chronic condition management (putting puzzle pieces together)
(Photo: iStock)

Now and then, a solution emerges for a large, seemingly intractable problem. In some instances, progress results when someone looks at a challenge with fresh eyes and sees a fix that wasn’t obvious before. More often, significant progress is born from a sustained history of incremental successes that, at some point, become a powerfully capable solution. This article describes one such solution, MedsEngine, that, in our opinion, has allowed chronic condition management to take a giant leap.

One of healthcare’s biggest challenges: chronic condition management

One of health care’s biggest challenges is better management of major chronic conditions, that among others, includes:

      • hypertension
      • diabetes
      • heart failure
      • asthma

In 2016, chronic conditions and the downstream health and productivity events they generate consumed almost one-fifth of US Gross Domestic Product.1 These include:

      • heart attacks,
      • strokes,
      • amputations,
      • emergency visits,
      • hospital admissions,
      • absenteeism

This class of conditions represents our most important health care outpatient improvement opportunity.

Results of efforts to improve chronic condition management have been meager

That said, efforts to manage chronic conditions have yielded despairingly weak results. Performance can be measured by the percentage of cases that are “controlled,” meaning patients’ metrics are within safe limits.

Currently, only 44% of Americans with hypertension are controlled.2 Fewer than 10% of diabetics are controlled when their blood glucose, blood pressure, and cholesterol goals are considered.3 Among heart failure patients with reduced ejection fraction, only 1% are controlled.4 Better control would translate to better health outcomes, fewer high-cost events, and lower costs.

  • The usual excuses for poor performance

The standard responses to poor results have been to assign blame. You’ve probably heard these excuses about why performance was subpar:

        • Patients are lax about taking their meds.
        • Doctors don’t give patients the attention they need.
        • Chronic conditions are simply too resistant to control.

With these assumptions as a backdrop, most interventions aim to change patient behavior, typically with little success.

  • Two essential elements for successful chronic condition management

These reactions ignore the complex structure of chronic diseases and what it takes to manage that complexity. As it turns out, two elements are necessary for successful chronic condition management:

        1. Physicians must prescribe the right medications for each patient.
        2. Patients must be engaged, participating in therapy, and self-care.

Let’s put aside the second, on the assumption that the right drugs deliver superior health outcomes, a reward that should easily win patients’ buy-in.

Insight: Choosing the right therapy for a chronic condition is complicated

Insight is the hoped-for reward for taking on the intricacies associated with such an ambitious project. The insight of MediSync, the MedsEngine’s developer, is that prescribing the most appropriate drugs is a lot more complicated than commonly thought. 

The number of variables involved in choosing optimal medical therapies results in millions of permutations. For example, there are five distinct hemodynamic causes for hypertension. MediSync has further identified 28 “comorbid” medical conditions.

MediSync uses twelve different drug classes – with multiple drugs within each class – to improve hypertension outcomes. The problem is that most physicians are comfortable using no more than five or six drug classes. Also, drug recommendations can change, based on age and race.

Most other professions have come to appreciate that extremely complex calculations are best done by computers. None of this calls into question the intelligence of physicians. It’s just that the level of complexity exceeds human mastery.

In the end, few physicians working without an aid like the MedsEngine prescribe the best medications. And few of their patients achieve safe blood pressure levels.

Artificial Intelligence (AI) is required to handle a large number of variables

Artificial Intelligence (AI) is an optimal solution for this type of challenge. When properly designed, it can capably and reliably handle large numbers of variables.

Related Content:  Artificial Intelligence: Can It Improve Results of Cancer Screening Programs?

That has been the vision of MediSync, a firm that, in other parts of its business, develops management solutions for large, high performing primary care and multi-specialty physician practices. It has taken two decades to sort out the next steps and do the work that brought the MedsEngine to fruition.

The MediSync team, composed of medical group managers and leaders, recognized the complexity of today’s medical sciences and focused on chronic disease outcomes. They started 18 years ago with “paper and pencil” decision support tools and achieved remarkable chronic condition outcomes. (See Table 1.)

Table 1 graphic chronic condition managementBut as the number and complication of diagnoses grew, paper and pencil tools became increasingly problematic.

Moving to an Ai-driven tool

MediSync began to create the MedsEngine, an AI-driven tool that deploys complex, mathematical algorithms reflecting the best current understanding of each chronic disease’s physiology and pharmacology, and the relevant interactions occurring among and between them.

Pulling patient information from the electronic health record, the MedsEngine could determine the specific physiology involved and the medications best suited to that. But it also required being transparent about the sources of each part of the science, so that physicians and other clinicians could trust and buy into its credibility.

