Smooth Transitions: Accelerating Coordination from Concept to Reality
Anuj Desai
VP Market Development
Victoria Tiase
Director, Informatics Strategy
Patricia Meisner
CEO & Co-Founder
Ken Ong, MD
Chief Medical Informatics Officer
Joseph Mayer, MD
Founder & CEO

Health Care’s Dynamic Landscape
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Health care reform is sweeping the nation
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Federal government is strongly promoting adoption of EMRs and their meaningful use
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The unprecedented uptake of mobile technology has created a huge opportunity for mobile health applications
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Hospitals, providers, employers and payers are eager to take advantage of digital health solutions to create cost savings and improve health/wellness

New York State Healthcare
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New York State is pioneering the Delivery System Reform Incentive Payment(DSRIP) Plan to redesign Medicaid and safety net care and payments, at a cost of $6.42 billion
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DSRIP projects and participants must:
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Include infrastructure that increases accessto outpatient care and care integration
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Improve integration across settings
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Take responsibility for the overall health needs of a defined population of Medicaid and low-income New Yorkers
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Reduce avoidable hospital use

HIT: Ripe for Innovation
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Even with relative success of meaningful use program, clinical data remains in silos
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HIE’s arebeginning to gain traction
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For value based care to be a reality, all of a patient’s providers must be brought together in one ongoing conversation
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Innovative digital health solutions are emerging from startup companies and they need face time with providers

The Opportunities for Digital Health
Health care stakeholders seek digital health solutions focusing on:
Care collaboration (e.g. integrated care, secure messaging, transitions of care)
Collaborative care solutions that reflect the continuum of information about a patient and support team- based care, management of patients by risk category, secure messaging, and transitions of care.
Patient engagement (e.g. wellness and fitness, medication adherence)
Personal health management solutions facilitating better healthcare decisions and improving communication on care management between the provider and the patient/family members.
Predictive analytics (e.g. avoiding readmissions)
Analysis of clinical data for multiple purposes, including identifying high risk patients, based on standard criteria for risk.
Workflow improvement (e.g. cybersecurity, decision support tools)
Improving provider healthcare workflow processing/throughput and supporting cost containment initiatives.

The New York Digital Health Accelerator
The New York Digital Health Accelerator is a program run by the New York eHealthCollaborative and the Partnership Fund for New York City for early-and growth-stage digital health companiesthat are developing cutting edge technology products for healthcare providers and patients in the areas of care coordination, patient engagement, predictive analytics and workflow improvement.
Program’s Unique Feature
The ability of the participants to engage directly with the senior leadershipof a broad network of twenty three healthcare provider organizations in New York for mentorship and pilot programs.
Inaugural Class Highlights
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The eight Accelerator companies launched 17 pilots with healthcare providers
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The companies created over 120 new high tech jobsin New York
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One year following the conclusion of the program, the companies have raised an additional $24MM from outside sources and two companies have been acquired

Mentor Network –2014 Class

New York Digital Health Accelerator – 2014 Class
AllazoHealthaddresses the problem of medication non-adherence by leveraging existing member data to anticipate which patients will not take their medications and to predict how best to effectively influence each patient to take their medication.
Clinigence’ssolution –built around clinical data analytics, sematic data aggregation, and predictive modeling –provides real-time clinically- based reports about care gaps. This helps healthcare providers improve outcomes and proactively address the shift to value-basedmodels.
Covertixhelps healthcare organizations protect and control confidential data shared between patients, healthcare professionals, hospital networks and third party vendors to improve their coordination of care.
iQuartic’stechnology merges, structures and mines EHR, PBM, claims and mHealthdata for analytics that inform and benchmark care based on outcomes/best practices and adjusted population.
Noommakes software to help people live healthier. For consumers, the NoomWeight Loss Coach, with over 11 million downloads, coaches users on nutrition and exercise. Noom’svarious patient engagement apps are based on its popular consumer-facing app.
Quality Reviews' flagship mobile product, RateMyHospital®, empowers patients to provide meaningful and real-time feedback about provider services.
Sense Healthuses mobile technology to build personal connections between providers and high-risk Medicaid patients to improve outcomes and the quality of care.

