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Mandy Bell

Health Care Without Boundaries

Reimagining What’s Possible

Healthcare Needs

Healthcare Gaps

Avera’s roots stretch back to the frontier

of medicine of the Benedictine and

Presentation Sisters; who were called to

provide health care in Dakota Territory in

1897. This tradition of caring continues today:

“Avera is a health ministry rooted in the

Gospel. Our mission is to make a positive

impact in the lives and health of persons and

communities by providing quality services

guided by Christian Values.”

Answering the Call

Copyright Avera eCARE 2019

Avera Health

CRITICAL ACCESS

33HOSPITALS

80%HOSPITALS


Over 440 sites in 29 states

2+ million lives impacted

Serves 13 percent of all Critical Access Hospitals in the nation

Avera eCARE


INTERNATIONALAND

NATIONAL

• San Antonio, TX• Fort Wayne, IN• Troy, MI• Israel• India• Kenya

WORKFORCE

250+eCARE

Employees

LOCAL IMPACT

eCARE averages

100 externalguests per

month

eCARE Hubs

1993

Consult

2004

ICU Care

2008

Pharmacy

2012

Senior Care

2012

Correctional Health

2015

School Health

2009

Emergency

2017

Hospitalist

2017

Specialty Clinic

2015

AveraNOW

2017

Behavioral Health

Avera eCARE Service Lines

Acute & Post Acute Services

Ambulatory Services

Offering the most diversified telemedicine service in the U.S.

HOSPITALS & HEALTH SYSTEMS

Acute Care –All Ages

NURSING HOMES & ASSISTED LIVINGS

Seniors

SCHOOLS Children

CLINICSSpecialty Care –

All Ages

CORRECTIONAL FACILITIESInmates

Current Partners


Improve Access to Care

ImproveWorkforce

Sustainability

Improve Care & Outcomes

Lower Costs

Guiding Principles


And more

Experience

ER Nurse

Crisis

Assessment

SANE

Exam

Support

Board

Certified

Emergency

Physician

Debriefing

Services

Stroke

Neurologist

Burn

Surgeon

Access: 24/7 Emergency Specialty Care


25% increase in delivery contribution margin

24% Decrease in Stays of >2 days at 39 Weeks

19% Overall Reduction in C-Sections

Vaginal Deliveries without Complications Increased by 26.8% at 38 Weeks

Patients Saved a Total of 58,186 Miles of Driving

$500-$1,000 estimated savings to payers per patient

125 mother’s served

T O D A T E

Improving Care: Gestational Diabetes

2x Increase in Daily Census

25% Reduction in ER StaffingCosts

“Tele-ED helps us to keep those young physicians

here, where they still get to have a family life, time

away, and not be tied to their phones.”

Supporting the Rural Workforce


81.5% of clinicians believe that eCARE Emergency has helped with recruitment and retention

Proven Results

$342 Estimated Medicare

Cost Savings PBPM

SNF/LTC Outcomes

Lower Costs


Healthcare WithoutBoundaries

Clinic Triage

Outpatient

Employee Assistance

Mobile Crisis

Emergency Room

Inpatient

School Health

Long Term Care

Group Homes

Behavioral Health, Anywhere


Senior Living

Our program connects individuals and staff to RNs & providers at the eCARE for 24/7 support & urgent care.

Support RNs and staff, reducing burnout and overtime

Increase confidence of resident and family, improving occupancy and length of stay

Decrease barriers to accessing care, improving resident experience


91% of students who had an eCARE School

Health nurse video visit were able to stay in school instead of going home

• Nurse Extender Services

• Primary School Nurse Services

• Help managing chronic conditions (diabetes, asthma)

• Help with acute sickness or injury

• Case management for parent contacts regarding prescription refills, mental health needs and available resources

Services:

Benefits:

497 367

1497

2182

2015-16 2016-17 2017-18 2018-19

Video Encounters and # of Schools

79

17

28

Growth:


▪ Online

▪ Mobile App

▪ Kiosks available in grocery stores

▪ Health Plan Benefit

▪ Colleges – Parent Pre-Pay

▪ High Schools

▪ Health coaching

▪ Coordinated care

▪ Specialty Pharmacy

▪ Respiratory Therapy (COPD)

▪ Gestational Diabetes

▪ Lactation Consulting

▪ Employee Assistance

Program (EAP)

