# Presentation: 525380

## AHIC Chronic Care Workgroup 	

- August 16, 2006

- Malcolm Costello, VP Marketing, _[mcostello@kryptiq.com](mailto:mcostello@kryptiq.com)_
- Barbara Klein, VP Provider Sales, Northeast, _[bklein@kryptiq.com](mailto:bklein@kryptiq.com)_

## Axioms

- The lack of clinical data mobility is at the heart of cost and quality issues in healthcare

- From the Testimony of Luis Machuca CEO, Kryptiq Corporation
- Before Environment, Technology and Standards Subcommittee "Health Care Information Technology: What are the Opportunities for and Barriers to Interoperable Health Information Technology Systems?"
- February 23, 2006

- 2.  Secure clinical messaging represents the single biggest opportunity to quickly and cost effectively modernize our healthcare system and

- 3.  The relevant technologies to accomplish this are neither complex nor expensive.

**Notes:**
Three axioms are fundamental to our work.  (read).  We’ll illustrate these today through 5 case studies involving secure messaging solutions.

## A Day without Secure Messaging...An Example

**Notes:**
To lead into our first case study, we’d like to share a short story that illustrates well the problem with current modes of physician-patient communication...

## 7 phone calls

**4/25/05 3:10 PM** - got machine. Will try later. ............David W. Bauer MD
**4/26/05 8:55 AM** - machine again. Will try later. ............David W. Bauer MD
**4/26/05 9:34 AM**  pt called back and states to call her at the same number between 10 and 11. ............Patricia Binion LVN
**4/26/05 10:31 AM** please try again.   ............Maria Ticas LVN
**4/26/05 12:45 PM** - voice mail.. ............David W. Bauer MD
**4/26/05 3:25 PM** - as above. No better at all. Will call in abx and decongestant/mucolytic.............David W. Bauer MD

- 1 patient, 1 physician, 3 nurses
- 27 hours elapsed time

**Notes:**
Here we have a record of a patient calling in a Rx problem to her doctor.  (read highlights of transcription).  This one problem led to 7 phone calls, etc...(see flow)

## Case Study 1: Out-of-Office Patient Encounters

**Site:**  Memorial Family Medicine, Houston, TX
- 14 physicians, 42 residents, 3 offices
**Implementation: **
- Secure messaging implemented to extend EHR
- Solution needed for:
- Lab results to patients
- Rx refill requests
- Phone calls from patients
- Referrals

**Financial**** ****model****:****  **Reduce costs associated with:
- Clinic staff and physician follow-up via phone
- Mail/supplies

**Notes:**
Here’s what the practice did to fix this problem...

## Costs of Manual Workflows:  Clinic Estimates

- For every one office visit:
- 0.87 lab results
- 0.22 radiology results
- 0.63 phone calls
**Total:  1.72 non-office interactions for every one office interaction!**
- Annual _test results costs_ per physician:
- 5232 test results (4800 visits X 1.09 results/visit)
- $2145.12 in supplies
**65.4 hours of staff time time managing results! **(45 seconds staff time per result)

- Annual _phone call costs_ per physician:
- 4800 visits/year
- 0.63 phone calls/visit
- Average 0.9 failed return call attempts
- Average 90 seconds per failed contact
**Total: 68.04 hours of failed contacts!** (doesn’t include time actually speaking with patients)

**Notes:**
The practice has spent a fair amount of time detailing the costs of manual workflows in order to calculate their ROI of secure messaging...

## Implementation Findings

**Impact on work flows:**
- Allows for fast, spontaneous, interactive physician-patient communication
- Directly documented in EHR—no added steps
- Asynchronous—makes solution _convenient_ and improves _confidence_ in secure message delivery for both physicians and patients

**ROI:**
**Cost savings (for 14 clinic physicians)**
- Over $30K saved in annual test results _mail costs_
- Over $19K saved in _staff time_ spent managing test results
- Over $20K saved in _staff time_ for phone follow-up post-visit (labor @ $21/hr)
**Over $4,900 saved per physician/per year **
**for office visit follow-up **

**Implementation Findings**

## Survey Results: Patients Value Secure Messaging

- How clearly did your doctor communicate your results to you?
- 1 = much less clear than other offices
- 10 = much clearer than other offices
- How quickly...?
- 1 = much slower than other offices
- 10 = much faster than other offices
- Overall assessment
- 1 = much worse than other offices
- 10 = much better than other offices

- From David W. Bauer, MD...
- 	*“**On average, patients read our secure e-mails within 15 minutes of receiving them, and they tend to read the result three times.”*

