Mcclure~Masstlc~11~3~09

Patient Centered Care: The Programs and

Platform to Support It

Douglas J. McClure Corporate Manager

Center for Connected Health Partners HealthCare

November 3rd 2009

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Three Delivery Models

Live Interactive Consultations

Asynchronous Consultations

Connected Health

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Connected Health is Patient Centered Care

Four Cornerstones of Connected Health

• Accurate physiologic information • Shared with the patient • Data-driven coaching • Optimized provider involvement

Connected Health Growth

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•  Programs have transitioned from “research” to self supporting

•  New research programs are developing the programs of the future – example medication adherence.

•  Some programs are being turned into business offerings outside of Partners.

•  Programs incubated and supported by CEO, CFO and COO.

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500

1000

1500

2000

2500

3000

3500

4000

FY05 FY06 FY07 FY08 FY09(pro) FY10(pro)

Diabetes Self Monitoring

SmartBeat

E-visits

Adherence

Connected Cardiac Care

Heart failure - homebound

Heart failure - Motorola trial

Heart failure - clinical trial

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Center for Connected Health Pipeline

Research

& Development

Program

Development

Self Sustaining Programs

•  Founded in 1995

•  35 Full time Staff

•  12 projects and programs at any time

•  Move ideas to programs

•  Sustained and diverse funding strategy

Care Models

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CHF Remote-Monitoring Research finds:   Patients using remote monitoring service

required 40% fewer nursing visits to the home; Patients using remote monitoring service had a 33% reduction in hospital admissions

  Patients reported improved quality of life and increased involvement in their care

Program:   Expansion of services in Home Care for all

homebound Medicare patients.   270 patients on service at any time.

  FY09 growth +20%

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Connected Health - Diabetes

•  Population: Diabetics – requiring daily glucose readings

•  Technology: glucometer, gateway, web interface

•  Coaching: diabetes educator

•  Goal: improved control

•  Business justification: •  Meet P4P targets •  Decreased downstream

complications

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Connected Health: Hypertension

•  Population: Newly diagnosed or difficult to control hypertensives

•  Technology: bp cuff, gateway, web interface

•  Coaching: automated

•  Goal: improved control

•  Business justification: •  Improved employee health •  Decreased downstream

complications

Connected Health: Activity & Weight

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•  Population: Wellness, cross-over

•  Technology: activity monitor, weight scale, upload software, web interface

•  Coaching: Automated

•  Goal: Increased activity, weight loss

•  Business justification: •  Employee benefit •  Productivity, decreased

care costs

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Research : Programs and Components of the Future

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You’ve done a great job this week! Let’s review

the calories you’ve burned.

1. Wearable monitor records subject’s activity levels

2. Activity data sent wirelessly to central server

3. Personalized coaching to improve adherence to activity regime

Good adherence Poor adherence

I’m sorry you’ve found it tough to

meet your targets this week. Let’s try

and work out a solution

Virtual Coach

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Imperative: Improving medication adherence

Inventors of Tomorrow

The Patriot Ledger May 7th 2007

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The Platform

Connected Health Platform

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Provider Intervention

Coaching motivation

Monitoring

Communications

Opportunity Knocking

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Hypertension Diabetes Heart Failure

Db

Transmission Transmission Transmission

Db Db

Chaos Following

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Db

Transmission

Data

Decision Support

Presentation & Messaging

Devices/Sensors

Hypertension

Db

Transmission

Diabetes

Transmission Transmission

Db

Heart Failure

A Unified Platform

RMDR

Transmission Connectivity

Database

CDR

EMR

EMPI

Enterprise Clinical Apps Integration

Devices/Sensors

Decision Support

Presentation & Messaging

Patients, Providers, CareGivers

PG

Connected Health Care Suite

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Connected Health Care Suite

Care Portals (Diabetes, HF, etc.)

Patients Care Givers Care Providers Physicians

CCH Apps •  Asset & Patient Mgmt

•  Program Mgmt & Evaluation

Partners Enterprise Clinical Apps

•  LMR, CDR, EMPI

Remote Monitoring Services

•  RMDR, Internet

Partners Entity Apps •  Care Registries, PtCT, 4Next

Services

Decision Support

Common Clinical Mgmt System

Services

Services Services

Data Providers & Consumers of the RMDR

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RMDR

Diabetes Connect Application (Consumer)

Patient Weight Profile Application (Consumer)

Weight Scale Data

Glucometer Data

Partners Healthcare

Environment

Companies &

Integration

Pedometer

Blood Pressure

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Conclusions

•  Connected health is evolving as a new dimension in HIT.

•  Patient behavior change is a critical goal.

•  Monitoring increases engagement and improves coaching.

•  Quality, access and efficiency are improved.

•  Visit us at www.connected-health.org to learn more.

•  [email protected]