Chronic Care: Wagner's Chronic Care Model

Over 100 million people in the US are suffering from at least one chronic illness. "Three-quarters of the $2 trillion-plus that we spend on U.S. health care each year goes to paying the bills for chronic illness: cardiovascular and pulmonary disease, cancers, diabetes, arthritis, high blood pressure, depression."

The Chronic Care Model focuses on practice improvement for patient-centered evidence-based proactive care of chronically ill populations.

Science and Society's February 2009 edition features an audio interview with Ed Wagner, the father of the Chronic Care Model. The interview reviews the implications of the chronic care model for "redesigning the health care delivery system, creating a better-prepared practice team, and developing methods for increasing patients’ knowledge, skills, and confidence." Improving Chronic Illness Care provides a video overview of the Chronic Care Model by Dr. Wagner.

1500 medical practices are using the Chronic Care Model. The Chronic Care Model "comprises six interrelated system changes: effective team care; planned interactions; self-management support; community resources; integrated decision support; and patient registries and other supportive information technology (IT)."

From a technology perspective, registries, decision support, patient/provider communication, patient education and information exchange for care coordination are all important enablers. "Registries track patients with specific chronic diseases, helping medical teams to make the most of each office visit and follow evidence-based care guidelines."

The chronic care model is designed to address the deficiencies in current practice of chronic care including:

• "Rushed practitioners not following established practice guidelines
• Lack of care coordination
• Lack of active follow-up to ensure the best outcomes
• Patients inadequately trained to manage their illness"

Health Affairs January/February edition was dedicated to The Crisis in Chronic Disease. Susan Dentzer finds that "the evidence continues to pile up that the famed Chronic CareModel developed by Ed Wagner and colleagues at Group Health Puget Sound delivers superior patient care and health outcomes. (The evidence is starting to trickle in about the model’s overall cost-effectiveness.)"

In a recent interview, Dr. Ben Littenberg summarized that "the Chronic Care Model is a very influential idea about how to do a good job in taking care of people with ongoing medical problems like high blood pressure, arthritis, and in our case, diabetes. It tells what resources the health care system must have to get the most out of the interaction between the doctor and the patient. These include systems to support clinical decision making, up-to-date and easy-to-use clinical information, reminders, support for patient self-management, and so on. Turning a typical primary care medical office into a fully-functional chronic care model practice is a good thing, but it is complex, expensive and time-consuming. It requires extensive retraining of the physicians, nurses and other staff, installation of comprehensive electronic medical records systems, changes in the way patients and staff interact, and even an overhaul of the way care is paid for. So, very few practices have successfully transformed themselves."

Roberts Wood Johnson had contracted with Rand to evaluate the impact of the Chronic Care model. "Highlights of the findings include:

• Organizations were able to improve, making an average of 48 changes in 5.8 out of the 6 CCM areas;
• Patients with diabetes had significant decreases to their risk of cardiovascular disease;
• CHF pilot patients more knowledgeable and more often on recommended therapy, had 35% fewer hospital days;
• Asthma and diabetes pilot patients were more likely to receive appropriate therapy.

When contacted a year later, the care teams reported that involvement in the collaboratives was rewarding. Over that year, 82% of sites had sustained the changes and 79% of sites had spread change to other places or diseases."

Dr. Wagner is focusing his current efforts on regional models for chronic care.


The Chronic Care Model was developed in part with support from Robert Woods Johnson grant by Improving Chronic Illness Care with direction and technical assistance from the The MacColl Institute for Healthcare Innovation at the Group Health Center for Health Studies.

The Week in Review - March 26, 2009

A look back at some of the best news stories (and some entertaining diversions) from the week in health care.
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"The number of medically disenfranchised has reached 60 million" according to a report from the National Association of Community Health Centers.

David Blumenthal, the new National Coordinator for Health Information Technology, weighs in on stimulating the adoption of health information technology. John Glaser will join David Blumenthal as an ONC advisor for 6 months, while retaining his role at Partners Healthcare.

