Kevin Fickenscher, M.D., CPE, FACPE, FAAFP President, Healthcare Division Chief Medical Officer AMC Health, Inc. Former President and CEO American Medical Informatics Association

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The Radical
Transformation and
Disintermediation of
Healthcare: Evolving
Technologies in Care
Delivery
INSERT
Kevin Fickenscher, MD
President/CEO
New York, New York

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 An Overview of the
Forces Precipitating
Change in American
Healthcare
 Technology as a
Transformational and
Disintermediating
Force
 The Implications
The Session…
“You never change
things by fighting
against the existing
reality. To change
something, build a
new model that
makes the old
model obsolete.”
F. Buckminster Fuller

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The Metaphor...

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The Metaphor...

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Jonathon Swift
1711“Vision...is
the art of
seeing
things
invisible.”
Jonathon Swift
1711

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“The real voyage of
discovery consists not of
finding new lands but of
seeing the territory with
new eyes.”
- Marcel Proust

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The Premise…
 Society is demanding for all goods and services but –
especially for health care – that we…
- ↓ Costs
- ↑ Quality
- ↑ Service
 The inherent incentives of the health care industry are
disparate, inconsistent and dysfunctional – causing
leaders significant challenges
 Society is moving inextricably towards an information
democracy rather than professionally dominated
theocracy
= Focal point for health care change
= Appropriate management of information required
= Intellectual capital of medicine
= Simultaneously empowering (consumers) and disempowering
(physicians)

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So, what
are
the forces
that are
affecting
healthcare
?
The Domains of Change – in Healthcare…

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 Breakdown of traditional boundaries
 Workforce globalization
 Cross-industry convergence
 Rising tide of technology
 Continuous care delivery models
 Shift from volume to value
Health Care Forces
“Change is
the price of
survival.”
Sir Winston Churchill

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So, What Does It All Mean?
 Consolidation – of hospitals / physicians
 Efficiency and Effectiveness – the new watchwords
 Productivity – the essential ingredient
 Accountability – the required capability
 Globalization – of care delivery
 Virtualization – of support and delivery
 Information Exchange / Data Analytics – fostering
open data sharing, transparency and interoperability
And, The Implications?

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The Most Critical
Question!
12
Why?

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Whydon’t
people CARE?
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But, I think they
do CARE! They just
don’t CARE
enough… 14

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Why?
15

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We can no longer tolerate…

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Value-Based
Payment Fee-for-Service Outcome Based
Incentives
Pass-A-Tube-Get-
A-Payment
Keep-Em-Healthy-
And-Make-A-Living
Focus Episodes Populations
Role of the
Provider
Interaction on
Individual Interactions
Team-Based Care
Continuum
Information Retrospective Predictive
The New World
Volume-Based 

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Payment
Focus
Role of the
Provider
Incentives
Volume-Based  Value-Based
The New World
Information

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This is why
people don’t CARE
enough…
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The Anticipation…

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“"You can never
plan the future by
the past."
Edmund Burke
From
Deployment of Standards
To
Ubiquitous Interoperability

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From the Primacy of Proprietary Systems
to the Priority of Open Source…

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The Inevitable Move Toward Open Source
Standards…
 Metcalfe's Law predicts that the value of interoperability increases
geometrically with the number of compatible participants
 Reed's Law predicts that the utility of a network (implied by
interoperable equivalence) increases exponentially due to the number of
possible subgroups that interoperability enables
 CommonWell Health Alliance (the "Alliance") – HIT (vendor)
interoperability initiative includes: Allscripts, AthenaHealth, Cerner, CVS
Caremark, CPSI, Greenway, McKesson, RelayHealth and Sunquest

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H
User Security
Files
The Goal? Apps Data Integration Across
The Healthcare Ecosystem
Secure
Cloud
Hosp
P
Payer
LabSNF
Warehous
e
EMR
(Inpatient)
EMR
(Outpatient)
Claims
User Access and Device Access Manager
Content Manager and Integration Manager
Audit Logging and Reporting
Public
Content
Multiple
data
sources
PCP / Specialist
Clinicians &
Leadership
Comprehensive
Care Coordinators
(C3) or Other Clinical
Associates
Patient

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“"You can never
plan the future by
the past."
Edmund Burke
From
Virtual Monitoring
To
Virtual Care Delivery

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 When is a radiologist a
radiologist?
 How is a cardiologist different
than a radiologist?
 How can a dermatologist
support a primary care
provider virtually?
 What’s the value difference
between a nurse practitioner
and a family physician?
 If 85 – 90% of pediatric care is
protocol driven, who should
provide it?
Requiring Professional Collaboration…

