transforming by qingyunliuliu


									  Transforming Healthcare
   The Role of Electronic Medical
   Records and Information

Dale Sanders
CIO, Cayman Islands National Health System
Healthcare 20/20: Cayman Islands National Healthcare Conference
November 2010
Can Technology Transform
• Technology is transformative only if coupled with
  changes to business and clinical culture & processes
• Technology alone can do nothing….
• But without technology, healthcare cannot transform

          Information              Model &
           Technology              Motives

  Chief Information Officers (CIO)
• Two basic flavors
  – Vanilla
     • Is attracted to and takes care of the
       technology, keeps it running, reacts to
       requests for services
  – Chocolate
     • Less attracted to technology, more attracted to
       business strategy and processes, and the role
       that information technology can play
     • Can technology create new strategies and
                 Trivia Question
What’s the longest living artifact in all
 businesses now?
   A.   Buildings
   B.   Processes
   C.   Equipment
   D.   That one old guy in Facilities Engineering
   E.   Data
All industries are now competing on analytics

• Core philosophies, principles and assertions
   – Underlying my style as a CIO

• Their Effect on Healthcare IT, Past and Future

• Strategic IT Issues Facing the HSA
   – The unique coincidence of events in history that can
     launch the Cayman Islands to a new level of influence and

Core Business Philosophies
and Principles
     Pure Motives and Intentions
• Applies personally and professionally
   – Short term gain vs. long term failure
• How can I always make the best decision?
   – Sustainable long term: Courage, charity, selflessness, love
   – Not sustainable: Fear, shame, greed, vengeance,
• Is this business motive on solid ground?
• The Lincoln story
   – From Saving the Union to Abolishing Slavery

          Taking Calculated Risks
• You cannot transform yourself, your organization,
  your healthcare, your country… without taking risks
• Risk = Probability of a Bad Event x Consequences
   – What’s the worst that can happen?
   – What’s the best that can happen?
   – What’s the probability of both?
• Healthcare is enormously risk averse
   – Careerism : Overly cautious-- be safe-- not progressive
   – Criticism drowns courage
   – Litigation drives fear

Human Behavior: Homo Economicus
• 80% of life is spent earning and managing money
• “The Wealth of Nations”, by Adam Smith
   – Written in the late 1700’s
   – Still the classic treatise on the connection between
     human behavior and economic systems

• Sanders’ interpretation
   – Always more efficient for me to spend the money I earn, than for you
     to spend the money I earn
   – First Order Economics: I spend the money I earn
   – Second Order Economics: You spend the money I earn
   – If need be, create the illusion of 1st Order

Commoditization of Knowledge
and Technology
• What was once known or affordable by only a few, is
  now known and owned by everyone
   – Prices decline accordingly
• Enabled by software, the “Rate of Commoditization”
  is increasing
   – $69 for divorce paperwork on
• Recognize it, plan for it, accelerate it…
• Commoditization of IT drive can drive the
  commoditization of healthcare

     Mean Time To Improvement
• MTTI: The average length of time that expires
  between improvements in products, services,
  processes, or personal behavior
• What’s the cultural MTTI in healthcare?
   – 17 years to adopt the protocol for Community Acquired
     Pneumonia (CAP)
   – MTTI at Apple? Google? Amazon? HSA?
• The role of IT in MTTI

 Moving at the Speed of Software
• Your company, regardless of industry, is
  now controlled by software
• You can move and adapt as fast your
  software can move and adapt
• Investment in expensive bricks and mortar facilities
  can kill your ability to leverage the Speed of Software

• Invest in agile software-- MTTI

 IT is an Investment, not an Expense
  If invested wisely….!

• Telecommunications, securities trading, and
  retail and general merchandising
  – 1990s: Heavy investment in IT
     • 8% of operating revenue, now down to 3%
  – 6-8% per year compounded growth in productivity
    ever since
• Healthcare is a late bloomer to IT adoption
  – And doesn’t adopt it well…

  Business Motives for Better Healthcare
• If you were President of the United States, why
  would you be motivated to lead a healthy
   – What fuels re-election? Jobs and the economy
• If you were CEO of Dart Enterprises, why would you
  be motivated to employ a healthy workforce?
   – The elimination of human suffering…maybe


    Business Models Tested at “Limits”

  Everybody is                                       Everybody is
   severely ill                                        healthy

•US hospitals are                                  •US hospitals are out
profitable                                         of business
•Businesses &                                      •Businesses & gov’t
gov’t services are   Would a US healthcare CEO     services are thriving
failing              dream of this in their 25-
                     year Strategic Plan?

