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exponentially greater. It is vital that
communications technologies can revolutionize health care in the same way that they have transformed other sectors of the U.S. economy. The health care sector lags every other major service industry in its investment information technology. For instance, financial-services companies invest 11 percent of their revenues in information technology to improve the quality of their services, the diversity of their products, and efficiency by moving the point of service closer to the consumer. The health care industry invests 2 percent. The vicious cycle of health care cost increases is one reason for this underinvestment, as it diverts funds from strategic information-technology investments to providing current services in a continuous crisis mode. Technology investment in health care has focused on high-tech diagnostic devices that reinforce an acute care model. The more routine, day-to-day management of chronic conditions calls for a different breed of information and communications technologies that facilitate ongoing monitoring, patient education, and care coordination to improve outcomes and reduce costs.
Section 649 of the Medicare bill makes explicit the connection between deploying information
Proven Models of Technology-Based technology and successfully managing care of
Chronic Care Improvement chronic illness, and between monitoring patients and evaluating outcomes. This The VA is a model of technology-based section of the law allows physicians in the chronic care improvement in action, and demonstration areas to participate if they
shows the impact of such programs in agree to "the use of health
improving quality and information technology to
patient satisfaction and manage the clinical care of Medicare reform's chronic caro lowering the utilization of eligible beneficiaries ..." and Improvement provisions
expensive in-patient "the electronic reporting of underlino how Information and
hospital services. The VA clinical quality and outcomes
is directly responsible for measures Summarizing
communications technologies the health care of 6 what Section 649 hopes to can revolutionize health care million veterans. That accomplish, CMS recently In the same way that they have
grown stated, "This demonstration transformed other sectors of
rapidly in recent years aims to promote continuity of
because of eligibility the U.S. economy. care, to help stabilize
expansion that has medical conditions, to
outpaced the agency's prevent or minimize acute exacerbations of budget."
mismatch between chronic conditions, and to reduce adverse responsibilities and resources has forced the health outcomes, such as adverse drug VA to transform its model of care, with an interactions."15
emphasis on reducing spending associated
eHealth Initiative data. 17
Robert Roswell, M.D., Transforming VA Healthcare, U.S. Medicine, January 2003.
©2004 All Rights Reserved
with the highest cost beneficiaries – typically communication with the patient through the patients with chronic diseases.
use of technology. With that also comes an
increase in the patient's involvement in their Technology-based chronic care improvement health status. Through technology, we can has been a linchpin of the VA's transformation provide care on an 'as needed,' 'just in time" effort. Patients with chronic conditions who are basis.' at risk of hospitalization receive in-home monitoring devices which require no in April 2000, the Veterans Integrated computer skills and hook up to an ordinary Services Network in Florida started programs phone line - upon being discharged from the to maintain veterans with high-risk chronic hospital. The devices enable those veterans to conditions in their homes under a technologymanage their own illnesses,
based model. The VA in 2002 providing guidance and
released an analysis of these feedback based on the Through technology, wo
programs that showed a 40 information they provide, while can provide care on an percent reduction in emergency keeping them connected on to 'as needed,' 'Just in
room visits, a 63 percent care providers at a VA hospital
decrease in time" basis.'
hospital or clinic. Each day, these
admissions, a 60 percent drop patients and their devices
in bed days of care, a 64 engage in what amounts to a
percent decrease in nursing conversation an automated program of home admissions, and 88 percent scripted communications that is personalized reduction in nursing home bed days of care. to their needs. The device advises patients to Patient satisfaction rates topped 90 percent. contact the VA if one or more of their The VA has achieved similar results in responses indicate that their conditions are expanding the programs to 10 other states deteriorating. The dialogue varies each day and territories. 20 based on a patient's progress in the educational program and to ensure that the Building on its success with technology-based interaction stays fresh and interesting.
