Joon sup Lee, MD is Chief of Cardiology and Executive Director of the University of Pittsburgh Medical Center’s Heart and Vascular Institute. Dr. Lee received his MD from Duke University, School of Medicine in Durham, NC. We caught up with Dr. Lee at MedAxiom’s CV Transforum ’17 to learn about how UPMC’s unique asset structure has allowed it to engage in data-driven value-based-care-initiatives. Dr. Lee leads UPMC HVI, one of the largest care delivery organizations in the country, and gives his thoughts on the efficacy of remote monitoring in smaller vs. large patient populations.
MA: Dr. Lee, thank you for taking some time at this year’s conference to speak with Feats and Heart Beats. It sounds like University of Pittsburgh Medical Center is committed to moving from volume to value based medicine as quickly and efficiently as possible, what is unique about UPMC that is enabling the shift so quickly?
Dr. Lee: I think couple of aspects are relatively unique especially for an organization this size. It is a large health care organization that started as a classic provider organization. It contains within it the brick and mortar buildings and a large number of physicians that were part of the organization under a single umbrella. Also, we added the health insurance arm in 1996 which has grown quite a bit; currently about 40% of the patients are health plan members, so in essence it’s semi capitated.
MA: I see, yes it seems that larger organizations that provide both health insurance and care tend to move towards value based medicine a bit faster.
Dr. Lee: Yeah, it’s more of a natural fit right? Because the entirety of the dollar for health care is under a singular organization and there is less concern about what they are shifting from on pot to another.
Also, UPMC has been aggressive in terms of hiring and buying a lot of post care assets. We have skilled nursing facilities, senior communities and home health organizations all under the umbrella. It really gives us an opportunity to integrate. One of the efforts we’re doing for example is the Skilled Nursing Facility, which is a common discharge location unfortunately for cardiovascular patients. We’ve created a dedicated floor for cardiovascular, post cardiac surgery and post heart failure patients where the nurses are a little more specialized, so we’re definitely making an effort to integrate the whole continuum of care, instead of just saying, ‘we are going take great care of you to make sure you’re going to survive the heart attack but good luck with the rest of that’, right. So you know it’s much more of a continuous type of spectrum.
MA: Saving on costs and maintaining the quality of care, that’s where we want to be heading right?
Dr. Lee: Absolutely
MA: Ok, switching gears for a moment. I’m interested in strategies that UPMC is using to address drivers of readmission and improve outcomes for patients participating in cardiac rehab.
Dr. Lee: Sure, I think there has been an aggressive promotion of cardiac rehab within the organization because we certainly believe that it plays an important role in terms of patient outcome. Unfortunately, that has not been the area that has commanded a lot of focus within most cardiovascular organizations. We think that that has been underserved so we have been very aggressive as an overall organization in terms of promoting that.
MA: Is there any sort of mobile technology that UPMC employs that allows for collection of patient entered data, symptoms/vitals etc.
Dr. Lee: We have something called My UPMC, which is basically an encouraged direct digital link and a communication tool between our patients and our providers. It’s HIPAA secure and so instead of using email and even telephone call it allows truly asynchronous communication with the providers, the physicians, nurses and APP’s with the patients that they can direct.
MA: That sounds handy for a good remote monitoring program. Do you think remote monitoring software has a big role to play in the shift to value based care?
Dr. Lee: Yea, we’re betting pretty big on that. I think if you look across the spectrum, the results of remote monitoring on readmission and hard endooints has been somewhat mixed. Some small programs have had some success but no one has really solved it because if they had we’d all be using that right? We have some important partnerships with some remote monitoring but we’re very focused on selecting the right population. The patient population where that’s going make the difference, we believe that that’s part of the problem.
MA: I see. What population do you feel it would be most effective for?
Dr. Lee: Well, if you pick the sickest population, no model of remote monitoring is going to make them better unfortunately. If you pick the least sick patients, they really don’t need much more resources because they do well any way. So, where is the sweet spot where additional resources spent on remote monitoring can make a meaningful difference? Like everyone else, we are struggling with that a little bit but that’s how we view the data. We don’t have an answer to what that sweet spot is because obviously were talking about utilizing increased resources for this population right, and we can’t afford to do it for every… If you take heart failure for example, we can’t really afford to do it for every patient who has heart failure.
MA: I see, what is the blocker exactly?
Dr. Lee: Well, the remote monitoring programs that we have are relatively resource intensive. They include physical devices that allow remote monitoring, vital signs and how the patients are doing, and then we also have to have personnel that are going take that information, analyze and flag it and then clinical people who are going respond to that. Getting all that data doesn’t help us if we’re not able to make decisions based on that data.
MA: Of course, yes that does sound resource intensive.
Dr. Lee: Right, and one of the advantages of remote monitoring in traditional cardiac rehab is that patients get monitored and they get identified earlier when they are falling into trouble. That’s truly one of the benefits.
MA: True, and as remote monitoring software develops, we will get to a place where the program won’t require so many analysts and clinicians. If the software used algorithms to send alerts, create population reports, other handy features like that; then you wouldn’t need that benefit.
Dr. Lee: Yes, and for now we very much have focused on looking at the parameters and doing analytics that can be auto measured. We want to be able to do it to a large population, I think this is part of the reason that a lot of the remote monitoring trials are very successful. They look at a small population but can’t scale up. You can do a great job if you have a really great study coordinator who’s a very good clinician, that clinician can make the system work. The problem is that only works if you have fifty patients, but what if you have ten thousand patients? That’s very difficult…
MA: I see, what hospitals need is a scalable remote monitoring program; as effective as with 10,000 patients as with 50…makes sense.
Dr. Lee, thank you for taking the time to speak with Feats in Heartbeats. Enjoy the rest of the conference!
Dr. Lee: Great, thank you.