exploring the business case for quality - how medical care can evolve to meet patient needs

www.healthtechcenter.org 1

Exploring the Business Case for Quality - How Medical Care Can Evolve to Meet

Patient Needs

Molly Joel Coye, MD, MPHFounder and CEO

Health Technology Center


The need for transformation:IOM Report - “The chassis is broken”

• You can’t get there from here:

“The American health care delivery system is in need of

fundamental change. The current care systems cannot do the

job. Trying harder will not work. Changing systems of care will.”

Winston Churchill had it right:

"The Americans will always do the right thing... after they've exhausted all the alternatives.”


Aligning environmental forces

Four Critical Forces:

• Information Technology• Payment - Reimbursement incentives

• Clinical knowledge• Professional Workforce


What didn’t work?

• Medical education and continuing medical education • Practice structure: medical groups and Independent Practice

Associations• CQI• Accountability: measures and reporting• Information systems and physician profiling• Physician compensation and financial incentives

• And why?– US healthcare market organization– leadership and culture– technology capabilities and support– consumer interest and pressure


CQI: The Intermountain Health System Story

Brent James: LDS Hospital, Salt Lake City, Utah

• 60 CQI projects over 10 years that were successful:– improved quality outcomes and patient satisfaction– narrowed variation and almost always reduced costs– only 2 were ever disseminated beyond index institutions

• Why? - Example of antibiotic use to control pneumonia in hospital– reduced adverse events associated with antibitotic errors by 30%.– reduced mortality of patients treated with antibiotics 27%.– reduced overall antibiotic use by 23%.– reduced antibiotic costs per treated patient by 58%.

Chassin, Health Affairs 5/97


The IOM Report: Information technology improves quality

• Safety Computerized physician order-entry reduced adverse drug events by 55% (Bates, 1998)

• Effectiveness Reminder systems and computer assisted diagnosis and management improves compliance with practice guidelines (Durieux, 2000; Evans, 1998)

• Patient-Centered Internet can provide access to clinical knowledge, online support groups,customized health education and disease management messages


The IOM Report: Information technology improves quality

• Timeliness mothers receiving computer-generated reminders had 25% higher on-time immunization rate for their infants (Alemi, 1996)

• Efficiency 9% of redundant lab tests at a hospital could be eliminated using a computerized system (Bates, 1998)

• Equity Internet-based health communication can improve access and provide a broader array of options for interacting with clinicians


The IOM Report: Information technology strategies

• There must be a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education.

• This commitment should lead to the elimination of most handwritten clinical data by 2010


IOM: What will be required ?

Inside healthcare organizations: • Re-organize operations around core clinical processes

– E.g., Pregnancy and delivery, diabetes ...– Reflect patient AND provider experience

• Align measurement - external reporting as a sub-set of operations data (SEC / FASB)

• Integrate ‘pieces’ of care - the patient as hub, not the site of care



The external environment = purchasers, regulators

• Align payment– budget, not FFS at organization level– option: reflect clinical processes

• Align consumer information

• Give consumers more discretion– fate of defined contribution???

• Align payment



The common denominators are:

• consumers and providers (and purchasers) get information that is meaningful for– selection of providers = BUSINESS CASE– improvement = knowledge

• payment (price, volume) rewards improved performance for meaningful units of care

– budgets for populations– payment to providers for care processes– actuarial versus performance risk

• Leapfrog Initiative– volumes/cardiac procedures

– Intensive Care staffing

– CPOE


IOM + Quality Forum: Action at the health system level

Health Delivery System Steps

• Link information systems to clinical processes and financial analyses

– build registries

– support clinical practice: acute and ambulatory care

– adopt new technologies in concert

• Focus on variation:

– capacity to detect

– capacity to assess

– capacity to change

• Focus on quality waste

• Build the internal business case while waiting for the external environment to change

Knowledge about Processes and Results

Purpose

Goals

Results(Performance)

Knowledgeabout

Performance Motivation

ConsumersPayers

RegulatorsPatients

ContractorsReferringClinicians

Etc.

Organizations

Selection Change

• Process Improvement• New Design• ProcessControl Measurement

for Selection Improvement

Care Delivery Teams

and Practitioners


Churchill also said, "Give us the tools and we will finish the job."

