future of clinical neuroscience: chasing perfection
TRANSCRIPT
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FUTURE OF CLINICAL
NEUROSCIENCE:
Chasing Perfection
Neil A. Martin, MD
Geisinger Health System
Director, Neuroscience Institute
System Chief Quality Officer
August, 2017
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Disclosures
• Karl Storz / GCQ: Consultant (informatics)
• VisionTree: Equity holder
• Surgical Theater, Equity
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Geisinger Health System 3
What we doGeisinger Health System: Integrated health system, $6.5B
We care for patients
12 hospital campuses
216 clinic sites
2,500 providers
We provide quality,
affordable healthcare coverage
• 581,000 members
• 60,000 contracted
providers/facilities
We teach, research and innovate
• 504 students
at GCSoM
• 475 residents/fellows
• 900+ active research projects
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Geisinger Health System 4
Where we do it
Geisinger sites
Contracted sites
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Geisinger Health System 5
Our strategy
Patients & members Provide the best care to our
patients and members
Geisinger family Engage and fulfill all
members of the Geisinger
family
Financial health Achieve and maintain
the financial health to
fulfill our purpose
Markets Lead in our markets so
our friends and neighbors
get the best care
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Who wants average healthcare?
We want the best, not just average.
In fact, we want perfection.
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We are going to relentlessly chase perfection,
knowing full well that we will not catch it,
because nothing is perfect.
But we are going to chase it, because in the
process, we will catch excellence.
We are not remotely interested in just being
good.
VINCE LOMBARDI
Hall of Fame Coach
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Excellence is the gradual result of always striving to do better.
Pat Riley
NBA Champion as player, coach, and team president
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What if surgeons could rehearse
every operation on patient-
specific virtual simulations?
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First
Proficiency Virtuosity
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What if surgical residents could learn and practice every operation until they were proficient, even flawless –before ever touching a patient?
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Suction
Point #12/3 of the
distance to the
distal margin of
the hematoma
Right
Supraorbital
Burrhole;
Eyebrow
incision
Documentation of suction point #1 by screenshot
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Stereotactic image guidance: insertion of
Frazee scope sheath into hematoma
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Aspiration of hematoma and
measurement of hematoma volume
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LONG TERM
Systems Biology Virtual Patient
NEXT 3 YEARS
Neurogenomics Big Data Analytics InformaticsA.I.
Deep Learning
TODAY
Integration Structure Data Protocols
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THE BIG OPPORTUNITIES FOR US:
Clinical and Academic Competitive Advantages
TARGETS: Stroke, Alzheimers Disease/Dementia, Addiction,
Depression, Stress
Integration: Psychiatry/Behavioral Health, Neurology, Neurosurgery
Value-based Care Redesign: ProvenCare (ERAS), Ambulatory
Intervention
Clinical Neurogenomics: MyCode, Precision Medicine,
Pharmacogenomics
Big Data Analytics: Predictive, Proactive Medicine
Population Risk and Prevention: Alzheimers, Stroke
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INTEGRATION
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Primary Prevention
• Phenomics
• Genomics
• Big data analytics, risk
• Behavioral modification
• Pharmacology
Stroke Dx and Rx
• Neuroimaging
• Medical Rx
• Endovascular, Surgical Rx
• Neuro Critical Care
Recovery
• Neuro rehab
• Stem cells
• Depression Rx
Secondary Prevention
• Pharmacology
• Behavioral modification
STROKE
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Opioid Overdoses in the Geisinger Service
Area Over Past 10 Years
Boscarino JA, Kirchner HL, Pitcavage JM, et al. Factors associated with opioid
overdose: a 10-year retrospective study of patients in a large integrated health
care system. Substance Abuse and Rehabilitation. 2016;7:131-141.
doi:10.2147/SAR.S108302.
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Why has Opioid Misuse Proliferated?
3. Limited access to
addiction treatment
1. Overprescribing
2. Diversion of opiates
to family and friends
1.
2.
3.
