Chronic disease and population health management

Smart Technologies in
Chronic Disease &
Population Health Management
The case for outcome-based
approaches to better healthcare
© 2016 Napier Healthcare. All Rights Reserved.
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Smart Health Technology Integration
Better Chronic Disease Management and Patient Experience
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Our research shows the following to be true:-
 Chronic Disease Management (CDM) requires holistic case management.
 Remote monitoring of vital signs is achievable today.
 Longer term care plans for chronic diseases will vastly improve quality of care.
 With sufficient data, analytics will further drive successful health outcomes.
 Mostly with elderly and increasingly with younger patients, we have to personalise
the experience when they visit the facility. For instance, we should
 Consider an easier Registration process or NO PROCESS at all
 Use voice based GPS and WhatsApp
Chronic Disease Management and Patient Experience
What is to be Done?

The 2015 report by DesignSingapore Council, Design for Ageing Gracefully–Rethinking Health
& Wellness for the Elderly: Public Services, tells us that seniors:
 Are very comfortable using WhatsApp, Viber and Skype, for long distance calls and to exchange photos
etc. Those in the higher-income bracket (HDB 3 and above) tend to use tablets and smartphones.
Can we use WhatsApp to design a user experience for when they visit the hospital? Of course, use
bigger fonts in the messaging interface, always.
 Don’t like tech-enabled check-ins or SMS-based check-ins—it is too impersonal.
 Prefer familiar faces in the Care team. They don’t want to meet new people at every visit.
 Want “recreation” facilities in hospitals, if possible. Going to a hospital makes them feel “unsafe” and
usually denotes trouble.
What can we do to make them safe? Why not have Wellness integrated instead of only sick care?
 Feel under represented in healthcare delivery.
Can we hire the elderly to take care of the elderly?
 Watch a lot of TV.
Can that be used as a medium of interaction?
So what can we do?
Patient Experience
A Call for Empathetic Technology
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Enhancing Patient Experience
Empathetic Tech-based Options Available
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Technologies provide for the THREE keys to better patient experience:
Communication, Access to Information, Doctor/ Patient Relationship
 Radio Frequency Identification (RFID) tags
o Combined with location aware beacons
o Tracks the location of patients moving through the system
o Alerts hospital staff of patients’ arrival/presence
o Automatically sets environmental controls based on patient preferences
 Wearable technology to increase physicians’ face time with patients
o Sends AV feeds from patient consultation
o Scribe accesses the EHR remotely and enters patient notes
o Patient notes are reviewed and signed off by the doctor
 Mobile apps, kiosks, portals etc.
 Analytics to find at-risk population
o Helps people manage their health conditions at home—long before they reach an acute stage
o Reduces readmission rates
o Uses: remote monitoring devices connected via Bluetooth, a Cloud, digital chart displays

Population Health
A Holistic Approach to Chronic Disease Management
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Population Health
The Health Outcomes of People in a Community
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Population Health
Management (PHM)
What is it?
Goals Why is it needed?
Benefits
 Set of interventions
designed to
maintain/improve
health of
population across
the full continuum
of care.
 Covers low-risk
healthy individuals
to high-risk
individuals with one
or more chronic
conditions.
 Population: Better
coordinated care
 Physicians: Better
informed and
engaged with patients
 Health Care
Organizations:
Improved clinical
outcomes and
reduced costs
 Health Care System:
Increased preventive
care and closed care
gaps
 Address burden of
undiagnosed
chronic illness that
later present as acute
condition
 Address higher
costs on the system
due to chronic illness
 Improve health of
patient population
 Redefine
healthcare as a set
of interdependent
activities
 Mitigate risk
factors that
exacerbate illnessSource: International Diabetes Foundation
(www.idf.org/membership/wp/ Singapore)

Singapore Health Today
Ageing Population and Rising Incidence of Chronic Diseases
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Disease Prevalence (18-69 years) - 2010
Hypertension 23.5%
Diabetes 11.3%
High Total Cholesterol 17.4%
Obesity 10.8%
Daily Smoking 14.3%
Sources: Department of Statistics; Ministry of Health, Singapore; AIA
Vitality Age Survey 2012, Ministry of Health Disease Burden
 By 2030, the number of
elderly citizens (aged 65 and
above) will be 900,000.
 Leading causes of death:
major non-communicable
diseases such as cancer,
coronary heart diseases,
strokes, pneumonia, diabetes
and hypertension.
 Common risk factors:
smoking, obesity, physical
inactivity and alcohol
consumption.

