mark dente's presentation

1 /e-Infrastructure for the Future of Diagnostics

4 November 2011

The virtualization of the bricks and mortar of the Healthcare delivery setting:

The impact and direction of Healthcare IT

Mark A Dente, mdCMIOGE Healthcare IT


• Digitation & Connectivity of Data: Accessing and integrating information from multiple sources

• Advanced Data Processing & Information Fusion: Turning “Insight” into Action

• THE FUTURE is sooner than you think: Empower every person to live an independent, confident, healthier life through connected technologies


4 November 2011

• Meaningful Use & Quality Metrics - Clinical Decision Support

• New delivery Models like ACO’s - Patient and Population Health Mgmnt

• Shift care to lower cost settings - Chronic Disease Mgmnt & Remote Monitoring

• Early identification of at-risk individuals - Genomics Personalized therapy selection & Better therapy monitoring (Surveillance Monitoring)

Healthcare Challenges: Healthcare Challenges: Healthcare Challenges: Healthcare Challenges: Improve Outcomes &

Avoid or Reduce Cost


4 November 2011

The Clinical Knowledge-Processing Burden

Many years ago Today

This gap injures patients

Knowledge processing capacity

Knowledge processing requirement

“Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable”

Crane and RaymondThe Permanente Journal Winter 2003 Volume 7 No.1Kaiser Permanente Institute for Health Policy


4 November 2011

‘The complexity of modern medicine exceeds the inherent limitations of the unaided human mind.’David M. EddyMD, Ph.D.

Patient


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Meaningful use criteria reinforcing the need for the Patient Centered Care Team

• Exchange key clinical information electronically• Perform medication reconciliation for 80% of encounters• Provide summary care record for 80% of care transitions

Care Coordination

�Document exchange of meds, problems, allergies, labs, etc. w/discharge summary

�Portals for provider access

• Provide patients w/electronic copy of health information• Provide timely electronic access w/in 96 hours• Provide clinical summaries for each office visit

Engage Patients

�Document exchange of meds, problems, allergies, labs, etc. w/discharge summary

�Portals for patient access

• Leverage clinical decision support & interaction checking• Send reminders to patients, outreach, reduce disparities• Report ambulatory measures to CMS or states

Improve Quality

�Decision support based on HIE�Alerting & secure messaging�Quality reporting

• Protect electronic health information through technology• Review security risks and implement security updatesPrivacy �Highest security standards

�Audit trail of all HIE accesses

• Submit electronic data to immunization registries• Electronically submit reportable lab results• Provide syndromic surveillance data to public agenciesPublic Health

�Document submission to state registries

�Quality reporting


• Digitation & Connectivity of Data: Accessing and integrating information from multiple sources


4 November 2011

Data Interoperability

Government

Why is it important?• Real-time access to relevant clinical intelligence across the community

• Improve quality & coordination of care with.

• Prepare organizations for advanced stages of Meaningful Use and an Accountable Care model.

eHealth offers:• eHealth Info Exchange• eHealth Community Desk• Centricity Patient Online• eHealth Image Exchange


4 November 2011

Portal

Applications

Services

Community HealthCenter

Family

Care / CaseManagers

GroupPractices

Hospital

GranularInformation Exchange

eReferrals

InformationReconciliation

ImageExchange

Registries(disease, vax)

CareManagement

Decision Support /Event Alerts

Population Mgmt /Analytics

Care Network &

Communication

Surveillance

PATIENT

Other HIE

Medical Home

Population Health Management & Community of Care Network

Patient


4 November 2011

eHealth Community Desktop

� Widen community access with an easy, browser-based user interface

� Enable care teams, including case managers, to facilitate care coordination

� Bring various in-house applications together in one place

� Extend your HIE investment over time with add-on workflow and performance apps

� Increase HIE use with flexible screen layouts to match your look-and-feel

A web-based clinical portal that enables collaborative care across a community of clinicians without EMRs


4 November 2011

Patient Engagement – Centricity PT online

� Strengthens the HCO’s market/competitive position

� Improves efficiency of the patient management process

� Strengthens the patient-provider relationship

� Extends the HCO’s reach for proactive care management

� Enables HCO’s to meet all ARRA criteria for patient & family engagement

Patient Online is a single channel of communications that extends the provider workflow to the patient’s home to reduce costs, increase quality, and increase access to care.