                     Would a national healthcare
                     system dream of this?? Yes

         Employers Taking Control
• 65% of claims and 72% of costs associated with
  employee lifestyle claims
   – Smoking, drinking, diet/obesity, drug abuse
   – Hewitt Associates; n = 30,000 employees

• Direct contracting with healthcare providers
• Innovative financial incentives for participating in
  healthy lifestyles
   – Financial penalties for failure to participate and show
   – “No smokers” hiring policies

           Healthcare Economics
• Who spends the money?
   – Administrators, Physicians, Nurses, Pharmacists…
     sometime patients
      • Generally, physicians and nurses don’t know how much the
        procedures they order or the supplies they consume, cost
• Who provides the money?
   – Government and employers, sometimes patients
• At best, 3rd Order Economics

                 Business Motives
• Balancing treatment with wellness
   – Lesson learned at Intermountain Healthcare

                                                  Our Minister of Health

               Motivated                   Motivated
            economically to             economically to
           keep you coming              keep you healthy

  Commoditization in Healthcare
• The new “primary care providers”
   – Much of the knowledge and duties formerly associated
     with General Practitioners should now be delegated to
     PA’s, nurses, pharmacists, and patients
   – General Practitioners become Chronic Disease Managers
• Personal Trainers evolve into Personal Health
   – Working from a Lifetime Health Project Plan
• Home care and “MinuteClinics” replace ambulatory

           Retail Clinic Metrics
• 60% of patients who visit retail clinics don’t
  have a primary care provider…and don’t need
• 10 problems account for 90% of visits to retail
  – URI, sinusitis, bronchitis, pharyngitis,
    immunizations, inner and outer ear infections,
    conjunctivitis, UTI, BP monitoring, screening labs

Healthcare Information
•First Order Economics
•Lower MTTI
•Commoditization of Services &
        Commoditization & MTTI
• Evidence-based clinical protocols, embedded in
   – Knowledge is compiled from 20,000,000 articles per year
     and presented for use and reference at the point of care
   – Software enables the dissemination of knowledge,
     impossible only 3 years ago
• Analytics for measuring, managing, and improving
  the delivery of care across a population
   – Enables much faster progression around the MTTI cycle

    Justifying the Use of an EMR
• You can’t justify the use of an EMR based on
  clinician productivity at the point of care
  – Productivity stays about the same, at best, over
    time, sometimes permanently decreased
• The value of an EMR is systemic
  – Downstream benefits of data analysis for process
    improvement and patient management
  – Remote access, task automation
  – Clinical decision support, sometimes

EMRs’ Impact on Chronic Disease Mgt
 Asthma, Congestive Heart Failure (CHF), Chronic Obstructive
 Pulmonary Disease (COPD), and Diabetes

EMRs & Diabetes Management

CAD Discharge Med Management
               Patient and physician
               adherence to protocol

         EMRs Enable Lower MTTI
Case study
• Old clinical protocol
   – Diabetics with no history of CV disease prescribed prophylactic aspirin
• New evidence
   – Higher risk of GI bleeding and stroke outweigh benefits
• New protocol
   – More conservative use of aspirin in diabetics with low CV risk

• New protocol implemented in the EMR order sets at
   – 3 day MTTI

Computerized Medication Order Entry
Elimination of hand written prescriptions and orders

At 80% adoption
• Inpatient safety benefits (US)
   – Reduction of 200,000 adverse drug events/year
   – $1B in savings
• Outpatient safety benefits
   – Reduction of 2,000,000 events/year
   – $3.5B in savings

             The Antibiotic Assistant
• A clinical decision support tool developed at
  Intermountain Healthcare
Antibiotic     Dosage        Route          Interval   Predicted     Average
Protocol                                                Efficacy   Cost/Patient
Option 1       500mg           IV            Q12         98%         $7,256
Option 2       300mg           IV            Q24         96%         $1,236
Option 3        40mg           IV             Q6         90%         $1,759

 •All of these options are evidence based

 •Only one of these balances evidence & economics

  The Antibiotic Assistant Impact
• Outcomes improved 47%
• Avg # doses declined from 19 -> 5.3

• The replicable and bigger story
  – Antibiotic cost per treated patient: $123 -> $52

  – By simply displaying the cost to physicians

  – Information Technology created the illusion and
    benefits of First Order Economics…!

       Personal Health Records
• Should be assigned to EVERY patient
  – Whether they use it or not
• At Northwestern, 2009
  – 25,000 patients actively using a PHR
  – Patient satisfaction: 8.7 out of 10
  – Lab results, secure messaging/email with
    providers, medication refills, BMI and glucose
  – 0.3 email messages/patient/month

        The Downside to PHRs
• 600+ PHRs on the market now
  – My PHR at Northwestern is tightly coupled to
    Northwestern’s EMR system
  – No reasonable portability of my data
• We need the equivalent of
  – Integrates your personal financial records from
    multiple sources into a single perspective

     Transformational Technology
• Precision diagnostic technology increases
   – More investment and reward for precise diagnosis, less reward for
     broad brush therapeutics
• Evidence based medicine captured in software
   – Precise diagnosis, precise treatment
• Low cost, ubiquitous telemedicine
   – Every home, every care provider
• Smart phones
   – Protocols, orders, status communication
   – Financial transactions
• Centralized “command center” patient monitoring and
  healthcare management

         Commoditize Innovation
• Google-like search ability for EMRs
   – New feature in Cerner
• Facebook: 550 million people can’t all be wrong
   – Patients supporting one another in disease management
   – Health coaches as Friends
   – Already happening with obesity and diabetes
• Concepts from Amazon
   – Other physicians also ordered these medications and procedures
   – What are the reviews on these medications?
   – Building a “shopping cart” of orders for procedures and medications,
     with expenses

