Is Disease Management Dead?

Archelle Georgiou thinks so. Her very well-written post (on her own blog here and on Managed Care magazine here) is a thoughtful obituary. She puts the time of death last November, when the New England Journal published Nancy McCall and Jerry Cromwell's report on the CMS disease management pilot program (N Engl J Med 2011; 365:1704-1712). The various DM programs showed little or no benefit, but they cost CMS $400 million. Yes, I agree: disease management, as we know it, has bought the farm and ought to be buried.

Dr. Georgiou offers several quite cogent reasons for DM's failure. The most compelling is that DM as implemented has drifted from the format and target audience originally proven effective in clinical trials in the 1990's. Again, I think she is spot on.

What should we do to improve outcomes and reduce costs going forward? Many of the ideas being proposed appear promising, but have less of a justification than the currently-employed versions of DM have. We just wasted billions of dollars and many years by failing to use the evidence base correctly. It doesn't seem wise to me to abandon the requirement for solid evidence before we invest again. Rather, we should take steps to ensure that we use technologies and programs that are evidence-based AND that we employ them as close to tested as possible.

What are those technologies and programs? Classic disease management for heart failure patients has been proven effective many times and should be retained. Use of automatic systems to support chronic disease patients (and their providers) are very low cost and have also been proven in large randomized studies. Lowering co-pays and barriers to access for essential medications and services is another strategy with a large evidence base.

Let's not throw out the evidence-based baby with the DM bathwater.

The psychology of exchanging health information with patients

How does exchanging health information work to improve health? Getting the facts about your favorite subject (you!) is extraordinarily motivating. It is the reason why actionable communications like those embedded in effective patient outreach systems work. Here's a nice review of the psychology by Joe Kvedar at Connected Health: Self-Quantification as a Driver of Behavior Change

QR Codes for communicating with patients...

QR Codes are those funny little black and white squares that look like a checkerboard with a screw loose. They can contain a surprising amount of information. For instance, here is the URL for this blog:

If you scan this code with you phone, you will be directed ..... right back here.  You can also do text. This one contains some words of wisdom from Mark Twain:



QR Codes are starting to be used in marketing (I've seen them on posters and flyers), but now that smart phones are so ubiquitous, they provide an option for sharing information with patients (an others). If you turn their medication list into a QR Code, they can scan it right into their smart phone and have it handy whenever. Here is a 6-minute video from the folks at Skyline Family Practice, in Front Royal, Virginia with some examples:

(http://www.youtube.com/watch?v=FSBIXSk4nbg for the non-scanning crowd)


Have fun scanning!

National Medical Home Summit

Benjamin Littenberg, MD, Chief Medical Officer at Patient Engagement Systems to Discuss Advanced IT for Primary Care at the National Medical Home Summit The Fourth National Medical Home Summit, the Leading Forum on the Development and Implementation of the Patient Centered Medical Home, takes place Sept. 20-21 in San Francisco Media Contact: Christine Dunn Savoir Media (617) 484-1660 cdunn@savoirmedia.com Burlington, VT - September 16, 2011 - Benjamin Littenberg, MD, Chief Medical Officer for Patient Engagement Systems, a health-care technology company that provides solutions for improving primary care for people with chronic diseases, will be presenting "Advanced IT for the Medical Home: Engaging the Patient" at the Fourth National Medical Home Summit in San Francisco later this month. At the conference, Dr. Littenberg will discuss how information technology, when applied strategically and purposefully, can create engaged patients and be a key difference maker for PCMH efforts. Dr. Littenberg's presentation will include research that demonstrates that successful patient engagement improves outcomes and saves money. "The future of healthcare is evolving and primary care delivery is changing, making engaging with patients more important than ever to the financial and clinical success of the primary care practice research. The Medical Home model will help this evolution happen, but the right information utilities need to be in place to engrain new methods of health improvement," said Dr. Littenberg. Dr. Littenberg's Mini Summit presentation at the National Medical Home Summit will take place at 2:15 p.m. on Wednesday, Sept. 21. The Fourth National Medical Home Summit is being held on that day, as well as on Sept. 22, at the Grand Hyatt in San Francisco, California. Patient Engagement Systems provides technology solutions that have been demonstrated to improve coordination, compliance and the overall management of chronic conditions by supporting physician decision-making and communication with their patients. Physicians who work with Patient Engagement Systems have found that the technology extended, and expanded, their capability to provide high-quality, cost-effective, and consistent medical care -- ultimately improving health outcomes and reducing expenses. Patient Engagement Systems' technology is the only patient centered clinical solution that has demonstrated effectiveness in a National Institute of Health (NIH) funded study. The National Medical Home Summit is the leading forum on the development and implementation of the patient centered medical home (PCMH). The Summit, a hybrid conference and Internet event that is sponsored by the Jefferson School of Population Health, will bring together the leading authorities and practitioners in the medical home field to discuss how the PCMH model is working, where it has proven outcomes, how it is evolving, and how it fits into plans for delivery system reform. The conference will present the key building blocks of the medical home model, and four major medical home themes -- IT, care coordination, patient engagement, and the medical home workforce. Each of these topics will be discussed in depth in separate mini summits. For more information about the National Medical Home Summit, visitwww.MedicalHomeSummit.com For more information about PES, visit www.patientengagementsystems.com About Patient Engagement Systems® Patient Engagement Systems® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The PES system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs. The patent-pending PES technology uses automated reminders, alerts, flow sheets and population reports to help health care providers better care for their patients, and patients better manage their chronic conditions. PES has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. For more information about Patient Engagement Systems (PES), visit http://www.patientengagementsystems.com.

