Over the last decade or two, Kaiser Permanente has done such a good job at managing coronary artery disease (CAD) that it is no longer the number-one cause of mortality for Kaiser members. Last week, a number of media covered a Kaiser CAD management success story that was presented at an Alliance for Health Reform forum in Washington, DC.

This particular intervention, the Collaborative Cardiac Care Service (CCCS), is a multidisciplinary approach developed by KP’s Colorado region and summarized in an article in Summer 2008’s The Permanente Journal. It achieved dramatic improvements in care management, including:

• Improved cholesterol screening (increasing from 55% to 96%)
• Improved LDL control to <100 mg/dL (jumping from 22% to 77%)
• Reduction in all-cause mortality associated with CAD by 76%
• High patient and physician satisfaction

The CCCS intervention was extensive, involved a wide range of clinicians, and integrated existing chronic care management strategies with its new HealthConnect electronic infrastructure. What is also clear is that it relied on a wide range of information therapy (Ix) principles and strategies.

• CCCS made considerable use of information triggers to determine which Kaiser members to target, the particular information needs of each member, and when to prescribe the Ix.
• Critical components of CCCS involved the timely prescription of evidence-based information to Kaiser members — everything from smoking cessation to medication adherence and from testing reminders to diet & exercise education.
• CCCS also integrated different forms of Ix — many data elements collected through HealthConnect produced system-triggered information prescriptions, but they also had clinician-prescribed Ix from physicians, nurses, pharmacists, and counseling/educator experts. (I’m not sure whether the intervention specifically included consumer-prescribed Ix as well — e.g., information prescribing from other members in peer groups such as in group visits, social networks, etc.)

Ix interventions like this likely will not only improve care quality and reduce costs, but will lead to engaged and empowered consumers, like the Kaiser member described in the recent Wall Street Journal article on Ix.

On Saturday, I had the pleasure of presenting to the CHCF Health Care Leadership Network/CCI MD Alumni Session Spring Meeting in San Francisco. The goal of the day was to explore Health 2.0, personal health records (PHRs), the patient-centered medical home, and what patient-centeredness really means.

The first panel –that addressed Health 2.0 and PHRs as tools for patient-centered care — was fabulous and balanced between patients and physicians. Amy Tenderich, creator of the patient blog, DiabetesMine, discussed her view of the four phases of coping with a new chronic illness.

1. Diagnosis/denial
2. Finding your way — figure out how you can be your own advocate and find answers on your own
3. Dive in & make a difference — I loved her term “dynamic education” — ongoing or continuous; the information you get and provide needs to match where you are as a patient and an advocate
4. The long haul — keeping motivated & educated over the long-term and the importance of social networks that offer three things: emotional support, information/education, and a platform for advocacy

Paul Tang, MD, MS, Chief Medical Information Officer at Palo Alto Medical Foundation (PAMF), explained that he sees his role (and that of health care providers more generally) as being a supporting cast for people like Tenderich & Parten (see below). PAMF created a “diabetes dashboard” for their patients that helps them connect the dots between their goals & concerns and physiologic data (e.g., blood pressure, LDL, HbA1c, etc.).

Tang pointed out that the patient’s goal may have nothing to do with the clinical goals; for example, one of his patients with diabetes said his goal was, “I want to live to 90.” Tang wants to use tools and contextualized information to link that emotional, personally meaningful goal to data, actions and behaviors that can help his patients achieve it. Part of that is developing processes for real-time data monitoring (e.g., via glucose monitoring fed directly into the dashboard) that triggers information therapy (Ix) to be delivered at a “teachable moment.”

Bonnie Parten is a patient advocate from PeaceHealth in Bellingham, Washington and instrumental person in the development of their PHR that they call a shared care plan (I’ve described the user-centered design approach they used before). As always, I sure learned a lot from listening to consumers.

The shared care plan facilitated communication among multiple providers — whether it was for her own care or any of her many family members using the tool. It’s important to note that patients use the shared care plan as both/either a secure online portal or convenient paper version that be carried around in one’s purse or wallet. That meant that some of Parten’s  family members (with serious conditions) felt comfortable traveling in a way they hadn’t previously for fear of being stuck away from their personal health information in a medical emergency.

