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

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 Virtual Care Care Model Delivery Population Management Center for Innovation Medical Director Operations Director Clinical Ops VP Operations Director Medical Director Operations Director Mercy’s Center for Tele Health and Innovation Virtual Care Center Chief Innovation Officer Centralized HUB Model Decentralized Consult Store and Forward CollaborationCollaboration Chronic Care Management Scheduling Call Center Scheduling Nurse on Call Center Scheduling & referral management Care Coordination Post Acute Care Care Delivery Innovation ResearchResearch GrantsGrants AnalyticsAnalytics 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-Visits24/7E-Visits24/7 Asynchronous Care Home Health Support Support EHR support

5. Tele-Medicine Division Tele – Medicine Virtual Care Centralized HUB Model Decentralized Consult Store and Forward AsynchronousAsynchronous e-ICU e-LTAC Tele-Sepsis e-Hospital 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 Echo’s and EEG’s Radiology Pathology Dermatology 24-7 e-visit support Store + Forward patient visits home monitoring Medical Director Of Critical Care Services & 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 Mercy’s ACO Readiness: Components of Milliman’s study on accountable care organization (ACO) models IMPROVING DELIVERY Impact on Medicare – 8.25% Commercial – 9.61%

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