enhancing patient care through better data
TRANSCRIPT
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Enhancing Patient Care Through Better Data
Wayne Pan, MD, MBA, Chief Medical OfficerThe Individual Practice Association Medical Group of Santa Clara County Inc. (SCCIPA)
IHA’s Tenth Annual P4P Stakeholders Meeting • September 22, 2011 • Los Angeles
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What I Did During My Summer Vacation
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ourperspective
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retrospectoscope
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whoweare
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Santa Clara County1,304.01 sq. miles
1,781,642 (2010)$74,335
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5 PCP80 Specialists
57 PCP104 Specialists
173 PCP343 Specialists
11 PCP30 Specialists
SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)
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ourjourney
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theneed
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it’snottechnology
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signalvsnoise
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it’saboutthepatient
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peopleprocessesplatform
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peopleprocessesplatform3P’s
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peopleprocessesplatformCbig
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culturepeopleprocessesplatform
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culture?
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patientcentered
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efficient
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evidencebased
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promotequality
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makeiteasy
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4processes
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communication
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collaboration
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coordination
PCPs
Specialists
Patients
CaseManagers
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anticipation
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it’snottechnology
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technology 1st
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designphilosophy
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put hot triggers in the path of
motivated peopleBJ Fogg, PhD
Director, Persuasive Technology LabStanford University
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work with humannature
BJ Fogg, PhDDirector, Persuasive Technology Lab
Stanford University
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lazysocialhabitsBJ Fogg, PhD
Director, Persuasive Technology LabStanford University
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ourplatform
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common web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of care
platform
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common web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback and enter their own data
platform
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anticipation
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4dimensionaldata
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financial
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administrative
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clinical
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retrospective
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reactivecare
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behavioral+
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predictive
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proactivecare
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provideactionabledata
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@pointofcare
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@home
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thecareteam
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thecarecontinuum
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ourplatforms
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ACCESSEXPRESS
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peopleprocessesplatform
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hospitalistsSNFistsonsite case managerscomplex case managersutilization review staff
people
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hospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP
peopleprocesses
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SNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
peopleprocesses
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onsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs
peopleprocesses
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complex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks
peopleprocesses
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utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement
peopleprocesses
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thepatientjourney
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thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
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thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
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thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
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thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
Rx
discharge
dischargeinstructions
patient family
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thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
Rx
discharge
dischargeinstructions
patient family
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outpatient physician follow-up
dischargeinstructions
patient
discharge
hospitalistIPA
onsitecase
manager AE
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outpatient physician follow-up
dischargeinstructions
patient
PCP
IPA onsitecase
manager
48hr call
AE
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outpatient physician follow-up
dischargeinstructions
patient
PCP
internalnon-clinical
staff
post pcpvisit call
AE
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thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
Rx
discharge
dischargeinstructions
patient family
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medication reconciliation
admissionorders
patient
admission
hospitalist
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medication reconciliation
new Rx
patient
discharge
hospitalist
admissionorders
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medication reconciliation
reviewmedlist
patient
pcp visit
pcp
new Rxadmissionorders
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“new” medication reconciliation
new Rx
patient
discharge
retailpharmacy pcp
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thepatientjourney
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preventivecare
diabeticpatient
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
p
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo p AE
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
p
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endop
AE
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
p
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
p
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
p AE
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
pAE
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preventivecare
diabeticpatient
meds
self-testing
dieteducation
exercise
pcp
er
hosp
snf
endo
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peopleprocessesplatform
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culturepeopleprocessesplatform
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it’saboutthepatient
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