The Stanford Chronic Care Management System

Frequently Asked Questions

Answers to Frequently Asked Questions

  1. Why should a healthcare organization partner with Stanford to provide SCCMS to its patients?
  2. How does Stanford staff work with medical, nursing and IT staffs of participating healthcare organizations to implement SCCMS?
  3. What steps are taken to minimize any risk to patients resulting from their participation with SCCMS?
  4. What steps are taken to minimize institutional risks to partners resulting from their participation in SCCMS?
  5. What capabilities does SCCMS have that other systems do not have?
  6. Why should a partner buy SCCMS rather than developing it in house?
  7. What types of organizations are most likely to partner with Stanford to expand and refine SCCMS?
  8. What skill sets are required by partners wishing to implement SCCMS?
  9. What clinical information is required to implement SCCMS?
  10. What are the advantages to the primary care physician of his/her patient’s participation in SCCMS?
  11. What distinguishes Stanford from other groups offering care management programs?
  12. What is the process by which a partner acquires the IP underlying SCCMS?
  13. How did the Stanford Cardiac Rehabilitation Program conceive of the idea of SCCMS in the first place?

1. Why partner?

Why should a healthcare organization partner with Stanford to provide SCCMS to its patients?

Our skilled staff is available to work with interested healthcare providers to assure that SCCMS is implemented appropriately and that benchmarks of performance are met by the partner organization. While it is quite unusual for a research group to provide services of this type, we do this because we know that it is important to the success of our partners.

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2. Working together.

How does Stanford staff work with medical, nursing and IT staffs of participating healthcare organizations to implement SCCMS?

We arrange for a series of carefully structured meetings at the partner’s facility to achieve consensus on overall goals and objectives, and to finalize plans for implementing SCCMS.

We establish ongoing telephone, email and videoconferencing contacts with partners to address any problems that may emerge during the implementation process, and monitor program costs, process measures, and clinical outcomes with the partner.

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3. Minimizing risk to patients.

What steps are taken to minimize any risk to patients resulting from their participation with SCCMS?

There are two scenarios:

  1. Patients enrolled in clinical studies conducted by Stanford in which telephone triage is provided by Stanford staff. As in the past, the Stanford University Institutional Review Board monitors the safety of the project.
  2. Patients enrolled by partners’ staff and undergo treatment without oversight of the Stanford IRB.

Regardless of which scenario obtains, 4 major levels of safety are incorporated into SCCMS:

  1. Education of patients to recognize their own symptoms of importance, and to initiate prompt telephone contact with SCCMS staff at the onset of any symptoms.
  2. Immediate availability of telephone contact with SCCMS staff.
  3. Routine telephone follow-up by SCCMS in response to all telephone contacts initiated by patients.
  4. Immediate availability of patients’ medical records to SCCMS staff.

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4. Minimizing risk to partners.

What steps are taken to minimize institutional risks to partners resulting from their participation in SCCMS?

Patients’ participation in clinical trials of SCCMS conducted by Stanford are provided the protection of the Stanford IRB.

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5. Capabilities.

What capabilities does SCCMS have that other systems do not have?

The SCCMS telephone triage approach permits patients who are experiencing cardiovascular symptoms to call the nurse care manager immediately. Past experience has shown that most patients who have discussed their symptoms with the nurse care manager, can remain at home, while some attend a same-day cardiology clinic, and a very small percentage call 911 for transportation to the ER.

In contrast, almost all nurse telephone triage systems advise patients reporting any cardiovascular symptoms to call 911 for immediate transportation to the ER, incurring significant unnecessary costs.

Following a patient-initiated telephone contact, SCCMS provides for routine followup telephone contact with patients to assure continuity of care, and an update of the medical record that is incorporated into a report to the patient’s primary care physician.

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6. Why outsource?

Why should a partner buy SCCMS rather than developing it in house?

Few health care organizations want to bear the risks and costs of creating new clinical programs such as SCCMS from the ground up. Partnering with SCRP mitigates these risks and costs.

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7. Types of organizations.

What types of organizations are most likely to partner with Stanford to expand and refine SCCMS?

Those already in the healthcare delivery field, principally publicly-supported or pre-paid health plans and hospitals that will benefit significantly from more efficient management of patients, including provision of alternatives to the ER, such as same-day clinics. Large healthcare providers that coordinate regional care for patients are also suitable.

Private hospitals, including University-affiliated medical centers, are not generally disposed to adapt SCCMS because their revenue comes from providing ad hoc care to patients requiring ER evaluation.

Disease management companies support the use of SCCMS, so long as they do not breech the existing doctor-patient relationship. However, these companies are often enthusiastic supporters of SCCMS once economic incentives are aligned through prepaid programs for cancer and other chronic conditions.

Potential partners for SCCMS also include information technology firms concerned with developing interoperable medical records.

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8. Skills required.

What skill sets are required by partners wishing to implement SCCMS?

There are two general options: intramural and extramural.

