Preparing for an Aging Population and Improving Chronic Disease Management

Abstract

New models of health care delivery are inevitable. There is likely to be increasing emphasis on patient self-monitoring, health care delivery at patient homes, interdisciplinary treatment plans, a greater percentage of medical care delivered by non-physician health professionals, targeted health educational materials, and greater involvement and training of informal caregivers. The Information Technologies (IT) infrastructure of health systems will need to adapt. We have begun sorting out the implications of this future within a County public hospital system: defining the desirable features, relevant technologies, necessary modifications to the network, and additional data elements to be captured. We seek to build an infrastructure that will support new patient-focused technologies designed to more efficiently and effectively support older individuals. We hypothesize utility to further exploring the impact that new health care delivery models will have on health systems’ IT infrastructures.

Introduction

In the face of an aging population, increasing chronic disease, anticipated shortages of many types of health care workers, and soaring health care costs, new models of health care delivery are inevitable. Between 2005 and 2030, the number of adults aged 65 and older in the United States will increase from 37 million to over 70 million.¹ “An epidemic of chronic disease” confronts the American health care system.^1,2

Even now, chronic disease accounts for three-quarters of America’s direct health expenditures,^{3, 4} with eight out of ten older individuals challenged by one or more chronic diseases.³ In response, the Institute of Medicine has recommended that models of care be redesigned, and that provider and patient roles be broadened to achieve greater flexibility.¹ Technology will enable systems of health to be more integrated and reliable, addressing the needs of older adults in a more efficient and effective way.⁵ Remote-monitoring technologies will extend the reach of health care professionals into the home.¹ Technologies that support activities of daily living (ADLs) will facilitate greater independent functioning of older adults.¹

From the perspective of older adults and their informal caregivers, many of these redesigned approaches are likely to be welcome. A majority of older adults are very motivated to remain in their homes as long as possible.⁵ Patients and their informal caregivers are likely to increasingly become active and effective participants in their care plans.¹

Features of IT systems to support chronic disease management

Health systems’ IT infrastructures and tools will need to adapt to a variety of new health care delivery models and increasingly prevalent technologies. Many of these technologies can help maintain independence among older adults.^{3, 5, 6}

Below, we discuss a number of interacting health care trends and technologies that seem likely to influence future information system development: emerging health care delivery models including the medical home model, medication optimization, remote patient monitoring, personal health record (PHR) systems with secure email, electronic patient questionnaires, videoconferencing, and related notification systems.

We anticipate the need for new technology-driven methods to more effectively engage family members in the monitoring and medical care of patients. Emerging Web 2.0 technologies will likely facilitate multi-disciplinary collaboration among providers, families, and patients in creating and executing care plans. Although not discussed further, we anticipate increasing need to support home visits with the ability to write offline clinical notes and wireless VPN capability.

Support for emerging models of health care delivery

Table 1 lists fifteen models of chronic care found by Boult et al. to improve at least one important outcome.⁷ These outcomes include increased survival, decreased costs, lower health care utilization, and increased quality of care. Especially as reimbursement strategies evolve, a number of these (or similar ones) will likely emerge as dominant approaches.

Table 1:

Fifteen successful models of chronic care as determined by Boult et al.’s systematic review⁷

Interdisciplinary primary care

Care and case management

Disease management

Preventive home visits

Comprehensive geriatric assessment, geriatric evaluation and management

Pharmaceutical care

Chronic disease self-management

Proactive rehabilitation

Caregiver education and support

Transitional care

Substitutive hospital-at-home

Early-discharge hospital-at-home

Care in nursing homes Prevention and management of delirium

Comprehensive inpatient care

Many of these models emphasize patient self-monitoring, health care delivery at patient homes, interdisciplinary treatment plans, a greater percentage of medical care delivered by non-physician health professionals, targeted disease-specific health educational materials, and greater involvement and training of informal caregivers.

Support for the Medical Home model

To improve care coordination, multiple national health organizations have recommended adoption of the patient-centered medical home model.^{8, 9} This model emphasizes an ongoing patient relationship with a primary care physician charged with leading a team of individuals at the practice level, collectively taking responsibility for all of the patient’s medical care.