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• Neurocience
• Genomics
• Pharmacology
• Psychiatry
• Addiction Medicine
• Pharmacy
• Anesthesia
• Pharmacy
• Surgery
• Primary Care
• Pharmacy
• Neurology
• Psychiatry
• Neurosurgery
Chronic PainPost Surgical
Pain
NeuroscienceAddiction
Opioid Addiction
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Quality
The degree to which the clinical
process and the patient outcome
approaches perfection, every time.
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Is it possible to improve,
to approach perfection in healthcare,
in a systematic and reproducible way?
Do we know how to do it?
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Peter Pronovost, MD, Intensivist, Johns Hopkins
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THE PROBLEMCentral Line Associated Blood Stream
Infection (CLABSI)
Each year in the United States
80,000 catheter-related infections
28,000 deaths
Average cost of care is $45,000 each =
$2.3 billion annually
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THE INTERVENTION
Central Line Bundle (Checklist, Protocol)
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, avoidance of the femoral vein
5. Daily review, prompt removal of unnecessary lines
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THE RESULTAfter Central Line Bundle Applied
Mean rate per 1000 catheter-days decreased from 7.7 to 1.4.
80% reduction in infection
(P<0.002)
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Value-based Neurosurgery
Care redesign protocol for
microvascular decompression
surgery
Nancy McLaughlin, MD, PhD, Farzad Buxey,
Karen Chaw, Neil A. Martin, MD
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VALUE STREAM MAP
PREOP OP POSTOP
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Summary of Interventions
PRE-
OPERATIVE
INTRA-
OPERATIVE
POST-
OPERATIVE
-Discussion of the expected LOS 2 Days
--Introduction of a comprehensive time-out
-Technical improvements – dural closure- Marcaine injection, incision, pin sites
-Early mobilization
Sandardization of discharge criteria-Modifying PM rounds: Identification and prep of
patients for AM discharge
-Standardization of discharge instructions, steroid
taper, suture removal, and FU appointment
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• Total 49 pts: Mean age 56 yrs; 31 TN; 18 HFS
•Group 1 2008 – 18 months: 20 patients
•Group 2 2011 – 18 months: 29 patients
• Rate of complete symptom resolution or improvement: 97% TN and 100% HFS
• No mortality
Value based neurosurgery:
Microvascular decompression surgery
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DC
POSTOP
DAY 2
38
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Defining: “Perfect Surgery”
1. No mortality
2. No post-operative complication
3. Resolution of symptoms
4. Discharged home
5. Post-operative LOS 2 days or less
6. Discharge by noon
7. No readmissions related to surgery
8. No need for repeat surgery
Pre-Redesign: 5% perfect surgery
Post-Redesign: 31% perfect surgery
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From Quality to Value
Value = Quality/Cost
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The average cost of a surgical care episode
(index hospitalization + readmission/reoperation)
decreased 25% after redesign.
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Metabolic Disease Mgmt - Basic Elements
• 2 PCP visits per year
• Measures– Blood Pressure – every visit
• Intervention if not at goal*
– A1C Intervention if not at goal*
– LDL Intervention if not at goal*• Goal <100 for DM, <70 for DM with CAD
– Max Dose Statin* - every visit
– Eye Exam* - annual
– Foot Exam - annual
– Flu Vaccine - annual
– Pneumovax - once
– Smoking Hx - every visit
– Creatinine (Serum) - annual
– Potassium (Serum) - annual
– Microalbumin - annual
– Urine Protein – baseline (once)
– A1C – every 6 months
– LDL - annual
– EKG – baseline (once)
– NYHA Class – every visit
– ACE/ARB*- every visit• EF <40
– Beta Blocker/EBB*- every visit
– BMI – every visit
– Advance Directives/POLST?* PCP, Specialist, CM/HM, MTDM intervention needed
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Exceptions:
GFR <30
Metformin♥†
[GFR 60+: 2000mg]
[GFR 30-
60=1000mg]
3mth Repeat HgA1c Above Goal
Liraglutide♥
Exceptions:
hx of med.
