Years ago I was standing next to the Chief Trauma Surgeon (CTS) in an Emergency Department while the team worked feverishly to resuscitate an injured EMT. The EMT had been struck by a speeding car while at the scene of an accident. In one split second he went from being a first responder to being a patient. My job was to relay information to the Operating Room to make sure the Trauma Suite was prepared appropriately should this patient survive long enough to make it to surgery. The code had been going on for almost an hour and all the efforts of a dozen brilliant and highly trained professionals seemed to have no impact. In fact, things just seemed to be getting worse. Finally the resident came over and asked the CTS if we should ‘call it’. In hospital speak, that means to admit defeat and acknowledge that the patient cannot be resuscitated. It means, literally, to call the time of death. I watched while the weight of the decision spread over the face of the CTS and change his posture as if an actual physical weight had been put on his shoulders. After a few minutes, he turned without a word to walk towards the waiting room to speak to the family. He had only taken a few steps when he turned around and came back. “No, keep going.” The commitment and compassion I saw in his face that day has never left me. He was there for that EMT. The power of truly being there to make a difference hit home.
At Cisco, we are working to make it easier to “be there”. To bring knowledge and expertise right to where it is needed, no matter where you are, no matter who you are. We are using technology to connect not just machines and data bases, but people. Today, we see the powerful forces of social, mobility, the cloud and information coming together. Gartner describes this as the Nexus of Forces. This nexus is disrupting old models and creating new market transitions. Scaling these technologies is making things possible that were not possible before. And Cisco is working to be there, to help you be there.
Back in September, I had the opportunity to attend HIMSS APJC in Singapore and was really excited to learn more about the key trends in that part of the world, which houses some of the largest economies, populations, and economic growth. After talking with several customers and listening to several panel discussions, one common theme kept recurring – patient experience. It was my belief that patient experience was more of a USA hot-button as healthcare organizations in the USA are being forced by patient “consumerism”, whereby patients want their money’s worth and have a certain level of expectation. I was surprised to learn that patient experience is more of a global trend and that got me thinking as to what exactly is patient experience and how healthcare organizations are addressing it.
After talking with customers on a world-wide basis, I have learned that customers really do not have a standard definition for “patient experience”. In fact each one of them has a different interpretation and there are widely divergent views in the healthcare industry. The 2009 HealthLeaders Media Patient Experience Leadership Survey — covering more than 200 healthcare CEOs, CFOs, COOs, CNOs, directors, senior vice presidents, and other C-suite high-ranking healthcare officials — found that 33.5% of respondents said the patient experience is their “top priority,” and 54.5% said it’s “among their top five priorities.” And most responders thought it would be a priority in the future as well: 45% said it would be their top priority five years from now, and 50.5% said it would be in their top five priorities. Read More »
The need to control healthcare expenditure (per capita Medicare expenditure at $8973) is no longer in doubt. With over 36% of the $599 Billion Medicare spend on inpatient care, almost 19% on post acute care and over 13% on outpatient services healthcare is looking to new business architectures to contain costs as well as maintain quality. Accountable Care Organizations (ACO’s) is one such business model structured from a fee for service to a pay for performance model.
The aim of an ACO is to reduce healthcare costs, improve quality as well enhance patient experience. ACO’s are legal entities that organize around the concept of a patient centered medical home with primary care physicians forming the core who become the focal point for engaging with the patients to participate in driving superior outcomes. The ACO’s enroll healthcare participants in the care continuum who collaborate together in concert to meet the goals of the ACO. These participants would include specialists, extended care providers (skilled nursing, hospice, extended care), physicians, nurse, dieticians and social workers. Primary Care Physicians can participate in only one ACO; the others may participate in more than one ACO.
ACOs may be fully integrated or they may draw members from outside the organization into the legal structure through agreements to complete all needed participants in the care continuum.
ACO’s have shown benefits. Cigna has done a study showing significant savings in Accountable Care Organizations. Michigan’s Value Partnership Program or Blue Shield Blue Cross MA and others have shown promising savings.
