presentation to the california improvement - chcf.org · fairview medical group , ... creat aco lik...

Presentation to the California Improvement Network

Harnessing the Power of Data to Treat the

January 25 2012

Individual: Archimedes IndiGO

Patrick Herson MDMS FAAFP

January 25, 2012

Peter Alperin MDPatrick Herson, MD MS FAAFP

Ex. Medical Director, South Region

Fairview Medical Group

Peter Alperin, MD

Vice President, Medicine and Products

Archimedes, Inc.p ,

IndiGO: A Tool to Improve Healthcare IndiGO: A Tool to Improve Healthcare Quality and Reduce CostsQuality and Reduce Costs

... a KAISER PERMANENTE Innovation Confidential

Archimedes: The CompanyArchimedes: The Company

l h d l• Healthcare modeling company

• HQ in San Francisco

• Core technology ‐ Archimedes ModelCore technology Archimedes Model– Carefully validated, mathematical model of

human physiology,diseases interventions and healthcarediseases, interventions, and healthcare systems

– In development since 1993

• Owned by Kaiser Permanente– Spun out as independent organization

20062006

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A word about the Archimedes ModelA word about the Archimedes Model• Is a simulation model of physiology, diseases, and p y gy, ,healthcare systems

• Includes a full range of risk factors and variables grelating to diabetes, CVD, and other conditions

• Uses equations to represent physiological pathwaysq p p y g p y• Represents variables as continuous functions of time• Represents multiple conditions in a single modelRepresents multiple conditions in a single model

– CAD, DM and its complications, stroke, HTN, obesity, cancer (breast, colon, lung), asthma,

• Spans a broad range of interventions• Is validated against many clinical trialsg y

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Trials and Studies in Automated Validation Suite

Clinical Trials Epidemiological Studies• ARIC Cohort• ALLHAT

• CPS‐II Nutritional Cohort• Framingham Original Cohort

• ATBC• CARDS• DPP

• Lieberman: Colonoscopy Screening

M di C h t

DPP• Flechtner‐Mors: Diet• HPS

L k AHEAD • Medicare Cohort

• SEATTLE

• WESDR

• Look‐AHEAD• SHEP • TNT • WESDR• UKPDS45• WHI‐DMT

The Model is validated against this set ofThe Model is validated against this set of trials every time it is upgraded/modified. New validations continually being added

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Improving the content of careImproving the content of care

• If we want to improve the quality and reduce the cost of healthcare, we need p q y ,to look at the content of care

• The content of care is determined largely by physicians following guidelines• Current guidelines have inherent limitations because they were designed for• Current guidelines have inherent limitations because they were designed for

use without computers:• Focus on one variable at a time (e.g., BP)

• Ignore other risk factors• Ignore other risk factors

• Use sharp thresholds (e.g., SBP > 140)• Ignore the continuous nature of risk factor

• Example: National guideline for hypertension• Example: National guideline for hypertension• “Treat if SBP > 140, of if have diabetes, treat if SBP > 130

• It is now possible to design more effective guidelines that will simultaneously improve quality and lower costsimprove quality and lower costs

Oversimplification impacts qualityOversimplification impacts quality

Mrs Smith Mr Jones• Age• Height• Weight

Mrs. Smith425’6”244

Mr. Jones455’11”345Weight

• Smoker• Diabetes• History of MI or stroke

244nonono

345nonono

• SBP• DBP• LDL

HDL

1428811661

1388017835• HDL

• FPG• Currently on hypertension meds

6189no

35116no

• Risk of MI or stroke in 5 years 1 2% 7 1%

Who would JNC‐7 treat for hypertension?

• Risk of MI or stroke in 5 years• Absolute risk reduction if lower BP

1.2%0.4%

7.1%2.1%

What can IndiGO do to help?( di id li d id li d )(Individualized Guidelines and Outcomes)

• How IndiGO works• How IndiGO works• Takes into account all pertinent individual health information• Calculates risks of outcomes using the Archimedes Model• Calculates effect of potential treatments on those risks• Calculate side effects and harms• Combines multiple outcome effects into a single benefit score for each• Combines multiple outcome effects into a single benefit score for each

treatment

• How IndiGO can be used• How IndiGO can be used• Identify patients who will benefit but do not qualify for standard

guidelines• Rank interventions for a single patient according to benefit• Prioritize panel of patients according to their total potential benefit• Educate patient on the benefits of treatmentEducate patient on the benefits of treatment

Copyright 2010 Archimedes

Integration with other systemsIntegration with other systems

• Easily integrated with EHR or chronic disease• Easily integrated with EHR or chronic disease registry systems

• Currently integrated into EPIC• Currently integrated into EPIC• Conversations ongoing with Cerner, Allscripts

l f d• Examples of current and past integrations:• At the point of care in EPIC with Fairview Clinics• At the point of care in a chronic disease registry tool with KPWith ti t t l t KP ( d t ti )• With patient portal at KP (under construction)

Inputs of current IndiGO

• Demographics (Age, gender, etc.)• Biomarkers (labs, vitals, etc.)• Behaviors (smoking, etc.)Behaviors (smoking, etc.)• Medical history (h/o MI, stroke, etc.)• Medications: current and previous• Medications: current and previous• Allergies and contraindications

Outputs of current IndiGOOutputs of current IndiGO

Risk of Outcomes Benefit of Interventions• Cardiovascular Disease (CVD)

– MI– Strokeb

• Statins• Anti‐hypertensives

– ACE Inhibitors• Diabetes Onset• Diabetes Complications

– Foot ulcers– Retinopathy

ACE Inhibitors– Beta Blockers– Thiazide Diuretics

Calcium Channel Blockers– Retinopathy• Renal Disease• Cancers

– Breast

– Calcium Channel Blockers– Combinations

• AspirinNi i– Colon

– Lung

• Niacin• HbA1c Reduction• Weight Loss• Smoking Cessation• Exercise• Fish Oil• Cancer Screening


