Patient-Centered Disease Specific Model for Better Outcomes

By Frank Tucker | Feb 21, 2013

Written by Tony Inae

Spi­ral­ing health-​care costs, frag­mented care, and med­ical errors indi­cate a need for a fun­da­men­tal shift in the par­a­digm of our health-​care sys­tem. In its report Cross­ing the Qual­ity Chasm, the Insti­tute of Med­i­cine called for new tech­nolo­gies, includ­ing elec­tronic patient health records, to shift our health-​care sys­tem from one that pro­vides episodic and acute care toward one that nur­tures heal­ing rela­tion­ships between patients and fam­i­lies and health-​care pro­fes­sion­als. Under the new par­a­digm, con­sumers, aided by new tech­nolo­gies, assume added respon­si­bil­ity for self-​care, per­sonal health management, and care giv­ing. Nowhere is the need for a shift more evi­dent than in the care of patients with the chronic ill­ness of dia­betes mellitus.

Dia­betes affects mul­ti­ple organ sys­tems with car­dio­vas­cu­lar dis­eases, hyper­ten­sion, heart fail­ure and chronic kid­ney dis­ease coex­ist­ing. Health-​care costs for dia­betes care are sky­rock­et­ing. In 2007, the direct and indi­rect costs of dia­betes care are $174 bil­lion a year in the United States (Amer­i­can Dia­betes Asso­ci­a­tion. Eco­nomic costs of dia­betes in the U.S. in 2007. Dia­betes Care 31:596 – 615, 2008). As the Dis­trict of Colum­bia Depart­ment of Health noted in its Dia­betes Sur­veil­lance Report 2004, Wash­ing­ton, D.C. spends $300 mil­lion dol­lars a year in direct costs for diabetes-​related mor­bidi­ties and hospitalizations.

Stud­ies have shown the abil­ity to reduce mor­bid­ity and mor­tal­ity of chronic con­di­tions through team based dis­ease man­age­ment. Dia­betes care requires coor­di­na­tion of an extended team of health-​care providers and the patient coop­er­a­tive engage­ment with lifestyle mod­i­fi­ca­tion, diet, exer­cise, weight loss, med­ica­tion com­pli­ance, and clinic follow-​up com­pli­ance. Care­ful mon­i­tor­ing of patients with dia­betes has been shown to reduce com­pli­ca­tions and acute exac­er­ba­tions, which in turn can lead to major eco­nomic and health benefits.

At its broad­est, our goal is to cre­ate a patient cen­tered dia­betes man­age­ment frame­work to suc­cess­fully man­age dia­betes and empower health-​care con­sumers to fully par­tic­i­pate in the man­age­ment of their dis­ease through infor­ma­tion access, tai­lored self-​care, home mon­i­tor­ing, edu­ca­tion on lifestyle choices, secured mes­sag­ing, and shared decision-​making with their providers between clinic visit inter­vals. Joint patient-​provider man­age­ment of a patient’s dis­ease won’t stop at the end of the clinic visit.


By democ­ra­tiz­ing health infor­ma­tion and empow­er­ing the patient, we believe this will help move the patient and health­care team closer together in a vir­tual envi­ron­ment, so that patients will become more engaged in their dia­betes man­age­ment. We advo­cate a Patient-​Centered Dis­ease Spe­cific (PCDS) Model for dia­betes patient man­age­ment for urban vul­ner­a­ble pop­u­la­tions using health infor­ma­tion tech­nol­ogy appli­ca­tions to address bar­ri­ers to suc­cess­ful dia­betes man­age­ment. The best place to start to lower the over­all cost of health­care in this coun­try, is to show indi­vid­u­als how to take an active part in man­ag­ing their own health and to allow for patient mon­i­tor­ing between clinic vis­its to reduce, avoid, and delay the sequela of dia­betes, reduce and avoid Emer­gency Room vis­its, pre­ventable hos­pi­tal stays, urgent care vis­its, and pre­ma­ture death from dis­ease. This rev­o­lu­tion­ary PCDS Model will pro­mote bet­ter health and improve over­all health out­comes of the pop­u­la­tions by tar­get­ing one patient at a time. This will lower the cost of care for Medicare, Med­ic­aid, and CHIP ben­e­fi­cia­ries by improv­ing the qual­ity of care between patients and health­care providers by remov­ing phys­i­cal bar­ri­ers of mon­i­tor­ing and com­mu­ni­ca­tion dur­ing the inter­vals between clinic visits.

