There is no question that certain kinds of patients, especially those with chronic diseases, can cost a significant amount of dollars to a healthcare provider. According to numbers from the Centers for Disease Control and Prevention (CDC), chronic diseases account for more than 75 percent of the more than $2.5 trillion spent on healthcare in the United States each year. Those who use the CDC’s Chronic Disease Calculator won’t be finding any beautiful equations there.

The need to get these patients the proper preventive services has driven patient engagement efforts across the country. Leaders at the Summa Health System, a multi-hospital, integrated healthcare delivery provider headquartered in Akron, Ohio, are always looking to improve quality outcomes and reduce costs for patients with chronic diseases such as diabetes. David Littlejohn, R.N., is helping to lead the charge in an initiative as the organization’s quality improvement director.

“Diabetics are one of the largest groups of people that take up most of the healthcare dollars,” Littlejohn says. “And there are so many other chronic diseases wrapped up around diabetes.”

Summa, which is a Medicare accountable care organization (ACO), has a history of notable work in improving diabetes outcomes, and ultimately lowering costs. For example, in 2011, the health system audited 29 primary care physicians (PCPs) on various CMS-endorsed clinical quality measures, (HbA1C, LDL, BP Systolic, BP Diastolic) and ranked better than the national benchmarks on all four.

In the realm of patient engagement, Summa has implemented a strategy for its ambulatory care providers. According to Littlejohn, it has brought together approximately 1,400 physicians to use a single database, where outcomes and measures on chronic disease care can be shared. From there, initiatives can be put into practice in the field.

With this data repository, Summa has teamed up with Emmi Solutions (Chicago), a patient engagement software provider which had already provided it with patient education videos, to ensure that diabetic patients of the organization’s physician hospital organization (PHO) are being made aware of certain preventative measures. In its original pilot the measure, Summa focused on was an eye exam.

“We focused on this measure, because the eye physicians aren’t in our network and they do not send back these results directly to us. So we don’t know if the patient has followed up on our recommendation to get an eye exam. Our database is lacking. If we don’t get the claims data from the insurer, then we’re unable to be effective as a PHO during contracting,” Littlejohn says.

Littlejohn says the Emmi solution calls a pre-determined list of at-risk patients, who Summa knows hasn’t been informed of the procedure or hasn’t had it done, and reminds them to take the exam. In the original pilot program, Summa got in touch with 105 patients out of 600, and 24 acted because of the reminder.

“We’re continuing to see results from that,” Littlejohn says, adding there was cost-savings associated with the initiative. Furthermore, the automated call allowed Summa practitioners to focus on more important tasks.

 In the future, Littlejohn would like to see patients contacted through additional avenues such as their cell phone or through email. He says the organization saw success with email reminders when it used them to get patients to view the Emmi patient education videos. Those videos, he says, helped Summa improve its HCAHPS scores.

Littlejohn sees this type of platform being used for other types of preventative services, and he says the organization has already earmarked initiatives for A1c tests, as well a colonoscopy and breast cancer screenings. To make all this happen, he says the central data repository is the most important element.

“You have to have a central data repository to probably be effective with something like this,” Littlejohn says. “Our data repository pulls data from several different sources. It pulls from our specialist groups, from our primary care groups, our internal medicine groups, and all the lab services. And we’re able to see the most recent data for anyone. For this sort of thing to be effective, you have to be on top of your data and effectively manage the data so you can reach out to these people.”