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About the series

As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.

H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.

The infrastructure connecting a health care organization's continuum of care may be in place — electronic health record systems dialing up other sites of care, accepting lab, medication and other critical patient data from outside the hospital's four walls — but it still largely remains a mass of potential. Tapping that potential requires tools to turn information into population management leads and aids.

The starting point for population health management is the computerized registry, a strategy to give EHR data new meaning, says Donald Caruso, M.D., medical director at Cheshire Medical Center/Dartmouth-Hitchcock Keene, N.H.

"Registries are absolutely critical to population management and doing it right," says Caruso. "Electronic records only take you so far without having that data flow into a registry, and then being able to risk-stratify that population."

Well-implemented EHRs contain the bulk of the information on people's history and current conditions necessary to isolate the sickest and costliest patients, identify what's wrong with them and develop plans to apply limited resources to best use in preventing ill health or forestalling complications — the essence of population health management. From a technical standpoint, however, EHRs "were not initially conceived to be a population health management tool," says Lori Stephenson,R.N., director of quality improvement for Rocky Mountain Health Plans.

Fundamentally, the heavily transaction-oriented EHR and the analysis-minded, population health function mix like oil and water. An EHR "is designed really to be a repository of data about one patient," multiplied by the number of patients, says Margret Amatayakul, a health IT consultant in Chicago. It accepts data into a patient's record, looks up tests, orders diagnostic scans, pumps out prescriptions. A simple query, like how many hospitalized patients were readmitted within 30 days, could degrade an EHR's performance and potentially "slow it to a crawl," she says. A registry is a separate database configured to organize and analyze data, and prompt action on what it turns up.

In Colorado, a federally sponsored Beacon Community has settled on procurement of a registry product and is aiding physician practices in making it a supplement to their EHRs, says Stephenson, who is involved in that effort. The three-step process includes identifying patients within their populations who fall into subcategories of those with diabetes, asthma or cardiovascular disease; applying clinical guidelines to determine who isn't getting necessary care; and putting IT tools in place to help act on that information.

An EHR is able to identify the percentage of a group out of compliance with a guideline, but "it may be limited in its ability to tell you which patients those are," says Stephenson. "Added registry functionality will let you get down to that patient level of detail that some of the EHRs won't."

EHRs sometimes are sophisticated enough to allow a provider to pull out, for example, one set of patients with a particular diagnosis, but "they don't give you the multisystem [medical] problems that most people with chronic diseases have," says Caruso. As health care tries to break down medical specialty barriers and care for chronically ill people holistically, information has to follow in the same way.

Cheshire uses a registry that considers all of a patient's concurrent diagnoses at once. "Disease-specific registries really don't work, it has to become a population-based registry," says Caruso. "Because otherwise you're calling patients three times about their three individual conditions, and they don't really like that." A registry that pre-sents all problems also enables a caregiver to weigh how one affects another — such as going into a diet discussion knowing it has to be a low-protein diet because of low kidney function.

With back-end wizardry in place, practices find they can use the registry to mine and man the population level of care routinely and cost-effectively. In Grand Junction, Colo., practitioners at Foresight Family Physicians are "looking at registry information on a regular basis," says Greg Reicks, D.O. The practice uses nonmedical people in the front office to run reports and present them to medical assistants, who then follow protocols including contacting people for needed care, with stellar results [see sidebar].

At Cheshire, a "patient data coordinator," a new class of nonmedical staff possessing a high school diploma or associate degree and "incredible organizational skills," manages registry functions, each coordinator assigned to a particular care team, says Caruso.

Micro to Macro

The focus of registry usage at Cheshire Medical Center/Dartmouth-Hitchcock Keene is at the level of its 125-provider medical practice, but "you can see the effect at the hospital level," says Caruso, M.D. For one, a hospital readmission level that had remained steady at 18 percent for 20 years fell to 8–9 percent since 2010 with the introduction of the registry and care coordination for people at high risk of returning to the hospital within 30 days.

Now in an accountable care organization arrangement, Cheshire's emphasis also is on keeping people from becoming sick enough to require hospitalization, and admissions for respiratory illness within the past year declined 48 percent as the registry was applied to the management of patients with chronic obstructive pulmonary disease.

"We never would have been able to do that with just the EHR; the registry allows us to identify those people and keep track of them," says Caruso.

Prevention is a big part of it. A nurse coordinator sees that a COPD patient hasn't had immunizations against pneumonia or the flu, knows to schedule it outright, or is aware that the patient is coming in anyway and sees that it's done, Caruso explains.

"It allows us to have a systematic approach, where before it was left to the physician to remember," he says.

Registry = Results

Technical installation of a registry won't accomplish much without first preparing a health care organization to populate it with information and use the results wisely, says Stephenson, who is guiding implementation in physician practices through the Colorado Beacon Consortium.

"As trite as it might sound, the evaluation of physician workflow, and the consistency of the systems around that, are very important," she says. That includes always recording reportable information in the same EHR field so the registry can uniformly capture it, says Stephenson.

Foresight Family Physicians went through the learning process with the Beacon trainers, not only to master the software, but also to develop new workflows and figure out the best ways to take information from the registry and manage patients effectively, says practice physician Reicks. For mammogram screening, practitioners settled on a registry run daily for any woman older than 50 who comes in for a visit without having had a recent-enough screening. Within two years, the target screening rate went from 45 to 70 percent.

Cholesterol testing for patients with diabetes or vascular disease also improved. "Prior to using registries, we didn't track people who were not getting the recommended testing done," says Reicks. With intervention by health coaches, rates of recommended screening went from 70 to nearly 95 percent.

Building a Smart EHR in Seven Steps

EHR systems have differing degrees of functional ability to feed registries and work with the resulting leads for patient management. Well-positioned EHRs should be able to:

1 | Capture at the point of care the data needed to populate a registry for analysis.

2 | Support data capture according to standard clinical guidelines and consistent vocabulary.

3 | Enable patient follow-up lists to be generated based on dates of last tests, results and other factors specific to the disease condition monitored.

4 | Automatically generate reminder letters, phone messages or email to patients as they wish to be notified.

5 | Connect with the practice's appointment scheduling system to show when standing orders are due and to conduct studies in advance of a visit.

6 | Generate alerts when abnormal results need attention.

7 | Generate reminders for studies, medication refills and other actions so they can be addressed as part of the visit.

Source: Margret\A Consulting LLC