Clinical practice improvement.

In 1990, 90 percent of healthcare was delivered on a fee-for-service, unmanaged basis. Today, that figure is only 15 percent and reflects a fundamental transformation in the way healthcare is financed, organized and delivered.

Managed care is evolving into integrated delivery systems, organizing to provide "seamless" healthcare for its large population. The structures of these systems are diverse and are organized around hospitals, group practices, insurance carriers and combinations thereof.

These organizations, however, share a common attribute: The assumption of risk for the provision of a multitude of medical and health-related services to enrollees. Capitated payments, constructed from varying formulas, create the permember per-month (PMPM) financing required to support specific contracts. However, with increased competition, cost differentiation among health plans is narrowing.

In the quest to improve and manage the health status of enrollees, managed-care organizations will once again look toward practitioners to manage health quality and risk.

Health-information technology will be deployed to support the collection, measurement, integration, analysis and dissemination of best practices. This is particularly significant in true disease-management initiatives--those that focus on managing the care process and health of the whole patient across the full continuum of healthcare delivery.

Susan D. Horn, senior scientist of the recently formed Salt Lake Citybased Institute for Clinical Outcomes Research (ICOR), believes that a methodology exists to determine best practices over the continuum of care.

That methodology, termed clinical practice improvement (CPI) is dynamic. "CPI creates a clinical laboratory that is built into the everyday practice setting to find and test best medical-care practices," Horn said.

A CPI study effectively uses a consensus of practitioners and measures feedback to effectively eliminate inappropriate treatment variation for groups of comparable patients, she added.

The MCOP, a multisite CPI study, examined variations in patient clinical status and resource-use outcomes measures over one year among HMO patients with either chronic and/or acute conditions.

Six HMOs participated in the study, which included five diseases typically managed on an outpatient basis: asthma, otitis media, arthritis, epigastric pain or ulcers and hypertension. The methodology is comprised of four basic components: planning or selecting the key process within the system; monitoring, which captures data items crucial to the delivery of care often collected in the medical record; process stabilization or identification and elimination of inappropriate variation; and improving or using fact-based information and decisions for the care process.

In addition to the electronic medical record, the CPI study was aided by two software programs created by Salt Lake City-based Intermountain Health Care, the inpatient Computerized Severity Index and the Ambulatory Patient Severity system.

The resultant MCOP database of 12,997 patients, which included more than 99,000 office visits, 480 emergency department visits, 240,000 prescriptions and utilization of 852 unique chemical entities, is a significant resource for the design of systems-based disease-management initiatives.

The Mayo Clinic, Rochester, Minn., is a strategic partner in disease management at John Deere Health Care, the subsidiary of Deere & Co. John Deere Health Care operates an IPA-model HMO enrolling 300,000 people and three primary care clinics, covering an estimated 17,000 lives (mainly John Deere employees and their dependents).

John Deere is developing strategies for 12 diseases, according to Steven D. Hagedorn, M.D., consultant in family medicine at the Mayo Clinic. These disease-management guidelines began as a response by the Mayo Clinic and other providers to Minneapolis' Business Health Care Action Group.

Hagedorn, who has been a member of four disease-management development teams for the past three years, also has been involved with the implementation of some guidelines.

He believes that shared medical records and patient-record systems are the cornerstone to the development of disease-management strategies and will continue to "evolutionize the ambulatory setting."

In the new era of disease management, managed-care executives and their clinicians are accountable for the optimal health of their patients and the economic survival of their organizations. CPI methodology using extensive information technology will help define best-practice opportunities and at the same time create disease-management repositories for future industry direction.