Health for life

EHR portals at work?

The Disease Management Care Blog had this thoughtful reply logged onto its "Follow-Up" post on the topic of EHR patient portals. Logged by Rebecca M Coelius MD, Medical Officer for Innovation at HHS/ONC, the DMCB recognized that this was important enough to warrant its own separate page.

While we wish that the results were more conclusive and positive, the Office of the National Coordinator for Health Information Technology (ONC) applauds the meta-analysis and the recent upswing in articles on patient portals and other patient-facing technologies. The number of patients and caregivers who desire greater participation and transparency in their healthcare makes continued research in this area vital. Yet, in a close read of the full Annals of Internal Medicine meta-analysis article and in many of the studies it cites, there were unquestionably statistically significant positive clinical outcomes, as well as positive patient experiences, associated with certain patient portal functions.

The ONC does not believe that Health IT alone is a panacea, or that meeting the form of Meaningful Use, while not embracing the new functions the technologies it enables, is likely to result in measurable improvements. The study authors caution that it was case management that tipped the utility of portals from unclear or small to more substantial, but it is important to note that the case management activities happened via the portal itself. This is a perfect example of Health IT as an enabler of new ways of reaching and caring for patients; we would not separate the two concepts.

To the study’s described limitations, we offer two significant additions. First, the definition of a patient portal remains loosely specified, so it is difficult to make conclusive statements about the entire category. The meta-analysis did attempt to list which functions were present for each study, but half of the studies that looked at patient outcomes gave only a partial description of portal features, and a deeper assessment of the quality of functions and their relevance to the outcomes measured was not present for any study.

A more illustrative future approach would be to evaluate individual functions of portals for impact on patient participation in their care and specific health outcomes, and then ask what design principles and organizational contexts were necessary to make that function successful. For example, the impressive OpenNotes project demonstrated that patients with access to provider notes had a better understanding of their health and condition, improved recall of their care plan, and increased likelihood of taking medications as prescribed. In a New England Journal of Medicine study on weight loss interventions, over twice the number of patients in the remote support intervention groups (telephone, website access, and e-mail support) lost more than 5% of their weight versus the control group. Secure messaging and the ability to view personal health information are two cornerstones of portal functionality within Meaningful Use.

Second, more than 10% of these studies are ten years old, and over a third were published five or more years ago. We understand the necessity of adequate numbers for meta-analyses, but statistical significance does not necessarily confer relevant insights. Technology, and patient perences and capabilities for using technology have fundamentally changed over the study time periods included, not to mention the maturation among health-care organizations themselves and the expectations of patients.

The very premise of the patient portal is a rapidly ageing one. As the ONC articulated in a 2013 Health Affairs article, there are shifting attitudes related to the traditional roles of patients and providers, and exploding demand and penetration of smartphones, health and wellness apps, and connected devices. We are moving the conversation from engaging people with our existing healthcare system through “portals”, to using technology to move outside our system to reach them every day where health truly happens. What we need to measure and incentivize in the future is not the value of portals, but the value of delivering the right information and intervention to the right person, at the right time, through the right interface based on an individual user’s context.

"Stand up, bend over and let me see that itchy rash!"

In another lesson on how its clinical world is changing, the Disease Management Care Blog recently witnessed a "virtual" computer-based video patient-physician office visit. The patient seemed to like the convenience, while the physician reminded the skeptical DMCB that most of any medical diagnosis is based on the patient history, not the physician examination. 

It worked pretty well.  Whats more, the literature suggests that this is not all that new,  there are studies that suggest high levels of patient satisfaction and a surprising willingness to pay for the service out of pocket.  Time will tell on whether this leads to comparable clinical outcomes at an acceptable cost.

But what has struck the DMCB most of all was a business model "dichotomy."  Talk to most policymakers about virtual office visits and youll discover that it is being hailed as another advance in increasing consumer-patient access to cost-effective care.  In other words, persons living in Faraway Montana will be able to discuss their rash with the expert Dr. Windowchat anywhere in the world.  The DMCB thinks of this as the "enlightened" side of "telemedicine."

While that may have merit, when the DMCB googles "virtual office visits," it finds a decidedly contrary business model: busy and computer-savvy suburbanites with the kind of disposable income who can pay out-of-pocket for the convenience of not having to sit in a waiting room.  From a health insurance perspective, this is quite compelling, since it substitutes a lower level of service for a population that is prone to overutilization.  The DMCB knows the doctors like it better when the insurers arent involved in a high cash-flow yes-Ill-take-VISA transactional business.  This is the "real" side of telemedicine.

