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Deploying
an I.T. Cure for Chronic Diseases |
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By Greg Gillespie, News Editor ,
Health Data Management |
Health care organizations for some time have
struggled to successfully manage patients with chronic
conditions, including HIV/AIDS, diabetes, heart disease
and emphysema. Many patients contract these diseases
later in life, or have problems maintaining new
exercise, diet and drug regimens. Further, a sudden
change in condition can trigger a life-threatening
emergency.
As a result of these and other factors, chronically ill
patients are in large part a high maintenance group that
must be monitored constantly to ensure they maintain
optimum health.
For some provider and payer organizations, the use of
home monitoring devices, the Internet, data mining
techniques and other information technology solutions is
creating a link between patient, caregiver and payer
that enables patients to feed a steady stream of crucial
health information to caregivers.
"Disease management programs offer an extraordinary
opportunity for information technology to enhance the
lives of patients, especially those patients who are
alone or homebound," says John Osberg, president of
Informed Partners LLP, a Marietta, Ga.-based health care
consulting firm. "I.T. presents real possibilities to
increase the quality of care and significantly reduce
the cost of care for these patients."
However, though disease management often is touted as a
major trend in health care, it nonetheless faces serious
hurdles, some industry observers say.
Many provider and payer organizations have created
disease management programs that offer educational
materials and support groups for patients suffering from
chronic conditions. But a smaller number are operating
programs that incorporate case management; and of these,
even fewer are using any technology-bar the telephone-to
foster communication among patients and physicians.
Slow evolution
There are a number of reasons for the slow evolution
of disease management, says Elizabeth Ward, M.D., CEO of
the Seattle-based Foundation for Health Care Quality, a
not-for-profit organization that works to improve health
care practices. Disease management programs are
perceived by some physicians as an intrusion on the
physician-patient relationship. Many disease management
programs are funded by managed care programs, Ward says,
and some physicians believe payers will try to dictate
treatments and second-guess physicians' treatment
decisions. Also, disease management information systems
can be extremely complicated, Ward adds. The amount of
data being collected, and the documentation required for
that data, can be immense. Many provider and payer
organizations cannot find qualified staff or do not have
the information systems required to collect, store and
analyze such data, she says.
"Developing and maintaining disease management programs
requires serious investment, and it's difficult for some
health care organizations, especially smaller hospitals
and group practices, to provide these services," Ward
says.
While these hurdles can be daunting, increasing demand
from patients for easy-to-use and effective treatment
programs likely will compel health care organizations to
increasingly use the Internet and other technologies to
help them more easily operate disease management
programs, says Osberg, the I.T. consultant.
"There's a huge movement toward improving communication
with patients, and that's in large part being driven by
consumer demand," Osberg says. "Health care keeps
thinking of disease management as a program being
sponsored by payers and providers. In the future,
though, it will be driven by patients' demands to have
the option to use technology to keep in contact with
their physicians as well as get real-time help and
real-time information."
Regardless of the hurdles, some provider and payer
organizations are blazing new trails, using technology
to offer sophisticated disease management programs for
large patient populations. These organizations say that
technology has enabled them to provide virtually
real-time, customized care to patients and intervene
quickly when an emergency arises. This not only helps
keep patients healthier but can reduce the amount of
costly emergency treatments patients may require. And
the data collection involved in these disease management
programs can enable the organizations to garner a wealth
of data about their patients to use in outcomes research
and the individual patients' future care. Additionally,
these organizations report, disease management programs
generally make patients more aware of their disease and
more vigilant about maintaining good health.
But even with increased vigilance, danger lurks around
the corner for many chronically ill patients. One wrong
meal or missed workout can cause their health to suffer
and send them to the emergency department.
Most disease management programs rely on telephone calls
to maintain the regular contact that's critical to
success. Some health care organizations, though, have
found the Internet to be a more effective communication
medium. In addition, Internet technologies are enabling
these organizations to react quickly when a patient's
health is threatened.
In 1997, after a liver transplant, John Pickering was
diagnosed with diabetes. He found it difficult to
maintain safe glucose levels and had to keep in frequent
contact via the telephone with disease management nurses
at Fallon Health Systems, a Boston-based managed care
organization that covers 210,000 members in central
Massachusetts. But last September, Pickering started
using an Internet-based disease management application.
Daily routine
A few times each day, Pickering accesses a
password-protected Web site to report his glucose
levels. He also fills out a Web-based questionnaire
about common diabetic problems such as dizziness or
shaking.
The web site system checks his glucose levels to see
whether they fall within safe parameters determined by
his physician. If his readings are outside the
parameters, or if he reports health problems, an alert
is sent via the Web server to the PC of a disease
management nurse, who then contacts Pickering directly
via the telephone.
The Internet-based system also enables Pickering to view
an online graph of his glucose levels over the course of
a given period of time. In addition, the site updates
health information on diabetes on a regular basis,
offering patients the latest educational materials on
the disease.
Being able to monitor his condition daily and get health
information immediately has led to greater control of
his condition, Pickering says.
"This has normalized my lifestyle and helped me
understand how the disease affects me," Pickering says.
"Before, I didn't have the ability to look at it on a
day-to-day basis, and I used to end up in the emergency
room because I wasn't fully aware of how my diet can
impact how I feel."
In addition, the speed and efficiency of the system has
enabled his physician to respond more effectively to any
changes in his condition, Pickering says.
In March, Pickering's glucose levels dropped to
dangerously low levels on a Friday. A disease management
nurse was alerted to the problem via the Internet-based
system and immediately called Pickering's primary care
physician. The physician looked over Pickering's recent
glucose levels and decided to change his insulin level
that day
.