Our organizations are outlining IT enhancements that will facilitate such local adoption. These include:

• Identification of a primary care provider (PCPs) for all patients followed in the outpatient setting

• Lab and referral tracking – End-to-end tracking of lab and referral orders (i.e., ordering, completion of the lab test/referral, and delivery of the test result/consult to the primary care provider)

• Alerts to PCPs about their patients who have been admitted, discharged, or visited the emergency department

These medical home efforts will be supported by our state-wide regional health information network, the Indiana Network for Patient Care (INPC).¹⁰ Such community-based information systems have been noted to be important to alleviating fragmented care across the clinic, hospital, acute rehabilitation, and extended care settings so often visited by older adults.¹¹

Medication optimization

The Center for Technology and Aging has noted three areas of opportunity for medication optimization: 1) medication reconciliation, 2) medication adherence, and 3) medication monitoring.⁶ It has been estimated that medication non-adherence results in $100 billion each year in excess hospitalizations.¹²

We intend to optimize patients’ medications by a number of means:

• Monitor medication adherence by patient-directed questions (discussed further below) and electronic refill histories available from SureScripts and our hospital-based pharmacies. If there is evidence of missed medication refills, computer reminders will be routed to the patient.

• Provide a ready means to request refills online.

• Alert the primary care provider to suspected poor medication adherence at the point of care – e.g., when the subject is in clinic as part of a routine encounter.

• Provide the means for patients to maintain an active medication list in the PHR, as well as capture their self-reported compliance and import related electronic pharmacy data to serve as the initial list. As part of local medication reconciliation efforts, we have begun linking pharmacy data to picture images of pills. Such pictures may prove particularly useful for patients as they record what medications they’re actively taking.

• Automated review of medication lists – We intend to incorporate decision support rules, such as those derived from Beer’s criteria to decrease potentially inappropriate prescribing to older individuals.¹³

Remote patient monitoring

It has been estimated that nearly $200 billion could be saved during the next 25 years if remote monitoring tools were utilized for congestive heart failure, diabetes, chronic obstructive pulmonary disease (COPD), and chronic wounds or skin ulcers.^3,14

Devices such as weight scales, glucometers, implantable cardioverter-defibrillators, and blood pressure monitors can collect and report health data.³ In turn, these data can provide the basis of alerts to formal and informal caregivers when health conditions decline, allowing for intervention and modification of treatment plans.³ We intend to capture these data in the patient’s PHR by direct interfaces to monitoring devices, or perhaps for the short term, by manual entry. These will feed the data repository where they will be used for decision support.

PHR with secure email

While evidence supporting wide PHR adoption remains limited, these systems have the potential to help patients become active participants in their health.¹⁵ They are also frequently associated with high consumer satisfaction rates.¹⁵ As a first step, we have begun to support secure emails among providers and patients.

Electronic patient questionnaires

We are exploring the means to administer patient questionnaires using the PHR software. Validated questionnaires might provide an early signal for a decline in a patient’s clinical trajectory, allowing for timely intervention. Using devices that capture similar patient-generated information, the Veteran’s Health Administration has demonstrated improved chronic disease management, cost savings, and reduced hospital admissions and ED visits.³

Table 2 lists many of the types of data that might be collected from vulnerable patients enrolled in a chronic disease management program. Questions generally fall into one of several categories: risk indicators, adherence to therapeutic regimens, and disease-specific questions.

Table 2:

Example domains of patient questions

Geriatric issues, risk indicators of frailty, and activities of daily living (ADL) dependency

Walking speed, grip strength, rising from chair, weakness, falls, unintentional weight loss, low physical activity, fatigue, helplessness, cognition, difficulty with eating/bathing/dressing/toileting/transferring/maintaining continence.

Adherence to recommended therapies

Exercise, medications, nutrition

Chronic disease self-management

CHF – Weight, BP monitoring, symptoms such as shortness of breath

Asthma/COPD – Spirometry, symptoms such as shortness of breath, increased dyspnea, cough

Diabetes - Glucose monitoring, foot care, BP monitoring

Many questions would not need to be answered on a daily basis. For example, detailed questions could be reserved for the individual who “feels bad,” rather than “normal.” We intend to “push” some small subset of questions for the patient’s attention each time they log into the PHR. The list of pushed questions would be generated largely on the basis how long since the patient answered those particular questions.

