Rethinking the Future of Outpatient Chronic Care

"This [telemedicine] concept has been around, but when it was done a decade or so ago, it wasn't done with technology. It was done by calling patients at home. It worked but was cost prohibitive," Harris says. The current project required no extra practitioners. "We just built it into their workflow."

The big challenge will be getting reimbursement systems to reflect this type of model of care. "There's no question in my mind that reimbursement systems today are based on the old model of care, which is we get reimbursed when the patient is sitting in front of us," Harris says. "Part of this study is to demonstrate we can deliver high-quality care and we can do it at lower cost."

At the Vanderbilt Medical Group and Clinic in Nashville, a question sticks in the mind of Jim Jirjis, MD, the chief medical informatics officer: At the end of the day, do people want to pay today for the benefit tomorrow?
For those who are the sickest of the sick, the answer is simple: Yes, it makes sense to help that population, Jirjis says. But what about that middle territory, where individuals aren't really ill yet but could be in the very near future if they don't get appropriate care now. This includes treatment for chronic conditions such as high blood pressure, diabetes, or congestive heart failure.

The future primary care system will not have anywhere near the capacity to take care of all those chronically ill patients under the old model, Jirjis says. So he is now implementing a medical home pilot using Vanderbilt's home-grown EMR that can assist in data mining and decision support.

Jirjis says this new model looks at providing "advanced stratification" for various chronic conditions. Rather than just label patients "hypertensive," for example, they are grouped into one of five categories: prehypertensive, new diagnosis, established but controlled, newly out-of-control, and ill with comorbidities.