Parten shared some other gems that only patients can teach us.

• Sometimes the shared care plan provides a little healthy competition among her family members to see who can get the best blood pressure control.
• The PHR allowed adult children to track their parents’ health from far away.
• In many cases, the accurate information in the shared care plan was critically important to Parten’s providers, whose EHRs often contained inaccurate or incomplete information.
• Presenting the shared care plan to her clinicians at the beginning of each encounter saves five minutes off of every visit (no wonder her doctors love her) and probably make the time spent together much productive.

But, Parten noted near the end, “the most important part was that I got to know my dad in a way I never knew him.”Marc Pierson, MD, was one of the physician leaders who made the shared care plan a reality at PeaceHealth, though he said that its success derived from the fact that he “shut up for two years and listened to patients like Bonnie.”

Pierson said that “listening to patients for two years completely changed my perspective on what being a doctor is all about. Specifically, he learned:

• The home is where: most caring occurs; most health care decisions are made (good or bad); and all habits are made (good or bad).
• Complex care requires coordination between numerous organizations and agencies.
• A new type of information “system” is needed (he doesn’t mean information technology, per se) that is centered on the patient and connected to anyone supporting the patient.

There was a terrific mid-afternoon panel (which I’ll try to provide more detail on in a future post), but the morning was a perfect set-up for me to discuss our evolving thinking on the consumers’ health home. I’ve described some of our thinking before. The basic issue is that we have (like the “Rent” song says) 525,600 minutes in a year and most of us can probably count how many of them are spent in a “medical home” (a traditional health care setting). As Pierson says, most of health needs are addressed, and behaviors are formed, in the home (or workplace, school, community, etc.). If we really want to help people manage their health, consistently choose healthy behaviors and ultimately live healthy lives, we better give them the information they need, where and when they need it.

 A picture is worth a thousand words, so here’s one way to think about it (click on image above to make it bigger) as it relates the Institute of Medicine’s first recommendation (from their landmark 2001 report on “Crossing the Quality Chasm”) for how 21st-century health care should be delivered — focused on continuous healing relationships. In other words, the health home has to start with the person at the center, give them some tools and then identify all the points in their lives with Ix can be meaningful to them.

I posted on February 19 about the launch of our Ix for Rx Management work. We are embarking on research to examine how information therapy (Ix) strategies can address the huge problems associated with inadequate medication adherence, safety, and selection.

This work will lead to a series of public webinars and one or more white papers in September and October of this year and probably additional events, learning collaboratives or other activities in 2010. As we launch this work, I’d love to have input from as many people as possible as to where the most important issues are and what are the best leverage points for addressing them.

I welcome comments on the following questions:

• What are the greatest barriers to medication adherence (from list below or others)?
  • Knowledge
  • Motivation
  • Health literacy
  • Cost
  • Provider support
  • Social support
• What are the best Ix levers for improving medication adherence (e.g.,email/cell phone reminders targeted to moment in care)?
• How can Ix strategies be deployed to reduce medication errors?
• What Ix tools are most useful in ensuring appropriate selection of medications for an individual?

“Drugs don’t work in patients who don’t take them.” So said former U.S. Surgeon General C. Everett Koop, MD. Back to something I wrote last week on this blog, sometimes a statement obvious on its face can be profound.

The question, of course, is: Why? Why do people take only about half of the medications that they should to help them prevent disease, recuperate from acute illness, and manage chronic conditions? Why do an estimated 125,000 people die every in the U.S. because of medication non-adherence? And what could we do with the $100 billion our country will spend in 2009 because of this problem?

There’s no shortage of research to help us answer these questions, one of the best sources being the Cochrane Collaboration review on “Interventions for enhancing medication adherence.” In fact, many information therapy (Ix) interventions have proven at least somewhat successful; Ix has been a critical component of the successful interventions below.

• Targeted information
• Timely reminders
• Self-monitoring
• Reinforcement
• Counseling

I attended a stakeholder meeting today convened by the National Consumers League regarding a proposed national medication adherence campaign. One of the big issues that arose is the degree to which a public relations campaign designed to raise consumer awareness can lead to substantial increases in medication adherence.

