A chronic condition management platform, deployed by Microsoft at Denver Health Medical Center, a safety net hospital in Colorado, is helping clinicians improve case management, customer outreach and analytics – and is reducing the costs associate with the readmission of diabetes patients.

Officials say the platform could well lay the foundation for a larger program designed to encourage patients to self-manage conditions.

"The onset of an aging population and the increase of chronic diseases is adding extreme costs to our healthcare system," says Jack Hersey, general manager, U.S. Public Sector Health and Human Services at Microsoft. He points out that roughly 83 percent of all healthcare spending is on managing chronic illness, and that diabetes alone costs U.S. $83 billion annually.

"That's something that technology can really help address," he says.

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With diabetes affecting more than 25 million people, Denver Health saw a value in enlisting Microsoft's bidirectional chronic condition management (CCM) platform to enable between-visit patient-provider communication for its high-risk diabetes patients.

The technology facilitates patient-provided data collection through text message queries to diabetic patients about home blood sugar measurements and also facilitates sending reminders to patients of upcoming appointments.

Case coordinators at Denver Health then review self-reported patient data and follow up with patients by phone, in accordance with established clinical guidelines.

The CCM platform uses several integrated Microsoft technologies, including Microsoft Office SharePoint Server 2007, Microsoft Dynamics CRM and Microsoft SQL Server 2008. That software is coupled with healthcare process design and technology development from Hopkinton, Mass.-based EMC Corp., which can help create a flexible platform for providers of any size to address a number of chronic diseases.

In the first phase of Denver Health’s CCM program, patients both responded to the text messages and improved their home glucose monitoring. Providers reported on the engagement of patients around their diabetes care and on the identification of patients suffering from low blood sugar.

“The long-standing model of chronic disease management through the standard provider office visit does not support the patients’ need to manage their disease on a daily basis," said Andy Steele, MD, director of Medical Informatics at Denver Health. "We believe that using bidirectional communications within a chronic condition management system may be an effective method to provide care for chronic conditions beyond the traditional clinic setting.”

Gregg Veltri, chief information officer at Denver Health, added that the hospital is "considering expanding the CCM platform to integrate with other clinical databases in order to identify and reach out to at-risk patients."

As CMS ties reimbursement to readmissions, with providers getting less money for patients who come back to the hospital for the same problem in a given amount of time, "those providers that are more forward thinking are really looking at how they can ensure they're maximizing Medicaid payments, and that they're preparing for those reimbursement changes," says Hersey. "There are going to be increasing numbers of individuals entering the system, so they really need to be thinking about how to manage those costs."

And while "EHRs are really good at all the internal aspects of managing patients," he says, a robust CRM platform "allows the hospital to reach outside of their organization to manage chronically ill patients."

Text messaging (the platform also allows for e-mail and voice communications) helps Denver Health proactively reach out to patients once they've checked out of the hostpital, reminding them to take medications and report back on their glucose levels.

"Once these patients start inputing that data, we centralize it in Microsoft Dynamics CRM, which allows us to really analyze which of those patients are at risk of returning back to the hospital," says Hersey. "The people at greatest risk of returning are moved to outpatient setting – to a clinic, or to a physician that's part of the Denver Health organization, for care. Instead of having them return to the hospital for a $3,000 emergency room visit, they can now see them for $100 physician visit."

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“Denver Health is always looking for new ways to improve patient care, and EMC is pleased to be collaborating with them and with Microsoft on this innovative initiative," said David Dimond, national healthcare leader, EMC Consulting. "These types of efforts can have far-reaching impacts on the healthcare industry, and EMC is constantly striving to help its customers to better use technology to enhance patient care and streamline the healthcare delivery process."