Dr. Ashish Jha talks about the conversion to electronic medical records in this NPR interview. He found that "comprehensive" EHR systems are used by only 1.5% of hospitals and only 7.6% of hospitals have a "basic" EHR.

The California HealthCare Foundation releases a report on patient registration kiosks delivering value and increased patient satisfaction. Yet they are adopted by less than 10% of healthcare organizations.

Drs. Bates, Halamka and Middleton make the case for the effectiveness of healthcare technology.

Will IT Save Healthcare? on National Public Radio's "To the Point".

Can technology enable patients to be better advocates for their own care? The Wall Street Journal reports on how patients use "information therapy".

CCHIT plans to accelerate advanced technology certification programs in Clinical Decision Support, Interoperability, Quality and Security in order to better align with the objectives in the ARRA stimulus package.

Chronic Care: Improving Patients' Quality of Life

The March 16 edition of the American Journal of Managed Care reports that a "laboratory-based decision support system designed for low cost and easy integration into primary care... showed significant improvements in clinical care and health care utilization." The study was funded in part by the National Institute of Diabetes and Digestive and Kidney Diseases.

Dr. Ben Littenberg (MD, FACP) is the principal investigator for the study. He is the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing and Director of General Internal Medicine for the University of Vermont College of Medicine. He is also CEO of Vermont Clinical Decision Support which distributes the Vermedx® Diabetes Information System (VDIS), the subject of this study.

Dr. Littenberg sat down with Healthcare Technology News to talk about his findings.

HTN: Can you please talk about Wagner's Chronic Care Model and its influence on your work?

Ben Littenberg: The Chronic Care Model is a very influential idea about how to do a good job in taking care of people with ongoing medical problems like high blood pressure, arthritis, and in our case, diabetes. It tells what resources the health care system must have to get the most out of the interaction between the doctor and the patient. These include systems to support clinical decision making, up-to-date and easy-to-use clinical information, reminders, support for patient self-management, and so on. Turning a typical primary care medical office into a fully-functional chronic care model practice is a good thing, but it is complex, expensive and time-consuming. It requires extensive retraining of the physicians, nurses and other staff, installation of comprehensive electronic medical records systems, changes in the way patients and staff interact, and even an overhaul of the way care is paid for. So, very few practices have successfully transformed themselves. When we designed Vermedx(R), we took as much of the chronic care model as we could while still maintaining very low cost per patient, very little disruption of the clinical work-flow, and no requirement that the practice invest money on computers or other fixed costs.

HTN: What is the current state of technology to assist in the management of diabetes?

Ben Littenberg: Drugs for diabetes have gotten much better in the last 20 years. Also, we know a lot now about how to prevent the complications of diabetes - heart attacks, strokes, kidney failure, blindness, amputations, and so on. However, it takes a lot of very careful attention to lots and lots of data. How high is the blood sugar? When was it measured? When should the cholesterol be tested again? How close is the patient to goal? Office systems have failed to keep up with the needs of the patients and providers. Paper records just don't work well in this setting. A typical laboratory report shows the numeric value of the result and a so-called "normal" range, but it doesn't tell you what the test means or what to do about it.

Most offices have no organized method for keeping track of all the blood and urine tests used in diabetes, let alone a system that reminds the patient when a test is due and even advises the doctor on what to do.

HTN: How is VDIS different?

Ben Littenberg: Vermedx automatically collects the laboratory test results on diabetic patients and reports them to the doctor (or other health care provider). It puts the test results into context, shows trends over time, and suggests actions. It also takes action when a test should have been done, but wasn't. It sends reminders to the practice and letters (from the providers) to the patients encouraging them to get into care. If the test results are very high, it also notifies the patient to get back to the practice to change the care plan. Vermedx also provides a population view of the doctor's entire panel of diabetic patients: who is doing well, who needs help, and how the practice is doing compared to others.

HTN: Your study found a sustained continuing decrease in utilization that is striking. Please tell us about the results.