• Now we have new tools - technologies - with which to make these changes

• IOM Committee on Quality of Healthcare in America:

technology is no longer an option - it is an imperative• Healthcare leaders feel the pressure to change (Leapfrog) -

– pipeline of technologies overwhelming

– strategy options not easily apparent

– and traditional methods of technology adoption no longer work

• So..which tools? Which technologies?


Which tools, which technologies?

• Information Technology – ICU in a gurney

• Devices – Hepatic dialysis

– Polymers

• Pharmaceuticals– Inhaled insulin

• Biotechnology


Technology as strategy

• A tool is not a strategy• Strategies involve disruptive technologies

– radical disruption of business models and customer experience

– make care radically better and cheaper for the consumer

• The puzzle of the open market in healthcare:– ‘orphan technologies’ - NAS/IOM study– emerging business case for quality– emerging business case for cost reduction

• learn from the developing world -

employ technology for intentional change


Strategies for intentional change in the US

• Current pace of innovation and adoption so slow that– National Academies’ Board on Science, Technology and Economic

Policy and

– IOM Board on HealthCare Services

– convened special project to identify public policies needed to “stimulate the development, adoption, and diffusion of high-value medical innovation.” (June 2001)


Intentional, disruptive change - which tools for chronic disease?

Sam steps onto scale. “Good Morning, Sam.” Scale reports weight, sends over web, reports progress & gives tailored Yes/No survey. Takes ~20 seconds

Sam’s nurse reviews symptoms, provides assistance or notifies Sam’s MD.

MD receives alert reports, adjusts Rx, revises surveys or initiates a visit. Substantial savings in emergencyvisits and hospitalizations.


But tools are not strategy

• Strategy speaks to how we will – select tools

– finance them

– learn to use them

– and why

• Sensible strategies in the face of overwhelming possiblities involve collaboration - – turn fragmentation into a virtue

– health systems form a national network of laboratories \

– need systematic harvesting and dissemination of learnings


Strategy I: Check each technology against the IOM six aims for quality improvement

• Safe • Effective• Patient-centered (who defines…)

– Heart Scan– Fully half of all adults polled interested in genetic test for a very serious

disease even if there was no known treatment or a way to prevent it. – Would spend $300-400 for testing if treatment was available

• Timely• Efficient• Equitable

= the ringer

cost

diffusion

IT

Clinical technologies


Strategy II: Check each technology against the ‘three-legged stool’

• Quality – orphan technologies

• chronic disease monitoring and remote patient management• Intensive Care staffing - Visicu.com

• Cost – Where quality improvement

• narrows variation, • eliminates error and • decreases process time

• Access

• and the fourth leg: consumer demand


Strategy III: Check for drag

• Barriers - and solutions - are cross-industry• The checklist:

– Culture

– Guild

– Lack of Toyotas

– Quality hazards of implementation

– Contradictory reimbursement schemes

– Capital - human and financial

– Leadership

– Uncertainty - (Churchill again)

"True genius resides in the capacity for evaluation of uncertain,

hazardous and conflicting information."


Strategy IV: Build national leadership

• Urgency stressed by the NAS - IOM project• Value underscored by research on the value of innovation• Industry-wide strategies:

– Provider systems and health plans• Leadership• Standards• Toyotas• Professional commitment• Collaboration in learning networks

– Developers • Strategies• Crash projects for development to solve industry problems

– Government strategies –• Standards• Coverage, reimbursement, conditions of participation• Financing - new investment strategies


Strategy VI: Develop forecasting information for delivery system leaders

Strategic information, from a new non-profit -The Health Technology Center

– Nature of scientific advances– Clinical program impacts– Probable products and services– Potential impact on delivery systems: clinical programs, facilities,

workforce and market strategy – Potential impact on insurers: cost, coverage and reimbursement– Staging: timeline, promoters and inhibitors, sentinel events, wild cards– Leading companies developing technology, potential partners– Strategic assessment: options, migration pathways


HealthTech Reports 2001-2002

Completed Reports• Minimally Invasive Surgery• Drug Delivery Devices• Sensors for Monitoring• Organ Assistance and Substitution• Stem Cells• Genetic Testing• Imaging• Tissue and Fluid Bioengineering• PACS and CAD• Point of Care: Mobile Computing• Networking• Cancer Pharmaceuticals and Biologics

Now Underway:

• Robotics

• Remote Patient Management

• Security Technologies

• Cardiovascular Pharmaceuticals

• Anti-infectives


Clocking the strategy - vision and tactics

The vision is: To achieve a threshold change in the quality of

healthcare within this decade; major change within 5 years.

