intersystemsin healthcare seminar 2013 医療連携・地域包括ケ … · microsoft powerpoint -...

InterSystems in Healthcare Seminar 2013

医療連携・地域包括ケア推進フォーラム

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Goals of presentation

1. Provide overview of global health systems

2. Outline the IDEA steps for population health management

3. Discuss the importance of strategic interoperability

4. Explore the concept of engaged communities

5. Describe how analytics for action can improve population health

creative partner for technology breakthroughs• 35 years

• offices in 25 countries

• customers in over 100 countries

• $500 million in revenue

• value long-term relationships

1) Percentage of population over 65y2) Role of the primary care physician3) Care coordination efforts4) Status of electronic health records

Population: 62.2M Primary Care: first point of contact, gatekeepers to specialistsOver 65y: 16.5% Care Coordination: NHS Health and Social Care Act 2012EHR Use: 97% Quality and Outcomes Framework



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Population: 9.4M Primary Care: no formal gatekeeping, but first point-of-contact,Over 65y: 18.3% shift from inpatient to outpatient and day treatment facilitiesEHR Use: 88% Care Coordination: 0-7-90-90 rule to improve access and quality

Population: 309.1M Primary Care: highly depends on insurance plan Over 65y: 13.1% Care Coordination: shift towards patient-centered andEHR Use: 69% accountable care models that share costs and risk

Population: 127.1M Primary Care: patients select physician under “Free Access”Over 65y: 23% Care Coordination: financial incentives for post-discharge careEHR use: 20%

UK Sweden UnitedStates

Japan

Elderly Population 16.5% 18.3% 13.1% 23.0%

Primary Care Provider Yes Yes No No

Primary Care as Gatekeeper Yes No No No

Care Coordination Efforts National National National National

Status of EHR Use 97% 88% 69% 20%

Japan

Elderly Population 23.0%

Primary Care Provider No

Primary Care as Gatekeeper

No

Care Coordination Efforts National

Status of EHR Use 20%









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Analyze Engage

Steps for Population Health Management

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Patients change…Populations change







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Traditional Interfacing:a handshake between applications thatfocuses on synchronizing applications

Strategic Interoperability:each application is unique with specific data requirements

Five Rights of Strategic Interoperability:

Right dataRight amountRight personRight timeRight action

Average patient sees 2 primary care physicians, 5 specialists, in 4 different practices

N Engl J Med 2007; 356:1130-9

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Prenatal• Community Practices• Affiliated Practices• NSLIJ Faculty Practices

Labor & Delivery

• Perinatal EMR

Inpatient Postnatal

• Inpatient EMR

Post-Partum

• Community Practices• Affiliated Practices• NSLIJ Faculty Practices

Imaging Centers

Prenatal

Labor & Delivery

Inpatient Postnatal

Imaging Centers

Post-Partum

InterSystems HealthShare









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Engaging Patient Population = Care Coordination

1. Connects patients to their health records2. Allows multiple caregivers to participate3. Anticipates medical needs4. Distributes relevant information5. Empowers patients as consumers



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A primary care provider needs to interact with 229 physicians and 117 different practices to care for entire panel of patients.

Ann Intern Med. 2009 Feb 17;150(4):236-42

Engaging Provider Community = Care Coordination

1. Improve patient care2. Reduce costs3. Improve population health



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Steps for Population Health Management Retrospective data will only tell you where you have been.

It will not keep you moving forward.

Tracking the Delta

Prescription

Written

Prescription

Filled/RefilledCompliance

Appointment

Scheduled

Patient

RegistrationMissed F/U

Lab Result

Delivery

Ancillary Studies

ScheduledMissed Study



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