The Future of Health Care
Matthew Morgan MD, MSc, FRCP(C), FACP
Vice President, Patient Experience and Outcomes,
Mount Sinai Hospital, Toronto, Canada
Chronic diseases constitute a significant burden
The Health Care Gap: Evidence reveals a significant gap between
and are not being managed well.
recommended care and care actually delivered.
A significant health system challenge
 50% of adults live with chronic illness
 80% of adults over age 65 have a chronic
disease
 60% of hospitalizations are due to chronic
disease
 2/3 of medical admissions via emergency
are due to exacerbation of a chronic
disease
 80% of family doctor visits are chronic
disease-related
 60 to 80% medical costs are related to
chronic disease
… and the quality of care varies
substantially
76
Breast Cancer
73
Prenatal Care
Coronary Artery
Disease
68
65
Hypertension
58
COPD
49
Hyperlipidemia
45
Diabetes Mellitus
Alcohol
Dependence
11
0
25
50
75
100
Percentage of recommended care received (US data)
Source: McGlynn et al. NEJM 2003
Patients with chronic diseases do not receive recommended
health care.
Diabetes care in six countries
CAN
AUS
NZ
UK
US
GER
%
%
%
%
%
%
A1C in last 6 mos.
90
86
79
85
90
91
Feet exam in last year
52
57
66
75
70
65
Eye exam in last year
73
73
66
83
69
85
Cholesterol checked in last
year
91
93
87
92
92
95
38
41
40
58
56
55
Indicator
All 4 services received
In last year
Source: Schoen et al. (2005) “Taking the pulse of health care systems: experiences of patients
with health problems in six countries.” Health Affairs.
3
The Chronic Care Model requires system transformation, physician
leadership and high performance team work.
Source: www.improvingchroniccare.org
4
Physicians, Health Care Organizations and Patient Populations
must be effectively organized to deliver integrated health care.
Health Care Trends
• Shift in focus from acute care to community
– Acute care facilities no longer sole decisionmakers
Community
• Single accountability for the well-being of a
region’s population health
– Improved integration of health services
between provider organizations
– Significant consolidation of services, resulting
in increased purchasing power
Health Care
Organizations
Health Care
Providers
– Further consolidation to continue
within/between health regions
• Increased need for an EHR to support
integration across the continuum of care
The future of health care requires integration and
coordination of general community, health care
organizations and health care providers
Implications
• Need population-based health regions with the integrated leadership, structure and
authority to drive large-scale health care improvements
• Need to enable primary care reform to support population-based health care delivery
• Need a smart informatics approach with a longitudinal EHR
• Need to incent high performance teams to deliver high quality, safe, efficient care
• Need to engage patients in the design, delivery and improvement of health care
delivery
5
Successful physician engagement is an art, science and essential skill
for health care managers and leaders.
6
www.ihi.org
To establish a successful performance improvement program,
three elements are required.
Access to timely, high
quality data that can
be analyzed and
interpreted
Data
Skills
Performance
Improvement
Methodology
Analytical capabilities to
interpret and use data for
identifying, prioritizing and
implementing operational
improvement interventions
Planning &
Incentives
Integration of performance improvement targets and accountabilities into operational plans,
performance objectives and incentive programs
Using data to inform and monitor performance improvement activities must be
embedded in management structures and processes
7
There are some common pitfalls that inhibit leaders from
effectively using information to drive performance improvement.
The content of reports is based on what data is available, not what actions need to be informed
• Many reports are generated, but few are regularly used to drive decision making and management action
• The indicators reported are not linked to performance improvement objectives
• Poor data quality renders some reports unusable
Reports are generated, but data is not thoroughly analyzed and interpreted
• Point-in-time graphs and charts are created, but few actually present data that enables managers to draw conclusions and plan and
implement interventions to improve performance
• Content of the reports is useful, but there is a lack of skill in interpreting and using the data to prioritize and implement interventions
to improve performance
Finger pointing ensues when performance is poor
• Focus is on blame for poor performance, rather than on identifying opportunities to improve
• Accountability for moving the performance of an indicator is not assigned to any one individual
• Accountability for performance is assigned to individuals that do not have the authority/capability to affect an indicator
Improvement efforts run in parallel to line management structures responsible for operations
• Improving performance is seen as additional work, above and beyond standard management responsibilities
• Line managers are not held accountable for performance improvement in their departments
• Individual incentives are not aligned with ability to improve performance
8
Diabetes Patient Registry
A Case Study in Physician Leadership
(people, processes and technology)
9
The objective was to identify and remove care gaps in the
management of chronic diseases and issue reminders to patients
and providers.
