Managing chronic conditions through automated patient engagement

For years, physicians have been challenged to maintain quality of care while continuing to see more patients as part of an effort to maintain revenue in the face of continual reimbursement cuts. These clinical and financial pressures are accelerating as insurers, led by the Centers for Medicare & Medicaid Services (CMS), shift from fee-for-service to value-based purchasing and payment models that reward and penalize doctors based on performance and outcomes achieved, rather than the number of patients seen and procedures performed.

To meet the new challenges of care delivery and payment reform, physicians must revamp how they run their practices. They must improve clinically and financially and act proactively to involve patients in managing their health.

Although it is valuable for doctors to engage every patient in their own long-term healthcare, it is crucial to target those with chronic conditions, who account for more than 75 percent of the nation’s health spending. The more physicians can enlist, partner and work together with these patients, the greater the likelihood that they can increase care plan adherence and impart the behavioral and lifestyle changes that are key to improving clinical outcomes. By engaging patients, physicians can minimize avoidable emergency visits, hospitalizations and readmissions, placing them in an excellent position to collect bonuses for meeting quality metrics or share in savings.

Role of technology in engaging patients
There are several steps practices can take to engage patients to improve quality. One is to implement technology tools to enhance care, patient engagement, productivity, and clinical and operational efficiencies. 

The ability to glean information about a patient population for strategic management of chronic conditions is a key prerequisite for delivering high quality care. The most effective way for physicians do this, especially given their ever-increasing demands, is to automate the processes of gathering and analyzing data, and disseminating targeted treatment information.  Automated patient engagement tools can be used in conjunction with or independent of EHRs, but are better suited to align physicians with the emerging outcome-based care and payment models.

Automated patient engagement systems use clinical data to alert caregivers to patient needs and to create personalized, actionable, tailored messages from the provider to the patient. These messages activate patients to take specific actions that are consistent with care plans (e.g., self-medicate, get follow-up testing, return for a follow-up visit).

Patient engagement tools enable physicians to extend care outside of the office visit and help keep patients engaged on a continual basis, without placing undue burdens on physicians or their staff. Such tools have been shown in rigorous clinical studies to improve outcomes and reduce utilization. Practices that are already using these tools report improved reimbursement as well as higher patient satisfaction.

Fee-for-service will not disappear overnight. However, this model is quickly being replaced by public and private payers who are looking to outcomes-based payment models to improve quality of care and lower costs. Practices that revamp their operations and leverage technology and automation to engage at-risk patients for preventive and follow-up care can achieve a reputation for high quality care, while maintaining a healthy bottom line.

Benjamin Littenberg, MD is the Henry and Carleen Tufo Professor of Medicine at the University of Vermont. He also is an internist at the 480-doctor University of Vermont Medical Group at Fletcher Allen and chief medical officer of Patient Engagement Systems, a healthcare technology company that provides solutions for improving primary care for people with chronic diseases.