26 th Annual National Forum on Quality Improvement in Healthcare December 7, 2014 The Future Will See You Now: HIT s Impact on Health and Healing Andrey Ostrovsky, MD Care at Hand @andreyostrovsky Laura L. Adams RI Quality Institute @LAdamsRIQuality A Bit About Your Faculty Andrey Ostrovsky, MD Co-Founder & CEO Laura Adams President & CEO We take care of the technology. You take care of the patients. 1
Session Objectives P3 List at least three ways in which technology is upsetting the status quo of healthcare delivery Discuss the impact on personal privacy of electronically enabled health and healing Identify immediate actions that organizations should take to avoid becoming "prey" in the new ecology of health and healing to catalyze system redesign and quickly discover new hospital business models for the future, need to be literate in digital health selection framework and improvement science Session Outline P4 The Need and the Opportunity The Digital Health Selection Framework (DHSF) How the DHSF Might be Used in Rhode Island Workshop #1: Process Improvement 101 Break (2:30 3:00 PM) Workshop #2: Going Through the DHSF Steps Sharing Lessons Learned Summary and Take-aways 2
The Need and the Opportunity 3
2012 Bipartisan Policy Center Report: Lots to Lose: How America s 2012 Bipartisan Policy Center Report: Health Lots and to Obesity Lose: How Crisis America s Threatens our Economic Future Health and Obesity Crisis Threatens our Economic Future Enter New Payment Models 4
Creating Health People are already in control of their own health and more capable of managing it than we give them credit for. There s some data/information that only the patient can provide, e.g. advance directives, functional health status, pain levels, in-home monitoring, etc. Come and get it care won t move the critical metrics for which providers are going to be paid. It s going to take a community the health care system can t do it alone. 5
Creating Health (cont d) 60% of U.S. adults say they track their weight, diet, or exercise routine; 33% track health indicators or symptoms, like blood pressure, blood sugar, headaches, or sleep patterns (Pew Research Center, 2013) Wear and Forget Tracking (Penny Ford-Carleton) Wired upload: wristbands, clip-ons, smart clothing, etc. Wireless upload Hub Cloud Seamless continuous sensing Increasingly innovative sensors Beyond vital signs to indicators of mood, motivation, & overall health (e.g. EmotionSense which tracks social interaction) Appapalooza!! 6
The Gartner Hype Cycle for Technology Visibility Technology Trigger Peak of Inflated Expectations Trough of Disillusionment Slope of Enlightenment Plateau of Productivity Maturity Adapted from: "Hype Cycle for Healthcare Provider Technologies, 2005" G00127850 Maturity Gartner Hype Cycle Applied to Apps Visibility Hi! You have a problem. I have the fix. "Build it and the money will come." Hello? Meet Mr. Reality. Darwinian selection. Clarified value proposition. Technology Trigger Peak of Inflated Expectations Trough of Disillusionment Maturity Adapted from "Hype Cycle for Healthcare Provider Technologies, 2005," G00127850 Used with Permission 12 11 07 7
Gartner Hype Cycle Applied to Apps Visibility Hi! You have a problem. I have the fix. "Build it and the money will come." Hello? Meet Mr. Reality. Darwinian selection. Clarified value proposition. Yes, sir. Buy a predictable product. Technology Trigger Peak of Inflated Expectations Trough of Disillusionment Maturity Slope of Enlightenment Plateau of Productivity Adapted from "Hype Cycle for Healthcare Provider Technologies, 2005," G00127850 Used with Permission 12 11 07 The Digital Health Selection Framework (DHSF) 8
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19 20 Ostrovsky A & Barnett M. Accelerating Change: Fostering Innovation in Health Care Delivery at Academic Medical Centers. Healthcare: Journal of Delivery Science and Innovation. Apr 2014. 10
21 Many apps little guidance 22 11
23 Startup Health Insights 24 12
Scatterplot of Technologies by Three Evaluation Criteria 25 Ostrovsky A, Deen N, Simon A, & Mate K. A Framework for Selecting Digital Health Technology. Institute for Healthcare Improvement Innovation Report. Cambridge, MA. 2014. Findings 26 Digital health companies usually do not simultaneously emphasize achievement of all three Triple Aim Components Investment decisions made with little evidence to support achievement of the Triple Aim Investment independent of the Level of Evidence, Technology Type, or End User Reimbursement associated with particular Technology Types Unmet needs for technologies focused on all three End User types 13
Research to practice in 3 weeks 27 Adaptation of the Context-driven Component Evaluation (CdCE) Process 28 14
Technology Evaluation Inclusion Criteria 29 Descriptions of Technology Level of Evidence 30 15
Technology Type Descriptions 31 Technology Type Descriptions (cont) 32 16
End User Descriptions 33 How Laura Would Use the DHSF in RI 17
Consumer Portal Some Apps are Obvious 18
Workshop #1: Process Improvement 101 19
Cash Balance 12/7/2014 Rapid Cycle Testing Quality Improvement Quality Improvement Aim Measurement Drivers Adapted from Langley et al. The Improvement Guid Why is rapid cycle testing so important? 20
