The key to population health: Know your chronic disease patients and coach them

In my column last month, I talked about the need for a new physician interface that sits on top of the EHR and integrates data from multiple sources. This interface could also help us make use of the vast amount of consumer-generated data headed our way, via fitness trackers, smart watches, and phone and tablet apps. But only if we integrate it carefully.


Few physicians are eager to have that data pouring into their EHR. What are we supposed to do with this stuff? How do we make it useful? We don't need to know every step recorded by a Fitbit, and we don't need all the data from healthy patients. That said, there is a place for some of this data within our efforts to create a healthier nation.

U.S. ranks low because we don't manage chronic disease well
Population health is critical to the future of healthcare in the U.S. Compared with other developed nations, the U.S. has ranked poorly on cost and outcomes. This is predominantly our inability to effectively manage chronic disease, which shortens people's lives, degrades their quality of life and costs the U.S. healthcare system enormous amounts of money. If we learn how to effectively manage chronic conditions, and avoid hospitalizations and serious complications, we can improve life for patients and greatly reduce the ballooning cost burden we all share.

Caring for patients with chronic conditions is one of the toughest jobs we face as physicians, because these patients need help every day, not just in the clinic. We need to coach them toward better health behaviors. To do that, we need two things: frequent contact with the patients and accurate data about their health and activities.

Using remote monitoring and telehealth
The combination of remote monitoring and telehealth can give us the power to really change lives. To use this new technology efficiently, though, the data needs to be a part of a physician's regular workflow and the most relevant data needs to be presented in a clear, easy-to-use dashboard. If the data is hard to find, it won't be used. Physicians are too busy already, and they don't have the bandwidth necessary to work with a new system or decipher poorly presented data.

We also need to be cautious about the source and quantity of data we integrate. We don't need every step from a Fitbit, and we don't need all the data from patients who are in great health. They currently don't need our help and coaching

What we need is precisely targeted data from reliable, medical-grade monitoring devices used by patients who need coaching. There is a place for data from activity trackers within the system, but it needs to be appropriately filtered and integrated with data from devices that monitor glucose, blood pressure, weight and other vital signs.

There also needs to be a carefully thought-out program of feedback and coaching to make this data meaningful to the patient. Ideally, the physician's team should include a well-trained health coach to design a feedback plan for each patient (with the physician's input). The coach doesn't have to be on the physician's staff, as there are plenty of options for delegating this task to an outsourcing company that specializes in telehealth and health coaching.

Data integration is pivotal
There are two interesting approaches to integrating this data: a new user interface that marries data from the devices with EHR data and presents a comprehensive dashboard; or an integration platform that sends data to the physician's EHR and displays the dashboard there.

Whichever route is taken, the key is to provide a system that is seamless with caregivers' routine workflow, so the data is instantly accessible, properly filtered and analyzed, and presented in a dashboard that gives relevant data to guide treatment and coaching decisions.

A real-life example that works
One example of a chronic disease management system that uses remote monitoring data and telehealth is at Baystate Health, a large community-based integrated health system in Western Massachusetts. Baystate is part of the Pioneer Valley Accountable Care Organization, which was recently designated as one of the first Next Generation ACOs in the country by CMS. Baystate developed an innovative program integrating remote monitoring and telehealth in care delivery. The program was led by TechSpring, Baystate's technology innovation center.

It uses a solution from Health Net Connect to proactively monitor patients with diabetes in an effort to reduce or eliminate 30-day readmissions. Health Net Connect sends telehealth-equipped suitcases to diabetic patients. The suitcase contains tools needed to monitor the patient in their home, such as a tablet for virtual visits and a glucose meter.

Patient data is recorded by the tablet and sent securely via cellular connection to the Health Net Connect dashboard used by Baystate's clinical teams.

It is critical that care managers are able to quickly view patient data from remote monitoring in the same interface with all the other patient data. No extra applications should be needed to access the data, no manual input required, no change to the clinician's workflow. Easy access means less time wasted and more physician and patient engagement.

But making the data available within existing EHRs or care management platforms takes the right technology. Health Net Connect talks in JSON and an EHR might only speak HL7. (Disclosure: I work for Dell, the company that provides the integration engine used to do the translation from JSON to HL7 for Health Net Connect.)

The alternative to the EHR-based dashboard is a new application type being developed by a number of entrepreneurs, many of which are expected to hit the market in the next year.

Know them well, coach them daily
The success of population health and chronic disease management efforts hinges on a few key elements: identifying those at risk; having access to the right data about them; creating actionable insights about patients; and coaching them daily toward healthier choices. It's not really rocket science, but it does require the right technology and a coordinated plan to make it effective and affordable.

The key to successful disease management requires integration into the clinical workflows and environment.'That was the focus of Baystate's program, which requires trial and error. Technology is secondary; overcoming the barriers of adoption is the real work and real need.

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