Cardinal Health, Inc. · NYSE:CAH
Cardinal Health — Investor Presentation (August 2013)
42 slides from Cardinal Health's investor presentation, Aug 9, 2013
Slide 1: Coagulation Management Programs: Best Practices to Drive Outcomes
Coagulation Management Programs Best Practices to Drive Outcomes Michael A. Evans, RPh Director, Ambulatory Clinical Pharmacy Programs System Therapeutics Geisinger Health System Friday, August 9th , 2013 2 p.m. EST
Slide 2: Objectives
Objectives • Provide an overview and history of Geisinger Health Systems • Describe how and why the Geisinger Anticoagulation Clinic was established and how it has evolved • Share Systematic Anticoagulation Management Best Practices • Process • Technology Options • IT • Discuss critical success fact
Slide 3: Overview of Geisinger
Overview of Geisinger • Not-for-profit organization established in 1915 • Provides complete continuum of health care to more than 2.6 million people in 44 Pennsylvania counties • 6 hospitals/medical centers • 49 primary care and specialty clinics • 14 retail pharmacies • Urgent care clinics • Home c
Slide 4: Mission Statement
Mission Statement Enhancing quality of life through an integrated health service organization based on a balanced program of patient care, education, research and community service. |4
Slide 5: Geisinger recognition and awards
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Slide 6: Geisinger Health System coverage area
Geisinger Health System coverage area Revised 7‐25‐12. Geisinger PR & Marketing Department
Slide 7: Why Focus on Anticoagulation Management?
Why Focus on Anticoagulation Management? • Patient population costly to care for • Cost avoidance • Readmissions • ER visits • Hospitalizations • Prevention of adverse events • Pharmacists understand kinetics of Warfarin • How to manage drug and diet interactions • How to educate patients on diet an
Slide 8: Getting the Process Started
Getting the Process Started 1. Identified need and initiated request to start a clinic 2. Declined initially by Medical Executive Committee 3. Head of Neurology agreed to be champion 4. Began 100 person study which lasted 6 months 5. Outcomes were very positive 6. Received support from the Med Exec
Slide 9: Where are GHS programs today?
Where are GHS programs today? • Anticoagulation Management Program Started in 1996 31 practice Now over 40 locations across Over 13,500 with 3 Pharmacists the GHS Active Patients Pharmacists service area 70% INRs EPIC within Standardized 41,670 Total Coagulation therapeutic Protocol Patients Module
Slide 10: Process
Systematic Anticoagulation Management Process Technology IT Outcomes Aligning with Healthcare Reform Objectives | 10
Slide 11: Driving Process Efficiency – Why Point of Care?
Driving Process Efficiency – Why Point of Care? • Venipuncture was only reliable method • Venipuncture is multiple step process • See graphic of Lean Process slide 14 • Patient check in at facility laboratory • EHR medical record release into LIS • Generation of tube label • Process specimen for cou
Slide 12: Driving Process Efficiency – Why Point of Care?
Driving Process Efficiency – Why Point of Care? • Best case total process time via venipuncture is 6 hours if facility has a lab on site to process the INR • Most typical follow up time with the patient is the day following the lab test • Involves several phone calls with possibility of patient misu
Slide 13: Driving Process Efficiency – Why Point of Care?
Driving Process Efficiency – Why Point of Care? • Transitioned from Venipuncture to POC once POC methods correlated with lab results • Face-to-face interaction drives better outcomes and increased patient satisfaction • Typical visit lasts 10 minutes (see process slide 14) | 13 Process Technology IT
Slide 14: Side by Side LEAN Process Mapping: PT-INR
Side by Side LEAN Process Mapping: PT-INR Point of Care System Coumadin Clinic Stago (Danville Clinic) | 14 Process Technology IT Outcomes Alignment
Slide 15: Driving Process Efficiency – Why Point of Care?
