Clinical Information Technology Systems Play Larger Role in Chronic Disease Care

Twice each day, Robert Lanza steps on a scale in his home in Laguna Woods to weigh himself. The task might seem mundane, except that Lanza’s scale asks him a series of questions about his health and then transmits that information, along with his weight, to a physician. Lanza is one of close to 1,500 California Medicare patients with congestive heart failure who are part of a CMS-sponsored HeartPartners pilot program designed to measure the effectiveness of disease management programs.

HeartPartners, which began earlier this year, includes PacifiCare Health Systems, its pharmacy-benefit management subsidiary Prescription Solutions, home monitoring company Alere Medical and chronic care company QMed. The three-year program, which includes patients in California and Arizona, could be offered nationwide if it is successful. Patients who participate receive free monitoring equipment in addition to a low-cost prescription drug plan. Patients weigh themselves twice a day and answer a series of questions. Because of the nature of congestive heart failure, slight changes in weight can signal problems. Lanza said changes in his weight have prompted a call back from a nurse within 10 minutes of him transmitting the information.

Before joining the program, Lanza said he was hospitalized after he let swelling in his ankles go unchecked. That’s just the sort of scenario the program is designed to prevent. CMS hopes that the project, in turn, will lower Medicare costs. While there is no preliminary data to prove this, similar disease management programs in California have shown a measurable impact on hospitalization rates, according to Dr. Gordon Norman, vice president for disease management at Pacificare and medical director for HeartPartners.

While the HeartPartners program is more the exception than the norm, it is not the only program in California or nationwide to employ technology to help provide better care for patients with chronic diseases.

The California Association of Physician Groups, which includes 135 physician groups that employ or contract with some 38,000 physicians, is using a $200,000, 18-month grant from the California HealthCare Foundation to support improvement in chronic disease care by establishing standards for clinical and laboratory information data exchange. The effort involves health plans, providers and laboratories. The group currently is working on a standard for laboratory data. CAPG also is developing a data repository to provide benchmarking reports on a number of quality measurements.

“California’s organized groups do a better job of disease management than anyone else in the country,” CAPG CEO Donald Crane said. “There is a lot of improvement to be had. Much of that will happen through protocols and having our data repository.”

Pay-for-performance initiatives in California also are increasing interest in computerized disease registries, which helps physicians monitor patient information and look for gaps in care for patients with a chronic condition, according to Jane Metzger — an analyst with First Consulting Group, who looked at such registries for a CHCF report released earlier this year. “One of the things a registry allows you to do is look at the numbers,” Metzger said. “Without a registry, they [physicians] have no clue what’s widely adopted as a standard of care.”

Although Kaiser Permanente doesn’t have an IT-driven disease management program, it does have a heart failure registry, which helps Kaiser get a better handle on quality monitoring, according to Leslee Budge, a practice leader for cardiovascular disease with Kaiser Permanente’s Care Management Institute. In Northern California, Kaiser’s heart failure program has helped reduce rehospitilization rates for heart failure. Budge predicted that IT would play a bigger role in Kaiser’s disease management programs once its $1.8 billion, three-year project to give every Kaiser physician an electronic health record is complete.

Uncertainties Over Savings Remain

While some experts see promise in disease management programs — especially those that utilize IT in some form to improve patient care or reduce costs — the jury is still out on whether these programs have a measurable impact on either. A recent report from the Congressional Budget Office found that there was insufficient evidence that disease management programs reduce Medicare spending. The report did not examine IT’s role in disease management, but it did look at disease management programs for congestive heart failure, coronary artery disease and diabetes patients. Medicare plans to test disease management programs for some 20,000 patients around the country and CBO will assess the projects’ benefits and costs.

However, Norman said the report examined data from disease management programs that were several years old. “If the CBO report gets rewritten with modern data, it won’t come to that conclusion,” he said. Still, Norman acknowledges that disease management programs face formidable challenges, such as poor coordination among providers and a lack of good financing models to pay for such programs.

Another study that appeared in the Oct. 19 issue of the Annals of Internal Medicine called disease management’s efficacy into question. The study, which examined 462 patients who were recovering from heart failure, tested whether a nurse care management system that allowed patients to manage their illness through telephone instructions and nurse follow-ups would prevent re-hospitalization. Half of the patients who used the system were rehospitalized, even if they received nurse care management, researchers at the Stanford University School of Medicine found.

IT May Be Tool, Not Cure

Part of the reason disease management is still a challenge is that moving around simple data elements is still difficult for many organizations, Norman said. If this data were better organized through the use of IT, improvements in care would naturally follow, he said. “It’s a tragic commentary, but what it means is there is low-hanging fruit everywhere you look,” he said.

Budge also sees great potential in disease management programs that utilize technology. One Kaiser study found that patients who received tailored messages about weight management showed significant improvement.

While technology may be a necessary component in disease management programs, experts say that on its own, it can’t solve the highly fragmented nature of the system, which is one of the biggest roadblocks to successfully treating patients with chronic diseases and lowering costs. For now, patients like Robert Lanza said programs such as HeartPartners help him feel better taken care of and remind him to be more vigilant about his health.

“To have some help in that regard is beyond measure,” he said.

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