Vancouver’s CDM pilot takes team approach

Project focuses on the most resource-intensive of patients and uses technology to make them active partners in their own care.

By Paul Brent

It is estimated that a whopping 70 percent of British Columbia’s healthcare dollars go to treating chronic illnesses. A pilot project now under way at Vancouver Coastal Health aims to ease the strain on the province’s healthcare system by connecting specialists, family physicians, chronic disease nurses and patients in a seamless process of shared care.

The main goals of VCH’s Chronic Disease Management Care Connectivity Pilot are to ensure that important patient health data and healthcare plans are accurately and securely transmitted between care providers as well as making patients active partners in their treatment plans.

Piggybacked on VCH’s innovative and patient-centric CareConnect Electronic Health Record (EHR), the CDM pilot intends to take a team-based approach to chronic care. One of the biggest challenges is keeping track of chronic disease sufferers as they make their way through the care continuum from emergency rooms and community care facilities to their family doctors. “Through it all there is a lot of really important information and planning and health data that is at risk of getting lost between those transmission points,” said Diane Gerwin, initiative director for the CDM Care Connectivity Pilot. “Our goal is to make sure that we share, with patient consent, critical pieces of information on a need-to-know basis that each provider has access to.”

For its pilot, Vancouver Coastal Health has selected the most resource demanding of chronic disease sufferers: patients must have at least two of five conditions (diabetes, congestive heart disease, COPD, hypertension, and chronic kidney disease); be aged 19 or older (in fact, many are frail and elderly); and been admitted to hospital in the last 24 months or had two or more related emergency visits. Since last fall, the pilot has signed on 340 patients and intends to exceed its minimum test group of 500 when the pilot enters the measurement phase in September.

The CDM Care Connectivity project’s care planning and management system is based upon a modified version of Intrahealth’s clinical profile software program. “The care planning tool that we envisioned didn’t exist in its entirety in any of the applications that we were using, so we had to do some work with our providers around building that and had provider working groups to do that,” explained Gerwin. That effort included incorporating expert paper-based treatment protocols into the system and taking single disease state protocols and modifying them into “multi-disease care plans that were patient-centric rather than disease-centric,” she added.

It is still in the early days of the pilot as it began only at the start of this year; however, feedback from healthcare professionals has been positive, Gerwin said. “The technology that we are able to bring to the table is in a mature enough state that the physicians and the medical office assistants feel that they can provide input into enhancements and changes so that it meets their needs and fits with their workflow.”

While technology makes the CDM pilot possible, a key actor has been introduced at the center of the process who directs and monitors the interaction of healthcare providers and the disease sufferers.

“The intent of the chronic disease management pilot is to add more human capital to the equation,” said Dr. Alan Brookstone, Vancouver Coastal Health’s physician lead for the CDM pilot project. “We tend to see technology as the panacea when in fact it really needs to be seen as an enabling tool.”

To that end, the project has placed the chronic disease nurse with experience in the role of “quarterback” when it comes to managing patient care. The pilot’s chronic disease nurses “have access to more tools and more information,” said Brookstone. “They play a key role in ensuring that the ball does not get dropped.”

The chronic disease nurses’ roles include monitoring and maintaining a patient’s treatment plan, ensuring key providers such as general practitioners and specialists approve and buy into the plan, and that patients are educated and informed about their course of treatment.

Having an easily accessible electronic record of a chronic disease patient’s treatment is expected to ease the strain on the acute care system in a number of ways. One is by arming existing service providers, such as the 24-hour B.C. Nurseline, with easy-to-access information to provide meaningful advice to patients.

“In the past, when any patients, whether they are CDM patients or not, have called [Nurseline], the nurses are running blind,” explained Gerwin. “They are reliant on the patient communicating what their symptoms are, what their issues are, and the outcome of the call was frequently, ‘Go to the emergency department.’ What we are finding is, now because they are dealing with a patient that they actually have information on, it is not always ‘Go to the emergency department,’ that is the right answer,” she said. “Sometimes it is ‘Call the chronic disease nurse on Monday,’ or ‘Have you considered taking those pills with lunch instead of on an empty stomach?’ Those types of things.”

Starting in September, the pilot will see the direction of calls reverse when it is planned that Nurseline will handle outbound calling of chronic disease participants after they are discharged from acute facilities. They will be contacted to ensure they understand their treatment plan, the use of medications, and asked if they have any questions or concerns. “It is because the re-admission rate for this population is really high,” explained Gerwin.