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Advantages of TELECARE…
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 Timely access to actionable information
for better patient care management
 Knowing what is going on with a patient’s
course of care, in between visits, when he
or she cannot be physically in front of the
clinician
 Detecting pre-acute conditions before the
patient clinically decompensates
 Not waiting for the call from the ER before
knowing that a patient is trending in the
wrong direction

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OPPORTUNITY ANALYSIS = Super-Utilizers
 Opportunity: reduce cost of top 1% by 20% or top 5% by 20%
 Result: US Healthcare savings of $55B or $128B per year

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Defined by Over a Decade of Experience
MODEL FOR SUCCESS
Outcomes &
Assessment
Reporting
It’s never just
about the
technology!!
Clinical
Support/
TCM
Data
Collection
Set Up,
Installation &
Retrieval
Patient
Engagement &
Registration
Patient
Identification &
Referral
Compliance
Support
EHR
Integration
MD
Collaboration
Internal &
External
Promotion
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HARNESSING THE POWER
OF REMOTE PATIENT MONITORING

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HOW IT WORKS
Self-reported
symptom &
behavior info via
IVR
Biometric information
via telemonitoring
devices
“Live” virtual
diagnostic assessment
via televideo/steth
Medication compliance
information via smart
dispensers
Data is collected, sorted and verified and presented as
critical, actionable information on a secure web portal
Patient’s
Physician
Care Manager
PERS Data
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DATA SOURCES
TECHNOLOGIES FROM DOZENS OF DIFFERENT MANUFACTURERS
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PERS Glucometer
Adapters
Medication
Adherence
Thermometers
Pulse
Oximeters
Cellular
Modems
Multi-user Kiosk
Wireless
Scales
BP Monitors
Interactive
Voice Response
Device/Data Source
Neutral
Televideo w/steth Meaningful
and clinically
actionable
information from
the patient’s
home

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 The Problem:
• @ 240,000 admissions/year
• 28% (range: 25 – 36%) of “cellulitis” admissions are
inappropriate or a misdiagnosis not requiring hospitalization
• = $83.4B/year in wasted admissions
 Why?
1. Common lower limb disorders = lipodermatosclerosis,
irritant dermatitis, venous eczema, lymphedema…and,
thrombophlebitis
2. Most common dx is thrombophlebitis of the lower leg
because it is red and inflamed but it’s not; simply
inflammation of the small blood vessels
3. No clinical test can be done
4. Signs of chronic phlebitis will be present
5. The right hx is that it’s been coming and going and not
acute
 And, solving the problem can be as simple as wearing
support hose, putting your feet up every day; and, losing
weight…
An Example of Making a Difference – Cellulitis…

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LOOKING FORWARD…
Bringing
the lab
home
GPS tracking and
Communications
Motion Analysis and
Action Detection
Technologies
Wearable
Sensors
Smart
Clothing
Sleep apnea
Monitoring
Point of Care
Wound
Assessment
Device

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RESULTS
SUSTAINABLE OUTCOMES ACROSS DIVERSE HEALTHCARE ENVIRONMENTS
8
HARNESSING THE POWER
OF REMOTE PATIENT MONITORING FOR
ENHANCE TELECARE
Decrease costs
>35%
ROIs exceeding
3:1
Reduce all-cause
30-day
readmissions
Enhance Care
Management
efficiencies
Improve
biometrics +
reduce risks
Reduce
hospitalizations
and ALOS
Reduce Field
Nurse Visits by
50%
Daily patient
compliance >80%

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“"You can never
plan the future by
the past."
Edmund Burke
From
Service Integration
To
Service Continuum

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Traditional Focus of Care Delivery…
Acute
AmbCare

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Alternate: Comprehensive Coordinated
Care (C3)
Preventive
Acute
SNF
Hospice
Alt Living
Remote Patient Monitoring
Transition
Chronic
AmbCare

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“"You can never
plan the future by
the past."
Edmund Burke
From
Data Mining
To
Peripheral Intelligence

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Decision-Support
Dashboards
Benchmarking
Personalization
Pattern Recognition
Data Mining
Knowledge Management
Artificial Intelligence
Standardization
Peripheral Intelligence
CaaS
Predictive Knowledge Management…
Using Informatics to Change Practice

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Standardization
Peripheral Intelligence
CaaS
In May, 2010 Lancet
Neurology published a
study showing that the
generic drug lithium did
nothing to slow the course
of amyotrophic lateral
sclerosis (ALS
In December, 2008,
PatientsLikeMe, a for-profit
patient networking site and
data aggregator based in
Cambridge, MA, came to a
similar conclusion, more
quickly and at much less
cost.
Predictive Knowledge Management…
Using Informatics to Change Practice

