Welcome back to an experiment - posting a potential project on this blog to get input, in preparation for funding in the future. In several previous posts on the topic of hypertension management, I have laid out some of the gaps in care, and here is a visual that shows how this could potentially be put together in a pilot project with multiple partners.

(click on image to enlarge)

Chronic Illness Lifecycle-1

In order:

  1. A Health Risk Appraisal, to help identify untreated or unaware hypertensives (no primary care visits in the past 12 months is significantly associated with untreated state)
  2. Electronic Health Record, that receives HRA data, and records target blood pressure
  3. Patient access, via messaging and labs, for patient and family involvement in care (the key intervention here)
  4. Biometric monitoring
  5. Social Media/Health 2.0 - I have not yet found a social network for blood pressure - to compare targets, medication use, promote adherence - I will post on this on its own
  6. A personal health record system that receives standard-encoded data (e.g. CCR) to consolidate the data and send summaries back to the provider
  7. Purchaser/Employer/Health Plan design and programs to support care in the workplace
  8. Pay for performance, blood pressure coming to California’s program in 2009 (not a large proportion of reimbursement, but could be the basis for funding a pilot program

You may look at this and think about a parter or service that could fill each gap. Feel free to comment on ideas and organizations that are or interested in doing this. I will post the current A3 project plan tomorrow to give a sense of timeline. We are hoping to get some interested partners together in June/July to put together the right subset of this ecosystem (we can’t do it all) moving forward.

In addition to the partners mentioned above (provider, consumer group, employer, health plan, technology provider, Health2/Web2) we will also add clinical champion for the condition we’re studying, hypertension, which won’t be me - I’m championing patient and family involvement through health information technology (of course :)).

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