optimising the system of care - hospital authority · optimising the system of care ... bumrungrad...

www.sg2.com

Optimising the System of CARE

Using Technology to Optimise Clinical Services

Christopher Farr Senior Fellow, Sg2

May 2012

Changing Landscape of Health Care Delivery

Enabling Multidisciplinary Care

Enabling Subspecialisation

Using Decision Support to Build Standardised Pathways

Building a Network Beyond the Hospital

Reaching the Patient at Home

Developing Your System of CARE

Agenda

Confidential and Proprietary © May 2012 Sg2 3

Traditional Challenges of Hospital Management

Clinician

recruitment

Market

reputation

Relationships

with payers

Case

management

Hospitalists

Work flow

improvement

Staffing levels

Compensation

Overtime,

agency nursing

Consistent

earnings

Cost-effective

credit

Consolidation

LOS = length of stay.

Fill

Beds

Manage

LOS

Control

Labour

Costs

Manage

Balance

Sheet


Card

iovascu

lar

Neu

roscie

nces

On

co

log

y

Ort

ho

paed

ics

Ga

str

oin

tes

tin

al

Uro

log

y

Su

rgic

al S

pe

cia

ltie

s

Em

erg

en

cy S

erv

ice

s

Disease-Based Services

Operating Room Services

Digital Information (EMR, CPOE, etc)

Diagnostics = Imaging + Pathology + IT

Patient Services (Monitoring, Nursing, Pharmacy, etc)

Integrative

Services

Fo

un

dati

on

al

Serv

ices

Today’s Hospital Organisational Model Still Looks Inward

IT = information technology; EMR = electronic medical record; CPOE = computerised physician order entry.


The Future Is About Building a High-Performance System of Care

Reduce Cost of Care Manage Care Transitions Align Providers

IP = inpatient; SNF = skilled nursing facility; OP = outpatient.

Retail

Pharmacy

Wellness and

Fitness Centre

Diagnostic/

Imaging

Centre

Urgent

Care

Centre

Home

Doctor

Clinics

Ambulatory

Procedure

Centre

IP Rehab

Hospital

Home Care

Acuity

Community-Based

Care

Acute

Care

Post-

Acute

Care

SNF

OP

Rehab

http://images.google.com/imgres?imgurl=http://www.eyetumour.com/images/large/liverpool_hospital_map.jpg&imgrefurl=http://www.eyetumour.com/liverpool_hospital_directions.php&usg=__cajn31CYaLoQvxfcysm_FUMY2Bo=&h=911&w=1280&sz=127&hl=en&start=7&sig2=CnVsQ_4YzPWCGQ9eY6LJ3Q&um=1&itbs=1&tbnid=Ba_KzC-aWWS4nM:&tbnh=107&tbnw=150&prev=/images?q=discharge+hospital&um=1&hl=en&sa=G&rls=com.microsoft:en-us:IE-SearchBox&imgtype=lineart&as_st=y&tbs=isch:1&ei=u4OqS_uEEpqutgeU6pS7BQ


Build Foundations to Support an Integrated System

Integrated IT

Systems

Care

Continuum

Clinical

Engagement

IT integrated

across System of

CARE, workforce

Aligned operations

and financial data

Virtual technology

to optimise

coordination

Case management

Remote monitoring

Focus clinical staff

organisation

around your

System of CARE


Kaiser Permanente implemented

HealthConnect® in 2004.

EMR that unites documentation

across IP and OP settings

Personal health record

Secure patient-provider messaging

via Web site

Real-time update messages

and records incorporated into patient records

Scheduled telephone visits grew 8-fold from 2004−2007.

Secure email messaging grew nearly 6-fold from

2005−2007.

Electronic Medical Records Will Be a Critical Requirement

Source: Chen C et al. Health Aff (Millwood) 2009;28:323–333.


EMR Can Increase Patient Satisfaction While Dramatically Reducing Office Visits

Kaiser Permanente (Cont’d)

Number of patients rating overall

satisfaction at an 8 (out of 10)

or above:

2004: 84%

2007: 87%

Total office visit rate declined 26.2% from 2004 to 2007.

Primary care visits decreased by 25.3%.

Specialty visits decreased by 21.5%.

Even though the setting of care changed dramatically,

patient and member satisfaction still increased.


A Strong EMR Allows Innovative Approaches to Service Expansion

Traditional Approach: More Hospitals

Kaiser’s strategy was to build a complete,

self-sustaining hospital in every market

it serves.

Each hospital had ≥50 clinicians, radiology,

pharmacy, lab and other ―one-stop shop‖ services.