**Notes:**
The practice is very interested in patient feedback.  Here’s what they found.

## Provider and Consumer Value

*	*
*	**“**ClinicalMessenger is dramatically changing the way we work together and with our patients,” *said Dr. David Bauer of Memorial Family Medicine.* “I no longer have to leave generic messages asking patients to call me back, or wondering if my patients can remember what I told them. Messages can be sent conveniently, we have an audit trail that confirms receipt and patients have a record that they can refer to repeatedly if needed.” *
*	*
- 	Same patient on Zyrtec, 3 weeks later:  *“...PS – I really love that I’m able to communicate with you via email. If at any point you feel I should make an appointment to discuss further with you on any of these items, just let me know.”*

## Case Study 2: Secure Messaging and E-Referrals

**Sites:**
- Providence Medical Group,135 PCPs across 40 locations
**Implementation:**
- 8-month study begun in 2004 to test secure messaging of patient referrals between two high-volume organizations
- Results from study led to extensive roll-out across both organizations and with affiliated providers

**Financial model:**  Reduced administrative costs for 55-step manual process per referral

- The Oregon Clinic, 90+ specialists covering 10 major specialties in 18 locations

**Notes:**
Next ,we have a large study which focused on physician-physician interaction but which had dramatic impacts on patient access to care...

## Costs Savings from Reductions in Manual Flows

- Centralized Referral Administration
- Offsite Scanning (prior to eReferrals)
**SAVING $4.97 per referral**

**Costs Savings from Reductions in Manual Flows**

- _The Oregon Clinic_
- Distributed Referral Administration
- Clinic-based scanning (prior to eReferrals)
**SAVING $5.40 per referral**

- Total Savings: $10.37 per referral

**Notes:**
This shows a breakdown of costs savings at each site.  Pretty significant! Impact on flows: Referral time reduced from weeks to minutes, Improved access and timeliness of information, Reduction in errors and rework, Reduction in paperwork and scanning

## Provider and Consumer Value

*	**“**Using paper-based referrals, we’d have patients showing up before their paperwork did.  Doctors were handing patients printouts of their charts and telling them to take them when they go for their referral, because their information might not make it in time for their appointment.”* Michael Reagin, Director of Research and Development, Information Services Group, PHS
- 	*“**Every day during the study, I received calls from members (physicians) of our organization who had heard about our use of e-Referrals and wanted to know how soon they would be able to participate.” *Michelle Haller, Project Manager, PHS
*	*
*	*

## Case Study 3: Improve Patient Satisfaction 

**Site:** Norumbega Medical Specialists, Bangor, Maine
- Approx. 20 family physicians
- 5 offices in rural areas throughout Maine
**Implementation:**
- Low patient satisfaction with test results reporting revealed from staff anecdotes and patient survey
- QI process led to implementation of secure messaging

**Financial model:** Decreased administrative costs for test results through:
- elimination of non-value steps
- replacing paper/mail with secure messaging

**Notes:**
Our third case study involves a small clinic in Maine that came to a secure messaging solution via a internal QI process that revealed low patient satisfaction with receiving test results...

## Implementation Findings

- Reduced error rate for reporting test results from 3% to nearly 0%
**ROI:**
- $19K savings/year in mail costs avoided
- 	(almost $1K per physician/year for one workflow)
**Provider and Consumer Value:**** **
- Patient satisfaction with test results management increased from 89% to 97% post-implementation

**A view from the solo practitioner:*****	***
*	*
*	**“**Expectations about getting lab results have changed tremendously.  Now the patient can be reasonably assured that the day after we draw the blood the results will be available to them.  Under the old workflow, the expectation was almost surreal "We'll get in contact with you about your results" leaving the patient in limbo.”*
- Tom Landholt, MD
- PatientCare Family Clinic, Springfield, MO

**Implementation Findings**

**Notes:**
Using secure messaging for lab results has resulted in significant cost savings and improved patient satisfaction by replacing  just one workflow with secure messaging...Others using this solution have this to say about secure messaging and test results management (read Tom Landholt quote)

## Case Study 4: Patient-Initiated Secure Messaging

**Site: **Michigan State University Clinic
**Implementation: **
- Pilot in one university clinic staffed by 12 physicians
- All physicians agree to secure messaging even if they don’t use it (cultural shift)
- 3 physicians, 6 clinic staff utilize secure messaging with patients
- Increasing use of e-forms for data capture from patients

**Financial model:****  **
- Address phone call burden & telephone tag
- Send EMR documents electronically
- Decrease fax requirements (send, receive)
- Reduce physician time capturing information from patients

**Notes:**
Next is a site currently developing its secure messaging solution.  MSU is very interested in capturing consumer experience with the new technology and continuously improving it to meet consumer needs.  

