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E-CareManagement News

March 5, 2001


"An elephant in the living room" is often used as a metaphor of what it's like to live in a home with alcoholism -- everyone knows it's there, but no one talks about it. Admitting there is an elephant is a first step toward recovery.
Last week the Institute of Medicine (IOM) described the elephant in the living room of the U.S. health care system. The IOM issued a landmark report "Crossing the Quality Chasm: A New Health System for the 21st Century". Read about the elephant and what to do about it or download the executive summary

In 1999 the IOM issued "To Err is Human", a report describing issues relating to medical errors and patient safety. IOM committee chair William Richardson described that report as the "tip of the iceberg", and the most recent "Crossing the Quality Chasm" as "the rest of the iceberg".
Key excerpts from the executive summary:

  • Research on the quality of care reveals a health care system that frequently falls short in its ability to translate knowledge into practice.


  • For several decades, the needs of the American public have been shifting from predominantly acute, episodic care to care for chronic conditions. Chronic conditions are now the leading cause of illness, disability, and death; they affect almost half of the U.S. population and account for the majority of health care expenditures.


  • Yet there remains a dearth of clinical programs with the infrastructure required to provide the full complement of services needed by people with heart disease, diabetes, asthma, and other common chronic conditions....The fact that more than 40% of people with chronic conditions have more than one such condition argues strongly for more sophisticated mechanisms to communicate and coordinate care....Yet physician groups, hospitals, and other health care organizations operate as silos, often providing care without the benefit of complete information about the patient's condition, medical history, services provided in other settings, or medications prescribed by other clinicians.


  • To initiate the process of change, the committee believes the health care system must focus greater attention on the development of care processes for the common conditions that afflict many people. A limited number of such conditions, about 15 to 25, account for the majority of health care services....Nearly all of these conditions are chronic. By focusing attention on a limited number of common conditions, the committee believes it will be possible to make sizable improvements in the quality of care received by many individuals within the coming decade.


  • In identifying these priority conditions, the agency (AHRQ) should consider using the list of conditions identified through the Medical Expenditure Panel Survey 2000. According to the most recent survey data, the top 15 priority conditions are:

  • * Cancer 
    * Diabetes 
    * Emphysema 
    * High cholesterol 
    * HIV/AIDS 
    * Hypertension 
    * Ischemic heart disease 
    * Stroke 
    * Arthritis 
    * Asthma 
    * Gall bladder disease 
    * Stomach ulcers 
    * Back problems 
    * Alzheimer's disease and other dementias
    * Depression and anxiety disorders


  • Health care organizations, clinicians, purchasers, and other stakeholders should then work together to: 

  • (1) organize evidence-based care processes consistent with best practices, 
    (2) organize major prevention programs to target key health risk behaviors associated with the onset of progression of these conditions,
    (3) develop the information infrastructure needed to support the provision of care and the ongoing measurement of care processes and patient outcomes, and 
    (4) align the incentives inherent in payment and accountability processes with the goal of quality improvement.

  • Commentary:
    A must read! This report paints a critical role for disease management processes and for disease management companies in the reform of the U.S. health system.

    The language of the report is extremely technical and the findings are not as easily put into sound bites as the last IOM report (e.g., "98,000 deaths annually due to medical errors"). Nonetheless, this report promises to be a turning point in ushering out the era of cost-focused managed care.

    Finally, hats off to the IOM in recognizing the crucial role that reimbursement reform must play to incentivize health care providers and DM companies.


    A recent study suggests that the short answer to this question is a resounding "YES". VHA, a nationwide network of community-owned health care systems and their physicians, has published "Consumer Demand for Clinical Quality: The Giant Awakens"

    CONCLUSIONS from the study:

    1) Consumers are seeking credible and meaningful clinical health care information and feel it is important to be actively involved in their care or the care of their families.
    2) Clinical quality issues are central to consumers' definition of health care quality and are more important selection drivers than service issues.
    3) Clearly presented concepts of evidence-based medicine and system-based measures for patient safety are readily understood and embraced by consumers as information that would influence their choice of provider.
    4) Consumers see hospitals as bricks and mortar, performing a minor role in assuring clinical quality, but believe they should be performing a more active role.

    RECOMMENDATIONS from the study:

    1) Health care organizations should actively and publicly assume accountability for clinical quality.
    2) Health care organizations should take definitive and aggressive action to achieve, measure and publicly report clinical excellence as a means of market place differentiation.
    3) Physicians and staff should be made aware of the needs and expectations of the "new consumer" and should engage patients as active partners in health care decision making.
    4) Health care organizations must respond quickly if they intend to take advantage of the opportunity to position themselves as clinical quality leaders.