Although awareness certainly is an important precursor, it may be the easiest step in the pathway that takes the average consumer along the road to information consumption, then knowledge accumulation, and ultimately leading to behavior change. We know there’s a large body of research that tells us that, in order to be successful, our Ix initiatives need to “meet people where they are.” More specifically, we need to target the information to the individual’s particular moment in care and tailor it to their particular needs and circumstances.

With that in mind, the Center for Information Therapy will soon embark on a new body of work around “Ix for Rx Management.” The goal will be to summarize research — on the problem but even more so about the solutions — then stimulate innovation and diffuse best practices.

Although medication adherence is one of the top issues, we will also explore other Rx management issues to address medication safety, poly-pharmacy, and other issues. Over the next few weeks, we will roll out more details on our plans in this arena, and I urge those interested in our work to get in touch with us.

Two days into my vacation, my 4 1/2-year-old wakes up with some wheezing. As I wrote in April, his first asthma event was a shock to us but because it came during one of the worst pollen seasons in recent memory this spring and he had no symptoms since that initial course of treatment, it had settled deep in the back of our minds.

We were a few hundred miles from home (where Ryan’s nebulizer was) and couldn’t figure out what to do, so we called our pediatrician on-call that Sunday morning. She advised us to seek care before beginning the second leg of our vacation journey (another 6-hour drive).

I spent a couple of hours reading books to Ryan at the nearest urgent-care clinic. The facility and clinicians were fine, but did not provide clear explanations and–although I did leave the office with a written after-visit summary–it was completely disconnected from my previous care experience.

I desperately wanted access to a personal health record (PHR)–some tool that would allow me to connect Ryan’s past asthma encounter with the current event. I knew that the medications were different, but was unclear as to the rationale.

• Why is he getting just one inhaled medication (the albuterol for short-term relief) instead of two (no Pulmicort or other inhaled corticosteroid for long-term control)?
• Why did they prescribe an oral steroid this time instead?
• How necessary is the prescribed antibiotic since he only seemed to have a cold (in fact, we decided not to fill that prescription and it turned out he clearly didn’t need it)?
• Perhaps most importantly, how do we monitor his progress and know how often to give him the inhaled meds?

Ryan seems to be doing fine now, but we clearly need to set up more of an asthma care plan to be prepared if/when something else triggers another respiratory reaction. I hope I can find the right tools to help me and his mom manage this condition in the long term.

I was on a panel today at the Chronic Care & Prevention Congress put on by the World Congress. The session’s title was “Innovative Technologies Showcasing Results in the Management of Chronic Care Shaping Future Policy to Drive Innovations in Healthcare.”

The lead presenter for our panel was the always insightful Joe Coughlin, PhD, of the MIT Age Lab. Joe has a lot of thoughtful and out-of-the-box things to say, but I think they boil down to the basic message that people designing health care behavior change interventions need to “meet people where they are” (my words) and they need to be “fun” (Joe’s words).

I particularly liked Joe’s closing slide on the disconnect between chronic care management today and consumers’ values (particularly the values of baby boomer women–who Joe says make on the order of 90% of the health care decisions in the US…that seems a little bit high to me, but his point is well taken). I think I’ve gotten most of this right–if I’ve mistaken anything, I hope Joe can correct me. The today is first and the consumer values are second in each dichotomy below.

• Data intensive vs. Useful knowledge
• Empower physicians vs. Empower consumers
• Trust authority vs. Trust experience
• Populations based vs. Personalized services
• Physician-patient-centric vs. Social networks
• Hospital & home focus vs. Ubiquitous
• Deliberate speed vs. Internet time
• Disease & illness care vs. Proactive vitality (wellness)

I fundamentally agree with Joe on his insights, although–as with many things–the current state of the chronic care management world has probably begun to move away from the left side a little bit already. What will be interesting to see is how many progressive provider organizations and other health care institutions proactively move toward the right side of these dichotomies. If not, consumers likely will eventually get fed up with providers and turn elsewhere (e.g., the Internet, Wal-Mart, Health 2.0 companies, etc.) to get what they need.