## Impact:  Messages and Messengers Slowly Increasing

- 256 registered patients, of whom 94 (37%)
- 	have used system to date

**Notes:**
As for impact, as we said, this site has focused first on capturing patient use data.  And they have some interesting facts to share...(go through data)

## “Fear of (Frequent) Flying” Patients

**Messages initiated by patients:**
- Avg # messages per patient per year	1.17
- Avg # messages per patient per day	0.003
**1 message per day for every **_**313 patients**_

**Notes:**
Physicians cite fear of a flood of e-mail messages from patients as a reason for not utilizing secure messaging.  Yet here we see even the heaviest user sent one message about every 2 weeks—and all of these were considered appropriate.  Most patients send 1-2 messages per year.

## Messages Sent by Patients: What they Want

**Notes:**
Patients use secure messaging for lots of reasons.  These categories were selected by patients from a pop-down menu.  “Advice” tended to be used when patients needed an answer to a question.  “Health update” was used when patients relayed additional health information to their physician (i.e., from another doctor).  Others labels are self-explanatory.

## Practice Redesign:  GreenField Health System....

- Established in 2001:  4 internists, 1 adolescent medicine specialists
- Utilized secure messaging and patient portals from day one
- Core philosophy:  50% of patient-physician encounters do not require an office visit
- To date, almost 16,000 patient secure e-mail encounters (2-3 e-mails per encounter)

**Consumer Value**
- 	“My wife is extremely pleased with her treatment at the hands of [physician name]... Yesterday she called her previous physician to request a form which she thought was owed her, and she couldn't get through the switchboard to even ask the question.  Enough said."

**Notes:**
Before we leave the discussion of patient use of secure-email, we’d like to show a bit of data from Greenfield Health System—a leading example of practice redesign through the integration of IT...(flow)  Avg time spent by physician on phone or e-mail—about 6-8 minutes/e-mail. (click) The next graph shows time of day of patient e-mails.  You can see the patients are getting care delivered during the day BUT WITHOUT leaving their home or office.  Here’s a patient quote which captures, I think, the true value of this technology...(click)

## Case Study 5: Chronic Care Management

**Site:**** **Providence Medical Group, 135 PCPs
**Implementation:**** **
- Rolled-out 3 DM modules across entire medical group:  Diabetes, CHD and stroke prevention
- Implemented tools and methodology consistent with DMAA definition of disease management
- Monitored _diabetes_ module through 18-month study involving 9,000 patients

**Project goals:**
- Shift from episodic care to chronic care management  using a population-based  management tool
- Improve physician adherence to evidence-based medicine
- Improve timely patient outreach to increase process compliance and patient goal attainment

**Notes:**
Finally, our last case study shows a new approach to chronic care management.  We’re all well aware of the quality chasm w/respect to care for chronic conditions.  We’ve found through IT interventions, that appropriate and timely care can be consistently delivered. This study examined the impact of our diabetes care management solution—CareManager—a 5 X award winning product.

## Proven Results

| Measure | Baseline | Dec’05 |
| --- | --- | --- |
| LDL<100 mg/dl | 27% | 56% |
| HbA1c<7% | 40% | 53% |
| BP<140/90 | 28% | 51% |
| Aspirin Rx | 52% | 86% |
| Foot Exam | 18% | 73% |
| Retinal Exam | 11% | 55% |
| Pneunomax | 44% | 84% |

- Results based on 18 month study of 9,000 patients with diabetes, in a 120 physician primary care group

- _...__Drives Improved Clinical Outcomes_

- _Improved Individual Performance..._

**Notes:**
And its impact...(go through stats briefly).  Dramatic improvements in health outcomes!  

## Broad Adoption Follows Integration of Secure Messaging

*	**“**Having the "report card" available... has a direct impact on the patient's perception of their diabetes. Seeing the red parameters light up gets them paying attention in a hurry.” *
- Tom Landholt, MD
- PatientCare Family Clinic, Springfield, MO

- Facilitates physician-patient communication and coordination of chronic care
- Additional modules in deployment
- Tobacco cessation
- Cancer screening

**Notes:**
The next version to be realized this Fall, incorporates secure messaging directly into the tool to aid physician follow-up with patients (flow).

## Secure Messaging:  What We’ve Learned

- Findings from our case studies substantiate CITL findings
- 	*“**We found system interoperability critical to realizing the full financial benefits of IT investment,”* said Blackford Middleton, M.D., chairman of CITL. *“The findings of the Providence/Oregon Clinic study are consistent with the research findings of our report.”*
- Secure messaging has proven ROI and delivers human conversations and interpretation in the context of well-structured data
- Integration of e-mail into daily workflows is key to adoption and to reaching goals set out by deployment of technology
- Just as e-mail catalyzed PC adoption, secure messaging has potential to accelerate clinical IT adoption
- Solutions available now to bridge the gap between EHR and non-EHR settings

**Notes:**
So, what has all of us this work taught us?  A few points to make...

## Questions?