Introduction
The importance of effective Chronic Disease Management (1) is gaining increasing recognition across developed countries as a means to improve population health and well-being while decreasing net healthcare expenditure.  In the United Kingdom, 80% of GP consultations are related to chronic diseases (2), in the United States 7 out of every 10 deaths are caused by chronic diseases, while in Canada, 60% of hospitalisations are due to chronic disease.

While the UK has been very successful in identifying chronic diseases, and relatively successful in managing them at a primary care level, a lack of integration and failure to leverage technology at a care community level has resulted in fragmentation.  Examples from other health systems where innovative technology has been successfully used to support increased collaboration and integration across communities of providers offer an insight into the benefits that can be realised. 

A US perspective
The New York City (NYC) Health and Hospitals Corporation (HHC) is the largest public hospital system in the United States.  With more than $4 billion in annual revenues, NYC HHC provides healthcare services for 1.3 million New Yorkers, treating nearly one-fifth of all hospital discharges in New York and providing over 5 million clinic visits per year.

NYC has a higher prevalence of chronic disease than the US national average: the rate of diabetes is 1.7 times the national average and the rate of hospitalisation due to asthma is twice the national average.  HHC patient data was available electronically within seven proprietary data warehouses, but none of it was linked up.  To improve the management of long-term conditions, a Chronic Care Collaborative was established at HHC to set and track standardised goals for chronic care and develop information systems to track the clinical care of the chronic disease population.  HHC’s Chronic Care Collaborative includes multi-disciplinary clinicians from across multiple hospitals, clinics and diagnostic and treatment centres. 

The Chronic Care Collaborative has set out the development of a Patient Registry to track the care of patients with diabetes, asthma, congestive heart failure and depression, providing clinicians with a disease-specific view of their patients’ data, and enabling better management of their diseases.   The primary features of the Patient Registry include:

• Simple management of patient populations grouped by care teams and providers;
• Advanced search capabilities to identify sub-populations and high-risk patients;
• Customised view of patients’ disease-specific measures including lab test results, prescriptions, visit history, problems, and demographics;
• View of performance indicators to track those patients who are not meeting targets, and
• Ability to compare performance indicators across care teams, facilities and the corporation.

Since its introduction in July 2005, the Patient Registry has gained over 200 users managing over 45,000 patients. It is an innovative technical solution that will ultimately improve the quality of care delivered at HHC and in turn improve the overall health of New Yorkers.

A Canadian perspective
This approach is also underway in the province of Alberta, Canada.  A partnership between the two large regional health authorities has been formed to build upon mature Chronic Disease Management (CDM) registries already in place in each region (Edmonton and Calgary) and to extend information about CDM patients to the primary care physicians and teams in the community.

The objective is to optimise the care of Albertans with diabetes, hypertension and other related conditions in the primary care environment.  Alberta has a primary care model of Primary care Networks (PCN’s), which is a group of several physician offices funded jointly with specific goals and objectives tied to improving population health.  This project is seen as a key enabler to that initiative.  However, the CDM solution will also extend to individual and group physician offices outside the PCN.

The goals of this initiative are to: 

• Allow clinicians to identify and confirm the diagnosis of patients with diabetes, hypertension and associated conditions and precursors, facilitate linkage to primary care physicians (PCPs), and aid patient enrolment in regional CDM programs;
• Better enable the co-ordination of disease management between PCPs and regional specialty care centres;
• Provide clinical decision support tools to improve care management;
• Provide a simple format for primary care teams to assess the management of a chronic disease patients and/or populations against clinical standards, and
• Create a population-based diabetes and hypertension indicator dashboard to monitor and improve the quality of diabetes care.

The scope of this solution is defined as a patient profile viewer and a population dashboard to be used by clinicians for the management of their diabetes / hypertension CDM populations. Both of these components will provide read-only functionality; the data content will be based on a regional minimum data set.  This approach, which is relatively quick to deploy, circumvents issues of cross-system data integrity and data sharing protocols, and provides early benefits plus a future path should clinicians want more.

Conclusion
Exciting and collaborative approaches are being adopted to improve information management with regard to long term conditions.  Although England is a leader in the use of electronic medical records in primary care at a patient level, these two examples demonstrate the potential benefits of using enabling technologies to rapidly integrate and present information on demand across broad patient populations and between organisations. 

Policy is quite clear that joined-up healthcare requires joined-up information.  The demand for this is urgent because the NHS is constructed in a way that collaborative information is both necessary and useful, e.g. cancer networks.  However, the technology solutions are not keeping up with both policy and user demand.  In Canada and America, they have recognised that the perfect solution is too far away, and have invested in transitional solutions. The importance of ensuring early and sustained value is derived from change is essential to keep momentum and enthusiasm. There may be a trade-off in overall best value between the perfect solution and the practical solution but experience in healthcare has shown that if it takes too long, people are not prepared to wait.  

February 2008