Collaborative Care:

An Economic Imperative for Care

Delivery Systems

Mark Blatt MDWorldwide Medical DirectorIntel Corporation February 2012

Collaborative Care: An Economic Imperative for Care Delivery SystemsAgenda

Current Trends

The Evidence for Care Coordination

Going mobile to Coordinate care• Right Device for Right task• Collaborative workflows• Compute Model matters• Secure Mobile computing

Summary

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The Current Environment

Is Solo Practice a failed Business model ?

Has Fee for Service meet its Limits?

• Mandatory penalties. State AGs sue in civil court– Starting at $100 per violation

($25k/yr) going up to $50,000 repeat violations w/ “willful Neglect” ($1.5M/ yr)

• Projected PHI is essentially ”encrypted PHI”

• Mandatory Reporting with 60 days and publication at HHS Breach site for violations >500

Hi-Tech Breach Notification

2. HiTech Act, Division A Title XII, Subtitle D Part 1 Sections 13401-11

http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/postedbreaches.html

Breach Notifications Week of June 1

Hospital Readmissions(We Don’t Do a Good Job Here)

Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days

34.0% were rehospitalized within 90 days50.2% of the patients who were rehospitalized within 30 days

after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization

Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition

About 10% of rehospitalizations were likely to have been plannedThe average stay of rehospitalized patients was 0.6 day longer than

that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously

Authors estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion

N Engl J Med 2009;360:1418-28.

Beginning October 1, 2012, DRG payments to hospitals who have “excess” readmissions for certain conditions will be reduced.

The floor adjustment factor will be 99% for fiscal year 2013, 98% for 2014, and 97% for fiscal year 2015 and thereafter.

First three conditions to track AMI, heart failure and pneumonia.

October 1, 2014, the list expandsCOPD (chronic obstructive pulmonary disease), CABG (coronary artery bypass graft),PTCA (percutaneous transluminal coronary angioplasty), and other vascular conditions.

Section 3025 – Hospital Readmissions

3. The Patient Protection and Affordable Care Act (HR 3590 enrolled: Sec 3025)

Coordination and Collaborative

Workflows

The Evidence

Controlling Costs Starts with Better Management of Chronic Diseases

• Medicare beneficiaries with multiple chronic illnesses see an average of 13 different physicians• Fill 50 different prescriptions a year• Account for 76% of all hospital admissions• Account for 88% of all prescriptions filled• Account for 72% of physician visits• And are 100 times more likely to have a preventable hospitalization

than someone with no chronic conditions

Testimony of Gerard F. Anderson, Ph.D., Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, before the Senate Special Committee on Aging, “The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007).

We must improve management of Chronic Diseases through

Better Care Coordination

How Physicians Currently Use Mobile Device(s)

11 QuantiaMD* Research Report, “Tablets Set to Change Medical Practice”, June 15, 2011. See www.quantiamd.com/q-qcp/QuantiaMD_Research_TabletsSetToChangeMedicalPractice.pdf

“Super-Mobile” Physicians drive higher utilization,demand tablet access to sensitive patient data

Patients Report Experiencing Poor Coordination

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.

Percent U.S. adults reported in past two years:

No one contacted you about test results, or you had to call repeatedly to get results

Test results/medical records were not available at the time of appointment

Your primary care doctor did not receive a report back from a specialist

Any of the above

25

21

19

15

13

47

0 20 40 60

Doctors failed to provide important medical information to other doctors or nurses you think should have it

Your specialist did not receive basic medical information from your primary care doctor

37

7582

6168

62

76

0

25

50

75

100

AUS CAN GER NETH NZ UK US

Commonwealth Survey of PCPsHow does the US compare with other in communications

Percent reporting that they receive information back for “almost all” referrals (80% or more) to Other Doctors/Specialists:

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Evidence for Care Coordination

2007 prospective cohort study of 756 patients with “life-limiting illnesses ” in California• In the “patient-centered” group (358):

– 38% fewer admissions– 36% fewer inpatient days– 30% fewer ED visits

• 26% lower cost

Sweeney L, Halpert A, Waranoff J. Patient-Centered Management of Complex Patients Can Reduce Costs Without Shortening Life. Am J Manag Care. 2007;13:84-92.

