In the United States, over 133 million people – almost half of all Americans – are living with a chronic condition with an expected increase to 157 million by 2020.4
People with chronic conditions account for 83% of all health care spending, while those individuals with 5 or more chronic conditions account for 68% of all Medicare spending.5
These individuals typically require specialized care from multiple care providers and visit up to 16 different physicians each year.6
Care coordination is needed to share information among providers, provide a unified care plan to the patient, and avoid costly adverse events and redundancies in care. The duty of care coordination frequently falls to the patient’s primary care team where the demands associated with care coordination can be daunting. Besides tracking and coordinating care coordination activities, complex alerts are needed to remind clinicians to provide appropriate, evidence-based care to patients in a timely fashion. These fundamental care coordination activities are not adequately addressed in current care delivery models or HIT and are largely not reimbursed by insurers.
For seniors with complex needs in 7 primary care clinics in Utah, CMP reduced overall mortality by 20%, hospitalizations by 24%, and complications due to diabetes by 15–25%.1,7
Significant savings were realized from these care improvements – up to $274,000 per clinic for Medicare.1 Providers who referred patients to CMP experienced an 8–12% productivity increase compared to those who did not refer patients.8 While the CMP program demonstrated the benefits of care coordination, clinicians indicated a clear desire for more effective HIT tools that integrated closely with their care coordination workflow. For this reason, an extensive user-centered development process utilized structured surveys and semi-structured interviews of numerous clinicians to determine the most critical and highly desired features in such HIT tools.1
With this knowledge, the core functions of ICCIS were developed to facilitate the care management workflow – to create encounters, record care activities, receive reminders, review patient history, complete assessments, and set goals. The encounter form allows a care manager to create and track any type of encounter, from office visit to email, with the patient, family, or other caregivers. The tickler is a centralized reminder list of tasks and communications that are proactively planned, but incomplete, which allows population-based tasks to be merged with individual encounter tasks into one easy-to-use, actionable list. The patient worksheet summarizes important data a clinician may need to review before seeing a patient, including active diagnoses, medications, patient goals, referrals, appropriate assessments, and recommended care tasks. Advanced reporting is available to review care management activities and assess trends in the health of a clinic’s patient population. A high risk patient list report provides a means to quickly track and enroll high risk clinic patients in care management. ICCIS’s quality measure reports display the clinic’s adherence to 27 quality measures with statistically significant trends and can be run by clinic, by team, or by individual physician. ICCIS is able to track and report on detailed aspects of patient care due to specialized documentation. Current EHRs have difficulty capturing these aspects of patient care in such detail, which is critical in the ability to develop advanced, actionable reports for clinicians. The intended users of ICCIS were primarily physicians and care managers but some functionality could be used by clinic managers as well.
ICCIS was originally implemented in six clinics in Oregon where extensive training in care management was provided by the CMP team. These primary care clinics included over 30 physicians, 17 non-physician clinicians, and approximately 59,000 active patients in practice. The majority of these clinics were rural-based practices, not affiliated with any health systems or academic medical settings. These clinics also played a central role in the initial development process of ICCIS. ICCIS was then utilized to monitor the clinics and study the impact of incentives on care coordination and quality improvement activities within each clinic. The clinics were randomized to receive pay-for-performance incentives for quality improvement or fee-for-service payments for care coordination activities, which may have impacted how each clinic utilized ICCIS. The clinics enrolled 4,043 patients in care management over the sixteen month study period and are able to offer extensive feedback based on their use of ICCIS. Specifically, the clinics were able to provide insight into the implementation, utilization, and maintenance of ICCIS as a specialized HIT tool for care coordination.