Under the intramural option, partners’ staff provides telephone triage and followup. Nurse care managers and a supervising cardiologist are required to implement the system. An IT specialist is needed to emulate SCCMS on the partner’s existing electronic medical record. A supervising physician, which could be the supervising cardiologist, is needed to evaluate the clinical outcomes and costs of implementing SCCMS and represent the program to administrators responsible for resource allocation. An assistant is needed to provide educational materials to patients and families, and interact with patients at specified intervals by telephone or email regarding clinical outcomes and patients’ satisfaction with SCCMS.

Under the extramural option, all functions of patient enrollment, intervention, followup with medical and nursing staff are provided by Stanford personnel and periodic reports on project costs and clinical outcomes are created by Stanford staff for distribution to the partners’ supervising physician.

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9. Clinical information required.

What clinical information is required to implement SCCMS?

The main requirement is the documentation of coronary artery disease. The richest source of current, reliable information on patient’s current medical status and their future need for medical services is a hospital summary or ER report. In most cases, fewer than 30 clinical variables are required to establish the patient’s prognosis and inform decisions regarding the patient’s future needs. These data are often found in several sources, including the hospital and ER and the medical records maintained separately by the physicians providing patient care.

Some of the most salient data potentially available from patients enrolled in SCCMS is otherwise unavailable in EMR’s maintained by physicians and hospitals. These data concern patients’ day to day clinical status, including symptoms, limitations of activities, medications actually taken, health-related habits and encounters with healthcare providers in disparate locations.

The nurse care manager gathers and enters these data, and follows up as needed by telephone to obtain needed details of tests and treatments.

Interoperable electronic medical record systems such as Smart Health, currently under development in Silicon Valley, will facilitate access to data currently residing in multiple electronic medical records operated by clinics, hospitals and physician offices.

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10. Advantages to primary care physicians.

What are the advantages to the primary care physician of his/her patient’s participation in SCCMS?

Most of the patient-initiated contacts with SCCMS staff are not cardiac emergencies and do not require the immediate attention of the primary physician. The clinical outcomes of patient-initiated telephone encounters deemed to require the immediate attention of the primary physician are summarized and communicated with the physician within 24-72 hours of the patient’s initial contact. At the time of the patient’s enrollment, the physician can elect to be contacted for all patient-initiated contacts or only those requiring a same-day clinic visit or ER visit. In any case, SCCMS staff follows an established protocol to meet the patient’s needs and communicate with the primary physician.

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11. The Stanford Cardiac Rehabilitation Program

What distinguishes Stanford from other groups offering care management programs?

We are a nonprofit organization focused on scientific demonstration of the efficacy of care management systems that we have developed. Successful dissemination of new systems like SCCMS requires a deep understanding of how care is presently provided by potential partners and how small changes in partners’ existing methods to permit the use of SCCMS. We tailor SCCMS to partners’ needs and follow up with them to assure that any issues in the dissemination process are resolved promptly. The Stanford team has experience in medical, nursing, informatics and administrative issues arising from dissemination of SCCMS into the patient care provided by partners.

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12. Acquiring the System.

What is the process by which a partner acquires the IP underlying SCCMS?

An interested partner licenses the intellectual property from Stanford University for a fee negotiated by the Stanford University Office of Technology Licensing.

In addition, partners can provide a directed research grant to Stanford University that supports the efforts of the Stanford team in implementing dissemination research projects focused on demonstrating the cost effectiveness of SCCMS in treatment practice. These grants permit Stanford staff to work with partners to evaluate important benchmarks of success regarding SCCMS. In addition, partners may elect to consult directly with Stanford staff on issues lying outside the scope of the directed research grants.

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13. The original idea.

How did the Stanford Cardiac Rehabilitation Program conceive of the idea of SCCMS in the first place?

The idea evolved over nearly 30 years, during which the Stanford team demonstrated the efficacy of successive generations of physician-directed, nurse-managed telephone-mediated care management approaches for the management of chronic cardiovascular conditions.

It was the failure of the last of these studies, conducted in Kaiser Permanente Hospitals 1999-2001 and focused on reducing readmissions for heart failure, that the investigators had an epiphany: to change treatment practice, it is necessary to establish telephone contact with patients at the very outset of symptoms of concern to them, not after they have seen their physicians in clinic or undergone ER evaluation. The “default” decision in these clinical settings is to refer patients from clinic to the ER and from the ER to the hospital. However, if patients call immediately after the onset of symptoms, it is usually possible to resolve their problems without the need for ER visits or hospitalizations.

The Stanford team would not have evolved SCCMS without prior experience in managing non-urgent conditions by telephone. The critical insight came from posing the question “Is this patient having a true cardiac emergency or something else?” Our pilot study provided patients with the means to contact SCCMS staff by telephone on a 24/7 basis. The results of the study indicated clearly that most patient-initiated contacts did not require an emergency response, although a few patients did undergo clinic evaluation on the same day.

The Stanford team is presently conducting a clinical trial of patients enrolled into SCCMS who will be compared with patients receiving usual care in the 2 years preceding the onset of the clinical trial. Stanford is seeking collaboration with various healthcare providers interested in incorporating SCCMS into their clinical practice.

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