Can this shared savings be increased using collaboration, video and Telehealth technologies? There are indicators that it can:
VA has shown a 19% reduction in hospitalization through its Telehealth program
Geisinger Health Plan has shown a 44% reduction in readmissions with Telehealth
Over 75% of Asthma admissions could have been avoided by using Telehealth
The payout to an ACO is calculated as:
Payout to ACO= (Cost Saving) x (Shared Saving %) x (Quality Performance)
An ACO is a business architecture where caregivers need to collaborate in the delivery of care, very closely, across the care continuum. The Primary Care physician needs to remain engaged with the patient as the patient transitions through different touch-points in the care continuum. Patients remain engaged and vested in their own well-being. The physicians will practice at the top of their license leaving certain functions to appropriately trained nursing.
Healthcare IT will play a major role; one of the requirements is for at least 50% of the primary care physicians to be meaningful use users. ACOs also have to demonstrate evidence-based practice. The ACO eco system should collaborate around an EMR that could be delivered on the cloud as a service to the ecosystem.
The ACO needs to identify at-risk patients and maintain close contact. Case Managers or care coordinators will leverage technology to keep the high touch with at risk patients.
Patients also need to have access to their trending health records as well as receive focused education
An ACO can increase its cost savings through immersive video and collaborations:
Care transitions managed through proactive video collaboration between caregivers help in reducing medical errors and re-admissions
With immersive video based collaboration where the specialists and the primary care physician examine a patient at the same time using multi-point Telehealth saves costs. Such interactions also allow the primary care physician to make more informed decisions over a period of time. ACOs can see huge savings through this provider partnership.
Care coordinators can maintain a video based touch with outpatients and direct nursing visits where needed or bring in physicians or specialists into a video consult with the patient avoiding unnecessary visits to an ER
Telehealth can provide specialist access to patients in skilled or extended care facilities cutting down avoidable ER visits
Telehealth solutions that create physician groups can allow the right care provider, based on specialty or language, to provide care where needed
Technology can be leveraged to manage chronic conditions. “No show patients” is a huge drain in the operational waste in healthcare systems. Whether delivering virtual care in mental health situations, or examining patients who have difficulty traveling to clinics, video consults for movement disorder, neurologic or cardiac patients post operative consults – Telehealth can bring down healthcare costs.
Telehealth can allow specialists to avoid travel to remote clinic. The time saved provides efficiencies whereas the additional patients that a specialist can examine in the time saved provides transformational benefits
Structured collaborative education using technologies such as Webex can be more effective than a written brochure
Video, collaboration and Telehealth can also help in increasing the quality performance measures for ACOs:
The ability of a patient using immersive video and collaboration to stay in touch through care coordinators with physicians, specialists, nurses or social workers enhances the patient caregiver experience.
To succeed ACOs have to create appropriate team plays. Collaboration allows ACOs to dynamically build appropriate care teams to manage patients in different care settings. This helps in driving care coordination and patient safety metrics
Appropriate technologies as well as high touch virtual collaboration through immersive video can help with at-risk patients in any care setting. Structured education and trending personal health records drives adherence, compliance and better outcomes.
All that is good but is there an ROI for collaborative solution video and Telehealth? Yes, our ROI models have shown that such solutions can increase shared savings as well as improve the quality metrics.
However, the health of the ROI will depend on a sound network architecture and the investment in appropriate Video and Telehealth solutions:
The Telehealth solution should be scalable. Statistically 20% of the patients are responsible for 80% of the costs. Even with the smallest ACO with 5000 patients that translates to at least 1000 patients that need closer care. Even if 20% of these are at-risk that translates to over 200 patients that need a high touch video collaboration. This besides the Telehealth network across the care continuum of the ACO eco-system.
