Abstract
The existing models for chronic disease management (DM), including the chronic care model (CCM) and DM offer a well-accepted conceptual framework for continuous care of patients with chronic diseases. However, there are logistical and process challenges to developing scalable primary care models consistent with these concepts. We are developing a second generation prototype care process for primary-care-based management of cardiovascular disease (CVD) that is consistent with these models. We will describe the research and development and prototyping process for creating new health services models. We will specifically describe workflow and technology solutions for the following steps in the care process:
identify patients who should be evaluated for CVD risk (i.e., males 45+, females 55+) using an automated and systematic process;
collect CVD risk data in an automatic and systematic fashion during routine primary care visits, including collection of behavioral health data via a web-based questionnaire;
calculate a modified Framingham Risk Score based on self-reported data (i.e. smoking, alcohol) and clinical and lab values from the medical record;
communicate to patients their 10-year risk of heart attack;
engage moderate to high-risk patients to return for a primary care visit during which they initially decide on interventions (i.e., medications, coaching, education, etc.) for each risk factor; and
develop sophisticated clinical decision support that completes a real-time evaluation of patient data and manufactures a draft order set, clinical notes, and after visit summary in advance of the patient and physician encounter.
Finally, we will describe outcomes relevant to evaluating the prototype and plans for system-level scaling.
- Received September 11, 2008.
