Health IT Summit Miami 2015 - Presentation “Innovation and Chronic Disease Management”

1. Innovation and Chronic
Disease Management
Jonathan Wilt
AVP, Center for Innovation
Ochsner Health System

2. Necessity is the mother of invention.
The Republic, Book II, 369BC, Plato
& innovation

3. Healthcare Spending as a Percent of
Gross Domestic Product
17.7%
11.9%
11.6%
11.2%
9.6%
9.4%
9.3%
9.0%
7.9%
7.7%
7.4%0% 9% 18%
United States
Netherlands
France
Canada
Japan
United Kingdom
OECD Average
Finland
Hungary
Israel
South Korea
Source: OECD. http://www.vox.com/cards/how-doctors-are-paid/how-else-could-the-us-bring-down-health-care-costs#E5744046

4. 3 6 4 1 5 2 7
4 7 5 2 1 3 6
2 7 6 3 5 1 4
6 5 3 1 4 2 7
4 5 7 2 1 3 6
2 5 3 6 1 7 4
6.5 5 3 1 4 2 6.5
6 3.5 3.5 2 5 1 7
6 7 2 1 3 4 5
2 6 5 3 4 1 7
4 5 3 1 6 2 7
1 2 3 4 5 6 7
$3,357 $3,895 $3,588 $3,837 $2,454 $2,992 $7,290
AUS CAN GER NETH NZ UK US
OVERALL RANKING (2010)
Quality Care
Access
Efficiency
Equity
Long, Healthy, Productive Lives
Health Expenditures/Capita, 2007
Cost-Related Problem
Timeliness of Care
Effective Care
Safe Care
Coordinated Care
Patient-Centered Care
Source: The Commonwealth Fund: Mirror Mirror On The Wall: How the Performance of
the U.S. Health Care System Compares Internationally 2010 Update
How the US Health Care System Compares Internationally

5. 600,000
700,000
800,000
900,000
2008 2010 2015 2020
Demand Supply
Projected Supply and Demand,
Physicians (all specialties)
Physician supply not keeping pace with increasing demand for healthcare services
91,500
62,900
Source: AAMC Center for Workforce Studies, June 2010 Analysis

6. Major Epidemics in History

7. Bubonic Plague
1347-1350
>25 Million deaths
30-70% of the Population
Cholera
1817-1860 1865-1900
>50 Million deaths
10% of the Population
Influenza
1918-1919
>75 Million deaths
30-70% of the Population

8. CHRONIC
DISEASE
Today
75% of all Deaths
50% of the Population
CHRONIC
DISEASES
ACCOUNT FOR
3 4
DEATHS
OUT
OF

9. Chronic Disease
 75% of U.S. health care dollars goes to treatment of
chronic disease.
 Nation’s leading cause of death and disability causing
70% of all deaths.
 50% of all adult American have at least one chronic
disease.
 90% of seniors have at least one chronic disease, and
77% have two or more chronic conditions.
Median outpatient visit length is < 15 minutes covering a median of 6 topics
Source: Centers for Disease Control and Prevention. http://www.cdc.gov/chronicdisease/index.htm
BMJ 2013;346:f2614. http://transformativehealth.info/a-c-suite-view/patient-engagement-a-strategic-imperative-for-preventing-readmissions/
Tai-Seale M, et al. Health Serv Res. 2007;42:1871-1894. Gottschalk A, et al. Ann Fam Med. 2005;3:488-493.

10. Four Common Causes of
Chronic Disease
Health Behaviors
 Lack of physical activity
 Poor nutrition
 Tobacco use
 Excessive alcohol consumption
obesity
• diabetes
• hypertension
• heart failure
• coronary heart disease
• stroke
• cancer
• OSA
• atrial fibrillation
• hyperlipidemia
• gallstones
• back pain
• infertility
• skin infections
• gastric ulcers
Source: http://www.cdc.gov/chronicdisease/overview/index.htm

11. Projected Growth in Population with Chronic Conditions
2013-2025
Dall TM, et al Health Affairs 2013;32:2013-2020.

12. Adherence to Quality Indicators in Chronic Disease
Condition No. of Indicators
% of Recommended
Care Received
Overall Care 439 54.9%
Hypertension 27 64.7%
Heart Failure 36 63.9%
COPD 20 58.0%
Asthma 25 53.5%
Hyperlipidemia 7 48.6%
Diabetes mellitus 13 45.4%
Peptic ulcer disease 8 32.7%
Atrial fibrillation 10 24.7%
McGlynn EA, et al. N Engl J Med 2003;348:2635-45.