Ben Littenberg: With NIH funding, we conducted a long-term randomized study of VDIS in community primary care. Over 7,000 patients in 64 practices participated. The patients in that study who received VDIS reported far fewer trips to the Emergency Room, unscheduled hospital admissions and doctor visits than patients who didn't get VDIS. The problem was that we didn't have access to the medical bills in that study. The recent study in the American Journal of Managed Care looked at patients getting Vermedx as part of their usual care and was able to compare the insurance claims paid to other diabetic adults who did not have Vermedx. Before VDIS was available, both groups had steadily rising costs month-by-month. The control patients' claims kept going up, but less than a year after turning on the system, the VDIS patients' claims started going down. The savings were $504 per patient in the first year, went up to $3,563 in year 4, and kept getting better!

HTN: For the VDIS patients, what were the differences in health outcomes?

Ben Littenberg: VDIS patients are much more likely to get their laboratory tests on time. Although they are no more likely to reach goals for blood sugar or cholesterol, they spend less time in the Emergency Room and hospital, which indicates a substantial improvement in quality of life.

HTN: Understanding that your study does not suggest causality between VDIS and utilization, what is your hypothesis about the relationship?

Ben Littenberg: Actually, the first study was randomized and therefore, does provide good evidence of causality. However, nobody is entirely certain how it works. Since the blood test results aren't different, it probably doesn't work by preventing complications. One theory is that improved communications give patients confidence - they know that they will be back in touch with the doctor and don't need to call for every little issue. It's like those reminder postcards to get your car's oil changed. You know you're going to bring the car in soon, so you might be less anxious about getting service right away for some funny noise under the dashboard. Of course, you're also being seen on a schedule - before you have an emergency!

HTN: VDIS sends alerts to both physicians and patients. What is your view of the relative effectiveness of focus on the physician or focus on patient self-management?

Ben Littenberg: They both seem to be valuable. The core idea behind the Chronic Care Model is to activate the patient to get involved in their care AND prepare the practice to meet that patient's needs. Working on both ends of the relationship is much more effective than either one alone.

HHS Names National Coordinator for Health Information Technology

HHS has named Dr. David Blumenthal to the post of National Coordinator for Health Information Technology.

Blumenthal is an expert in health policy and health care systems and is the founding director for the Institute of Health Policy at Mass General.

According to his bio, "Dr. Blumenthal’s research interests include the extent and consequences of academic-industrial relationships in the life sciences; professionalism and the determinants of physician behavior; the organization and financing of physicians services; the dissemination of health information technology; and quality management in health care organizations." Blumenthal served as Senior Health Advisor to Barack Obama during his campaign.

The Week in Review - March 19, 2009

A look back at some of the best news stories (and some entertaining diversions) from the week in health care.
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Is it that "Obama's EHR push (is) not so easy to execute"? Or is it a "bad bet on medical records"? Or is it an "$80 billion exaggeration"?

On the other hand, perhaps it's the "staging (of) a revolution".
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It's the right thing to do, but will fee-for-service providers think so?: Technology to "skip the doctor's office".

Employers are intensifying efforts around managing chronic health conditions.

Bargaining down self-pay bills.

Does the bad economy cause patients to A) put off surgery, b) rush to surgery, or c) all of the above?

Massachusetts eHealth Collaborative forms a for-profit subsidiary to advise nationally on EHR implementations, health information exchange and quality reporting with board members including John Glaser and John Halamka.

Health Affairs dedicates an entire issue to stimulating health IT.

And more on the stim package: "Broad federal initiatives for biomedical and comparative effectiveness research, the adoption of health information technology, and the protection of the privacy and security of medical records, the stimulus law should have major and immediate effects."

Northshore UniversityHealth System and Kaiser Permanente hospitals achieve HIMSS Analytics Stage 7 advanced implementation level for the patient record.

Large DNA study of the underpinnings of Parkinson's disease announced by 23andMe.

P4P process and technology adoption "have not translated into breakthrough quality improvements."

And lastly on health care reform, David Kibbe and Brian Klepper describe the "intensifying collapse of the health care system."

ARRA's Impact on e-Prescribing

On March 16, Reuters reported the results of a study analyzing the impact of the stimulus package on e-Prescribing. The study predicts that e-prescribing utilization will almost double in five years, compared to what it would have been without ARRA (the Amercian Recovery and Reinvestment Act of 2009).