The proof is in the data. The first table (above) shows the percentage of patients with a specific condition that is adequately controlled. The second table (below) shows cost and savings data across different populations.

MedEngine’s performance has been validated

This performance has been validated and recognized by credible third-party groups.  PriMED Physicians, a Dayton, OH primary care group, was one of two practices managed by MediSync that piloted the MedsEngine.

The American Medical Group Association (AMGA) ranked PriMED best in the US at achieving blood pressure outcomes of ≤140/90 mm Hg with 95% of their hypertension population under control.5 Similarly, the Centers for Disease Control certified PriMED as first in their Million Hearts awards program.6 It is the only large group nationally to exceed 90% of hypertension patients under control.

The same technology drove PriMED’s control of Type 2 diabetes. This program was also recognized by AMGA as first among US physician groups, achieving simultaneous control of all three major Type 2 diabetes markers: blood pressure, LDL, and HbA1c. 

There are clinical and financial impacts when chronic diseases are controlled

Relatively few primary care physicians currently track their success at controlling chronic conditions. It’s a small wonder when the results have been so lackluster. However, the ability to predictably control these major chronic diseases is a significant advance, with important clinical and financial impacts for the larger health system.

A system that allows providers to reliably achieve performance targets enhances patient care and value. Importantly, it also allows those providers to guarantee health outcomes and savings. This makes them far more desirable in a value-focused marketplace. In other words, the MedsEngine can serve as a foundation for care that is more evidence-based, accountable, and predictable.

The MedsEngine’s AI-driven platform capabilities are already established for three major chronic conditions:

  • hypertension
  • HFrEF (heart failure with reduced ejection fraction)
  • hyperlipidemia

And, the diabetes program is currently underway. Furthermore, MediSync intends to complete the top 12 chronic diseases addressed in primary care within three years. They include:

      • hypertension
      • diabetes
      • dyslipidemia
      • coronary artery disease and peripheral vascular disease
      • chronic kidney disease
      • heart failure
      • chronic obstructive pulmonary disease
      • asthma
      • depression
      • anxiety
      • osteoporosis
      • arthritis

The bottom line for chronic condition management

Mark DeRubeis, CEO of Premier Physicians in Pittsburgh, the other MedsEngine pilot site, summed up the promise represented by this approach:

“The MedsEngine offers the opportunity for exponential improvement in chronic care management. It enables you to get the diagnosis right the first time, to prescribe the right medicine the first time. If you look at the alternative to that, it may take two or three or four times the effort, and this enables you to cut all of that out and gain an efficiency that didn’t exist prior.”

The MedsEngine is the first of what will almost certainly be a flood of new digital tools that facilitate far more effective care. However, make no mistake, building these tools well is as complicated as the problems they seek to address. Fortunately, the rewards, in terms of better health and lower costs, are likely to be equally powerful.

References:

  1. Waters H, Graf M. The Cost of Chronic Disease in the U.S., Milken Institute, 2018 Aug. https://milkeninstitute.org/sites/default/files/reports-pdf/ChronicDiseases-HighRes-FINAL.pdf
  2. Munter P, Hardy S, Fine L, et al. Trends in Blood Pressure Control Among US Adults With Hypertension, 1999-2000 to 2017-2018, JAMA 2020;324(12):1190-1200. doi:10.1001/jama.2020.14545 https://jamanetwork.com/journals/jama/article-abstract/2770254?
  3. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2020. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
  4. Greene S, Butler J, Albert N, et al. Medical Therapy for Heart Failure With Reduced Ejection Fraction: The CHAMP-HF Registry, J Am Coll Cardiol, 2018 Jul 24;72(4):351-366. DOI: 10.1016/j.jacc.2018.04.070
  5. T2G Goal Post. The Monthly Newsletter of National Together 2 Goal Campaign, March 2018 edition. http://together2goal.org/assets/GoalPost/1803.html
     
  6. PrimeMed Press Release, Feb. 2015. https://www.primedphysicians.com/content/documents/PriMed-Media-Hypertension-Success.pdf

Keywords: chronic condition, chronic disease management, artificial intelligence, hypertension, diabetes, heart failure, MedsEngine, primary care, better health outcomes, cost savings


Financial disclosure: Both Brian Klepper and John Rodis have consulting relationships with MediSynch, the parent company of MedsEngine.

Brian Klepper Ph.D. and John Rodis, M.D.

