Innovation in Health Care DeliveryJonathan Wilt

AVP, Center for Innovation

Ochsner 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

Solve core business problems that can be scaled system-wide

Ochsner Center for Innovation

New Orleans based Ochsner Health System, announced it is the first Epic Systems client to successfully integrate its electronic health record (EHR) with the new Apple HealthKit. Approximately 53 percent of Americans have their medical records within the Epic EHR, and its MyChart application is the most used patient portal in the United States.

“In the past, we relied on patients to log information, bring it to us, and then we would input the data and decide a course of action,” said Robert Bober, MD, Director of Cardiac Molecular Imaging, Ochsner Medical Center. “Now we can share information seamlessly between patient and physician to allow real-time, accurate analysis of a patient’s health status. This is ideal for patients with chronic diseases such as heart failure, hypertension and diabetes.”

Ochsner Health System First Epic Client to Fully Integrate with Apple HealthKit

innovationOchsner

innovationOchsner

• Our focus is to develop entirely new ways for healthcare providers to dramatically improve the quality of care by managing patient conditions more effectively

• We do this by innovating health care delivery models and partnering with companies looking to revolutionize patient-centered care

http://www.innovationochsner.com/

But before we can innovate…..

• Ochsner is a growing health system, and must be diligent in designing a sustainable IT infrastructure

• System-wide standardization is critical to our ability to innovate

Innovation

Speed and Flexibility

System-wide Standards

Integration is key

• Integration trumps best-of-breed

• New products must able to integrate seamlessly with our hub EHR system, Epic

Maximizing our EHR

• We don’t want to spend millions on add-ons when our EHR can already do it

A scorecard of how effectively you’re using the system

Ochsner Health System

Ranked #1 in the nation

Where do we begin?

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

CHRONICDISEASES

ACCOUNT FOR

3 4DEATHS

OUTOF

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 DiseaseHealth 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 Conditions2013-2025

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 targetingbehavioral patterns

What’s the Necessity?What’s the Necessity?

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 25.724.2

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 by the patient on Windows tablets

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

Xpotential

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.

“Health Care 2020: Reengineering Health Care Delivery to Combat Chronic Disease,” by Richard V. Milani, MD, and Carl J. Lavie, MD (DOI: http://dx.doi.org/10.1016/j.amjmed.2014.10.047). It appears in The American Journal of Medicine, Volume 128, Issue 4 (April 2015) published by Elsevier

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

HealthKit provides a standardized platform for a variety of in-home devices

We can concentrate on the largest few manufacturers for Android users Withings Fitbit

This standardization is critical to remain agile – we want more data but can’t build custom interfaces to every future device

New data points from home

Increased patient engagement

Medication adherence

Quality of Life

Family engagement

Level of understanding of diseases

Dietary issues

What we look for in new technologies

New wearables

Apple Watch may be able to facilitate frequent, meaningful communications between patients and care team

Huge opportunity to create the next wearable technology

National Innovation Challenge: 2015 challenge involves wearable technology concepts and/or mobile applications that take a proactive and improved approach to transforming healthcare outcomes

Data integrity

Hypertension Digital Medicine users are required to have their own smartphone

Devices cannot be linked to patients –must initiate BP measurement from your smartphone

Remember… Integration is key

• Integration trumps best-of-breed at Ochsner

• New products must able to integrate seamlessly with our hub EHR system, Epic

• Open.epic.com

Questions??

Open Positions:

User Support Specialist

RN Clinical Care Coordinator

Mobile App Developer

Entry level analyst

www.Ochsner.org/careers