The study forecasts a striking reduction in adverse drug events of over 3.5 million in 5 years and a half million reduction in hospitalizations. Total savings are forecast to be $56 billion, including federal government savings of $22 billion.

The study was sponsored by an interested party (PCMA) and conducted by Visante.

Not If, But When

In their March 16 edition, the American Medical News (published by the AMA) reports that it is "no longer a question of 'if'" physicians should invest in health care information technology. Bonuses to physicians are maximized if certified EHR's are operational by 2011 or 2012.

The lead highlights the significant financial benefit for physicians who "must act quickly to achieve the biggest benefit and avoid penalties." And contrary to many reports, AMNews gets it right in describing the payment of $35 billion in Medicare and Medicaid physician incentives. The net $20 billion normally associated with the health care technology stimulus includes the offsetting penalties that begin in 2016.

For the full explanation of bonuses and penalties (pdf) click on the graphic below:

Getting By or Getting Better?

There are 20 billion reasons to be hopeful about the passage of the stimulus plan’s HITECH provisions. Certainly the plan will drive greater physician and hospital adoption of EHR's and will ultimately help improve coordination of care across health care settings. The CBO believes that there is a roughly 3:1 financial return on this investment. That’s all good news.

But will the stimulus plan provide the lift that hospitals and systems need to realize the full potential of EHR’s, improving outcomes and reducing costs? Or will hospitals do just enough to justify reimbursement and to avoid future fee penalties?

The investment and implementation choices that are made today will be with us for a very long time. And there is reason to be concerned with the outcome.

I recently spoke with the president of a publicly traded large healthcare tech company that does business with most hospitals in the US. I asked for his take on the stimulus program and its effect on his business. His response was that the stimulus plan was certainly needed, but was insufficient to restore hospital capital spending on technology. His view is that the US Treasury's plan for the capital markets is much more critical to financial recovery in healthcare.

The best way to test this hypothesis is with the credit rating agencies that evaluate risk and financial health of healthcare organizations. Fitch Ratings recently released their special report on 2009 Nonprofit Hospitals and Healthcare Systems Outlook which found that hospitals "will be severely tested and under intense pressure over the next 12- 18 months."

The outlook is "negative" (a very strong word for a credit ratings agency) based on "constrained access to capital, a deteriorating payor mix, elevated interest rates, severe investment losses, ... increasing uncompensated care and higher capital costs." They forecast that government reimbursement will remain constrained by the economic crisis, employers will continue to shift healthcare costs to employees and small employers will face greater challenges providing healthcare for their employees. "These factors, coupled with increasing unemployment and declining utilization will likely depress operating profitability well into 2010... Economic stimulus initiatives and healthcare reform efforts could be beneficial over the longer term but are not expected to provide significant immediate relief."

Financial market conditions including swap risk, the collapse of variable-rate demand bonds, the lack of fixed-rate debt, pension fund obligations and higher capital interest costs are all contributing to reduced liquidity for hospitals.

For many hospitals, the level of days cash on hand, a key financial operating metric, has fallen 20-30% from 2007 to 2008. In addition, hospitals are facing operating pressure related to increases in uncompensated care and declining utilization, which is expected to reduce profitability for 18-36 months. Fitch expects that hospitals will respond by "curtailing or deferring capital spending, reducing staffing, cutting costs to bolster profitability... (and) anticipates these actions to continue throughout 2009..."

Hospitals can expect "volumes to continue declining as consumers delay or postpone non-urgent procedures and as unemployment levels continue to rise." While reimbursement levels should be adequate, hospitals should anticipate "continued increases in bad debts and charity care..." A recent AMA study on the impact of the economic crisis on hospitals reinforces many of these findings.

Fitch contends that hospitals are going to need to focus more on driving revenue and productivity gains. (For examples of these initiatives, see High Margin Revenue Cycle Strategies.) Reflective of a more strategic view of healthcare technology, "the degree to which providers have invested in health information technology can also influence Fitch’s assessment of long term viability."

