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Mobile Health at Ochsner: The Apple HealthKit and Epic EMR Integration

  1. Innovation in Health Care Delivery Jonathan Wilt AVP, Center for Innovation Ochsner Health System
  2. Ochsner Center for Innovation  Created in 2013  Tasked with going above and beyond the typical, incremental optimization of software systems and clinical workflows  Use the newest technologies to innovate care delivery models  Solve core business problems that can be scaled system-wide
  3. Ochsner Center for Innovation New Orleans based Ochsner Health System, announced it is the first Epic Systems client to successfully integrate its electronic health record (EHR) with the new Apple HealthKit. Approximately 53 percent of Americans have their medical records within the Epic EHR, and its MyChart application is the most used patient portal in the United States. “In the past, we relied on patients to log information, bring it to us, and then we would input the data and decide a course of action,” said Robert Bober, MD, Director of Cardiac Molecular Imaging, Ochsner Medical Center. “Now we can share information seamlessly between patient and physician to allow real-time, accurate analysis of a patient’s health status. This is ideal for patients with chronic diseases such as heart failure, hypertension and diabetes.” Ochsner Health System First Epic Client to Fully Integrate with Apple HealthKit
  4. innovationOchsner
  5. innovationOchsner • Our focus is to develop entirely new ways for healthcare providers to dramatically improve the quality of care by managing patient conditions more effectively • We do this by innovating health care delivery models and partnering with companies looking to revolutionize patient-centered care
  6. But before we can innovate….. • Ochsner is a growing health system, and must be diligent in designing a sustainable IT infrastructure • System-wide standardization is critical to our ability to innovate Innovation Speed and Flexibility System-wide Standards
  7. Integration is key • Integration trumps best-of- breed • New products must able to integrate seamlessly with our hub EHR system, Epic
  8. Maximizing our EHR • We don’t want to spend millions on add-ons when our EHR can already do it A scorecard of how effectively you’re using the system Ochsner Health System Ranked #1 in the nation
  9. Where do we begin?
  10. Necessity is the mother of invention. The Republic, Book II, 369BC, Plato & innovation
  11. Healthcare Spending as a Percent of Gross Domestic Product 17.7% 11.9% 11.6% 11.2% 9.6% 9.4% 9.3% 9.0% 7.9% 7.7% 7.4%0% 9% 18% United States Netherlands France Canada Japan United Kingdom OECD Average Finland Hungary Israel South Korea Source: OECD.
  12. 3 6 4 1 5 2 7 4 7 5 2 1 3 6 2 7 6 3 5 1 4 6 5 3 1 4 2 7 4 5 7 2 1 3 6 2 5 3 6 1 7 4 6.5 5 3 1 4 2 6.5 6 3.5 3.5 2 5 1 7 6 7 2 1 3 4 5 2 6 5 3 4 1 7 4 5 3 1 6 2 7 1 2 3 4 5 6 7 $3,357 $3,895 $3,588 $3,837 $2,454 $2,992 $7,290 AUS CAN GER NETH NZ UK US OVERALL RANKING (2010) Quality Care Access Efficiency Equity Long, Healthy, Productive Lives Health Expenditures/Capita, 2007 Cost-Related Problem Timeliness of Care Effective Care Safe Care Coordinated Care Patient-Centered Care Source: The Commonwealth Fund: Mirror Mirror On The Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update How the US Health Care System Compares Internationally
  13. 600,000 700,000 800,000 900,000 2008 2010 2015 2020 Demand Supply Projected Supply and Demand, Physicians (all specialties) Physician supply not keeping pace with increasing demand for healthcare services 91,500 62,900 Source: AAMC Center for Workforce Studies, June 2010 Analysis
  14. Major Epidemics in History
  15. Bubonic Plague 1347-1350 >25 Million deaths 30-70% of the Population Cholera 1817-1860 1865-1900 >50 Million deaths 10% of the Population Influenza 1918-1919 >75 Million deaths 30-70% of the Population
  16. CHRONIC DISEASE Today 75% of all Deaths 50% of the Population CHRONIC DISEASES ACCOUNT FOR 3 4 DEATHS OUT OF
  17. Chronic Disease  75% of U.S. health care dollars goes to treatment of chronic disease.  Nation’s leading cause of death and disability causing 70% of all deaths.  50% of all adult American have at least one chronic disease.  90% of seniors have at least one chronic disease, and 77% have two or more chronic conditions. Median outpatient visit length is < 15 minutes covering a median of 6 topics Source: Centers for Disease Control and Prevention. BMJ 2013;346:f2614. Tai-Seale M, et al. Health Serv Res. 2007;42:1871-1894. Gottschalk A, et al. Ann Fam Med. 2005;3:488-493.
