Most_Wired_Arundel_Baldwin.jpgKnowing who is treating the patient and what is being done when the patient is outside your health system is one of the key challenges of managing the health of a population. Anne Arundel Medical Center, Annapolis, Md., uses its state-designated health information exchange and its electronic health record system vendor's data-exchange platform for moving patient information between health systems and then importing it into its own electronic health records. “We have partnered with a nearby hospital of another health system to set standards on how we document and transmit certain critical clinical information," says Barbara Baldwin, vice president and chief information officer (pictured at right). "These standards allow us to display care alerts between hospitals in real time.” An advanced view of the population, with geospatial analysis of costs and common conditions normalized to census blocks, provides information used in analytics for interventions aimed at key groups, such as patients with diabetes or patients from nursing homes.

EHRs don’t come with a comprehensive set of population health management tools. Just half of the Most Wired organizations interface EHR data with population health applications. Using various analytics, in conjunction with collecting the data within custom and standard fields in its EHR, Grande Ronde Hospital, La Grande, Ore., tracks and finds trends in a number of population health metrics. One of the shortcomings is the inability to tie patient data together from different systems with absolute certainty that it is the same patient, even when it comes to de-identified data," says Parhez Sattar, senior director of information technology. "Another is the implied prerequisite of a large population base with tools priced for larger organizations. That’s a challenge for smaller communities and organizations that still need to do population health as part of value-based care.”