The Executive Suite: Hallmark indicators: Signposts to chronic care management

For clinicians, the key to chronic care management is having ready access to hallmark indicators that can mark the progression or control of a disease.These hallmark indicators (also called ‘key indicators’) are typically a set of six or seven measures that a physician would monitor, over time, to track the progression or regression of a particular illness. With diabetes, for example, indicators would include blood sugars, glucose levels, renal function, foot neuropathy, and other measures.

With easy access to hallmark indicators at the point of care, providers can proactively engage the patient, their family, and home care providers and make them aware that these are things that must be monitored closely, as they could indicate a problem.

Monitoring and reporting key indicators in real time can help communication between the provider, the patient, and the payer and make chronic care management vastly more efficient. However, the success of such a dialogue hinges on providing comprehensive, problem-oriented views of clinically contextual information to providers at the point of care.

Ideally, hallmark indicators are presented on a ‘dashboard’ at the point of care––providing physicians and nurses with at-a-glance access to historical data for the patient and the ability to identify trends and determine where a condition is heading. But most clinicians don’t have ready access to such information. Many indicators are results from lab tests, are not compiled in a list for a specific condition and are usually strewn throughout an EHR––packed in with everything else and requiring time and effort to locate.

One example of such a dashboard is at Phoenix Children’s Hospital, which has over 60 disease-specific panels displaying key indicators for clinicians to use at the point of care. Using them, the hospital reduced disease progression for juvenile arthritis by about 80% by actively monitoring a hallmark indicator––joint counts––both in the physician’s office or with the patient calling them in from home, and then coupling that information with the medications and lab tests. With that view, physicians can determine that by fine tuning the medications how they can improve outcomes. They are successfully moving the quality-of-life needle––both for the afflicted children and those who monitor their condition. Today, the hospital uses these dashboards to monitor 60 distinct diseases ranging from chronic lung conditions to gastrointestinal disorders and are seeing similar results.

This clearly illustrates that when clinicians are given the data they need in an accessible, consumable format, they can improve the quality of the patient’s life much more easily. The same is possible for nearly all the chronic diseases because they all have hallmark indicators. It’s just a matter of getting the right information in the right place, at the right time, in front of the right person.

The sharing of this information benefits payers as well. Payers are interested in reducing cost, which is done 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 to provide data directly from the patient to the HER, and then to the doctor. This allows the care team to see in real time if they are treating a particularly vulnerable patient who must have their insulin frequently adjusted. It’s an easy way to connect the dots.

The same applies for a condition like COPD. Symptoms such as shortness of breath can be reported on a phone and recorded into the EHR. The physician is alerted and can start intervention earlier. Similarly, with congestive heart failure (CHF) a sudden weight increase can indicate water retention, which could signal an exacerbation. Patients can track their weight with scales that log the results directly to a smartphone app, where it can be tracked in real time. If a provider and a patient are communicating––even electronically––there can be alerts set up. The provider can respond and ask about a weight increase, which could be as resolved with something as simple medication adjustment. Again, access to indicators and having an automated dialogue in place is essential.

Such real-time tracking is increasingly mainstream and will become more sophisticated over time. Apple now offers a watch that includes atrial fibrillation detection, and will soon offer blood sugar detection. These advances will make chronic care much easier by providing real-time data in a window where interventions can be applied patients become critically ill.

During my years as an internist, many of my patients had four or five different conditions, and many had some overlapping/common indicators. Multiply this by the number of patients covered by a practice, and you get a sense of how much data is flooding the medical record.

This raises the question: How does a clinician, in a timely manner, navigate and sort all that information to find the data pertinent to a specific condition? The data must be filtered and presented so the clinician has all the information pertaining to this patient related to this disease. To be effective, the presented information needs to be 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, the volume of incoming data today is so immense that things can easily be missed. Since we have the technology, why not let the computers do the heavy lifting so physicians can drive better outcomes?