The Telehealth solution should accommodate and adapt to a variety of tethered and untethered end points as well as bandwidths
The Telehealth solution should be resilient and stay alive in the case of server failure
The Telehealth/Video and Collaboration solution should be built on a medical grade network infrastructure with a solid foundational architecture
The Telehealth solution should be simpler than a telephone to use. Single click collaboration will widen adoption
Primary care physicians and specialist need to collaborate on patients. The Telehealth solution should allow physicians, specialists and radiologists seamless collaboration with medical images without having to exit out of the collaboration session
The Telehealth solution should have the ability to push or pull data to/from EMR’s
ACOs are team plays so the Telehealth solution should allow the primary care physician and a team of specialists or care givers to examine a patient at the same time with vitals being shared to providers that need to see or listen to the telemetry. A variety of telemetry devices will allow different specialist to take advantage of the solution and provide cost saving virtual care
The Telehealth solution should allow grouping of specialists from different systems by specialty, care team or language. The system should abstract all complexities of contact center, collaboration technology, presence, firewall traversal and build these virtual groups as if they existed in one physical organization
Physicians are not always available, the solution should indicate presence status of the care givers so that the available care provider can be brought into a consult when needed
Finally an ACO creates a virtual organization and the Telehealth solution should integrate into the business and IT architecture of the ACO
An ACO is a collaborative organization. Healthcare services will be delivered over the network. The business architecture will implement on the IT and Network architecture; it is important to ensure that the network architecture foundation is strong and secure.
There will be big ACO successes and some not so big. Factors that will drive success are:
Healthcare ICT and careful architecture considerations
Immersive and pervasive collaboration and team play
An ACO creates a new way to deliver care. Process will be key to ensure operational efficiencies. Mapping out the care process across the continuum for each condition, cardiac bypass or diabetes or any other condition, then creating a checklist and ensuring adherence and compliance with the process across the care continuum will help in predictable outcomes. A team of process designers to design these processes and then measure them through appropriate metrics will allow optimizing and realizing desired outcomes as well as shared savings. Success will depend on vision, strategy and execution.
The Healthcare industry whether payer, provider, pharma or medical device manufacturer finds itself at a very interesting crossroad: the patient is the center of attention and each entity now has an increased focus in achieving outcomes from delivered services.
For providers care coordination of at risk patients in particular accountable care, the threat that re-admissions pose, the need to move non critical patients from ER to more cost effective walk-in facilities; operational efficiencies in specialty access, nursing operations and a flattening of in-patient revenue and the need to build referrals for acute care are driving changes to existing business models.
Pharma is long past blockbuster drugs and the merger and acquisition spree to diversify its drug portfolio and is certainly not immune to an outcome centric approach. Pricing will be determined by outcomes and pricing erosion by generics. Pharma will look at ways and means to reach out to patients to manage adherence, making clinical trials more efficient and simultaneously collaborating with other organizations for research into newer drugs.
Medical device manufacturers are seeing new buying centers in the US as a result of the payment sunshine act and in Europe the muscle of a buying consortium. A significant portion of the portfolio is subject to commoditization from players from China and Turkey amongst others. These manufacturers are taking their case to emerging markets and are looking to services to protect their franchise in mature markets.
Finally payers are reacting to the changes brought in by the Accountable Care Act. The exchanges, (look what happened to the payers before and after the exchange became operational in Massachusetts), 50 million new enrollees will enter the system, some through the exchanges others through Medicaid expansion, limits on administrative expenses, no rescission just to name a few. Payers are experimenting with accountable care models, some consolidating managed care medicaid assets, info-medic technologies or simply acquiring hospitals to become payer providers.
This is a “services” moment for the healthcare industry, service that focuses outcomes.
Healthcare providers are responding to changes in the business needs, analyzing opportunities to drive operational efficiencies as well as delivering care through accountable care models. Accountable care requires access to patients wherever they are in the care continuum- in hospital, extended nursing, skilled nursing, hospice or home. Care needs to reach the patient in any care setting. This shifts the paradigm from patients walking in the door to receive care to care coordination and care being delivered to the patient anywhere. Technologies such as video and telehealth can bring access to the patient in any care setting, allowing borderless delivery of healthcare as a service.