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Community Desktop Image Exchange


• Advanced Data Processing & Information Fusion: Turning “Insight” into Action


4 November 2011

Key Partners:

Intermountain Healthcare

Mayo - Rochester

++

MayoMayo

Holistic approach


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Holistic approach to Data

Interface Manager

HL7

XDS

ATNA

PIX

PDQ

CDA

Knowledge Repository

Maps Models Codes Rules FormsQueriesConstraints

1Terminology Translation, Decision Support &

Business Rules

Unified Data Repository of Models &

Terminology Based Data

Applications Assembled from User Generated Alerts, Queries and Forms

Knowledge Workers

Standard Models &

Terminology

Coded, Computable

Clinical Data

Configured by

Knowledge Workers

Shareable &

Reusable Assets

2 3 4 5

Interface (e.g. HL7) to Model Transforms


4 November 2011

Clinical Data Fusion: Qualibria Terminology ServicesThe Terminology Foundation contains services and rich management tools for code mapping, browsing and querying:•Load external code systems, including: SNOMED-CT, LOINC, ICD-9, ICD-10, CPT, RxNorm, HL7 Vocabularies, HCPCS, Genomics Ontologies, NCI Metathesaurus, Open Biomedical Ontologies,etc.

Many entry forms for one concept

• myocardial infarction

• MI

• S/P MI 1987

• hx of heart attacks

4500 Elemental terms available today

Transforming data into insight: Advanced processing & Information fusion


4 November 2011

• Impact of Discharge Med Program on Heart Failure Readmissions/Mortality

• ACE inhibitor prescription at hospital discharge increased from 65% to 95% in 5 years

• How did these Intermountain heart failure patients do?

• One-year readmissions reduced from 46.5 % to 38.5%

• 551 readmissions prevented per year

• $2,480,000 saved based on avoided readmissions

• One-year mortality rate reduced from 22.7% to 17.8%

• 331 lives saved per year

• Quality is cheaper, safer, better all around !

Value Created by Cardiology Program

Dr. Don LappeChair, Cardiology

Defining the best practice clinical protocol


4 November 2011

Acute Care Program demonstrated Proof of Ventilator Weaning Protocol Effectiveness

• Acute Respiratory Distress Syndrome (ARDS) survival rate used to be <10%

• Intermountain physicians created a software based protocol to help patients wean from the ventilators faster

• Patients weaned a full 24 hours earlier than before from ventilator

• Acute Respiratory Distress Syndrome survival rate increased from 10% to over 44%

Outcome Physician Protocol

Median Weaning Time (hrs)

28 8

Time on Ventilator (hrs) 118 94

Blood Gas Orders 93 45

Chest X-Ray Orders 12 3

Dr. Alan Morris, LDS Hospital


4 November 2011

Healthcare associated infections: Qualibria

$635.0

$-

$1

$2

$3

$4

$5

$6

$7

$8

$9

0% 5% 10% 15%

Per capita HC exp. (000)

Healthcare infection rate

US

Japan

Germany

UK

Spain

China

Brazil

Annual U.S. cost of healthcare associated infections

1.7 million occurrences

$35 billion

99,000 lives

A 250-bed

hospital…

473 occurrences

$11 million

27 lives

For GE internal use only. Not for external distribution

29,093

40,598

56,326

72,449

99,000

124,583

Prostatecancer

Breastcancer

Influenza Diabetes Healthcareassociatedinfections

Chroniclower

respiratorydiseases

Annual Cost in Lives by Cause (US)


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For GE internal use only. Not for external distribution

• Disseminate best practices

• Increase adherence to protocols

• Decrease time on ventilator

• Improve medication utilization

• Reduce length of stay

• Decrease patient costs


4 November 2011


4 November 2011

Real-time best practice dashboard


• THE FUTURE is sooner than you think: Empower every person to live an independent, confident, healthier life through connected technologies


4 November 2011

Achieving Patient & Population Health Management

Longitudinal

Interoperability Collaboration Analytics AccountabilityProactive

PopulationManagement

Actionable &Usable Systems

WorkflowIntegration

One Patient,One Record

PatientActivation

CareTransitions

Communication& Transparency

Gaps in Care

PredictiveModeling

PopulationStratification

Guideline &Standards

Driven

ResourceManagement &

Productivity

Cost &Utilization

Management

Evolving CarePlan

HealthMaintenance &

Wellness

CareManagement


4 November 2011

e Health - Beyond HIE Information Exchange

Portal

Applications

Services

Community HealthCenter

Family

Care / CaseManagers

GroupPractices

Hospital

GranularInformation Exchange

eReferrals

InformationReconciliation

ImageExchange

Registries(disease, vax)

