That's why Friesen was glad to see one of her older female diabetic patients come in for a recent appointment. Two years had passed since this patient's last exam, well beyond the recommended interval. When the patient's visit was finished, she remarked, on her way out the door, that "her period had returned," the internist recalls. Concerned about uterine bleeding, Friesen ordered an immediate outpatient biopsy, which revealed the patient had endometrial cancer. "She had a hysterectomy and is now cancer-free," Friesen says.
The internist credits the EHR-and its adjoining analytics features-with saving the patient's life.
Here's how: First, Friesen was provided a quality report from Kaiser that compared the relative control her panel of diabetic patients had of their disease compared with similar patients treated by the internist's peers in the 800-physician multi-specialty practice. Friesen's next step was to act on the data. "I saw I was lagging so we did outreach, and started calling patients" who were overdue for a visit, a chore also facilitated by the EHR, from Epic.
The system cycled the data on patient lab scores and other indicators through an adjoining analytics feature called Health Trak, which greatly expands her capabilities to track and monitor her chronic patients, says Friesen. She worked in a private group practice-one without an EHR-for over a decade before joining Kaiser, a highly automated integrated delivery system with its own health plan and employed physicians. "In the private world, no way would I have gone through the charts, pulled out all the labs and visits, and said, 'Hey, you have to call this patient.'"
A national crisis
Friesen's story underscores two key facts about chronic disease management. First, the rise in chronic diseases-one reflected in the rapidly rising incidence of obesity-represents a major clinical and financial challenge to the health care industry (see box, page 29; see sidebar on story about one hospital's effort to reduce overweight among its own employees, this page). Facing unsustainably escalating costs, both private and public payers are beginning to offer incentive payments around successful chronic disease management programs. Second, the successful management of chronic conditions largely depends on patient compliance and involvement, which is making caregivers rethink the traditional doctor-patient relationship. "It's the partnering with the patient that can make a difference," Friesen says.
Given these two facts, a growing number of providers are turning to EHR and related technology at the point of outpatient care-the front line in chronic disease management-to add any number of vital tools to the physician arsenal, including chemistry tracking, alerts and reminders, and documentation templates. They also set the stage for a patient portal, which, for providers like Kaiser, is expanding the doctor-patient relationship.
Not all physicians, however, are convinced of the utility of an ambulatory EHR in tackling chronic conditions. Some favor chronic disease management systems (see sidebar on how one California county improved population health, page 30), which target populations, not individuals.
Regardless of disease tracking preference, many providers are turning to I.T. to keep patients in the loop between visits-and thus avoid clinic absences that can result in deteriorating conditions. Here, text messaging, interactive voice response systems, and even direct downloads from medical devices in the patient home are playing an increased role. Providers are also looking to data exchanges to coordinate care among primary care and specialists-which many describe as the missing link in chronic disease management.
Help wanted
When it comes to chronic disease, no doubt that providers need help. At Mound Family Practice, a four-physician group in Miamisburg, Ohio, at least half the patient visits pertain to chronic conditions, says Brent Ashcraft, M.D., president. "We treat the metabolic syndrome kind of things," he says. "Diabetes, hypertension and hyperlipidimia high cholesterol are the top three."
Mound Family Practice has been using EHR technology, from Greenway Medical, for five years. The EHR's lab reporting and tracking features are valuable for chronic disease management, Ashcraft says. The group has customized a "master chemistry flow sheet," a graphical representation of a battery of lab scores and other key disease indicators.
Labs flow directly into the EHR via an interface with Quest Lab, populating the flow sheet. Ashcraft can now track historic values dating back nearly four years, when the practice turned on the interface. The EHR also charts other data not on the chemistry flow sheet, such as weight, blood pressure and pulse, which combine in a vital signs section.
For the office visit workflow, patients do their lab work prior to the visit, giving Ashcraft the chance to review the results face to face. The practice also performs EKG readings, which Ashcraft says many of his chronic condition patients require annually. Those readings also port directly to the EHR. "I can compare up to four historical EKG results at once," he says.
Communication effort
The EHR has the capacity to send and receive fax documents directly, a capacity which comes in handy with chronic condition patients, Ashcraft adds. For example, he asks some patients to fax in copies of their blood sugar scores they take at home between visits. Those documents append to the chart as an image file, as do other reports from radiologists or consulting specialists.
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