US healthcare • For-profit, non-universal PHI system vs the (non-) profit universal systems (SHI or single-payer) • Total $ disproportionally spent on healthcare for a proportion of population based on multiple sources of private financing (insurance coverage / OOP) and not on need alone. • more and better care for those that can afford it, • the rest get sufficient coverage based on their budget, • and some get “none” (stabilised and treated in ER, unfunded mandate) • 15.5 % Americans lacked coverage for a core set of services than residents of all other OECD countries (-1) had • 25% of American adults say they or a family member has put off treatment for a serious medical condition because of cost • More than 13% of American adults report knowing of at least one friend or family member in the past five years who died after not receiving needed medical treatment because they were unable to pay for it. 27
Health insurance in the United States • 907 health insurance companies • 60% of Americans are covered through an employer- sponsored program, while about 9% purchase health insurance directly. Initially all-private, increasingly complex public/private mix • Plurality of payers / insurers / health plans, providers / delivery parties. • Supplementary and complementary payers and deliverers. • Major difference in State funding on medicare / medicaid. • An estimated $2.1 billion is spent annually across the healthcare system chasing and maintaining provider data. 28
Primordial soup, but a v networked one • About half of population receive their healthcare through an HMO or some other managed care organisation. But also more integrated “health systems” than we have: • Integrated delivery systems and integrated delivery networks • Some have an HMO component, while others are a network of physicians only, or of physicians and hospitals. • The goal is to serve as a self-contained healthcare ecosystem, coordinate delivery of care (and manage population health). • Provider systems are starting new health plans, acquiring existing health insurers, evolving from an existing ACO into a licensed health insurance company, JV with established health insurers. 29
Integration across providers and payers • Horizontal integration: scale • Vertical integration • Integration between providers: hospitals and PC • Integration between some providers and payers • Sometimes integration across payer – hospital care – primary care BUT • “population” = those that are in the plan, not the true population. Evidence of positive impact of this: • EHR within and across orgs • eConsults between GPs and specialists Main requirement for better use of digital: health system integration Unified health system like KP or even: UCSF, UCLA, VA, USC, CS 30
Adding to the mix: telehealth / tele-primary care providers: synergy? • I observed a lot of patient-facing digital inc concierge medicine and direct-to-consumer primary care • Some start from DtC and move upstream, some the opposite. DtC has struggled to take off. Why do we bother with PC? • With HI: insurer would rather treat you cheaply and not at surgical intervention or LTC treatment. • With PHI: as above, but also applies to employer. Why digital PC: • As above, AND cheaper for insurer to pay provider for delivery, cheaper to access for patient as lower co-pay, and employer doesn’t lose you for half a day. 31
Continued How to drive utilisation? • Anthem has decreased the copay for these visits to $5, compared to a $25 to $35 copay if a member visits face to face their primary care doctor. • An Anthem HealthCore study of claims analysis for utilization of acute non-urgent care, found telehealth saved 6% in costs by diverting members who would otherwise have gone to the emergency room. • Blue Cross Blue Shield of South Carolina: "This isn't a 'build it and they will come' kinda of thing" "You really need to develop strategies to drive utilization.“ • They set a policy around telemedicine in order to boost care in rural areas. 32
Continued VA Video Connect platform • To start: VA had more than 1.3 million video telehealth encounters with more than 490,000 Veterans in 2018. • In 2019: pilot video consultations in Walmart rooms, in rural areas Synergy example: partnership between Anthem, American Well, and Samsung • American Well's telehealth service available to Anthem members with Galaxy phones, via the Samsung Health app • Aiming to become a ‘one-stop-shop’ platform for consumers to track their health, share data, and communicate with healthcare professionals. Doctor on Demand in 2019 made a deal with Humana to sell what it calls the first "virtual only" plan design, which involves assigning primary care doctors upon sign-up based on a set of questions from the worker. 33
