![]() A registry can also be combined with automated outreach applications to alert patients when it’s time to make an office appointment. When combined with best-practice protocols, the software can be used to alert providers and care managers to care gaps. A registry shows when a person was last seen by their healthcare provider, what was done for them, their health status at the last contact, their latest lab results and when the patient is due to visit again. To help understand the core IT functions needed for PHM, here are a few basics.Ī patient registry provides a central database for quality improvement and PHM. Sorting out this jumble of applications can be bewildering, and getting them to work together may require health IT experts who are available only in large organizations. Besides the EHR-based PHM modules, there is a plethora of standalone solutions, each of which addresses a particular part of the PHM puzzle. ![]() Health IT for Populationmanagement: The basicsĪ wide array of health IT solutions have been devised for PHM. But he admits that these solutions can be helpful to some extent, “especially in the ambulatory physician market.” For example, he says, EHRs can help physicians with quality measurement and reporting. Moore is skeptical about the value of EHR-based PHM applications. Thus many physicians are looking to their EHR vendors to supply what they need. In fact, only organizations that include at least 500 to 1,000 physicians can afford sophisticated analytic software, says John Moore, founder and CEO of Boston-based Chilmark Research, a health IT research firm.ĮHRs were not designed for PHM, but the leading EHR vendors have begun adding PHM modules to their offerings and are developing more (see EHR Solutions sidebar on page XX). Most of the applications required for PHM are too expensive for small- or medium-sized practices. “There are going to be howls of outrage, but MACRA is going to move physicians much faster into organizations that are capable of doing value-based care,” he says. The Medicare Access & CHIP Reauthorization Act (MACRA) will accelerate this movement when it takes effect in 2019, predicts Lawrence Casalino, MD, professor of public health and chief of the division of health policy and economics at Weill-Cornell College in New York. Some observers expect that most small- and medium-sized practices will eventually join larger organizations, such as independent practice associations (IPAs), accountable care organizations (ACOs), and bigger medical groups Smaller practices are expected to merge or form joint ventures to meet the challenge of value-based care and acquiring the IT infrastructure needed to support it. ![]() Moreover, organizations must measure their performance on quality, efficiency and patient experience measures, as well as the performance of individual sites and providers. Providers must also be alerted to the care gaps of individuals and must have a well-organized system to close those gaps. They need to understand the health risks of particular subpopulations and the financial implications of those risks. They must also be able to monitor the health and compliance of patients between visits. To start with, physicians need data not only on what has been done for each patient within their practice, but also on the services provided to that patient in other care settings. Medicine has always been about information, but the amount of data needed to manage the health of a population is a quantum leap above the volume of information contained in the typical patient record. While human interventions are needed to achieve this goal, information technology also has an essential role to play in PHM. In other words, they must keep their patient populations as healthy as possible so as to produce better outcomes at a lower cost-the definition of value. Physician practices that aim to succeed under this new payment model-especially those that plan to take on financial risk-must learn how to manage population health. Over the next few years, value-based reimbursement is expected to replace a large portion of fee-for-service. Physicians nationwide don’t really have a choice if they want to get paid what they’re worth in the future. Just when physicians thought they had electronic health records (EHRs) under control, they must now learn how to use other health IT applications that support the shift to a new kind of healthcare delivery known as population health management (PHM).
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