This is fourth of a multi-part series on a patient’s experience managing a chronic condition, in this case hypertension. A diagnosis has been made, and our patient has hopefully followed up and has hopefully been maintained on appropriate therapy (there is a 1 in 3 chance that this is happening). Now it is time for our patient’s health care sponsor (such as his employer) to review the health care benefit.

Click on the image to see it larger size

Patient Story (Frydman)

There is no patient story in this phase. At some point during the year, our patient’s employer will discuss provided health care coverage with a health plan or plan(s) who have set rates for coverage in the coming year. On the diagram, there’s no red dot indicating the presence of data because in many (most?) cases there is not a lot of data to guide this conversation. Many health plans have claims data, to show how many services and what types have been paid for throughout the year. They may not have data about the effectiveness of those services. For example, they may not know what percent of office visits for high blood pressure showed effective control. On the employers’ part, they may not have much data, either. If they are self-insured, they may have similar levels of claims data, but not measures of performance.

Even in health care organizations with advanced electronic medical records, the determination of “% patients with appropriate blood pressure control” may not be done in an automated fashion - a random selection of charts may be used to come up with this percentage. The electronic health record may facilitate the selection and review of charts, but nothing more. This is dependent on the health care environment being studied.

(If there are health plan and providers who would like to inform this part of the story, comments are open)

Clinical and Public Health pearls (Houston-Miller and Eytan)

• High blood pressure is one of the most costly conditions for employers, more than cancer, diabetes, heart disease, and behavioral health conditions. This does not take into account that hypertension is responsible for a significant amount of morbidity among patients with heart disease and diabetes. This post shows the costs of each. The first graph shows the cost per person with the condition. When you average the costs across an entire employed population, the large numbers of patients with hypertension escalates the cost of this condition above all others. For those people interested in the cost profile of chronic conditions to employers, The Center for Studying Health System Change hosted a forum where expert Ron Goetzel, Ph.D. provided an updated look at the data. It is compelling.
• Fewer than 10% of the cases of undetected or uncontrolled hypertension could be associated with lack of health care use. In other words, health plans and employers are already paying for this current state. It does not exist because patients are not getting enough health care.

Comment

Where is the data? and What’s Missing? In this case, there isn’t much data in the conversation. The conversation is around use of services, and in that setting, an assumption is typically made that more services is better. The result is that these stakeholders cannot engage at their potential to ensure that services are as effective as possible.

It is possible that a patient or provider may share data about the effectiveness of their blood pressure control services which are being purchased and paid for by employer and health plan respectively. Blood pressure control is already a HEDIS measure, and is a development Pay for Performance measure in California in 2009.

Next post, the yearly checkback, completing the cycle. Comments welcomed, of course

I think word has gotten out that I am something of an urban dweller; Susan Edgman-Levitan was nice enough to ask me, “Ted, are you hanging in there?” as we spent several days in Yountville, California at the American Board of Internal Medicine Foundation forum on Achieving Patient-Centered care.

I ended up doing just fine - it’s about the content, not the place, and a scenic jog through the vineyards of Yountville can’t be argued with.

And the content was right up my alley, with thanks to the ABIM Foundation for hosting this discussion. The discussions at the Forum are being compiled by the ABIM Foundation, so I will let them report on that rather than me, but I can share my perceptions of the event here.

First of all, patients and families were involved throughout, as faculty and equal participants. This continues an important precedent in helping health care leaders achieve comfort with this idea.

One of the most powerful moments was Margaret Murphy sharing the story of her son Kevin’s death (You can read more about it here) within the Irish health system. I really appreciated Mrs. Murphy’s use of images in her storytelling - in the future, a presentation without at least 50 % images and a video or two is going to be minimum bar to go in front of an audience. There was discussion about Kevin’s death being the result of diagnostic error. I think that’s true, and I also think that if the family had access to all of his medical information from the beginning, it might have changed the diagnostic approach or caught the fatal series of errors before they happened.

For my part, I presented the following slides in the 10 minutes I had alotted, around the topic of the use of health information technology to put patients, families, and communities in the center of care.

Enjoy (I hope) and thanks to the ABIM Foundation for hosting this discussion and follow-up.

Click on any image to see them larger

Rickerby, J, and J Woodward. “Patients’ experiences and opinions of home blood pressure measurement.” J Hum Hypertens 17, no. 7 (0): 495-503.

Pare, Guy, Mirou Jaana, and Claude Sicotte. “Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base.” J Am Med Inform Assoc 14, no. 3 (May 1, 2007): 269-277

Little, Paul, Jane Barnett, Lucy Barnsley, Jean Marjoram, Alex Fitzgerald-Barron, and David Mant. “Comparison of acceptability of and preferences for different methods of measuring blood pressure in primary care.” BMJ 325, no. 7358 (August 3, 2002): 258-259.