    The survey population consisted of participants who had experience with the health care system AND were more likely to seek out health information. Be careful in projecting results to the population at large. Nonetheless, this group is likely to represent innovators and early adopters.

    One aspect of this survey that is particularly interesting is the exploration of evidence-based medicine and evidence-based treatment messages presented directly to consumers. While a majority of consumers initially were not familiar with evidence-based approaches, the authors found that consumers could quickly understand the concepts and that future health care decisions could be dramatically influenced.


    The issue of health literacy -- the set of skills needed to read, understand, and act on basic health care information -- is an issue championed by the American Medical Association, Pfizer, and other concerned organizations.

  • The estimated additional health care expenditures due to low health literacy skills are about $73 billion in 1998 health care dollars. This includes an estimated $30 billion for the population that is functionally illiterate plus $43 billion for the population that is marginally literate.

  • Health literacy is an especially significant challenge for patients with chronic conditions. ...patients with low health literacy and chronic diseases, such as diabetes, asthma, or hypertension, have less knowledge of their disease and its treatment and fewer correct self-management skills than literate patients....Individuals who rated their health as fair/poor were twice as likely to have inadequate health literacy compared with individuals who rated their health as good/excellent - 38.7% vs. 19.2%. Read more at AMA Foundation Tackling the Problem of Health Illiteracy.


    The National Pharmaceutical Council has compiled an extensive annotated bibliography on the benefits of disease management services for congestive heart failure patients.


    "Today, we really do have the opportunity to tap into wires already in place in our homes for security and telecommunications purposes to enable constant monitoring, tracking, and transmitting of home care patient information to and from our homes." Read more in a forsightful article by Audrey Kinsella MA, MS.


    Deloitte and Touche has published its annual survey of certified benefit specialists, "Top 5 Benefit Priorities for 2001". For the second year in a row, "control health care costs" tops the list.

    1996 Intranet/Internet Applications.. 45%
    1997 Health Care Reform.. 38%
    1998 Investment Education.. 43%
    1999 Intranet/Internet Applications.. 47%
    2000 Control Health Care Costs.. 70%
    2001 Control Health Care Costs.. 71%

    Commentary: a sobering reality check when considered in light of the IOM "Crossing the Quality Chasm" study.


    The Agency for Healthcare Research and Quality (AHRQ) has issued a report evaluating telemedicine technologies. The report describes 3 categories of telemedicine: (1) Store-and-forward, (2) Self-monitoring/testing, and (3) Clinician-interactive services.

    The Evidence-Based Practice Center (EPC) team identified 455 telemedicine programs, of which 362 are in the U.S. About 50 programs provide services in patient homes.

    Conclusions from the study:
    This report finds that the use of telemedicine is small but growing. Active programs demonstrate that the technology can work, and their growing number indicates that telemedicine can be used beneficially from clinical and economic standpoints. The longevity of these programs, however, is not clear, and many may fail to survive beyond initial funding or enthusiasm.

    The evidence for the efficacy of telemedicine technology is less clear. The problem is not that studies have strong evidence against efficacy, but rather that their methodologies preclude definitive statements. Many of them have small sample sizes that preclude statistical power, and the settings of others may not be equivalent to clinical settings. Still others focus on patient populations that might be less likely than others to benefit from improved health services, such as people who have complex chronic diseases. 

    The report implies that the EPC team struggled to find rigorous evidence. Of the initial 177 articles examined by the EPC, 77 were included in their analysis (and of these 48 relate to clinician-interactive services). These AHRQ evaluations will be increasingly influential in future reimbursement decisions by Medicare and other payors.


    Sponsored by Johns Hopkins University and the Robert Wood Johnson Foundation, Harris Interactive conducted a survey that reveals concerns about the quality of care for people with chronic conditions. For example, 72% of Americans say it is difficult for people living with chronic conditions to get necessary care from their health care providers.

    Disclosure -- No BHT clients were mentioned this issue.

    E-Care Management News is an e-newsletter that tracks a major change in health care and managed care—the paradigm shift from “managing cost” to “managing care”.  This e-newsletter is brought to you by Better Health Technologies, LLC (  BHT provides consulting and business development services relating to disease management, demand management, and patient health information technologies.

    You may copy, reprint or forward this newsletter to friends, colleagues or customers, as long as the use is not for resale or profit and the following copyright notice is included intact. Copyright © 2001, Better Health Technologies, LLC. All rights reserved.


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