Software and systems of care empower patients and providers
Chronic disease is a major drain on health care’s human and financial resources. As the leading cause of illness, disability and death in the United States, according to the Centers for Disease Control and Prevention, it accounts for more than three-quarters of health care costs. To better manage these costly and complex diseases, more and more providers are looking at solutions that provide both population-based and patient-specific feedback. The goal is to create systems of care that make greater inroads at a macro level and also improve the lives of individual patients.
Beaufort (S.C.) Memorial Hospital, MaineHealth in Portland, and Presbyterian Healthcare Services in Albuquerque, N.M., are accomplishing this in slightly different ways, but a centerpiece of each initiative is Web-based software that enables case managers and physicians to see individual progress and identify ways of changing processes to improve outcomes across the board.
Each organization emphasizes that IT is merely a tool and that successful chronic disease management is an intense, multifaceted team effort. “You can’t take a disease like diabetes and move a dot on a graph without a lot of focus, a lot of resources and a lot of persistence,” says Dennis Angellis, M.D., chief medical officer for Presbyterian Health Plan.
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Percentage of hospitals providing patients with online care management for the following chronic diseases (average) |
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Presbyterian Healthcare Services, Albuquerque, N.M.
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PRESBYTERIAN HEALTHCARE SERVICES, ALBUQUERQUE, N.M. |
| President and CEO: James Hinton CIO: Donna Agnew Number of beds: 900 Number of employees: 9,500 Number of IT employees: 274 IT operating budget as a percentage of total operating budget: 2.5% IT capital budget as a percentage of total capital budget: 25% |
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Presbyterian Healthcare Services has embraced technology as a way to improve the entire health care experience for patients and make the practice of medicine slightly less complicated, which are meaningful goals in chronic disease populations.
“Any sort of system that enables patients to participate actively in their care, that decreases the burden on the health care system and allows me more time to educate my patients is something we’re going to consider,” says David Scrase, M.D., executive vice president and chief operating officer. Scrase also maintains an internal medicine practice at Presbyterian.
One of the main ways Presbyterian uses technology to benefit both patients and providers is through Presbyterian Health Plan’s (PHP) chronic disease management program, which involves about 20,000 members who have diabetes, asthma or coronary artery disease. The program includes a cluster of resources both visible to patients and behind the scenes. A major component is PHP’s contract with LifeMasters, a disease management company. LifeMasters case managers use administrative data and test results to educate patients and help them monitor and improve their health. The system features online, interactive voice recognition and telephonic communication.
Patients receive monthly progress reports on key indicators such as hemoglobin A1c levels. Their physicians receive quarterly reports, with more frequent updates from case managers when problems arise. Physicians also receive blank reports for nonparticipating patients. The latter “help us create systems in our offices so that we can address those patients,” Scrase says.
PHP uses a light touch to help practices struggling with below-average outcomes. For instance, in 2008 it expects to have a multidisciplinary team visit about 85 practices with less-than-optimal performance. “We don’t tell the doctor what to do, and we don’t blame them. Our goal is to find out what’s going on in the practice and find ways to support them,” explains CMO Angellis. The health plan awards $10,000 bonuses to practices with the best overall performance and with the greatest improvement in chronic disease measures.
PHP also uses a predictive modeling program to identify and engage patients who, based on utilization and diagnosis patterns, appear likely to develop chronic diseases. Angellis estimates the disease management efforts save between $5 million and $10 million per year. They’ve made their mark on the health status of PHP members, too: In 2003, 65 percent of PHP patients with diabetes had poor control of their diabetes; today, only 20 percent of those patients are not in good control.
Physicians in Presbyterian Medical Group also can avail themselves of the disease registry DocSite, which provides online access to national clinical guidelines and enables practices to track chronic disease outcomes for non-PHP member patients. Presbyterian is in discussions with a statewide coalition to implement this system for doctors throughout New Mexico.
In May 2007, Presbyterian launched Pres e-Care, an online portal for prescription renewals, appointment scheduling and virtual appointments. Although the system is not just for chronic disease patients, it offers yet another venue for such individuals to have convenient and timely access to their primary care providers. In addition, Presbyterian Home Healthcare has approximately 100 chronic disease patients in a telehealth program, with live Web- and telephone-based video visits.
The various portals reflect Presbyterian Healthcare Services’ strategy to create a cohesive resource for patients and PHP members. “It’s part of a multiyear road map to drive automation, increase self-service and provide a more seamless and comprehensive experience for our patients,” according to Keith Rivera, e-business director.
Beaufort (S.C.) Memorial Hospital
| Vital Statistics BEAUFORT (S.C.) MEMORIAL HOSPITAL |
| President and CEO: Richard K. Toomey Vice president and CIO: Kathy Ross Number of beds: 197 Number of employees: 1,000 Number of IT employees: 19 IT operating budget as a percentage of total operating budget: 2.1% IT capital budget as a percentage of total capital budget: 31% |
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Beaufort Memorial Hospital is using online tools to enhance its diabetes care and cardiac and pulmonary rehabilitation programs, and to leverage them as part of a broader community wellness effort. “This is only the starting point. The Low Country [South Carolina’s coastal counties] is challenged in terms of health status, and technology is a tool that will help us continue to meet the need for chronic disease management,” says Richard K. Toomey, president and CEO.