I have not seen a health system that has answers to all these (and does it matter?): • Who are the right patients to see via video? • To get to book these appointments? How many result in additional face to face visits? • How to risk stratify via the triage stage? Prioritise? • Supply-induced demand: does it hold truth for primary care more than e.g. surgery? • Digital skills divide • Impact on clinicians (burnout and decision fatigue major issue in US • What is really needed: capacity, capability and willingness to prioritise, consider, act • Who pays for the tech, its implementation, and activity? 34
Take home messages What has worked: • integration between providers, especially: hospital and primary care, • capital and incentivisation by fee for service • its allocation based on drivers such as: • increased access via digital, • convenience and 2ndary non-healthcare benefits that will drive uptake (video consultations without leaving work / home) and • on earlier action and prevention (PHI and SHI key drivers). What hasn’t worked: • Where necessary, NOT incentivising uptake by providers, or paying for tech and implementation. • Alternative routes to access to primary care; harder to replace something that works. • Build it and they will come. 35
Thank you Dimitri Varsamis PhD Senior Policy Lead, General Practice Strategy and Contracts Primary Care Strategy and NHS Contracts Group, NHS England https://www.england.nhs.uk/gp/gpfv/investment/gp-contract/ Made possible with funding from the Winston Churchill Memorial Trust, and represents the views of the author only, not of NHS England or the Trust. Hear more from me on: HIMSS SoCal podcast https://himsssocalpodcast.wordpress.com/2019/11/14/episode-27-developing -digital-first-models-of-primary-care-ft-dimitri-varsamis/ 36
Dr Ed Turnham Clinic Lead for GP Online Consultations at Norfolk and Waveney STP and CCIO at Arden & GEM CSU “Digital-First General Practice using Online Consultations in Norfolk and Waveney.” #Convenzi s
Digital-First Primary Care: using FootFall for Norfolk & Waveney CCGs Dr Ed Turnham Clinical Lead for GP Online Consultations at Norfolk and Waveney STP CCIO for Norfolk and Waveney at Arden & GEM CSU
September 2018 – possible approach 1 Bolt-on Online Consultations to practice website 0.2% of consultations Disagreement about Seen as a short-cut to Extra work for GPs (Edwards et al., 2018) what it should be used getting an for (Banks et al., 2018) appointment
September 2018 – possible approach Digital Triage Phone request Online message Phone Online request Admin triage GP triage Face-to- face Admin resolve Send to other team
AskMyGP – encounter resolution mode How Requested by practice patient resolved Reproduced with consent of
AskMyGP – Digital Triage Reproduced with consent of
AskMyGP – Digital Triage – key numbers Demand is stable over Average response time 78% of patients say the time at 8% of patients per around 90 minutes new system is better week Reproduced with consent of
FootFall https://www.aclemedicalcentre.co.uk/
FootFall https://www.aclemedicalcentre.co.uk/
FootFall
Our early findings Requests by source Requests as a proportion of practice population 8% 7% 6% 5% 4% 3% 2% 1% 0% 40 41 42 43 44 45 46 47 Week Self Proxy Staff
Digital Triage - key ingredients for success • Get patients online • Equity • Rapid response. Keep the patients on board + updated • Training, training, training • Process change • Avoid duplication of clinical work
Digital Triage – not telephone triage How Requested by practice patient resolved Reproduced with consent of
Demand predictor Encounters per clinical session, by mode of resolution 25 20 8.4 7.4 7.2 15 6.5 5.4 10 8.0 7.0 6.8 6.2 5.1 5 5.8 5.0 4.9 4.5 3.7 0 Monday Tuesday Wednesday Thursday Friday Messages Phone F2F
Workload predictor Time taken per clinical session, by mode of resolution 3.0 2.5 2.0 2.0 1.7 1.7 Hours 1.5 1.5 1.3 1.0 0.8 0.7 0.7 0.5 0.6 0.5 0.2 0.2 0.2 0.2 0.1 0.0 Monday Tuesday Wednesday Thursday Friday Messages Phone F2F
Workload smoothing Time taken per clinical session, by mode of resolution 3.0 2.5 0.2 0.6 2.0 1.5 1.6 Hours 1.6 1.5 1.5 1.3 1.0 0.8 0.7 0.7 0.5 0.6 0.5 0.2 0.2 0.2 0.2 0.1 0.0 Monday Tuesday Wednesday Thursday Friday Messages Phone Same day F2F Prebookable F2F