Future Concept: Microclinics

Lease space in strip malls staffed with

2 clinicians and connected to Kaiser’s EMR.

Cover 80% of market needs and transition to

hospitals farther away when needed.

Leverage video conferencing for specialist

consultations when necessary.

Cost 50% less per member compared to hospitals.

Courtesy of Sentara Healthcare.

Source: Capps R. The good enough revolution: when cheap and simple is just fine. Wired Oct 14, 2009.


Productivity Software Drives Operational Excellence

Bumrungrad International Hospital, Bangkok, Thailand

3,000 outpatients per day

About 65% of outpatients present without an appointment and

wait 10 minutes on average to see a doctor.

Hospital information system supports short waits and easy access.

Scheduling by demand history analysis:

IT system assigns patients to the doctor with the shortest wait time.

Comprehensive EMR, scheduling, CPOE, PACS/RIS, pharmacy, etc

45

Minutes

PACS = picture archiving and communication system; RIS = radiology information system.

Registration 1

Waiting Room 2

Clinician Exam 3

Routine

Diagnostics 4 Payment 6

Prescription 5








Agenda


Technology Offers New Opportunities for Coordination and Collaboration

Caregivers must function in multidisciplinary teams supported by

appropriate remuneration incentives.

Eg: Stroke team

Eg: Remote intensive

care unit

Eg: Nursing units

Eg: Telestroke

Eg: Subspecialist

appointments Regional practitioners

Integrated care team

Virtual, integrated team

Virtual, outsourced

services

Coordinated

caregivers

Integrated

Independent


Improving Availability of Neurology Services in Northern Ireland, UK

Hub hospital:

Royal Victoria Hospital—part of

the Belfast Health and Social

Care Trust

2 spoke hospitals:

2 rural hospitals—part of the

Western Health and Social Care

Trust

The Challenge: Provide access to a

neurologist for diagnosis and follow-

up with consistent, high-quality care

for both city and country patients

Photo courtesy of Christopher Farr.


The Solution: Low-Cost Teleneurology Empowers Remote Patient-Centred Care

Patient Impact Neurologist Impact Operational Impact

Reduced waiting times

Improved speed of

diagnosis

Reduced ALOS

Increased access to

specialists

Reduced travel times

Increased patient

volumes

Improved patient

management

Cost-effective

Easy to set up

Improved resource

allocation

Increased specialist

care

ALOS = average length of stay.

Before Implementing the Teleneurology Program

Only 10% to 11% of inpatients in the rural hospitals were referred to a

neurologist.

After Implementation

40% of inpatients are referred for the teleneurology service.

Service now includes outpatient referrals and patient follow-up visits








Agenda


Prince Court Medical Centre Kuala Lumpur, Malaysia

Wholly owned by Petronas:

Malaysia’s national petroleum

company

JCI accredited

Facilities: 300 beds, 10 ORs and

63 outpatient suites

Specialties: Heart and lung, oncology,

nephrology, burns, gynecology

The Challenge: How does a 300-bed

facility provide comprehensive, high-end

pathology and radiology services with

subspecialty interpretations?

JCI = Joint Commission International; OR = operating room. Photo courtesy of Christopher Farr.


The Solution: A Partnership With the University of Vienna, Austria

Telepathology and teleradiology services

for interpretation, over-reading and

consultations

University of Vienna cytogenetics team reads

for Malaysia and Vienna.

EMR, CPOE, RIS and PACS with single

accession number

Shared image server that allows ―instant,‖

simultaneous reading of slides in Malaysia

and Austria

Common laboratory test platforms, imaging

and lab protocols between the 2 institutions

Training and working exchange visits

between institutions



The Growth Story

Expert interpretation services

provide a unique differentiator

and build referring physician

confidence.

Prince Court builds market

share by offering services not

available elsewhere in Malaysia.

Opportunity exists for Vienna

to ―export‖ its skills—a new

business venture.

After-hours interpretations

available from its Malaysian

partner to support radiology

and pathology in Vienna.








Agenda


Why Do I Order Diagnostic Exams for My Patients?

Pathology Radiology

Assess risk

Screen for disease

Diagnose disease

Confirm diagnosis

Stage disease

Characterise disease

Monitor disease

Plan treatment

Guide treatment

Monitor treatment


Effective Diagnostic Testing Informs Patient Management

Test Ordered (Appropriate?)