Brian Klepper, Ph.D. is a Principal of Worksite Health Advisors and a nationally prominent health care analyst and commentator. He speaks, writes, and advises extensively on high-performance health care, primary care clinics, and the management of clinical and financial risk.

A purchaser advocate, he has focused on the market and policy dynamics of the health care cost crisis and readily available solutions to purchasers willing to approach the problem laterally. His current focus is on high performing health care organizations that consistently deliver better health outcomes at a lower cost than conventional approaches in high-value niches.

Dr. Klepper has been involved in several transformative health care efforts favoring patient and health care purchaser interests. His 2009 testimony to an HHS panel resulted in the revocation of an industry group’s monopoly on Health Information Technology certification. In 2010-2013, he spearheaded a national effort, culminating in a lawsuit against CMS and HHS, to expose the AMA’s RBRVS Update Committee’s role in distorting US’ care and cost patterns.

Brian is a regular contributor to the health care trade press. He is a reviewer for the journals Health Affairs and The Journal of Ambulatory Care Management, and an advisor to several health care organizations. He is the Founder and Moderator of The Healthcare Benefits Hackers listserv, a vibrant discussion forum with 850+ participants focused on health care value and high performance. George Washington University’s Masters in Health Administration Program ranked Brian's writing, archived at Care & Cost, the top 2016 blog by a health care professional. Feedspot named it a 2017 top 100 health care blog.

In his spare time, Brian is an offshore sailor.

John F. Rodis, M.D., M.B.A., is the founder and president of Arista Health, LLC, driving quality, safety, and patient experience and reduce risk in hospitals and health systems. He served as president of Saint Francis Hospital from 2015-2020, the eighth leader of Saint Francis and the first physician to serve as president since its founding in 1897. Dr. Rodis previously served as Saint Francis’ Executive Vice President and Chief Operating Officer, Chief Physician Executive. Prior to his executive leadership roles, Dr. Rodis served as Chairman of the Department of Obstetrics and Gynecology and Physician Leader of the Women and Infants Service Line, a position he assumed in 2011.

Under Dr. Rodis’ leadership, Saint Francis, a 617-bed major teaching hospital, the largest Catholic hospital in New England, earned its Level 1 Trauma Designation, opened its Smilow Cancer Hospital at Saint Francis and the Karl J. Krapek Comprehensive Women’s Health Center. During his tenure as president, the hospital garnered numerous awards and recognition including the 2018 and 2019 Women’s Choice Award® as one of America’s 100 Best Hospitals for Patient Experience, was named as one of the nation’s 100 Top Hospitals by IBM Watson Health™ and one of the World’s 1000 Best Hospitals by Newsweek. Moreover, the hospital recently attained its fourth consecutive “A” for Patient Safety from the Leapfrog Group, its seventh A in the last four years.

Before joining Saint Francis, Dr. Rodis served as Senior Vice President for Medical Affairs and Chief Medical Officer at Stamford Hospital, where he also previously held the position of Chairman of the Department of Obstetrics and Gynecology. Prior to that, he was at the University of Connecticut Health Center, where he was the Obstetrics and Gynecology Residency Program Director, a member of the Division of Maternal-Fetal Medicine and Director of Perinatal Genetics.

Dr. Rodis received his medical degree from the Autonomous University of Guadalajara, Guadalajara, Mexico. He completed his residency in obstetrics and gynecology at St. Joseph’s Hospital and Medical Center, Paterson, NJ. He completed fellowships in Maternal-Fetal Medicine and Clinical Genetics at the University of Connecticut Health Center. He also received his Master of Business Administration from Rensselaer Polytechnic Institute.

He holds the rank of Professor of Obstetrics and Gynecology at both the University of Connecticut School of Medicine as well as the Frank H. Netter MD School of Medicine at Quinnipiac University. He has attained a Black Belt in Lean Daily Management.

Dr. Rodis is Board certified in Obstetrics and Gynecology and Maternal-Fetal Medicine. He is a Fellow of the American College of Obstetrics and Gynecology, and a member of the Society for Maternal-Fetal Medicine and is a Fellow of the American College of Healthcare Executives.

He is the author or co-author of over 100 papers published in peer-reviewed professional journals. He served as an oral examiner for the American Board of Obstetrics and Gynecology (ABOG) for 19 years. He served as Chairman of the Connecticut Hospital Association’s Quality Committee and was a member of its Executive Committee and Board of Directors. He currently serves on the Board of Trustees of the University of Saint Joseph. He was awarded the 2020 Regent’s Senior Careerist Award by the Connecticut Association of Healthcare Executives.

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