Driving Process Efficiency – Why Point of Care? • Service can be billed for • Increased patient satisfaction • The POC design has been copied to 31 clinic sites in the Geisinger Health System • In-person visits increase patient medication adherence • Full medication reconciliation performed at each
Slide 16: Workflow: Anticoagulation/MTMP Care Process Summary
Workflow: Anticoagulation/MTMP Care Process Summary 1. Any Geisinger patient is eligible. 2. Patients identified for enrollment via provider referral and during hospital discharge/admission process. 3. Referrals sent electronically to central referral pool, patients scheduled within 24 hours. 4. All
Slide 17: Workflow: Electronic Medical Record Benefits
Workflow: Electronic Medical Record Benefits 1. Warfarin Best Practice Alert (BPA) • Notification when a provider orders a warfarin-interacting medication. • Anticoagulation pharmacists make appropriate dosage changes 2. Patient List Membership and Missed to follow-up report. • All patients part of
Slide 18: Technology
Systematic Anticoagulation Management Process Technology IT Outcomes Aligning with Healthcare Reform Objectives | 18
Slide 19: Selecting the Right POC Coagulation System
Selecting the Right POC Coagulation System | 19 Process Technology IT Outcomes Alignment
Slide 20: Selecting the Right POC Coagulation System
Selecting the Right POC Coagulation System • PT/INR results from POC testing device showed high bias when compared to venous PT/INR • Investigation into the device was not definitive • Study performed at 3 GHS Anticoagulation Clinics in 3 different Geographic Locations • Compared ISTAT (Abbott), Coa
Slide 21: Selecting the Right POC Coagulation System: Methods
Selecting the Right POC Coagulation System Methods • Pharmacist performed 2 different fingersticks on the patient • FS performed on the same hand but different fingers • Used 2 different lancet devices • Similar in length and depth but not identical • BD brand for ISTAT • CoaguChek brand for the Coa
Slide 22: Selecting the Right POC Coagulation System: Results
Selecting the Right POC Coagulation System Results • Pharmacist clinical decision impact was assessed • Would the dose of warfarin be adjusted based on the result without knowing the venous PT/INR • Table 1- Clinical impact of POCT INR results vs. Stago Warfarin dose Venous INR POCT INR POCT INR adj
Slide 23: Selecting the Right POC Coagulation System
Selecting the Right POC Coagulation System • CoaguChek showed a lower magnitude of bias than the ISTAT • A two-fold better comparability with results within TEa tolerance • A four-fold lower adverse clinical impact with respect to avoidance of unnecessary medication adjustments • Decided to replace
Slide 24: Systematic Anticoagulation Management
Systematic Anticoagulation Management Process Technology IT Outcomes Aligning with Healthcare Reform Objectives | 24
Slide 25: Solving the Data Management “Problem”
Solving the Data Management “Problem” • Important decision in choosing a POC device is to have direct interface with our EHR • Decrease documentation and translation errors • Geisinger worked with EPIC to develop custom Anticoagulation Navigator • For reporting and stream lined documentation • Curre
Slide 26: Data Management Systems Architecture
Data Warehouse Management EMR(s) Systems Medical Case Mgmt Core Information: Integrated e.g. Drug MTM* References Operational Management Acute Care Clinical Data Dispensing Pharmacy Total Cost of Systems Retail Care Pharmacy Data Home Infusion Specialty Pharmacy Financial Data Drug Purchases Reporti
Slide 27: Outcomes
Systematic Anticoagulation Management Process Technology IT Outcomes Aligning with Healthcare Reform Objectives | 27
Slide 28: Geisinger Anticoagulation Clinic – Patient Impact
Geisinger Anticoagulation Clinic – Patient Impact Comparison of GHS Anticoagulation Management Service with Literature Incidence of Adverse Events Usual GHS Non- Reference Practice (non- Anticoag GHS Anticoag Anticoag GHS Clinic Clinics (1) Clinics (2) Patients)* Patients (3) Rate of Bleeding 8.21%
Slide 29: Other Key Patient Measures