CareManagement

Decision Support /Event Alerts

Population Mgmt /Analytics

Care Network &

Communication

Surveillance

Other HIE

Medical Home

Population Health Management & Community of Care Network

• Preventative care bundle 9.2�14.7%

• Aligns incentives across provider, patient and payer

• �18 % admission, � 36% readmissions

Geisinger’s Proven Health & ProvenCare

Geisinger Health Plan

Care Management targets the sickest-of-the-sick (5% of US pop = 49% of cost)

Patient


4 November 2011

The Medical Quality Improvement Consortium (MQIC) MQIC is a continuously updated database of 20 million unique, de-identified

patients – aimed at helping identify and inform industry best practices

• Make data-driven decisions at the point of care

• Enhance management of specific conditions and populations

• Benchmark against similar practices for quality of care information

• Participate more easily in PQRS, CMS eRx, and Bridges to Excellence Diabetes Recognition


4 November 2011

Moving Averages Example

140

150

160

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210

220

230

8/11 9/30 11/19 1/8 2/27 4/18

-20

-10

0

10

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60

70

weight

short-term ave

long-term ave

difference

Alert limit

Search for best l ong-term window and cutoff

0.0%

1 0.0%

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0 .0% 0 .5% 1.0% 1.5% 2.0% 2.5% 3.0%

False

Tru

e

sea rch

Base line

Pro spects

New winner

Only 2 day s warning

on event #2

Stable fit

Effect of scale precision

0%

10%

20%

30%

40%

50%

60%

70%

0 1 2 3

Sca le Precision

Tru

e a

lert

%

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Fa

lse

ale

rt %

TRUE

FALSE

Effect of Measurement Accuracy

0%

10%

20%

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50%

60%

70%

0 1 2 3

Extra noise in readings (un it=1lb stdev)

Tru

e a

lert

%

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se

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rt %

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FALSE

Effect of Patient Compliance

0%

10%

20%

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50%

60%

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50% 60% 70% 80% 90% 100%

Comp lican ce: % days weight record ed

Tru

e a

lert

%

0%

1%

2%

3%

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5%

Fal

se

Ale

rt %

TRUE

FALSE

Scale Precision Accuracy Compliance

Personalized weight gain detection algorithms

Electrolytes

GE Confidential & Proprietary

Beta Blockers

Consider increasing beta

blocker.Consider smaller increments i f t his is

a re-try.

1-4 weeks

passed since last

increase?[21]

Bradycardia?

(pulse < 60)[43]

Symptoms of bradycardia? (Dizziness? Lightheaded-ness? Fatigue?)

[60,62,64]

Consider decreasing or discont inuing BB.

Perform TSH/digoxin labs.Consider cardiology referral

(pacemaker) .

Taking bet a blocker?

[21]

Higher dose already tr ied?

[21]

Order EKG

for hear t rhyt hm.Per form

TSH/digoxin labs .

Consider decreasing non-HF meds that may causebradycardia

BB:titrat ion

Pulse < 45?[43]

Possible to decrease ot her meds t hat may

cause bradycardia?(digoxin, CCB, sot alol,

amiodarone)

[25]

Severe fat igue?

(act ivit y-re lated questions)

[64]

Consider discontinuing BB.

Consider swit ching t o cardiac-se lect ive

BB.

Consider spirometry.

Wit hin 2 w eeks

aft er BB ini tiat ion /upt it rat ion?

[21]

2n d or 3 rddegree heart block? (EKG) [82]

Pat ient needs immediate at tention.

Discont inue beta blocker and other

drugs that may cause hear t block (digoxin,

CCB, sotalol , amiodarone)

Consider cardiology refer ral (pacemaker ).

BB:he artblock

BB:br adycardia

BB:HFsymptomsBB:fatigue

Dyspnea in lung pat ient wit hin 2 days after BB ini tiat ion?

[21,66,84]

Bradycardia?

(pulse < 50)[43]

Fluid retention?

Consider increasing diuret ic(s).

Consider

decreasing beta blockers.

Lower than target dose?

[21]

4 weeks since last try and OK t o re-t ry (not previously decreased or discont inued for dyspnea in lung patient )?

[21]

Bradycardia?

(pulse < 55) and

upt it rat ing

on BB?[21,43]

BB:l ungpatient

Fatigue lasted

for over 6weeks?[64]

Consider decreasing beta blocker.

