1. The Meaningful Care Organization –
Developing Patient Engagement Strategies
to Weather the Perfect Storm of 2013
Timothy Kelly, MS, MBA
Dialog Medical
A Standard Register Healthcare Company
2013 TxHIMA Annual Meeting & Convention
Omni Fort Worth Hotel
June 28-30, 2013
2. 2013 – A “Perfect Storm”
Four Converging Legislative Initiatives
3. Cash for Clunkers
and Meaningful Use
Cash for Clunkers
<$3 billion
Grassley seeks accounting of 'Cash for
Clunkers' costs. The Washington Post.
January 7, 2010.
“Meaningful Use”
(Healthcare Information Technology)
~$36 billion
Rock and a hard place: An analysis of the $36
billion impact from health IT stimulus funding.
Price Waterhouse Coopers. April 2009.
4. HITECH Act
Meaningful Use (MU)
American Recovery and Reinvestment Act of
2009
HITECH Act
Meaningful Use
5. HITECH Act
“The changes we’re
announcing today
will lead to more
coordination of
patient care…and
greater patient
engagement in their
own care”
Health and Human Services Secretary Kathleen Sebelius
announcing the Stage 2 Final Rule. August 23, 2012.
6. HITECH Act
$12.6 billion in incentives paid
to date (program inception
through February 2013)
85% of eligible hospitals are
participating in the EHR
Incentive Program
75% of eligible hospitals have
received an incentive payment
to date
Source: CMS Fact Sheet: A Record of Progress on Health Information
Technology. CMS Media Relations. April 23, 2013.
7. Accountable Care Organizations
Accountable Care Organizations (ACOs)
Patient Protection and Affordable Care Act of
2010
Medicare Shared Savings Program
Accountable Care Organizations
8. Accountable Care Organizations
Accountable Care Organizations (ACOs)
Voluntary groups of physicians, hospitals and other
healthcare providers:
Responsible for care of a clearly defined Medicare
population
Designed to foster patient-centered, coordinated care
If it succeeds in providing high-quality care while
reducing cost, it shares in savings achieved for
Medicare
Source: Berwick DM. N Engl J Med 2011;365:1753-1756.
9. Accountable Care Organizations
Three Goals of ACOs
Better care for individuals
Better health for
populations
Slower growth in costs
through improvements in
care
Berwick DM. N Engl J Med 2011;364(16):e32.
10. Accountable Care Organizations
Accountable Care Organizations (ACOs)
Currently part of an
ACO?
Plan to implement or join and
ACO?
Yes - 11%
No - 39%
No - 89%
Yes - 61%
Source: January 2012 survey of hospitals, physician organizations and health
systems reported in: Tocknell MD. The Unsettled State of the ACO.
HealthLeaders Media Intelligence Report. April 2012.
11. Accountable Care Organizations
Over 250 ACOs
106 on January 1, 20131
1 in 10 Americans is covered under
an ACO2
Federal savings from this initiative
could be up to $940 million over four
years.1
Top Driver for creating an ACO – To
engage physicians
56 percent of the respondents that
are or plan to be part of an ACO3
2
HHS News Release. January 10, 2013.
1
Gandhi N, Weil R. The ACO Surprise. New York: Oliver Wyman, November 2012.
3Tocknell MD. The Unsettled State of the ACO. HealthLeaders Media Intelligence Report. April 2012.
12. Hospital Readmissions
Reduction Program
National average readmission
rate (Medicare patients): 19%
Cost to Medicare is
$17.5 billion annually
2,217 hospitals will face
penalties of over $280 million
in 2013
Source: Rau J, Kaiser Health News, October 12, 2012
www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx
13. Hospital Value-Based
Purchasing (VBP) Program
Goals of Hospital VBP Program:
Improve patient experience
Patient
Satisfaction (30%)
Better clinical outcomes
1 percent Medicare Holdback
$ 850 million in 2013
Hospital Value-Based Purchasing Program Fact Sheet.
Department of Health and Human Services. ICN 907664
November 2011.
