Hospitals Experiment with Disease Management Tools

HIT Innovations Help Health Systems Find Way in New Environment

Hospitals and health systems are beginning to more carefully craft care plans for patients with chronic conditions such as diabetes, depression, heart disease, lung disease and cancer that seek to engage the patient in his or her own care as well as readying themselves for pending changes in reimbursement that looks to tie the achievement of care goals to payment.

Alan Snell, MD, CMIO of St. Vincent Health in Indianapolis, is busy expanding the reach of the 18-hospital system’s disease management program. Following the strategic plan laid down by St. Vincent’s parent, Ascension Health, the Indiana system is trying to improve the management of such chronic conditions as depression, diabetes, heart disease, lung disease and cancer. While much of the action is taking place in St. Vincent’s ambulatory-care clinics, which use Allscripts’ electronic health record, the program also will involve its acute-care facilities, which are in the process of implementing Eclipsys’ Sunrise Clinical Manager.

“Patients with chronic diseases can have five to seven physicians caring for them at the same time, and where mistakes are often made is in handoffs between inpatient and outpatient settings,” notes Snell. “So medication reconciliation in transitions of care is very important, and making the medication lists readily available electronically is a goal of ours.”

St. Vincent’s interest in chronic disease management reflects an accelerating trend across the country, observers say. Many healthcare organizations—especially large, integrated systems that are electronically enabled and public hospitals with outpatient clinics—are diving into this field, despite the fact that treatment of chronic diseases is largely a function of ambulatory care.

“Hospitals are becoming much more interested in managing the transition to post-acute care and preventing readmissions,” says Erica Drazen, managing partner in the emerging practices division of CSC Consulting in Lexington, Mass. “So you see hospitals extending their services out of the hospital for follow-up care of diseases like congestive heart failure (CHF), including medication reconciliation and maybe giving the CHF patients a home device to help them monitor their weight gain.”

Michelle Holmes, senior manager of ECG Management Consulting in Seattle, agrees. “Across both acute and ambulatory settings, we’re seeing a growing interest and effort around preventive care, including disease management.”

Hospital leaders are doing this partly because they expect healthcare reform to lead to Medicare reimbursement changes. That could include the bundling of acute and post-acute care payments and the advent of “accountable care organizations,” in which hospitals would receive a global budget for all patient care. Hospitals also will have to focus more on chronic care to meet the “meaningful use” criteria for government health IT incentives.

More immediately, hospitals must cope with a recent Medicare rule change that broadens the window of nonpayment for readmissions from seven days to 30 days after discharge. According to Snell, that one change will cost St. Vincent $34 million a year unless it does something to keep discharged patients from being readmitted. “So it behooves us to start being very proactive about being able to better manage patients in a home setting, especially those with chronic diseases,” he says.

Many tools are available

Effective disease management requires extensive changes in care processes within an enterprise, observes James Walker, MD, chief health information officer at Geisinger Health System in Danville, Pa. But you also need “electronics,” he points out, to remind everyone involved in the patient’s care, including the patient himself or herself, of what needs to be done at what times and in what places.

Those electronic information systems may include electronic health records (EHRs), many of which provide customizable alerts and reminders for preventive and chronic care. But EHRs are not designed for population health management, and a variety of other disease management tools have been developed for use alongside an EHR or in its absence. These range from electronic registries and chronic disease management systems (CDMS) to clinical messaging systems and personal health records (PHRs).

A registry lists patients with a particular condition, the services that have been performed for them, and what they are due for and when. Clinical guidelines and callout triggers may be imbedded in the software. Data can be manually entered or, more typically, are drawn from practice management or EHR systems. Registries and CDMSs are often regarded as the same, notes Holmes, but the latter programs usually include richer features, such as the ability to address comorbidities. Examples of commercial CDMS products include Patient Planner from Docsite, i2i Tracks from i2iSystems, and Patient Electronic Care System from the Aristos Group.

Some ambulatory-care EHRs have registry capabilities. But inpatient EHRs generally focus on acute care, so most lack registries and other disease management functions. That is starting to change, but vendors are still not seeing strong demand for this from their customers. That is partly because most hospitals are still in the early phases of installing EHRs, if they have them at all, notes Holmes.

Eclipsys, which is adding disease management features to its EHR, is “ahead of the pack,” says Eclipsys CMIO Rick Mansour, MD. While Sunrise Clinical Manager has had an oncology disease management module for some time, the company is now preparing to introduce new patient portal components that will help chronic disease patients manage their conditions better. Patients will be able to use the portals to report on their own health status from home, and new analytic software will help nurse case managers sort out important data. In addition, the Eclipsys EHR can already analyze population-level trends by disease state.

Orlando Health, a seven-hospital system in Orlando, Fla., that uses Eclipsys, is building the infrastructure for a disease management program that will place a heavy emphasis on monitoring of patients at home or wherever else they are. Today, the system’s home health nurses take vital signs, and some patients have devices that capture the same kind of information, notes Rick Schooler, vice president and CIO of Orlando Health. In the future, he says, this data will be transmitted into the electronic health record so that providers can track it and be alerted when a negative trend appears.

Variety of approaches

For any health system that wants to improve chronic care, the first steps are to identify those patients who have a particular disease and to analyze gaps in care at an enterprise level. Health IT can help organizations determine “where the opportunities for improvement are, so they can get started in an effective way,” notes Holmes.

