Here are the slides that I used.
I recommended five priorities to create a foundation for care management and population health:
1. Universal adoption of EHRs – every clinician in an ACO needs to record data electronically, ideally using the same EHR vendor. If not the same EHR, then using common pick lists/vocabularies enables data to be comparable across practices. At BIDMC we created a model office workflow to ensure data is recorded by individuals with the same role at the same time in the same processes using the same value sets.
2. Healthcare Information Exchange – data should be shared among caregivers for care coordination and panel management. Approaches can include viewing data in remote locations, pushing summaries between providers, or pulling summaries from multiple sites of care. BIDMC has created novel approaches to secure data sharing as well as participated in many federal and state HIE pilots.
3. Business Intelligence/Analytics – once data is collected and shared, it needs to be analyzed retrospectively to identify gaps in care and prospectively to ensure patients receive the right care at the right time during their encounters with clinicians. BIDMC has worked with the Massachusetts eHealth Collaborative to create a community-wide quality data center as well as piloted popHealth to support our analytic needs.
4. Universal availability of PHRs – engaging patients and families in their care, ensuring communication of care plans and achieving seamless handoffs, is essential to keeping patients well. BIDMC has offered comprehensive PHRs to all of its patients since 1999.
5. Decision Support Services – care management requires alerts, reminders, pathways, and guidelines. Ideally, all members of the care team will receive decision support inside their electronic record based on enterprise rule sets. At BIDMC, we’ve used the concept of Decision Support Service Providers to to turn data into knowledge and wisdom inside our EHRs and web applications.
Of these five tactics, the biggest challenge is defining the care management rules – what conditions, wellness measures, home care interventions, best practices, and evidence should be incorporated into the point of care and analytic systems? Yesterday, at the BIDMC Clinical IT Governance Committee, we agreed to to charter a working group of experts to set these priorities so that our care management strategy is well planned and not a random collection of individual projects, driven by individuals with specific niche requirements (squeaky wheels or siloed departmental requests). It’s a good start.