+
Core Measures (70%)
VBP Performance
Score
18. Meaningful Use Objectives
Meaningful Use Objectives
Stage 1 Objectives for Hospitals
14 Core Objectives, 10 Menu Objectives (attain 5)
First eligible payment year: 2011
Stage 2 Objectives for Hospitals
16 Core Objectives, 6 Menu Objectives (attain 3)
First eligible payment year: 2014
Effectively incorporate all of the Stage 1 objectives,
along with additional objectives and higher
measurement thresholds
19. Meaningful Use Objectives
Stage 2 Meaningful Use Objectives
Core Objectives
Patient
Demographics
Input
Vital Signs
Clinical Decision Support
CPOE
Transitions of Care
View, Download and
Output
Transmit to Third Party
Privacy and Security
Smoking Status
Input
Lab Results into EHR
Patient-Specific Education Output
Medication Reconciliation Input
19
Core Objectives
Generate Patient Lists
Immunization Registries
Lab Results to Public
Health Agencies
Syndromic Surveillance
Menu Objectives
Imaging Results
Advance Directives
ePrescribing
Electronic Notes
Electronic Lab Results
Family Health History
Patient
Input
Input
20. Why Focus on Patient-Centered
Strategies that are “Output” or
Communication-Oriented”?
26. “Output-Oriented” MU Objectives
Patient-Specific Education
Patients who are provided patientspecific education resources
Number of unique patients admitted to
the hospital’s inpatient or emergency
departments during the reporting period
> 10%
27. “Output-Oriented” MU Objectives
View, Download and Transmit to Third Party
2 Measures for this Meaningful Use objective
Both must be satisfied in order to meet the objective
28. “Output-Oriented” MU Objectives
View, Download and Transmit to Third Party
Patients whose information is available
online within 36 hours of discharge
Number of unique patients discharged
from the hospital’s inpatient or emergency
department during the reporting period
Patients who view, download or transmit to a
third party the information provided online
Number of unique patients discharged
from the hospital’s inpatient or emergency
department during the reporting period
*This measure was 10% in the Proposed Stage 2 Rule
> 50%
> 5%*
30. Best Practices
American College of Surgeons
The informed consent discussion conducted by the surgeon should
include:
1. The nature of the illness and the natural consequences of no
treatment.
2. The nature of the proposed operation, including the estimated
risks of mortality and morbidity.
3. The more common known complications, which should be
described and discussed. The patient should understand the
risks as well as the benefits of the proposed operation. The
discussion should include a description of what to expect during
the hospitalization and post hospital convalescence.
4. Alternative forms of treatment, including nonoperative
techniques.
American College of Surgeons Statements on Principles. Revised September 18, 2008.
http://www.facs.org/fellows_info/statements/stonprin.html#anchor171960 (Accessed 5/10/13.)
31. Best Practices
Argument for Informed Consent
Only 39% of 3,269 closed claims against
anesthesiologists were judged to have
adequate informed consent1
Inadequate informed consent was pursued as
a secondary cause in more than 90% of
ophthalmologic malpractice cases2
Lack of informed consent is one of the top 10
reasons for hospital malpractice claims3
1Caplan
RA, Posner KL. ASA Newsletter 1995;59(6):9-12.
2Kiss CG, Richter-Mueksch S, Stifter E, et at. Arch Ophthalmol 2004;122:94-98.
3Glabman M. Trustee 2004;57(2):12-16.
34. Best Practices
Argument for
Informed Consent
Need the consent for the
Pre-Procedure
Verification and/or the
Time-Out
Verification of the
consent is one of the
most effective practices
for avoiding wrongpatient/wrong-procedure/
wrong-site surgery1
1Clarke
JR, Johnston J, Finley ED. Ann
Surg 2007;246:395-405.
36. Best Practices
Pre-Procedure Instructions
Reduce the risk
of potentially
life-threatening
perioperative
complications.
Tea C. Perioperative concepts
and nursing management. In:
Smeltzer SC, et al, eds.
Brunner and Suddarth’s
Textbook of Medical-Surgical
Nursing. Philadelphia, PA:
Wolters Kluwer
Health/Lippincott Williams &
Wilkins; 2010:422-483.
Courtesy of the Baltimore VA Medical Center
37. Best Practices
Pre-Procedure Instructions
Lower the incidence of
preventable surgery
cancellations.
Henderson BA et al. Incidence and causes
of ocular surgery cancellations in an
ambulatory surgical center. J Catarct
Refract Surg. 2006;32(1):95-102
Pletta C et al. Efficiency improvement plan
through patient education on thyroid
imaging procedures. J Nucl Med.
