Bridging the Cultural Chasm

Despite the lack of decision- or health-support systems in healthcare today, patients and physicians alike are being held increasingly accountable for the healthcare decisions they make. Both lack access to the broad array of information in healthcare — including such things as specific clinical and patient information, practice guidelines and drug interactions — that is critical at every point of decision making and care to provide the best possible outcomes. And according to a report by the Markle Foundation, no single entity in our increasingly complex, fragmented and pluralistic healthcare system is capable of, or responsible for, collecting and maintaining all of the important health information about any one individual (Achieving Electronic Connectivity in Healthcare: A Preliminary Roadmap, Connecting for Health, July 2004).

It is now generally accepted that the healthcare system needs electronic connectivity in every aspect, and that this can best be achieved via a central, readily accessed electronic health record (EHR) and a patient-controlled personal health record (PHR). Given the formidable task of instituting complete EHRs with full connectivity among providers, it is unlikely to happen in the near future.

Compared to the technological complexity of creating standardized EMRs, the development of PHRs seems simple. Both however, are entwined in a cultural chasm that will prove challenging and that can only be addressed through health support systems that enhance the patient-physician relationship, exchange valuable information in ways that both patient and physician find convenient and useful, and that put the patient at the center of care.

Physicians have for so long been the ones in control of the medical record that delegating or sharing any of that responsibility will require as much of a shift in thinking and training as it will in systems. Likewise, patients are used to, and in many cases reluctant to shift away from, the notion that “doctor knows best,” despite the fact that best practices are provided only about 50 percent of the time.

Personal health information is usually dispersed among multiple providers and participants. Health plans, generalist and specialist physician offices, hospitals, laboratories, pharmacies, pharmacy benefit managers and disease management organizations all collect some (and sometimes duplicative) information.

Patients with chronic illness and their caregivers need access to their medical information to actively manage their conditions in collaboration with their practitioners. But the reality is, they typically don’t have easy access to such information — nor do they always know they need it. Patients need to be provided tools to integrate and manage all of their information across all providers and across time. Practitioners are poorly prepared for the necessary and imminent shift in information collection and management, collaborative patient participation and, ultimately, patient control.

Some providers, however, can play a significant role in setting the stage for what will be a huge paradigm shift in healthcare where patients move from peripheral positions of decision making to central positions of decision making and information control.

Disease management companies are uniquely positioned to facilitate both greater electronic connectivity between multiple providers and patients/caregivers, as well as support, prepare and facilitate the patient and practitioner for the paradigm shift in decision making and information control. As experienced health coaches with access to a broad array of clinical information, disease managers can teach patients how to be the model patients for the 21st century — fully informed, involved patients managing their health conditions in collaboration with their practitioners.

Disease management collects a vast amount of clinical information and puts it in the hands of patients and physicians in ways that patients can understand and physicians and patients can use. Disease management organizations can serve as the conduits of electronically collected, organized and stored clinical information to practitioners and patients, thus helping them build and populate their EHR/PHR.

Disease management supports and enhances the patient-physician relationship and educates people with chronic conditions about the best ways to partner with their physicians and optimally manage their diseases. Think of disease management as everything that happens between the time patients leave the doctor’s office and the time they return. Disease management reaches out to people in whatever way they deem most convenient and supports them in the same way they live with their disease, which is 24 hours a day, seven days a week, 365 days a year; not just the five, 10 or 15 minutes they get with their physicians during a typical office visit. Support can be as simple as advising someone with diabetes what they should or shouldn’t eat when they go to their favorite restaurant. Or it can be as potentially life saving as advising a cardiac patient who is experiencing shortness of breath to consult the doctor.

Disease management works from within the system, but it doesn’t wait for patients to show up in the doctor’s office or the emergency room. Using claims and other data, disease management is capable of identifying thousands of patients with any disease and engaging them in structured and repeated interactions. Those interactions build personal relationships and trust, resulting in the kinds of changes that get and keep people healthier. Such interactions lead to a vast array of clinical information stored electronically that can be readily transmitted to the patient and their practitioners (EMR and PHR respectively).

