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Innovation and Chronic Disease Management Jonathan Wilt
AVP, Center for Innovation
Ochsner Health System
Necessity is the mother of invention.
The Republic, Book II, 369BC, Plato
& innovation
Healthcare Spending as a Percent of Gross Domestic Product
17.7%
11.9%
11.6%
11.2%
9.6%
9.4%
9.3%
9.0%
7.9%
7.7%
7.4% 0% 9% 18%
United States
Netherlands
France
Canada
Japan
United Kingdom
OECD Average
Finland
Hungary
Israel
South Korea
Source: OECD. http://www.vox.com/cards/how-doctors-are-paid/how-else-could-the-us-bring-down-health-care-costs#E5744046
3 6 4 1 5 2 7
4 7 5 2 1 3 6
2 7 6 3 5 1 4
6 5 3 1 4 2 7
4 5 7 2 1 3 6
2 5 3 6 1 7 4
6.5 5 3 1 4 2 6.5
6 3.5 3.5 2 5 1 7
6 7 2 1 3 4 5
2 6 5 3 4 1 7
4 5 3 1 6 2 7
1 2 3 4 5 6 7
$3,357 $3,895 $3,588 $3,837 $2,454 $2,992 $7,290
AUS CAN GER NETH NZ UK US
OVERALL RANKING (2010)
Quality Care
Access
Efficiency
Equity
Long, Healthy, Productive Lives
Health Expenditures/Capita, 2007
Cost-Related Problem
Timeliness of Care
Effective Care
Safe Care
Coordinated Care
Patient-Centered Care
Source: The Commonwealth Fund: Mirror Mirror On The Wall: How the Performance of
the U.S. Health Care System Compares Internationally 2010 Update
How the US Health Care System Compares Internationally
600,000
700,000
800,000
900,000
2008 2010 2015 2020
Demand Supply
Projected Supply and Demand, Physicians (all specialties) Physician supply not keeping pace with increasing demand for healthcare services
91,500
62,900
Source: AAMC Center for Workforce Studies, June 2010 Analysis
Major Epidemics in History
Bubonic Plague
1347-1350 >25 Million deaths
30-70% of the Population
Cholera
1817-1860 1865-1900
>50 Million deaths
10% of the Population
Influenza
1918-1919
>75 Million deaths
30-70% of the Population
CHRONIC DISEASE
Today
75% of all Deaths
50% of the Population
CHRONIC DISEASES
ACCOUNT FOR
3 4 DEATHS
OUT OF
Chronic Disease 75% of U.S. health care dollars goes to treatment of
chronic disease.
Nation’s leading cause of death and disability causing 70% of all deaths.
50% of all adult American have at least one chronic disease.
90% of seniors have at least one chronic disease, and 77% have two or more chronic conditions.
Median outpatient visit length is < 15 minutes covering a median of 6 topics
Source: Centers for Disease Control and Prevention. http://www.cdc.gov/chronicdisease/index.htm
BMJ 2013;346:f2614. http://transformativehealth.info/a-c-suite-view/patient-engagement-a-strategic-imperative-for-preventing-readmissions/
Tai-Seale M, et al. Health Serv Res. 2007;42:1871-1894. Gottschalk A, et al. Ann Fam Med. 2005;3:488-493.
Four Common Causes of Chronic Disease Health Behaviors
Lack of physical activity
Poor nutrition
Tobacco use
Excessive alcohol consumption
obesity
• diabetes
• hypertension
• heart failure
• coronary heart disease
• stroke
• cancer
• OSA
• atrial fibrillation
• hyperlipidemia
• gallstones
• back pain
• infertility
• skin infections
• gastric ulcers
Source: http://www.cdc.gov/chronicdisease/overview/index.htm
Projected Growth in Population with Chronic Conditions 2013-2025
Dall TM, et al Health Affairs 2013;32:2013-2020.