Not pictured: Port, Kristjan, Kairit Palm, and Margus Viigimaa. “Daily usage and efficiency of remote home monitoring in hypertensive patients over a one-year period.” J Telemed Telecare 11, no. suppl_1 (July 1, 2005): 34-36.

There’s a potentially serious gap in the Connectivity for Californians initiative that we are addressing. Here’s a quote that illustrates it:

It is very clear from the interview data that patients have their own ideas, and spend a lot more time thinking about their BP than is apparent in the average 10-min consultation in general practice.

The gap is patient involvement in the design and planning of this initiative, or any healthcare initiative for that matter. Patients have many more ideas about what the problems are to be solved than can be gleaned even from articles like this - the articles simply show that the ideas are out there. Fortunately, we are committing ourselves to have a patient representative involved from the beginning, and that is coming together before any work is started.

The quote above is from the first paper by Rickerby, et. al (click on the images to the right to review any of the papers yourself), which described a qualitative study to look at a small number of patients’ attitudes toward monitoring their own blood pressure, in a practice that routinely recommends this.

The question (#1)

The reason I have reviewed these particular papers is because of the commonly posed question to me over the past several months, in the form of, “Ted, will/are patients really motivated to check their own blood pressure?” with the implication that they are not and they won’t. It’s a fair question that deserves an informed response. Several of the readers on this blog have given me some information from their own lives. These papers add to that knowledge.

The answer (#1)

They are and they will.

The question (#2)

This came up during reading of the papers. Does patient engagement come from having knowledge? Or does knowledge come from being engaged? This came up because patients in the first study who did not have knowledge about why they should monitor their blood pressure or how to do it seemed less engaged.

The answer (#2)

Unclear, with the implication being about whether to work to engage patients with more knowledge or use knowledge as a means test for engagement. I think regardless of the answer, there’s no reason not to provide information to patients. That answer is good enough in this case.

Read on for more conclusions….

Read the rest of this entry »

(presentations online here)

Paul Grundy, MD - “Think huge”

Purchaser guide - there have been many of these, but the first time one prepared with consumers and providers

Health Information Technology - help educate, advocate, demonstrate around PCMH the technology that will be necessary to help physicians make the transformation

Panel - What Does it Cost to Become a Patient Centered Medical Home?

Bob Berenson, MD, Senior Fellow, The Urban Institute

“A good medical home”- patient with superficial phlebitis treated via one office visit, 6 phone calls, 6 e-mails, including hematologic consultation, one reimbursement for in-office care

Julia Pillsbury, DO, Alternate RUC Representative, American Academy of Pediatrics

New G codes for Medical Home-type work. Crosswalked to currently existing codes, some subsume current G codes, some do not. Tier 1, 2, and 3, between 6.5 to 9.2 minutes per patient per month, may be around $50/member/month.

Patient Partnership

Sabrina Corlette, Director of Health Policy, The National Partnership for Women and Families

Grant from the Wellpoint Foundation to introduce consumer advocates to PCMH and involve them and shaping it. Environmental scan, Focus Groups, Develop consumer/patient principles

Debbie Peikes, Ph.D., Mathematica Policy Research

We should involve patients and providers in primary care assignment, using claims retrospectively is expedient perhaps but has difficulties

As the title says, my Internet holiday is complete. It was as fun as being in the cloud, to be sure. I’ll be back to regular publishing now, and comments and pings are turned back on.

Patient Centered Primary Care Collaborative, Washington, DC

I’m resuming life in the cloud by attending the Patient Centered Primary Care Collaborative Stakeholders Working Meeting, here in Washington, DC. I hope to post updates throughout the day - we are all fortunate that this group operates with an impressive level of openness and interest in collaboration (just as its name implies). The agenda and materials are online for others to peruse.

By the way, here’s what an Internet Holiday looks like.

• A patient’s advice to hospital communicators | Article | Homepage articles - When you read this, it seems like everyone is trapped in a system that they are powerless to change. Patients probably wouldn't have it work this way. A great way to have the doctor slow down is to have them prepare an after visit summary.

• Businessweek’s Cutting Edge of Health Care includes After Visit Summaries - Click on playbook to see it - after care and visit summaries are the cutting edge according to BusinessWeek. We've arrived.

• Facts about the 2008 National Patient Safety Goals | Joint Commission - Goal 13A - Involve patients and families in their care as a patient safety strategy

• NAHIT Releases HIT Definitions | News | Healthcare Informatics - Long awaited, and helpful. The difference between "P" and "E"HR appears just to be control. "P"HR is controlled by the patient. I still believe that the customer of both is the patient, and these definitions are consistent with that idea.

• Questions Are the Answer - AHRQ - Agency for Healthcare Research and Quality - supporting reduction of medical errors and accuracy - through patient involvement. Now the health system can meet patients half way by providing this information as part of every encounter.