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.