Adherence to Quality Indicators in Chronic Disease
Condition No. of Indicators % of Recommended
Care Received
Overall Care 439 54.9%
Hypertension 27 64.7%
Heart Failure 36 63.9%
COPD 20 58.0%
Asthma 25 53.5%
Hyperlipidemia 7 48.6%
Diabetes mellitus 13 45.4%
Peptic ulcer disease 8 32.7%
Atrial fibrillation 10 24.7%
McGlynn EA, et al. N Engl J Med 2003;348:2635-45.
Last
Costs too high Poor quality
Modern day epidemic Receiving recommended care
Demand outpacing supply
What’s the Necessity? What’s the Necessity?
Factors Influencing Health Status
40%
15%
30%
5% 10%
Schroeder SA. N Engl J Med 2007;357:1221-8.
Environmental exposure
Genetic predisposition
Factors Influencing Health Status
Electronic Health Records
Meaningful Use
Core Measures
Transparency
HCAHPS, CAHPS
HEDIS, SCIP
Pay for Performance
PACS
Joint Commission, Leapfrog
40%
15%
30%
5% 10%
Health care
Health care
Schroeder SA. N Engl J Med 2007;357:1221-8.
Factors Influencing Health Status
Social Circumstances
Living conditions (live alone)
Transportation
Access to care
Medication affordability
Social network support
Education level
40%
15%
30%
5% 10%
Social Circumstances
Health care
Schroeder SA. N Engl J Med 2007;357:1221-8.
Factors Influencing Health Status
40%
15%
10%
Schroeder SA. N Engl J Med 2007;357:1221-8.
Behavioral patterns
Social Circumstances
Health care
Behavioral patterns
Depression
Medication adherence
Social network influence
Physician/Health-System perception
Lifestyle: diet, activity
Patient activation
Last
Costs too high Poor quality
Modern day epidemic Receiving recommended care
Demand outpacing supply
Not effectively targeting behavioral patterns
What’s the Necessity? What’s the Necessity?
Traditional Innovations Inside Health Systems
Electronic Health Records
Meaningful Use
Core Measures
Transparency
HCAHPS, CAHPS
HEDIS, SCIP
Pay for Performance
PACS
Joint Commission, Leapfrog
Telemedicine
LEAN
Concept of an Innovation Team Our Chief Clinical Transformation officer was leading innovation efforts in these
traditional innovation areas, and this was also my primary focus from an IT perspective
Internal discussions about creating an innovation team to focus on larger issues in the industry
Inspiration • Skunk Works – Total control by manager, restrict access to project to protect the
innovative ideas • IDEO – Super small teams, informal, no hierarchy, a free flow of ideas, and quick
prototyping
How to pull this off at a Health System?
Ochsner Center for Innovation Created in 2013
Tasked with going above and beyond the typical, incremental optimization of software systems and clinical workflows
Use the newest technologies to innovate care delivery models
Not just another IT department – use pharmacists, nurses and operational liaisons to support new programs
Integration into operations and IT is crucial to the long term success and maintainability of our programs, so we cannot be isolated • Separate space, but still close to IT • Open work areas, conference rooms, white boards
An Evolving Team Structure Initial team was made up of volunteers in both IT and operations, two part-time
pharmacists, and myself as the only full-time member.
Technical team met twice a week to develop our programs and divide up work. Patient care team worked remotely supporting our programs.