Fitch concludes that "while much work remains to be done in defining, funding and implementing meaningful change in the healthcare industry, a common theme of various federal and state reform proposals centers on creating payment incentives that encourage value – the delivery of effective, appropriate care in an efficient manner."

With this backdrop, it’s easy to imagine a few scenarios where hospitals treat healthcare technology as a strategic enabler, and many other scenarios where hospitals work to just get by, doing enough to reap the financial reward but no more.

In one of its few moments of inspiration, Congress gave HHS the authority to define "meaningful use" of healthcare technology. The "meaningful use" metric determines whether providers are paid for their EHR investments.

Historian Paul Johnson said that "the word 'meaningful' when used today is nearly always meaningless." Given the many pressures on hospitals to just get by, this one key definition, and the way it is operationalized, may define the trajectory, results, patient outcomes and costs that we live with for years to come.

The Week in Review - March 12, 2009

A look back at some of the best news stories (and some entertaining diversions) from the week in health care.


Aspirational goals and a lion's roar at the summit. The knives stayed sheathed through this opening act.

The coming ICE age in healthcare technology - a terrific article by futurist Mark Anderson

What aisle are your EHR's in?

A CEO talks about the economy and its effect on the medical center. Up to $20 million in operating losses means job cuts - - just not sure how many.

Will hospitals address EHR "meaningful use" by getting by or getting better? Meditech Community Bulletin gets the scoop on a future Healthcare Technology News article.

Telehealth: Is there a "doctor in the mouse"?

"Combating alert fatigue" in e-prescribing.

Not sure what sort of crowd is going to show up... The latest medical wiki has big names behind it and social networking baked in.

Highlights of medical news of the obvious.

Grand Rounds is published at DocGurley.com and highlights a "glimpse at the horror show that is ICD-10 (undoubtedly R-rated due to inappropriate complexity)."

LOL Award - First place goes to HISTalk (Inga) for: "Finally, I just want to know if it was a man or a woman who created this product."

The Uninsured Crisis

Health Care Reform is a critical and central topic to our national financial well-being, the health of the population at large and the health of our industry. As such, Healthcare Technology News will cover news on Health Care Reform

The Institute of Medicine has released the pre-publication version of America's Uninsured Crisis: Consequences for Health and Health Care. The IOM Committee on Health Insurance Status and Its Consequences found that the country is "caught in a downward spiral: health insurance coverage is declining and will continue to decline."

Some of the committee's key findings include that

• "Health insurance coverage in the US is declining and the situation will get worse. The crisis is engulfing employer-sponsored insurance, the cornerstone of private health coverage, and also threatens expansion in public coverage.
  
• Despite the availability of some safety net services, there is a chasm between health care needs and access to effective health care services for uninsured children and adults. Health insurance coverage in the United States is integral to individuals' personal well-being and health.
• Local health care delivery appears to be vulnerable to the financial pressures associated with high community-level uninsurance rates. Analyses commissioned by the committee and other recent research strongly suggest that when community-level insurance rates are relatively high, insured adults are more likely to have difficulties obtaining needed health care."

This last finding is counter-intuitive and the process by which this occurs is not well understood by the committee. Nevertheless the committee found that "higher community uninsurance is negatively associated with several well-validated indicators of access to and satisfaction with health care for privately insured adults including having a place to go when sick, having a doctor's visit, visiting a doctor for routine preventive care and seeing a specialist when needed..."

The report also refers to the Center for Studying Health System Change which found that "problems in local health care delivery - not necessarily attributable to uninsurance - can be intensified by higher uninsurance rates. For example, providers and capital investment tend to locate ... away from communities with high uninsurance...", among other factors.

The committee concludes that the US must work "on an urgent basis to achieve health insurance coverage for everyone and, in order to make that coverage sustainable, to reduce the costs of health care and the rate of increase in per capita health care spending."

Link here to IOM's report brief on "America's Uninsured Crisis".

ICD-10 Regulations Are Final (again)

Upon taking office, White House Chief of Staff Rahm Emanuel called for a regulatory review that included ICD-10 and related transactions. That review is complete and the regulations stand as originally issued.