Consider ot her sources of fat igue

( thyroid, depression, worsening HF, sleep

apnea, anemia)

Pulse > 60?[43]

no

yes

[38,53]

input

codes

Medical Records

Detection

Algorithms

Home Health Data

Medical Guidelines

Chronic Disease Monitoring

Application

Advanced Data:

Activity

Chronic Disease ExampleAnomaly detection and guidelines decision support


4 November 2011

Tiny Sensors pick up activity data in the residence and send to GE Server

The Algorithm knows if the activity is “normal” – if not, an alert is created and sent to caregiver

The Well Check is Made and the loop is Closed

Benefits• Peace of Mind for

Family• Customizable Alerts• Delay of Continued

Care/Skilled Nursing• Extended Care

Coverage without additional staff

• Attraction/Retention of residents

Z-wave technologyIntelligent software:alerts, algorithms, etc.

Basic Package

Physician to the Patient Chronic Dx Management Approach

Patient Level Tools for the Care Team


4 November 2011

Technology Enablers

Healthcare Desires

• Flexibility – systems for full acuity range; equipment stays with patient

• Efficiency – productivity and improved quality/reduced errors

• Home/Remote Monitoring – also disruptive to Hospital Monitoring

• Wearable – “Don’t know it’s there”

• Tracking – Patients, Parameters, Assets, Employees

• Extremely Wireless – Zero Wires

• New Sensors /Parameters /Disease States

Technology Enablers

• Miniaturization(Nano, MEMS, EE, RF, CMUT)

• Sensors/Parameters(Fusion, Implants, New Types)

• Wireless Technologies(Reliability, Capacity, Power)

• Expert Systems(Intelligence, Decisions, CAD)

• Info/Data/Apps Architecture(Workflow, Integration, Apps)

• Use/Human Factors(Goof Proof, Ease of Use)


4 November 2011

Sleep disorder

Dementia

healthy

Heart Failure

Activity as a Vital Sign

• Actigraphy sensors• Correlated to HF status• 60 person field trial• Columbia University

Home Health Activity

Fall Risk Assessment

Prevent Falls Thru Identification

• Research effort• “Automate” PT instruments• Daily assessments• University of Mo. – Columbia


4 November 2011

SHARED INFRASTRUCTURE

[CDS + Clinical HIE + Consumer Decision Support + Motivation]

HEALTH-WEALTH IMPACT

Health information Disease

management tools

Enterprise

Health@HomeeHealth

Corporate Stakeholders: Pharma, Employers

• EMR based intervention studies enables outcomes driven brand/marketing strategies

Direct To Consumer

POL POL is an existing

building block

to access Centricity IB

Physicians & patients

Model is proven,

enables our ability to extend

to adjacent stakeholders

Physicians, Hospitals, IDNs, RHIOs

• Leverages the richness of the physician to patient interaction; enables longitudinal approach to care

Existing NBC health

ecosystem

enables broad & localized

Consumer reach

Connects HCIT within the home

to enable care and communicate

w/ patient/family members

GE HCIT: Chronic Dx, Social Networking & Consumerism

Solving disparity of care challenges


4 November 2011

The Dundee Courier, 13th April, 2007


4 November 2011


4 November 2011

Many diseases have an underlying genetic connection

Goh et al. PNAS 104 (2007) Detail of Gene - Disease Network


4 November 2011

Alzheimer’s Clinical Data Prognostic Modeling

AD Prognostic Model

Survival/Progression

Probability

Rate of Cognitive

Decline

Time To

Progression/Death

Cognitive

Genetics Clinical

APOE4 (>0)

%Hippocampal (+)

%Ventricular (-)

%Subar. CSF (-)

%Temporal Lobe (+)

%Total HSIA (-)

%Supra. CNS (+)Intracranial

%Hippocampal

%Ventricular (-)

%Subar. CSF (-)

%Temporal Lobe

%Total HSIA (-)

%Supra. CNS (-)

Adak, Illouz, Gorman, Tandon, Zimmerman, Guariglia, Moore, Kaye, ““““Predicting the rate of cognitive decline in aging and early Alzheimer disease”, Neurology. 2004 Jul 13;63(1):108-14.

AD BioSignature

• Early diagnosis• Personalized treatment• Therapy monitoring

IVD, Genetics, circulating markers

Team of 10+ research scientistscommitted in 2011

Algorithms, statistics, informatics

In-vivo ImagingPET, MRi, SPECT

Clinical Informatics


4 November 2011

Thank youThank [email protected]

July 4th Boston: USS Constitution (Old Iron Sides)

mark dente's presentation

Health & Medicine

patient access

future of diagnostics4

today4 einfrastructure

patient5 einfrastructure

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acos patient

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