The change model is mostly hydraulic:– increase the pressure to change Leapfrog, HCFA, health plan

negotiations– remove barriers reimbursement incentives,

technology investment– build the ‘escape hatch’ practical options: migration

paths to quality– definitely unpredictable who would have thought the

VA would lead?– potentially explosive physician reaction, lawsuits,

legislation


Strategy VII: Build migration pathways

• Operating visions will span– quality aims

– clinical processes

– infrastructure

– leadership and organization

• Multiple pathways for each vision– segment by relevant differentiation among shareholders

– tactical choices understood in context

– tactical choices supported by relevant VHA analyses

5 year migration pathway 5 yrs 10 yrs

Quality healthcare: from vision to reality in a decade

strategic objectives

visionary goals

tactical choices


A new architecture for healthcare: Axis 1 = the IOM six aims for quality

Safe 5 yrs 10 yrs

Effective 5 yrs 10 yrs

Patient-centered 5 yrs 10 yrs

TimelyEfficientEquitable

hand-heldprescriptionlookup; phamacy screening

CPOE ambulatory prescriptionselectronic entry

clinical processesdefined, patient registries built

15 chronicdiseaseprogramsimplemented

ambulatory/in-homechronic disease monitoring


A new architecture for healthcare: Axis 1 = the IOM six aims for quality

Safe 5 yrs 10 yrs

Effective 5 yrs 10 yrs

Patient-centered 5 yrs 10 yrs

TimelyEfficientEquitable

hand-heldprescriptionlookup; phamacy screening

CPOE ambulatory prescriptionselectronic entry

clinical processesdefined, patient registries built

15 chronicdiseaseprogramsimplemented

ambulatory/in-homechronic disease monitoring

IT STRATEGY - investments - workforce - leadership


A new architecture for healthcare: Axis 2 = clinical processes

Pregnancy and Delivery 5 yrs 10 yrs

Cardiac Care 5 yrs 10 yrs

Diabetes 5 yrs 10 yrs

IOM 15 priority chronic conditions+80-20 rule for your institutions, populations

C/S rate, variation

genetictesting

genetic therapy

cardiac registriesestablished

endovascularsurgerycertification achieved

ambulatory and in-homemonitoring; angiogenics

X Y pancreatic transplants, stem cell


Noninvasive continuous

glucose monitor FDA

approved

Two Sensor Applications: Technology Timeline

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Noninvasive continuous

glucose monitor

developed

Noninvasive continuous glucose monitor becomes

community standard

Smart clothes FDA approved

Smart clothes become

“accepted therapeutic

choice”

Cygnus’ GlucoWatch Biographer

Smart clothes developed

Long-term implantable

glucose monitor developed


glucose monitor FDA

approved


glucose monitor becomes

community standard

Sensatex’s Smart ShirtChipRx’s Schematic of a Self-Regulating Responsive Therapeutic System


The VisionThe Vision

Advance the use of new technologies to make people healthier

Strategic PartnersSutter Health Providence HealthKaiser Permanente Carolinas HealthGroup Health of Puget Sound Peace HealthVHA Inc. California Public HospitalsAscension Health Institute for the FuturePremier, Inc. Wellpoint Health NetworksHCA CareScienceMarkle Foundation HRETMills-Peninsula Health System ECRISequoia Healthcare District Parkview HealthMilbank Foundation The California Endowment


Just give us the tools…

The future is here. It's just not widely distributed yet.

exploring the business case for quality - how medical care can evolve to meet patient needs

Documents

consumer health

health affairs

customized health education

medical care

systems of care

clinical education

health services research

orgthe iom report