As successful projects were implemented, more funding was secured to hire more full-time team members
To date, we now have funding for 5 full-time team members in addition to the over 10 part-time volunteers participating
Initial Team Structure
An Evolving Team Structure
Partnership with IT The IT department uses the Center for Innovation to grow their talent and teach
them to think outside of the box
Co-sponsor annual innovation challenges to generate new ideas and interest in the team
New career path from IT to the Center for Innovation for people who may not want to become managers
Prove Value Quickly Developing and testing new care delivery models takes time, and we needed to
create value quickly
There were prerequisite foundational systems to build and implement before new care delivery models could be piloted
Team focused on a couple of key issues to prove value quickly and buy time
• Reimbursement for our capitated population is dependent on physicians billing HCCs (Hierarchical Condition Categories) once a year
• Inaccurate coding costs us millions in lost revenue for the conditions we treat, so this is great bang for your buck
Prove Value Quickly The prevalence of morbid obesity is now over 6% of the US population and a brand
new HCC in 2013
Only 18% of qualifying patient visits (BMI>40) contained a visit diagnosis of morbid obesity in 2012 totaling only 40% of the patients for the year
Survey period Sample (n) Overweight Obese Extremely obese
Percent (standard error)
1988–1994 16,235 33.1 (0.6) 22.9 (0.7) 2.8 (0.2)
1999–2000 4,117 34.0 (1.0) 30.5 (1.5) 4.7 (0.6)
2001–2002 4,413 35.1 (1.1) 30.5 (1.1) 5.1 (0.5)
2003–2004 4,431 34.1 (1.1) 32.2 (1.2) 4.8 (0.6)
2005–2006 4,356 32.6 (0.8) 34.3 (1.4) 5.9 (0.5)
2007–2008 5,550 34.3 (0.8) 33.7 (1.1) 5.7 (0.4)
2009–2010 5,926 33.0 (1.0) 35.7 (0.9) 6.3 (0.2)
2011–2012 5,181 33.6 (1.3) 34.9 (1.4) 6.4 (0.6)
Prove Value Quickly We designed specialty tools in the Epic EMR to not just remind physicians to
address morbid obesity (HCC was worth $2900 in 2013), but also remember to address all HCCs.
For those of you on Epic, you can view our past UGM presentation and we can share our coding.
Growing the Team With the improved capture rate of HCCs, we easily proved our value and secured
funding for full-time employees
We recruited the most creative and best critical thinkers from around the country. • Ability to look at problems in unconventional ways
• Ability to generate new and useful ideas
• Ability to analyze which ideas are worth pursuing and which are not
• Ability to articulate new ideas to others and convince others that ideas are worth pursuing
• Possess a tolerance for ambiguity and willingness to overcome obstacles
• Possess a willingness to take reasonable risks
• Self Starter
Growing the Team Lesson learned:
There is a lot of interest in the organization to join the team, however it is sometimes difficult to find the right people.
Many people want to join to do something different, rather than make a difference. We need passionate, driven team members to tackle these seemingly impossible issues
Focus on Chronic Disease Management Focus in 2014 and 2015 is chronic disease management
Using the newest technologies available, target the 65% of contributing factors we have control over – not just 10%
40%
15%
30%
5%
10%
Prioritizing Diseases Inpatient Readmissions - CHF
Elixhauser A (AHRQ), Steiner C (AHRQ). Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. April 2013. Agency for Healthcare Research and Quality, Rockville, MD.
26.1 25.7 24.2
0
5
10
15
20
25
30
18-44 45-64 65+
All-cause 30-day readmission rates for congestive heart failure
Age
Prioritizing Diseases Outpatient diagnoses - Hypertension
Chronic Condition % of outpatient visits
Hypertension 27.0
Hyperlipidemia 15.7
Diabetes 15.1
Depression 12.4
Arthritis 10.2
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey.
Congestive Heart Failure Targeted approach for all heart failure
patients including detailed screening (i.e. depression, med adherence, etc.) with dedicated HF nurses.
Comprehensive OP monitoring with HF care team
Monitors daily weight for changes and reaches out to patient to provide real-time guidance and treatment.
Level 1: Guided Decision Support
Level 2: Assessments
Affordability of meds
Medication adherence
Drug-drug, drug-condition interactions
HF Quality of Life
Depression screen
Family / Caregiver support
Transportation issues
Education level / level of HF understanding
Alcohol / drug use
Dietary sodium quantification
In-depth evaluation and quantification of patient specific characteristics
Level 2: Interactive Assessments
Everything is completed on Windows tablets using Welcome!
Patient scores high on sodium consumption
• “Who shops for your groceries”?
• “Who prepares your meals”?
