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    Leveraging data integration to manage chronic conditions

    Recently, a 3-million-patient health system began developing remote monitoring programs for patients with chronic conditions, such as hypertension and type 2 diabetes. Its motivation for investing in preventive technology is not being driven by reimbursement incentives, which many argue will be the stimulant of a value-based care shift.

    Instead, this health system is being driven by a single, stark reality: over the next three to five years, a large number of physicians are retiring and even fewer are entering the workforce. By 2019, this health system is expects its 2,500-to-1 patient-to-physician ratio to increase to 5,000-to-1.

    Addressing the imminent physician shortage will be a challenge for health systems that are already facing escalating regulatory pressures, an increasing number of patients, and a growing elderly population being treated for chronic conditions. The challenge of managing more patients with fewer resources is not unique. Stop gaps such as extending clinic hours, hiring Advanced Practice Registered Nurses, and investing in medical education are necessary, but like many protocols in healthcare, these only treat the symptoms, not the root cause.

    The best way to confront an increasing patient population with a decreasing workforce is by implementing remote monitoring and patient-generated health-data (PGHD) integration strategies that yield more productivity. By delivering patient-generated and other data when and where it is needed, providers can more easily and effectively deliver prompt and efficient care to control costs and improve clinical quality.

    Remote monitoring efficiencies through mobile

    Disease management programs are commonplace, but extant services are often comprised of routine in-person visits, weekly or monthly care management phone calls and staff that manually record patient-reported data. The challenges of this time- and resource-intensive, hands-on model are often first noticed in rural populations. When a patient's medical institution may be two or more hours away, making regular face-to-face visits is cumbersome and unrealistic. The expenses associated with repeatedly traveling long distances and making recurrent phone calls becomes more burdensome when a patient is pre-chronic. On the provider side, there is usually not adequate reimbursement available for the follow-up visits needed to help prevent the onset of a condition. Technology, specifically solutions producing and integrating PGHD, can be leveraged to address many of the challenges faced by patients and physicians today.

    For example, Sutter Health in Northern California has implemented a remote monitoring program for patients with hypertension. Patients enrolled in the program use their smartphones to download the program's app and, with the assistance of nurses, connect a blood pressure monitor, weight scale and consumer-grade physical activity tracker to the mobile application. Patients take readings with these devices daily and receive educational tips to keep them engaged. The patients’ data feed into a Sutter-created dashboard that integrates with the electronic health record (EHR) and gives care coordinators the ability to determine at a glance how well thousands of patients are responding to their medication and adhering to protocol. The program also identifies patients who are not performing as well as expected.

    The utilization of remotely-collected patient data enables Sutter physicians and care teams to devote resources to patients who need care the most, and allow healthy, adherent patients to continue managing their condition without interruptions.

    Next: Preventive care

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