APAN-Hawaii 24/January/2008 in Honolulu

Naoki Nakashima, M.D., Ph.D.Naoki Nakashima, M.D., Ph.D.Department of Medical InformaticsDepartment of Medical InformaticsKyushu University HospitalKyushu University Hospital

A Japanese model of disease management for diabetes mellitus from primary to tertiary prevention

Background of the projectBackground of the project

Pre-Diabetes

Not Cared

Specialist Doctors

Cared

130 millions citizenin Japan

10 millions

4 millions1million

Family doctors

DropoutAcute and

Chronic Diabetic

Complications

Increase of Increase of Medical CostMedical Cost

3millions

Diabetes Mellitus

Problems１． Continuously increasing patients and complications２． Low hospitalization rate of patients (51%)　　　３． Shortage of specialist Drs. (=3,300） for diabetes

Patients QOLMedical cost

Japanese Government will startJapanese Government will start “ Particular Health Check-up Syste“ Particular Health Check-up System (PHCS = Tokutei Kenshin)”m (PHCS = Tokutei Kenshin)” from April 2008from April 2008

All of 40All of 40 ～～ 74yo Japanese citizen (56 million) wil74yo Japanese citizen (56 million) will have to take standardized health examinationl have to take standardized health examination

List of basic examinationList of basic examination Questionnaire (weight change, smoking, exercise)Questionnaire (weight change, smoking, exercise) A physical examination A physical examination

Height, Weight (BMI), Waist, Blood PressureHeight, Weight (BMI), Waist, Blood Pressure Blood chemistryBlood chemistry

TG, HDL-C, LDL-C, GOT, GPT, γ-GTP, Cre, Blood glucose (fasTG, HDL-C, LDL-C, GOT, GPT, γ-GTP, Cre, Blood glucose (fasting or postprandial), HbA1c, Uric acidting or postprandial), HbA1c, Uric acid

Moderate and high risk groups are required to reModerate and high risk groups are required to receive standard health instruction ceive standard health instruction

Data Data AccumulationAccumulation

And And StratificationStratification

Arrangement Arrangement of Health of Health Check-upCheck-up

Health Check-Health Check-upup

Arrangement Arrangement of Health of Health

InstructionInstruction

Navigation Navigation system of system of InstructionInstruction

Health Health InstructionInstruction

Dunning of Health Dunning of Health Check-upCheck-up

Planning Planning next yearnext year

Data Data analysisanalysis

Daily Health Daily Health Instruction and Instruction and

SupportSupportEncourage to attend Encourage to attend

a clinica clinic

Dunning of Health Dunning of Health InstructionInstruction

Information Provided

Motivation Support

Aggressive Support

Affected by Life Style Diseases

Yearly Work Flow of Particular Health Check-Up System

Start !

Stratification

Intervention

AnalysisPlan

Assessment

Stratification Logic for Particular Stratification Logic for Particular Health Check-up and Healthcare Health Check-up and Healthcare

Instruction systemInstruction system

Big Waist　　　　　　　　　　　（ M 85cm, ≧F 90cm)≧

Normal Waist　　　　　　 Obese　　　　　　　（ M<85cm, F<90cm)　　　　　　　　 （ BMI 25≧ ）　　　　 Normal Waist Normal Weight 　　　　　　　（ M<85cm, F<90cm)　　　　　　　 　　 （ BMI<25 ）　　　　

Waist and Obesity

Grouping for

Healthcare

Instruction

Aggressive SupportGroup

Motivation SupportGroup

Information provided

Group

≧21

≧31, 2

0

Number of Risk Factors*

65-74y.o.

0

*Risk Factors① 　 Blood Glucose ：

Fasting ≧ 100 mg/dlHbA1c ≧ 5.2 %Under medication

② 　 Lipidemia ：Triglyceride ≧ 150 mg/dlHDL-cholesterol<40 mg/dlUnder madication

③ 　 BP ： Systoric ≧ 130 mmHgDiastoric ≧ 85 mmHgUnder medication

④ 　 Smoking history ：　 +

*④ is counted if there is one point at least in ① ～③ .

Decision line to attend a Decision line to attend a clinic/hospitalclinic/hospital

The Result of Physical and Blood Examination was:

１） Blood Glucosea Fasting ≧126mg/dl 　 orb HbA1c ≧ 　 6.1 %

２） Lipidemia a TG ≧300mg/dl 　 orb HDL-Chol ＜ 35mg/dl

３） BP a Systoric ≧140mmHg 　 orb Diastoric ≧90mg/dl

４） LDL-Chol ≧140mg/dl

Rate of stratification group by the “Particular Rate of stratification group by the “Particular Health Check-up and Healthcare Instruction Health Check-up and Healthcare Instruction

Program” estimated by Ministry of Health, Labor Program” estimated by Ministry of Health, Labor and Welfareand Welfare

　 information provided motivation support aggressive support 　　　 total

(low risk group) (moderate risk group) (high risk group)

Male： ６５．７ １５．５１８．８ 　１００％Female： ８４．０ １１．５ 　４．５　 　１００％Total： ７５．１ １３．４１１．５ 　１００％

What does “Specified Examination for Health and What does “Specified Examination for Health and Relations” mean?Relations” mean?

