February 22, 2019

Clinical Registries Help Create Patient “Star Map” for Primary Care Universe

“With this tool we can organize a vast amount of data into usable information. It’s like having a star map of the universe,” Mary Merriam, RN, Brigham Health.

It’s no secret that the implementation of a shared electronic health record (EHR) across the Partners System has been as complex in adoption as it was in its five year rollout. While it may take time for primary care providers to feel comfortable in this Epic based world, their care teams are beginning to see the benefits to quality and patient care that come with the universe of patient data maintained within the electronic health record.

Using tools available within Epic, population health management teams and primary care providers (PCPs) are now able to access real-time patient data to help identify and better manage patients with chronic conditions who need follow-up or patients needing preventive care.

Previously, population health teams maintained separate databases and relied on manual reports sourced by payer claims to manage specific patient populations. This multi-step process resulted in lagged information, offering limited benefit to patient care. Now, with direct access to real time patient information, population health managers are able to support the primary care provider, care team and the patient, by minimizing gaps in care.

“I find our population health registries helpful in that they often provide us, as providers, an additional opportunity to address basic care goals that often get placed on the back burner or overlooked during busy, multi-problem encounters,” says Ryan Gosselin, M.D., M.B.A., a primary care physician at North Shore Physicians Group in Lynn.

“As we reach out to patients for data, such as BP readings, or to invite them back into the clinic for a focused visit to address a specific population health goal, it lets them know that we’re thinking about and managing their health even when they’re not right in front of us,” says Dr. Gosselin.”

Frontline clinicians are often too busy to engage with big data sets while trying to provide in-person patient care, which created a need for a Population Health Coordinator role on the primary care team. Mary Merriam, RN, Director of Program Operations for Central Population Management at Brigham and Women’s Hospital, is a lead for these unique team members. “We bring clinical data to the clinicians as a partner to help manage their patients,” says Merriam.

Primary care focused Population Health Coordinators use the clinical registry tool to help improve patient care. The tool, located within Epic, pulls real-time patient data from electronic health records (EHR) into an online report designed to support patient outreach and condition-specific interventions. The database of clinical information allows users to track gaps in their patients’ care – for example, poorly controlled blood pressure, cholesterol or blood sugar, or, a lapse in a recommended cancer screening – and act to close those gaps.

“With this tool we can organize a vast amount of data into usable information,” says Merriam. “It’s like having a star map of the universe. Having this type of data helps both the Population Health Coordinators and care teams manage their patients and their needs both in and outside of practice.”

The report displays a PCP’s entire patient panel and indicates each patient’s list of conditions, which health or cancer screenings they may be due for, and other patient information such as the date of the patient’s next appointment. The coordinators work closely with clinicians and escalate any patient-facing issues that need immediate attention.

“Primary Care Physicians are responsible for managing their whole population of patients. Doing this in today’s environment where there is a proliferation of data for every patient is a daunting task,” says Christian Dankers, MD, MBA, Associate Chief Quality Officer for Partners HealthCare.

“The registries offer clinicians the ability to look across their panel and easily identify gaps in care and organize necessary interventions or follow-up,” he says.

In addition to helping physicians optimize their workflows, this work is pushing Partners to the cutting edge of quality measurement and performance in ambulatory quality. Partners has been able to move quality measurement away from claims-based Healthcare Effectiveness Data and Information Set metrics (HEDIS), which many found to be too narrow a view of patient risks and care gaps. Now, Partners practices have transitioned to quality measurements based on more clinically relevant metrics pulled directly from the EHR.

“Right now, we’re trying to understand performance on our quality measures and look more closely at why our patients might not be at goal,”  says Dr. Dankers. “We want to do more to further enhance the value of this tool for the frontline providers. The hope is that as this tool evolves, we’ll be able to provide clinicians even more usable information.”


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