Smooth Transitions: Accelerating Coordination from Concept to Reality

Anuj DesaiVP Market Development

Victoria TiaseDirector, Informatics

Strategy

Patricia MeisnerCEO & Co-Founder

Ken Ong, MDChief Medical

Informatics Officer

Joseph Mayer, MDFounder & CEO

Health Care’s Dynamic Landscape

• Health care reform is sweeping the nation• Federal government is strongly promoting adoption of EMRs and their

meaningful use• The unprecedented uptake of mobile technology has created a huge

opportunity for mobile health applications• Hospitals, providers, employers and payers are eager to take advantage of

digital health solutions to create cost savings and improve health/wellness

New York State Healthcare

• New York State is pioneering the Delivery System Reform Incentive Payment (DSRIP) Plan to redesign Medicaid and safety net care and payments, at a cost of $6.42 billion

• DSRIP projects and participants must: – Include infrastructure that increases access to outpatient care and care

integration– Improve integration across settings– Take responsibility for the overall health needs of a defined population of

Medicaid and low-income New Yorkers– Reduce avoidable hospital use

HIT: Ripe for Innovation

• Even with relative success of meaningful use program, clinical data remains in silos

• HIE’s are beginning to gain traction

• For value based care to be a reality, all of a patient’s providers must be brought together in one ongoing conversation

• Innovative digital health solutions are emerging from startup companies and they need face time with providers

The Opportunities for Digital Health

Health care stakeholders seek digital health solutions focusing on:

Care collaboration (e.g. integrated care, secure messaging, transitions of care)Collaborative care solutions that reflect the continuum of information about a patient and support team-based care, management of patients by risk category, secure messaging, and transitions of care.

Patient engagement (e.g. wellness and fitness, medication adherence)Personal health management solutions facilitating better healthcare decisions and improving communication on care management between the provider and the patient/family members.

Predictive analytics (e.g. avoiding readmissions)Analysis of clinical data for multiple purposes, including identifying high risk patients, based on standard criteria for risk.

Workflow improvement (e.g. cybersecurity, decision support tools)Improving provider healthcare workflow processing/throughput and supporting cost containment initiatives.

The New York Digital Health Accelerator

The New York Digital Health Accelerator is a program run by the New York eHealth Collaborative and the Partnership Fund for New York City for early- and growth-stage digital health companies that are developing cutting edge technology products for healthcare providers and patients in the areas of care coordination, patient engagement, predictive analytics and workflow improvement.

Program’s Unique FeatureThe ability of the participants to engage directly with the senior leadership of a broad network of twenty three healthcare provider organizations in New York for mentorship and pilot programs.

Inaugural Class Highlights The eight Accelerator companies launched 17 pilots with healthcare providers The companies created over 120 new high tech jobs in New York One year following the conclusion of the program, the companies have raised an additional $24MM

from outside sources and two companies have been acquired

Mentor Network – 2014 Class

New York Digital Health Accelerator –2014 Class

AllazoHealth addresses the problem of medication non-adherence by leveraging existing member data to anticipate which patients will not take their medications and to predict how best to effectively influence each patient to take their medication.

Clinigence’s solution – built around clinical data analytics, sematic data aggregation, and predictive modeling – provides real-time clinically-based reports about care gaps. This helps healthcare providers improve outcomes and proactively address the shift to value-based models.

Covertix helps healthcare organizations protect and control confidential data shared between patients, healthcare professionals, hospital networks and third party vendors to improve their coordination of care.

iQuartic’s technology merges, structures and mines EHR, PBM, claims and mHealth data for analytics that inform and benchmark care based on outcomes/best practices and adjusted population.

Noom makes software to help people live healthier. For consumers, the Noom Weight Loss Coach, with over 11 million downloads, coaches users on nutrition and exercise. Noom’s various patient engagement apps are based on its popular consumer-facing app.

Quality Reviews' flagship mobile product, RateMyHospital®, empowers patients to provide meaningful and real-time feedback about provider services.