Cash Balance Cash Balance 12/7/2014 Why is rapid cycle testing so important? Get better outcomes faster and cheaper 21
Quality Improvement Overview Quality Improvement: Aim Quality Improvement Aim Measurement Drivers Adapted from Langley et al. The Improvement Guid 22
Components of an Aim Statement Who s problem are we trying to solve? What problem are we trying going to solve? How are you going to solve that problem? What is unique about how you can solve that problem compared to others? How big should the improvement be to make it worth their while? When should be the deadline to decide if the improvement was achieved? Characteristics of an Aim Statement Specific Measurable Not contain extraneous information Realistic 23
Examples We will help hospitals reduce 30 day readmissions by 40% by providing care transitions services at ½ the cost of traditional transition services within 6 months We will help hospitals achieve MU2 compliance for 2 of 16 requirements by serving as a post-acute recipient of a discharge care plan while providing essential community resources within 12 months We will help Duals plans decrease SNF LOS by 30% by providing a community based transition service that can identify and prevent early medical and nonmedical risk factors for readmission within 6 months Quality Improvement: Measurement Quality Improvement Aim Measurement Drivers Adapted from Langley et al. The Improvement Guid 24
Measurement: Research vs QI Measurement for improvement should not be confused with measurement for research Measurement for Research Measurement for QI Purpose To discover new knowledge To bring new knowledge to daily practice Tests One large blind test Many sequential, observable tests Biases Control for as many biases as possible Stabilize the biases from test to test Data Gather as much data as possible Gather just enough data to learn and complete another cycle Duratio n Can take long periods of time to obtain results Small tests of significant changes accelerate the rate of improvement Can t do evidence based practice effectively without QI Evidence based practice needs to adapted to the local environment to be effective. To adapt evidence based practice to the local environment, need to use quality improvement 25
Measurement: Tips for effective measurement Remember: Data will be plotted over time Improvement requires change, and change is, by definition, a temporal phenomenon Seek usefulness, not perfection Measurement is not the goal; improvement is the goal Use sampling Sampling is a simple, efficient way to help a team understand how a system is performing Integrate measurement into the daily routine Useful data are often easy to obtain without relying on information systems Quality Improvement: Drivers Quality Improvement Aim Measurement Drivers Adapted from Langley et al. The Improvement Guid 26
Drivers: component parts Aim or goal of the improvement effort Primary drivers - system components that contribute directly to the chosen aim or goal. Processes, rules of conduct, structure Secondary drivers - elements of the primary drivers and which can be used to create change projects. Components and activities Relationship arrows - show the connection between the primary and secondary drivers. A single secondary driver may impact upon a number of primary drivers Change Strategies - Specific actions/interventions can you make that will affect these drivers, aka, potential QI changes to be tested Aim Statement Primary Drivers Secondary Drivers Change Strategies Coaches doing administrative work rather than enrolling Use partial FTE of admin staff to do scheduling Help AAA secure direct reimbursement from hospitals by providing care transitions services at net positive ROI for hospitals 3 months Inefficient use of coaches Inefficient data management High refusal rate Same coaches doing hospital and field work Inefficient enrollment process Paper based/accessbased data management Reinforce hospital vs field role for each hospital Care at Hand on-boarding & risk assessment Care at Hand to house patient profiles, care plans, list bill Opt-in process Formally change language to opt-out process 27
Drivers: 2 key questions To differentiate between primary and secondary drivers just ask the question: If I made an improvement in this driver, what would it achieve? To tell if a set of primary drivers is complete, ask yourself the following: If I could influence (or improve) against all of these drivers, is there anything else that could go wrong and prevent me achieving my aim? Instructions Create you driver diagram using a scenario from your current work environment Prioritize change strategies and select 2 or 3 amenable to a technology solution 28
Instructions Share your diagram and prioritized change strategies within your group Choose a spokesperson to share some themes from your group (e.g. aims, main driver, primary change strategies amenable to a technology solution) PDSA Wizard 29
Break Workshop #2: Going Through the DHSF Steps 30
Sharing Lessons Learned Summary and Take-aways 31
-Chuck Palahniuk Andrey Ostrovsky, MD Co-Founder & Chief Executive Officer Care at Hand @andreyostrovsky andrey@careathand.com 32
Laura Adams, President & CEO Rhode Island Quality Institute 50 Holden Street, Suite 300 Providence, Rhode Island, 02908 401-276-9141 ext. 271 @LAdamsRIQuality ladams@riqi.org 33