Medication Management and Reconciliation
at the Point of Care

Best Possible Medication History at the Right Time and Right Place
Engages All Stakeholders:
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Patients and Caregivers
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Healthcare Team
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Payers
Aggregation & Validation of Data (including Patient Self- Medication)
Identification of Risk
Medication Action Plans for Care Team & Patient
Patient’s
On-Hand
Meds
Engagement is Greatest
At the
Patient/Provider
Encounter

ActualMedsPilot Objectives
Goal: Proof of Concept
1.
Non-licensed Community Health Workers could use ActualMedssoftware at the point of care
2.
Meaningful patient self-medication information, including Rx, OTC and home remedies on-hand, could be collected and evaluated
Solution Claims:
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ActualMedsdelivers cost-effective medication management through automation and re-distribution of labor
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Patient self-medication behavior can reveal previously unidentified risk

Results and Conclusions
Details of pilot design and results were reported at ACU Annual Meeting and Health IT Forum: Delivering Quality Care for the Underserved, June 25-27 2014, Alexandria, VA. :
“Use of Enabling HIT by Community Health Workers to Document Patient Self- Medication Behaviors of High-Risk Diabetes Patients in a Home Setting” Anne Marie Biernacki, Chief Technology Officer ActualMedsCorp.; Carmen Cruz, Manager of Community Health and Evaluation at New York Presbyterian Hospital.
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ActualMedscanprovide a software and service framework for team-based medication management
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The ability to capture patient self- medication information at the point of care is a key part of medication management and reconciliation that has potential to improve patient outcomes.

Thank You
Patricia Meisner, CEO
pmeisner@actualmeds.com
www.actualmeds.com
Twitter: @ActualMeds; @PatMeisner
Medication Management Software and Services for:

Medication Reconciliation at Transitions of Care
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Medication Therapy Management ( Part D MTM)
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Medication Management for Dual Eligiblesand Complex Care
Serving:
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New York FIDA Plans ( Dual Eligibles)
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Medicare Advantage and Part D Plans
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Accountable Care Organizations
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Patient Centered Medical Homes

Digital Health Accelerator Case Study: NewYork-Presbyterian Hospital
Victoria Tiase, MSN, RN,
Director of Informatics Strategy

NewYork-Presbyterian Hospital (NYP)
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NYP is composed of six main facilities located in and around New York City
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Columbia University Medical Center
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Weill Cornell Medical Center
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2,600 patient beds
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2 million inpatient and outpatient visits
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US News & World Report Honor Roll -#1 in NYC

Background
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CHWs support the NYP WIN for Health program in the Washington Heights neighborhood of northern Manhattan
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CHWs strive to establish relationships with patients and serve as the “bridge” to community and health services
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obtain “between visit” information from the patient at established time intervals and convey that information to the NYP providers
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are health professionals but have lower level of health literacy than physicians or nurses
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have specialized documentation needs and, via a paper-based assessment, document pre-intervention activities such as healthy eating, home safety, and need for referrals
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use of community health workers is likely to increase due to accountable care models and the need for care coordination

Pilot Overview
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NYP provided Community Health Workers (CHWs) with tablets in order to capture medication data from patients using a web-based program
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Goal of the project: determine if software supplied by ActualMedsis suitable for use by NYP CHWs to collect medication data from patients/caregivers in a community setting
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We hoped this would serve as proof of concept for clinical use of CHW-obtained data in the community setting

Results
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Nine CHWs collected medication data during home visits that took place between May 6, 2013 and June 28, 2013
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The CHWs attempted medication data collection on 16 patients, 15 were successful
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The CHWs were trained 3.5hrs on average
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Medications recorded included prescriptions, OTCs and home remedies
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CHWs can successfully use a tablet device in the home setting to conduct a medication review with a patient
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The main hurdle to continued use is need for a resource for reconciliation