chronic care improvement programs, the VA in
2003 established the Office of Care VA nurse care managers review patient Coordination (OCC) to oversee the roll-out of responses each day to identify and respond to such programs nationally. The og is potential problems. Care managers log on to a operating under a set of core principles that Web-based application that tracks the data include implementing a patient-centric model generated by patients using their in-home of care and "(m)aking the home the preferred monitoring devices. Responses from patients place of care whenever appropriate." The are assigned color codes – green, yellow, and OCC's ultimate goal is to expand care red - associated with a risk level that reflects coordination to 1.2 million veterans by 2008.21 their health status, based on the information the patient provided. They follow up by phone The chronic care improvement model is also with patients whose conditions have been spreading to Medicaid. Driven by the flagged as red for high risk or yellow for continuing squeeze on budgets, 31 states medium risk, and who may not have called in between 2002 and 2004 will have established upon being prompted by the device.
or expanded chronic care improvement
"We no longer have the resources to see a patient multiple times a year, 'just in case they may have a complication developing," Dr. Robert Roswell, who at the time was Department of Veterans Affairs' Under Secretary for Health, wrote last year. "We must find new ways to manage our patients' disease processes continuously on a 24-7 basis and see the patient 'just in time' when a complication or need starts to develop. There will be a need for increased
J. Cherry, K. Dryden, R. Kobb, P. Hilsen, N. Nedd,
Department of Veterans Affairs Office of Care Coordination, Office of Care Coordination Outline for Strategic Direction, 2004-2008.
©2004 All Rights Reserved
programs.22 The Centers for Medicare and
Decision-support tools that enable Medicaid Services in February 2004 sent a
care providers to identify and respond letter to state Medicaid directors urging further
to problems based on evidence-based adoption of chronic care improvement
practice guidelines; and initiatives, with the incentive of federal
Clinical information databases for matching funds.? The letter specifically
evaluation of outcomes and defines chronic care improvement as
monitoring the performance of the covered medical service that can be provided
program. by nurses, pharmacists, or physicians. While chronic care improvement programs have realized their earliest successes primarily in Realizing the Promise of Technologyintegrated delivery systems such as the VA, Based Chronic Care Improvement the letter notes that a variety of approaches are now being developed for implementing The recent Medicare Trustees' report proves such programs in a fee-for
that continuing with the current service environment, including
crisis-driven model of Medicare contracting with disease- Government and private is not sustainable, and that, management organizations or efforts to shift the
without changes, the system individual fee-for-service
model of care from a
will be bankrupt by 2019. physicians.
Despite the fact that anything 20* century acute care
unsustainable must eventually Examples of success at the VA system to a 21* century change, and the widespread and private organizations such
chronic care system can recognition that improving as Pacificare demonstrate that help turn the tide.
chronic care for an aging a chronic care improvement
population is essential, many program built on an integrated
obstacles remain to technology solution is appropriate and implementing the chronic care improvement necessary to provide high quality chronic care model. These include: at home that also saves money by preventing hospitalizations. These programs incorporate
A lack of awareness of the existence the major elements and requirements of
and proven effectiveness of a model chronic care improvement that the new
of chronic care improvement that Medicare law prescribes, including:
employs an integrated technology
solution for monitoring and patient In-home monitoring devices that guide
and high-risk patients in daily
evaluation of outcomes and program exchange of relevant clinical
performance. information, including health self
Systemic incentives that remain assessment, symptoms and vital
aligned toward providing care when signs;
patients get sick, as opposed to Personalized guidance and support
keeping them well. through the vehicle of the in-home communication devices that also Government and private efforts to shift the facilitate patient education about self- model of care from a 20th century acute care care behaviors;
system to a 21st century chronic care system Nurse care managers who serve as can help turn the tide. Policy makers can take the point of communication with these steps to speed the shift by ensuring that patients, and who provide a conduit the promise of the Medicare reform bill is for education of and collaboration realized: between physicians;
Ensuring that Section 721 of the Kaiser Family Foundation, "States Respond to Fiscal
Medicare Modernization Act is a Pressure: State Medicaid Growth and Cost Containment."