Moving Forward with Accountable Care
The Future of Healthcare Delivery is Outcome-Focused
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The Accountable Care Model
Based on Accountable Care*, Focused on Outcomes
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Accountable Care/ Affiliated Care Network
Affiliated Care Network between
general physicians and hospitals
(enabled by a referral system
between GP’s and hospitals)
Remote patient monitoring solutions
aid in preventive approach to care
(both for chronic diseases and
ageing population)
The focus is on management of
chronic diseases for people in a
community.
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* Accountable Care ties provider reimbursements to
quality metrics and reductions in the total cost of care
for an assigned population of patients, and is an
increasingly important, Federally sponsored initiative in
the USA.

Napier Healthcare is Ready to Deliver
High-Value and Cost-Effective PHM on the National Scale
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The Napier Advantage
Enhancing healthcare delivery with an outcome-based model
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Chronic Disease Management – Population Health Management
National Electronic Health Record (NEHR)
Care
Coordination
Care Plan
&
Vital Signs
Monitoring
Portal
Analytics
Case
Management
such as
Pega or CRM
currently in
use
+
To take this concept to fruition, we must work with government agencies:
IDA, MOH and the Smart Nation Program Office.
Existing / Maybe
New Solutions
Transitions of
Care
& Referral
Management

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APPENDIX

Framework: Population Health Management (PHM)
The Continuum of Care and Patient-Centered Interventions
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Source: CareContinuum Alliance,
A Population Health Guide for
Primary Care Models, 2012

The PHM Workflow
Steps in the Provision Model
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Stratify, Design & Monitor
Population
Identify Gaps in Care
Stratify Risks
Engage Patients
Managed Care
Measure Outcomes
PHM Workflow Chronic Disease Management
Identify the disease profile (e.g., Diabetes) along with the target
population based on demographics and risk factors
Health assessment: Map the risk factors and the gaps in care at all
levels—preventive, primary and above
Identify and stratify the population based on the level of risk involved
(gaps in care, demographic, social etc.)
Community outreach and patient engagement programs
Technology enabled chronic disease management program to reduce
the gaps—referral program, health promotion, risk management etc.
Remote patient monitoring to measure the outcomes of the program

PHM: Key Components
Foundation for Comprehensive Care and Management of Costs
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1. Physicians
Provide care consistent with PHM goals
2. Primary Care Physicians/General
Practitioners
This group enables scalability for larger
populations
3. Data Analysis
Data is aggregated from EMRs,
ePrescriptions, Practice Managers, Payers,
HIEs and Labs to be analyzed for
actionable outcomes
4. Benefit Program Coordination
Financial incentives to be offered for
participation in PHM
5. Technology
Enables information to be pushed to
patients
6. Referral Mechanism
Eases the path along the continuum of
care between primary and tertiary levels
7. Physician Incentives
Ensures involvement at PCP level
8. Replication Ability
Applied to community at large

Analytics in PHM
Laying the Path to Actionable Insights
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Source of Data Action Items
Electronic Medical Records
Electronic Prescriptions
Practice Manager Data
Payers Information
Hospital Information Exchanges
Laboratories
Data
Analysis
 Deliver Preventive Care
 Treat Chronic Diseases
 Perform Patient Outreach
 Assess risk and Analyze
cost
 Report Outcomes and close
care gaps
 Clinical data (Biometric, Lab & HRA data)
 Utilization data (How do people access/ use healthcare?)
 Adherence data (Care plans, Medication plans & Preventive care)
 Operational data (Participation, productivity, disability data and other metrics)
 Financial data (How does healthcare activity translate into dollars (savings)?)
 Satisfaction data (How participants/ stakeholders view your efforts?)
Top Areas
for Data
Analysis
Source: Health
Intelligence
Network, Napier
Analysis

Technology Adoption in Healthcare
The Factors Influencing IT Investments
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Source: Technology in the NHS—
Transforming the Patient’s Experience
of Care

THANK YOU
w w w. n a p i e r h e a l t h c a r e . c o m
i n f o @ n a p i e r h e a l t h c a r e . c o m
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Chronic disease and population health management

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