 | Dr. Paul Genecin (left) and Dr. Ravi Durvasula have worked together to implement databases at the Yale Health Plan that are already paying off in terms of patient health benefits. |
Online databases benefit
Imagine walking into the doctor's office for a check-up and, at the touch of a button, your up-to-date health history -- including prescriptions, risk factors for disease and other facts -- is made instantly available to the physician in a confidential, secure database.
In addition to being convenient, this system could save your life. If, for example, you forget to mention that you are taking a medication for diabetes or that you are allergic to penicillin, the system will alert the physician, who will factor that information into treatment of your other conditions, thus reducing the possibility of adverse medication interactions.
Patient-oriented databases such as these are just some of the initiatives the Yale University Health Services (YUHS), commonly referred to as the "Health Plan," has begun implementing in the quest for population-based medicine -- an approach that not only aims to provide care for what ails people medically, but to prevent illness, maximize wellness and optimize productivity in the Yale population, whether or not people happen to come in for appointments.
"Taking the population focus, we look at what the priorities are with respect to health interventions for people, through disease-specific registries," says Dr. Paul Genecin, director of YUHS and associate clinical professor of internal medicine at the School of Medicine.
"Yale University Health Services is more than just an insurance company," he adds. "It is a unique care delivery system serving a population of about 28,000 Yale faculty, staff, students and their families, so a population focus is intrinsic to our approach to care. We live among the people we serve, and this gives us a unique opportunity to provide enhanced care."
Genecin developed the evolving population-based program with Dr. Ravi Durvasula, YUHS medical director and assistant clinical professor in the Department of Epidemiology and Public Health at the School of Medicine. They began the program with the goal of immunizing members ages 63 and over against the flu and pneumococcal disease (the most frequent cause of community acquired pneumonia). At the time, the Health Plan's pneumococcal vaccination rate was about 15% to 20%, just at the national average. YUHS mailed personal letters to older members at the start of flu season, urging them to be immunized with the pneumovax. Within one year, the percentage of those immunized shot up to 44%, and the vaccination rate now stands at about 83%. Genecin says this is more than triple the national average and higher than the state average.
"The payoff is people who are well-immunized with fewer complicated cases of pneumonia," says Durvasula.
YUHS is now using the population model in other areas. For example, women of a given age should have screening mammograms and pap smears; children should have a spectrum of immunizations throughout childhood; and people with HIV, asthma, diabetes, heart disease and other illnesses should have specific interventions that optimize their health and minimize the effects of the illness. Population medicine will help ensure these steps are taken, say the YUHS administrators, regardless of whether patients remember to come in themselves.
"This could be something very concrete, such as following the health of patients' skin," says Genecin. "We use a secure, confidential database of people with skin conditions that warrant follow-up."
In the area of pediatrics, the majority of the children served by the Health Plan are healthy, so the focus is on prevention. "We ask questions about anything from how members feed their children, to whether they travel in safety seats, to whether parents have weapons, such as handguns, in the home," says Genecin.
YUHS recently won an award from the Connecticut Department of Public Health. The state was looking for the highest rates of immunization among children from birth to age 3 achieved in a large-scale practice. "We achieved a rate of 96%, which was the highest in the state," says Genecin, who credits the patient databases and the dedication of the YUHS pediatrics staff for the accomplishment.
The YUHS pediatrics department is also using its database to address the alarming asthma epidemic among children. Genecin says that the interventions required to keep these children well are very complicated because they involve environmental assessment. "By definition, Health Plan members work during the day, so it's very complicated for them logistically to provide the care their asthmatic children need. Unless they get the care they need, these children are unable to function properly in school and in other daily activities."
YUHS is very proactive in caring for the roughly 250 asthmatic children enrolled in the Health Plan. A great deal of coordination is required to keep track of these children and to make sure they are getting the right care. There are two classes of asthma treatments: inhaled steroids and bronchodilators. Drugs like albuterol are non-steroidal bronchodilators, and are used for acute asthma, or for someone who suddenly begins having trouble breathing. If over-used in some asthmatics, Durvasula says, these drugs are only putting out brushfires and not controlling the disease -- potentially leading to problems with growth, lung damage and long-term developmental problems. Steroid inhalers, on the other hand, control the overall process and help control the disease state and reduce flare-ups -- but they don't offer immediate relief during an asthma attack.
"We've looked at the ratio of prescription to see how many bronchodilators are being used as opposed to steroids and identified 25 children who seemed to be getting too many bronchodilators," says Durvasula. "By targeting those children through the database, we can reach out to the families and start prescribing appropriate steroid inhalers to better control the disease -- and hopefully avoid preventable visits to the hospital and missed school days."
