It’s probably a pretty safe bet to say that most clinicians think of a patient’s health data primarily as having some immediate clinical value.
Doctors are trying to work towards specific health outcomes, as part of the traditional ways that they do their jobs. They’re not likely to spend a lot of time and energy reflecting on all of the potential that patient data has, particularly when it’s housed in digital medical record systems. In many cases, the biggest things that physicians want out of their EHR system are a user-intuitive interface, interoperability and good, transparent presentation of information.
A lot of this mindset comes from the reality that healthcare models are hard to transform quickly. However, there is a new kind of idea that’s revolutionizing how we think of doctor visits.
What is Chronic Care Management and What Does It Do?
Chronic Care Management or CCM is often defined as the practice of treating a patient with two or more chronic conditions, but the ideas behind CCM are useful in a larger context, to look at how ongoing care can benefit from the latest technologies at our disposal.
Chronic Care Management systems can go further than just displaying information from doctor visits and showing medication regimens.
These types of systems can help change the fundamental equation on how doctors make people healthier. By giving the patient more of a role, these digital systems can foster a more collaborative approach: things like real-time heart rate monitoring, digitally connected blood sugar checking and other tools can give more of a full picture of what’s happening with a patient when they’re not in a provider office.
In the past, doctors looked at the patients through the lens of their doctor visits. In the future, we’re likely to see more of the different kinds of dynamic home care that CCM systems are making possible. For instance, when diabetes patients understand more about controlling their blood sugar levels from day to day, and have access to more self-help tools through a next-generation CCM system, they’re more likely to make better decisions that impact their health and a positive way. The CDC has released some information about the use of CCM models in controlling diabetes.
Apart from empowering patients and their caregivers, new CCM models also expand the collaborative circle to other stakeholders, such as family members who may be involved in the patient’s care, or legal professionals working with that person to help manage their affairs. When everyone in the big picture is more fully clued in on health outcomes, there is a big potential for lifestyle changes and other interventions that can dramatically increase health. The data in these CCM systems can also come in handy in working with government stakeholders such as the Centers for Medicare and Medicaid Services or CMS, which contemplates the use of CCM data for chronic care.
Using the Principle of Machine Learning
Machine learning is a new kind of technology that’s been applied to many industries, and it works to enhance chronic care management systems as well.
Essentially, what machine learning does involves looking for hidden connections in data, and evaluating patterns to come up with results that human decision-makers will understand. IT professionals have other words to describe this type of process, such as “heuristics” or “behavior analysis”, but the term “machine learning” makes sense. It’s the idea that given enough inputs, digital systems can be smarter about showing what’s happening in a complex system — and there is perhaps no more complex system than the human body, which is why this is so full of potential.
Two major benefits of a machine learning process are making new chronic care management systems very attractive to medical professionals. The first one is better management for an individual patient in ongoing care. By having so much aggregated information and practical ways to present it, patients know a lot more about how they’re doing all the time, not just when they see a doctor.
The second benefit relates to what providers and others referred to as “populations” — groups of people that can be analyzed to improve care as a whole. One of the best examples is to think about evaluating large populations of people to understand more about disease rates or genetic conditions. We’ve done this for many decades, but machine learning systems will propel this kind of research to the next level, and add to the knowledge that our medical system has about disease rates and much more.
With the power of new CCM platforms, there’s much more value in the data that’s stored on a clinician’s desktop. Think about how the Chronic Care Management principle can innovate in porting data from modern EHR/EMR systems.