“We track those patients in quite a sophisticated manner and are very proactive in looking at their compliance with things like refilling their prescriptions, coming in for their doctors appointments, their lab tests,” says Fasano. “If they're connected via our KP network, they're updating their own tests for their levels each day on a self-reported basis.”

Kaiser is also piloting automated tools like pressure cuffs and glucometers that upload results from the patient's home.” Those go through the care registries and we look at this from a care gap standpoint and do reports each day.” These reports, he adds, go directly to the physicians so they can call the patients themselves.

“There is substantial accountability, and the results we're seeing are striking as a consequence,” says Fasano, citing one region cutting its hospital admissions in half due to better managing diabetes complications. “When you consider what these care registries - on top of electronic medical records - can do for you, it's quite powerful,” he says.

Though Kaiser's level of integration and accountability is fairly unique, the care registry tool is not, and is often readily available to the CIO.

“Many more products have this capability than the general public thinks,” says Drazen. “An EHR has the tools to produce lists of patients with certain diagnoses and print out what they've had or haven't had, or are due for or overdue for.”

Schooler points out that although some do, not all enterprise vendors have systems with built-in care management plans, so some hospitals will have to rely on yet another technology that creates yet another integration challenge. Schooler says his Atlanta-based Eclipsys system does have a module called disease manager that he is utilizing in Orlando's oncology cancer center.

Other tools available, according to Drazen, are those for post discharge such as telehealth and home monitoring. Schooler is already using these tools, and plans to ramp things up. Orlando's home monitoring is done through its home health division, but that home health platform is currently not integrated with the hospital EMR.

“The main thing that must occur, at a minimum, is that the technologies that are used for the monitoring and the technologies used for an EMR have got to be able to exchange information,” he says. “We're doing strategic planning now that will call for us to be able to integrate our home health technologies with our MPI and our EMRs, as well as introducing levels of integration and proactive management of those patients that we need to be managing in the home. We're planning it, and it's part of our strategy.”

Part of the difficulty in strategizing is that in addition to a skewed reimbursement model, many say one of the biggest challenges in implementing a chronic disease management program for hospital CIOs is resources.

“They're struggling to do medication reconciliation for goodness sake, let alone, ‘Have you had your foot checked?’ if you're a diabetic,” says Drazen.

According to Drazen, once systems are in place to look across the patient population and find patients that haven't received the proper services, hospitals can do outreach to bring them in - exactly as Kaiser is doing. The problem is often finding someone to make that phone call.

But if a hospital isn't Kaiser, what can it do to approach chronic disease management proactively?

“If you have an opportunity to move it forward you should, and you should be looking for advocates in the community who can help make it happen,” says Drazen. Inside the hospital, she says, the CIO also can look to a physician hospital organization for guidance.

IT tools are available, too, though CIOs often forget to ask about the availability of care-management modules when they are caught up in an EHR RFP.

“Make sure that any EHR you buy includes a module for care planning in the outpatient setting after discharge from the hospital,” advises Sidorov, explaining that a care plan is distinct from a discharge plan in that it is a specifically constructed medical intervention plan directed by experts. The care plan also differs from a discharge plan, he says, in that it needs to be in place while the patient is in the hospital in order for the necessary education to begin. “It's up to the CIOs to specifically look for this module and challenge their vendors to get it in place,” he says. “The hospital is responsible for making sure the follow up is there and that the care plan gets transmitted to whoever is providing care.”

Most agree that the old model of care, which begins and ends within the hospital will soon be a thing of the past, and prevention and management of chronic diseases should be on every CIO's radar. “They need to understand that the future of healthcare is going to call for increased attention to care management outside the walls of the hospital,” says Schooler. “What we're going to have to do is prevent the fire, not just deal with the alarm.”