The Path to Transforming Healthcare

Professor Michael Georgeff CeBIT eHealth Conference 2011

Healthcare Today: Crippled by Knowledge Failures

• Error relating to drug therapy reported in 5-20% of all drug administrations

• 50% of doctors do not use best practice (evidence-based) care plans

• 80% of care plans for chronic disease not followed up

• 15-30% of people don’t take prescribed medications

• 50% unnecessary acute episodes/hospitalisation from lack of knowledge of patient condition

• 50% variation in practice outcomes across regions

• 50% of patients with established heart disease are not being targeted with technology that can reduce recurrence by 30%

• 180,000 avoidable admissions to Victorian hospitals each year (30 airbuses of people every month)

The Australian PCEHR

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The Australian Government is investing $467 million over two years to:

Deliver real system change and benefits for consumers and their healthcare providers

Establish a national personally controlled electronic health record system

Provide people – and the health provider they choose – to access their key health information, online – when and where it is needed

Enable people who choose to have a personally controlled electronic health record to register online from July 2012

Concept of Operations

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The UK Health Record

5

Proposed benefits:

Better care (improved clinical decision-making)

Safer care (reduced risk of harm, especially medication errors)

More efficient care (e.g., quicker consultations)

More equitable care (useful to patients unable to communicate)

Reduction in onward referral (e.g., avoidance of hospital admissions)

Greater patient satisfaction (by allowing people to state care preferences, receive better care)

But does it work?

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The UK PCR (HealthSpace) was built on the assumption that

• a significant proportion of patients will have the motivation and capacity to ‘self manage’ their long term condition using the PCR

• this will reduce costs to the NHS

• patients’ access to their PCR will contribute substantially to improving data quality

The findings show that few people are currently interested in using the PCR to manage their illness

It may be time to revisit all these assumptions

How do we avoid this result?

Key #1: Applications, not Data

Key #2: Follow the Internet Road

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“The dream behind the Web is of a common information space in which we communicate by sharing information. Its universality is essential: the fact that a hypertext link can point to anything, be it personal, local or global, be it draft or highly polished” (Tim Berners-Lee)

Designed from the beginning to have no central authority and to operate “while in tatters”

Cost the taxpayer little or nothing, as each node was independent and had to manage its own financing and its own technical requirements

Context is critical: What kind of future do we want?

Drivers for Reform Not enough

• Health promotion• Prevention• Early detection and intervention

Lack of• Access• Integration • Coordination

Reducing satisfaction• Consumers• providers

Increasing costs• Government• Individuals

Courtesy ANU Australian Primary Health Care Research Institute

Shifting focus to Primary Health Care

Encourage better chronic disease management

Support integration & multidisciplinary care

Make care more accessible

Improve the focus on prevention and early intervention

Use technology to support best practice

Build the evidence base for effective quality primary health care

Courtesy ANU Australian Primary Health Care Research Institute

Case Study: Transforming the Management of Chronic Disease

Chronic Disease: Big and Growing

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Major burden on the health system:Australia $60 billion; US $1,270 billion per annum

Drastic effect on quality of life, morbidity and mortality and a major economic burden in developed and developing economies:GDP Loss (2015): Australia $12B; US: $2,000B, China $75B

The Evidence: Chronically Ill Patients require Continuous Collaborative Care

The model of care for chronic illness recommended by the Royal Australian College of General Practitioners requires•Longitudinal, planned care•In collaboration with the entire care team•Including the patient•With regular follow up and review

Source: http://www.racgp.org.au/guidelines/sharinghealthcare

• Not enough time to handle the added complexity

• Too much paperwork and bureaucracy to meet Medicare requirements

• Too high a risk of negative Medicare audit• Distracts from patient needs

Why this doesn’t work: What GPs are telling us

Barriers to Best Practice CareToo much paperwork

Collaboration too time

consuming

Tracking adherence too

hardCollaboration

doesn’t happen

Annual MBS CDM Items per FWE GP (Australia)M

BS

CD

M It

ems

How can we change this situation?

Provide a means to

•Take away the complexity

•Make collaboration easy

•Remove the administrative overhead

•Help support the patient

•Ensure high quality, best practice care

The only way to achieve these objectives is to automate the end-to-end business processes

underlying the management of chronic disease

What are those processes?