Webinar: Advanced IT for the Medical Home: Engaging the Patient

Advanced IT for the Medical Home: Engaging the Patient    A special conference for senior executives & administrators from physician groups, emerging Accountable Care Organizations, health systems, Patient Centered Medical Homes, health plans, and government agencies.   To register for this interactive, 45 minute webinar, please click here. System Requirements PC-based attendees require: Windows® 7, Vista, XP or 2003 Server       Macintosh®-based attendees require:  Mac OS® X 10.5 or newer  Answers to Your Specific Questions If you have questions on our webinar and/or webinar formats, please contact us atmarketing@ptengage.com Webinar Date:  Monday, October 3rd Time:  12:00 pm Eastern Primary care is at the core of most every major initiative for health care reform - not the least of which is the Patient Centered Medical Home. The PCMH model will succeed or fail depending on how well primary care providers can engage their patients in a coordinated, continual, and directed pattern of care.  Information technology, when applied strategically and purposefully, can create engaged patients and be a key difference maker for PCMH efforts.     Benjamin Littenberg, MD FACP will share his experience as a practicing physician, academician, and information scientist about how primary care delivery is changing, and how engaging with patients is more important than ever to the financial and clinical success of the primary care practice.  Focused Discussion Attendees will learn: · How well the medical home model orients itself to patient engagement · How primary care physician-lead groups have implemented technology solutions that support PCMH criteria · What research and standard practices have established about how patient engagement improves the overall clinical experience and what that means for Medical Home providers · What are the anticipated impacts - risks and rewards - of PCMH on how providers and patients interact Seminar Speaker Benjamin Littenberg MD, FACP  Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, Director of General Internal Medicine Division of General Internal Medicine, University of Vermont Chief Medical Officer, Patient Engagement Systems, Inc. Dr. Littenberg is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine at the University of Vermont. He received his medical degree from Case Western Reserve University and trained in internal medicine at Hartford Hospital in Connecticut. He was a Robert Wood Johnson Clinical Scholar at Stanford University before becoming Assistant Professor of Medicine at Dartmouth. Following an appointment as Associate Professor of Medicine at Washington University in St. Louis, he assumed his present position in 1999. Dr. Littenberg practices General Internal Medicine in Burlington, Vermont. His research interests center on technology assessment and quality improvement. Recent projects include new ways to measure quality of care in cancer, novel strategies for reporting test results to patients, better approaches to antibiotics in sinusitis, safety improvements in outpatient prescriptions, and strategies to address health literacy. In Vermont, Dr. Littenberg has been active on the Board of the Vermont Program for Quality in Health Care. He has developed statewide registry-based approaches to quality and safety improvement with the Vermont Breast Cancer Surveillance System and as Principal Investigator of the NIH-funded research grant for the Patient Engagement Systems Diabetes Information System which engendered Patient Engagement Systems.           Patient Engagement Systems 89 Beaumont Ave. Given Courtyard, 4 South Burlington, VT 05405 (802) 656-4576  About Patient Engagement Systems® Patient Engagement Systems® technology enhances patient engagement by fostering communication between patient and caregiver, and by delivering decision support to health-care providers. The PES system has been proven in a National Institute of Health clinical trial to improve health outcomes and reduce costs. The patent-pending PES technology uses automated reminders, alerts, flow sheets and population reports to help health care providers better care for their patients, and patients better manage their chronic conditions. PES has been used by thousands of patients with diabetes in Vermont, New York, California and Texas. Clients include municipalities, private hospital systems, physician organizations, and managed care organizations. For more information about Patient Engagement Systems (PES), visit http://www.patientengagementsystems.com.

Exchanging Health Information to improve medication adherence

Getting the right medicine into the right patient at the right time is a particularly challenging problem in outpatient care. Consider the required steps:

1. Prescriber selects the right medication
2. Prescriber prescribes the right medication
3. Patient carries the paper prescription to the pharmacy
4. Pharmacist interprets the written prescription correctly
5. Pharmacist selects, packages and labels the medication correctly
6. Patient returns to pharmacy
7. Patient receives the correct package
8. Patient takes the medication as prescribed
9. Patient requests refill at appropriate time
10. Return to Step 5

There are lots of variations on this scheme depending on insurance, expired prescriptions, need for clarifications, etc, etc., etc. A big one recently is that Step #3 is sometimes replaced by a network connection with quite high reliability.

There have been a number of studies on "secondary non-adherence" in which the pharmacy records identify patients who don't get refills (Step #9). There have even been some analyses of patients who drop off their paper prescription but fail to pick up the medicines (Step #6). However, until recently, the gap between prescribing and dispensing the first unit (Steps #3, "Primary Non-adherence") has been very difficult to study because of the lack of information exchange between the prescriber and the dispenser.

Marsha A. Raebel and the good folks at the Kaiser Permanente Institute for Health Research in Colorado just published an article in The Journal of General Internal Medicine about using health technology to identify those patients who need help in getting their first fill. They looked at over 12,000 new electronic prescriptions for  blood pressure, cholesterol or diabetes. Overall, about 7% failed to pick up their first medication, even though these patients had pretty good insurance coverage.

It is not clear yet why these folks don't show up to pick up their pills. Nor is it clear exactly what should be done about it. However, it is clear that this kind of health information exchange between prescribers and pharmacists should trigger an alert to someone inside the system: "This patient is not getting the intended care - call them and find out why!!"

Characteristics of Patients with Primary Non-adherence to Medications for Hypertension, Diabetes, and Lipid Disorders

Marsha A. Raebel, Jennifer L. Ellis, Nikki M. Carroll, Elizabeth A. Bayliss and Brandy McGinnis, et al.

Journal of General Internal Medicine Online First™, 30 August 2011