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 Minal Bakhai National Clinical Lead Digital First Primary Care at NHS England and Improvement “Building a Digital - first Primary Care.” #Convenzi s
Digital First Primary Care Presented by Dr. Minal Bakhai Deputy Director and National Clinical Lead for Digital First Primary Care, NHS England and Improvement General Practitioner, Brent CCG NHS England and NHS Improvement
“A 2016 Lancet paper said GPs’ workload had risen by 16% in the seven years up to 2014, with more frequent and longer GP consultations” 39 |
Current “as - is” patient pathway • Appointment booking without triage • Lack of patient signposting to appropriate services • Disconnected PC, community and UEC patient pathways Digital First • Frequent fliers – appointment skew 40 | Accelerator change to current process
Getting the front door right: What most patients currently do 41 |
The primary care landscape There are significant opportunities to use primary care capacity more effectively. Investing in and harnessing digital technology is a necessary and important part of the solution in order to tackle: • Increase in demand and workload • Patient expectations and satisfaction • An increase in patients with complex health conditions • Staff retention 42 |
The big picture of demand vs. capacity is optimistic 43 |
Do patients want a face- to-face appointment? The assumption that every patient in contact with a GP wants or Median time to respond = 38 minutes needs a face-to-face appointment is false and is a major cause of GP 44 | overload... Twitter, Steve the Skeptic askmyGP data (n=44 practices, total list size 447,000)
Our aspirations 45 |
The digital first patient journey Patients are able to easily access and flow through primary care pathways using digital tools. RESPONSE A&E SIGNPOSTING UTC E Get advice, check Hub n my symptoms t Secondary care r referral y Outpatients Finding the most Go online appropriate care Get the right help Self Care p pathway (triage) Self referral o NHS App Social Prescriber i NHS.uk n 111.nhs.uk Pharmacy t Book appointments Practice website online s Local Apps View records online Right person/team in the GP practice Order meds or PCN online Tele[hone & Online Video messages 46 | consults
Continuity: did patients get the staff they requested? 47 |
A B C D E F A B C D E F Average waiting times are going down and monthly DNAs are reduced.
Case study – Witley Surgery 60% 87% 30% Number of appointments Number of patients who Patients reporting that the moved to an online prefer to contact the practice new online system is better. consultation on the first day. online rather than by phone. The number of face-to-face consultations has reduced by 43%, home visits by 73%, with an overall saving of 10% of clinicians’ time. 49 |
Continuity: did patients get the staff member they requested? 50 |
Time Spent with Patients In Clinic Increase in face-to-face time with patients due to ability to plan appointment length appropriately. 51 |
Case study – Tudor Lodge askmyGP, weekly activity as a 52 | proportion of patient list
Case study – Tudor Lodge 76% 53% 76% Number of patients who Patients are seen on the Patients reporting that the prefer to contact the practice same day. new online system is better. online rather than by phone. Overall productivity has doubled. Time to respond is less than 30 minutes. Increase in face-to- face time with patients that need it. When asked: “Would you go back? Not a chance” Practice Manager 53 |
Virtual Hubs Resident is able to access a platform which allows them to consult online with eHub clinicians Online consultations are managed centrally by a group of clinicians working eHub provides on behalf of a group of GP digital and possible F2F services. Practices Where eHub appointment is not in patients’ best interest, capacity at registered GP is sought. eHub could be set up as: 1. Separate entity 2. Part of access hub 3. Linked to UCC/UTC if applicable 54 |
Case study – Hurley Group eHub 10X 700 hours 88% Hours saved in Increase in GP recruitment Online consultations closed administrative time for interest remotely practices Average online consultation takes three minutes Integration of wider clinical workforce Improved staff satisfaction and retention 55 |
The digital first vision 56 |
Digital first primary care – the vision What can patients expect? The NHS Long Term Plan commits that every patient will have the right to be offered digital-first primary care by 2023/24. The use of digital channels will be at the choice of the individual patient , with those who can’t or don’t wish to use digital tools still able to access services over the phone or in person. Patients should be able to easily access advice, support and treatment from primary care using digital and online tools . These tools should be integrated to provide a streamlined experience for patients , and direct them to the right digital or in- person service for their needs. 57 |
58 |
Benefits 59 |
