Avicenna Medical Blog

Taking Care of Patients with Chronic Conditions

Posted by Yehuda Bechar on Mon, Jun 07, 2010 @ 04:12 PM

First lets define "chronic condition". There are many definitions of  "chronic condition", some more expansive than others. I would characterize it as any condition that requires ongoing adjustments by the affected person and interactions with the health care system.
As I mentioned on a previous blog (Chronic Disease Management and Adverse Drug Events) the care of patients with chronic conditions needs to be improved and streamlined.
Some deficiencies that exist today include:
    •    Rushed practitioners not following established practice guidelines
    •    Lack of care coordination
    •    Lack of active follow-up to ensure the best outcomes
    •    Patients inadequately trained to manage their illnesses
Most of these deficiencies exacerbate when the volume of patients seen by health care professionals (physicians, nurses, medical assistants) starts to increase. After all it would be very easy to take care of 5 or 10 patients. But when a single professional needs to take care of hundreds of patients the quality of care and attention to each patient starts to fall. There is no single way to improve the quality of care in chronic settings. An effective chronic disease program requires systems that can identify patients, track their progress and invest them in the care process. But, most health care systems are set up for acute, reactive care, not proactive care of patients with chronic conditions. The same is true for most EMR's (that were created on those settings) they are great at identifying and gathering information on a single patient. But what happens when your organization needs to deliver care to hundreds or thousands of patients.
    •    Is the typical EMR enough?
    •    Does it really work the way you do?
    •    Does it make the work of your staff easy?
    •    Does it improve the efficiency of your staff?
    •    Does it let you set treatment plans at the granularity that you desire?
    •    Does it ensures that every single patient receives the care and is monitored following standardize procedures?
    •    Does it let you coordinate care among primary care physicians and specialists?

At this point I have to start writing about AviTracks and how we at Avicenna tackle all this issues.
To be able to improve the quality of care for chronic disease patients a new kind of clinical application needs to be use.  And that is exactly the setting where AviTracks was born.  AviTracks was initially developed by the University of Michigan Health System to take care of anticoagulation patients. With the success experience on that setting other care units started to ask for a similar applications.  That is when the founders of Avicenna realized there was a real need out there that was not met by regular EMRs. Avicenna took over the task to develop a single application that would cover the needs of all those specialties: Oncology, Rheumatology, Gastroenterology, Pulmonary, Hepatology, Nephrology, Dermatology, to mention some.  That is how AviTracks was borned, it never intended to replace and EMR but to provide the functionality and the work-flow that specialty clinics could not find and needed in order to be more efficient.
AviTracks combines: Patient-centered care, Evidence-based care, and Population-based care.

Patient-centered care: Every patient received the care related to his/her specific condition and risk level. Pertinent information, education, and responsibility is given to the patient to allow them to get more involved in their own care. AviTracks also allows you to share information about treatment plans a current condition with other providers and let anyone take action (creating automatic notifications to all parties involved in the patient's treatment) making easier to coordinate treatments.
Evidence-based care: Numerous studies have shown that physician practice patterns vary widely, even where highly effective, cost-efficient treatments have been identified (for example, prescribing beta blockers after a heart attack). AviTracks let you implementing evidence-based care and compare the results for different treatments or different teams within your institution.  AviTracks helps you identify best guidelines, practice policies, and clinical pathways.

Population-based care: As we have mentioned AviTracks lets you satisfy the health care needs of all your patients, even the patient who hasn't set foot in your office for years. This goes against the natural tendency of most health care systems, which is to focus only on the acute problem of the patient sitting in the exam room, never mind the problems lurking in the shadows. What population-based care requires is that you: 1. Identify who your patients are and what conditions they have (a patient registry) and 2. Monitor their care proactively. The second part of population-based care is being proactive and keeping patients from falling through the cracks.

Tags: Chronic Care Management / CCM, Disease Management