EHRs and Chronic Disease Management

Chronic Disease Management is sometimes used as a way to neatly package a pool of services for a specific group of patients. This can result in a tunnel vision type approach to treatment that can be effective when automating a set of processes; however, patients with chronic disease tend to be older, often suffer from co-morbid disease, and require the support of a wider range of healthcare providers. Developing strategies to improve the management of this population is challenging and requires a wide range of approaches including clinical process redesign, development of clinical practice guidelines, ancillary support services, shared care teams, etc. The principles are more clearly described in a posting on the Patient-Centered Medical Home (PCMH), PCMH-Neighbor (PCMH-N), and Accountable Care Organizations (ACOs).

In an optimized EHR practice, what can clinicians hope to accomplish?

  • Unprecedented access to individual patient data.
  • The ability to identify individuals amongst a population that may be suffering from one or more undiagnosed chronic diseases.
  • The use of registry and recall data and functions to improve clinical outcomes.
  • The use of EHRs to aggregate data for practice level population health improvement.
  • Combining the local aggregation of data with state and national data for system planning, benchmarking, and for system-wide best practices.

With these as targets, it is possible to determine which parts of the EHR need to be optimized:

  • Data quality is a key requirement to ensure that information is accurately entered and coded within the EHR for later search and retrieval.
  • Regularly review templates used to record clinical data.
  • Good processes are facilitated by properly configured alert and reminder systems. If not using reminders effectively in your EHR, request training from your practice super-user or contact the vendor for an optimization session.
  • The ability to run a query at your discretion is what makes medicine interesting. Custom searches can be configured in many EHR systems, allowing a user to review a patient population and confirm how well (or poorly) one’s patients are being managed.

Do you use your EHR for population management and for optimization of care in patients with co-morbid disease? How has your EHR helped or hindered your care delivery? Add your thoughts or comments by clicking on the “Comments” link below.

    This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.


    3 responses to "EHRs and Chronic Disease Management"
    • January 27, 2011
      A Cavale

      While I agree with a lot of your presumptions, it is important to remember that physicians in clinical practice are primarily responsible for delivering care to individual patients, not population management. There are other professionals for that function. Clinicians should not be expected to perform population management. This is one of the main reasons clinicians have such aversion to EHR’s (please log in to Sermo if you need proof).
      Our EHR allows us to manage our diabetics between myself, my CDE and RD. Reminders are immensely helpful, not only for clinical purposes but also for risk reduction. I don’t use decision support – it is counter-productive and conflicts with the need to provide individualized care/treatment options for patients. Again, this is a futile attempt by EHR-backers, and must be eliminated as a criteria of MU.

    • January 29, 2011
      Srinivas Merugu

      I am afraid I have to disagree with the previous comment. Perhaps they are thinking of a “public health” perspective when population management actually refers to a practice’s population of patients. I am an Internist and have been using a registry (CDEMS) to manage my patients – individually and as part of a population. I do not have an EHR yet, but will be implementing GE’s Centricity within the next 6 months. I am actually looking forward to integrating my current registry’s population management function in to the EHR’s – not sure how well this will work since the vendor provides no guarantees that it will. The registry is what allows me to find out which of my diabetics have not had their testing done on time, how my practice is performing overall for diabetes care, preventive care etc. I then develop plans to improve my practice’s performance in specific areas.

    • August 4, 2011
      Mike Washington

      Chronic diseases–such as heart disease, cancer, and diabetes–are placing a growing burden on the U.S. health care system. In response, some health care organizations are instituting chronic disease management (CDM) programs to reduce the incidence of preventable hospitalizations and adverse events by more effectively and comprehensively managing the health of patients with chronic conditions. Many of these organizations are implementing health information technology (health IT) to facilitate their chronic disease management programs.

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