1. Monitoring a patient’s quality of care and recovery while at home following discharge from hospital. Dr John Semple QoC Health

2. Disclosure Shareholder in QoC Health which is business built around the technology platform discussed here. Surgeon in Chief at Women’s College Hospital.

3. Changing Health Care Paradigms Old model centred on large health care institutions with intensive resources and a mandate of being all things to all people. New models of ambulatory care pushing the envelope by minimizing length of stay and utilizing new surgical technologies. 80% of all surgical procedures in North America are done as ambulatory cases. Growing trend of expedited discharge.

4. The Landscape as Supported by ECFAA and the Drummond Report: There is a need to: Reduce inpatient length of stay and expediting discharge Increase ambulatory surgeries (currently 80% of surgical procedures in North America are ambulatory) Improve continuity and transitions of care Improve patient empowerment and involvement in care Monitor quality indicators and improve care Improve system efficiencies and patient flow Reduce unnecessary admissions Leverage existing technologies to enhance patient care Shift care from the hospital to the community

5. Women’s College Hospital Oct 2010- became totally ambulatory No in patient beds Patients could stay 23 hrs (overnight) We measure length of stay (LOS) in hours where as other hospitals measure LOS in days. Specific ambulatory surgical programs, innovative models of care. Critical mass of surgeons with primary ambulatory surgical practice and cross appointed at an in patient facility.

7. Discharge time by date of surgery

8. Post Operative Experience at Home First 30 days post op are key. Readmissions Unexpected visits to ER, Undetected complications Patient satisfaction Quality of care Quality of Recovery

9. What intentions or novel developments are we pursuing or considering investing in that would represent true clinical innovation? we will use a mobile/smartphone/tablet platform solution which will provide an innovative method to reliably assess the quality of recovery using a modified questionnaire (QoR-9). The goal is to improve the relationship between patients and health care providers leveraging emerging technologies. The instrument focuses on five dimensions; emotional state, physical comfort, psychological support, physical independence, nausea and pain.

10. Figure 1. The quality of recovery score (QoR Score). Myles P S et al. Anesth Analg 1999;88:83-90 ©1999 by Lippincott Williams & Wilkins

11. Mobile Technology for Monitoring Patient Recovery at Home: Patients The QoC Patient Direct Platform: Patients provide daily feedback on standard areas of recovery such as pain, nausea, anxiety, and custom indicators specific to diagnosis Patients take daily pictures of surgical wound sites Patients access educational information on their procedure and recovery along with key health team contacts *The following examples and screenshots are from use of the QoC mobile technology at Women’s College Hospital (WCH)

12. The Patient Application On loading and Telemetry Platform

13. The Patient Application Examples of Indicators Touch screen: Likert questions and sliding scale for pain and drain indicators

14. Mobile Technology for Monitoring Patient Recovery at Home: Care Providers The QoC Health Care Provider Portal: Care providers log into a secure web portal to access the patient feedback on indicators and daily pictures Care providers can act on declines in patient condition before the first scheduled follow-up visit Care providers can eliminate or extend time periods between follow-up visits if recovery indicators are trending positively *The following examples and screenshots are from use of the QoC mobile technology at WCH in the breast reconstruction population

15. Care Provide Portal Viewing Daily Patient Results List of patients showing indicators with red flags A patient’s results showing picture stream and indicators

16. Care Provide Portal Viewing Daily Patient Results Snapshot of a sample of list of patients with red flags

17. Care Provide Portal Viewing Daily Patient Results Snapshot of a patient’s results with photo stream and indicators

18. Care Provide Portal Viewing Daily Patient Results Snapshot of a patient’s results with photo stream and indicators

19. Care Provide Portal Viewing Daily Patient Results Snapshot of picture quality and ability to zoom in for better examination

20. Care Provide Portal Viewing Daily Patient Results Snapshot of a patient’s results with photo stream and indicators

21. Care Provide Portal Viewing Daily Patient Results Snapshot of an indicator spark line showing trend over time

22. The QoC Patient Direct Platform is currently being piloted at WCH 3 surgeons, 60 patients (30 breast reconstruction, 30 orthopedic) The pilot focuses on the 30 day recovery period post discharge Patients are from urban, rural, and remote geographic areas Preliminary results show that 70% of patients presented excellent recovery results and could have foregone a follow up visit In 5% of patients, the surgeon was able to identify wound redness and separation based on the photo stream, allowing earlier treatment and avoidance of worsening conditions for the patient The Women’s College Experience

23. Benefits of Monitoring Quality of Care and Recovery Post-Discharge For the Patients: Improved Quality of Care through monitoring of recovery at home Early identification of developing complications Easy electronic access to educational materials For the Physicians: Daily reports on patients recovery at home Report flags to quickly identify complications Ability to tailor care based on individual patient need For the Hospital: Improved efficiencies through enhanced scheduling of follow-up visits Reduction in unscheduled visits/admissions Access to post-discharge recovery data: trending, benchmarking, best practice

24. Private, Secure, Scalable, Modern Architecture Designed from the ground up to ensure security and privacy Designed to conform to leading healthcare audit and interoperability standards including PHIPA, HL7, ITIL and SAS70 Multiple layers of encryption, including resting state AES encryption, in transmission content encryption using unique per patient public / private key pairs, and in transmission TLS/SSL protocol encryption Modern infrastructure design leveraging distributed infrastructure as a service (IaaS) and cloud computing services (SaaS) for seamless accessibility, redundancy and scalability

25. Data Data from 30 day post op recovery period-new Quantitative – QoR 30+, 450 points of data Individual, procedure/treatment/pharma, population, aggregate. Who owns data? patient, care providers, public access. Qualitative- photo stream- – sequential, comparative (intra/inter) and contextual.

26. Linking Back to The Landscape The Mobile QoC Patient Direct Technology Supports: Reducing inpatient length of stay and expediting discharge Increasing ambulatory surgeries (currently 80% of surgical procedures in North America are ambulatory) Improving continuity and transitions of care Improving patient empowerment and involvement in care Monitoring quality indicators and improve care Improving system efficiencies and patient flow Reducing unnecessary admissions Leveraging existing technologies to enhance patient care Shifting care from the hospital to the community

27. Summary Growing trend of expedited discharge. New models of ambulatory care pushing the envelope by minimizing length of stay and utilizing new surgical technologies. Smartphone/tablet platform solution which will provide an innovative method to reliably assess the quality of recovery thru the transition from hospital into the home.