Improving Collaborative Care in Diabetes - Episode 4

Shared Information Across Health Care Systems in Diabetes

Troy Trygstad, PharmD, MBA, PhD; Steven Peskin, MD, MBA; Richard Wynn, MD; and Dhiren Patel, PharmD, discuss the importance of sharing information across health care systems to optimally care for patients with type 2 diabetes mellitus.

Troy Trygstad, PharmD, MBA, PhD: Steven, from a managed care plan perspective, maybe with payment reform, or pay for performance, or maybe even with meaningful use with technology, how do you foster these care team member-to-care team member relationships that maybe enhance and aid in the relationship with the patient? I’ll give you an example. A good friend of mine came up with this ideation of thinking about this. His typical prescription might be metformin, 500 mg. Take 1 tablet twice a day, number 60 with 5 refills. That’s it.

What if there was a prescription that said, “Metformin, 500 mg a day. Take 1, b.i.d, number 60 with 5 refills. The patient is newly diagnosed. Their hemoglobin A1C is 12.3%.”

Steven Peskin, MD, MBA: That’s a lot more information.

Troy Trygstad, PharmD, MBA, PhD: “They don’t like needles. They’re scared of needles.” And, “We’d like for you to call and check and make sure that they don’t have an upset stomach or anything wrong going on with the medication in the next 3 days. We’d like for you to make sure that they get back to the office to check the hemoglobin A1C within 3 months.” And, “Oh, by the way, the care manager’s phone number and name is the following.” What kind of a different relationship does that look like? What is the role of the payer, the purchaser, and the folks that are paying for this wonderful health care delivery system, to foster those types of relationships?

Steven Peskin, MD, MBA: We’re focused on paying for value over volume, as you kind of laid out there, Troy. That means that we’re rewarding clinicians for outcome. So, for example, last year we had a lower total cost of care for persons with diabetes in what we call our value-based programs. And improved outcome. We’re able to measure hemoglobin A1C. “Get your diabetic annual retinal exam. Pay attention to neuropathy.” The comprehensive diabetes measures. So, that’s really how we’re working to reward those kinds of outcomes, both economic outcomes and clinical outcomes, and to harmonize those.

Additionally, we’re doing an increasing amount of clinical data exchange with our partners. So, we are allowing for our claim data to be harmonized with EMR (electronic medical record) data, and are developing a health information exchange. That’s certainly another area where we’re looking to improve the care process.

Troy Trygstad, PharmD, MBA, PhD: Right. Is there a role just from information that you know of? You know who their designated primary care provider or the care manager is. Does it make sense to share that with the pharmacy, for instance? Does it make sense to share care management information with the practice? Does it make sense to have, for instance, shared metrics? What if different types of health care providers were held to the same types of metrics?

Steven Peskin, MD, MBA: It does. Absolutely.

Troy Trygstad, PharmD, MBA, PhD: Does that foster more of this team-based care?

Steven Peskin, MD, MBA: Our pharmacy team is increasingly working with clinical pharmacists and our health systems. They are actually at the table, simultaneously, with physicians and nurses and administrators, in terms of looking at how we are going to longitudinally improve our outcomes—our clinical outcomes, our economic outcomes, and our patient satisfaction or patient experience–to address that Triple Aim. Those are the kinds of conversations that are going on, and I’m very happy to say that pharmacists are increasingly at the table.

Richard Wynn, MD: One of the challenges for the information system is that discharge gap. We are in a market with 2 dominant health care systems who are independent practices. And probably, a majority of the patients in the city are still in independent practices. But getting communications and getting that discharge information, this was changed for this reason. “We sent the patient home with this prescription.” It is very difficult to obtain this in the time we’d like. That’s a very important part of good outcomes. It would be very helpful if the payers paid attention to that and made sure that the information systems were translatable, and that access was given to independent pharmacies and practices to see that.

Steven Peskin, MD, MBA: Notice of admission is something we’ve been doing for years. Notice of emergency department visits is something we’re doing increasingly. And there are other kinds of relevant clinical information to crosswalk from one health system to another—from a health system to an independent physician–and they are a very important part of the work ahead.

Dhiren Patel, PharmD: To add to that point, I think there’s a lot of data in how that’s been very beneficial in the closed system. I have the opportunity to work in a closed system. Like what you just described, it doesn’t matter for the staff pharmacist, the clinical pharmacists, or the attending. Everyone has access to that patient, if they continue to receive care within the VA system, right?

And so, we’ve had electronic medical records since, probably, the late 1990s. If the patient goes to the Phoenix VA, or the Boston VA, I can pull up labs. I can pull up their care plans. We’ve seen those other examples from the Geisinger’s and the Kaiser’s of the world. That closed system and that sharing of information is really, really beneficial, especially in a disease like this, where you have so many specialists that are touching that patient.

We know about the cardiovascular burden of diabetes. Now more and more folks are going to be working on that patient for any specific reason. You mentioned eye exams and foot exams. Those are kind of tied to metrics. But one of the things that we’re experiencing in our area is that some of these drugs now have cardiovascular data. And so, we now have our cardiology colleagues conversing with us, which previously hasn’t happened. And so, I’m glad you brought that question up. This shared piece of literature has helped open up the doors. I’ll get a call from a cardiovascular colleague saying, “Hey, we know about the cardiovascular data, but we’re unsure of how to prescribe this diabetes medication. Can we work together in figuring out if we can get this patient on it, for these cardioprotective reasons?”

Steven Peskin, MD, MBA: Just one comment on that. I really appreciate and am at the altar of data. That said, to paraphrase this, culture eats technology for lunch. So, if you don’t have the kind of relationships that Tripp described, and if you don’t have that trust that Richard has with his patients—and, hopefully, I have with mine–it all is for naught. You can have all of the wonderful data that you want. If you don’t establish rapport, trust, and mutual respect, then it all goes out the window.