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Improve population health efforts by mining the medical record


Four areas where physicians can use the EHR to propel population health efforts.

Today, physician practices have significant familiarity with the principles of value-based care; however other practice priorities often take precedence over evolving into value-based reimbursement relationships. But focusing on the principles of value-based care can benefit physician practices as well as their patients and the health system. While it can be difficult for practices, whether they are primary or specialty care, to discern how to begin the value-based, population health management journey, the electronic medical record is a great place to start because it offers a wealth of insights that can help the team identify and manage patient health risks.

Starting with four areas of focus informed by the EHR, practices can propel their organization toward real results in improving patient health while simultaneously reducing the risk of hospital admissions or readmissions.                       

Annual Wellness Visits

Much of the success or failure of population health programs relies on proactive outreach. Such outreach can seem beyond the capabilities of some primary care practices. But as the patient’s most frequent point of contact with the health care system, the primary care practice plays a key role – some might say the key role – in the success or failure of a population health strategy.

Patients with chronic conditions drive a disproportionate share of Medicare spending. CMS established the Annual Wellness Visit benefit as a means of early identification of risk factors that can lead to preventable or chronic conditions. Provided at no cost to Medicare patients, these visits offer an opportunity for the care team to obtain insights into patient risks (both health-related and environmental), emerging or undiagnosed conditions, overdue preventive services and social determinants of health that may impact the patient’s health and plan of care.

For example, the patient may have difficultly accessing enough healthy, nutritious food. They could be unsteady on their feet and living in an environment where they must navigate steps or are otherwise at risk for falls. Perhaps they could benefit from a risk assessment for depression or need additional help managing chronic conditions such as diabetes.

These issues can be readily identified and treated when patients use their annual wellness benefits. The primary care practice can help ensure patients receive their annual wellness checks by using the EHR system to identify patients who are due for their exam and contact them to set this appointment.

Chronic disease management

While the wellness visit is a great opportunity to uncover emergent chronic conditions, the physician practice plays a central role in helping patients in manage their conditions following diagnosis.

Most EHRs have capabilities to support the primary care practice in this effort. One way to help patients effectively manage chronic disease is by using the EHR’s disease registry capability to create and maintain lists of patients with chronic conditions, which can then be used to identify areas where gaps in care exist.

With these lists, the care team can identify complex patients, track outcomes and assess whether their conditions are being managed according to protocol. The technology can also provide data that identifies patients who need preventive, diagnostic or specialist follow-up care. In addition, identification of patients with higher risks will enable the practice to target individuals who could most benefit from education, coaching, other health management or support resources.

Preventive Care

Routine screenings and immunizations play an important role in promoting the health of patients within a primary care panel. Incorporating the review of outstanding preventive care into the regular clinic workflow optimizes individual health and creates the discipline needed for success in a value-based reimbursement environment. Even if patient is not diagnosed with a chronic condition, they could be identified as “at risk” (pre-diabetes, for instance) through regular screening. Early identification will help the practice put measures in place to keep a closer eye on their well-being and health status.

As importantly, documentation of preventive care aids in ensuring quality metrics are captured in the EHR for public reporting under the CMS Quality Payment Program, which adjusts practice payment based on performance in areas of quality, cost, interoperability promotion and improvement activities.  

The ideal time to perform preventive care services is when the patient is already in for an appointment, especially the annual wellness visit, but getting a patient to undertake these services requires some additional planning. Depending on gender, age and family history, a patient may be due for a mammogram, colonoscopy, flu shot or other preventive services. EHRs can provide that information, but it’s not always in the workflow. Designing a workflow along with the nursing and physician staff to proactively identify the services patients are due is both good health care and good business.  

Managing Transitions

Patient follow-through on the discharge plan of care and follow-up with the primary care physician are critical to an optimal recovery following a hospitalization. A clear process for handing-off the discharged patient from the inpatient care team to the primary care physician facilitates the transition back to the community and provides early identification of complications or barriers to following a plan of care. The success of these handoffs helps avoid readmissions or trips to the ER.

Transitional care coordination efforts should start with those most vulnerable to a readmission – likely those with chronic conditions. These patients should be directed to visit their primary care physician within a certain window of time post-discharge, determined by the complexity of their condition. If the primary care practice doesn’t hear from those patients, they should initiate follow-up contact. We encourage practices, case managers and discharge planners to “hardwire” the follow-up after a handoff. The hardwiring could take the form of EHR prompts, phone calls, or other forms of connection between the practice and health system. The goal is to have the patient leave the hospital with his or her primary care appointment in hand.

These strategies offer numerous benefits. Patients are better able to manage their health conditions and risks. For the physician practice, there is greater professional satisfaction in having a more holistic understanding of the patient. Specialists who share the care of patients through an integrated medical record have a more complete view of the patient, which enhances specialty care delivery. The hospital gains greater confidence that post-discharge plans of care will be followed and that they will see fewer avoidable returns to the facility for ED or inpatient care. Finally, demonstration of these competencies through quality and outcomes data positions the primary care practice as a good partner in managing patient health and risks to patients, payors and purchasers alike.

Theresa Lewis is assistant vice president, physician services consulting, with Quorum Health Resources.

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