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Leveraging data integration to manage chronic conditions


Is digital health integration the missing link in understanding chronic diseases and what should physicians be asking to ensure the data they want to receive is captured effectively?

Recently, a 3-million-patient health system began developing remote monitoring programs for patients with chronic conditions, such as hypertension and type 2 diabetes. Its motivation for investing in preventive technology is not being driven by reimbursement incentives, which many argue will be the stimulant of a value-based care shift.

Instead, this health system is being driven by a single, stark reality: over the next three to five years, a large number of physicians are retiring and even fewer are entering the workforce. By 2019, this health system is expects its 2,500-to-1 patient-to-physician ratio to increase to 5,000-to-1.

Addressing the imminent physician shortage will be a challenge for health systems that are already facing escalating regulatory pressures, an increasing number of patients, and a growing elderly population being treated for chronic conditions. The challenge of managing more patients with fewer resources is not unique. Stop gaps such as extending clinic hours, hiring Advanced Practice Registered Nurses, and investing in medical education are necessary, but like many protocols in healthcare, these only treat the symptoms, not the root cause.

The best way to confront an increasing patient population with a decreasing workforce is by implementing remote monitoring and patient-generated health-data (PGHD) integration strategies that yield more productivity. By delivering patient-generated and other data when and where it is needed, providers can more easily and effectively deliver prompt and efficient care to control costs and improve clinical quality.

Remote monitoring efficiencies through mobile

Disease management programs are commonplace, but extant services are often comprised of routine in-person visits, weekly or monthly care management phone calls and staff that manually record patient-reported data. The challenges of this time- and resource-intensive, hands-on model are often first noticed in rural populations. When a patient's medical institution may be two or more hours away, making regular face-to-face visits is cumbersome and unrealistic. The expenses associated with repeatedly traveling long distances and making recurrent phone calls becomes more burdensome when a patient is pre-chronic. On the provider side, there is usually not adequate reimbursement available for the follow-up visits needed to help prevent the onset of a condition. Technology, specifically solutions producing and integrating PGHD, can be leveraged to address many of the challenges faced by patients and physicians today.

For example, Sutter Health in Northern California has implemented a remote monitoring program for patients with hypertension. Patients enrolled in the program use their smartphones to download the program's app and, with the assistance of nurses, connect a blood pressure monitor, weight scale and consumer-grade physical activity tracker to the mobile application. Patients take readings with these devices daily and receive educational tips to keep them engaged. The patients’ data feed into a Sutter-created dashboard that integrates with the electronic health record (EHR) and gives care coordinators the ability to determine at a glance how well thousands of patients are responding to their medication and adhering to protocol. The program also identifies patients who are not performing as well as expected.

The utilization of remotely-collected patient data enables Sutter physicians and care teams to devote resources to patients who need care the most, and allow healthy, adherent patients to continue managing their condition without interruptions.

Next: Preventive care


Preventive care yields financial benefits

This model of leveraging PGHD to scale resources and focus efforts on sick patients, while also monitoring healthy patients presents tremendous potential for the future of patient care. However, adequate prevention-based financial incentives for health systems and individual practices for these types of programs is not yet a reality.

Brockton Hospital, part of the Signature Health System in Massachusetts, in partnership with iGetBetter, appears to be overcoming that challenge. The health system is leveraging PGHD to reduce readmissions for patients with heart failure and chronic obstructive pulmonary disorder. These efforts have led to remarkably improved patient care and outcomes, but more relevant, Brockton has witnessed a substantial cost savings. A pilot involving 31 heart failure patients conducted in 2014 aimed to reduce readmissions utilizing connected blood pressure monitors and weight scales. Data from the devices fed directly into iGetBetter’s care management portal.

Without this intervention strategy, Brockton typically experienced a 28% readmission rate, which would have meant eight of the 31 patients in the pilot at a cost of $27,000 per readmission. In this study, zero patients were readmitted, leading to an immediate savings of $216,000. Programs like this demonstrate the immediate value of PGHD and provide a useful incentive for helping clinicians and IT staff begin to understand how to effectively capture and utilize patient data generated outside of the clinical setting.

Opportunities for provider organizations of all sizes

Much of the talk about leveraging PGHD is centered on work being done by large health systems in major metropolitan areas. Individual and regional practices can take advantage of contributed data without these institutions’ large IT budgets by utilizing the Centers for Medicare and Medicaid Services (CMS) reimbursement codes that incentivize disease prevention, remotely monitoring patients with multiple comorbidities, and remote collection and analysis of patient data. Outsourcing care management to third-party companies is also becoming an option. In exchange for a monthly fee, these companies will coordinate care for patients, monitor treatment protocol adherence and even offer around-the-clock nursing access to patients by phone or mobile app.

Engaging with patients in preventive care measures, whether through mobile or other means, and obtaining access to in-time status data, is essential to improving clinical outcomes and controlling costs amidst the impending physician shortage. By capturing and integrating reliable PGHD with other EHR data to guide clinical interventions and care decisions, health systems will have an advantage that will pay off in care quality and financial returns.


Drew Schiller is the co-founder and chief technology officer of Validic, a digital health platform provider.

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