Utilization of Telemedicine in Mercy Health System

1. Mercy Health System Tele- Medicine 2012

2. UTILIZATION 3,937 staffed beds 574,666 ED visits (FY11) 6,566,057 outpatient visits (FY11) 160,382 inpatient discharges (FY11) 2 HOSPITALS 25 acute care hospitals 6 managed hospitals 3 heart hospitals 2 children's hospitals 1 rehab hospital AMBULATORY SERVICES 233 clinic locations 27 urgent care centers 7 outpatient surgery centers 4 retail clinics MEDICAL STAFF & CO-WORKERS 37,000 co-workers 1,580 integrated physicians 5,369 active medical staff (includes integrated and non-integrated physicians: OHH) 619 advanced practitioners MISSOURI STATS: >1.5 million people served 1,071 integrated physicians 413 primary care physicians 9 acute care hospitals 134 clinic locations MISSOURI STATS: >1.5 million people served 1,071 integrated physicians 413 primary care physicians 9 acute care hospitals 134 clinic locations IMPROVING DELIVERY IMPROVING DELIVERY

3. What are we solving for a new model of care Access to Care Primary Care Specialty Care Provider Shortages PCP and Specialty Cost pressures Hospital will be a cost center and not a revenue center Patient Centeredness High service model

4. Tele Medicine Tele Medicine Virtual Care Virtual Care Care Model Delivery Care Model Delivery Population Management Population Management Center for Innovation Center for Innovation Medical Director Operations Director Clinical Ops VP Operations Director Medical Director Operations Director Mercys Center for Tele Health and Innovation Virtual Care Center Chief Innovation Officer Centralized HUB Model Centralized HUB Model Centralized HUB Model Centralized HUB Model Decentralized Consult Decentralized Consult Decentralized Consult Decentralized Consult Store and Forward Store and Forward Store and Forward Store and Forward Collaboration Collaboration Collaboration Collaboration Chronic Care Management Chronic Care Management Chronic Care Management Chronic Care Management Scheduling Scheduling Call Center Call Center Scheduling Scheduling Call Center Call Center Nurse on Call Center Nurse on Call Center Nurse on Call Center Nurse on Call Center Scheduling & referral management Scheduling & referral management Scheduling & referral management Scheduling & referral management Care Coordination Care Coordination Care Coordination Care Coordination Post Acute Care Post Acute Care Post Acute Care Post Acute Care Care Delivery Innovation Care Delivery Innovation Care Delivery Innovation Care Delivery Innovation Research Research Research Research Grants Grants Grants Grants Analytics Analytics Analytics Analytics Epic Informaticist Epic Informaticist Epic Informaticist Epic Informaticist Resources have a central feel and central supervision Resources are distributed although Scheduling and supervision are central Resources may be either central or distributed encounter is asynchronous and my involve images and or consultation Resources are distributed and are outside of Mercy encounter is asynchronous and my involve images and or consultation E-Visits E-Visits 24/7 24/7 E-Visits E-Visits 24/7 24/7 Asynchronous Care Asynchronous Care Asynchronous Care Asynchronous Care Home Health Home Health Support Support Home Health Home Health Support Support EHR support EHR support EHR support EHR support

5. Tele-Medicine Division Tele Medicine Tele Medicine Virtual Care Virtual Care Centralized HUB Model Centralized HUB Model Centralized HUB Model Centralized HUB Model Decentralized Consult Decentralized Consult Decentralized Consult Decentralized Consult Store and Forward Store and Forward Store and Forward Store and Forward Asynchronous Asynchronous Asynchronous Asynchronous e-ICU e-LTAC Tele-Sepsis e-Hospital Telemedicine core infrastructure Telemedicine core infrastructure Distributed Scheduling Credentialing/Licensing HR Finance Reimbursement management Analytics (CIC?) Epic expertise Account Management Customer relations/Call center e-after care Specialist/patient Specialist/physician 15 Specialties Video Remote Interpretation Selected as spine destination Tele-Stroke network Imaging from Critical Access Facilities Pediatric Cardiac Echos and EEGs Radiology Pathology Dermatology 24-7 e-visit support Store + Forward patient visits home monitoring Medical Director Medical Director Of Of Critical Care Services Critical Care Services & special projects & special projects Connector

6. 6 Inpatient hospital utilization management Avoiding medically unnecessary admissions Avoiding medically unnecessary discharge delays Aligned hospitalist programs Outpatient utilization management Case and chronic condition (disease) management Primary care population management Primary care e-visits Specialist e-consults Urgent care centers Aligned provider incentive programs Mature PCP-driven group practice Extended office hours Incorporation of advanced practice RNs and/or PAs into primary care teams 24 hour on-call access for patients Mercys ACO Readiness: Components of Millimans study on accountable care organization (ACO) models Components of Millimans study on accountable care organization (ACO) models IMPROVING DELIVERY IMPROVING DELIVERY Impact on Medicare 8.25% Commercial 9.61%

7. e-ICU e-ICU School Clinics School Clinics Work site clinics Work site clinics After Care Models After Care Models e-Hospitals e-Hospitals Tele- specialty Tele- specialty Medical Home Medical Home e-Hospitals e-Hospitals Community clinics Community clinics Analytics EHR support EHR support Convenient care Convenient care Predictive Modeling Predictive Modeling E-visit 24/7 E-visit 24/7 Store & Forward Store & Forward Concierges Service Concierges Service Nurse on Call Nurse on Call Tele-Home Health Tele-Home Health Home Monitoring Home Monitoring Palliative Care Palliative Care Virtual Care Services Access Access Volume Volume Market share Market share Care Coordination Care Coordination < 10% < 10% Shared Savings/Risk Contracts Shared Savings/Risk Contracts >50% >50% e-SNF e-LTACH e-LTACH Tele-med Primary Care Community Kiosks Community Kiosks Navigator Services Navigator Services PHR PHR VRI VRI EHR Optimization Family Support Family Support Remote Rounding Remote Rounding Tele Surgical f/u Tele Surgical f/u e-NICU e-NICU ACO contracts Medicare Advantage 30,000 lives CMS ACO 250,000 lives Traditional FFS contracts Tele - Sepsis Tele - Sepsis Video Remote Interpretation Video Remote Interpretation E-ICU & Tele- stroke E-ICU & Tele- stroke

8. E-ICU + tele-stroke ICU mortality rates 20% below predicted 30% reduction in ICU length of stay 50% decrease in Central Line Blood Stream Infections >95% compliance with VAP bundle protocols and corresponding significant decline in VAP cases Tele-stroke trebled the appropriate use of tPa in Arkansas ER setting

9. Sepsis Mortality decrease with people in severe sepsis and septic shock of 50% and 60% respectively Compliance with sepsis bundles increased by 30-40% ICU LOS decreased from 8.16 days to 3.43 days Over 9 months of the program 100 lives were saved.

10. Video Remote Interpretation VRI In 2007, over 55 million Americans spoke a language other than English at home Represents nearly 20% of the population Increased from 14% of the US population in 1990 and 11% in 1980 Less likely to have a usual source of medical care They receive preventive services at reduced rates They have an increased risk of non adherence to medication Children with asthma have an increased of intubation Higher rates of hospitalizations and medication complications Greater resources are used in their care and they have lower levels of patient satisfaction

11. Mercy Health System Tele- Medicine 2012