▪ Physician LIGHT™ Program

▪ Cancer Navigation

Urgent Care

Campus Urgent Care

Health & Wellness

Women’s Health

Business Health

Cancer Care


Health Care’s

Digital Disruption

Health Systems are Analog in a DIGITAL World

Millennials demanding Digital

• 71% want to use mobile app to book appointments

• 74% prefer to see doctor virtually

• 75% look at online reviews before selecting physician

• 42% have used synchronous video telemedicine

Health Systems using Analog• Only 17% have e-visits visits

widely available• Only 14% have video visits

widely available• Only 20% have implemented

online self scheduling• Only 47% have implemented

messaging between patient and providers


15 Years Ago

10 Years Ago

Today

Rapid Change in Technology & Environment


• How we interact

• How we shop

• How we watch TV

• How we read

• How we vacation

• How we work at home

• How we get around

Change in the last decadeChange in the Last Decade


Expectations are Changing


Large-scale Combination of Non-Acute Care and

Insurance

New Healthcare Platform, Products, and Experience

We are moving from a Hospital-Dominant Ecosystem to a Healthcare-Dominant Ecosystem

Health Care Innovations

Wearable technology combined with smartphone, tablet, or computer apps allow patients to monitor health data and transmit

them in real time to health professionals.


Health Care Innovations

Smart homes outfitted with sensors to monitor sleep quality, medication use, falls, use of stove, toilet, and shower.


AI in Healthcare – It’s Here

• Identifying DNA mutations in tumors

• Classifying Echocardiograms• Predicting Heart Attack & Stroke• Diagnosing Skin Cancer• Adjusting ICU Treatment• Detecting Breast Cancer Risk• Predicting Suicide Risk• Identifying End of Life for Referral

to Palliative Care

https://medicalfuturist.com/top-ai-algorithms-healthcare


https://medicalfuturist.com/top-ai-algorithms-healthcare

65 Enacted Telehealth Bills by 39 States in 2018

https://www.cchpca.org/sites/default/files/2018-12/2018%20Legislative%20Roundup%20FINAL.pdf?utm_source=Telehealth+Enthusiasts&utm_campaign=a85ee891fc-EMAIL_CAMPAIGN_2018_12_10_06_57&utm_medium=email&utm_term=0_ae00b0e89a-a85ee891fc-353229733 Copyright Avera eCARE 2019

https://www.cchpca.org/sites/default/files/2018-12/2018%20Legislative%20Roundup%20FINAL.pdf?utm_source=Telehealth+Enthusiasts&utm_campaign=a85ee891fc-EMAIL_CAMPAIGN_2018_12_10_06_57&utm_medium=email&utm_term=0_ae00b0e89a-a85ee891fc-353229733

Change is Hard

Inefficiencies and duplications

Technology costs and challenges

Reimbursement hurdles

Regulatory and security hurdles

Licensure and credentialing

Workflow and culture changes

Overcoming Barriers


It’s been a long road…but maybe we’re at lift off?

$2.5

$28.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Medicare Claims for Telehealth$28.7M

500,000

2016 Medicare reimbursements under its Part B telehealth benefit

Billed services to Medicare alone in 2016

In Services billed over 2015

Of all Traditional Medicare Beneficiaries

33% Increase

https://www.healthcarelawtoday.com/2017/08/28/medicare-payments-for-telehealth-increased-28-in-2016-what-you-should-know/

2001: CBO Annual Estimate = $30 M


0.25%

Developing the Structure of Avera eCAREBUSINESS MODEL

Relationships

Create collegiality culture among hub and site providers – become ‘part of the team’ and

make job easier

IT infrastructure

Build technology infrastructure to take virtualize care deliver

Workforce

Develop team of experienced providers

and support specialists & recruitment and

retention

Leadership Support

Investment in technology and innovation, demonstrate

national value and impact, diversify revenues, be

passionate about impact of access to affordable quality

care

FundingBuild vision for investors

to show value and develop strong grant

writers


Bringing the Services to Life

Sales & Contracting

Staffing & Training

Clinical Workflows

Pricing / Funding

Regulatory Compliance Plan

Metrics & Reporting

Project Management

Change Management Technology

Data Collection

ProcessImproveme

nt

Communications

Accelerating Change

Ward M, Merchant AS, Carter KD, Zhu X, Ullrich F, Wittrock A, Bell A. “Use of Telemedicine For ED Physician Coverage In Critical Access Hospitals Increased After CMS Policy Clarification.” Health Affairs (Millwood). 2018, 12, 37. doi: 10.1377/hlthaff.2018.05103 https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05103

Mohr, N. M., Young, T., Harland, K. K., Skow, B., Wittrock, A., Bell, A., & Ward, M. M. (2018). Emergency Department Telemedicine Shortens Rural Time-to-Provider and Emergency Department Transfer Times. Telemed J E Health. doi: 10.1089/tmj.2017.0262 https://www.ncbi.nlm.nih.gov/pubmed/29293413

