beyond theory: implementing a patient-centric health ecosystem · including >2,200 healthcare...

© 2010 Inverness Medical Innovations. All rights reserved. Alere is a trademark of the Inverness group of companies.© 2010 Inverness Medical Innovations. All rights reserved. Alere is a trademark of the Inverness group of companies.

Beyond Theory: Implementing a

Patient-Centric Health Ecosystem

Gordon Norman, MD, MBA

Chief Innovation Officer, Alere

Chairman, DMAA: The Care Continuum Alliance


Now That We’ve Unbound Health

Care, Who Will Put it Back Together

Again… And How?

Doctors? ACOs? PCMHs? mHealth? eHealth?

EHRs? GoogleHealth? Healthvault? Apple?

Legislature? HHS? Surgeon General? States?

Employers? Business coalitions? HR Depts?

Entrepreneurs? VCs/private equity? Pharma?

Consumers? Lawyers? Courts? Magicians?

© 2010 Inverness Medical Innovations. All rights reserved. Alere is a trademark of the Inverness group of companies. 2

© 2010 Inverness Medical Innovations. All rights reserved. Alere is a trademark of the Inverness group of companies.

Who is Alere?

• Alere (formerly Inverness Medical Innovations), a global

leader in point-of-care diagnostics, and Alere Health, a

leader in personal health support solutions, comprise a

family of innovative health companies that leverage health

information technology, home monitoring services, rapid

diagnostic tools, clinical outreach, and health coaching for

better health outcomes

• A $2 billion company with 11,000 employees globally,

including >2,200 healthcare professionals, with clients in all

50 U.S. states and a worldwide diagnostics business

• Together, we are:

• Providing the most complete range of Connected devices and

services that actively integrate data collection;

• Empowering individuals to make better choices; and

• Enabling payers, providers and individuals to make Smarthealthcare decisions.

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What Does Alere Health Do?

• We improve individuals’ health

• from preconception to end of life

• across entire spectrum of health needs

• wellness & prevention for those at risk

• disease management for chronically ill

• case management for those with critical illness

• specialized services for women and children

• We connect diagnostic and monitoring devices with

personalized health management services to empower

healthcare providers and their patients with tools and

information they need to make smart healthcare decisions

• By doing so, we improve health outcomes resulting in

fewer urgent medical interactions, reduction in hospital

visits, avoidance of unnecessary healthcare spending, and

greater workforce productivity

4


Supporting the Health Continuum

Care Gaps

Diagnostic

Screening

Care Gaps

Diagnostic

Screening

Diagnostic

Screening

Care Gaps

Care Gaps

Diagnostic

Screening

Women & Children’s

Preconception

OB Risk Assmt/Ed

OB Case Mgt/Home

Perinatal screening

NICU

PCMH, ACO Support

Collaborative Care Platform

Gaps in Care Closure

P4P / PQRI Tracking, Reporting

Wellness

Portal/HPA

Coaching

Online

Screening

Tobacco

Mind & Body

WellnessCase Management

Oncology

Complex Care

Catastrophic

Intensive Care

End of Life

Collaborative Care

Solutions™

Disease ManagementAsthma

Diabetes

Heart Failure

CAD

COPD

Chronic Pain

Personal

Health

Support

PatientCentered Care

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What’s a Health Ecosystem?

Biologic Ecosystem

A complex set of relationships of living

organisms functioning as a unit and

interacting with their physical environment to

form a stable system.

Health Ecosystem

The interplay of many factors, including the

environment, personal attributes and

relationships, cultural influences, technology,

and health resources that affect individual

health status.