ED Visits by Source of Care and Income

http://www.aafp.org/afp/2009/0115/p94.html

Evidence for Care Coordination

Geisinger Health System in Pennsylvania• 36 primary care practices with NCQA

Level 3

PCMH certification vs. control practices• Positive results:

– 40% reduction in 30-day readmissions– 20% reduction in (total) admissions– 7% lower costs

Arvantes, J. Geisinger Health System Reports That PCMH Model Improves Quality, Lowers Costs. AAFP

News Now. May 26, 2010.

New West Physicians (Denver, CO)

76 Providers (41 FP, 17 IM, 8 Hospitalist, 10 mid levels)Level 1 PCMH NCQA (pending) • Extended Hour and After hrs Access (24x7)• EMR is all offices connected to hospital, labs, path• EPrescribing and electronic prescription delivery • Quality improvement CDM programs

• $4.4M cumulative HIT investment ($11M incr. rev ‘07-’09)• Centralized coordinated Post discharge and follow up with 24 hrs

(including we deliver your meds)• Daily team meetings: 30 minute review of the day

RESULT: 1% 30 day readmit rate (usual 6-18%+)

American Hosp Association Jan 2011 ACO Case Study: New Physicians West

Collaborative Workflows

Example Use Cases

To Support Care Coordination for Better Outcomes, Mobilized Data is Critical

Gather & Store Data

Share the Data

Mobilize Data

EMPOWER citizens

End-To-End Story Care Coordination Across the Continuum

Mobile Data is Critical

Personal Health Record

Patient-Centric Care

Electronic Health Record

Data Repository

Clinical Decision Support HealthCheckup

Self Check& Control

Home

Emergency

RemoteDiagnostic

Clinic

Community Hospital

Academic Hospital ResearchPharmacy Long term

Care

Visiting Care

DataExchange

DataExchange

Right Form Factor/Capabilities for the JobS

IZE

FUNCTIONALITY

NotebooksUltrabooks

Smartphones and Handhelds

Simple forms, data collection/viewing,

small media

Multi-FunctionImmersive/Visual Internet

Some Convergence Basic/Medium Internet

Disinfectable, sealed, rugged, Barcode, RFID, Handwriting

In Hand UsageFrequent/ Short Sessions

Table Top UsageFewer/Longer Sessions

USER EXPERIENCE

Tablets

Medium forms, data collection/viewing, media

Pock

eta

ble

Port

able

MCA+

Content creation,

collaboration manageability, image editing

+MCAs have a variety of processors from Atom to Core i5 & i7 vPro

Netbooks

Significant data entry, medium data collection/ viewing, media

What Real time Collaboration Might look like

Possible Collaborative Workflows

• EMS: Treat in place: EMT/ doc / homecare nurse/ community care worker

• ED Discharge to home : doc/ homecare nurse/ community care worker

• ED Admit: ED nurse / floor nurse / transportation

• Consults Acute inpatient: doc/doc/therapists/ pharmacist/ etc)

• Consults Chronic Disease outpatient: doc/ doc/ therapists/ homecare nurse / community care worker/ etc

• Homecare: doc/ homecare nurse/ community care worker

Terminal Services

Virtual Hosted Desktop

Virtual Container

OS Image Streaming

Application Virtualiz-

ation

Healthcare Security & Privacy Across Desktop Virtualization Options

PHI at Rest ServerServerServerClient

or ServerClient

or Server

Able to WorkOffline Yes Yes No No No

Manageand Patch CentralizedCentralizedCentralizedCentralizedCentralized

Risk IsolationStrategy

Client / Server

Client /Server

Client / Server

Virtual App Isolation

Virtual Containers

2nd Generation Intel® Core™ vPro™ Processor Family Based PCs Support ALL Desktop Virtualization Models