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HEALTHIER
COMMUNITIES
PRACTICE
INTELLIGENCE
KNOWLEDGE
INFORMATION
DATA
An INFORMATICS SAVVY ORGANIZATION is one
that has an informatics-skilled workforce, a
disciplined approach to information system
design and use, and reliably managed IT
operation.
INFORMATICS
implies a disciplined
approach to information
systems design and use that
drives improvements in public
health practice.
PUBLIC HEALTH PRACTICE
LEVELOFVALUE
Source: Modified from work by Marty LaVenture, Bill Brand, Minnesota Department of Health. Karen Zeleznak,
Bloomington Minnesota Division of Public Health
Using Informatics to Change Practice

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Los Angeles – A Case Study in Public and Clinical Health
Can You Imagine?

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Imagine, if you will…

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“"You can never
plan the future by
the past."
Edmund Burke
From Quality as Outcome
To
Quality as Requirement

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Managing the COMPLEXITY…
Coordinating the Care
Figure 2 - The Anatomy of Healthcare Delivery

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 The Five Normals:
1. Normal weight
2. No smoking
3. Normal glucose / Hgb A(1)c
4. Normal cholesterol
5. Keep vaccinations up-to-date, esp. flu
 How to manage:
1. Annual wellness visit.
2. Tobacco cessation.
3. Body Mass Index (BMI).
4. Diabetes screening test.
5. Cardiovascular disease screening.
6. Cholesterol level screening.
7. Screening tests
Focusing on the SIMPLICITY…
The Five Normals

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“"You can never
plan the future by
the past."
Edmund Burke
From
Social Media
To
Social Activation

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Use of Health Apps in Care Management…
 Patient Engagement = enhanced electronic collaboration between
patients/members with healthcare organization(s), all major mobile
devices and Web
 Administrative / Employee = Reuse existing security and data to
improve operations, ex; scheduling, forms, management reporting, bed
management, workforce, etc.
 Partner & Vendor / Third Party delivery / ACO = Apps integrate with
external databases/systems to provide new function and access, such
as; ACO Provider and Payer integrated info, billing, etc.
 Health Delivery = New simplified and targeted access to complex
content (e.g., genetics lab)
 Health Education = Integrated content management and secure social
networking allows for new collaboration, and tracking (e.g, my healthy
world)
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Example: Social Activation & Engagement…
 Retrofit (www.retrofitme.com) – data-driven weight loss program
focused on professionals using wireless monitoring of weight,
activity and sleep
 Results:
- 90% lose weight w/ average retention = 12 months (longest in industry / industry
average = 6 – 12 weeks)
- Men = 50% of customers
- Average customer loses 9% of weight @ 20# + 90% keep weight after one year
 Target busy professionals; upper income (avg = $80K/year)
 Why are the results better at Retrofit that WeightWatchers with 80% vs
30% 12 month retention + 12 month weight loss: 20# vs 14# ???
 Reason = Social Engagement
4

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From Deployment of Standards To
Ubiquitous Interoperability
From Service Integration To Service
Continuum
From Virtual Monitoring To Virtual
Care Delivery
From Data Mining To Peripheral
Intelligence
From Quality as Outcome To Quality
as Requirement
From Social Media To Social
Activation
S
U
M
M
A
R
Y

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And, The Implications?

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A Story: The Woman and The Mountain

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The tools are
available…but, the
transformation of
healthcare is missing the
essential requirement of
all change initiatives…
So, What Does It All Mean?
Are you ready to participate?

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Systems-Centric
not
Professions-Centric
The World of Healthcare is Changing…

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Global and Aggregated
not
Segmented
The World of Healthcare is Changing…

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Networked and Virtual
not
Proprietary
The World of Healthcare is Changing…

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Innovation-oriented
not
Replication-focused
The World of Healthcare is Changing…

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Embracing
the future:
reaching for
the reality
beyond the
rhetoric…
A Perspective on the New Millennium...

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A Final Consideration…Are you ready to
learn how to climb the lake?
If so…You’re ready to be a healthcare leader!

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And, one final question:
How much do
you CARE?
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Twitter http://www.twitter.com/MDkev
Email drkevin@creostrategicsolustions.com
…inspiring
creative change to
transform
healthcare that
benefits the
human condition
Check Out My New Book: Toto's Reflections: The Leadership Lessons from The Wizard of Oz
Kevin Fickenscher, MD
President , Healthcare Services
(301) 540-0795 – Assistant (Susan Seiger)
(415) 450-1515 – Mobile