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• Specific to the individual

• More complex than

generally appreciated

• Myriad influences ranging

from global to local factors

• Some interactions evident;

others not easily discerned

• Social relationships are

important (e.g., Nicolas

Christakis’ recent work)

• Personal health behavior is

affected by all dimensions

• Traditional “health care”

targets very few of these

potential levers of influence

• Appreciating health

ecosystems helps us work

within them more effectively

7

Understanding Health Ecosystems



Determinants of Personal Health

Behavior

Change

Schroeder S. N Engl J Med 2007;357:1221-1228

8


Navigating the Health Ecosystem

9


End Results of Current System

• Persistent medical cost inflation at 2-3X general inflation

• Looming Part A Trust Fund insolvency (2017 or sooner)

• Chronic conditions proliferating for B’Boomers and adolescents alike

• 60% of U.S. are overweight or obese

• Health disparities not improving; some widening

• Lifestyle, diet, habits thwart best public health efforts

• Quality of care highly variable – “geography is destiny”

• Medical errors result in 98,000 deaths annually

• PCP, nursing shortages regionally, and worsening

• U.S. business competitiveness undermined by health costs and impacts on

productivity

• Today’s youth may be 1st American generation to have lower longevity than

their parents

• Widespread recognition that U.S. gets poor value for our healthcare spend

• Sustainable universal health coverage elusive w/o better health value for $

10


“Coin Toss Quality” for Medical Care

“Our results indicate that,

on average, Americans

receive about half of

recommended medical

care processes. Although

this point estimate of the

size of the quality problem

may continue to be

debated, the gap between

what we know works and

what is actually done is

substantial enough to

warrant attention.”

MCGlynn EA et al. The Quality of Health Care Delivered to Adults in the United States NEJM 06-JUN-2003; 348(26): 2635-2645

GoalMean

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Hardly the “Fairest” of Them All

Davis et al. Mirror, Mirror On the Wall. How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update, Commonwealth Fund, June, 2010

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So It’s Broken… Now What?

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“Health”

A state of complete physical, mental, and

social well-being and not merely the

absence of disease or infirmity (WHO,

1948)

A Very Important Distinction

“Health”

The highest achievable state of relative

physical, mental, and social well-being

given uncontrollable or irreversible health

influences (2010)

“Health Care”

The prevention, treatment, and

management of illness and the

preservation of mental and physical well-

being through the services offered by the

medical and allied health professions

“Caring for Health”

What you do to improve your state of

health, w/ or w/o help of others

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Caring For Health Is Different!

15


From Physician-Centric Models…

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• Care delivered by clinicians

• Efficient for providers of care

• Patient convenience optional

• Acute care focus (“sick care”)

• Care reactive, episodic

• Primary care devalued

• Specialty care, technology

• Care segmented by condition

• Hierarchical relationship with

clinician in charge of care

• Patients take passive role

• Clinician biased by assumed

values, preferences

• Clinician defines “successful

care” in clinical terms only

Patients

Nurses

Hospital

Community

ResourcesPharmacy

Subacute

Facilities

M.D.Me DeityM.D.

Admit

Discharge Admit

Discharge

PrescribeRefer


To Patient-Centric Health Ecosystems

• Patient needs, values,

preferences dictate more

of what happens, when,

how to improve health

• Expanded care team

organized around PCPs

serve as core of personal

health ecosystem

• Integration through health

information exchange,

controlled by patients

• Care architecture supports

highly personalized care

• Enhanced self-care

augmented by additional

external resources as

needed

&

PCP

Convenience

Care

CoordinationEngagement

Decision

Support

Patient

Access

Retail Clinics

Worksite

Clinics

Disease Management

Personalized

Communications

Price / Quality

Information

PHR / EHR /

HRA Dataflow

Coaching &

Incentives

Remote

Monitoring

Wellness

Prevention

SCPDiagnostics

Health

Advocacy

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• What’s lacking today is

connectivity, context

across the components

• Pervasive health

information exchange

and integration is

required for improving

personal health

• We want all parties to

share data to have

integrated information

that’s contextualized for

health decision support

• Technology to make this

happen is no longer the

key barrier

Adapted from FBR Capital Markets, Patient-Centric Care: The Direction of 21st Century Healthcare, 12/2007

&

PCP

Convenience

Care


Decision

Support

Patient

Access

Retail Clinics

Worksite

Clinics

Disease Management

Personalized

Communications

Price / Quality

Information

PHR / EHR /

HRA Dataflow

Coaching &

Incentives

Remote

Monitoring

Wellness

Prevention

SCPDiagnostics

Health

Advocacy

PCP

Convenience

Care


Decision

Support

Patient

Access

Retail Clinics

Worksite

Clinics

Disease Management

Personalized

Communications

Price / Quality

Information

PHR / EHR /

HRA Dataflow

Coaching &

Incentives

Remote

Monitoring

Wellness

Prevention

SCPDiagnostics

Health

Advocacy

Remaining Gaps in The Ecosystem

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It’s Not Easy Being Patient-Centric