thyroid
ca/MEN2
Empagliflozin♥‡
(not for use as
monotherapy)
Exceptions:
GFR <60, hx
recurrent GU
infections
Linagliptin
3mth Repeat HgA1c Above Goal
Empagliflozi
n♥
3mth Repeat HgA1c Above Goal
Basal Insulin(consider discontinuing sulfonylurea))
Bolus Insulin(consider discontinuing DPP4/SGLT2; continue GLP-1 only if BMI 30+)
3mth Repeat HgA1c Above Goal
Linagliptin(not for use with
concurrent
Liraglutide)
Glipizide(Consider
Repaglinide if
CKD 3B-5 or
post-prandial
glucose elevated)
Exceptions:
GFR <60,
hx
recurrent
GU
infections
Exceptions:
HgA1c >0.5%
above goal
Exceptions:
elderly, frail,
risk of
hypoglycem
ia
o
r
o
r
o
ro
r
If HgA1c is >1% above
goal
HgA
1c
<8.0
%
HgA1
c
≥8.0
%
HgA1c
≥10% or
symptoms±
HgA1c Goal <7%▪ No history of severe
hypoglycemia
▪ No advanced
micro/macrovascular
complications
▪ No advanced comorbidities
HgA1c Goal <8%▪ Age >65 and/or:
▪ Mild/mod. cognitive impairment
▪ History severe hypoglycemia
▪ Cerebro/cardiovascular disease
▪ Advanced microvascular
complications
Symptom Management▪ Terminal illness
▪ Severe cognitive impairment
▪ End-stage complications
▪ End-stage comorbidities
▪ Life expectancy <5 years
Note: 1st add-
on only if
Liraglutide and
Empagliflozin
C/I
Key
†: consider ER formulation to decrease
risk of GI intolerance
♥: CV risk reduction
‡: HF admission reduction; consider as
1st add-on if HF and HgA1c ≤0.5% above
goal; add Liraglutide if HgA1c remains
above goal
±: if symptomatic: metformin + basal
insulin +/- additional non-insulin therapy; if
asymptomatic: dual or triple non-insulin
therapy appropriate
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How Do Build and Enhance Quality in Your
Program?
THREE Things
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▪Structure
▪Measurement
▪Protocols
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QUALITY STRUCTURE
PeopleQuality Director, (analyst)
Regular MeetingsM&M, Monthly Service Line Review, Weekly Serious Event review
Dashboard
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QUALITY MEASURES
SAFETYInfection, DVT
OUTCOMESMortality, Discharge to Home
EFFICIENCYLength of Stay, Readmission
EXPERIENCEHCAPS, Press Gainey, Recommend
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CLINICAL PROTOCOLS
SURGICAL EPISODEProvenCare CABG , ERAS
CHRONIC DISEASEDiabetes Care Pathway
URGENTSepsis
PROCESSCentral Line Bundle
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INFORMATICS
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Geisinger’s Toolset for Digital Patient Engagement
Patient
Portal
Text
Messaging
Mobile
Apps
Mobile
Devices
Electronic
Books
Patient
Reported
Outcomes
“Only 1% of a person’s life is spent with healthcare professionals”
(Chase, 2013)
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Big Data Analytics
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Geisinger Unified Data Architecture
Big Data
Systems
Traditional
Data Systems
Unstructured
Streaming
Real-time
Well defined
Row/Tables
24 hr Delay
Geisinger
Unified
Data
Architecture
Longitudinal
Records
Text
Analytics
Real-time
Dashboards
Healthcare
Apps
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Big data for provider experience and care quality
• Abdominal Aortic Aneurysm
• Frequently asymptomatic
• >90% mortality if ruptures
• Rupture risk increases with aneurysm size
• Found incidentally on diagnostic studies
• Some patients are lost to follow-up
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AAA Close the Loop Program
• Retrospectively identify AAA patients not receiving follow-up for surgical repair (>4.0cm)
• 2 million reports reviewed through Natural Language Understanding
• Categorized patients by vascular risk
• 3,400 patients were contacted via PCP for follow-up
• 134 patients were identified for on-going monitoring
• 27 patients received life-saving AAA repair surgery
Courtesy of Dr James Elmore (Vascular Surgery)
Erskine AR, Karunakaran B, Slotkin JR, Feinberg DT (2016). How Geisinger Health
System uses big data to save lives. Harvard Business Review. December.
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Population Genomics
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Clinical–omics
Systems
Neuromedicine
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Predictive Preventive
Personalized Participatory
P4 Clinical Neuroscience