According to a recent report from Agency for Healthcare Research and Quality (AHRQ, Rockville, Md.,) chronic diseases account for three quarters of the all national healthcare expenditures. Despite efforts, most Americans continue to receive care only for acute episodes. But change may soon be coming for these conditions.
“Meaningful use is very likely to require chronic disease management,” says Erica Drazen, Sc.D., partner in the Emerging Practices Group at Falls Church, Va.-based CSC. “I think this trend is related to payment reforms, and that's what's going to really motivate hospitals.”
Currently, many still view chronic disease management as coming under the purview of primary care. “I can't blame CIOs for feeling this is an ambulatory issue, especially when under the current DRG system the whole point of hospitalization is care in the hospital,” says Jaan Sidorov, M.D., Quality and Research Committee member and former board member of DMAA: The Care Continuum Alliance (Washington, D.C.). “That doesn't mean that the team of healthcare professionals doesn't have the responsibility to take care of the patient on a more global basis.” Sidorov maintains that the episode of care in the hospital should fit with what has happened before and after discharge.
Though still in its early stages, using IT for hospital-based chronic disease management (sometimes called disease or care management) is already being embraced by forward-thinking CIOs as a way to protect the bottom line while improving the health of patients.
One leader who sees the so-called writing on the wall is Rick Schooler, vice president and CIO of the eight-hospital Orlando Health system in Florida. “Care management is a new term for us,” says Schooler. “It's the way we're looking at our future in terms of our strategies to ensure that we don't have patients coming back to our hospitals for readmission for something that could have been handled proactively in the home.”
The problem until now is that, with a fee-for-service model, there has not been a business case for hospitals managing chronic care outside their four walls. But as Medicare moves to penalize hospitals by reducing payments for readmissions within a certain time frame, the business case is coming into focus.
“You haven't seen a lot of this because, quite frankly, it's not something that hospitals could make money at - the more patients come back, the more we admit and the more we get paid,” says Schooler. “It all comes down to the money.”
Schooler says he believes that dynamic will change as reimbursement models come into play which ding hospitals for having an out-of-sight, out-of-mind policy toward their patients. “Traditionally these are not money making services,” he says. “What they are going to be in the future is a way to prevent losing money because there will likely be no reimbursement for readmissions like this.”
There are exceptions, of course - most cite organizations with better-aligned payment paradigms like California healthcare giant Kaiser Permanente as an example of an institution that has found success. Phil Fasano, senior vice president and CIO of Kaiser, says it's all about mission and vision. “We're a preventive care organization and chronic disease management is just part of who we are,” he says. “It's part of the culture.”
But are hospitals, besides leading edge IDNs like Kaiser, beginning to take ownership of chronic disease management? According to Drazen, the answer is not yet - even with healthcare reform looming. “Unfortunately, not that many hospitals are thinking that far ahead, so they may do some things with ARRA money that don't help them respond to becoming an accountable caregiver,” she says. “The people really doing things are accountable care organizations already, like Kaiser.”
But Sidorov says he believes a shift is coming. “What I'm seeing nationwide is a greater emphasis on hospitals and their networks of primary care providers being turned into accountable care organizations,” he says. “The line that separates the outpatient care from the inpatient is breaking down; IDNs like Kaiser and Geisinger make sure that the transition is as seamless as possible.”
So how does Kaiser provide that seamless transition to ensure that chronic diseases are properly managed? In addition to the culture of the organization, of course, a big component is Kaiser's Epic (Verona, Wis.) electronic record - the central repository for the entire patient relationship, available to inpatient and outpatient providers, and to the patients themselves.
In addition to Epic, Fasano says Kaiser has created care registries - analytics tools used to support clinicians dealing with chronic conditions like diabetes - based on rules developed at Kaiser. Fasano says the registries are a suite of tools the organization built that analyze its data in Epic against Kaiser's evidence-based medicine preventive care protocols.
“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.”