"In the past, I would have ended up in the emergency
room over the weekend, but this time I was able to get
back to safe levels before I had any serious problems,"
Pickering explains.
Tailor made
Internet technologies also can enable provider and
payer organizations to tailor programs for specific
patients and collect huge amounts of data on those
patients.
The advantages of this kind of data collection are
threefold. First, it enables providers and payers to
develop outcomes management programs to better
understand how a disease affects a large population.
Second, it enables physicians to quickly determine the
best treatment for individual patients based on their
medical history. And third, patients can access the data
in real time to check on their progress, which can bring
out the competitive streak in many individuals, says
William Webster, director of the HealthLife program at
the Heart Institute of the Greenville Hospital System,
S.C.
"This is a great way to motivate patients-when they
start seeing how much progress they're making toward
their goal, their motivation goes up and they really
challenge themselves," Webster contends.
The four-hospital Greenville Hospital System recently
launched a disease management program that tracks the
condition of 1,400 patients with cardiac disease. Using
an Internet-based application, the provider organization
maintains a running total of the amount of exercise each
cardiac patient performs. Greenville Hospital caregivers
then provide that information to those patients each
time they visit the Heart Institute.
Each patient enrolled in the delivery system's disease
management program fills out medical history reports and
health satisfaction surveys when they enter the program.
Their physicians at that time set cardiovascular
exercise regimens for them. These regimens are converted
to aerobic miles of exercise. The medical history,
surveys and exercise goals are stored in a file on-line.
Patients visit the Heart Institute-some as often as
three times a week-to use the institute's exercise
machines. After they are through with their workout,
they log onto a PC at the institute, enter their name
and password, and access the system via an encrypted
Internet connection.
The patients enter the information about the duration
and difficulty of their workout. The system converts
that into aerobic miles and tells patients how many
miles they have exercised to date and how they are
progressing toward their monthly goals. It also asks
them a series of questions about their diet, weight, and
smoking and social habits.
Besides the real-time challenge the system presents to
patients, the system also enables the Heart Institute to
generate detailed reports on each patient, Webster
explains. These reports are sent to the patients'
primary care physicians or cardiologists on a regular
basis and are used much like a scorecard, showing each
physician how their patients are doing individually as
well as compared with the rest of the disease management
cardiac population.
In addition, the staff at the Heart Institute also uses
the aggregate data to conduct outcomes management by
studying the data on certain subsets of patients, such
as those who are having problems with their weight and
diet regimens. This enables the institute to get a
better idea how these factors affect the health of the
patients in the disease management program, Webster
says.
"The potential of this information system is limitless
because it enables us to get the data immediately,
research that data immediately, and establish a real
partnership between the patient, physicians and payer
organizations," he says. "Now we can really manage these
cases on an individual basis and ensure everyone knows
how patients are progressing."
Priceless data
Having this type of documented, longitudinal data on
each patient is crucial to manage these types of
diseases, says Ward, the CEO of the Foundation for
Health Care Quality.
"Data collection always has been a tremendous challenge,
and it's even more so when you're setting up these
complicated programs to manage large numbers of patients
that often need to be monitored daily," Ward says.
"There has to be a process for collecting data that
physicians feel comfortable with-they want to ensure
they are getting the important data when they need it so
they can make treatment decisions."
This process is made easier if all the patient
information is being funneled through a centralized
computer-based patient records system, says Homer Chin,
M.D., medical director for clinical information systems
at Kaiser Permanente Northwest, Portland, Ore.
Kaiser Permanente Northwest has 15,000 patients enrolled
in its diabetes disease management program, which
leverages the organization's electronic medical records
system and data warehouse to ensure that its physicians
and other clinicians have the most up-to-date
information about their patients with diabetes.
"We made a commitment to ensuring that all our systems
are integrated into our electronic record and data
warehouse," Chin says. "We don't want to have a
situation where information a case manager or physician
needs is split up in disparate systems."
The integrated delivery system uses a database query
application to identify patients suffering from
diabetes. The application checks the delivery system's
data warehouse on a periodic basis to find patients
using insulin or who have symptoms that indicate
diabetes.
These patient files are then sent to a diabetes registry
database. From there, each patient is assigned to a case
manager, who contacts the patient by phone and sets up a
medication, diet and exercise regime. Further, Kaiser
Permanente Northwest's electronic medical records
system, contains treatment guidelines developed by
Kaiser's medical staff for diabetes treatment
.
When a case manager accesses a patient's electronic
medical record, the guidelines provide them with an
outline for a regimen for that particular patient. For
example, if the patient is over 35 years old, the
guideline recommends they take an aspirin a day, Chin
explains.
Drugs and procedures must be ordered through the
electronic medical records system. The system enables
case managers and physicians to build a longitudinal
record for each diabetes patient that helps them review
past treatments and document any changes in condition.
Each contact with a patient-phone calls, clinical
encounters and prescription refills-is documented in the
medical record by authorized staff members in each
department, such as pharmacy and laboratory.
In addition, Kaiser uses the database query application
to continuously check its data warehouse for patients
who are having problems keeping their blood sugar levels
under control, Chin says. If a patient reports a reading
over a certain level, the application can send an alert
to the case manager and primary care physician that the
patient may need immediate attention. It also checks to
see if the patient is getting the standard care outlined
in the diabetes treatment guideline.
For example, Kaiser can use the query application to
identify patients who haven't had a renal exam in over a
year and alerts case managers and physicians that their
patient may be overdue for a test or procedure.
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