The DMCB suspects this is one of those innovations that offers something for everyone: increased access for those with not enough of it and "disruptive" technology for a health care industry still locked into expensive and labor intensive one-on-one doctor-patient visits.  From all points of view, this form of telemedicines future is very bright.

The Disease Management Care Blog finally caught up with it. 

Heres its take:

Its a well-written and traditionally crafted summary of CMS six demonstrations that had the participation of 34 programs:

Care Management for High Cost Beneficiaries
Medicare Coordinated Care
Disease Management for Dual Eligibles
Informatics for Diabetes Education and Telemedicine
Disease Management for Severely Chronically Ill Beneficiaries
Medicare Health Support

Why Demos?

Demos are used by CMS to test innovative care strategies before they are formally adopted as a covered benefit in the fee-for-service program. These demos were funded because CMS knows that half of all Medicare beneficiaries have five or more chronic conditions and that they account for 75% of its costs. In addition, up to 50% of beneficiaries are not receiving recommended care, such as vaccinations and cancer screening.

How Did the Demos Work?

The programs enrolled persons with a variety of chronic conditions such as diabetes and heart failure. Kick off dates ranged from 2000 to 2005. "Hierarchical condition categories" or high baseline expenditures were used to identify and target the persons at high risk. All used care coordination nurses who were typically - but not always - remote and disconnected from the physicians. There was little information on admission criteria to the programs, on the training or credentials of the care managers, the approaches used in to manage transitions across care settings or improving medication compliance.

What Was the Bottom Line?

On average, the programs were unable to achieve savings in excess of Medicares fees.

The programs reduced hospitalizations by an average of 7%. In order for Medicare to have saved money based on the disease management fees, the hospitalizations would have had to be reduced by 11%. Programs that involved greater in-person interactions between nurses and patients appeared to have greater success in reducing admissions rates.

The evaluation was also statistically stymied by relatively low numbers of patients in some of the programs. It is possible that there were savings, but if they exist, they were too small to be detected by widely accepted statistical methods.

So What DMCB Conclusions Can Be Drawn and Why?

There are two:

1.The "versions" of disease management used by Medicare from 2000-2005 relied on approaches used in commercial settings from 1995-2000. These deployed remotely stationed nurses calling patients with worrisome cost patterns. From 2000-2005, commercial insurers and employers knew that wasnt working and transitioned to more sophisticated engagement protocols as well as in-person care programs tailored for patients with high as well as modifiable risk.

In other words, the impact of later versions - like this, this and this - of disease management in fee-for-service Medicare remains largely unknown. Thats why the CBO report ends with the conclusion that....

"...the demonstration results indicate that additional experimentation, evaluation, and inement over a period of years will probably be needed to identify policies involving disease management and care coordination that can significantly reduce Medicare expenditures."

Of course, by the time CMS gets done with more years of "experiments," "evaluation" and "inement," those results will likewise be obsolete.

2. This begs the question: if Medicare cant achieve savings, why do practically all insurers and most self-insured employers still include disease management programs in their benefit designs?

The DMCB suggests that in addition to a growing body of peer-reviewed literature showing that more modern (and still untested by Medicare) disease management is "efficacious," non-governmental insurers have some additional advantages that increase real world effectiveness:

1.Using disease management as only one component in an overlapping suite of other mutually supportive programs, including consumer-based incentives to rely on primary care, value-based insurance designs, intelligently restricted networks and concurrent wellness and prevention programs.

2. Access to internal assessments of program success that will never be submitted for publication in the peer reviewed literature.

3. Flexible program adaptation to the myriad local cultural and community factors that determine success. After all, what works in a motorcycle factory in the Midwest may not work in a cubicle farm in Silicon Valley.

The DMCB Bottom Line:

While the CBO report is technically correct, it promotes the tired canard is that modern disease management consists of naive nurses making blind calls and exhorting baffled consumers to take better care of themselves. In addition, the idea that single standard can be implemented everywhere in a stand-alone fashion is a pipe dream. No wonder Medicares disease management demos have failed.

The Feds need to figure out how to implement disease management, not what doesnt work.