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Care reminders

Public report cards

Personal health record

Online health information Nutritionist

Fitness center

Wellness health coach

Care coordinator Worksite health program

Urgent care facility

Imaging center

Retail clinic

Ancillary care providers

Specialty care referrals

Primary care “home” Electronic health record



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Care reminders

Public report cards



Fitness center




Imaging center

Retail clinic






21

Care reminders

Public report cards



Fitness center




Retail clinic




Imaging center


Human Beings Are Exceedingly

Complex Biosystems

22


Why Do We Behave As We Do?

23


Changing Health Behaviors

• Do you know WHAT to change

and WHY?

• Do you WANT to change?

• Do you know HOW to change?

• Successful health behavior

change typically requires

information, motivation, and

behavioral skills

• The health ecosystem must

provide all three for a high

probability of sustained behavior

change

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Different Skill Sets For Different Roles

Skill SetMost Physicians

& Nurses

Most Health

Coaches

Provide information Good Fair to Good

Stimulate motivation Poor Good

Enhance behavioral skills Poor Good

• It’s a matter of different perceived roles, training, philosophy,

practice, rewards, reinforcement

• Doctors have not historically perceived their role to change

behaviors, but rather to render health advice & treat disease

• Coaches are expected to help individuals achieve health goals by

building motivation, skills, and providing support

• Each practicing at the “top of their license” can be highly

complementary and synergistic, if connected and coordinated

around a unified care plan and shared data

25


What We Physicians Are NOT Usually

Taught in Medical Training

• Working in care teams

• Continuous quality improvement

• Epidemiologic health perspective

• Social psychology, adult learning

• Stages of change management

• Patient-centered interviewing

• Large dataset management with

advanced analytics

• Clinical process improvement

• Community resource integration

• Motivational interviewing

• Building self-efficacy, activation

• Sustaining behavior change

• Predictive modeling

• Disease registries

• Interoperable EHRs/PHRs

• Remote biometric monitoring

• Consumer-oriented education,

motivation techniques

• Behavioral incentives

• Scalable platforms for inbound,

outbound patient contact

• Low health literacy counseling

• Culturally-sensitive health

education approaches

• Overcoming resistance

to change, recidivism

26


Slow Adoption of Health Innovation

• From time new knowledge discovered until >50% of

physicians act on that knowledge = 15-17 years

Everett Rogers, Diffusion of Innovations, 1995

% o

f popula

tion

time

Adoption Half-life = 17y

Knowledge Half-life = 10y

The further we come,

the behinder we get??

Balas, Boren. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000

27


Clinical Inertia Common in Patient Care

O’Connor et al. Clinical Inertia and Outpatient Medical Errors, Advances in Patient Safety V2. 2005

• Clinical Inertia: lack of treatment intensification in a patient

not at evidence-based goals for care

28


Losing The Faith

29


What About Health Reform?

• PPACA health reform legislation has initiated a 10-20 year

change process of great complexity & uncertain outcomes

• Diversity of issues, regulatory implementation process,

unintended consequences, activist intervention, partisan

governance, make forecasts challenging for outcomes

• Many seasoned observers are skeptical that current reforms

are enough to turn the corner on cost, quality, and value

• Bottom-up regional health reform at the state and local level

offer nearer term options, and many such experiments are

underway which bear watching

• Employers and health plans can be innovative by

establishing proof of concept in locales where interests may

be more aligned, status quo inertia can be overcome

• The magnitude and seriousness of the problem demands

innovation and experimentation at every level possible

30


Coverage w/o Access = Faux Reform

• MA healthcare reform has exposed reality that expanding coverage

can overwhelm an already saturated primary care delivery system

• MA is not unique in facing primary care shortages

• Shortages are not limited to primary care, but these are most critical

31


U.S. Students Retreat from 1° Care

32


Just as Boomers Hit Medicare…

• In 1950, primary care to specialist ratio of active medical workforce was >2:1 – currently it is <1:2

• In 2006, only 3,032 (15%) of 20,072 residency applicants matched into primary care residencies

• By 2020, U.S. will have estimated shortage of 40,000-200,000 PCPs, with 78 million Boomers seeking more chronic care

33


Does a PCP Shortage Really Matter?