The effort started modestly when Beaufort created a database to track health-improvement action plans for patients enrolled in cardiac, pulmonary and diabetes management programs, as well as for members of its LifeFit Wellness Center. Early on it became clear that the homegrown product wasn’t adequate, and Beaufort contracted with Intervent USA, a lifestyle intervention delivery system now part of Nationwide Better Health. Beaufort case managers use Intervent software to develop guideline-recommended action plans and track outcomes for individual patients. Interactions are mainly between case managers and clients, but primary care physicians receive reports via hard copy, e-mail or fax, depending on physician preference.
The initiative has had a tangible impact on the health of participants: Those most at risk who go through Beaufort’s disease management program lower their 10-year odds of developing heart disease by 40 percent, according to Mark Senn, senior director of LifeFit wellness services. Beaufort’s Intervent application also has boosted the efficiency of its overall disease management efforts. Before the wellness center opened, the diabetes, pulmonary and cardiac rehabilitation programs “existed in silos. There was no synergy between them and no cross-referrals,” Senn says. “If a patient who was also diabetic went to the cardiac rehab program, they wouldn’t have been referred to the diabetes-care program. Now it happens automatically.”
Use of the Intervent software also has boosted the efficiency of the combined wellness and disease management programs. “We’re seeing 10 times more people and achieving better outcomes than before,” Senn says. Beaufort recently purchased wireless tablet computers so that case managers can update action plans and review test results in real time while working with clients. Case managers also earn incentives based on the success of their clients.
The integrated, intensive approach has produced financial benefits. The wellness center, which is open to Beaufort’s employees, has saved an estimated $400,000 in health premiums, according to Senn. Beaufort officials hope their own experience with lower premiums will entice other local employers to sponsor the programs for their workers, says Pat Foulger, vice president of quality and risk. Foulger is a walking testimonial for the wellness center’s risk-management impact, having lost 54 pounds since joining the center.
Beaufort now is taking the first steps toward expanding disease management beyond the confines of its facility. It is piloting a fee-based distance mentoring program with a local gated community that will include online, telephone and face-to-face interactions with case managers. A free-of-charge, online-only version also will be offered.
Mainehealth, Portland
| Vital Statistics MAINE MEDICAL CENTER, PORTLAND |
| President: Vincent S. Conti CIO: Stephen Rosenfeld, M.D. Number of beds: 606 Number of employees: 5,670 Number of IT employees: 145 IT operating budget as apercentage of total operating budget: 4.5% IT capital budget as a percentage of total capital budget: 20% |
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MaineHealth’s foray into online chronic disease management started with the vision of Lisa Letourneau, M.D., senior director of clinical integration. While taking a graduate course on quality, she realized that to affect chronic disease outcomes, “we needed to stop waiting for the EMR. It seemed to be a rolling two-to-five years away. That’s when I started developing the concept for a Web-based registry,” she says.
Letourneau began building support for her idea of a Web-based clinical information registry (CIR), which would give physicians a secure way to consolidate and track important clinical information on patients with chronic diseases. Physicians would have ready access to patient and practice-specific trend reports for individuals with asthma, cardiovascular disease, depression and diabetes. The CIR would be the foundation in a system of support for practices in the physician hospital organization affiliated with MaineHealth’s flagship facility, Maine Medical Center (MMC-PHO). Other elements included nurse case managers who would provide one-on-one patient education and motivation on-site at physician offices, and a quality rewards program to encourage top-performing practices.
The concept seemed perfect for the situation. The practices in the MMC-PHO were spread over the rural hinterland, and some had not implemented electronic medical records. Plus, the state of Maine had the fourth-highest rate of chronic disease in the nation, a circumstance that called for creative solutions.
“We invested in this because it addresses needs outside the four walls of the hospital and supports our physicians in caring for chronically ill patients,” says Vincent S. Conti, president and CEO. “By going one step upstream from hospitalization, we’re improving outcomes in the community, which is consistent with the mission of the hospital.”
The project started on a shoestring. Letourneau found a chronic disease registry that was in the public domain, but updating it was a chore, so the decision was made to develop a solution internally.
“The commercial products were not as well-developed [in 2002 and 2003], and we felt it would be easier for two IT people [at Maine Medical Center] to develop it than to tell 70 to 90 physician practices, ‘You must pay for [this software].’ Maybe the cost would have been the same, but the approach was different,” Letourneau says.
The resulting CIR and related support mechanisms since have been embraced by MMC-PHO physicians, although not without some pains along the way.
“Our biggest challenge has been sustaining it in the practices because of the added burden on providers’ workflow,” says Stephen Rosenfeld, M.D., CIO of MaineHealth and Maine Medical Center. Because practices are required to input data in both their EMRs or charts and the CIR, MaineHealth provided technical assistance and supplemental staffing during implementation to ease the burden on each practice. This was partially funded by third-party payers, which recognized the value of supporting such an endeavor, according to Rosenfeld.
The system has made a real difference in patient outcomes. For instance, patients with optimal control of diabetes rose from 16 percent in 2004 to 25 percent in 2006. Those with poor control declined over the same period from 46 percent to 36 percent. In Rosenfeld’s mind, the greatest impact has been in enabling physicians to raise the standard of care across a population of patients.
“Three years ago, any of our doctors would have felt honestly they were taking good care of patients with chronic diseases, but in the context of seeing patients, the information [they] needed to know whether that was really true wasn’t there,” he says. “Now they can see it, and it’s changed their approach.”
Gina Rollins is a freelance writer based in Silver Spring, Md.
This article first appeared in the Winter issue of HHN's Most Wired Magazine.
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