Including healthcare instruction and Including healthcare instruction and encouragement of medication, in addition to encouragement of medication, in addition to health examinationhealth examination

Insurers’ duty, which is based on the lawInsurers’ duty, which is based on the law 　　　　　　 Cost is depend on insurersCost is depend on insurers If insurers neglect their duties, they have to If insurers neglect their duties, they have to

pay bigger shares of the support for medical pay bigger shares of the support for medical cost of the latter high ages as a penaltycost of the latter high ages as a penalty

Target number is about 56 million (45% of the Target number is about 56 million (45% of the population) in Japan. population) in Japan.

It intends to make the results of health It intends to make the results of health examination by standardized electronic data.examination by standardized electronic data.

DTD of HL7 CDA-R2 L3DTD of HL7 CDA-R2 L3

Circulation of medical and Circulation of medical and insurance information after 2011insurance information after 2011

Medical institutes

Citizens (patients)

Insurance medical fee payment fund

Insurers(payers)

Reimbursement info（ medical action info ）

Medical info(medical result info ）

Healthcare info（ health exam result info ）

To organize “National DB of Electronic Health Record (EHR)”

Reimbursement info （ medical action info ）Reimbursement info （ medical action info ）

20112011～～

20112011～～

20082008～～

What is “Carna Project” ?

The Carna project is a newly developed Japanese disease management for life style disease. It aim the primary and secondary/tertiary prevention of diabetes mellitus/complication through prior interventions by the call-center. Carna’s goal is to establish a high quality medical care system with reasonable cost.

Carna ConsortiumCarna Consortium

Kyushu University

Diabetes Specialist Doctors

Saiseikai Kumamoto Hospital

Kyushu Electronic Power Co. and group （ QIC ，　 QBS ）

Tokio Marine & Nichido Fire Insurance Co.

Fukuoka Prefecture Medical Association

Fukuoka City Medical Association

The Authorization document from Fukuoka Prefecture Medical Association

Members

Assented by

2003-2005 Japan Science and Technology Agency(Ministry of Education, Culture, Sports, Science and Technology )

2005 　 Ministry of Economy, Trade and Industry2006 　 Ministry of Economy, Trade and Industry2003- Kyushu Electronic Power Co. Total fund = 4 million US$ / 5years

Funded by

Carna project has highly regarded for;Carna project has highly regarded for; Quality managementQuality management -Standard guideline of medical/health care courses -Standard guideline of medical/health care courses -Algorithm of all work flows in the call center -Algorithm of all work flows in the call center -ICT-ICT Appropriate matching of services to individualsAppropriate matching of services to individuals -Patient profiling-Patient profiling -Matching of member and health instructor-Matching of member and health instructor Adaptation to the Japanese political measure and Adaptation to the Japanese political measure and

medical systemmedical system Efficient and secure data managementEfficient and secure data management Ethical considerationsEthical considerations -Privacy policy-Privacy policy

Summary of Carna ProjectSummary of Carna Project

Outbound Call Center

Patients

Mail

Phone

Family Drs.（ Company Drs.）

Points

Coupon

Strengthen RelationshipStrengthen Relationship

DM Dentist KidneyOphthalmologist

Specialists

Team Care

Service

Clinics

Critical Pathway

EdutainmentEdutainment

Tourism Co.

Restaurants

Service Providers Service Providers

Gymnasium

Private Insurance

Co.

Carna Office

Individuals

Local Government

CompanyPublic HealthInsurance

+ Secondary, Tertiary Prevention④Provide Care Plan, Outcome Management　（ Relational Critical Pathway for Diabetes）⑤Question to Find Complications Earlier⑥Question to Check knowledge・Education ⑦Push to go to Clinic・ Avoid to Drop Out⑧Quick Report of HbA1c to Patient

Service

　　　　　＜＜ Service ｓ＞＞Primary Prevention①Life style instruction program (Critical pathways for 5 action stage for self-care)②Data Management and Analysis③Individual “Target” to Get Carna Points

①Services with Critical Pathways

We have developed 5 kinds of critical pathway (CP) for 5 stages. We decided the specific outcomes in each CP (outcome oriented CP).