• Quality and cost

correlations say

otherwise

• Ample studies

replicate these

findings elsewhere

• Maybe primary care is

overrated…

• Perhaps this is a

timely step toward a

specialist-driven

system with better

health outcomes?

34


Will Newer Forms of Accountable

Care Delivery Solve the Problems?

• PCMHs, ACOs are exciting developments that have great

promise but are highly dependent on revised payment from

majority of payers to realign incentives

• There is a serious PCP shortage now that will grow worse before

it can correct in response to any proposed incentives

• Growth of concierge practices may be great for those who can

afford it but further accelerates the PCP shortage

• The best provider-based “medical home” in the world is only a

partial solution since most “caring for health” occurs in your own

home, at work, in the community

• PCMHs and ACOs may become key components of the health

ecosystem for many; yet there are other health needs we have

that they cannot readily fulfill

• We need delivery systems to connect with other health

components and partners into a coherent, interoperable, personal

ecosystem that we can control

35


Creating, Sustaining, & Advancing

A Workplace Culture of Health

• Leveraging technology, analytics• Remote monitoring, home testing,

PHRs, secure messaging, social

communities

• Using aggregated data for predictive

analyses, gaps in care, personalized

interventions

• Progressively raising the bar• Increasing goals as targets achieved

• Integrating patient-centered models• Providing strong health ecosystem

support for employees

• Supporting PCMH, ACO approaches

• Encouraging collaboration between

health management vendors and

physicians via connectivity, HIE, &

interoperable EHRs/PHRs

• Fundamental value recognition• Employees as human capital

• Indirect vs. direct health-related costs

• Executive champions

• Integrated strategy across “verticals”• Health benefits design, absence

/disability mgt, wellness programs,

incentives, partners

• Ongoing value documentation• Clinical indicators, health behaviors

• Direct and indirect health-related costs

• Value translated to core financial terms

• Balancing “skin in the game” with

effective incentives• Balancing cost mitigation vs. cost shifting

• CDHP vs. VBID vs. Wellness

36


Good For Health & Good For Business

• Every $1 of medical & Rx costs is matched by

$2.30 of health-related productivity costs

• Health-related presenteeism has larger

impact on lost productivity than absenteeism

• Top five health conditions driving total

medical/Rx and health-related productivity

costs are depression, obesity, arthritis,

back/neck pain and anxiety

• Evidence based medicine should go beyond

clinical outcomes or financial outcomes and

include functional outcomes

• Co-morbidities drive the largest effects on

productivity loss so integrated personal health

support approaches are critically important

JOEM, "Health and Productivity as a Business

Strategy: A Multi-Employer Study", 51:4, April,

2009. pp 411-428

37


Value Consensus Strong

“In a critical meta-analysis of the

literature on costs and savings

associated with such programs, we

found that medical costs fall by

about $3.27 for every dollar spent

on wellness programs and that

absenteeism costs fall by about

$2.73 for every dollar spent.

This return on investment suggests

that the wider adoption of such

programs could prove beneficial for

budgets and productivity as well as

health outcomes.”

Health Affairs 2010. 29:2

38


Why a Proper Health Ecosystem?

• Government-led top-down health care reform alone cannot fix

our health ecosystem or personal health status (but it may help)

• Bottoms-up reforms are within reach with high potential value

• Periodic health care is useful – sometimes life saving – but no

substitute for “caring for health”, which is more about how we

live our lives between encounters with the delivery system

• The most important and specialized care provider in the world

for you, is you! (deep expertise, 24/7 on call, no holidays)