While the CDM pilot’s organizers have not yet sought feedback from all the participants – that process will also start in September – they have found that physicians, many of whom are sole practitioners, welcome the support they are receiving from the chronic disease nurses and helpline services.

Based on information sessions the CDM pilot group has with primary care physicians and specialists, Brookstone said VCH came upon a worrisome discovery: a “significant number” of specialists are “holding onto their patients longer and doing primary care for those patients” concerned that the system will fail them as they are transferred to community or primary care or because they don’t have a family doctor. “If we could solve that problem, we could open up anywhere between 10% and 20% capacity from a wait list point of view to see specialists,” estimates Brookstone.

That not only means convincing specialists that their chronic disease patients will be well-cared for under the pilot project’s nurse-directed care plan, but also that primary care physicians have to be convinced to take over responsibility of these resource-hungry patients. Brookstone figured that most physicians have between five and 10 high-need chronic patients already and most would resist taking on any more. “The numbers of patients are not all that high,” he said. “So you are identifying physicians who, if they have got support through a chronic care nurse who is helping develop and coordinate a care plan for that patient, would they be willing to take on another two or another three?”

The pilot’s organizers say that at five months, it is too early to quantify how successful it has been to date at reducing emergency visits – measurement of such benchmarks won’t begin until September. “We have some avoided visits,” acknowledged Gerwin, who added that many trips to the emergency can’t be avoided, so finding out just how many can be eliminated will be gleaned as part of the project. She added that the pilot not only needs to address patient behavior, but to ensure that relationships are strengthened between specialists, general practitioners, chronic disease nurses and helpline nurses.

While the CDM pilot bases its selection criteria largely on emergency visits, the eventual hope is to take the project from a retrospective view of acute care utilization to a more predictive one. To that end, the organizers are exploring predictive modeling with tools developed in the U.S. by Johns Hopkins. If successful, this would identify patients that haven’t necessarily had a hospital admission or an emergency department visit, but would appear to be candidates, based on a rating developed in conjunction with their GP. "We would want to see how to prevent that hospital admission. That is our ultimate goal, to get ahead of it," said Gerwin

Organizers expect to announce soon another round of government funding that will extend and expand the program for at least another two years more.

Remote monitoring is also high on the CDM pilot’s to-do list. The organizers expect to start with telephone support and then move into active home monitoring. “Our plan involves partnering with device companies and the universities to basically allow patients to input their blood pressure into a website or their weight,” said Gerwin. Eventually, “we can monitor their symptoms on a more active basis and then provide them with both learning opportunities and advice on a daily basis which keeps them healthier at home.”  •

BACK TO THE CONTENTS LISTING

The doctor is in – your inbox that is

CMA’s mydoctor.ca Health Portal aims to take doctor/patient communication to a new level.
Are physicians ready to buy into it?

By Gail Balfour

Remember those quaint old days when house calls were not considered above and beyond the call of duty? A new online health portal is striving to bring back some of that personal interaction, convenience and accessibility patients have been craving from their overworked, time-strapped physicians. However, the jury is still out on whether or not most doctors will actually be interested in that level of communication with their clients.

The mydoctor.ca Health Portal, launched in April by the Canadian Medical Association and created by Ottawa-based Practice Solutions Ltd., connects patients with their doctors over the Internet using secure messaging, personal electronic health records and various monitoring tools.

Dr. Timothy Foggin, a family physician based in Burnaby, B.C., was a bit wary of the messaging component of the product at first, thinking it would add time to his workday, but now he says it has saved him time, and he wouldn’t be without it.

“Patients are participating more in their own healthcare. That’s the way it should be and the way it has to go,” Foggin said. “It can bring back some of the personal touches. It’s like the modern, online version of the home visit in many respects. It allows me to check in with patients.”

In addition to the secure messaging component, mydoctor.ca provides tools to monitor chronic diseases and conditions such as obesity, asthma and high blood pressure. More tools, such as one for diabetes, will be added soon.

Four years ago, mydoctor.ca was merely a software wizard physicians could use to build their own websites for their practices. Some of these even contained patient education brochures on subjects ranging from ingrown toenails to head lice. But the new Health Portal component takes those websites one step further, said Dr. Jay Mercer, medical director of CMA.ca in Ottawa.

“We wanted to create something that wasn’t just a one-way communication; now there is two-way secure communication,” he said.

“Patients want to be more involved in what’s going on. They want to participate more in the decision making and the data gathering.

So what we have done is create a vehicle for them to accomplish that.”

Mercer said the portal was designed to make doctors more efficient and improve the quality of care, while at the same time, empower the patients to be more involved.

