Widespread adoption of health IT is critical to the success of population health management, according to Patient-Centered Primary Care Collaborative report.
Only 1 in 4 doctors routinely use advanced health IT tools such as computerized alerts, reminder systems to notify patients about preventative or follow up care and prompts to provide patients with test results (Schoen, Health Affairs 2006). Despite upward trends in health IT adoption, there is still a significant gap in implementing a streamlined population health management approach, according to a Patient-Centered Primary Care Collaborative report released this month.
The report titled, “Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood,” offers a first-time, comprehensive view of health IT-enabled population health management that is built on a foundation of the patient-centered medical home, and further extends into the medical neighborhood.
With the medical neighborhood centered around patient centered medical home (PCMH), which serves as the center of the patient’s primary care ecosystem. The medical neighborhood connects primary care practices to hospitals, home health agencies and others to encourage health and wellness.
Widespread adoption of health IT is vital to the success of the medical neighborhood by identifying health trends in local communities, exchange information across organizations, coordinating care as patient’s transition between providers and enables secure communications between providers and their patients and families.
Highlights of the report include:
- Overview of the population health approach
- Health IT tools that is embedded in the five key attributes of the PCMH and medical neighborhood.
It also includes a recommended “Top Ten List” of health IT based population health management tools, including
1. Electronic Health Records
EHRs document diagnoses, vital signs, tests and treatments, populate registries, and create the structured data needed for advanced analytics.
2. Patient Registries
The central database of PHM, registries are used for patient monitoring, patient outreach, point-of-care reminders, care management, health risk stratification, care gap identification, quality reporting, performance evaluation, and other purposes.
3. Health Information Exchange
Enables effective coordination of care across the medical neighborhood and between care team members. Secure messaging that uses the standardized direct protocol is another way to exchange information from one provider to another.
4. Risk Stratification
Risk stratification and predictive modeling applications enable providers to intervene appropriately with high-risk patients and those who might become high-risk.
5. Automated Outreach
By applying analytics to registries, organizations can generate automated messaging to patients who need preventive or chronic disease care, according to standardized clinical protocols.
6. Referral Tracking
Referral management tools help practices keep track of referrals to other providers and make sure that they receive the results back from those consultations.
7. Patient Portals
Essential to the process of continuous care, web portals attached to EHRs help providers share records with patients and engage patients in self-management.
8. Telehealth/Telemedicine
Treatment of patients using audio and video conferencing are another method of engaging and caring for patients between face-to-face visits and can also reduce the need for those encounters.
9. Remote Patient Monitoring
Remote monitoring can also help patients control chronic conditions such as diabetes and hypertension.
10. Advanced Population Analytics
Applied to the data in registries and data warehouses, these analytics can be used to evaluate how different segments of patient populations are doing and to assess the clinical and financial performance of individual providers, sites of care, and the organization as a whole.
For more information on the report, visit http://www.pcpcc.org/resource/managing-populations-maximizing-technology
