day in-the-life endo wide 2 with vid

1.For Endo Pharmaceuticals
David Voran, MD
Medical Director, Innovation Clinic of Heartland Clinic, Platte City, MO
July 19, 2011
Day-In-The-Life of a Primary Care Physician
A Presentation For

2. Agenda
Provide better understanding of clinicians.
Foster innovative ideas to improve communication, quality and patient care.
Introduce me, where I work and our organization
Help you understand my biases
Present a PCPs Day
Goal: Try to frame current events to help with your decision making
What we know and dont know
Technology in the clinicians office
Impact of current events on healthcare
Changing nature of Pharma/Physician relationships
Illustrate Pharmaceutical Decision Support in an ePrescribeWorld
Emphasize the opportunities that exist
List Needs and Possible Solutions
Answer further questions
3. Heartland Health
4. Heartland Clinic of Platte City
Free standing clinic
30 miles away from hospital
Located in suburb of Kansas City
3.5 physician FTE
1,000-1,200 visits/month
Numerous specialists visit weekly
Designated the Innovation Clinic
Fully digital clinic
Most patients connected electronically through web portal
Have met or exceeded Meaningful Use Stage 1 criteria
5. Ambulatory Primary Care Office
So Whats a Day Like?
6. Typical Day
20-24 patient visits
Mini meetings
1-3 procedures
Exam room operative or diagnostic
1 meeting
Staffing, billing, marketing or professional
20-40 asynchronous messages
Nurses, patients colleagues
10-15 interruptions
Pharmacies
phone calls
detail reps
7. Single EMR
7
Inpatient: Patient List
Ambulatory: Schedule
8. Integrated HIE
9. Clinic Visit Note: Where the Action Is
Standardized SOAP
Subjective
What the patient says
Objective
What we see and measure
Assessment
Diagnosis
Plan
Prescriptions, orders, education and follow up
All in one template-based place
Templates provide structure and consistency distribute work to even the patients
10. Remote access: Productivity Enhancer
Through web portals
Redundancy
Support all browsers
All devices
PCs, Macs, iPad, smartphones
By all who need access
Patients via web portal
View their record
Message physicians
Schedule visits
Request medication refills
11. Real Example
Login from home to review lab results
Lab Result
Patient Summary
12. Real Example (continued)
One click to context aware information resource
One click to message the patient
One click to active and historical medications
One click and begin typing in desired medication
Choose a prescription
Choosing a pharmacy
Checking external pharmacy fill history
19. Messaging Example
Typical Messages from patients
20. Messaging Example (continued)
Needs prescription renewed
One click to medication list
Right click and choose Renew
Accept defaults and sign
24. Decisions, Decisions, Decisions
What to ask?
What to examine?
What to include?
What to exclude?
Diagnosis
~40% uncertainty
What tests to order?
What to prescribe?
Categories
Quantity
25 - 50 decisions each visit
625 - 2,500 a day
25. Interruptions: The biggest bane
Not easy to recover from many of them
Interruptions are more than lack of timely decision support
Technology has eliminated more than half
Patient portal
Electronic messaging
Many pharmacies still resorting to telephones and faxes
Electronic communications preferred
Good news is that the industry is slowly catching on
Long way to go
26. ePrescribe something that is really starting to work well
Pharmaceutical Decision Support
27. Prescribing: A Major Player
ePrescribe Uses CPOE interface
Part of the documentation process
Launched from the template
Actions rendered as text in the note
Usually done at the point of care
Can get outside information before decisions are made
Can tell which meds are on formulary before ordering
List of various medications available with generic components
Shows alternatives
Dramatically reduces interruptions and increases productive time in the exam room
28. Drug Decision Support
29. At the end of the day
30. View from within
Pressures facing healthcare
31. Executives and Decision Makers
Vendor lock
Most organizations locked into long-term HIT contracts
Competition rather than cooperation
Incapable of sharing services
Provider discontent
Technology advances
High costs of medical technology
Security woes
Foggy long term vision
Workforce shortages, especially primary and nursing care
Trajectory of change exceeds bandwidth
Conflicting & Changing rules and regulations
(federal, states, payers)
ARRA impact
Who is the customer?
Unsustainable of fee-for-service reimbursement
Economic downturn
32. Clinical Pressures
Rapidly growing knowledge
Changing evidence
Uncertainty of diagnosis
Increasing disease complexity
Lifestyle diseases
Solution is life-style changes not medicine
Needed information not in your system
GIGO
Lack of administrative support
Pressure to churn patients
Average physician needs to bring in $450K per year
Need to see >24 pts/day
Decreasing time to make medical decisions
15 minutes or less to gather, assimilate, diagnose and document
Fewer well paying patients
3rd party payer intrusions on medical decision making
Long hours
33. Much more than EMR/EHRs
Only 50% of the information needed for the next medical decision can be found in the EMR/EHR
Technology in the Doctors Office
34. POC Technology
Push as much technology to the point of care as possible
Device is as much for the patient as the provider
Used as a window to the world
Evolution
notebook > tablet > standard workstations > expanded large screen workstations > multi-touch wide-screen devices
35. Connect everything to the exam room computer
Bodelin Proscope
Dino-Lite Earscope
MIR Winspiro
Eye-Fi cards:
Enable easyreal-timehands-off transfer of photos into EMR
Electronic scales
Stadiometers
Diagnostic Tools
Other Information Tools
36. Apps:Provide data not in EMRs
Doximity
connects physicians to physicians securely
Helps tie those not sharing same system
Voalt
connects nurses to nurses to optimize tasks and patient care
Borders on unnecessarily tapping IT bandwidth
ePocrates
drug and disease content optimized for smart phones
Fooducate
Educates individuals about nutritional content of food by pointing the smart phone at the food label
37. My own apps and tools
iPad applications
iPhone Applications
38. AliveCor
Wireless ECG app built on iPhone 4 and specialized case
Example of innovation
Adding specialized function to consumer products
39. Fundamental Principle
Everything
goes
to
ground
Everything thats now done in a tertiary hospital will be done in the clinic and eventually be in the hands of the consumer
Inescapable and unrelenting mass consumerization of technology
Medical diagnostic technology is the next big consumerization opportunity
Dramatically lowering the cost and availability of tools
Must be willing to use them