13. Last
Costs too high Poor quality
Modern day epidemic Receiving recommended care
Demand outpacing supply
What’s the Necessity?What’s the Necessity?

14. Factors Influencing Health Status
40%
15%
30%
5%
10%
Schroeder SA. N Engl J Med 2007;357:1221-8.
Environmental
exposure
Genetic predisposition

15. Factors Influencing Health Status
 Electronic Health Records
 Meaningful Use
 Core Measures
 Transparency
 HCAHPS, CAHPS
 HEDIS, SCIP
 Pay for Performance
 PACS
 Joint Commission, Leapfrog
40%
15%
30%
5%
10%
Health care
Health care
Schroeder SA. N Engl J Med 2007;357:1221-8.

16. Factors Influencing Health Status
Social Circumstances
 Living conditions (live alone)
 Transportation
 Access to care
 Medication affordability
 Social network support
 Education level
40%
15%
30%
5%
10%
Social
Circumstances
Health care
Schroeder SA. N Engl J Med 2007;357:1221-8.

17. Factors Influencing Health Status
40%
15%
10%
Schroeder SA. N Engl J Med 2007;357:1221-8.
Behavioral patterns
Social
Circumstances
Health care
Behavioral patterns
 Depression
 Medication adherence
 Social network influence
 Physician/Health-System perception
 Lifestyle: diet, activity
 Patient activation

18. Last
Costs too high Poor quality
Modern day epidemic Receiving recommended care
Demand outpacing supply
Not effectively targeting
behavioral patterns
What’s the Necessity?What’s the Necessity?

19. Traditional Innovations Inside Health Systems
 Electronic Health Records
 Meaningful Use
 Core Measures
 Transparency
 HCAHPS, CAHPS
 HEDIS, SCIP
 Pay for Performance
 PACS
 Joint Commission, Leapfrog
 Telemedicine
 LEAN

20. Concept of an Innovation Team
 Our Chief Clinical Transformation officer was leading innovation efforts in these
traditional innovation areas, and this was also my primary focus from an IT
perspective
 Internal discussions about creating an innovation team to focus on larger issues in
the industry
 Inspiration
• Skunk Works – Total control by manager, restrict access to project to protect the
innovative ideas
• IDEO – Super small teams, informal, no hierarchy, a free flow of ideas, and quick
prototyping
 How to pull this off at a Health System?

21. Ochsner Center for Innovation
 Created in 2013
 Tasked with going above and beyond the typical, incremental optimization of
software systems and clinical workflows
 Use the newest technologies to innovate care delivery models
 Not just another IT department – use pharmacists, nurses and operational liaisons
to support new programs
 Integration into operations and IT is crucial to the long term success and
maintainability of our programs, so we cannot be isolated
• Separate space, but still close to IT
• Open work areas, conference rooms, white boards

22. An Evolving Team Structure
 Initial team was made up of volunteers in both IT and operations, two part-time
pharmacists, and myself as the only full-time member.
 Technical team met twice a week to develop our programs and divide up work.
Patient care team worked remotely supporting our programs.
 As successful projects were implemented, more funding was secured to hire more
full-time team members
 To date, we now have funding for 5 full-time team members in addition to the over
10 part-time volunteers participating

23. Initial Team Structure

24. An Evolving Team Structure

25. Partnership with IT
 The IT department uses the Center for Innovation to grow their talent and teach
them to think outside of the box
 Co-sponsor annual innovation challenges to generate new ideas and interest in the
team
 New career path from IT to the Center for Innovation for people who may not want
to become managers

26. Prove Value Quickly
 Developing and testing new care delivery models takes time, and we needed to
create value quickly
 There were prerequisite foundational systems to build and implement before new
care delivery models could be piloted
 Team focused on a couple of key issues to prove value quickly and buy time
• Reimbursement for our capitated population is dependent on physicians billing
HCCs (Hierarchical Condition Categories) once a year
• Inaccurate coding costs us millions in lost revenue for the conditions we treat, so
this is great bang for your buck

