HIT-supported Chronic Disease Management: the Maccabi Experience

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HIT-supported Chronic Disease Management: the Maccabi Experience. Kaye R. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

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HIT-supported Chronic Disease Management: the Maccabi Experience

  1. 1. Nearly 70-80% of health care costs result from chronic care  70% of the disease burden is due to 5 chronic conditions  Congestive heart failure  Asthma  Coronary artery disease.  Diabetes  Depression
  2. 2. Diabetes Ischemic Heart Disease
  3. 3.  Trying to adapt acute care model to Chronic Disease care  Reactive, not pro-active  Rushed practitioners not following established practice guidelines  Lack of care coordination and follow-up  Patients inadequately trained to manage their illness
  4. 4. Community Health System Resources and Health Care Organization Policies Clinical Information Self- Delivery Systems Decision Management System Support Support Design Informed, Productive Prepared, Activated Interactions Proactive Patient Practice Team Improved Outcomes Wagner et al, Health Affairs 2001;20(6):64-78.
  5. 5.  Clinical information Systems  Decision Support  Self-management Support  Delivery System Design
  6. 6.  Provide timely reminders for providers and patients  Identify relevant sub-populations for proactive care  Facilitate individual patient care planning  Share information with patients and providers to coordinate care  Monitor performance of practice team and care system
  7. 7. Electronic Medical Record In Maccabi used by all providers for over 15 years, capturing demographic and medical data and providing the clinician with support in caring for his patient.
  8. 8. Medical (Disease) Registries Based on all of the information in the data base, enable tracking individual patients as well as populations to manage chronic illness and preventive care.
  9. 9. Medical History Family Results History Visits & Lab Hospitaliza- tions Demographic Medications parameters Treatments Imaging
  10. 10. 1st year of data n % of MHS collection (2007) population Home Care 1998 5,500 0.3 Infertility 1998 10,000 0.6 Cancer 2000 36,300 2.1 Cardiovascular 1998 72,720 4.0 Diabetes 1998 85,000 4.7 Hypertension 1998 233,000 13.0 All of the above 442,520 25.0
  11. 11.  The Clinical Decision Support System provides an integrated comprehensive view of patients status including data on the patient’s status relative to prevention, disease management , medication management etc.  The system is based on clinical guidelines and alerts the provider, in real time, to the following:  Patient information indicative of aberrations in patient status.  Recommendation for needed tests/treatment based on cumulative data on the patient in the system.  Links to relevant medical knowledge.
  12. 12.  Drug interaction warnings  Prescription prioritization recommendations  Mandatory data fields (BP, smoking)  Recommended laboratory test alerts  Diagnosis-related lab test panels  Organizational alerts  Rules engine based alerts
  13. 13. Robert Smith Active Health Problems Chronic Medication Last Visit Dr. Jones - FP Allergies Risk Factors
  14. 14. Print Recommendations for present visit: List • recommended referrers • delay to next visit Cancel Action Refer for Cholesterol test Refer for Diphtheria/tetanus Document results & blood pressure measurement delay all next visit Confirm Reason Patient suffers from hypertension. No documented Blood Pressure Measures in the last year
  15. 15. Gantt Chronic Medications Gantt Past Medications Blood Pressure Trend
  16. 16. Blood Pressure Trend Gantt Chronic Medications Gantt Past Medications Blood Pressure Trend
  17. 17. Patient Allergy to Penicillin. Wish to prescribe despite sensitivity? Cancel Approve
  18. 18.  Lists of Patients with Diabetes  Status Reports with patient names and phone numbers:  Last HbA1C Test – when done and value  Last Eye Exam  Last Foot Examination  Last LDL test and value  Diabetic Patients without flu shots
  19. 19. Patients in Diabetes Registry Statistics: Diabetes Patients Clinic: TA Clinic Address: hazionot 17 Dr.: R. Smith Year: 2008 Average Patient Age: 52.6 Numbers of Visits: 348 Maccabi Region Clinic Average HbA1C % HbA1C Average LDL % Done LDL % Done Creat % Done Urine % Done Eye Exam % Patients Aspirin % Patients Ace Inhibitors % Visit Dietician % Patients HbA1C over 9.5 % Patients HbA1C under 7 % Patients HbA1C under 100
  20. 20. Patients in Diabetes Registry Patients who have not had an Eye Exam Time Period Between October 2007 – September 2008 Eye Phone Num. First Name Last Name ID #
  21. 21.  Computerized consultation with specialists  Virtual consults by e-mail and video conference  Diabetes expert teaching program  Diabetes education team visits  Joint consults  E-learning
  22. 22.  Stress patient’s role in managing health  Strategies including assessment, goal-setting, action planning, problem-solving and follow-up  Appropriate infrastructure  Patient education materials  Share information with patients
  23. 23. Eye Examination: this is not a test that can be performed by an optometrist or a test for a driver's license but rather an in-depth eye examination by a qualified ophthalmologist. This test is very important for the early detection of eye problems as a result of diabetes. There are excellent methods for treating these problems if they are detected at the early stages. It is recommended that this test be done once a year Urine protein test: The objective of this test is to identify potential damage to the kidneys as a result of diabetes. If the discharge of protein or albumen in the urine is high, it can be treated by medication. It is recommended to do this test (micro-albumen/creatnine or 24 hour urine collection for micro albumen or protein) once a year. Here are the results over time of the test results in our system
  24. 24. Dear Joseph Kern ID# 500000000 Data last updated 31/5/2009 Dear member, We are presenting you with your personal data with regard to your Diabetes, The control of your diabetes is largely dependent on your understanding and your cooperation with your doctor. Here is your personal information with respect to several items critical to your health HBA1C Information These data are based on your blood test results and indicate the extent to which your diabetes was under control for the 3 months HbA1C trend prior to the test. It is recommended to do this test twice a year or according to your doctor's recommendation. The recommended level for this test is less than 7% Date: 30/9/2009 most recent HbA1C value:8.4% According to our records, your last HbA1C test was more Recommended Value – 7% than a year ago, Please contact your doctor for a referral for this lab test LDL Cholesterol Information This is the type of cholesterol that is known to be a risk factor for cardiovascular disease. It is important that a diabetic patient do this LDL trend test once a year or according to his doctor's recommendation. The recommended value for this test is less than 100/dl
  25. 25. Maccabi OnLine
  26. 26.  Built in guidelines based on the patient’s personal medical information, clinical guidelines and his care plan  Input from sensors (weight, blood pressure, pulse, glucometer, ECG) and from the patient  Input from doctor’s EMR, case management record  Interactive – provides instruction, answers patient questions  Proactive – provides response to inputs, alerts to patient, doctor, nurse case manager  Remote intervention by care providers based on patient input, input from sensors, alerts
  27. 27.  Willingness of doctor to take responsibility for comprehensive care of patient including Disease Management  New role for the nurse, as case manager, educator  Willingness of Patient to take responsibility for managing his disease  Willingness of doctor, nurse and patient to work together to manage the disease
  28. 28.  Providing both the clinicians and the patient with the tools for Disease Management:  Electronic Medical Record  Clinical Data exchange (test results, drugs purchased, etc.)  Central medical record or data warehouse  Medical Registries for chronic disease  For the doctor – alerts, reminders, embedded clinical guidelines, feedback, patient lists  For the patient - courses, education, interactive Patient Health Record. alerts, reminders

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