To ensure success under value-based care models, providers need specific clinical information readily available at the point of care to make decisions and take measures to improve outcomes. Unfortunately, in most instances, they simply don't have it.

No one person can keep track of every relevant indicator for a disease. But with the key hallmark indicators, providers can proactively engage the patient, their family and their home care provider, and say, "These are the things you should watch closely that could indicate a problem."

The patients should be monitored, regularly, beyond documenting them during the physician encounter, to avoid trips to the ER and acute episodes. So, real-time tracking of key indicators can help turn the corner, and communication between the provider, the patient and the payer team could make chronic care management work.

Healthcare IT News sat down with Dr. Jay Anders, chief medical officer at Medicomp Systems, which develops tools to help make data more usable, to discuss chronic care management today.

Q. If the key to chronic care management is having ready access to hallmark indicators that can mark the progression or control of a disease, what are the hallmark indicators, and do caregivers have ready access today?

A. Hallmark indicators, also called key indicators, are a set of six or seven things that determine the direction of a specific condition. For example, for diabetes it's A1C, blood sugars, renal function, etc. They are measures that a physician would monitor over time to see the progression or regression of a particular illness.

These hallmark indicators are things that ideally would be presented on a dashboard for a clinician to review at the point of care. That way, they can see at a glance what's happened in the past and identify trends to determine where a condition is heading.

But do clinicians regularly have ready access to this information? No. The indicators typically are scattered throughout an EHR. Most are lab tests, but they are not assembled in a list for that specific disease. Clinicians need easy access to these six or seven things at the point of care.

So, for example, if you're treating juvenile arthritis, you'd look at joint counts – how many joints are inflamed. That is a hallmark indicator. And they are not readily available at the point of care. They are packed in with everything else and require time and effort to find. We don't have this luxury at the point of care.

Q. With the key hallmark indicators, providers could proactively engage the patient, pointing out things he or she should watch closely that could indicate a problem. Please give a detailed example of this.

A. One real-world example is with Phoenix Children's Hospital, where they have more than 60 disease panels – dashboards with key indicators on them for the clinician to use at the point of care. Let's use juvenile arthritis as an example again.

Putting the joint count with the medication that has just been prescribed, or increased or decreased, tells the physician something. And Phoenix Children's took their disease progression down about 80% because they were actively monitoring the joint counts either in the office, or with the patient calling them in from home, and then coupling that with the medications and lab tests.

With that view, they then can tell that by fine-tuning the medications how they can get these patients better. So, they've moved the quality needle. It's quality of life for these kids, as well as quality of life for the clinician who must monitor the condition. So, they've got 60 different diseases right now, ranging from chronic lung conditions to chronic GI conditions, and they are seeing that type of result across all those domains.

That example shows if you give the clinician what they need to know in an easy, consumable format, they can improve the quality of the patient's life much more easily. And this is possible for nearly all the chronic diseases because they all have these indicators.

It's just a matter of how you present the information to the clinician at the point of care. It's a matter of the right information in the right place, at the right time, in front of the right person.

Q. Real-time tracking of key indicators can foster the needed communication between all parties to help make chronic care management work. How?

A. The payer part is an interesting sideline. Payers are primarily interested in reducing cost. And you reduce cost by keeping people out of the hospital and managing them very, very carefully.

If you think about diabetes, for instance, there are a lot of home monitoring systems now that can go directly from the patient to the EHR to the clinician. So, they can see in real time if they've got a real brittle diabetic who needs their insulin adjusted frequently. It's an easy way to connect all those dots.

The same applies for a condition like COPD. The symptom of wheezing, or shortness of breath, can be reported on a phone and is entered into the EHR. The physician is alerted and can start intervention earlier.

Congestive heart failure (CHF) is another example. People track their daily weight. It's simple – step on the scale. And today there are scales that log your weight directly to your phone, to an app, where it can be tracked in real time.

With CHF, weight increase indicates water retention, which can indicate an exacerbation coming on. And if a provider and a patient are communicating – even electronically – there can be alerts set up. The provider asks, "Your weight's up five pounds today, what's going on?" Perhaps, they simply need to adjust their meds. But having this sort of automated dialogue in place is crucial.

Real-time tracking is becoming mainstream and will be more so as these devices become more sophisticated. Apple Watch now includes atrial fibrillation detection, and they are working on blood sugar detection. All combined, this will make chronic care a lot easier because it provides real-time data in a window where you can intervene before the patient really gets sick.

Q. You say providers need comprehensive, problem-oriented views of clinically contextual information to effectively initiate this dialogue. What does this look like?

A. As an internist, most of my patients had four to five different conditions at any point. And some would bleed over into each other. So, there's a considerable amount of data coming into the medical record.

How does a clinician sift through all that and view the data pertinent to a specific condition, say hypertension or coronary artery disease? The data needs to be filtered and presented to the clinician – much like the hallmark indicators, but a little more information – so they have all the information pertaining to this patient related to this disease.

To be effective, the presented information needs to filter out "clinical noise" so the clinician can focus on a particular problem. Then, they can easily switch to the next problem and focus on that to make the needed decisions.

Clinicians are constantly putting this type of information into clinical content, in their heads. But the amount of incoming data is so immense that something could be missed. So why not let the computer sort it out? We have the capability.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.