As the OpenStack Summit in San Diego is about to start, I wanted to look back upon this past year and talk about Cisco’s future with OpenStack.
When first learning about Rackspace and NASA coming together to create OpenStack, we saw an opportunity for Cisco to contribute to an important open source project to build a new platform for cloud computing. Since then, we’ve seen the community grow and more companies get involved to build on OpenStack as a platform for their own cloud services.
During this time, our OpenStack@Cisco team has contributed expertise and code to advance the platform. Working with several other vendors at the Santa Clara design summit in 2011, we started the Quantum networking service as an incubation project which I’m pleased to say has now moved into core with the Folsom release. This project makes networking a first class citizen alongside compute (Nova), and storage (Horizon), representing a significant step forward in how cloud computing platforms are built and operated.
In a previous blog, I discussed the value of media awareness with desktop video applications like Jabber for Windows. More recently, we have extended support to the WebEx meeting center client using the same media services interface (MSI) development kit as used with the Cisco Jabber client. Just as media awareness enables the network to differentiate between the various unified communications flows—voice, video and IM/Presence—with the WebEx meeting client we have added metadata tags to represent the data sharing flows that are used as part of WebEx web collaboration.
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.
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At last week’s iHT2 Health Summit at the New York Academy of Medicine, I had the pleasure of introducing Dr. Ben Kanter, chief medical information officer at Palomar Health, California’s largest health district. During his presentation, Dr. Kanter discussed the new $1B, 11-story Palomar Health Medical Center in western Escondido which opened for patient care on August 19, 2012. Called the “Hospital of the Future” by healthcare pundits, the new Palomar facility integrates key technologies, such as EMR, video and collaboration solutions, into an environment that uses nature, light, and outdoor space which work together to promote healing.
During the design phase, Palomar’s leadership team, including Dr. Kanter, worked closely with Cisco on the goal of creating a higher level of mobility and collaboration among clinicians, patients and their families. Cisco technologies currently in use include unified communications (video, WebEx, Wireless IP Phones) along with Unified Computing System, all tied together via a wired and wireless Cisco medical-grade network.
Dr. Ben Kanter, chief medical information officer at Palomar Health:
“The ability Cisco provides to tie everyone in the hospital together – patients, nurses, pharmacists, physicians, infection control, administrative teams -- through a security optimized, mobile and video-enabled environment, will have significant, positive impact across the healthcare continuum. Now patients have greater freedoms within the hospital, without compromising their health, as they are observed both inside and outside of hospital walls. And the ability for our doctors to review patient information from a mobile device, and conference in a nurse and a specialist at the same time to discuss the case, will completely change patient care.”
We invite you to learn more about Palomar Health and to watch a four-minute highlights video about the new medical center.