Behind Sutter Health's new chronic disease management program

Understanding the U.S.'s chronic disease problem

Chronic disease burden continues to grow in the U.S., with the Centers for Disease Control and Prevention estimating that 129 million people in the U.S. have at least one chronic illness. But although chronic illness is common, it's not well-controlled.

"We're not doing a good job in healthcare at managing chronic diseases," Richard Milani, chief clinical innovation officer at Sutter Health, said in an interview.

Hypertension control rates linger at or below 25%, while diabetes control has gone down as diagnoses have ticked up.

While the reasons for poor chronic disease management are manifold, according to Milani, they can be boiled down into three distinct buckets.

Foremost, healthcare providers don't have enough information about patients in between office visits, and they can't feasibly conduct enough office visits to accurately capture health metrics data.

Next, adherence to evidence-based guidelines is subpar, with Milani saying the odds of someone getting evidence-based care anywhere in the U.S. is only around 50%. Much of the time, this is because evidence-based guidelines shift frequently due to the emerging data, and it's hard for providers to stay on top of those changes.

"The problem at the physician level is not whether they're smart enough," Milani stressed. "The problem is that they have to be a mile wide and a few inches deep, so to speak."

Finally, chronic disease management requires patient behavior change.

While healthcare providers can adhere to evidence-based guidelines, those interventions don't mean much without patient engagement and behavior change.

With an adequate understanding of behavioral economics, it is possible to slowly drive that behavior change, but medical schools don't always cover that topic in depth. And even if they did, office visits aren't long enough for providers to fully deploy that understanding.

In short, healthcare providers need more tools -- from digital health devices to more diverse and specialized clinical care team members -- to create the depth needed to truly address chronic illness.

According to Milani, that's exactly what Sutter Sync enables.

What is Sutter Sync?

Milani said that Sutter Sync creates a new system better designed to address lifelong illness, as opposed to the acute problems the current U.S. health system is better at addressing.

"What we've done is re-engineer and develop a new system that attacks all three of those problems," Milani explained. "One, we have data coming directly from home that's feeding us on a weekly basis. Two, the data's going to a dedicated team as opposed to the PCP, who instead works alongside them. And then three, we employ behavioral scientists so that we can do the things effectively."

What sets Sutter Sync apart is that the health system has developed its own remote monitoring devices, which gets at the data problem Milani listed.

According to Milani, it was paramount to deploy those devices with the user experience in mind, limiting the digital divide that so often beleaguers innovative projects. The name of the game was to simplify, Milani said, from the way the devices fed data into the EHR to the number of apps the patient had to download and use.

For example, Sutter partnered with Epic to integrate its devices (right now, the health system has deployed a blood pressure cuff, scale and glucometer for hypertensive patients) directly into the EHR by way of the patient portal.

Typically, when patients get prescribed blood pressure cuffs and other devices, they need to go out and purchase them, download the cuff's app and then allow data sharing between the app and the EHR or patient portal.

Milani said automatic integration with Sutter's EHR is more seamless and cuts out those steps for the patient, which is a win for individuals who might have limited digital health literacy. The only app that a patient must have to make this work is MyChart, he noted.

This might also be less costly to the patient, Milani added. Although he did not disclose the cost of the devices to patients, he did acknowledge that Sutter is not trying to make a margin off them, whereas vendors have a fiduciary responsibility to do so.

Making tech work with human-powered expertise

Milani insisted that the program's success hinges on more than just the remote monitoring devices, which are leveraged to fill in the data gaps between office visits.

Indeed, having a dedicated team of PharmDs to keep up with ever-evolving guidelines and another dedicated to patient engagement and behavior change is essential to moving the needle on chronic disease management.

"Now, the data comes in and we can sort the data hierarchically," Milani explained. "Then, the pharmacist knows where this person is and what they need to do to manage that."

In terms of the behavior team, Milani said these experts help craft the educational content and nudging that comes within the program. All of that is spearheaded by health coaches and built through behavioral science, he said. The data that's coming in real-time from the remote monitoring devices also helps guide the behavioral science team.

At this point, Sutter has deployed the Sutter Sync program on its hypertensive population, with a pilot for pregnant people. In the future, the health system intends on broadening its scope across disease states, while enhancing the program to adjust for patient health literacy and language preferences.

Still, Sutter knows it can't all-out cure chronic disease with this program -- that'd be next to impossible. Rather, Milani said the health system aims to incrementally move the needle, not just on disease control, but also the longevity of that disease control.

However, by setting up a plan that gets at chronic disease management from all directions, Sutter hopes it can better support patients.

"There are a lot of little pieces that go into an individual being successful in staying on top of this chronic disease that they'll have lifelong," Milani concluded. "We do everything we can in our power to try and work on those things."

Sara Heath has reported news related to patient engagement and health equity since 2015.