Nearly 70-80% of health care costs result from chroniccare

70% of the disease burden is due to 5 chronic conditions

Congestive heart failure

Asthma

Coronary artery disease.

Diabetes

Depression

Diabetes

Ischemic Heart Disease

Trying to adapt acute care model to Chronic Disease

care

Reactive, not pro-active

Rushed practitioners not following established

practice guidelines

Lack of care coordination and

follow-up

Patients inadequately trained to manage their illness

Informed,

Activated

Patient

Productive

Interactions

Prepared,

Proactive

Practice Team

Delivery

System

Design

Decision

Support

Clinical

Information

SystemsSelf-

Management

Support

Health System

Resources and

Policies

Community

Health Care Organization

Improved OutcomesWagner et al, Health Affairs 2001;20(6):64-78.

Clinical information Systems

Decision Support

Self-management Support

Delivery System Design

Provide timely reminders for providers and patients

Identify relevant sub-populations for proactive care

Facilitate individual patient care planning

Share information with patients and providers to

coordinate care

Monitor performance of practice team and care

system

Electronic Medical Record

In Maccabi used by all providers for over 15 years,

capturing demographic and medical data and

providing the clinician with support in caring for his

patient.

Medical (Disease) Registries

Based on all of the information in the data base,

enable tracking individual patients as well

as populations to manage chronic illness and

preventive care.

Medical

History

Family

History

Visits &

Hospitaliza-tions

Demographic

parameters

ImagingTreatments

Medications

Lab

Results

1st year of data

collection

n

(2007)

% of MHS

population

Home Care 1998 5,500 0.3

Infertility 1998 10,000 0.6

Cancer 2000 36,300 2.1

Cardiovascular 1998 72,720 4.0

Diabetes 1998 85,000 4.7

Hypertension 1998 233,000 13.0

All of the above 442,520 25.0

The Clinical Decision Support System provides an integrated

comprehensive view of patients status including data on the

patient’s status relative to prevention, disease management ,

medication management etc.

The system is based on clinical guidelines and alerts the provider,

in real time, to the following:

Patient information indicative of aberrations in patient status.

Recommendation for needed tests/treatment based on cumulative data

on the patient in the system.

Links to relevant medical knowledge.

Drug interaction warnings

Prescription prioritization recommendations

Mandatory data fields (BP, smoking)

Recommended laboratory test alerts

Diagnosis-related lab test panels

Organizational alerts

Rules engine based alerts

Active Health

Problems Chronic Medication

Allergies

Last Visit

Risk Factors

Dr. Jones - FP

Robert Smith

Refer for Cholesterol test

Refer for Diphtheria/tetanus

Document results & blood pressure measurement

Print

List

Confirm

Cancel

Recommendations for present visit:

• recommended referrers

• delay to next visit

delay all next visit

Action

Reason

Patient suffers from hypertension. No documented

Blood Pressure Measures in the last year

Gantt Chronic Medications

Gantt Past Medications

Blood Pressure Trend

Gantt Chronic Medications

Gantt Past Medications

Blood Pressure Trend

Blood Pressure Trend

Patient Allergy to Penicillin.

Wish to prescribe despite sensitivity?

ApproveCancel

Lists of Patients with Diabetes

Status Reports with patient names and phone numbers:

Last HbA1C Test – when done and value

Last Eye Exam

Last Foot Examination

Last LDL test and value

Diabetic Patients without flu shots

Patients in Diabetes Registry

Statistics: Diabetes Patients

Average HbA1C% HbA1C

Average LDL% Done LDL

% Done Creat% Done Urine

% Done Eye Exam% Patients Aspirin

% Patients Ace Inhibitors% Visit Dietician

% Patients HbA1C over 9.5

% Patients HbA1C under 7% Patients HbA1C under 100

Clinic: TA Clinic Address: hazionot 17 Dr.: R. Smith Year: 2008

Average Patient Age: 52.6

Numbers of Visits: 348

Maccabi Region Clinic

ID #Last NameFirst NamePhone Num.Eye

Patients in Diabetes Registry

Patients who have not had an Eye Exam

Time Period Between October 2007 – September 2008

Computerized consultation with specialists

Virtual consults by e-mail and video conference

Diabetes expert teaching program

Diabetes education team visits

Joint consults

E-learning

Stress patient’s role in managing health

Strategies including assessment, goal-setting,

action planning, problem-solving and follow-up

Appropriate infrastructure

Patient education materials

Share information with patients

Eye Examination: this is not a test that can be performed by an optometrist or a test for a driver's license but

rather an in-depth eye examination by a qualified ophthalmologist. This test is very important for the early

detection of eye problems as a result of diabetes. There are excellent methods for treating these problems if they

are detected at the early stages. It is recommended that this test be done once a year

Urine protein test: The objective of this test is to identify potential damage to the kidneys as a result of diabetes.

If the discharge of protein or albumen in the urine is high, it can be treated by medication. It is recommended to

do this test (micro-albumen/creatnine or 24 hour urine collection for micro albumen or protein) once a year.

Here are the results over time of the test results in our system

Dear Joseph Kern ID# 500000000 Data last updated 31/5/2009

Dear member,

We are presenting you with your personal data with regard to your Diabetes, The control of your diabetes is largely dependent on

your understanding and your cooperation with your doctor. Here is your personal information with respect to several items critical to

your healthHBA1C Information

These data are based on your blood test results and indicate the

extent to which your diabetes was under control for the 3 months

prior to the test. It is recommended to do this test twice a year or

according to your doctor's recommendation. The recommended level

for this test is less than 7%

Recommended Value – 7%

LDL Cholesterol Information

This is the type of cholesterol that is known to be a risk factor for

cardiovascular disease. It is important that a diabetic patient do this

test once a year or according to his doctor's recommendation. The

recommended value for this test is less than 100/dl

HbA1C trend

LDL trend

Date: 30/9/2009 most recent HbA1C value:8.4%

According to our records, your last HbA1C test was more

than a year ago, Please contact your doctor for a referral

for this lab test

MaccabiOnLine

Built in guidelines based on the patient’s personal

medical information, clinical guidelines and his care plan

Input from sensors (weight, blood pressure, pulse,

glucometer, ECG) and from the patient

Input from doctor’s EMR, case management record

Interactive – provides instruction, answers patient

questions

Proactive – provides response to inputs, alerts to patient,

doctor, nurse case manager

Remote intervention by care providers based on patient

input, input from sensors, alerts

Willingness of doctor to take responsibility for

comprehensive care of patient including Disease

Management

New role for the nurse, as case manager, educator

Willingness of Patient to take responsibility for

managing his disease

Willingness of doctor, nurse and patient to work

together to manage the disease

Providing both the clinicians and the patient with the tools

for Disease Management:

Electronic Medical Record

Clinical Data exchange (test results, drugs purchased,

etc.)

Central medical record or data warehouse

Medical Registries for chronic disease

For the doctor – alerts, reminders, embedded clinical

guidelines, feedback, patient lists

For the patient - courses, education, interactive Patient

Health Record. alerts, reminders