End to End Disease Management• Assure the delivery of effective, efficient

clinical care and self-management support

• Provide navigation through the health care process

Planning• Identify relevant subpopulations for proactive

care

• Use planned interactions to support evidence-based care

• Embed evidence-based guidelines into daily clinical practice

Collaboration• Facilitate care coordination within and across

organizations

• Define roles and distribute tasks among team members

• Share information with patients and providers to coordinate care

Monitoring• Monitor performance of practice team and

care system

• Provide timely reminders for providers and patients

Review and Follow Up• Regularly assess disease control, adherence,

and self-management status

• Ensure regular follow-up by the care team

Patient Self Management• Empower and prepare patients to manage their

health and health care

• Involve the patient in assessment, goal-setting, action planning, problem-solving and follow-up

• Organize resources to provide ongoing self-management support to patients

To whom do they apply?

Kaiser Permanente CAD Trial, 12,000 patients

cdmNet

cdmNet: managing the full cycle of care

Hospital Patient

A web-based (“cloud”) service supporting collaboration across the entire care team

GP Care Team

• Extracts patient data from GP desktop

• Creates electronic, personalised, best-practice care plan

• Shares care plan and health record with care team and patient

• Monitors and updates care plan and health record

• Automates follow-up and review

• Supports patient self management

• Manages Medicare compliance

Team and Patient Contact Details

07/13/10 16

24

Clinical Information from GP Desktop

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Measurements from Full Care Team

Personalised Evidence-Based Plan

Simplified Review and Follow-up

Automatically Documented

Patient View

Intelligent Tracking and Alerting

Accessible Anywhere, Anytime

Team Progress Notes

GP initiatesGP initiates

Podiatrist requests plan changePodiatrist requests plan change

Diab Ed notes non-attendanceDiab Ed notes non-attendance

Diab Ed notes non-conformanceDiab Ed notes non-conformance

Diab Ed advises medicationsDiab Ed advises medications

Optician advises resultsOptician advises results

Diab Ed advises meds, non conformance, need to see GPDiab Ed advises meds, non conformance, need to see GP

GP alters meds in responseGP alters meds in response

Diab Ed advises medicationDiab Ed advises medication

CDMS Notes Shared across Care Team(example taken over 6 month period)

GP Performance Feedback

The Trials:Barwon South Western (Vic)

Eastern Goldfields (WA)

Making Care Planning Work

Results from Barwon South Western (Vic) and Eastern Goldfields (WA) trials (n = 13, t-test, p < 0.01)

Annual MBS CDM Items per FWE GP (Australia)Automation of care plans –easier than templates

Team Care Arrangements with one click No more faxing –

reviews are now easy

TCA reviews with one click

• 88-205% increase in GPMPs• 80-201% increase in TCAs• 310-595% increase in GPMP Reviews• 220-358% increase in TCA Reviews• PLUS all plans are best practice

• 88-205% increase in GPMPs• 80-201% increase in TCAs• 310-595% increase in GPMP Reviews• 220-358% increase in TCA Reviews• PLUS all plans are best practice

% G

PMP

Patie

nts

Rec

eivi

ng S

ervi

ce

Delivering Best Practice Care

Results from Barwon South Western (Vic) trial (n = 99)

• 103% increase in patients receiving HbA1c tests• 66% increase in microalbumin tests• 80% increase in HDL tests• 1595% increase in dietician services• 253% increase in podiatry services• 498% increase in medications review services

• 103% increase in patients receiving HbA1c tests• 66% increase in microalbumin tests• 80% increase in HDL tests• 1595% increase in dietician services• 253% increase in podiatry services• 498% increase in medications review services

Potential Benefits

Practice Benefits• Saves time: cdmNet increases productivity by 250%

• Eliminates paperwork: cdmNet automates all documentation

• Simplifies collaboration and review: cdmNet removes the overhead of collaboration, monitoring and review

• Improves safety and quality of care: cdmNet improves adherence to best practice guidelines

• Increases net revenues: regular users increase annual CDM revenues by over $35,000 per GP

• Reduces risk: cdmNet tracks patient care and facilitates Medicare compliance

• Maximises flexibility: cdmNet works in any practice environment

Economic BenefitsOver 10 years, diabetes alone, 50% uptake

• Benefits to Health System– GP MBS CDM Items: $680 million for increased services

– Allied Health MBS CDM Items: $580 million

– Hospital Productivity Savings: $600 million from reduced separations

– Patients: $4.8 billion from increased workforce participation

• Cost to the Commonwealth Government – $1,260 million for MBS CDM Items

– $2,280 million for PBS medicines

• Compensated by increased tax revenues– $2,930 million from taxes on individuals and their consequential

higher workforce participation rate

– $370 million from taxes on payments to healthcare professionals.

