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