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Patient alerts improve compliance

Patient alerts improve compliance

ActiveHealth tests Care Considerations beyond physician messaging

Consumerism is a hot topic in healthcare as insurers and employers move more costs and responsibilities onto the individual.

Members are making more financial decisions because of consumer-directed health plans, health savings accounts, higher deductibles, and cost and quality information, but there is one area in which the patient is usually not involved that could play a role in reducing gaps in care and improving outcomes.

ActiveHealth Management, a New York City–based health management services company that offers disease management, clinical decision support, and personal health records, recently tested whether clinical alerts informing patients about gaps in care, potential medical errors, and opportunities to improve care would also boost compliance.

ActiveHealth’s CareEngine System is a clinical decision support technology that continuously gathers medical, pharmacy, and laboratory claims data for members and compares the data against the latest findings in evidence-based literature.

A team of clinicians at ActiveHealth and a panel from Harvard Medical School spend countless hours reviewing literature and alerts to make sure the clinical alerts generated by the CareEngine system have the most up-to-date information.

ActiveHealth usually sends the clinical alerts, called Care Considerations, to physicians about potential issues, but recently studied the effects of also sending these alerts to patients.

The study found that clinical alerts based on evidence-based medical guidelines were followed at a greater rate when they were sent to patients and their physicians compared to when the alerts were sent only to physicians.

Stephen Rosenberg, MD, MPH, senior vice president of outcomes research at ActiveHealth, says notifying members about evidence-based care dovetails with the consumerism movement.

“People want to be more involved and have the knowledge and the tools to be more involved in their own care. This, in a way, empowers the consumer. We are not just telling the doctor, ‘You ought to do this for the patient.’ We are telling the patient, ‘This is in your best interest,’ ” Rosenberg says.

The authors of Supporting the Patient’s Role in Guideline Compliance: A Controlled Study, published in the November 2008 American Journal of Managed Care, wrote, “A clinically sound, evidence-based system for detecting possible gaps in care and bringing them to the attention of both patients and their physicians in a timely and constructive manner would benefit all segments of the population.”

The study found:

  • Sending Care Considerations to patients as well as physicians increased compliance by 12.5%
  • Care Considerations that recommended screening, diagnostic, and monitoring tests had the greatest effect on patient compliance

“The primary goals of the program are enhanced compliance with evidence-based clinical guidelines, a decrease in adverse events (e.g., strokes, asthma attacks) that should follow from compliance with guidelines, a reduction in related healthcare utilization (especially emergency room visits and admissions), and a decrease in healthcare cost as a consequence,” the authors of the study wrote.

The system currently includes about 900 types of clinical alerts in the areas of drug interactions, vaccinations, adding or intensifying therapy, and condition or drug monitoring.

The alerts and ActiveHealth’s responses are divided into three levels. Level 1 alerts focus on potentially life-threatening situations; ActiveHealth responds by calling physicians about the problem. Level 2 alerts are a serious but not immediately life-threatening situation; in these cases, ActiveHealth faxes the information to physicians. Level 3 alerts apply to routine monitoring and preventive issues and are sent through the mail.

ActiveHealth collects daily drug data from pharmacies but receives medical claims on a weekly basis or every other week. The regularity of claims data receipt is important for Care Considerations. “If there’s a longer time lag, obviously we are not being as timely sending out the warning, or there might be a false positive,” Rosenberg says.

He adds that sending clinical alerts to physicians can reinforce the latest evidence-based guidelines but does not “reach optimal levels.” One reason why this happens is that physicians may not pay attention to the clinical alerts because of the amount of information, some of it unreliable, that they receive on a daily basis from outside sources.

“These problems suggest that supplementing alerts to physicians with notices to their patients might be beneficial—encouraging patients to follow their physicians’ advice or to remind their physicians about overlooked guidelines,” wrote the study’s authors.

Rosenberg says ActiveHealth’s alerts are grounded in evidence-based care and don’t specifically deal with saving money, which is often the reason for health plan and pharmacy benefit manager correspondence to physicians.

“As physicians trust the system more, they will use it more. Unfortunately, today, physicians get bombarded by a lot of information by a lot of sources, and unfortunately, a lot of it is not good quality, and they tend to discard all of it,” says Gregory B. Steinberg, MD, chief medical officer at ActiveHealth Management.

Steinberg says ActiveHealth is exploring ways to distinguish the company’s correspondence from others. “We’re looking to find ways to get our message into physician work flow in a more elegant way,” he says.

Study finds compliance improvements

ActiveHealth’s 12-month randomized study compared overall changes in compliance with Care Considerations in a baseline year (2005) to a study year (2006). The study group included four large employers (with a combined membership of more than 100,000) that contracted with ActiveHealth to send Care Considerations to both patients and physicians in 2006. The control group consisted of 28 large employers (with a combined membership of more than 700,000) that continued with physician Care Considerations only.

During the study year, more than 13,000 measureable alerts were sent to members of the study group, whereas 64,000 were sent to the physicians of control group members. Six percent of the study group received one or more measurable clinical alerts with the most frequent alerts: add a statin, screen for or treat osteoporosis, perform an eye exam, add an ACE inhibitor, and test for microalbuminuria. (See Figure 22 below.)

The study authors found that informing the patient in addition to the physician about clinical alerts improved compliance in most instances. (See Figure 23 on p. 18.)

The vast majority of the messaging in the study and control groups were Level 2 (constituting about 70% of the messages in both groups), and the two top outcome types were the same for each: add a medication and get tested. (See Figure 24 on p. 19.)

The researchers also found that differences in compliance depended on gender and age.

“In the study and control groups combined, men were 1.34% more likely than women to comply with alerts, but the addition of patient messaging did not have significantly different impacts on men and women. In the study and control groups combined, patients more than 50 years of age were 33.2% more likely than younger patients to comply with alerts, but again, the impact of patient messaging did not differ significantly for patients of different ages,” wrote the study authors.

The study’s authors gave three possible reasons as explanation for the benefits of sending patients clinical alerts:

  • Messages reminded patients and reinforced physician instructions
  • Patients who received the alerts brought information to the physician and reminded him or her to write prescriptions or order tests
  • The physician alert was sent to the wrong physician, but the alerted patient brought the message to the correct caregiver

Real-time communication in the future

The study suggested ways to add on to the patient alerts. “Such a system can be developed by adding patient messaging to an existing program of clinically advanced physician alerts, as demonstrated in this study, or by adding physician alerts to a system that began with patient reminders. Whichever approach is taken, the result should be one in which the two sets of messages are coordinated to reinforce each other and to strengthen the patient-physician relationship,” the authors wrote.

Rosenberg says ActiveHealth is working on quicker communication. Within three years, the company will communicate the alerts electronically rather than via phone, fax, or letter. The company is working on pilots with physicians that provide real-time communication. This will allow ActiveHealth to communicate with doctors within seconds and allow for better coordination, Rosenberg says.

“The unfortunate reality is that most physicians sadly do not have electronic capability to allow us to have the electronic handshake,” Steinberg says.