As provider systems vie for patients, patient experience and outcomes will be key differentiators. Smart hospitals with technology can provide the creative edge as well as enable new ways to deliver care. In room videos that provide entertainment, education, physician rounding, EMR access for visiting physicians, patient access to families, surveillance and monitoring, connecting patients to nurses can significantly enhance care, experience and with collaborative multi specialty access from specialists anywhere impact even outcomes. Whether in-patient with acute conditions, outpatients in rehab or with chronic conditions payments will be tied to quality cost and access. As care transitions from one setting to another systems needs to integrate the delivery of healthcare and manage these transitions. Provider systems may see the need to share assets such as EMR, PACs, Quality management, analytics and deliver them as a service to the extended ecosystem.
With access and new business models such as accountable care the nature of healthcare will gradually change from prescription to participation. Care coordinators will draw in physicians and specialist to oversee patient examination. Immersive video and Telehealth will allow a group of specialists to examine and determine a treatment plan.
Collaboration across the care continuum is key and immersive collaboration with high definition video is centric to this change. Video in some form or the other has been around for over 25 years, but it existed in pockets or as some would like to call it science projects it never became mainstream. For collaboration video to become mainstream it has to address business problems and become part of the business architecture, in essence integrate into the IT architecture. Standalone video collaboration systems create islands of automation but do not integrate into hospital business assets the scheduling, EMR, ePACS, billing and quality management systems. Further they lack scalability.
As Healthcare operations integrate care pathways with collaboration and participation, home health, care coordination they need to work with various technologies video, wireless, the need to accommodate smart phone, smartPADs – location, context, security, content creation and distribution, delivery of smart Apps, contact centers and patient relationship management. Healthcare services have to be delivered using the network as a platform. This needs the business architecture to be integrated to the IT architecture and the IT architecture to the Network architecture. The network architecture can be built on a solid medical grade network that is smart, intelligent, extensible, sustainable, flexible, modular, scalable, interoperable, economical and future proof. This is complex and needs a strong architectural foundation with services and applications that use these services.
At the end of the day is there an ROI?
Over the past year we have worked on various models to define a potential ROI for the new healthcare needs. We took a business centric approach looking at the business problem and then identifying value drivers that either brings operational efficiencies or drive new revenue. We focused healthcare segment provider, pharma as well as medical device manufacturers. We built several models some for our customers and validated them:
Accountable care - to what extent can collaboration, video and Telehealth solutions increase cost savings and improve quality metrics to increase the shared savings
Corporate Campus Clinics – how can Telehealth extend the reach to satellite branches, increase uptake through specialties at the main campus and the spoke branches driving benefit both to the Company in increased savings as well as increased penetration and revenue to the medical service provider
What is the business justification for Telehealth and video to assist in reducing readmissions
What is the ROI in moving patients from ER to Urgent care and how could that change be managed
The business justification for using collaboration technologies to increase referrals as well as build specialty networks for operational efficiencies
Is there an ROI in Training and education?
Some of these models looked at problems that were not driven by reimbursement but had enough value drivers to deliver hard savings and justify the investment. Our models show there is a positive ROI in each of these settings.
As any model goes any change is multidimensional. Any new delivery model should become part of business strategy. A structure should be created to implement this new strategy; appropriate architecture approach and platform solutions should drive the strategy, processes need to change to implement the strategy, finally people should be trained with appropriate change management to make this work.
Is there an ROI, yes but the health of that ROI will depend on how well the organization manages this multidimensional change.
At Cisco we believe that when governments keep pace with the latest technologies they improve efficiency and better serve their constituents.
Australia is knownas a government at the forefront of technological innovation. Since 2009 the Australian government has rolled out 36 Cisco TelePresence units across Australia, in Commonwealth offices, Prime Minister and Cabinet offices, Parliament House and state government offices.
The Australian Government has participated in more than 1800 meetings via Cisco TelePresence and has saved more than $26 million in travel costs since deploying in 2009. This is double the amount of savings the country anticipated, according to a recent ZDNet article. So it’s no surprise that the country is looking to expand its telepresence usage.