What we want to achieve Digitally enabled services Service transformation enabled by Technology drives improvements in the quality, safety technology and efficiency of healthcare delivery within existing Digital technology is a core component of quality service models . Providers are better placed to deal with improvement across STPs and Integrated Care Systems. the pressure of rising demand but cannot fully address This enables the scale & pace of change required to Technological maturity the root causes of it manage population health and address : The Health & Wellbeing Gap • The Funding & Efficiency Gap • The Care & Quality Gap • Current state Transformed care processes Low levels of digitisation limit the potential impact of By looking beyond existing organisational structures, care efforts to improve existing processes and service models. becomes more person-centred, better coordinated and Does not address fundamental issues affecting long-term proactive. This starts to address underlying challenges, sustainability of individual providers or local health but gaps in key digital enablers limit the scope, economies as a whole. Low levels of digital maturity, speed & effectiveness of change particularly regarding infrastructure & cyber security, create operational risk Clinical transformation Service transformation Consumer transformation 60 | Digital First Primary Care
Unlocking success in digital transformation Integration Effective Utilisation Across PCNs and health systems Primary care staff and patients are (e.g. at ICS/STP level) to deliver appropriately trained and supported to streamlined services for patients use digital tools – leading to high levels (so patients can be directed to the of utilisation. right service quickly and easily) Functional Capabilities The core functional capabilities A learning culture practices and PCNs will need to Primary care has access to data, have to deliver digital first primary analytics and evaluation to support care (such as online appointment learning and a focus on impacts. booking, triage mechanisms and secure messaging) Digital Essential Infrastructure first The core infrastructure and IT Supplier Engagement systems needed so practices and There is effective engagement with PCNs can deliver digital first suppliers to encourage compliance primary primary care and can work with standards, innovation and collaboratively and share development. information. care 61 |
The vision for digital first primary care Health systems are Digital products Primary care Digital products Commissioners deploying both meet nationally contracting, can be easily are designing nationally developed regulation and procured and integrated digital commissioned and standards to payments support deployed by primary care locally procured enable effective development of commissioners pathways products to build integration and to these integrated these pathways ensure safety digital pathways Patients are able to easily access and flow through primary care pathways using digital tools safely and effectively Staff receive time, resource, training and implementation and service improvement support to optimise the use of digital tools and meet the growing and changing demands on Primary Care 62 |
Digital first accelerators Twelve accelerator site have been selected to develop digital first primary care. Other regions are working to establish their own accelerator sites. 1 Devon London 2-6 7 East Kent 8 12 8 Shropshire, Telford and Wrekin 9 9 West Birmingham and Black Country 11 10 10 Hereford and Worcester 2-6 1 Cambridge and Peterborough 11 Norfolk and Waveney 12 7 63 |
Digital Maturity IT IS NOT JUST IT IS • Logical journey towards a data • More technology driven learning healthcare system • More technology • Better/ faster technology supported by tech • Better/ faster technology • Functionality “Do you have X?” • Congruence: fundamentally • Functionality “Do you have X?” changing workflows, aligning • Capability “Can you do X?” • Capability “Can you do X?” digital strategy with outcomes, • Digitising paper pathway • Digitising paper pathway aligning incentives • Outcomes based delivery of ever improving high-quality care …….digitising alone doesn’t …….Digitising alone doesn’t mean • Changing your processes, culture anything mean anything and behaviours 64 |
A journey 65 |
Digital first programme Implementation support Case study library Training Community of Practice Deep dive evaluation Evaluation standards and data analytics Funding Blueprinting DPS framework 66 |
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 8% Requests as a proportion of practice population 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 0.5 0.7 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 0.5 0.7 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 • T Assign each request to the • 1) The solution: c doctor who knows the Assign the first request of • 2) Identify the 10-20% of patients who patient best, or the doctor p the day to Dr A, the second are most complex, and therefore are whom the patient wo most in need of continuity (i.e. use to Dr B, and so on. requests. • T simple population segmentation). s a Focus on getting them seen by the This is good for continuity, Workload will be fair doctor who knows them best. but the popular doctors between doctors, but The remaining patients can be dealt will get more work than there is no continuity of with by any doctor. other doctors. When a care for patients. This allows the practice to spread doctor is away for a day or workload evenly while maintaining more, they may come back continuity when it is important. to a huge backlog of work.
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 Book, Patient Intake Appointment Patient Patient Insight Cancel & & Care Triage & Remote Engagement (PHR) Consultation Request Navigation 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.
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