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User SessionAvailability

Data Sync with Server

Data Sync with Server

Session on Server

Session on Server

Session on Server

2Enterprise VDI

Cloud

(1) User RequestsVirtual Desktop

(2) VDI Cloud Svc QueriesDevice Media, GFx, Network Capabilities

(3) If High End Client andLow BW connection,then render/decode locally on client

(4) If Low End Client & High BW connectionthen render/decode in DCand stream bitmap

Local App

Central Data

Low Server Utilization (1%)

Redirected Media (MMR)

Client SideServer Side

The Case For MMR (Multimedia Redirect)

Streaming and Virtual Hosted Desktop Study:Phase 2

IT@Intel White Paper, Intel Information Technology Computing Models, April 2010

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Secure Mobile Computing (MPOC) and Care Collaboration

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Mobility Drives Higher Need for Protection

Frequent2M laptops/year are reported as stolen and 97% are never found23

Costly The average cost of a lost laptop is $49,24624

Often from the inside70% of all reported security breacheswere due to insiders25

78% of US organizations have some type of

encryption strategy in 2009, up from 66 percent in 200726

>59% of respondents say it is very important to encrypt employee’s

mobile devices26

23 Source: Processor, May19,2006. http://www.processor.com/editorial/article.asp?article=articles/P2820/30p20/30p20.asp&guid=024E96876DB944D89AA42906DB9FFE84; 24 Source: Ponemon Institute , April 2009 , http://communities.intel.com/docs/DOC-3076 ; 25 Source: CNET News.com, from Ponemon Institute Survey (163 F1000 companies) ,January 2005, http://forums.cnet.com/5208-6132_102-0.html?threadID=56566 ; 26 Source: Symantec Global Internet Security Threat Report Trends for 2008,Volume XIV, Symantec, April 2009 http://eval.symantec.com/mktginfo/enterprise/white_papers/b-whitepaper_internet_security_threat_report_xiv_04-2009.en-us.pdf

BIG QUESTION: PHI (CHI) on the Client? As data is more portable it is more susceptible to being lost or stolen.

Improved Security Central Manageability Fast Provisioning Network Security and Reliability Bandwidth Requirements

Flexible compute models Online/Offline data access Remote access Cost of Downtime / Data Loss Security Regulatory requirements

NO PHI on Client/ Thin only PHI on Client/ Rich compute

Placing PHI on Client requires Balancing Multiple Tensions

Data Breaches In Georgia

30http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/breachtool.html

Protecting Mobile PHIIntel Hardware Enabled Security Technologies

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• SSD (Solid State Drive) with AES: high performance, low power, robust, encrypted solid state drives

• AES-NI (Advanced Encryption Standard – New Instructions): high performance encryption of PHI at rest, in use, in transit IPT (Identity Protection Technology): strong 2-factor authentication

• Anti-Theft: mitigating loss or theft of client with PHI• vPro AMT (Active Management Technology):

improving manageability and compliance• VT/TXT (Virtualization and Trusted Execution

Technologies): protecting server confidentiality and integrity in a virtualized / cloud environment

EHR Client

AES-NI

IPT Client

Anti-Theft

vPro AMT

EHR Server

AES-NI

IPT Server

VT / TXT

HealthInfo

Exchange

SSL/TLSor IPSec

SSL/TLSor IPSec

SSD(AES)

Intel® Anti-Theft Technology

Protection: Tamper-resistant security feature in laptop hardware that detects potential theft and disables itself.

Non-Destructive: When returned, the laptop can be easily reactivated without harming laptop or data.

Owner Recovery Message: Disabled laptop can display unique recovery message and contact information to return laptop to its owner

Track, Manage & Recover laptops Enhanced Data Encryption solutions for Business

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SUMMARY

Mobile computing is more than simple data look up. Different devices for different tasks

Data consumption/ creation at the point of care are a good start

Collaborative workflows are where you want to go

Security when going mobile is paramount. Encryption and two factor authentication are good starts

Balanced compute models that take advantage of central server manageability and security with client side execution, lowers IT costs, and can improve the end-user experience

GATHER SHARE MOBILZE EMPOWER

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