Continuity of care with Digital Triage PATIENT AND DOCTOR BENEFITS SCALE • Here’s what I’m going to say - see if you can think of any ways to illustrate it… • Two extremes of approaches are possible within Digital Triage: • 1) Assign the first request of the day to Dr A, the second to Dr B, and so on. Workload will be fair between doctors, but there is no continuity of The solution: Assign each request to the care for patients. doctor who knows the Assign the first request of • § 2) Assign each request to the doctor who knows the patient best, or the doctor whom the patient requests. This is good for continuity, but the Identify the 10-20% of patients who patient best, or the doctor popular doctors will get more work than other doctors. When a doctor is away for a day or more, they may come back to a huge backlog of the day to Dr A, the second are most complex, and therefore are work. whom the patient requests. most in need of continuity (i.e. use to Dr B, and so on. • The solution: identify the 10-20% of patients who are most complex, and therefore are most in need of continuity (i.e. use simple population simple population segmentation). segmentation). Focus on getting them seen by the doctor who knows them best. The remaining patients can be dealt with by any doctor. This This is good for continuity, allows the practice to spread workload evenly while maintaining continuity when it is important. § Focus on getting them seen by the Workload will be fair but the popular doctors doctor who knows them best. between doctors, but will get more work than § The remaining patients can be dealt there is no continuity of other doctors. When a with by any doctor. care for patients. doctor is away for a day or § This allows the practice to spread more, they may come back workload evenly while maintaining to a huge backlog of work. continuity when it is important.
Next steps Tools to support Verifying patient’s Integrating into Online booking Video practices: demand- identity clinical system supply calculators, population segmentation etc.
Where video fits in Online Phone request message Phone Online request Admin triage GP triage Face-to- face Video Admin resolve Send to other team
References • https://bjgp.org/content/68/666/e1?ijkey=1b09bc08c14947fe84f792 9e78942948beaecedd&keytype2=tf_ipsecsha • https://bmjopen.bmj.com/content/7/11/e016901?int_source=trend md&int_medium=cpc&int_campaign=usage-042019
Thank you for listening! Any questions? Dr Ed Turnham Clinical Lead for GP Online Consultations at Norfolk and Waveney STP CCIO for Norfolk and Waveney at Arden & GEM CSU
Kieran Waterson Head of Sales (UK) at iPlato ‘myGP – delivering digital-first primary care in 2020’ #Convenzi s
Delivering Digital First Primary Care Kieran Waterston
What’s the problem? 1. Demand growth for healthcare services is unsustainable 2. Healthcare is behind other sectors in adopting digital In an attempt to change this patients are being given the right to have digital first service
What does digital look like elsewhere?
Touch points in Primary Care Appointment Appointment Booking & Consultation Reminders Cancellation Prescription Medical Record Queries Ordering Access Signposts Screening Advice
The myGP Platform Reception Clinician Appointment Book, Patient Intake Patient Patient Triage & Cancel & & Care Remote Engagement Insight (PHR) Request Navigation Consultation 25m patients
The myGP platform provides a streamlined interface solution between practices and patients
The myGP App
24/7 appointment booking & cancellation Patients can manage their access to healthcare wherever they are via myGP. Links directly with INPS, TPP & EMIS
Appointment reminders Patients receive appointment reminders as in-app messages. You can configure reminder settings in myGP platform. SMS costs removed automatically (typically 30%)
Improve uptake and awareness of health campaigns Patients who are entitled to a free flu jab or NHS screening test can be invited to book via myGP. Hidden appointments just for eligible patients
Cervical Screening Programme in London Organisation NHS England (NHSE) and Public Health England (PHE) Invite thousands of women to their due/overdue smear Goal test appointments. Start August 2018 End August 2021 Female women across London surgeries will receive a letter from Capita and 2.5 weeks after a text reminder to Description encourage them to book the smear test appointment. If no appointment is booked, a second letter will be sent from Capita.