The healthcare system necessarily must move to more evidence- based practices to eliminate the quality gap in healthcare. So far evidence-based information has been disseminated almost exclusively through the physician. But with the advent of the Internet and the more empowered healthcare consumer, patients can have access to evidence-based information to guide them in their shared decision making.

Some physicians have been initially skeptical of disease management services, but as our system moves to a more “pay-forperformance” model of reimbursement and recognition, doctors will ultimately see the value of informed, involved and responsible patients partnering with them to achieve the best and most costeffective outcomes.

Given that our healthcare system continues to make more demands on doctors without giving anything in return, it’s easy to understand their frustration and their reluctance to latch on to what they may feel is just another “cure du jour.” Even in our technological age, many physicians still don’t have the technological infrastructure to support these demands, much less take on additional information from other sources. HealthLeaders magazine reported that fewer than 15 percent of all physicians use the advanced technologies available, mostly because they’re cost –prohibitive, but also because of the uncertain return on investment and the inherent difficulties associated with implementation. Much of that will change as the federal government pursues various solutions, incentives and changes in reimbursement policies.

And while disease management companies are already heavily invested in state-of-the-art technologies, they must do a much better job of leveraging that technology to meet the needs of physicians and patients and work even more closely with them during this paradigm shift in healthcare.

Disease management is not just opening the door of possibility, but is leading the way to innovation in all aspects of information technology — including the commitment to help bring greater connectivity to patients and practitioners by supporting and contributing to the development of an EHR/PHR.

Case in Point

As part of a pilot program, HealthSpring of Tennessee and its disease management partner Healthways, are working collaboratively with the Sumner Medical Group (SMG) to develop an EHR that provides the most pertinent and up-to-date information possible to physicians and patients when they need it: at the point of care and healthcare decision making.

HealthSpring already was experiencing good clinical and financial results with its disease management program, HealthSpring Cares, but it saw the potential for even better outcomes through further and closer integration with physicians. The resulting payfor- performance pilot with SMG includes a dozen primary care physicians and approximately 1,400 patients — most of them Medicare Advantage members — in the HealthSpring Cares disease management program. The pilot provides for an active exchange of information between physicians and chronic care nurses to track patient interactions and adherence to standards of care. The goal is to more closely align the health plan, the patient and the provider with the goals of the disease management program and drive further improvements in health outcomes, in patient and physician satisfaction and in healthcare cost reductions. Participating physicians are eligible for a 20 percent performance bonus based on improved quality and outcomes measures, and patients are more accepting of the program because they are introduced to it by their physician.

HealthSpring and Healthways provide a nurse at SMG who is responsible for communicating with the entire healthcare team. They have established a process to provide a one-page abstract at the end of each office visit, which is shared with the HealthSpring Cares nurse manager, who is now contacting patients by phone on behalf of the physician’s office rather than HealthSpring. A synopsis of the nurse care call is then relayed back to the physician — another data point for the EMR. Work is under way to transmit this information electronically and in real time, providing the physician and the disease management nurses both with upto- date and vital information.

Most of the patients in the program recognize their nurse manager’s voice when she calls. Janet DePriest is the disease management nurse assigned to the program. She says patients often share certain things with her that they may feel uncomfortable sharing with their physicians, and it’s her job to take the time necessary to help them work through it, help them know the right questions to ask their doctor and to help interpret what the doctor has said. Physicians at SMG note that DePriest is often able to discover social factors or problems that patients are sometimes reluctant to share with their doctor. Patients are also much more likely to tell DePriest than they are their doctor when they don’t fill or don’t take their prescribed medication.

“I have people tell me all the time that they can’t talk to their doctor about certain things, and so we talk, and I try to help them devise a plan of what they’re going to say once they get to the doctor’s office, and I tell them these things aren’t going to embarrass the doctor, and we sort of develop a plan,” DePriest says. “Sometimes people are uncomfortable questioning the doctor so they say their nurse told them to ask. They don’t want to question the doctor, but it’s OK for me to.”