An example of one approach in dia­betes would be to:


1) Improve over­all patient out­comes health through bet­ter patient under­stand­ing of their dis­ease process and empow­er­ing the patient to take a more active role in dis­ease man­age­ment. Unlike sta­tic Per­sonal Health Records filled with infor­ma­tion, often times com­plex and mean­ing­less to the patient, PCDS sys­tem will down­load dia­betes spe­cific lab data from the hos­pi­tal EMR and Lab Sys­tems auto­mat­i­cally and dis­play the infor­ma­tion so that it is very sim­ple and easy to under­stand to the patient. It will give patients an instant color coded sta­tus of their dis­ease process show­ing “good”, “bad”, or “needs improve­ment”, will tell the patient “why” and then pro­vide the patient with a sim­ple step-​by-​step roadmap and check­list of what they need to do next. The patient will get a snap­shot of their cur­rent sta­tus of their dia­betes man­age­ment, show­ing lab results, trends, reminders of needed pre­ven­tive ser­vices, such as annual eye exams and repeat A1C labs, and cre­ate a very sim­ple way to sched­ule those needed ser­vices. Patients will know exactly what to do next in a very per­son­al­ized sim­ple way. PCDS model will help the con­sumer take a more active role in man­ag­ing their dis­ease through this edu­ca­tion and under­stand how lifestyle and dietary changes might affect over­all dia­betes con­trol and pro­mote shared decision-​making with the health care team.


2) Improve over­all patient out­comes health through more timely inter­ven­tions by clin­i­cal team between clinic vis­its. PCDS model will allow the patient to log their blood sugar read­ings and those read­ings will get auto­mat­i­cally sent to Dia­betes Care Man­agers. PCDS model will trend those read­ings notify the health care team when cer­tain thresh­olds are exceeded, or when the patient has not recorded blood sugar read­ings within a pre-​determined inter­val. As a result of this alert­ing sys­tem, the health care team can then proac­tively con­tact the patient and make inter­ven­tion sooner, such as the mod­i­fi­ca­tion of med­ica­tion dosage, more dietary edu­ca­tion, behav­ioral mod­i­fi­ca­tion, and hav­ing the patient return to the clinic sooner. As a result of this sys­tem mon­i­tor­ing between clinic vis­its, early inter­ven­tion can reduce and avoid pre­ventable Emer­gency Room vis­its, costly hos­pi­tal­iza­tions and unplanned urgent care visits.

3) Change the par­a­digm of dis­ease man­age­ment from the high reliance on health care sys­tems that reac­tively informs patients how to man­age dis­ease, to a model where patients are pro-​actively engaged in man­ag­ing their dis­ease with a sense of own­er­ship. Suc­cess­ful com­ple­tion of this new model could then be used across the nation lever­ag­ing the Nation­wide Health Infor­ma­tion Net­work (NwHIN), Health Infor­ma­tion Exchanges, and Bea­con Com­mu­nity ini­tia­tives empow­er­ing health-​care con­sumers irre­spec­tive of where they receive their care or where their health infor­ma­tion is stored. Patients will have a more tai­lored and com­plete snap­shot of their dis­ease process irre­spec­tive of where they received care or irre­spec­tive of which EMR is has their lab infor­ma­tion stored. We will then repli­cate this model for other chronic dis­ease con­di­tions, such as Hyper­ten­sion, Hyper­lipi­demia and Obe­sity, and cre­ate down­load­able mod­ules for this appli­ca­tion, so that the patient has a sin­gle appli­ca­tion to man­age all of their unique dis­eases. Unlike the tra­di­tional sta­tic Per­sonal Health Record (PHR), the PCDS model will be a patient-​centered and dis­ease spe­cific empow­er­ing the patient with deci­sion sup­port acti­vat­ing them as an active part in their chain of care.


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