London Cervical Screening Hub Engagement Hub Consent No consent Practice 1 Practice 2 Practice 3
Patient Experience From Station Road Book Smear Test Appointment Medical Centre. Your cervical smear test is due. Please call 020 3345 7891 or click on this link to download our app to book on your phone.
Results 97% of practices in London signed up to the project 384,112 women were invited for screening from consenting practices Mobile phone numbers were extracted for 88% of these women For women who received a text reminder, uptake at 18 weeks was higher by: 4.8% in all age groups 4.8% in women aged 25 to 49 5.9% in women aged 50 to 64 The average time between invitation and screening: 54 days for women who received an invitation letter and a text reminder and 71 days for women who received an invitation letter only
myGP Patient Surveys (FFT) Feedback is automatically shared with you so you can make informed improvements to your services.
Medication Reminders Patients can set up daily, weekly or monthly reminders for all of their medications. Push notifications are sent when it is time to take the medication. Adherence tracking helps patients to take control over their condition.
Repeat Prescriptions & Medical Record Access • EMIS- Already Released • TPP- Already Released • INPS- Under Development • 4504 practices in England have myGP users (Jan 2020)
Directions to the nearest pharmacy Patient's may be able to get their queries resolved at a pharmacy via a minor ailment scheme
Add Dependants Mary Smith Patients can book and cancel appointments for their children, family Jane Smith and dependants. Alex Smith 273,000 dependants have been added (Jan 2020)
Patient self-care tracking Patients can record and monitor their blood pressure and weight on myGP. This module is for patient use only and helps with long-term condition management. Almost 100,000 patients are doing this (Jan 2020)
Remote Monitoring
Remote Monitoring Self-monitoring is clinically proven to improve patient health outcomes. Request patients to capture biophysical data such as blood pressure or weight. Upon request, a temporary monitoring module will appear in the app.
Clinicians view in Platform
preGP
Care Navigation- preGP preGP Appointment Intelligent Care remoteGP Booking Navigation Remote consultation Patient Data capture
Intelligent care navigation When booking an appointment, patients are signposted to alternative pathways depending on appointment reason, e.g. pharmacy. Automated, clinically safe sign-posting. Proven to successfully reduce appointment demand by 20%.
preGP signposting
preGP signposting
Case Study • Patient list of 6179 • 29% active myGP app users • Over 1000 appointments listed on myGP across various slot types • 1849 appointment reminders sent via myGP or SMS • 27 cancellations (£810) • 10% reduction in calls to the surgery • One day of administration time saved • preGP + remote consultation diversion rate of 25% away from F2F appointment (£3,330 cost savings) • Total cost savings: £4,140
Remote Consultation
Appointment Triage- All online appointments visible on one screen
Communicate with patient via Chat
Remote Consultation Decrease unnecessary face to face appointments by resolving requests remotely. Check appointment details and make informed decisions about triaging. Organise a video or telephone consultation on myGP. Send in-app messages to request additional information.
The ability to start a Video call with just one click Simply click here to initiate Video
Video Call Controls During the call you can control: Sound Microphone Camera End Call
Video Calls – Patient Experience
Book & Cancel Easy Access Appointments Prescription Signposting Ordering Registration with If they add their Yes just mobile Online credentials number and DOB Medical Record Video Consult Access Remote Is the myGP active Monitoring at the practice? Book & Cancel Appointments Patient has to have Prescription No their online Ordering credentials Medical Record Access
QUESTION TIME Question Time Please email any questions to myGPSupport@iplato.net. kieran.waterston@iplato.com
Dr Pritesh Mistry Clinic Innovation and Research at the Royal College of General Practitioners “Primary care innovation: from frontline ingenuity to AI” #Convenzi s
Primary Care Innovation: from frontline ingenuity to AI Dr Pritesh Mistry – Head of Innovation Royal College of GPs
Declaration of interest I do not have a conflict of interest (financial, commercial, personal, professional, advisory, research-linked or other) relating to this event.
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