The prevalence of chronic disease in the United States will increase over the next several decades among all age groups, as will the associated care costs, and physical, mental and social consequences. Major obstacles to effective chronic care management (CCM) include:

– Patients rarely suffer from a single chronic condition at the time of their diagnosis¹. They are given multiple prescriptions and treatments with differing instructions and guidance, which is overwhelming and can lead to confusion and non-adherence².

– The number of patients seeking access to care and an ongoing healthcare provider shortage. In some areas it may take four to six months for a patient to schedule a routine appointment with their primary care provider or specialist.

Our healthcare system has largely been ineffective in managing chronic diseases to date, and now reimbursement changes are shifting the burden of chronic care management to the physician. Addressing this patient population will require a different approach since their conditions are typically the result of lifestyle choices. The solution will require a shift in focus from treatment to prevention, and leverage advanced technology to improve outcomes.

Technology’s Vital and Increasing Role

The primary cost associated with CCM today is personnel and staff time, but technology can alleviate that burden by automating administrative tasks. The rapid acceptance of technology as a healthcare tool presents an opportunity to drive prevention, detection, early intervention, and ongoing support without adding additional staff resources. 

Physicians can leverage advanced patient engagement technology to automatically identify high-risk patients (e.g., hypertension) within the EMR and enroll them in a communication pathway. Their physician or care team member should explain the importance of the program and recommend participation. The technology then gathers physiologic parameters over the course of time, provides strategies to make healthy lifestyle changes, and offers education on the consequences of unmanaged conditions, e.g., A1C and diabetes, or stress and depression as it relates to obesity. The messaging language must be easily understood, avoiding the use of medical terminology that may be confusing or misunderstood.

Physicians can choose from a diverse array of patient communication content to structure outreach programs in meaningful, accessible ways. In addition, most patient communication can be completed asynchronously, meaning patients and providers can read and respond to messages when it is convenient for them to do so. This asynchronous communication eliminates missed phone calls and the need to leave voice messages and reduces the number of times clinicians are interrupted in their day. In fact, offices and clinics experience an average 29% decrease in phone calls because communication pathways can address anticipated questions and reinforce educational content.

Personalized messages that use branching logic or artificial intelligence achieve higher levels of engagement and success because they respond to the patient’s unique needs. This outreach complements routine visits and in-person education, serving as an extension of the provider to positively influence patient behavior in their normal environment.

As patients engage with secure messages and enter important health information, the technology can help care teams identify and focus on patients who need more help or who can’t access technology. Staff is more efficient and able to safely manage larger patient caseloads while delivering better care and improved outcomes.

If patients have access to technology – a smartphone or computer with an internet connection — a care plan may include:

– Engagement best practices to activate patients in self-care. Consider timing, content, and tone of messages to ensure they are delivered when they’ll be most effective and meaningful to the patient. Providing a mix of information, motivation and encouragement keep patients focused on their health goals. 

– Connections to online resources that provide dietary guidance, emotional support resources, and educational materials and programs.

– Support groups offered in multiple formats that fit the needs, comfort level, and schedules of patients. These may include telehealth appointments, live-streamed one-on-one or group sessions, teach-back sessions, and recorded events that can be viewed on the patient’s schedule, and even repeatedly if needed.

For patients with limited access to technology, support services can be incorporated into routine care appointments or coordinated with team members so patients need only a single in-person visit. Since most people have access to email, it can be used as a platform to extend communication and care beyond the physical office.

Risks and Rewards of Leveraging Technology to Manage Chronically Ill Patients

Despite clear advantages, there are concerns that must be addressed with using a digital health platform to automatically monitor and communicate with chronically ill patients.

– Inaccurate information reported by the patient. Train patients through teach-back sessions and during in-person visits on how to properly collect data, e.g., blood pressure, blood sugar levels, etc., to mitigate most inaccurate reports. Consistently monitor data to identify anomalies, which will aid in spotting errors and provide opportunities for re-education.

– Care teams feeling displaced by technology. Physicians should clearly communicate the benefits of technology, demonstrate how it is an extension of the care team, and show how it enables the team to more effectively drive positive outcomes. 

– Patients may fear they are losing access to their care team. Proactive, personalized, empathetic communication actually strengthens the care team relationship and makes patients feel like they are being monitored consistently, not just during office visits. Integrate multiple touchpoints including asynchronous communication, telehealth, and group sessions, for example, to ensure patients experience a personal connection.

Despite these very real concerns, the rewards of leveraging technology to improve care for patients with chronic conditions far outweigh the risks.

– Appropriately developed care pathways ensure that information is collected in the safest way possible.

– Automated alerts mobilize the care team when intervention is needed.

– Short digestible messages, education, and encouraging nudges between visits improve the quality of care and outcomes while allowing physicians to care for more patients in the same amount of time.

– Asynchronous communication is more manageable for the clinicians and convenient for the patient.

– Providers will be successful in new reimbursement models because patients fare better, need less care, and require fewer therapeutic interventions. This drives costs down and improves outcomes.

Providers will be better equipped and more successful in preventing and treating chronic conditions by expanding beyond the bricks and mortar of a doctor’s office with patient engagement technology. While no one can effect change in every patient, empowering them to make informed decisions and engage in their own healthcare will have a meaningful and lasting impact. 

There is no doubt that patient engagement technology can revolutionize how we treat chronic conditions. The key to success, however, is choosing the right technology, one proven to deliver high patient engagement rates. After all, until we engage patients, outcomes will not improve. And unless we improve outcomes, we haven’t really achieved anything.

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Dr. John Janas

Dr. John Janas is the Medical Director at Twistle, a company that uses secure, patient-centric communication to drive care plan and protocol adherence, improving outcomes, lowering costs, and building loyalty. Dr. Janas empowers Twistle clients with clinical content and best practices to manage acute and chronic conditions in the home using patient engagement and remote patient monitoring (RPM) strategies. Janas applies his 35-plus years of clinical practice experience and 25 years of EMR implementation and content development expertise to help payers, physician groups and value-based care providers improve care management and reduce costs. 

Article By: Dr. John Janas

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