As an example, he mentioned one 77-year-old patient whose blood pressure, when tested in the office, was often too high.

“So I am getting one picture. But by getting her to take her (blood) pressure at home, I am getting a much richer data set.”

It turned out her blood pressure was actually too low the rest of the time, and she was at risk of falling. Because she was being monitored at home, Mercer was automatically paged when her levels fell below an acceptable rate.

“So it’s taken less time for me, because we haven’t needed a series of office visits, I’ve captured a bunch of data that I wouldn’t have been privy to (otherwise), and we have improved the quality of care, and maybe even avoided an adverse outcome.”

Home monitoring of patients is not a new idea. Dr. Alfi Beshay, a clinical hypertension specialist based in St. Catharines says out-of–office monitoring of patients has always been an integral part of his treatment plan, but this tool helps take it to the next level.

Before beta testing mydoctor.ca, patients would keep a written record between office visits, but these notes would often go missing because they were not kept in one place.

“Since we have had this tool on the Internet, it has become much easier to communicate with our patients,” Beshay said. “They are more organized; they don’t have to walk around with all these small pieces of paper. From wherever they are, they can just kind of log on to the Internet and add the blood measurements. They can print out tables and graphs, and bring these to any other doctor who is seeing them.”

While he was piloting the project, he didn’t ask his patients for a fee for this service, but said he will start charging a small one now, depending on the level of services they require.

This brings up one of the main complexities of the product. The portal will cost CMA members $240 a year (non members will pay a little more) to offer the service to their patients. Details about the cost of services to the patients themselves, however, and how they will pay for them are not clear yet, and will likely vary from doctor to doctor. It also remains to be seen just how many physicians will actually be interested in participating in the undertaking.

Dr. Karim Keshavjee, a family physician and CEO of Toronto-based InfoClin Inc., is not convinced this type of service will have widespread appeal for most doctors.

“Surveys in the US showed that 60 to 70 percent of patients want to be able to email their doctor,” Keshavjee said.

“On the other hand, when you ask physicians (if they want that), it’s only about 15 or 20 percent who want to do the same. Because they are busy and they just see that as yet another imposition on their time. They know that some patients are going to write blogs (to them) every day.”

He feels the only way a product like this will be sustainable, is if there is a clear reimbursement model for the physicians that makes sense.

“Doctors are going to be looking for ways to get their $240 back. Doctors make money by billing for services. This product…I can’t see it standing alone. It will definitely have to be bundled with a billing service.”

Keshavjee said companies would be smart to add this service to block billing packages, as it will likely attract another level of patients who may not have been willing to sign up for block billing up to this point. The ability to email their doctors may be what ultimately attracts them to pay this type of annual fee.

Block billing refers to a yearly fee paid for a package of non-insured services. These can include telephone consults, replaced lost prescriptions and mole removals, among other things.

“Patients demand these services, and most doctors aren’t set up to transact on a cash basis, so block billing is a nice way for them to collect their funds and then say these services are all included in your package for the next year.”

CMA has its own block billing service, which puts them in a good position to add mydoctor.ca Health Portal to their package. Similar block billing services in Ontario are offered by companies like Caller MD and Doctors Services Group. Different programs can range in cost from about $100 a year to in the thousands, Keshavjee said.

“If it’s a third of the patients in a clinic that has 1800 patients, that’s still 600 patients that would have this. And if you’ve got 600 patients paying you $100 or $200 a year, it might end up being a substantial sum.”

Paying for this service in one way or another is “inevitable” for patients who would like to participate, he said.

“This service is taking up a doctor’s time. Why should I give you a professional service, and take on the (potential) liability? We do want to interact with our patients…it’s not like we don’t want to. It’s just that it’s a matter of fairness and equity to our patients. I don’t want to offer it to everybody, because if I do, I might be overwhelmed.”

Other things to consider are ethics and policies around email and privacy when dealing with patients and sensitive medical information, he said.

“We do need to do more research on the appropriateness of email in this circumstance. Some things are still better done in person. We often need to do the back and forth sort of thing when talking to a patient.”

Another potential issue might be the patients themselves, as their regular participation is required, and that may be asking too much.

“The thing is, in order to enter your own data, you have to be pretty motivated. And a lot of people just aren’t that motivated to do that,” Keshavjee said.

“Enter your values daily, and after a while you might say: ‘Hey this is boring.’ There’s the novelty factor, and then there’s the rest of your life.” •

BACK TO THE CONTENTS LISTING

HOME - SUBSCRIBE - ADVERTISE - ARCHIVES - CONTACT US