Videoconferencing

Others have predicted that more health care will be provided remotely in the future, with patients increasingly able to communicate with health care providers from home.¹ This may be particularly valuable for more vulnerable patients, who benefit from closer attention. Videoconferencing has been found to be useful for diagnosis and treatment in specialties like neurology and psychiatry.¹⁶ It may also be useful for home-based chronic disease management.¹⁶

We are exploring the feasibility of videoconferencing to conduct group home-based exercise programs and support closer communication among vulnerable patients and medical care providers. We will strive to make videoconferencing as easy as picking up a phone. We will explore the possibility of having the subject’s workstation “ring” when a care provider is attempting to reach the individual.

Notification system

Remote patient monitoring, medication adherence, and patient questionnaire data will provide new opportunities for valuable decision support. Computer-generated alerts will need to be routed to providers. A notification system has been integrated into Regenstrief’s new CareWeb software.¹⁷ This notification system will be used to notify clinicians of secure email from patients.

Future software and IT Infrastructure

Our goal is to develop (1) a user-friendly home workstation with integrated video-conferencing, (2) enhancements to providers’ clinical workstations to similarly allow for video-conferencing, (3) an interface between a patient’s PHR and the INPC data repository, (4) a decision support engine, (5) enhancements to the communications infrastructure, and (6) potentially an interface to an interactive voice response (IVR) system.

Home workstation

We intend to implement web-based software and a hardware platform that will accommodate easy login, manual entry of clinical data into the PHR, videoconferencing, secure email with providers, and interfaces from equipment such as BP monitors and weight scales to the PHR.

A user-friendly interface might be implemented using touch screen workstations with large on-screen “buttons” to launch modules related to 1) group exercise 2) medication management 3) communication with providers, 4) remote patient monitoring data management, 5) request refills, 6) request an appointment or referral, and 7) access to the patient’s electronic health record. Screening questions with yes/no answers may help vulnerable individuals feel comfortable with the interface.

Enhancements to provider workstation

We anticipate the need to integrate videoconferencing software and a computer notification/reminder system into providers’ existing clinical workstation software.

Interface between the PHR and the data repository

Data entered into the PHR will be captured to the INPC data repository via Regenstrief’s interface engine, the open source Health Open Source Software (HOSS) Pipeline.

Decision support engine

Data collected from the patient and informal caregiver will be merged into the patient’s inpatient and outpatient electronic medical records. A decision support engine will generate appropriate computer reminders with alerts routed to providers and patients.

Eventually, patients may directly interact with robust self-management decision support tools to allow them to become even greater partners in the management of their own conditions. Such abilities may prove critical given anticipated lack of capacity in the healthcare system to adequately care for the emerging burden of disease

Interface to IVR system

An Interactive Voice Response (IVR) system will collect ADL data and transmit phone messages to program participants. The decision support engine may prove the best source of a nightly electronic list of patients to call and the messages/questions to be administered. Such mechanisms could supplement missing data important to decision support, remind patients to log in and interact with their PHR, remind patients of an anticipated need to refill their medications or imminent appointments. Reminders sent via the IVR system would also be sent to the home workstation/PHR.

Discussion

Changes in health care delivery will need to be accommodated by medical information systems over the next decades. As described by the Institute of Medicine, “simply expanding the capacity of the current system to meet the rising needs of older adults [will] not address the serious shortcomings in the care of this population.”¹ These shifts will undoubtedly stress the IT infrastructure of many large health systems. While this future is unlikely to be predicted precisely, many general characteristics of this new health care system seem within reach.

An aging population, increasing chronic disease, anticipated shortages of many types of health care workers, and soaring health care costs may finally provide the impetus for more patient-centric systems. Perhaps the most difficult challenges confronting all of these systems, however, will relate to the vulnerable populations that they seek to support.

Such patients may be cognitively impaired, partially disabled, or otherwise incapable of sophisticated interaction with new technologies. Assistive technologies that can reproduce the simplicity of canes and walkers (from the perspective of the patient) may prove most successful.

Driven by unsustainable costs, there is likely to be increasing emphasis on patient self-monitoring, health care delivery at patient homes, interdisciplinary treatment, more non-physician medical care, and greater involvement and training of informal caregivers. These will dictate the need for new IT tools and IT infrastructure. Much preparation from the Medical Informatics community is likely to be required.