27. Prove Value Quickly
 The prevalence of morbid obesity is now over 6% of the US population and a brand
new HCC in 2013
 Only 18% of qualifying patient visits (BMI>40) contained a visit diagnosis of morbid
obesity in 2012 totaling only 40% of the patients for the year
Survey period Sample (n) Overweight Obese Extremely obese
Percent (standard error)
1988–1994 16,235 33.1 (0.6) 22.9 (0.7) 2.8 (0.2)
1999–2000 4,117 34.0 (1.0) 30.5 (1.5) 4.7 (0.6)
2001–2002 4,413 35.1 (1.1) 30.5 (1.1) 5.1 (0.5)
2003–2004 4,431 34.1 (1.1) 32.2 (1.2) 4.8 (0.6)
2005–2006 4,356 32.6 (0.8) 34.3 (1.4) 5.9 (0.5)
2007–2008 5,550 34.3 (0.8) 33.7 (1.1) 5.7 (0.4)
2009–2010 5,926 33.0 (1.0) 35.7 (0.9) 6.3 (0.2)
2011–2012 5,181 33.6 (1.3) 34.9 (1.4) 6.4 (0.6)

28. Prove Value Quickly
 We designed specialty tools in the Epic EMR to not just remind physicians to
address morbid obesity (HCC was worth $2900 in 2013), but also remember to
address all HCCs.
 For those of you on Epic, you can view our past UGM presentation and we can
share our coding.

29. Growing the Team
 With the improved capture rate of HCCs, we easily proved our value and secured
funding for full-time employees
 We recruited the most creative and best critical thinkers from around the country.
• Ability to look at problems in unconventional ways
• Ability to generate new and useful ideas
• Ability to analyze which ideas are worth pursuing and which are not
• Ability to articulate new ideas to others and convince others that ideas are worth pursuing
• Possess a tolerance for ambiguity and willingness to overcome obstacles
• Possess a willingness to take reasonable risks
• Self Starter

30. Growing the Team
Lesson learned:
 There is a lot of interest in the organization to join the team, however it is
sometimes difficult to find the right people.
 Many people want to join to do something different, rather than make a difference.
We need passionate, driven team members to tackle these seemingly impossible
issues

31. Focus on Chronic Disease Management
 Focus in 2014 and 2015 is chronic disease management
 Using the newest technologies available, target the 65% of contributing factors we
have control over – not just 10%
40%
15%
30%
5%
10%

32. Prioritizing Diseases
 Inpatient Readmissions - CHF
Elixhauser A (AHRQ), Steiner C (AHRQ). Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. April
2013. Agency for Healthcare Research and Quality, Rockville, MD.
26.1 25.7
24.2
0
5
10
15
20
25
30
18-44 45-64 65+
All-cause 30-day readmission rates for
congestive heart failure
Age

33. Prioritizing Diseases
 Outpatient diagnoses - Hypertension
Chronic Condition % of outpatient visits
Hypertension 27.0
Hyperlipidemia 15.7
Diabetes 15.1
Depression 12.4
Arthritis 10.2
SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey.

34. Congestive Heart Failure
 Targeted approach for all heart failure
patients including detailed screening
(i.e. depression, med adherence, etc.)
with dedicated HF nurses.
 Comprehensive OP monitoring with
HF care team
 Monitors daily weight for changes and
reaches out to patient to provide real-
time guidance and treatment.

35. Level 1: Guided Decision Support

36. Level 2: Assessments
 Affordability of meds
 Medication adherence
 Drug-drug, drug-condition interactions
 HF Quality of Life
 Depression screen
 Family / Caregiver support
 Transportation issues
 Education level / level of HF understanding
 Alcohol / drug use
 Dietary sodium quantification
In-depth evaluation and quantification of patient specific characteristics

37. Level 2: Interactive Assessments
Everything is completed on Windows tablets using Welcome!
 Patient scores high on sodium consumption
• “Who shops for your groceries”?
• “Who prepares your meals”?
 Patient views video on what high sodium
means and why it is important; shown what
foods are high in sodium and which foods
make better choices
 Individual(s) who shops for and prepares
meals sent email with literature and video
link

38. Level 2: Inpatient Intervention
 Pharmacy consulted for adherence/affordability
(+/- social worker). If unaffordable, 30-day supply
of meds provided at discharge.
 Psychiatry consulted for depression, drug/alcohol
addiction.
 Nutrition consulted for high dietary sodium intake.
 Social services for transportation, caregiver
support, home health services.
 Educated in heart failure disease state; use of
monitoring scale; cause and effect relationships.