Context
•
A large New York public healthcare system, consisting of 11 acute care hospitals and
providing services to nearly 1.3 million people, established as a priority, the provision
of better care to chronic disease patients
•
Develop a chronic diseases patient registry and manage its implementation through
stakeholder engagement, workflow assessments and software development
•
In partnership with management, IT, physicians and the clinical teams developed a
system:
– Generates call lists for providers to contact high-risk patients who are not
receiving care based on clinical best practices
– Issues reminders to patients by automatically generating letters
– Provider reports that support improved management of chronic diseases
– Facility and system-level reports to support population-based planning for
services, care models and resource allocation
10
Performance indicators were established for each chronic
disease by a consortium of clinicians, led by physicians.
11
Benchmarking data are provided to physicians and care teams as
well as care gap reminders.
• Care teams are provided
with peer benchmarking
data to ensure consistency
of care
• The comparative data
must be presented in a
manner that’s easy to
understand
• Each care team manages
the list of their patients
with chronic diseases
• Reminders are provided to
care teams and
automatically mailed to
patients to support
management of their care
12
Indicators are summarized at a facility and system-level to monitor
performance and support target setting and accountability agreements.
Care Team-Level Indicators
Facility-Level Indicators
Network-Level Indicators
13
Reporting physician engagement over time helps ensures adoption.
Patient Registry User Enrollment and Utilization
90
80
300
User Enrollment
70
250
60
50
200
40
150
30
100
Unique User Logons per month
350
20
Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06
User Enrollment
• In the first six months
• User enrolment increased by 33%
• 10% month over month average increase in unique user logons
14
Increased use of the diabetes registry correlates to improved
patient care.
Comparison of Average Diabetes Indicators for Top Ten Physicians’ Care
Teams versus All Care Teams
Percent diabetic patients meeting criteria
60%
• The ten care teams who
used the diabetes patient
registry most frequently
had a higher percentage
of their diabetic patients
receiving care according to
clinical best practices
50%
40%
30%
57%
43%
20%
30%
10%
30%
23%
22%
0%
HbA1c
LDL
BP
Diabetes indicators
Top 10 Users Care Teams
All Care Teams
A Physician’s Perspective: To improve quality and decrease cost, the four
roles of the doctor must be separated and disrupted by innovation.
Osteosarcoma / Epilepsy / Rare diseases
›
›
›
›
›
Skill and judgment (specialist)
Scientific advancement
Disrupt with centres of excellence
eHealth enabled with e-referral,
synoptic data analysis, data mining,
networks, tele-consult
Reimburse with fee for service
Cataract Surgery / Inguinal Hernia / M.I.
›
Rules-based
precision
medicine
Intuitive
medicine
›
›
›
Disrupt with retail clinics and solution
shops
Disrupt with application of E.B.M.
eHealth enabled by AI (protocols,
pathways, CDS), telemedicine
Reimburse with fee for service + / pay for outcomes
Doctor
Diabetes / Depression / Obesity
›
›
›
Immunizations / Cancer Screening
Disrupt with network facilitated
business models
eHealth enabled by CDS, registries, telehealth, PHRs
Reimburse with fee for membership /
service as well as pay for outcomes
Oversight of
chronic
disease
Wellness
and
preventive
health
›
›
›
›
Disrupt with onsite technology
Disrupt with solution shops and value
add processes
eHealth enabled by CRM, populationbased registries
Reimburse with fee for membership /
service as well as pay for outcomes
Level 1 Quality: Reliable performance
Level 2 Quality: Convenient, affordable and responsive
Innovator’s Prescription, A Disruptive Solution for Health Care, Christensen 2009, Figure 4.1, p. 113
Patient and Family Centered Care
Understand the
patient experience
through meaningful
engagement
Deliver a patient
experience that
exceeds expectations
Patient-Family
Experience
Measure the patient
experience and recognize
value and achievement
Enhance the
patient experience
through best practices
and innovation
Engage patients and families as partners in the design, delivery and improvement of patient care
Create and sustain a culture in which all express ownership and responsibility for the experience
Thank you
mmorgan@mtsinai.on.ca