Dx Test Performed

Results Analysed and Interpreted

Report Prepared

Patient Management

Communication/Consult With Referring Physician

Computer-Aided Detection

Automation/Cost-Effectiveness

Integrated Structured Reporting

Clinical Decision Support

Community

Diagnostic Associates

IT and Network Integration

Referral


The New World: Integrated Reporting

Source: Image adapted from: The Importance of Radiology and Pathology Communication in the Diagnosis and Staging of Cancer:

Mammography as a Case Study. November 2010. http://aspe.hhs.gov/sp/reports/2010/PathRad/index.shtml Accessed January 2012.


Standard Approaches Improve Knowledge Sharing, Cut Duplication

Western Australia Department of Health—

Standardised Imaging Pathways

Developed by statewide imaging committee

Web-based tool organised by organ system

Designed to support the work of referrers

and providers of diagnostic imaging services

Education and decision support tool

Reduces inappropriate and increases

appropriate examinations

Each disease has a summary page,

a pathway, images, teaching points,

references and a PDF version

Library of normal anatomy

Image used with permission of the Government of Western Australia Department of Health.

Source: Government of Western Australia Department of Health.

www.imagingpathways.health.wa.gov.au. Accessed March 2010.


The Growth Story

Standardised pathways bring

consistent approach to imaging.

Trust that appropriate test is

ordered regardless of site of care

Trust that test is performed using

appropriate protocols

Program exploits statewide PACS

infrastructure.

Single accession number means

all images can be shared across

all public institutions and most

private providers.

Permits over-reads and consults

Expect to save significant costs—

frees up resources for growth



Minnesota (US) Adopts Imaging Clinical Decision Support Statewide

New statewide initiative:

6 health plans; 60 medical groups

Uses ACR/ACC guidelines for imaging

(avoids precertification requirements)

Advanced studies: MR, CT, PET,

cardiac SPECT

Tool integrated in EMR or accessed

through a Web portal

Data mining tracks and correlates clinical

outcomes from scan interpretations with

ordering physician’s clinical indications.

2007 pilot study estimated 9% reduction

in claims and increase of ―appropriate-

ness‖ from 79% to 89% in just 6 months.

5 medical groups saved $28M.

Estimated total savings is $84M.

Institute for Clinical

Systems Improvement (ICSI)

“Ensure Minnesotans only

receive medically appropriate

imaging tests…”

ACC = American College of Cardiology; ACR = American College of Radiology;

CT = computed tomography; MR = magnetic resonance; PET = positron emission

tomography; SPECT = single-photon emission computed tomography.

Source: ICSI. www.icsi.org. Accessed May 2011.








Agenda


Calgary Health Region—Alberta Provincial Stroke Strategy, Canada

Health promotion and disease prevention

Stroke algorithms and vascular risk reduction

programme

Emergency services and acute care

Stroke screening and diversion strategy

A&E protocol, TIA triage, 24/7 brain

attack team

Foothills Medical Centre

(stroke nurse, TCD, CT, MR, tPA protocol,

stroke unit)

Rehabilitation and community integration

Inpatient and tertiary neuro rehabilitation

Outpatient rehabilitation, physiatrist stroke follow-up,

swallowing programme, community accessible rehabilitation

Stroke Recovery Association, Brain Injury Coalition of Calgary

Best-in-Class Stroke Care Requires Teamwork

Calgary

A&E = accident and emergency; TIA = transient ischaemic attack; TCD = transcranial Doppler; tPA = tissue plasminogen activator.

Source: www.hsf.sk.ca/siss/documents/SaskCHRAPSSpresentationMarch07.ppt. Accessed March 2009.

UNIVERSITY OF

CALGARY

Calgary Stroke Program


Regional Leadership and Community Stakeholders Drive Coordinated Care

Programme established by Professor

Alastair Buchan, University of Oxford

Provincial Government—

Alberta Health and Wellness

Heart and Stroke Foundation

of Alberta, NWT and Nunavut

Leadership from each of 9 health regions

City of Calgary Fire Department

Stroke Recovery Association/Young

Stroke Survivors

University of Calgary, Foothills Medical

Centre

Sources: University of Oxford. News release.

www.ox.ac.uk/media/news_releases_for_journalists/071217.html. Published

December 17, 2007. Accessed August 2010; Alberta Provincial Stroke Strategy.

www.strokestrategy.ab.ca/about-APSS.html. Accessed August 2010.