Natafgi N, Shane D, Ullrich F, MacKinney C, Bell A, Ward M. (2017). Using Tele-Emergency to Avoid Patient Transfers in Rural Emergency Departments: An Assessment of Costs and Benefits. Journal of Telemedicine and Telecare. March 7, 2017. https://doi.org/10.1177/1357633X17696585

Mohr N, Vakkalanka JP, Harland K, Bell A, Skow B, Shane D, Ward M. (2017). Telemedicine use decreases rural emergency department length-of-stay for transferred North Dakota trauma patients [in press]. Telemed Journal of e-Health.https://doi.org/10.1089/tmj.2017.0083

VanOeveren L, Donner J, Antegrossi A, Mohr NM, Brown CA. (2017). Telemedicine-Assisted Intubation in Rural Emergency Departments: A National Emergency Airway Registry (NEAR) Study. Telemed Journal of e-Health 2017 Apr;23(4):290-7. https://doi.org/10.1089/tmj.2016.0140

Mohr NM, Harland KK, Chrischilles EA, Bell A, Shane DM, Ward MM. (2016) Emergency Department Telemedicine is Used for More Severely Injured Rural Trauma Patients, but Does Not Decrease Transfer: A Cohort Study. Academy of Emergency Medicine, 2016. http://onlinelibrary.wiley.com/doi/10.1111/acem.13120/abstract

Mohr NM, Harland KK, Chrischilles E, Donner J, Bell A, Shane DM, Ward MM. (2016). Telemedicine penetration and consultation among rural trauma patients in critical access hospital emergency departments in North Dakota. RTRC Research & Policy Brief, 2016 (1):1-4. http://ruraltelehealth.org/briefs/RTRC-NDTelemedTrauma-Brief-2016-sept.pdf

Potter AJ, Ward MM, Natafgi N, Ullrich F, MacKinney AC, Bell AL, Mueller, KJ. (2016). Perceptions of Benefits of Telemedicine in Rural Communities. Perspectives in Health Information Management. Summer 2016. http://perspectives.ahima.org/perceptions-of-the-benefits-of-telemedicine-in-rural-communities/

Ward MM, Ullrich F, MacKinney AC, Bell AL, Shipp S, Mueller KJ. (2016). Tele-emergency utilization: In what clinical situations is tele-emergency activated? Journal of Telemedicine and Telecare. 2016 Jan;22(1):25-31. https://www.ncbi.nlm.nih.gov/pubmed/26026189


Build the Evidence Base

https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05103

https://www.ncbi.nlm.nih.gov/pubmed/29293413

https://doi.org/10.1177/1357633X17696585

https://doi.org/10.1089/tmj.2017.0083

https://doi.org/10.1089/tmj.2016.0140

http://onlinelibrary.wiley.com/doi/10.1111/acem.13120/abstract

http://ruraltelehealth.org/briefs/RTRC-NDTelemedTrauma-Brief-2016-sept.pdf

http://perspectives.ahima.org/perceptions-of-the-benefits-of-telemedicine-in-rural-communities/

https://www.ncbi.nlm.nih.gov/pubmed/26026189

SOURCES: Brown, C. A., Bair, A. E., Pallin, D. J., Walls, R. M., & NEAR, I. I. (2015). Techniques, success, and adverse events of emergency department adult intubations. Annals of Emergency Medicine, 65(4), 363-370.e1. doi: http://dx.doi.org/10.1016/j.annemergmed.2014.10.036

Mohr, N. M., Young, T., Harland, K. K., Skow, B., Wittrock, A., Bell, A., & Ward, // M. M. (2018). Emergency Department Telemedicine Shortens Rural Time-to-Provider and Emergency DepartmentTransfer Times. Telemed J E Health. doi: 10.1089/tmj.2017.0262 https://www.ncbi.nlm.nih.gov/pubmed/29293413


Set the New Standard


Prepare the Next Generation

A Word of Caution


After all, Technology Solves Little Alone


Netflix didn’t kill Blockbuster.Ridiculous late fees did.

Uber didn’t kill the taxi business.Limited access and fare control did.

Apple didn’t kill the music industry.Being forced to buy full-length albums did.

Amazon didn’t kill other retailers.Poor customer service and experience did.

Who’s your customer?Where can you disrupt?

Technology by itself is not the disrupter, not being Customer-Centric is the biggest threat to any business

Digital Disruption Has Already Happened

How we interact

How we shop

How we watch TV

How we read

How we vacation

How we work at home

How we get around

Change in the last decadeChange in the Last Decade


Mandy Bell | [email protected]

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