success by requiring that Medicare September 2003 23
chronic care improvement programs, CMS press release, "CMS urges states to adopt disease management programs, agency will match state
particularly for patients with chronic costs," February 26, 2004.
conditions at risk of hospitalization
©2004 All Rights Reserved
and/or developing complications, most typically afflict the elderly - is an issue embrace proven approaches that that confronts govemments in advanced postintegrate in-home monitoring and industrial societies around the world. The communication devices, decision- Japanese government and European Union support tools, and clinical information increasingly are looking at technology-based databases evaluation of ou omes chronic care improvement programs as a nonand program performance.
zero-sum proposition that can improve the Using the authority granted by the lives of citizens and keep health care budgets Medicare bill to push for faster, more under control. wide-ranging roll-outs of proven chronic care improvement strategies. Japan and the European Union also see Using CMS' power as the world's chronic care improvement technologies as a largest payer for health care services promising direction for economic growth. A to push the U.S. health care delivery September 2002 European Commission report system to adopt the chronic care noted, "On the economic side, the health improvement model, through telematics market is expected to grow from increased education for physicians, less than 1 percent of the health expenditure and hospitals, and patients about in Europe to some 5 percent by 2005. This chronic care improvement approaches would make it a major industrial sector with proven effectiveness.
comparable to the pharmaceutical industry.
More significantly, this will be achieved while Chronic care improvement programs that save containing the total cost of health." lives and save money offer the U.S. a nonzero-sum solution to one of its biggest policy The U.S. government has identified the conundrums – providing quality health care to opportunity for American leadership in Americans at a cost the nation can afford amid technologies for chronic care improvement. the aging of the population. In
The Department of the absence of that
Commerce in late Technology-based chronic understanding, the policy
February released debate continues to focus on care improvement programs
report on what it called the zero-sum game of shifting give policy makers tho rarost the telehealth industry, costs; raising taxes, premiums, of opportunities - to manage calling it a huge potential and co-payments; and cutting a potentially diro problem
market whose growth is benefits. while turning it into an
currently impeded by
domestic regulatory Federal Reserve Chairman engine of economic growth.
barriers, such as Alan Greenspan reflected that
Medicare reimbursement strain of thinking in recently recommending
practices and state licensing requirements. that Congress consider steps, such as raising At a Capitol Hill briefing accompanying the the retirement age for Baby Boomers, to
release of the report, Commerce decrease pressure on Medicare and avert a Undersecretary Phil Bond called telehealth a crippling increase in taxes. "In view of this "global opportunity," adding, "It's the ultimate upward ratchet in government programs and export opportunity with the expanding markets the enormous uncertainty about the upper Overseas. bounds of future demands for medical care, I believe that a thorough review of our spending Technology-based chronic care improvement commitments - and at least some adjustment programs give policy makers the rarest of in those commitments is necessary for opportunities to manage a potentially dire prudent policy," Greenspan told the House problem while turning it into an engine of Budget Committee in February The aging of the population with the
European Commission, "Resource Book of IST Projects attendant increases in chronic illnesses that
relating to Health,September 2002.
U.S. Department of Commerce Office of Technology
Policy, Innovation, Demand and Investment in Telehealth, 2* Testimony before the U.S. House of Representatives
National Journal, Technology Daily PM Edition, Budget Committee, February 25, 2004.
February 26, 2004.
2004 All Rights Reserved
technology providers, employee groups, employers, payers, and government institutions to make better use of information technology resources.
economic growth. The chronic improvement model shifts our thinking from raising taxes and cutting services to transforming health care to keep people healthier at a lower cost. Medicare is the world's largest payer for chronic disease - and has been paying dearly for the complications of unmanaged chronic illness. Medicare now has the chance to become the world's largest payer for chronic care improvement services and enabling technologies. In doing so, it can lead in creating a sustainable U.S. health care system for the 21st century, while spurring innovation in the information-technology industry answering the global need to improve the lives of aging populations.