Of course, it’s not simple to do that. Billing and lab data are usually the minimum needed to classify a population by disease state, but they are not necessarily or often in a single data repository. And after identifying all of the patients with a particular condition, program managers may want to narrow it down further, looking for, say, hypertensive patients with blood pressure above a certain level on their last visit, Drazen notes. Holmes adds that analytic programs are required to determine how the care provided diverges from nationally recognized protocols.

Since chronic disease management centers on ambulatory care, it helps to have an enterprise-wide record that encompasses outpatient and inpatient data. The Geisinger Health System has an Epic EHR with a unified database of this type. “We run the database and identify everybody who has diabetes on their problem list or in a visit note, or has an HbA1c that’s above 6.5,” Walker says. “So we can identify all the people we need to address for diabetes, heart failure or chronic kidney disease.”

The next step is to use the alerts and reminders in the system to make sure that whenever a patient with a targeted disease comes in contact with the organization, clinicians are aware of their condition and what needs to be done for them. “If a diabetic patient comes through for a flu shot, you want to know if he or she is overdue for some service related to the diabetes,” Drazen explains.

Sutter Health, the large San Francisco-based healthcare system, uses “best- practice alerts” in its Epic EHR to keep physicians abreast of what their chronic-disease patients need. If a diabetic patient’s HbA1c value is greater than 8, says Christopher Jaeger, MD, vice president of medical informatics at Sutter, the physician is immediately notified of the need for intensified management, and a reminder is inserted into the problem list. Best-practice guidelines related to the relevant aspects of diabetes care appear not only in the electronic chart for that patient but also in the patient’s personal health record (PHR).

Effective disease management also involves proactive outreach to patients who need to be seen. An EHR, a registry, or a CDMS can trigger this kind of messaging. At Geisinger, Walker notes, “We identify all 22,000 diabetics, and then we run the database, and we say, ‘Show me all the patients with diabetes who haven’t been seen in a year.’ Then we send that list to the call center with a script, and the call center calls the patients up, and says, ‘Dr. Walker hasn’t seen you in a year, please make an appointment.’ About 80 percent of them come in for a visit.”

Most hospitals aren’t equipped with such advanced systems. But they can use registries to inform physicians which patients should be called back for follow-up. And many states now have federally funded programs that can help hospitals and clinics set up registries. The West Virginia University Office of Health Services Research, for example, gives community health centers and smaller hospitals “tools they can use to track patients who have one or more chronic health conditions,” says Adam Baus, the office’s senior program coordinator. “Our work is focusing on diabetes, cardiovascular disease, and asthma. We help providers set up electronic patient registries and help get those systems integrated into their office flow.”

Across the great divide

While most disease management is conducted outside of hospitals, the facilities have a key role to play in the handoffs between inpatient and outpatient care. Different institutions approach this challenge in various ways. St. Vincent’s discharge planners, for instance, try to make sure that patients have appointments with outpatient physicians, and they make follow-up calls to patients or family members. The organization intends to give non-staff referring physicians access to St. Vincent’s physician portal next year, so they can view daily summaries, discharge medications, and discharge summaries for their patients.

Non-credentialed doctors can already do that at Sutter. In addition, Sutter’s discharge planners use electronic information on home health services to obtain them for patients, and the Epic system spits out a list of reconciled medications, with directions on what to resume or discontinue, along with the new drugs that the patient is taking. This is part of the after-visit summary that is given to patients when they leave the hospital.

Many healthcare systems use clinical messaging systems, either standalone or in EHRs, to tie physicians to hospitals and to link them with each other. At Sutter, physicians use Epic’s internal messaging system to exchange referral and consult notes. The organization also is trying to get more patients to use it, “because we want them to participate as a member of the care team,” Jaeger notes.

A growing number of health systems are offering personal health records in their patient portals. These may contain discharge information as well as medication, problem and allergy lists. In some cases, they replicate part of a practice’s EHR, and they allow patients to add other information to the record. Patients can give permission for their providers to view the PHR.

Geisinger makes extensive use of the MyChart PHR in Epic. Aside from populating it with clinical data, it also sends messages to patients in their PHRs telling them when it’s time to get a test or see their doctor. Of Geisinger’s 500,000 active patients, 132,000 are using the PHR, Walker says. Those most likely to use it are patients with the most health problems, so “it reaches the people who most need to be involved,” he says.

Geisinger is way ahead of most other healthcare systems in this area. Orlando Health, for example, has mostly implemented its EHR, but foresees a one-to-three year period of infrastructure development before it can start to launch disease management programs, says Rick Schooler. Meanwhile, he says, Orlando Health and other organizations will continue their movement toward physician integration to prepare, not only for disease management, but also for a new way of being paid.

“What will change the landscape is when the feds say, ‘Orlando Health, you’re going to be the accountable care organization, and you’ll hand out the payments.’ There are federal pilots going on right now that deal with this concept of bundled payment. The bundling will include all the providers involved in the patient’s care, and the accountable entity will dole out the money. So we’ll eventually need agreements with all these physicians. It works a lot better if they’re integrated with your health system, which includes information integration. But if not, we’ll need to work with them very closely.”

Ken Terry is the author of the book Rx For Health Care Reform.