Patient views video on what high sodium means and why it is important; shown what foods are high in sodium and which foods make better choices
Individual(s) who shops for and prepares meals sent email with literature and video link
Level 2: Inpatient Intervention Pharmacy consulted for adherence/affordability
(+/- social worker). If unaffordable, 30-day supply of meds provided at discharge.
Psychiatry consulted for depression, drug/alcohol addiction.
Nutrition consulted for high dietary sodium intake.
Social services for transportation, caregiver support, home health services.
Educated in heart failure disease state; use of monitoring scale; cause and effect relationships.
Level 3: Outpatient home monitoring
metrics
scrubbed
thru
condition
specific
algorithms
patients
stratified
by risk
status
high risk
patients
intervened
by
medication
adjustment
and/or
outpatient
visit
X potential
readmission
avoided
Relationship between Improved Care Coordination and Readmission in Heart Failure Patients
0
5
10
15
20
25
30
35
40
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
% R
ea
dm
issio
ns
2012 2013 2014
14%
25%
Program
Hypertension Hypertension is the most common diagnosis made at primary care office visits.
Most common chronic condition, affecting about 30% of US adults, with estimated annual costs > $50 billion.
Only half of patients with hypertension achieve BP control; the leading cause of which is “therapeutic inertia” (86.9%).
Ranking Prevalence State
47 39.8% LA
48 40.2% MS
49 40.3% AL
50 41.0% W.Va
Roger VL, et al. Circulation. 2012;125(1):e2-e220.
Hsiao C, et al. National Ambulatory Medical Care Survey: 2007 Summary. Hyattsville, MD: National Center for Health Statiastics; 2010.
Margolis KL. JAMA 2013;310(1): 46-56.
Milani RV, et al. J Am Coll Cardiol 2013;62:2185-7.
Just as banking can be done outside the confines of a bank,
BP monitoring and management can and should be done at
home and in other nonclinical settings such as pharmacies
and community and senior centers. Out-of-clinic BP
monitoring with team care should largely replace
traditional office-based BP management for most patients.
Absent a contraindication to home monitoring, patients
should be provided with a validated BP monitor and BP
measurements should be transmitted to each patient’s
clinician, with follow-up patient-clinician communication
by telephone or by electronic visits, if necessary. If home
BP monitoring and team-based care were implemented
broadly, hypertension management would be easier for
patients, and the magnitude of BP reductions brought about
by this change could lead to substantial reductions in
cardiovascular events and mortality, which is something
patients, clinicians, and policy makers can take to the bank.
Home BP Telemonitoring: HyperLink Study Proportion of Patients with Controlled Blood Pressure
Follow-up Telemonitoring Usual Care p-value
6 months 71.8% 45.2% <0.001
12 months 71.2% 52.8% 0.001
18 months 71.8% 57.1% 0.003
Margolis KL. JAMA 2013;310(1): 46-56.
Innovative Model for Care Delivery Going Forward
1. Utilizes non-physician providers of care that supports physicians
2. Works in a “focused-factory” that can keep up with an ever expanding knowledge-base and growing set of quality measures
3. Assess, characterize, and potentially modify social circumstances and behavioral patterns to enhance overall health status
4. Exploit technology to its fullest in order to manage large populations of patients efficiently (i.e. decision-support tools)
5. Monitor and “touch” patients remotely (just-in-time) resulting in faster cycle-times for meeting goals and enhanced patient satisfaction
Apple HealthKit, Withings, Fitbit
In October 2014, Ochsner integrated HealthKit with our Epic EMR
HealthKit now provides a standardized platform for a variety of in-home devices
We can concentrate on the largest few manufacturers for Android users
Withings
Fitbit
Overall lessons learned
Senior executive support
Integration into operations and IT is crucial to the long term success and maintainability of our programs
Cannot maintain dozens of incoming patient entered data streams
Take your time and choose the right team
Ability to quickly get data from EMR – can’t rely on standard reporting processes for quick reports
Fail fast
What’s next?
Expand Chronic Disease Management programs
Conduct analysis on why 65% of readmissions aren’t from the admission dx
Research new wearables and integration of more areas of the home