DePriest also stresses with patients the importance of keeping track of their health to share with their doctor at the next visit — in essence she is helping patients take the first steps to building a PHR. She has steadily helped increase the number of patients in the program who are keeping logs of their blood sugars, letting them know that it helps their doctors better regulate their medication. If something unusual is happening with a patient, DePriest explains to them the importance of logging the details of that as well. She lets them know that the more detailed they can be with their doctor, the better decisions the doctor can make.

“I let them know that it’s going to help the doctor if they can tell him not just that their sugars are low, but that they’re always low around 11 o’clock at night, and it always happens the day they skip their lunch. Or if they’re feeling dizzy, it’s going to be a lot more helpful to the doctor if he knows they were dizzy three times this week when standing at the kitchen sink. These kinds of details really help put all the pieces together,” DePriest says.

Plus, now that the physicians at SMG have the potential to share in the financial reward for helping improve clinical outcomes, they see the disease management provider as part of the team instead of part of the problem.

The physicians at SMG are no different from their peers across the country, who, a recent study by Duke University Medical Center found, are being overwhelmed by the needs of patients with chronic diseases such as high blood pressure, heart disease and diabetes. According to the study, published in the May/June 2005 issue of the Annals of Family Medicine, new team-based approaches to care, changes in healthcare reimbursement and informed and proactive patients are essential to meet the healthcare needs of the burgeoning chronic disease population.

According to HealthSpring, early indications are that its attempt to realign the system is driving improved clinical quality measures and, as a result, cost savings that appear to be far in excess of the pilot program’s costs. The next step is adopting new technologies that will drive further integration and more online collaboration between the physician practice and the disease management provider.

Similar to provider networks across the country, some form of EHRs exist in only about half of all physicians’ offices in the HealthSpring network. HealthSpring’s vision is to generate enough savings as it rolls out more pay-for-performance pilots to pay for more investment in technology and to encourage physicians to reinvest performance bonuses into technology within their practices.

The ultimate goal is to create an open data exchange, giving physicians in-office access to Healthways’ EMR, Population Works, and making sure physician offices’ EMRs can talk to PopulationWorks. As simpler, more automated and better integrated systems are being developed, the focus must remain on what’s important to the physician and the patient at the point of care.

Disease management organizations also are ideally suited to educate patients about how to become informed and proactive consumers interacting with their information and making informed decisions about their care. Healthways is developing a program that will actively teach patients how to become better consumers of healthcare — showing them how to collect, manage and store their medical records and information, how to set and monitor target goals for health conditions and how to better collaborate with their physicians — assuming much more responsibility for their health information, health decisions and healthcare outcomes.

Summary: Keep It Simple and Focused

Modern society produces and disseminates information at a faster clip than even the most educated employees at our country’s largest and most sophisticated corporations can keep pace (McKinsey Quarterly 2005). Almost daily there are new, and often conflicting, reports about drug therapies, diseases, medical treatments and scientific breakthroughs. Every month approximately 30,000 new medical journal articles are published around the globe. The “information superhighway” that was supposed to help simplify our lives has in many ways added to the overload.What physicians, patients and their caregivers need most are tools and systems to help them cut through the clutter and stay focused on what’s important at the moment decisions are being made and care is being delivered.

Just making medical records available electronically isn’t going to do it. Patients have to become engaged and involved in their own care. PHRs encourage that, but healthcare consumers must be taught how to start and keep track of their PHR. Physicians need support to track and follow up with patients between office visits. The good news is that work has already begun and it doesn’t have to wait on the development of widespread, widely adopted EMRs.

Disease management companies are uniquely positioned to facilitate greater electronic connectivity between multiple providers and the patient/caregiver as well as support, prepare and facilitate the patient and practitioner for the paradigm shift in decision making and information control.