# Presentation: 134993

**Materials Developed in Consultation With:**
- Sophia Chang, M.D., M.P.H., California HealthCare Foundation
- Eric Dishman, Ph.D., M.S., Intel Corporation
- Rob Kolodner, M.D., Veterans Health Administration, VA
- Robert Wah, M.D., Office of the National Coordinator for Health Information Technology, HHS
- Edward Wagner, M.D., M.P.H., GroupHealth Cooperative

- This briefing has been developed under the auspices of **Health Systems Research, Inc.** under a contract with the Office of the National Coordinator for Health IT, HHS

- November 29, 2005

## Potential Opportunities

- Improve Care Coordination by Enhancing Provider/Patient Connectivity
- Leverage Everyday Technologies for Chronic Disease Support Systems
- Spotlight Innovations in Chronic Disease Management

## Scope and Boundaries of the Issue 

- The medical care costs of people with chronic
- diseases account for more than 75% of the nation’s
- $1.4 trillion medical care costs.
- Prevalence ~over 90 million Americans
- Top 5 Conditions:  Heart disease, Cancer, Stroke, 			  Diabetes, Pulmonary Diseases
- Compounded by mental health, including depression
- Annual costs:  Heart $194B, Cancer $190B,
-                         Diabetes $132
- Evidence that good chronic care will save money

**Notes:**
Source:  Wu, Shin-Yi and Green, Anthony.  Projection of Chronic Illness Prevalence and Cost Inflation.  RAND Corporation, October 2000.
CDC, >90 million estimate, mortality and cost data.

Additional significant morbidity from arthritis and depression

## Scope and Boundaries

- What is Good Chronic Disease Care?
- Moving evidence into practice (50/50 chance of getting appropriate care)
- Synthesizing huge volumes of information and making the right decisions at the right time
- Working counter to the acute care paradigm
- Helping patients manage their condition--over 90% if chronic disease management is done by the patient
- Effective coordination of complex care (across multiple patient conditions and many players)

**Notes:**
Source:  RAND, McGlynn data

## Environmental Scan 

- Provider Decision Support Tools
- Electronic Health Records (EHRs)
- From electronic chart to interactive decision support systems
- Evidence suggests not all commercial products lead to better chronic care
- Registries/Chronic Disease Management Systems
- Automated tracking of patient populations and their care
- Registry reminder functions associated with better chronic care
- Personal Digital Assistants (PDAs)
- Primarily used to support medication prescribing
- Disease Management Programs
- Working with higher risk patients
- (usually outside of regular care provider)

## Environmental Scan (cont.)

- Patient Support Tools
- Home monitoring devices
- Remind patients to monitor key clinical information (and transmit it back to provider or care manager)
- Personal health records
- Growing industry to provide tools for patients to manage their own health information
- Web-based education and support
- Supported by disease management programs, health plans, employers and disease-specific consumer groups

**Notes:**
Name Specific examples

## Environmental Scan (cont.)

- Creating convergence
- Web portals to EHR systems
- TriCare Online
- My Health_***e***_ Vet
- Commercial (e.g., Group Health, Kaiser,)
- “Sharable” Personal Health Records
- Peace Health
- Proprietary products
- Telehealth for virtual interactions
- Examples across VA, DoD, UC Davis

## Examples of Important Public Sector Initiatives

- CMS’ Medicare Health Support (formerly known as the Chronic Care Improvement Program
- Visit: http:/cms.hhs.gov/medicarereform/ccip
- VA’s Care Coordination Home Telehealth (CCHT)
- Visit: http://www.va.gov/occ/Tech.asp

## Key Stakeholders and the Benefits They Accrue from Advancements in this Area 

- Patients with chronic conditions and their caregivers —better outcomes, quality of life and self-efficacy
- Providers—improved care, efficiency and work satisfaction
- Technology companies— selling products that support chronic disease care and having healthy employees/families
- Payers—getting value for investments
- Society—overall cost savings

## Major Barriers 

- IT Product Issues
- User (both provider and patient) acceptance of medical/health-specific technologies
- high costs and limited technical support
- Competition and proprietary nature of market
- Disincentive for easy interoperability between (or swapping of) systems
- Interoperability
- Lack of normalized data
- Incomplete adoption of existing data standards
- Lack of automated flows of clinical data

## Major Barriers (cont.)

- Environmental Issues
- Financing mechanisms
- Regulatory barriers
- Patient privacy concerns
- IT interventions are necessary, but insufficient, to improve chronic disease care

## Parameters for Initial Breakthrough Project Recommendations

- Focus on important condition (prevalent, serious and/or costly)
- Piggyback on successful existing programs whenever possible
- Leverage a combination of stakeholders
- Clearly define a “breakthrough” success
- Focus should be on mass dissemination of evidence-based technologies

## Potential Implementation and Acceleration Opportunities - 1

- Improve Care Coordination with Electronic Connectivity
- among Providers and Patients** **
- Clinician **** clinician
- instant messaging, web based care plans, audio chat
- Clinician **** patient
- PHR access to EHR, secure email
- Instant message channels
- Interactive systems (voice response, telehealth)
- Patient **** caregivers/family
- online collaborate care coordination spaces
- search tools for personal health information
- Networking caregivers and patients
- using modern internet technologies

**Notes:**
Focus on technologies and new business models that enable better care coordination and community across patients, family members, and clinicians
Provider systems to prompt timely chronic disease care 
Support of between visit care and systematic F/U
Instant messaging across providers
Web-based shared care planning
Patient portals onto existing provider IT systems
Sharing key data with patients (by display, ultimately into decision supported IT systems)
Existing electronic lab and pharmacy data

## Potential Implementation and Acceleration Opportunities - 2

- Leverage everyday technologies for Chronic Disease
- support systems
- Cell phones/services as tool for real-time, all-the-time monitoring
- Disease management television channels with custom content
- Standards for in-home remote medical monitoring devices
- Drive R&D on use of today’s and tomorrow’s everyday technologies for new health & wellness services
- Use social marketing/pop culture to promote adoption

**Notes:**
Supporting specific behaviors (helping patients understand interaction between their behaviors and their symptoms/disease)
Using specialized home monitoring devices

SBIR/STTR programs

(e.g., medication reminders, even remote diagnostics, such as step counting, glucometer reading)

Using existing daily technologies
Using mass market to drive adoption of chronic disease systems
Cell phone supported medication reminders
Public access TV with interactive disease management content
Sharing patient self-monitoring data with providers (by display, ultimately into decision supported IT systems)

  Example: leverage prominent athletes to drive national “step counting campaign” through internet connected pedometers amongst target “at risk” populations 
e.     Example: create simple weight management PHR (online diary for fitness and nutrition tracking) for deployment with Oprah fan club

## Potential Implementation and Acceleration Opportunities - 3

- Spotlight Innovations in Chronic Disease Management
- Create national workshop/forum for identifying and disseminating proven technologies
- Have national workshop/forum identify promising technologies and encourage efficacy testing
- Convene top public and private leaders to address top barriers to widespread adoption
- Create Community-sponsored Chronic Care Innovation awards
- Coordinate private (e.g., venture capital) and public (e.g., interagency initiatives) funding pools focused on innovative chronic disease management technologies