CDM programs
• $4.4M cumulative HIT investment ($11M incr. rev ‘07-’09)• Centralized coordinated Post discharge and follow up with 24 hrs
(including we deliver your meds)• Daily team meetings: 30 minute review of the day
RESULT: 1% 30 day readmit rate (usual 6-18%+)
American Hosp Association Jan 2011 ACO Case Study: New Physicians West
Collaborative Workflows
Example Use Cases
To Support Care Coordination for Better Outcomes, Mobilized Data is Critical
Gather & Store Data
Share the Data
Mobilize Data
EMPOWER citizens
End-To-End Story Care Coordination Across the Continuum
Mobile Data is Critical
Personal Health Record
Patient-Centric Care
Electronic Health Record
Data Repository
Clinical Decision Support HealthCheckup
Self Check& Control
Home
Emergency
RemoteDiagnostic
Clinic
Community Hospital
Academic Hospital ResearchPharmacy Long term
Care
Visiting Care
DataExchange
DataExchange
Right Form Factor/Capabilities for the JobS
IZE
FUNCTIONALITY
NotebooksUltrabooks
Smartphones and Handhelds
Simple forms, data collection/viewing,
small media
Multi-FunctionImmersive/Visual Internet
Some Convergence Basic/Medium Internet
Disinfectable, sealed, rugged, Barcode, RFID, Handwriting
In Hand UsageFrequent/ Short Sessions
Table Top UsageFewer/Longer Sessions
USER EXPERIENCE
Tablets
Medium forms, data collection/viewing, media
Pock
eta
ble
Port
able
MCA+
Content creation,
collaboration manageability, image editing
+MCAs have a variety of processors from Atom to Core i5 & i7 vPro
Netbooks
Significant data entry, medium data collection/ viewing, media
What Real time Collaboration Might look like
Possible Collaborative Workflows
• EMS: Treat in place: EMT/ doc / homecare nurse/ community care worker
• ED Discharge to home : doc/ homecare nurse/ community care worker
• ED Admit: ED nurse / floor nurse / transportation
• Consults Acute inpatient: doc/doc/therapists/ pharmacist/ etc)
• Consults Chronic Disease outpatient: doc/ doc/ therapists/ homecare nurse / community care worker/ etc
• Homecare: doc/ homecare nurse/ community care worker
Terminal Services
Virtual Hosted Desktop
Virtual Container
OS Image Streaming
Application Virtualiz-
ation
Healthcare Security & Privacy Across Desktop Virtualization Options
PHI at Rest ServerServerServerClient
or ServerClient
or Server
Able to WorkOffline Yes Yes No No No
Manageand Patch CentralizedCentralizedCentralizedCentralizedCentralized
Risk IsolationStrategy
Client / Server
Client /Server
Client / Server
Virtual App Isolation
Virtual Containers
2nd Generation Intel® Core™ vPro™ Processor Family Based PCs Support ALL Desktop Virtualization Models
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User SessionAvailability
Data Sync with Server
Data Sync with Server
Session on Server
Session on Server
Session on Server
2Enterprise VDI
Cloud
(1) User RequestsVirtual Desktop
(2) VDI Cloud Svc QueriesDevice Media, GFx, Network Capabilities
(3) If High End Client andLow BW connection,then render/decode locally on client
(4) If Low End Client & High BW connectionthen render/decode in DCand stream bitmap
Local App
Central Data
Low Server Utilization (1%)
Redirected Media (MMR)
Client SideServer Side
The Case For MMR (Multimedia Redirect)
Streaming and Virtual Hosted Desktop Study:Phase 2
IT@Intel White Paper, Intel Information Technology Computing Models, April 2010
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Secure Mobile Computing (MPOC) and Care Collaboration
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Mobility Drives Higher Need for Protection
Frequent2M laptops/year are reported as stolen and 97% are never found23
Costly The average cost of a lost laptop is $49,24624
Often from the inside70% of all reported security breacheswere due to insiders25
78% of US organizations have some type of
encryption strategy in 2009, up from 66 percent in 200726
>59% of respondents say it is very important to encrypt employee’s
mobile devices26
23 Source: Processor, May19,2006. http://www.processor.com/editorial/article.asp?article=articles/P2820/30p20/30p20.asp&guid=024E96876DB944D89AA42906DB9FFE84; 24 Source: Ponemon Institute , April 2009 , http://communities.intel.com/docs/DOC-3076 ; 25 Source: CNET News.com, from Ponemon Institute Survey (163 F1000 companies) ,January 2005, http://forums.cnet.com/5208-6132_102-0.html?threadID=56566 ; 26 Source: Symantec Global Internet Security Threat Report Trends for 2008,Volume XIV, Symantec, April 2009 http://eval.symantec.com/mktginfo/enterprise/white_papers/b-whitepaper_internet_security_threat_report_xiv_04-2009.en-us.pdf
BIG QUESTION: PHI (CHI) on the Client? As data is more portable it is more susceptible to being lost or stolen.
Improved Security Central Manageability Fast Provisioning Network Security and Reliability Bandwidth Requirements
Flexible compute models Online/Offline data access Remote access Cost of Downtime / Data Loss Security Regulatory requirements
NO PHI on Client/ Thin only PHI on Client/ Rich compute
Placing PHI on Client requires Balancing Multiple Tensions
Data Breaches In Georgia
30http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html
Protecting Mobile PHIIntel Hardware Enabled Security Technologies
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• SSD (Solid State Drive) with AES: high performance, low power, robust, encrypted solid state drives
• AES-NI (Advanced Encryption Standard – New Instructions): high performance encryption of PHI at rest, in use, in transit IPT (Identity Protection Technology): strong 2-factor authentication
• Anti-Theft: mitigating loss or theft of client with PHI• vPro AMT (Active Management Technology):
improving manageability and compliance• VT/TXT (Virtualization and Trusted Execution
Technologies): protecting server confidentiality and integrity in a virtualized / cloud environment
EHR Client
AES-NI
IPT Client
Anti-Theft
vPro AMT
EHR Server
AES-NI
IPT Server
VT / TXT
HealthInfo
Exchange
SSL/TLSor IPSec
SSL/TLSor IPSec
SSD(AES)
Intel® Anti-Theft Technology
Protection: Tamper-resistant security feature in laptop hardware that detects potential theft and disables itself.
Non-Destructive: When returned, the laptop can be easily reactivated without harming laptop or data.
Owner Recovery Message: Disabled laptop can display unique recovery message and contact information to return laptop to its owner
Track, Manage & Recover laptops Enhanced Data Encryption solutions for Business
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SUMMARY
Mobile computing is more than simple data look up. Different devices for different tasks
Data consumption/ creation at the point of care are a good start
Collaborative workflows are where you want to go
Security when going mobile is paramount. Encryption and two factor authentication are good starts
Balanced compute models that take advantage of central server manageability and security with client side execution, lowers IT costs, and can improve the end-user experience
GATHER SHARE MOBILZE EMPOWER
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