＊ The CP for upper stage can be applied by achievement of outcomes (goal) in each CP. We continue same intervention until we get outcomes in each CP

Life Style Instruction ProgramLife Style Instruction Programwith Critical Pathways for 5 stageswith Critical Pathways for 5 stages

PrecontemplationRequirement for applyCondition of escapeOutcomes for goal

ContemplationRequirement for applyCondition of escapeOutcomes for goal

PreparationRequirement for applyCondition of escapeOutcomes for goal

ActionRequirement for applyCondition of escapeOutcomes for goal

MaintainRequirement for applyCondition of escapeOutcomes for goal

PRIMARY PREVENTIONPRIMARY PREVENTION

Summary of Carna ProjectSummary of Carna Project

Outbound Call Center

Patients

Mail

Phone

Family Drs.（ Company Drs.）

Points

Coupon

Strengthen RelationshipStrengthen Relationship

DM Dentist KidneyOphthalmologist

Specialists

Team Care

Service

Clinics

Critical Pathway

EdutainmentEdutainment

Tourism Co.

Restaurants

Service Providers Service Providers

Gymnasium

Private Insurance

Co.

Carna Office

Individuals

Local Government

CompanyPublic HealthInsurance

+ Secondary, Tertiary Prevention④Provide Care Plan, Outcome Management　（ Relational Critical Pathway for Diabetes）⑤Question to Find Complications Earlier⑥Question to Check knowledge・Education ⑦Push to go to Clinic・ Avoid to Drop Out⑧Quick Report of HbA1c to Patient

Service

　　　　　＜＜ Service ｓ＞＞Primary Prevention①Life style instruction program (Critical pathways for 5 action stage for self-care)②Data Management and Analysis③Individual “Target” to Get Carna Points

③ 　 Provide the Carna Points

（ patient ） Nothing happen by my efforts on diet and exercise ・・・

Point system

AchievemAchievement to the ent to the target linetarget line

Constant Constant answeranswer

to e-mailto e-mail

ImprovemeImprovement of Body nt of Body

weightweight

DECDECNOVNOVOCTOCTSEPSEPAUGAUGJULJULJUNJUNMAYMAYAPRAPRMARMARFEBFEBJANJAN

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

100point

As like as “mileage system” in flight companies, patient can exchange the accumulated points with coupons of various

healthy service or item.

You got 2200 points ！！

We Provide and Manage the Carna Points

Summary of CARNA ProjectSummary of CARNA Project

Out Bound Call Center

Patients

Mail

Phone

Primary Dr.（ Company Dr.）

Points

Coupon

Strengthen RelationshipStrengthen Relationship

DM Dentist KidneyOphthalmologist

Specialists

Team Care

Service

Clinics

Relational Critical Pathway

EdutainmentEdutainment

Tourism Co.

Restaurants

Service Providers Service Providers

Gymnasium

Private Insurance

Co.

CARNA office

Individuals

Local Government

CompanyPublic HealthInsurance

Service

SECONDARY/TERTIARY PREVENTIONSECONDARY/TERTIARY PREVENTION

+ Secondary, Tertiary Prevention④Provide Care Plan, Outcome Management　（ Relational Critical Pathway for Diabetes）⑤Question to Find Complications Earlier⑥Question to Check knowledge・Education ⑦Push to go to Clinic・ Avoid to Drop Out⑧Quick Report of HbA1c to Patient

　　　　　＜＜ Service ｓ＞＞Primary Prevention①Life style instruction program (Critical pathways for 5 action stage for self-care)②Data Management and Analysis③Individual “Target” to Get Carna Points

④④Provide Care Plan, Outcome Management　　（Relational Critical Pathway）

Out Bound Call Center

Patients

Mail

Phone

Primary Dr.（ Company Dr.）

Points

Coupon

Strengthen RelationshipStrengthen Relationship

DM Dentist KidneyOphthalmologist

Specialists

Team Care

Service

Clinics

Relational Critical Pathway

EdutainmentEdutainment

Tourism Co.

Restaurants

Service Providers Service Providers

Gymnasium

Private Insurance

Co.

CARNA office

Individuals

Local Government

CompanyPublic HealthInsurance

Service

SECONDARY/TERTIARY PREVENTIONSECONDARY/TERTIARY PREVENTION

+ Secondary, Tertiary Prevention④Provide Care Plan, Outcome Management　（ Relational Critical Pathway for Diabetes）⑤Question to Find Complications Earlier⑥Question to Check knowledge・Education ⑦Push to go to Clinic・ Avoid to Drop Out⑧Quick Report of HbA1c to Patient

　　　　　＜＜ Service ｓ＞＞Primary Prevention①Life style instruction program (Critical pathways for 5 action stage for self-care)②Data Management and Analysis③Individual “Target” to Get Carna Points ⑤⑥⑦Call Center Service

(Phone Call Question to Find Complications Earlier)

Summary of CARNA ProjectSummary of CARNA Project

Out Bound Call Center

Patients

Mail

Phone

Primary Dr.（ Company Dr.）

Points

Coupon

Strengthen RelationshipStrengthen Relationship

DM Dentist KidneyOphthalmologist

Specialists

Team Care

Service

Clinics

Relational Critical Pathway

EdutainmentEdutainment

Tourism Co.