Other Key Patient Measures • Time in Therapeutic Range • 70% of INR’s within TTR • All diagnoses, patients, and disease states • 82% adherence rate to medications • Patient Satisfaction (Surveys completed every 6 months (98-99.5% satisfaction) • Provider satisfaction completed annually | 29 Process
Slide 30: Cost of Care
Cost of Care Medication for 30 Laboratory Medication days monitoring management Total Warfarin=$3.66 $80 $40 $124 Dabigatran=$300 n/a n/a $300 Rivaroxaban=$300 n/a n/a $300 Apixaban=$300 n/a n/a $300 | 30 Process Technology IT Outcomes Alignment
Slide 31: Reversal Agent and Cost Implications
Reversal Agent and Cost Implications Agent FFP+PCC PCC+rFVIIa aPCC FFP(15ml/kg) $300 n/a n/a 3-factor PCC(25units/kg) $1900 $1900 n/a rFVIIa(20mcg/kg) n/a $2800 n/a aPCC(1000units) n/a n/a $1800 Cost $2200 $4700 $1800 Assumes 80-kg patient and rounding to nearest vial size. • Acquisition cost (avera
Slide 32: Drug Therapy Compliance
Drug Therapy Compliance • MTM patient compliance • Average compliance with warfarin therapy 82% • Comparison <50% for non-MTM managed patients Process Technology IT Outcomes Alignment
Slide 33: Stroke Prevention
Stroke Prevention • Patients with AF have a stroke risk of 4.5% per yr, which anticoagulation reduces to 1.4% per yr. (70% relative risk reduction with warfarin therapy). • Patients with additional risk factors (e.g., age >75 years, hypertension, heart failure, or diabetes) have an increased stroke
Slide 34: VTE Costs
VTE Costs • The total annual health care cost for a VTE range from $7,594 • To $16,644, depending on the type of event • And whether it was a primary or secondary diagnosis | 34 Process Technology IT Outcomes Alignment
Slide 35: Bleed Costs
Bleed Costs 45 approx. $40,000 40 35 30 25 20 15 $11,000 10 5 0 Mean Health Care costs Approx. of GI Bleed Intracranial Hemorrhage | 35 Process Technology IT Outcomes Alignment
Slide 36: Anti-Coagulation Program Critical Success Factors
Anti-Coagulation Program Critical Success Factors • Standardized process across clinics • Ensures safety, efficiency and accuracy • Centralized referral process for all patients • Every patient has a future scheduled appointment • Systematic patient follow-up reporting • Every Sunday a list is gener
Slide 37: Anti-Coagulation Program Critical Success Factors
Anti-Coagulation Program Critical Success Factors • Pharmacist role in delivering collaborative care • First anticoagulation, now expanding to other critical areas. • Collaboration for patients with diabetes, for example, has helped drive 64% of patients A1C’s to goal • Leadership support – CEO, CMO
Slide 38: Drive Change in your Chronic Disease Management Programs
Drive Change in your Chronic Disease Management Programs • Lead with principles in all discussions. (patient first, use of best practice, elimination of unjustified variation, waste, redundancy) • Inclusive, collaborative decision making processes at all levels • Meetings with clinical departments,
Slide 39: Aligning with Healthcare Reform Objectives
Systematic Anticoagulation Management Process Technology IT Outcomes Aligning with Healthcare Reform Objectives | 39
Slide 40: Essential needs to become an Accountable Care Organization (ACO)
Essential needs to become an Accountable Care Organization (ACO) • Integrate hospital and physician care Patient • Align incentives to meet quality Experience measures and reduce spending growth; share in the savings Health of at- Care Risk or Coordination Elderly • Accountable for quality, cost, AC
Slide 41: Key Takeaways
Key Takeaways • Effective processes, the right technology and integration with IT Systems is critical to a successful coagulation management program • An organized anticoagulation management program can drive substantial clinical effectiveness at a reduced overall cost, and should have increased emp
Slide 42: Thank you for attending!
Thank you for attending! We value your opinion and ask that you provide feedback by participating in a brief online survey. A recording of this webinar and corresponding slide deck will be available soon. Look for a follow up email with information. If you have any additional questions or comments,
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