Sense Health uses mobile technology to build personal connections between providers and high-risk Medicaid patients to improve outcomes and the quality of care.

Medication Management and Reconciliationat the Point of Care

Best Possible Medication History at the Right Time and Right Place

Engages All Stakeholders:• Patients and Caregivers• Healthcare Team• Payers

Aggregation & Validation of Data (including Patient Self-Medication)

Identification of Risk

Medication Action Plans for Care Team & Patient

Patient’s On-HandMeds

Engagement is Greatest

At the Patient/Provider

Encounter

ActualMeds Pilot Objectives

Goal: Proof of Concept

1. Non-licensed Community Health Workers could use ActualMedssoftware at the point of care

2. Meaningful patient self-medication information, including Rx, OTC and home remedies on-hand, could be collected and evaluated

Solution Claims:

ActualMeds delivers cost-effective medication management through automation and re-distribution of labor

Patient self-medication behavior can reveal previously unidentified risk

Results and Conclusions

Details of pilot design and results were reported at ACU Annual Meeting and Health IT Forum: Delivering Quality Care for the Underserved, June 25-27 2014, Alexandria, VA. :

“Use of Enabling HIT by Community Health Workers to Document Patient Self-Medication Behaviors of High-Risk Diabetes Patients in a Home Setting” Anne Marie Biernacki, Chief Technology Officer ActualMeds Corp.; Carmen Cruz, Manager of Community Health and Evaluation at New York Presbyterian Hospital.

ActualMeds can provide a software and service framework for team-based medication management

The ability to capture patient self-medication information at the point of care is a key part of medication management and reconciliation that has potential to improve patient outcomes.

Thank You

Patricia Meisner, CEOpmeisner@actualmeds.comwww.actualmeds.comTwitter: @ActualMeds; @PatMeisner

Medication Management Software and Services for:

Medication Reconciliation at Transitions of Care Medication Therapy Management ( Part D MTM) Medication Management for Dual Eligibles and Complex Care

Serving: New York FIDA Plans ( Dual Eligibles) Medicare Advantage and Part D Plans Accountable Care Organizations Patient Centered Medical Homes

Digital Health Accelerator Case Study:NewYork-Presbyterian Hospital

Victoria Tiase, MSN, RN, Director of Informatics Strategy

NewYork-Presbyterian Hospital (NYP)

• NYP is composed of six main facilities located in and around New York City– Columbia University Medical Center– Weill Cornell Medical Center– 2,600 patient beds– 2 million inpatient and outpatient visits

• US News & World Report Honor Roll - #1 in NYC

Background

• CHWs support the NYP WIN for Health program in the Washington Heights neighborhood of northern Manhattan

• CHWs strive to establish relationships with patients and serve as the “bridge” to community and health services– obtain “between visit” information from the patient at established time intervals and

convey that information to the NYP providers– are health professionals but have lower level of health literacy than physicians or

nurses– have specialized documentation needs and, via a paper-based assessment,

document pre-intervention activities such as healthy eating, home safety, and need for referrals

– use of community health workers is likely to increase due to accountable care models and the need for care coordination

Pilot Overview

• NYP provided Community Health Workers (CHWs) with tablets in order to capture medication data from patients using a web-based program

• Goal of the project: determine if software supplied by ActualMeds is suitable for use by NYP CHWs to collect medication data from patients/caregivers in a community setting

• We hoped this would serve as proof of concept for clinical use of CHW-obtained data in the community setting

Results

• Nine CHWs collected medication data during home visits that took place between May 6, 2013 and June 28, 2013

• The CHWs attempted medication data collection on 16 patients, 15 were successful • The CHWs were trained 3.5hrs on average • Medications recorded included prescriptions, OTCs and home remedies

• CHWs can successfully use a tablet device in the home setting to conduct a medication review with a patient

• The main hurdle to continued use is need for a resource for reconciliation