Text Messages and HIV Management
• 5,300 patients in Kenya on AR therapy; U of
  British Columbia; 2007-2009
• Weekly text msgs from nurse managers
  – Mambo? (are you ok?)
  – Sawa or shida (or > 48 hrs no response)
  – If shida, phone call follow-up
  – 9% improvement in drop of blood virus levels
  – One nurse per 1,000 patients
  – 33 phone calls per week

               Commoditized IT
• Apple store has 7,000+ applications written to
  support health care on the iPad and iPhone
   – Android-based phones are the fastest growing
   – Physicians: Epocrates, WebSphere MD
   – Patients: Diet, exercise, diabetes and depression
   – 15% of respondents 18-29 years used a healthcare related
     application on their mobile phone
• Healthcare providers needs to start endorsing and
  “prescribing” the use of these tools

Strategic Implications for
the Health Services
 Evolution of Electronic Medical Records
• The vendor market for EMRs is in-between the
  3rd and 4th Generation of EMRs
• The future of healthcare– which is now--
  demands a 5th Generation product

• The Speed of Software is at play here and the
  future is uncertain

  Evolution of EMRs and Healthcare Processes in the US

                            Bloated               Stimulus $
                            insurance             •ARRA            •Healthcare Reform
                            companies             •HITECH          •ACOs & CayHealth

1970s                                                                                    2015

 •Medicare                                 Economic                •ICD billing
 •Encounter-based billing                  Meltdown                •Fee for Quality
 •CPT billing                                                      •Capitation
 •Fee for Service (FFS)                                            •Direct contracting
                                                                   with employers

1970s                                                                                    2015

  EMR 1G          EMR 2G                EMR 3G              EMR 4G            EMR 5G?
  •HELP           •Vista                •Cerner             •eCW
  •TMR            •MediTech             •Epic               •Athena
          Commodity Pricing?
• Average of US $80,000 per bed to implement
  an enterprise Clinical Information System

• Expensive and lacking agility…

• This has to change

Design Motives of 3G & 4G EMRs
  –   FFS procedure billing     • No thoughts
  –   Convert the paper chart     – Economics of care
  –   Defensive medicine
  –   Information hand-off
• Afterthoughts
  –   Clinician efficiency
  –   Clinical quality
  –   Personal health records
  –   Health Information

Motives Behind 5G EMRs
  –   Clinician efficiency
  –   Evidence based medicine
  –   Diagnosis, capitated billing
  –   Supporting the Medical Home
  –   Economics of care
  –   Portability of data
  –   Patient engagement in their own care
       • Shareholder in the financial risk and benefit
• Natural consequences
  – Defendable medicine
  – Simplified billing

      The US Influence on EMRs
• HITECH Funding Initiative in the US
  – At least $20B in incentives to physicians and
    hospitals to stimulate the adoption of EMRs in
  – Something is wrong with this picture…
     • Did the iPod or iPhone require government incentives
       to stimulate adoption?
     • What will be the impact on EMR products and market?
     • Where’s the motivation to innovate if the consumer is
       forced to buy your product?

Current Vendor Landscape
                           *KLAS 2010

       What’s Going to Happen?
• HITECH funding stimulates the wrong kind of
   – Rush to invest in 3G and 4G EMRs
   – No residual vendor incentive to innovate
   – Hospitals and clinics: No money or will power left to invest
     again for another 10-15 years
• Will 5th Generation EMRs Emerge?
   – Yes, in about 2 years, which benefits late adopters

                 HSA IT Adoption
• Remarkably well for a relatively small system
   – But still, very problematic
• 4.6% of operating revenue on IT
• 85% of that on the Total Cost of Ownership of our
  core Cerner clinical information system
• Leaving 15% for everything else
   – Materials Management, Pharmacy, Human Resources, GL,
     Web presence, email, telephones, and many others…

               Critical Questions
• Can HSA and Cerner evolve together to meet HSA’s
• Can we afford Cerner– are the benefits worth the
   – $40,000 per employed physician per year Total Cost of Ownership
   – 85% of the total HSA IT budget
• Cerner contract expires in June 2013
   – We have less than three years to make a 15-year decision

    Other HSA Strategic IT Needs
• Real Time Claims Adjudication and Eligibility
• Supply Chain and Materials Management
• Outpatient Pharmacy Management
• Outpatient EMR, including Specialty Modules
• Extending the EMR to private physicians
• Electronic prescribing to all private pharmacies
• Modern Telephone System
• Dental EMR

         Summary of Thoughts
• HSA is facing a big decision regarding its EMR
  and core clinical information system
• IT alone is not enough for transformation
  – Must be accompanied with cultural change,
    patients and providers
• We are Homo Economicus not Homo Sapiens
  – Half joking, full truth 
• EMRs and IT have a proven and positive return
  on investment, if invested properly
In closing….
• The Cayman Islands are in a unique

• Culturally risk tolerant
• Financially capable and astute
• Legislatively agile

Next year at this conference, the rest of
the world will be paying to watch 


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