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.