  18. Four Common Causes of Chronic Disease Health Behaviors  Lack of physical activity  Poor nutrition  Tobacco use  Excessive alcohol consumption obesity • diabetes • hypertension • heart failure • coronary heart disease • stroke • cancer • OSA • atrial fibrillation • hyperlipidemia • gallstones • back pain • infertility • skin infections • gastric ulcers Source:
  19. Projected Growth in Population with Chronic Conditions 2013-2025 Dall TM, et al Health Affairs 2013;32:2013-2020.
  20. Adherence to Quality Indicators in Chronic Disease Condition No. of Indicators % of Recommended Care Received Overall Care 439 54.9% Hypertension 27 64.7% Heart Failure 36 63.9% COPD 20 58.0% Asthma 25 53.5% Hyperlipidemia 7 48.6% Diabetes mellitus 13 45.4% Peptic ulcer disease 8 32.7% Atrial fibrillation 10 24.7% McGlynn EA, et al. N Engl J Med 2003;348:2635-45.
  21. Last Costs too high Poor quality Modern day epidemic Receiving recommended care Demand outpacing supply What’s the Necessity?What’s the Necessity?
  22. Factors Influencing Health Status 40% 15% 30% 5% 10% Schroeder SA. N Engl J Med 2007;357:1221-8. Environmental exposure Genetic predisposition
  23. Factors Influencing Health Status  Electronic Health Records  Meaningful Use  Core Measures  Transparency  HCAHPS, CAHPS  HEDIS, SCIP  Pay for Performance  PACS  Joint Commission, Leapfrog 40% 15% 30% 5% 10% Health care Health care Schroeder SA. N Engl J Med 2007;357:1221-8.
  24. Factors Influencing Health Status Social Circumstances  Living conditions (live alone)  Transportation  Access to care  Medication affordability  Social network support  Education level 40% 15% 30% 5% 10% Social Circumstances Health care Schroeder SA. N Engl J Med 2007;357:1221-8.
  25. Factors Influencing Health Status 40% 15% 10% Schroeder SA. N Engl J Med 2007;357:1221-8. Behavioral patterns Social Circumstances Health care Behavioral patterns  Depression  Medication adherence  Social network influence  Physician/Health-System perception  Lifestyle: diet, activity  Patient activation
  26. Last Costs too high Poor quality Modern day epidemic Receiving recommended care Demand outpacing supply Not effectively targeting behavioral patterns What’s the Necessity?What’s the Necessity?
  27. Focus on Chronic Disease Management  Focus in 2014 and 2015 is chronic disease management  Using the newest technologies available, target the 65% of contributing factors we have control over – not just 10% 40% 15% 30% 5% 10%
  28. Prioritizing Diseases  Inpatient Readmissions - CHF Elixhauser A (AHRQ), Steiner C (AHRQ). Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. 26.1 25.7 24.2 0 5 10 15 20 25 30 18-44 45-64 65+ All-cause 30-day readmission rates for congestive heart failure Age
  29. Prioritizing Diseases  Outpatient diagnoses - Hypertension Chronic Condition % of outpatient visits Hypertension 27.0 Hyperlipidemia 15.7 Diabetes 15.1 Depression 12.4 Arthritis 10.2 SOURCE: CDC/NCHS, National Hospital Ambulatory Medical Care Survey.
  30. Congestive Heart Failure  Targeted approach for all heart failure patients including detailed screening (i.e. depression, med adherence, etc.) with dedicated HF nurses.  Comprehensive OP monitoring with HF care team  Monitors daily weight for changes and reaches out to patient to provide real- time guidance and treatment.
  31. Level 1: Guided Decision Support
  32. Level 2: Assessments  Affordability of meds  Medication adherence  Drug-drug, drug-condition interactions  HF Quality of Life  Depression screen  Family / Caregiver support  Transportation issues  Education level / level of HF understanding  Alcohol / drug use  Dietary sodium quantification In-depth evaluation and quantification of patient specific characteristics
  33. Level 2: Interactive Assessments Everything is completed by the patient on Windows tablets  Patient scores high on sodium consumption • “Who shops for your groceries”? • “Who prepares your meals”?  Patient views video on what high sodium means and why it is important; shown what foods are high in sodium and which foods make better choices  Individual(s) who shops for and prepares meals sent email with literature and video link
  34. Level 2: Inpatient Intervention  Pharmacy consulted for adherence/affordability (+/- social worker). If unaffordable, 30-day supply of meds provided at discharge.  Psychiatry consulted for depression, drug/alcohol addiction.  Nutrition consulted for high dietary sodium intake.  Social services for transportation, caregiver support, home health services.  Educated in heart failure disease state; use of monitoring scale; cause and effect relationships.
