Health initiative gives chronic care a facelift

By Erin McCann
08:24 AM
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Pittsburgh ACN puts health IT under the knife

PITTSBURGH – A new accountable care network (ACN) is in town. Putting health information technology to work, the network – organized by the Pittsburgh Regional Health Initiative (PRHI) – aims to reduce hospital readmissions and improve quality of care for chronically ill patients.

PRHI was awarded more than $10.4 million by the Centers for Medicare & Medicaid Services (CMS) to develop the Pittsburgh Accountable Care Network, which is projected to reduce regional healthcare costs by an estimated $74 million over a three-year period.

Information technology such as patient portals, peer-to-peer exchange and electronic health records will help focus specifically on reducing hospital readmissions of 25,000 Medicare patients with certain chronic diseases such as congestive heart failure (CHF) and coronary artery disease (CAD).

Making patient records more accessible among healthcare providers proves a crucial component in reaching the organization’s objectives, as Keith Kanel, MD, chief medical officer at PRHI and project director of the ACN, explained, “What we plan to do is create a network for independent hospitals, using IT to link these hospitals together.”

For instance, all the ambulatory processes will use the same unified system, an advancement, Kanel said will “ultimately allow us to share information broadly, no matter where the care is administered,” which will help to bridge those gaping information gaps in patient data.

One technology crucial to the network’s success in bridging these information gaps is peer-to-peer exchange.

Susan Flynn, CEO of Vale-U-Health – the physician hospital organization hosting the project’s prototype – describes peer-to-peer as virtually a “Facebook for physicians that allows them access to a patient’s lab results and medical history directly via a web-based framework.”

So when you have a patient with a chronic disease such as CAD, who is most likely taking several different medications, while also having numerous hospital admissions, it simplifies the process for healthcare providers, allowing for a timely access to a comprehensive, holistic record for that patient.

In addition to peer-to-peer exchange, the organization will also be joining the steadily increasing number of healthcare providers that use patient portal technology.

Bill Guiler, senior continuity of care specialist at Vale-U-Health, explains the portal will allow the patient to access his or her medical records via a secure website login. “It’s a place where patients can also communicate with their care managers directly via messaging. The technology gives us many avenues for real-time communication with doctors and real-time communication with patients.”

The ability to maintain patient-provider communication following patient discharge will help remedy the high rate of hospital readmissions, Flynn said. “When the patient disconnects with health professionals, that’s when their health can start to decline.” She said discharged patients often won’t get labs done as they should; they can also neglect preventative care practices or forget follow-ups, so the portal is integral for the continued health of the patient.

By increasing the number of nurse case managers and utilizing these communication technologies, Kanel has already seen 30-day readmissions decline by as much as 44 percent at PRHI.

The Pittsburgh-based ACO selected Westborough, Mass.-based technology company eClinicalWorks, which provides clinical IT solutions for the ambulatory market. Flynn said the choice to go with eClinicalWorks was driven in part by its health information exchange (HIE) technology, which PRHI is in the process of implementing.

The project, Flynn concluded, is ultimately about improving patient care. “This network will give us an additional tool to monitor and maintain patient health. The new technology allows healthcare providers to really have a handle on their patients, allowing us to treat the patient more holistically.”