The March 5th notice from CMS states that "a determination has been made that the effective date will not be extended and the comment period will not be reopened for either of these rules. The first rule finalizes new code sets to be used for reporting diagnoses and procedures on health care transactions. This final rule replaces the ICD-9-CM code sets, developed nearly 30 years ago, with greatly expanded ICD-10 code sets. The second final rule adopts updated versions of the standards governing electronic transactions under the authority of HIPAA. The updated versions replace the current standards and will promote greater use of electronic transactions... The final rules provide compliance dates of Jan. 1, 2012 for the transaction standards and Oct. 1, 2013 for the ICD-10 code set."

For a more in-depth review of regulations, see ICD-10: No Time to Relax.

The Week in Review - March 5, 2009

This is a new segment looking back at some of the best news stories (and some entertaining diversions) from the week in health care.
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So why is reforming health care so important or so hard?

The "other woman" of health care reform: Nancy-Ann DeParle.

Twittering in health care, seriously?

Obama's health care budget: kicking the can down the road? Or a down-payment on a reform?

Timing is everything. As Obama's budget is released, the Institute of Medicine reports on the chasm between health care needs and access to health care for the uninsured. And the ramifications? "Needless illness, suffering and even death".

A windy city look at the evolutionary changes happening across the healthcare spectrum: Crains (registration required) opines on Medical Evolution.

The latest Grand Rounds is published, featuring a Healthcare Technology News piece on health care IT's impact on complications, mortality and cost (it's all good).

Health care systems: Do they lead or lag the financial industry in analytics? John Halamka unleashes (gently) in Business Week.

For the strangest health care non-story of the week: In a sidebar column, CDC reports that "alleged beer pong / herpes simplex study is a hoax". The Colbert Report delivers further insight (warning R-rated):

The Colbert ReportMon - Thurs 11:30pm / 10:30c

Beer Pong Herpes Outbreak

Revenue Cycle Tightens for Physician Practices

by Vic Arnold, Managing Partner, A2M Resources

The current economic problems reported through the media are having an impact on healthcare that is profound. Large institutions in all parts of the country are announcing layoffs, reporting revenue declines and halting plans to build new facilities. Closer to home, physician practices are seeing a rise in ‘non-traditional' self pay patients as patients lose their jobs and move to COBRA or self pay status. Recent studies by the Institute of Medicine have even shown that the rise in the un-insured is impacting whole communities in a very negative way.

Efforts to 'improve the revenue cycle' are too often started after things are so bad that only radical (and expensive) change must be made and, money that could have been made is lost.

In the current economic environment, the need to maintain a well structured revenue cycle (meaning maintaining efficient and effective patient financial management, business office and contracts management functions) is in sharp focus.

Here are ten signs that the revenue cycle needs a tuneup:

1. The billing manager does not have an active performance improvement plan in place to achieve industry standard metrics such as: Days in A/R > 90, Charge Lag Variance Analysis, Net Collection Rate, and Write offs as a percent of the total A/R.

2. The claims payment first pass rate is less than 85%.

3. The electronic remits are less than 70% of total payments posted.

4. The billing office does more things than the following core needs:

• Charge Management & Edit Resolution
• Claim Production & Payor Claims Filing
• Payment Posting & Credit Balances
• Insurance Balance Follow Up
• Self Pay Follow Up
• IT functions to support the revenue cycle

5. The compliance plan has not had an external review by a competent firm or attorney in more than 3 years.

6. The charge master and charge forms (including electronic tools) have not been updated in more than 6 months.

7. The staffing plan for the revenue cycle has not been moved to a mathematically driven model based on transaction volume.

8. Payor meetings and reimbursement/contract reviews are not being done monthly/quarterly.

9. IT Vendors have not been on site to work with the staff in more than 90 days.

10. Cash collections have dropped more than 5% year over year and contracts have not been reviewed in over 6 months.

Given the economic climate, practices need to zero in and make a concerted effort to generate more revenue off the same level of physician productivity. Within the bounds of the compliance rules, physician groups should focus on the natural tendency of all systems (and the revenue cycle is a system) to go retrograde over time.