Contributor: Giving Clinicians Top-line Data to Help Manage Chronic Conditions

According to CDC data from the 2018 National Health Interview Survey, about half of American adults have at least 1 chronic condition—so it’s no wonder physicians and nurses spend so much time on chronic care management. They could spend less time, but one of the factors hindering their progress is a lack of access to hallmark indicators that can mark the progression or control of a disease.These indicators, also known as key indicators, are simply a collection of 6 or 7 measures that a clinician can monitor over time to track the status of a specific condition. For example, indicators for diabetes include blood sugars, glucose levels, renal function, and foot neuropathy.

If a health care provider has access to these hallmark indicators at the point of care, they are much better prepared to engage the patient, their family, and homecare providers and make sure they know that these things must be monitored closely to avoid problems. Real-time monitoring and reporting of hallmark indicators facilitates better communication among the provider, the patient, and the payer and makes chronic care management vastly more efficient. However, the success of this dialogue depends on the availability of comprehensive, problem-oriented views of clinically contextual information for providers at the point of care.

Presenting hallmark indicators on a “dashboard” at the point of care gives physicians and nurses at-a-glance access to a patient’s historical data and enables them to identify trends and understand where a condition is heading much more easily. The problem is, most clinicians have no such access to this information. Many indicators are lab results––not compiled in a list for a specific condition and often scattered throughout an electronic health record (EHR), along with everything else. They require time and effort to locate.

But there are exceptions. One such a dashboard is in place at Phoenix Children’s Hospital. It features over 60 disease-specific panels displaying key indicators for clinicians to use at the point of care. By actively monitoring a hallmark indicator for juvenile arthritis––joint counts––the hospital has reduced disease progression by about 80%. Viewing joint counts observed both in the physician’s office or from patient reports, then coupling that information with medications and lab tests, physicians can determine how to improve outcomes by fine-tuning medications. They are improving the quality-of-life needle both for the afflicted children and those monitoring their condition. Phoenix Children’s Hospital employs these dashboards to monitor 60 distinct diseases, ranging from gastrointestinal disorders to chronic lung conditions––and realizing similar results.

What does this illustrate? When clinicians are provided the condition-specific data they need in an accessible, consumable format, they can improve outcomes much more easily. And the same is possible for most chronic conditions because they all have hallmark indicators. It’s simply a matter of providing the right information in the right place, at the right time, to the right person.

Payers also benefit from this information. Payers are concerned with reducing costs, which is achieved by keeping members out of the hospital and carefully managing their chronic conditions. The technology to make this connection exists. For example, there are many home monitoring systems that provide data directly from the patient to the EHR, and then to the doctor. This allows the care team to see in real time if they are treating, for example, a particularly vulnerable patient with diabetes who requires frequent adjustments to their insulin. It’s a common-sense approach to connecting the dots.

The same applies to chronic obstructive pulmonary disease. Shortness of breath can be reported on a phone and recorded into the EHR. When the physician is alerted of critical findings, intervention can begin earlier. Similarly, with congestive heart failure, sudden weight increase can indicate water retention, which could signal an exacerbation. At home, patients can track their weight on scales that log results to a smartphone app. If a provider and a patient are communicating—even electronically—alerts can be set up, allowing the provider to respond in real time. The weight increase could be resolved with something as simple medication adjustment. Again, access to indicators and an automated dialogue are essential.

This new breed of real-time tracking is becoming mainstream and will only become more sophisticated over time. Apple now offers a watch that detects atrial fibrillation and will soon add blood sugar monitoring. Such advances will facilitate chronic care by providing real-time data so that interventions can be applied before patients become critically ill.

In my 16 years as an internist, I treated many patients with 4 or 5 different conditions—often with overlapping or common indicators. When you multiply this by the number of patients on a practice’s panel, you get a sense of how much data are flooding the medical record.

So, how does a clinician, in a timely manner, navigate and sort that voluminous patient data and find the information needed for a specific condition? To be effective, the presented information must be filtered—purged of “clinical noise” to allow the clinician to focus on a particular problem. Then they can easily switch to the next problem and focus on that to make the needed decisions.

Clinicians are constantly putting this type of information into clinical context––in their heads. However, given the immense volume of incoming data, things can easily be missed. We have the technology, so why not let the computers do filtering, sorting, and presenting and allow clinicians to focus on their core function––driving better patient outcomes.