2008;49(Supp 1):426P
Courtesy of the Baltimore VAMC
38. Best Practices for Viewing, Downloading
and Transmitting Patient Information
39. Best Practices
Discharge Instructions
Providing
patients with
incomplete
information at
discharge can
result in patient
harm.
Pennsylvania Patient
Safety Advisory. 2008.
Jun;5[2]:39-43.
Courtesy of the Portland VA Medical Center
40. Best Practices
Discharge Instructions
Reduced the 14-day
readmission rate
three-fold by
employing procedurespecific discharge
instructions (4.1 per
1,000 outpatient
procedures to 1.5 per
1,000).
Boast P, Potts C. PS&QH.
2010;7(1):14-16.
Courtesy of the Portland VA Medical Center
41. Best Practices
Discharge Instructions
Most valuable if
they are sent well
prior to the 36hour threshold
Provided prior
to admission
Paper as well
as electronic
43. The Meaningful Care Organization
Resources
Making Good on ACOs’ Promise — The Final Rule for the
Medicare Shared Savings Program. N Engl J Med
2011;365(19):1753-1756. November 10, 2011.
http://www.nejm.org/doi/pdf/10.1056/NEJMp1111671
Meaningful Use – The Whiteboard Story – Stage 1 Final Rule
Meaningful Use Objectives and Measures Compared to Stage
2 Final Objectives and Measures... Created as a reference tool
for public use and convenience by The Advisory Board Company.
http://www.advisory.com/~/media/Advisory-com/CampaignItems/MUStage-2-White-Board-Story-Poster-2.pdf
43
45. The Meaningful Care Organization
“Meaningful Care” Checklist
Yes
Is the initiative patient-centered?
Does it reduce risk?
Does it enhance safety?
Does it leverage the patient?
Can you utilize HIT (EHR or
other systems)?
Does it support Stage 1 or
Stage 2 Meaningful Objectives?
45
No
46. Will a Focus on Patient-Centered
Communications Impact the Selection
of Treatments/Procedures and
Potentially the Efficiency of an ACO?
47. Potential Impact on Efficiency?
Dartmouth Atlas Project
A series of nine reports of elective surgical procedures,
released in late 2012, found wide variations in the
treatments provided.
Improving Patient Decision-Making: Regional Series. The Dartmouth
Atlas of Health Care.
http://www.dartmouthatlas.org/pages/decision_making_series (Accessed
5/10/13.)
48. Potential Impact on Efficiency?
Dartmouth Atlas Project
Mastectomy rates range from 0.3 per 1,000 female
Medicare patients in the San Francisco area, to 2.3 in
Grand Forks, ND
49. Potential Impact on Efficiency?
Dartmouth Atlas Project
The report authors surmise that patients may not
understand their full range of options and choices may
be unduly influenced by providers and not patient
preferences.
Improving Patient Decision-Making: Regional Series. The Dartmouth
Atlas of Health Care.
http://www.dartmouthatlas.org/pages/decision_making_series (Accessed
5/10/13.)
50. Will a Focus on Patient-Centered
Communications Impact Readmissions
or Patient Satisfaction?
51. Potential Impact on
Readmissions/Satisfaction?
Press Ganey HCAHPS Analysis
Press Ganey analysis of hospital readmission penalty
scores vs. patient satisfaction scores.
Positive patient experience correlates well with low
readmission rates and high readmission rates
correlate well with poor patient experience.
The Relationship Between HCAHPS Performance and Readmission Penalties.
Press Ganey. http://healthcare.pressganey.com/content/201211-PIReadmissions
(Accessed 5/10/13.)
52. Potential Impact on
Readmissions/Satisfaction?
Press Ganey HCAHPS Analysis
The relationship
between patient
satisfaction and
readmissions is
not causal.
Rather it is most
likely predictive of
an environment
stratified by
patient-centered
communications.
53. The Meaningful Care Organization
Health Information
Technology
Stage 1
Stage 2 MU Objectives
Stage 3
Patient-Centered
Communications
Patient Education
Informed Consent
Pre-Procedure Instructions
Discharge Instructions
Greater Patient
Satisfaction
Lower Readmission
Rates
More Efficient ACOs