39. Level 3: Outpatient home monitoring
metrics
scrubbed
thru
condition
specific
algorithms
patients
stratified
by risk
status
high risk
patients
intervened
by
medication
adjustment
and/or
outpatient
visit
X
potential
readmission
avoided

40. RelationshipbetweenImproved Care Coordination andReadmission in
HeartFailurePatients
0
5
10
15
20
25
30
35
40
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan
%Readmissions
2012 2013 2014
14%
25%
Program

41. Hypertension
 Hypertension is the most common diagnosis made at primary care office visits.
 Most common chronic condition, affecting about 30% of US adults, with estimated
annual costs > $50 billion.
 Only half of patients with hypertension achieve BP control; the leading cause of
which is “therapeutic inertia” (86.9%).
Ranking Prevalence State
47 39.8% LA
48 40.2% MS
49 40.3% AL
50 41.0% W.Va
Roger VL, et al. Circulation. 2012;125(1):e2-e220.
Hsiao C, et al. National Ambulatory Medical Care Survey: 2007 Summary. Hyattsville, MD: National Center for Health Statiastics; 2010.
Margolis KL. JAMA 2013;310(1): 46-56.
Milani RV, et al. J Am Coll Cardiol 2013;62:2185-7.

42. Just as banking can be done outside the confines of a bank,
BP monitoring and management can and should be done at
home and in other nonclinical settings such as pharmacies
and community and senior centers. Out-of-clinic BP
monitoring with team care should largely replace
traditional office-based BP management for most patients.
Absent a contraindication to home monitoring, patients
should be provided with a validated BP monitor and BP
measurements should be transmitted to each patient’s
clinician, with follow-up patient-clinician communication
by telephone or by electronic visits, if necessary. If home
BP monitoring and team-based care were implemented
broadly, hypertension management would be easier for
patients, and the magnitude of BP reductions brought about
by this change could lead to substantial reductions in
cardiovascular events and mortality, which is something
patients, clinicians, and policy makers can take to the bank.

43. Home BP Telemonitoring: HyperLink Study
Proportion of Patients with Controlled Blood Pressure
Follow-up Telemonitoring Usual Care p-value
6 months 71.8% 45.2% <0.001
12 months 71.2% 52.8% 0.001
18 months 71.8% 57.1% 0.003
Margolis KL. JAMA 2013;310(1): 46-56.

44. Innovative Model for Care Delivery Going Forward
1. Utilizes non-physician providers of care that supports
physicians
2. Works in a “focused-factory” that can keep up with an ever
expanding knowledge-base and growing set of quality
measures
3. Assess, characterize, and potentially modify social
circumstances and behavioral patterns to enhance overall
health status
4. Exploit technology to its fullest in order to manage large
populations of patients efficiently (i.e. decision-support tools)
5. Monitor and “touch” patients remotely (just-in-time) resulting
in faster cycle-times for meeting goals and enhanced patient
satisfaction

45. Apple HealthKit, Withings, Fitbit
 In October 2014, Ochsner integrated
HealthKit with our Epic EMR
 HealthKit now provides a standardized
platform for a variety of in-home
devices
 We can concentrate on the largest few
manufacturers for Android users
 Withings
 Fitbit

46. Overall lessons learned
 Senior executive support
 Integration into operations and IT is crucial to the long term success and
maintainability of our programs
 Cannot maintain dozens of incoming patient entered data streams
 Take your time and choose the right team
 Ability to quickly get data from EMR – can’t rely on standard reporting processes for
quick reports
 Fail fast

47. What’s next?
 Expand Chronic Disease Management programs
 Conduct analysis on why 65% of readmissions aren’t
from the admission dx
 Research new wearables and integration of more
areas of the home