Evidence-Base Benefits

Policy Implications

Nothing will work alone

• Need to educate healthcare professionals of the benefits of collaborative care

• Need to adopt more effective practice processes

• Need to adopt proven change management principles across the entire system

• Need to measure benefits to drive uptake

• Incentives are key!!

Medicare Support

MBS Item Rebate Frequency

GP Management Plan $133.65 1-2 years

Team Care Arrangement $105.90 1-2 years

GPMP Review $66.80 Every 3-6 months

TCA Review $66.80 Every 3-6 months

Cycle of Care (SIP) $40/$100 12 months

Diabetes PIP $20 all Pt Calendar year

Practice Nurse Item 10997 $10.60 5 per year

Allied Health Incentives $50.95 5 per year

The Dilemma of Medicare Incentives

• Process improvement requires aligned incentives

• In CDM, Medicare provides special item numbers to encourage the key elements of the process

• But to access these adds further complexity and more processes

• Need effective IT support to “make the right thing to do the easy thing to do”

• And the incentives must properly align with desired outcomes! (careful market design)

Re-Designing the Model• Need to consider alternative incentive schemes

that reward practices and the care team for the providing the COMPLETE cycle of care, not just parts of it

• Need to gather the evidence to demonstrate quality of life and economic benefits

• Need to feed this back into policy and model design

• Proposed Coordinated Care for Diabetes Pilot a game changing opportunity – but only if built on world-best infrastructure and business processes

Where to from here?

Establish the Basic Infrastructure• Connectivity via standards (but flexible,

lightweight, future-proof)

• Healthcare Provider Directories

• Individual Healthcare Identifiers

• National Authentication Service

• Privacy legislation

• PCEHR Infrastructure – distributed, not driven by the acute sector

• Work with NeHTA foundations – they are moving in the right direction

Focus on High Priority Solutions

Convince Providers it is Time to Change

“Many health care providers believe themselves to already be doing “planned” visits. They note that their patients with chronic conditions come back at defined intervals. Upon closer inspection, however, these visits may look a lot like acute care.”

“The deficiencies of this approach include:•Rushed practitioners not following established practice guidelines •Lack of care coordination •Lack of active follow-up to ensure the best outcomes •Patients inadequately trained to manage their illnesses Overcoming these deficiencies will require nothing less than a transformation of health care”

The Chronic Care Model, MacColl Institute for Healthcare Innovation, Group Health Research Institute.

Forrester says “$34 B Market for Healthcare Unbound Technologies by 2015”80% is Chronic Care

Total

Acute

Chronic

ADL/elder $0.35 $0.37 $0.47 $0.59 $0.73 $0.98 $1.2 $1.6 $2.0 $2.4 $3.0 $3.7

$0.10 $0.13 $0.22 $0.38 $0.65 $1.2 $3.8 $12.1 $23.1 $26.3 $25.7 $26.7

$0.00 $0.00 $0.00 $0.00 $0.01 $0.02 $0.65 $2.0 $3.6 $3.5 $3.0 $3.2

$0.45 $0.50 $0.69 $0.97 $1.4 $2.1 $5.7 $15.7 $28.7 $32.3 $31.7 $33.6

(Numbers have been rounded)

$US(billions)

The Path Forward

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The PCEHR is only a part of the solution

Solutions are more important

Remember the internet

Contact and Acknowledgements

Professor Michael GeorgeffDepartment of General Practice, Monash UniversityCEO, Precedence Health CareEmail: michael.georgeff@precedencehealthcare.comPhone: +613 9023 0800

This work is supported by funding from the Australian Government under the Digital Regions Initiative and by the Victorian Department of Innovation, Industry and Regional Development under the Victorian Science

Agenda program.