  35. Level 3: Outpatient home monitoring metrics scrubbed thru condition specific algorithms patients stratified by risk status high risk patients intervened by medication adjustment and/or outpatient visit X potential readmission avoided
  36. Relationship betweenImproved Care Coordination andReadmission in Heart FailurePatients 0 5 10 15 20 25 30 35 40 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan %Readmissions 2012 2013 2014 14% 25% Program
  37. Hypertension  Hypertension is the most common diagnosis made at primary care office visits.  Most common chronic condition, affecting about 30% of US adults, with estimated annual costs > $50 billion.  Only half of patients with hypertension achieve BP control; the leading cause of which is “therapeutic inertia” (86.9%). Ranking Prevalence State 47 39.8% LA 48 40.2% MS 49 40.3% AL 50 41.0% W.Va Roger VL, et al. Circulation. 2012;125(1):e2-e220. Hsiao C, et al. National Ambulatory Medical Care Survey: 2007 Summary. Hyattsville, MD: National Center for Health Statiastics; 2010. Margolis KL. JAMA 2013;310(1): 46-56. Milani RV, et al. J Am Coll Cardiol 2013;62:2185-7.
  38. Just as banking can be done outside the confines of a bank, BP monitoring and management can and should be done at home and in other nonclinical settings such as pharmacies and community and senior centers. Out-of-clinic BP monitoring with team care should largely replace traditional office-based BP management for most patients. Absent a contraindication to home monitoring, patients should be provided with a validated BP monitor and BP measurements should be transmitted to each patient’s clinician, with follow-up patient-clinician communication by telephone or by electronic visits, if necessary. If home BP monitoring and team-based care were implemented broadly, hypertension management would be easier for patients, and the magnitude of BP reductions brought about by this change could lead to substantial reductions in cardiovascular events and mortality, which is something patients, clinicians, and policy makers can take to the bank.
  39. “Health Care 2020: Reengineering Health Care Delivery to Combat Chronic Disease,” by Richard V. Milani, MD, and Carl J. Lavie, MD (DOI: It appears in The American Journal of Medicine, Volume 128, Issue 4 (April 2015) published by Elsevier
  40. Home BP Telemonitoring: HyperLink Study Proportion of Patients with Controlled Blood Pressure Follow-up Telemonitoring Usual Care p-value 6 months 71.8% 45.2% <0.001 12 months 71.2% 52.8% 0.001 18 months 71.8% 57.1% 0.003 Margolis KL. JAMA 2013;310(1): 46-56.
  41. Innovative Model for Care Delivery Going Forward 1. Utilizes non-physician providers of care that supports physicians 2. Works in a “focused-factory” that can keep up with an ever expanding knowledge-base and growing set of quality measures 3. Assess, characterize, and potentially modify social circumstances and behavioral patterns to enhance overall health status 4. Exploit technology to its fullest in order to manage large populations of patients efficiently (i.e. decision-support tools) 5. Monitor and “touch” patients remotely (just-in-time) resulting in faster cycle-times for meeting goals and enhanced patient satisfaction
  42. Apple HealthKit, Withings, Fitbit  HealthKit provides a standardized platform for a variety of in-home devices  We can concentrate on the largest few manufacturers for Android users  Withings  Fitbit  This standardization is critical to remain agile – we want more data but can’t build custom interfaces to every future device
  43.  New data points from home  Increased patient engagement  Medication adherence  Quality of Life  Family engagement  Level of understanding of diseases  Dietary issues What we look for in new technologies
  44. New wearables  Apple Watch may be able to facilitate frequent, meaningful communications between patients and care team  Huge opportunity to create the next wearable technology  National Innovation Challenge: 2015 challenge involves wearable technology concepts and/or mobile applications that take a proactive and improved approach to transforming healthcare outcomes
  45. Data integrity  Hypertension Digital Medicine users are required to have their own smartphone  Devices cannot be linked to patients – must initiate BP measurement from your smartphone
  46. Remember… Integration is key • Integration trumps best-of- breed at Ochsner • New products must able to integrate seamlessly with our hub EHR system, Epic •
  47. Questions?? Open Positions:  User Support Specialist  RN Clinical Care Coordinator  Mobile App Developer  Entry level analyst