"The most immediate gain in asthma control is keeping children healthy," Durvasula adds. "This also keeps Yale's parents of asthmatics happy, productive and able to come to work."
YUHS has also increased the number of flu shots for asthmatic children, a group with a disproportionate incidence, severity and even mortality from influenza. "The pediatric asthma database allows us to identify these children and we were able to reach out to their families and to achieve an influenza immunization rate of 63% for asthmatic children, the highest rate in Connecticut" says Genecin. "The state average is about 31%, and this is a pretty enlightened state when it comes to asthma care."
The population-based registry has also had an affect on the 600 adult diabetics in the YUHS community. Complications from diabetes can result from over- or under-treatment. The disease is associated with health problems such as blindness, heart attack, neuropathy, amputation and other complications. Poor control of sugars, smoking, hypertension, elevated cholesterol and other risk factors increase the risk of complications in diabetics.
"We've begun to use population medicine approaches to look at the risk factors and to control them with interventions such as diet and weight monitoring, as well as eye screening," says Genecin. "Blindness is preventable in diabetics, but not without screening. While kidney failure is not completely preventable in diabetes, it is a well-known consequence of poorly controlled disease, and it can be minimized through control of blood sugar and the judicious use of certain medications. There are many things you can do to control diabetes symptoms and side effects and still have a full life."
The American Diabetes Association has developed guidelines for the routine screenings of diabetics, and those guidelines are the backbone of the YUHS diabetes registry, now in its third year. Through the registry, physicians or nurse practitioners at YUHS can identify diabetics and encourage them to have check-ups. "The screening rates we're achieving relative to the national averages are astronomical," says Genecin. "In three years, we've almost doubled the rates of screenings, such as foot screenings to detect ulcers. Because diabetes is so often asymptomatic, waiting for diabetics in the population to come in for visits is not an adequate strategy if your goal is aggressive prevention -- so we reach out to our diabetics and remind them to come in for testing and evaluation, with great results. If there is such a thing as a good place to be a diabetic, YUHS is it."
Durvasula and Genecin are also in the early planning stages of a larger database that would help them track and optimally treat YUHS members with severe cardiovascular risk factors. "We look forward to reaching out to populations at high risk for heart attack, stroke and other complications of vascular disease and to taking steps to prevent or minimize the effect of heart disease on the entire population, rather than just for those patients who come in for visits," says Durvasula.
"It's important that people understand that although the Health Plan is owned by Yale University, it does not share patients' personal information with anyone," says Genecin, adding that the YUHS databases are all compliant with The Health Insurance Portability and Accountability Act (HIPAA).
"The existence of a secure database, whether the information is in a medical chart or this new registry, is something that's used exclusively for clinical care and will not be disclosed without the patient's expressed consent," Genecin stresses.
In the future, Genecin and Durvasula plan on linking the databases and expanding the disease areas they cover. One area of concern for Durvasula is the overuse of antibiotics. He estimates that nationally, about 50 million antibiotics prescriptions per year are actually unnecessary. "Thousands of young, healthy people come in with colds and should never get antibiotics," says Durvasula. "Over-prescription of antibiotics encourages resistance to microbes. Just by doing the tracking in the registry and getting patients, clinicians and assistants involved, this year we had a 20% drop in inappropriate antibiotic prescription use at YUHS."
The success of the population-based registry is based on educating patients as well as clinicians, says Durvasula. "If our patients are well-educated about their condition, their behaviors will be altered and we will see increased compliance with medication and an overall better attitude about their care."
"Our philosophy is also based on the idea that you can use data to improve clinical performance and health outcomes," he notes. "In the practice of medicine, it's a philosophy that's underutilized."
"Medical practice is encounter-based," Durvasula adds. "In the traditional model of encounter-based care, I might be able to tell you how many people came in the door for asthma treatment, but I wouldn't know how many people with asthma did not come in the door for reasons such as denial, or that they're simply too busy. The population-based model is turning that around and prospectively reaching out to people to prevent complications."
"We see a future at YUHS in which the medical record is not only completely secure and confidential, but also automated or electronic," adds Durvasula. "It will be capable of providing useful clinical information to our clinicians that the traditional medical record could never provide, such as detailed data about risk for a host of preventable diseases -- and this record will contain the databases necessary to directly reach out to members of the Yale community who have various health risks and conditions and to invite them to come in for the preventive care that will help them to stay healthy."
Genecin and Durvasula see this as the natural next step in the Health Plan's clinical mission. "We will never give up the appointment-based health care system," says Genecin, "but we are developing exciting, innovative and very successful new techniques to treat disease and reduce disease risk -- in the University setting and in the YUHS structure -- that are ideally suited to these new approaches."
-- By Karen Peart
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