Restaurants

Service Providers Service Providers

Gymnasium

Private Insurance

Co.

CARNA office

Individuals

Local Government

CompanyPublic HealthInsurance

Service

SECONDARY/TERTIARY PREVENTIONSECONDARY/TERTIARY PREVENTION

+ Secondary, Tertiary Prevention④Provide Care Plan, Outcome Management　（ Relational Critical Pathway for Diabetes）⑤Question to Find Complications Earlier⑥Question to Check knowledge・Education ⑦Push to go to Clinic・ Avoid to Drop Out⑧Quick Report of HbA1c to Patient

　　　　　＜＜ Service ｓ＞＞Primary Prevention①Life style instruction program (Critical pathways for 5 action stage for self-care)②Data Management and Analysis③Individual “Target” to Get Carna Points

⑧Quick Report of HbA1c to Patent

Summary of CARNA ProjectSummary of CARNA Project

Carna’s two programs of disease management

Service for insurers(outsourcing of Tokutei Kenshin)

preventionhealth promotion association Family doctors Specialists doctors

Health promotion for healthy people

Service for clinics(outsourcing of lifestyle management

fee in medical payment)

Intervention by an initial health instruction and repeated instructions

Diagnosis of Diabetes Mellitus

Secondary/tertiary prevention without cooperation of family doctors(DM light service)

Primary prevention programSecondary/tertiary prevention program for diabetes mellitus

medication

Secondary/tertiary prevention with cooperation of family doctors(DM regular service)

Schedule of Carna’s Diabetes ProjectFinal formation of the diabteic project

Secondary/tertiary prevention（ Capitalized from 2010）Information provided

Motivation support

Aggressive support

Encouragement of hospitalization

Classic Diabetes program

・ Management of Critical path・ Support of hospitalization・ Support to find early complication・ Data Management of diabetes indicator・ Support of education ・ Intensive program for DM・ Consultation program

Verified test from 2006

Business target; insurers

We will start capitalization from primary prevention at first and extend the target to secondary/tertiary prevention later.

Primary prevention（ Capitalized from 2008）

Verified test from 2005

Business target; clinics

Future Directions

TokyoKumamoto

Pref.

Regional development

Primary prevention

Disease kinds

Post ope of cancerD

epressionIH

DH

eart FailureCO

PDAsthm

a

Secondary/Tertiary Prevention of

Diabetes MellitusIn Fukuoka Prefecture

Carna in 2008

in 2008Data management = 100,000 peopleHealth instruction = 2,000 people

0

20

40

60

80

100

Quick eating

Group of non-healthcare instruction Group of Healthcare instruction

Night eatingSkip breakfast

Eating before sleep

Eating outEating more than

same

generationWalking for 1 hour

Faster walking than

same

generationExercise twice/a week

Daily exercise

Feel better by sleeping

Sleeping well

Daily alcohol taking

SmokingSmoking number

StressMethod to release stress

Persisting

present lifestyle

Want to improve

present lifestyle

Soft drinkImproved

at least one item

40 18 14 41 97 26 80 45 86 63 17 98 40 26 26 76 31 32 18 3 10226 9 8 19 42 24 42 27 42 34 14 49 29 21 21 39 21 9 5 2 49

(%)

Effect of Face to Face Healthcare Instruction on the Healthcare Instruction Group(Motivation Support + Aggressive support) by an e-mail questionnaire

Conclusion The bill to reorganize the public medical insurance, which The bill to reorganize the public medical insurance, which will be enforced in 2008, and the project of 100% online reiwill be enforced in 2008, and the project of 100% online reimbursement, which will be achieved in 2011, will change thmbursement, which will be achieved in 2011, will change the circumstances of circulation and accumulation of medical, e circumstances of circulation and accumulation of medical, healthcare and insurance information. We need to establish shealthcare and insurance information. We need to establish secure and patient-centeredecure and patient-centered social system for the alterations. social system for the alterations. As a model of the social system, we presented a newly develAs a model of the social system, we presented a newly developed Japanese disease management for diabetes mellitus “Caoped Japanese disease management for diabetes mellitus “Carna”.rna”.

If you have any questions, call to Carna office, +81-92-642-6459Or carna@med.kyushu-u.ac.jp