Fort McMurray

Grande Prairie

Hinton

Cold Lake

Edmonton

Camrose

Lloyd-

minister

Wetaskiwin

Medicine

Hat

Lethbridge

Calgary

Red Deer

Key

Comprehensive

Stroke Centres

Other Primary

Stroke Sites

Regional Hospital

Primary Stroke

Centres

Calgary Stroke Program


Partnering With Ambulance Services Helps Improve Door-to-Needle Time

Wake Forest University Baptist Medical

Center, Winston-Salem, NC, US

Objective

Clear need to accelerate the 90-minute

door-to-needle time for stroke patients;

improve blood draw delays

Plan

Worked with ambulance service providers

to develop a process to draw blood en route

to the ED

Assembled lab draw kits distributed to ambulance

services free of charge; cost of lab kits <$1 (USD)

Results

35-minute reduction in door-to-needle time

Increased frequency of ED ―stroke‖ notification

by ambulance services

EMS = emergency medical services; ED = emergency department. Source: Wake Forest University Baptist Medical Center, 2010.








Agenda


Effective Care Cannot Occur Without Engaged Patients

Acute

Care

Support to Engage Patients

Transition Out of

Hospital

Transition to In-

Hospital Care

Patient Outcome

Text Reminders

Colored Magnets

Health Coaches

Online Medical Learning


Patient-Area Network Is the Key to Supporting Patients at Home

The delivery, facilitation and communication of health-related

information via mobile telecommunication and multimedia

technologies—including cell phones, tablet devices, PDAs and

wireless infrastructure in general

There’s a difference between data and actionable information.

Intervene (advice, support,

therapy)

Notify (patients, clinicians,

caregivers, EMS)

Evaluate Transmit

Data

Collect

Health Data

PDA = personal digital assistant.

Source: Center for Technology and Aging. Technologies for Remote Patient Monitoring for Older Adults. Published April 2010.


Mobile and Smartphones Bring the Exam Room to the Patient

Telemedicine

as a Channel

Telemedicine as an

Active Partner

Telemedicine as a

Decision-Support Tool

Mobile Phones Tele-ICU Automated

Tele-ophthalmology

Diagnosis Smartphones

© Image from BigStockPhoto.com.

ICU = intensive care unit.


Time and Place Dependencies Are Eliminated

Current Model Patient-Area Network Model

Low Frequency Visits High Touch

Acute Care Focused Right Treatment

Appointment Driven When They Need It

Location Centric Where They Are

High Cost Lower Cost


Blood Pressure Spirometer

Printed with permission

of Microlife USA.

Many Devices Can Be Integrated Into the Patient-Area Network

Wi-Fi Scale

Pulse Oximeter

Physical Activity Blood Glucose


The Spectrum of Remote Monitoring Opportunities Is Broad

Market

Segmentation

Wellness

and

Prevention

Chronic

Disease

Management

Acute Care Post-Acute

Care and

Rehabilitation

Aging at

Home

Focusing on: Prevention

and early

maintenance

Avoiding

critical events

Keeping

patients out

of hospital

Staying

on track

Avoiding move

to long-term

care

Generally

Includes:

Weight

measure

Exercise

Calories

consumed

Basic SMS

reminders

Diabetes

CHF

Hypertension

COPD

Medication

adherence

Secure SMS

test results

Crisis

management

Ensuring that

discharge

instructions

are followed

Improved and

managed

elective

admissions

Staying on

protocol

Monitoring

home therapy

Preventing

readmissions

Medication

optimisation

Remote

monitoring

of vital signs

and daily

activity

Assistive

technologies

There are many opportunities to create value and lower costs.

SMS = simple messaging service; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease.








Agenda


6 Steps to Building Your System of CARE

1 Vision: Establish a vision by disease

for the patient journey from home to

home along the System of CARE.

4 Information Technology: Identify the IT

services needed to effectively coordinate care

across all providers along the clinical pathway.

2 Clinical Pathway: Identify the specific

services and resources available to

support the patient journey.

5 Navigation: How does the patient move across

the System of CARE? What support services

are required to allow the patient to navigate the

System of CARE easily?

3 Pain Points: Identify where other

providers could better serve the

patient—and determine the best way

of working with them.

6 Work Flow: Identify how current processes,

practices and work flow need to change to

reduce duplication and waste.

Retail

Pharmacy

Wellness and

Fitness Centre

Diagnostic/

Imaging Centre

Urgent

Care

Centre

Hospital

Acuity

Community-Based Care Acute

Care

Post-

Acute

Care

Doctor

Clinics

Ambulatory

Procedure Centre

OP

Rehab

IP Rehab

SNF

Home Care Home


Sg2’s analytics-based health care expertise helps

hospitals and health systems integrate, prioritize and drive

growth and performance across the continuum of care.

Over 1,200 organizations around the world rely on Sg2’s

analytics, intelligence, consulting and educational services.

www.sg2.com + 1 847 779 5300

optimising the system of care - hospital authority · optimising the system of care ... bumrungrad...

Documents