• Creating an effective health ecosystem to support your health

effectively requires active effort and technology to link

appropriate resources, connections, and support

• No two individuals share the exact same health ecosystem, so

no two individuals should have identical health support to be

most relevant, effective, and efficient for optimizing health

39


A Patient-Centric Health EcosystemFor the 21st Century

• Aligns clinician, coach, self

caring for your health by being

person-centered

• Defragments health silos,

connects all the pieces

• Delivers

• Convenience

• Emphasis on proactive, continuous,

self-care

• Effective information,

encouragement, support

• Closely links

• Sites of care

• Expanded care teams

• Relevant health data

• Integrated care plans

• Personal health records

• Electronic health records

Coaching & Incentives

HealthAdvocacy

40


Media: Health As Random Events

41


Little Awareness of Risks & Benefits

42


We Make No Time For Health

43


For Many: All Work, No Play

44


For Others: You Are What You Watch

45


Relapses Are Frustrating, Challenging

46


Health Literacy Can Be Challenging

47


We Don’t Know the Cost of Anything Much Less the Value

48


Mass Medicalization & Moral Hazard

49


What Do We All Want From Our

21st Century Health Ecosystems?• Comprehensive health care

• High quality, convenient, affordable, care coordination, team-based,

safe, confidential, easy navigation, social community

• “Nothing about me, without me” - allow me to share in important

decisions, control my health ecosystem, define respective roles

• Empowerment to help me care for my health

• Make it easier for me to do the right thing for my health

• Offer me different options for achieving my goals

• Give me knowledge, but don’t forget motivation, skills, incentives

• Personalized, supportive approach

• Accept who, where I am now, but help me to get healthier

• Communicate and interact with me in the manner I prefer

• Data integration for holistic health decision support

• Across sites, sources of information, analysis, guidance

• Failsafe: tell me what I am forgetting or providers are overlooking

50


Signs of Incremental Progress?

• Strong workplace Culture of Health perspective

• Integrated continuum of care programs for pre-cradle to

end-of-life and all health states in between through a highly

personalized, convenient interface

• Communication flexibility and convenience that adapts to

and supports individual preferences

• Empowering technologies like remote monitoring, home

diagnostics, interoperable health information exchange for

EHRs, PHRs to assist physicians and individuals in making

appropriate, timely, and coordinated health decisions and

interventions

• Behavioral expertise, tools, and incentives to drive positive

change in participants’ choices, helping them achieve and

sustain their individual health goals

51


What’s It Going To Take?

Meaning:

• Culture change to respect

patient differences, values,

preferences as fundamental

aspect of how care is delivered

• Expanded team-based care

where specific roles optimally

leverage capabilities of different

players, all integrated for and

controlled by patients

• Adopting or partnering with

other organizations for

population health capabilities,

technologies

In Health Speak:

• Patient-centric foundation

• PCMHs, ACOs, Team-based

care

• Collaborative Care, Coordinated

Care, Virtual Team-based Care

52


What’s It Going To Take?

Meaning:

• Care team reimbursement

contingent on measured and

reported outcomes of care

• Patient OOP cost materially

related to health behaviors &

decisions

• Better connectivity,

interoperability of health data,

health communications, and

health decision support

• Greater quality and safety

transparency, literacy, and

incentives for value

In Health Speak:

• Payment reform, P4P, robust

quality measurement, reporting

• VBBD, P4P4P, HRAs, HSAs

• Connected EHRs, PHRs, HIEs

• CE + public reporting,

education, marketing + CQI

53


“The King’s men helped some, but the horses just made things worse!”

What Outcome Can We Expect?

54© 2010 Inverness Medical Innovations. All rights reserved. Alere is a trademark of the Inverness group of companies.


Ideal 21st Century “Caring For Health”

• Predictive

• Personalized

• Preventive

• Participatory

• Equipped

• Enabled

• Empowered

• Engaged

• “Caring for health” and “health care” are compatible, coordinated,

comprehensive, and mutually reinforcing

• All members of the health ecosystem contribute to an interoperable

unified care plan owned and controlled by the individual

• Outcomes of care are optimized through a satisfying experience

adapted to individual needs, values, preferences

• Improved health is achieved at lowest possible cost to individuals,

employers, plans, and society

Goal: P4 Care for E4 Consumers in a C4 Ecosystem• Convenient

• Connected

• Coherent

• Cost-effective

55


Thank [email protected]

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mailto:[email protected]

beyond theory: implementing a patient-centric health ecosystem · including >2,200 healthcare...

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