40. or where the holes are and where Pharma could help
Whats Needed
41. Eliminate Gotcha Decision Support
Alerts fire after decision instead of before
Need indicators that warn of impending alerts
Should act like formulary notifications
Continue to appear even after overridden many times
Why so many physicians use ePocrates, Medscape,and other quick search tools
42. Improve Product Selection
Product status
Dither out products that are no longer available
Indicate relative prices
Diagnostic orders
Medications
Lack of condition-based prescription recommendations
Make a diagnosis > produce a list of orders and medications indicated for this diagnosis
Number of these common medications no longer available to pharmacies
43. Improve Pharmacy Selection
Many pharmacies identified by number
Lack of maps
Fuzzy zip code
Need to show nearby pharmacies when zip codes are entered
Need selection choices similar to what we have on our mobile phones
Our expectations are so much higher now that were using mobile tools
44. What do we see and, more importantly, what are the boundaries with which we can confidently operate?
Framing the picture
45. From my point of view
In a period of change
Reimbursement, Rules, Relationships
Increased accountability, transparency
Democratization of Medical Knowledge
Patients participation, access and control
Accountability?
Increased role of Healthcare IT
No longer can be ignored
Traditional Healthcare bubble bursting
Extreme personalization
Based on genetics
Unique medications
Move towards Social Media paradigms in Healthcare IT
Virtualization of Healthcare
Hospitals and Clinics too costly
Most care delivered directly to the patient at home, office virtually
What we know
What we think is going to happen
46. Innovation Looking thru the Windshield
Law of accelerating returns
Key events happening at ever rates
PCs will match the power of the human brain around 2020
Approaching singularity
Culminate in the merger of biology and technology
Transcend limitations of our biological bodies and brains
No distinction between human and machine or between physical and virtual reality
47. Interesting healthcare predictions
Physics of the Future
Information technology
High temperature superconductors
Nanotechnology
Applications to Healthcare:
Healthcare diagnostic instruments and information moving out of the hospital to clinics, homes and individuals
Significant future care will be virtual, multimedia and come to the patient
Medicine will become personal
Control our genetics
Dr. MichioKaku: Professor of Theoretical Physics at the City University of New York
48. Whats driving change?
Computing power doubles every 18 months
Pn = Po x 2n
Pn = computer processing power in future years
Po = computer processing power in the beginning year
n = number of years to develop a new microprocessor divided by 2 (i.e., every 2 years)
Power of a network is proportional to the square of the number of nodes (users)
NetUse = k * N2
Applies to everything
Power of an EMR is proportional to the number of medical facilitiesusing it
Right now, medicine is still a mom & pop shop but is on the verge of migrating into much larger entities that will leverage Metcalfs law
Moores Law
Metcalfs Law
49. Technology Drivers (Illustrated)
Metcalfs Law
Moores Law
50. From web to apps
http://blog.flurry.com/bid/63907/Mobile-Apps-Put-the-Web-in-Their-Rear-view-Mirror
http://www.slideshare.net/kleinerperkins/kpcb-top-10-mobile-trends-feb-2011
51. Mobility enables integration
Explosion of mobile users
Exponential growth over previous computers
Enables massive integration at the person level
Ubiquitous computing
Affordable
Faster access
Personal
Fun to use
Measureable real-world activation
Real time reward/influence
52. Result: High Tech Everywhere
Chips to manufacture custom-made DNA segments.
Biosensors build into cars to monitor blood glucose, location based pollen and cloud based health info
Apps to help with complex decision making.
Nanoworms for real time monitoring.
Advanced medical robotics
Mental manipulation of computers
53. Tangible reward for Innovation
Beam me up doctor
The X PRIZE Foundation
$10 million prize for the public to develop a mobile application
Must diagnose patients "better than or equal to a panel of board certified physicians
Tricorder Prize
54. targeted at all roles throughout healthcare and integrated with existing services
Huge opportunity for Innovation
55. Data Mining Opportunities
Study existing EMR databases
Clinicians dont have the time nor are paid to datamine
Need for cooperative innovation
Pharm
Academic Medicine
56. Past Proposal Before its time?
