Driving Care Management Home: EHR and Patient Self-Monitoring
Health plans have begun to use biometric devices to assist in managing chronic diseases such as diabetes, asthma and chronic heart failure. These devices include glucometers, electronic scales, spirometers and sphygmomanometers. They generate data that, when analyzed through a clinical rules engine, share early indicators with providers and patients. Studies indicate that this approach improves selfcare by patients. Despite implementation challenges associated with cost, configuring technology for the home setting and integrating the process with EHR, some benefit plan designs and reimbursement programs use biometric devices to drive better outcomes.
Why Use Biometric Devices?
Biometric devices educate and empower the patient, increasing awareness, accountability and responsiveness.When integrated with EHR, these devices extend benefits beyond the patients immediate realm. Information also reaches physicians and healthcare professionals in real time, enabling proactive treatment.
Every health plan contains a group of people under case management for chronic diseases. Of those with conditions such as chronic heart failure, diabetes or asthma, the most severely affected account for an overwhelmingly high percentage of total treatment costs. They also tend to reap the benefits of EHR with biometric device integration and therefore tend to participate meaningfully when this approach is launched.
Clinical rules engines drive the true value of integrating biometric devices with EHR. These rules engines do not simply generate values with date and time stamps, they generate knowledge (based on objective algorithms) about trends and other key diagnostic issues related to those data.
The Glucometer
The glucometer checks blood sugar levels for diabetic patients. A 2003 study of veterans revealed that self-monitored blood glucose testing drives clinically important and sustained results. [1] When integrated into EHR, the device helps physicians ensure that their patients follow directions, and it tracks the results.
The Sphygmomanometer
The sphygmomanometer, which measures blood pressure, is typically used by patients with chronic heart failure or diabetes with elevated blood pressure. A three-month study showed significant improvement in nurse-managed telemonitoring of patients with chronic heart failure when EHR incorporated these devices. [2] The strategy reduces hospitalizations related to chronic heart failure, myocardial infarction and stroke.
The Electronic Scale
Generally used by patients with chronic heart failure, the electronic scale measures body weight. Mortality rates are significantly reduced for patients using technology-based daily-weight and symptom-monitoring systems. [3] In addition, inpatient visits decrease by an average of 57 percent and related delivery costs drop about 55 percent per patient per year. [4]
The Spirometer
The spirometer helps asthmatic patients measure peak respiratory flow on expiration. Spirometer studies have demonstrated significant improvement in mean quality of life scores after 12 months. [5] These studies also show that implementing a comprehensive disease management system increased expenditure on asthma drugs by 45 percent, but reduced hospitalization costs for asthma by 146 percent, total costs by 21 percent and total direct healthcare costs by 22 percent.
The Benefits, Risks and Challenges
For patients, linking self-monitoring devices to EHR provides many significant benefits. This approach increases proactive selfmanagement and enhances communication with physicians and other healthcare providers for improved outcomes and better quality of life.
Improved communication with patients means physicians can track compliance with instructions more meaningfully, versus use of patient-generated and usually incomplete paper calendars. Access to fundamental real-time clinical information leads to more timely and useful interventions between office visits.
Health plans see improved participation in chronic disease management programs, with consequent reductions in cost. Integrating biometric devices with EHR also makes it possible for health plans to collaborate with pharmaceutical organizations, academic medical centers and other entities. Finally, by having the same view of the same data, health plans and physicians can integrate their care plans and reinforce each others activities.
The major risk of integrating biometric devices with EHR is inefficiency or wasted activities due to false positives or device use by someone other than the patient. Proper tools and processes for identification can overcome this obstacle.
The primary challenge to implementing EHR/biometric device integration relates to behavior change on the part of patients and providers.
Although it would seem fundamental that patients would modify their behaviors to improve their quality of life, incentives tend to accelerate compliance. For example, health plans can improve glucometer compliance rates by waiving one month of co-payments for insulin or providing a 10-percentoff coupon for use at the pharmacy. Studies have shown that such approaches work well, especially for economically disadvantaged patients.
From the physicians perspective, changing processes means new and different ways of working with patients and a consequent increase in activities such as checking Web summaries or receiving pager notifications of patient trends. Health plans generally use two models to encourage physicians to accept these changes. They either pay a fee per member per year or enable billing for technology consults, such as patient communications via email. (These incentives must include timely requirements for reacting to information generated by biometric devices to manage liability concerns.)
Costs and technology challenges associated with integrating biometric devices can be considerable. Volume dictates the cost of technology, so projects must involve a significant population of patients and physicians to be cost-effective. Patients must receive devices costing from $100 to $200 and, in many cases, e-calendars ranging in cost from $400 to $500. This does not include ordering, packaging and shipping of equipment to each patient. Decision makers must determine whether to use wireless, telephony or some combination of both technologies. Rules engines must be developed and configured. Portals must be developed for physicians, patients and health coaches. Training and other support also comes into play.
Where Does It Stand?
Although some health plans have begun to integrate biometric devices into EHR as part of disease management programs, activities have not progressed much beyond that level. As success stories spread, however, the true value of this approach will become better known and appreciated. Having access to a continuum of data based on proactive information from real-time testing will prove too compelling to ignore.
Endnotes
- Diabetes Outcomes in Veterans Study [DOVES], Diabetes Care, June 2003.
- American Journal of Hypertension, 2003 and Heart Lung®, 2001.
- American Heart Journal, October 2003.
- Disease Management, 2003.
- American Journal of Respiratory and Critical Care Medicine, International Conference of the American Thoracic Society, Toronto, Canada.
