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November 4 - 6, 2013, Using Automated Patient Engagement and Clinical Decision Support  tools to Improve Outcomes and Reduce Costs: A Case Study

The CEO of Patient Engagement Systems (PES), Stanley Goldstein, teamed with Yvonne Sonnenberg, President, Empire Physicians Medical Group, to present their experience with patient engagement to the National Accountable Care Congress. Comparing the year prior to to the year following implementation, they showed that EPMG moved from a 2 star HEDIS rating in Domain 2 for diabetes to 4.5 stars. Other key findings include:

  • Patients who are engaged with and return to their primary care provider at appropriate times have better outcomes and use significantly fewer health care resources.
  • It is not just patient engagement but the creation of "meaningful" physician – patient engagement.
  • If primary care physicians are the Key to success under Health Care Reform, they need the tools to be successful, and these tools are now available!

View their entire presentation here (Windows Media File, 55MB)


On Saturday, October 19th two dozen individuals attended the Consortium’s Patient Centered Medical Home – Chronic Kidney Disease (CKD) symposium at Metro Health’s Corporate Conference Center in Grand Rapids. The symposium focused upon care coordination of CKD within the patient centered medical home. In addition, there was an emphasis on patient engagement and management of CKD. Participants included George Bruins, MD, Spectrum Primary Care and Sue Vos, RN, BSN, Michigan Center for Clinical Systems Improvement; Benjamin Littenberg, MD, FACP, University of Vermont; and Donna Nafziger, BSN, RN, CNN, American Regent.

Watch the 45 minute presentation here:



This webinar explores a disease that requires very complex treatment and equally complex business problems for providers and plans: Chronic Kidney Disease.

Even though CKD is known to affect more than 40 million people, early stages are typically underdiagnosed. Most CKD patients are first diagnosed at stage 3 or later, when associated complications like anemia can make patient health more difficult to manage.

This webinar is conducted by clinical and pharmaceutical experts who will share their experiences and knowledge as to why early detection, effective management of associated conditions, and care coordination is critical to effectively managing kidney disease. For anyone starting or planning Accountable Care Organizations and Medical Homes, we will also be discussing the implications for these new business and reimbursement arrangements.

Webinar cohosts are Dr. Ben Littenberg, the Chief Medical Officer for and founder of Patient Engagement Systems. He is also the Henry and Carleen Tufo Professor of Medicine, Professor of Nursing, and Director of General Internal Medicine at the University of Vermont Medical Center. Dr. Littenberg is a Fellow of the American College of Physicians.

Anisha Pirani is a Regional Clinical Liaison for American Regent. In her current role she is responsible for clinical education, training and clinical sales support of Venofer (IV Iron Sucrose), which is indicated to treat iron deficiency anemia associated with Chronic Kidney Disease. Anisha earned her BSc (hons) degree in Pharmacy at the University of Brighton in the United Kingdom. She is a licensed pharmacist and a member of the American Society of Health Systems Pharmacists, the Ontario College of Pharmacists, and the Pharmaceutical Board of Canada. She is involved with trade shows and educational events through several state pharmacy associations.

View the Presentation (Windows Media File, 67MB)


Annette Eros, President and CEO of The Kidney Trust, and Michael Choi, MD, Vice Chair, Education, National Kidney Foundation, share perspectives on the need to identify and manage chronic kidney disease (CKD) within the primary care, patient-centered model.

View the Presentation [Windows Media File]

October 3, 2011 - Advanced IT for the Medical Home: Engaging the Patient

On October 3rd Benjamin Littenberg, MD, Chief Medical Officer at PES, led an interactive discussion on how information technology, when applied strategically and purposefully, can create engaged patients and be a key difference maker for Patient Centered Medical Home (PCMH) efforts.

View the Presentation [Windows Media File]

May 12, 2011 Technology Enabled Behavior Changes for Diabetic Patients Presentation to Health STAT.

View the Presentation

March 24, 2011 - Does Improving Patient Engagement Result in More Appropriate Utilization?

Presents latest research about how an engaged patient is a key component of positive outcomes. Patient engagement is a core function of Patient Engagement Systems.

View the Presentation [Windows Media File]



MacLean, Charles, Michael MacCaskey, Benjamin Littenberg. Improving Testing for Proteinuria in Diabetes Using Decision Support: Role of Laboratory Ordering Systems. Lab Medicine 2013 44:353-357;  doi:10.1309/LMCFWN1FX1QZWRQ2
Stellefson M, Dipnarine K, Stopka C. The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. Prev Chronic Dis 2013;10:120180. DOI:
Rose, Jim. A "Bottom Up" Approach to Drive Patient Engagement. Case In Point 2013; February.
Littenberg, Benjamin, MD. Managing Chronic Conditions Through Automated Patient Engagement. PhysBizTech 2012; April 3.
Khan S, MacLean CD, Littenberg B. The Effect of the Vermont Diabetes Information System on Inpatient and Emergency Department Use: Results from a Randomized Trial. Health Outcomes Research in Medicine 2010; 1:e61-6.
MacLean, Charles D., MDCM; Gagnon, Michael, MS; Callas, Peter, PhD; and Littenberg, Benjamin, MD. The Vermont Diabetes Patient Engagement System: A Cluster Randomized Trial of a Population Based Decision Support System. Journal of General Internal Medicine, 2009; 10.1007/s11606-009-1147-x.
Littenberg, Benjamin; MacLean, Charles D.; Zygarowski, Karl; Drapola, Barbara; Duncan, James; Frank, Clifford. The Vermedx Diabetes Patient Engagement System Reduces Healthcare Utilization. American Journal of Managed Care, 2009; 15:31–35.
MacLean, Charles D.; Littenberg, Benjamin; Gagnon, Michael. Diabetes Decision Support: Initial Experience with the Vermont Diabetes Patient Engagement System in Community Primary Care. American Journal Public Health 2006; 96:593–595.
MacLean, Charles D.; Littenberg, Benjamin; Gagnon, Michael; Reardon M, Turner P, Jordan C. The Vermont Diabetes Patient Engagement System (DPES): Study Design and Subject Recruitment for a Cluster Randomized Trial of a Diabetes Registry in a Statewide Sample of Primary Care Practices. Clinical Trials 2004; 1:532–544.
Kennedy Amanda G.; MacLean Charles D.; Littenberg, Benjamin; Ades, Philip; Pinckney Richard G. The Challenge of Achieving National Cholesterol Goals in Patients with Diabetes. Diabetes Care 2005; 28:1029–34.
Littenberg, Benjamin;MacLean Charles D.; Hurowitz L. The Use of Adherence Aids by Adults with Diabetes: A Cross-Sectional Survey. BMC Family Practice 2006; 7:1.
MacLean, Charels D.; Kennedy, Amanda G.; Littenberg, Benjamin. Limitations of Diabetes Pharmacotherapy: Results from the Vermont Diabetes Patient Engagement System Study. BMC Family Practice 2006; 7:50.






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