Comparison of IndiGO and ATPIII statin id li h i dguidelines: who is treated

ATPIII IndiGO

k k

• ATPIII recommends statins to people with high LDL (blue dots)

Risk

Risk

• IndiGO recommends statins to people based on risk (red dots)

LDL LDL

on risk (red dots)


Ways IndiGO can improve careWays IndiGO can improve care

f h• Before the visit– Set priorities for outreach programs

• During the visit– Find high‐risk patients not identified by guidelinesFind high risk patients not identified by guidelines– Prioritize interventions for each patient

• After the visit• After the visit– Members more engaged– Better compliance– More likely to return


How IndiGO is being deployedHow IndiGO is being deployed

• In the exam room for use by providers at the point of carep– IndiGO integrated into EPIC

• Being used by care managers to prioritize care• Being used by care managers to prioritize care for populations

• On the web for direct patient access (under construction)construction)

Independent evaluation done by KP Care Management Institute

I d li• Increased compliance– Patients who had a care gap for statins under standard guidelines were 6

times more likely to close the gap after a PCP visit that included IndiGOF hi h i k i id ifi d b I diGO h 7 i i– For high risk patients identified by IndiGO, there was a 7 times improvement in prescription dispenses as compared to EHR and panel support tool alone

• Improved outcomes– A 13% reduction in 5‐year CVD more than EHR and panel support tool alone– For every 1 million members, we estimate 1400 heart and strokes averted

annually

• Significant physician acceptance—all physicians found IndiGO easy to use• High patient engagement• Reduced costsReduced costs

– An estimated $98M saved annually– An ROI in excess of 3 to 1


Why did medication uptake improve six‐fold?y p p

Based on anecdotal information we believe there appear to be aBased on anecdotal information we believe there appear to be a number of possible factors

• “Conversation with patient was entirely different”• Conversation with patient was entirely different

• Personalized information is powerful

• Choice and engagement• Choice and engagement

• Positive focus

• Doctors more likely to have conversation because it was more• Doctors more likely to have conversation because it was more likely to be successful


IndiGO Demo

California Improvement Network pPresentation

Engaging Patients: Leveraging care d h l

Patrick Herson MD MS FAAFP

teams and technologyPatrick Herson MD MS FAAFP

Executive Medical Director, South Region

Fairview Medical GroupFairview Medical GroupJanuary 25, 2012

Fairview Medical Group

Located in Minneapolis/St. Paul 7 county area

Multi specialty group practiceMulti-specialty group practice

40+ primary care clinicsp y

500+ total providers (~300 primary care)

1.5M patient visits in 2011

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External Market pressures

Minnesota has a publicly reported quality score• Minnesota has a publicly reported quality score program—Minnesota Community Measurement (MNCM)

• Business Health Care Action Group (BHCAG) has very active major employers pushing for more accountabilityactive major employers pushing for more accountability from payers and provider systems for outcomes, quality and satisfaction

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Internal pressures

Pressure from providers feeling cheated when they do• Pressure from providers feeling cheated when they do not get ‘credit’ for making considerable improvement in patient care but it doesn’t meet guideline cut-off—p ghandling continuous physiological variables with dichotomous end points (pass/fail)

• 40% of primary care pay now based on quality results—has led to ‘quality triage’ behaviorsD i t b i t iti t l ti• Desire to be savvier as we transition to a population based care model.

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Future Requires a New Value ChainImprove quality improve experience reduce costImprove quality, improve experience, reduce cost

Change Care

Creating Value and Outcomes

Consumer Provider

RealizingPatient

Activation and Value

Change Ch Realizing

Economic Return for New

Value

Employer / Plan

Consumer Engagement

Experience

Change Payment

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Value

Change Care: Keeping Patients Healthy with Team-Based Care

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Change payment

F i i h• Fairview has −Shared savings contracts with 4 local payers g p y−Agreement to participate in CMMI Pioneer

ACO program starting January 2012ACO program starting January 2012−Engaged state of Minnesota in dialogue to

t ACO lik i t fcreate an ACO like environment for Medicaid benificiaries

Change the experience

It is critical to engage our patients/members differently to succeed in a world of shareddifferently to succeed in a world of shared savings and capitation

• Archimedes IndiGO pilot in flight• Archimedes IndiGO pilot in flight• Video visits• PAM scores• Team based care modelTeam based care model• Zipnosis

Ideas being contemplated• Gaming technology—for condition specific

education and management• Social Media• Technology to speed check in processgy p p• Tools for patients to enter a lot of clinical

information prior to their visitp• “Watson”-like decision support—this is where

IndiGO fits

IndiGO at Fairview• 2 clinics (NorthEast and Oxboro), and two control clinics

for performance comparison• Total of 18 providers (MD, NP, PA) in the target clinics• More clinics will be added as we complete pilot (3-6

months approximately)• Using tool at the point of care• Clinics have high quality scores for Minnesota

Community Measurement on Diabetes and Vascular Disease with Oxboro being one of the top clinics in theDisease, with Oxboro being one of the top clinics in the State of MN for quality in these areas

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Evaluation of IndiGO at FMG

• How many patients received IndiGO and statistics for those patients: (overall, by clinic and by provider)(overall, by clinic and by provider)

• Summary stats (e.g. avg risk and benefit) • Changes in prescription usage from baseline• Changes in predicted risk from baseline• Estimate of averted events like MI's, strokes, diabetes complications,

etc • Patient satisfaction tested at point of care with questions related to

likelihood to follow through on care plan• Provider and staff satisfaction • Ease of incorporating the Archimedes output as another input for

C3PO conferences.

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