As the number of people with chronic conditions continues to grow, so too, does disease management (DM). The trend of DM is moving forward through increased identification, stratification and patient involvement. The trend is part of what Vince Kuraitis, founder and principal at Boise, Idaho-based Better Health Technologies LLC, calls "a redesigning in healthcare" regarding the move from an acute and episodic focus to the management of a lifelong condition.
In order for that transition to take place a series, the proper technology infrastructure is essential.
More and more, there is increased recognition that DM parallels other healthcare trends. "Typically you're working with people who are already high-cost individuals who may have a number of diseases, but the process of preventing disease and using prevention and wellness is the same," says Kuraitis. DM, he says, should not be thought of in and of itself, but as part of a continuum, part of a broader process of care.
For Ed Wagner, M.D., director of the Seattle-based MacColl Institute for Healthcare Innovation at the Center for Health Studies, Group Health Cooperative, "A critical element of good chronic disease care, good prevention care is the ability to look at your whole population." Having well-populated and properly managed data warehouses is key.
Electronic medical records (EMRs), dense databases and key registry functionality enable physicians to better care for their patients and keep a competitive edge while benchmarking themselves and providing transparency, as pay-for-performance (P4P) measures and consumer-driven healthcare gain speed. "Computers give you the ability to look at your whole practice, see how you are doing and see which patients need more attention," Wagner says. Patient portals are also important to managing chronic care.
Behind patient involvement are clinical electronic alerts based on best practices and evidence-based medicine. Through a series of reminders, physicians can be alerted to check for patient compliance, thus ensuring patient involvement. Technology alerts may also be used to signal patient non-compliance or danger at home.
The first step in the DM trend is deciding which members to include and how best to identify and stratify them.
At the Visiting Nurse Association (VNA) of Southeast Michigan in Oak Park, DM began in 2002, with congestive heart failure patients, which was one of its largest patient populations. After a small pilot with 32 patients, the organization was so pleased with the results that in September 2005 it added three more — diabetes, hypertension and chronic obstructive pulmonary disease (COPD) — and made DM a standard of care for these conditions. Since then, it has served 600 patients in the program.
"By monitoring their vitals it's almost as if we get advanced warning of what's happening within the body," says Gloria Brooks, chief operating officer at VNA of Southeast Michigan. To monitor patients, the VNA uses a device that can measure weight, blood pressure, blood oxygen and glucose levels in the home. When COPD patients' weight creeps up, perhaps signaling that the lungs have filled with liquid, they should expect a call from a nurse.
Presence in absence
According to Brooks, DM allows the nurses to be there, without really being there. It also requires patients to manage their own illnesses, hopefully keeping them out of the emergency room. "It's all about choices," Brooks says. "It starts to make a real 'connect the dots,' in what you're doing, what you're eating or not eating, and how that impacts your diagnosis."
Part of the IT of facilitating chronic care improvement goes to system management.
"If you really want to create mass personalized care, the key is to have the care be about the people who have diseases, not the diseases that people have," says Paul Wallace, M.D., medical director for health and productivity management programs at Kaiser Permanente's Permanente Foundation in Oakland, Calf. "The real leap," he says, "is taking everything we know about disease and flipping it around to understand the interrelatedness of those diseases and their management when they occur in real people."
The "demographic imperative" of DM, as David Nash, M.D. — chairman in the department of health policy at Philadelphia's Jefferson Medical College — says, is made up of a number of factors.
The first, he attributes to the increased number of patients with multiple chronic diseases and aging baby boomers, which he says stems from the ability to prolong life, "resulting in tens of millions of persons with multiple chronic illnesses." The second imperative, he says, is a system that is a non-system. It is "a healthcare system that pays for piecework and wonders why there is no coordination." The third, Nash says, is the role that consumers play in their own healthcare.
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