March 2007
Open up EMR to Pharma Scientific Divisions via subscription
Goals
Mine data
Communicate with providers and patients
Locate potential candidates for further diagnostics and/or early intervention
Ideas rejected
Too risky
57. What some others are doing now
Managing Cancer Care
Backing physicians with decision support tools at their fingertips
Communicating directly with members via SM and Text Messages
Offering chances to win money in a lottery based on adherence to treatment protocols
Dynamic pharmacy benefits designed to encourage members to fill prescriptions
Value-based benefit designs
Providing follow-through patient tracking for clinicians
Embedding care managers in practices
Enveloping evidence base protocols in providers EMRs
Collaborative Cancer Care Program
No reason Pharmaceutical companies cant play
58. Focus on the smallest entity
Focusing on the smallest component (the patient) provides the most leverage
Enables massive change rapidly
May offer the best long term solutions
Again, no reason pharma cant also play this game
59. Enable Real-time Connections
Work with vendors to create dynamic links during the prescribing process for both the physician and the patient
Just-in-time offers
Coupons, Vouchers, Access to resources, Enable connection to researchers
Could automate after market data collection directly from consumer
Physician and patient would be notified in real-time of additional resources and information
ePrescribe Pt Receives Mobile Invitation or Notification from Pharmacy that script is ready and vouchers accepted
Embed independent care managers for patients
Both real and virtual, manual and automated
60. Leveraging mobile apps
Embed in existing apps
Have aSocial MediaPresence
But be careful
Have to be honest and up front
Huge opportunities
Physicians and patientsneed more help than they are currently getting
Would push patients to content and management apps
Pull processes
Consumer directed content
61. Example of Integration between Apps
Golfshot
Golfplan
Golfscape
TW My Swing
Thru and thru integration
Playing
Keeps score and stats
GPS graphic range finder
Practicing
Customized video lessons
Upload your swing, compareagainst Tiger with feedback
All connected providing complete golfing experience
Buit in FB and Twitter feeds
62. places where innovative technology can have immediate and long-lasting, transformative impact
Short and Long Term Needs
63. Short Term Needs
Non disruptive technologies and applications to help with current day processes
Anything to reduce intrusive interruptions (read office hour detail rep visits)
Tools to help data transfer
Currently everyone uses fax but need CCD and CCR formats
Tools to facilitate communication between competing systems
HIEs are just not being accepted
PHRs (like Google Health) have failed actually pulled from market
Will join but not do the hard work of porting information
Technology to convert data to information
Secure mobile patient/physician communication tools
Anonymous monitoring of lab test results nationwide
Map of what diseases are occurring where
Weatherbug for medicine
Life-style change management tools at the individual level
64. Long Term Needs
Get me to the Church on time!
Social umbrella over multiple EHRs
All health and disease is social
Viruses and Bacteria follow social connections
Information systems must align with People, Bacteria and Viruses
Real-time suite of apps for providers and patients
Connected monitoring tools controlled by individuals
Management of patients in their homes and work place
Must work to keep them out of the clinics and hospitals
Virtual Personal Health Records
Connect and integrate personal data by linking multiple disparate systems in real-time
65. Rules May be Biggest Barrier
Legal, political and organizational inertia are the biggest impediments to innovation today
Policies, procedures and laws are all 20th century based
Instruments, diagnostics, information technology are all 21st century tools
Surrounded by global tools but constrained by parochial applications
66. Doing the splits
Exponential growth of technology
Linear growth of policies and politics
Existing rules and policies arent keeping up with technological advances and in danger of loosing not only their meaning but efficacy
The real innovation needed might be a new paradigm for regulation, perhaps from the bottom up instead of top-down (an app?).
67. . Or extending the discussion
Q & A
68. Widescreen Test Pattern (16:9)
Aspect Ratio Test
(Should appear circular)
4x3
16x9

day in-the-life endo wide 2 with vid

Health & Medicine