Posts Tagged ‘disease registry’

Top Tools, Workflows and Processes for a Patient-Centered Medical Home

February 4th, 2014 by Patricia Donovan

Online tools such as EHRs and registries facilitate care coordination in the patient-centered medical home.

Chart scrubbing, electronic medical records and disease registries form the framework of patient-centered care, according to respondents to the 2012 Patient-Centered Medical Home survey. The following tools, workflows and processes are enhancing patient-centered care delivery by responding organizations, as told in their own words:

  • Added patient advisory council, which has made great suggestions.
  • ‘Electronic medical record (EMR) lite’ with secure e-mail.
  • Extended hours obviating urgent care centers or ER visits.
  • Chart scrubbing: review of the charts of patients coming in for appointments so that the provider is made aware of everything that needs to happen at that visit so it can be taken care of proactively.
  • Microsystems.
  • Registry management.
  • Using lower level (education) workers in the process.
  • Patient profile to include all providers, specific care gaps, etc.
  • Discharge reconciliation registry.
  • Our EMR is the most effective; it supports everything else. Secondly, standardized written protocols/standing orders that allow the healthcare team to provide care that increases office efficiency and quality indicators.
  • It’s not about the tools, it’s about training the people to use the tools effectively and efficiently. ‘LEAN’-ing is not a cure; it’s another aspect of training.

Excerpted from: 33 Metrics for Care Transition Management

Kaiser Permanente Population Health Management: Team Approach, One Member at a Time

August 8th, 2013 by Patricia Donovan

Kaiser Permanente population health management

It takes a team to manage the health of Kaiser Permanente’s 9 million members. And like all winning teams, Kaiser’s has a mantra: total panel ownership.

That motto describes a transition within the integrated healthcare delivery system that occurred about ten years ago: when doctors shifted from being accountable solely for the patients presenting for care on a particular day in their clinic setting to being accountable for all patients in their panel, explains Jim Burrows, Ph.D., senior director of evaluation and analytics for Kaiser Permanente.

This quest for total panel ownership is achievable with a focus on three key areas: people, systems and technology, he says. Burrows shared highlights from these areas during a recent webinar on Managing Population Health with Integrated Registries and Effective Patient Touchpoints.

At the outset, Kaiser eschewed a condition-specific approach in favor of developing robust infrastructure that could support management of all conditions. At the heart is an integrated regional outreach system that tracks patients’ clinical touchpoints as they move through the system via an outpatient visit or a call to a nurse advice line.

In Kaiser Permanente’s “Proactive Care” approach, even specialists are part of its population health management approach: presenting at a dermatology appointment, a patient might be reminded of an overdue colonoscopy.

“The specialists themselves can view themselves as managers of populations and not only as physician specialists for whom individual patients are consulted,” notes Burrows.

At the primary care level, there’s an integrated panel management assistant who interacts with the physician and performs pre- and post-visit tasks so patients get the most from their visits.

Technology provides a backbone for Kaiser’s proactive care: its EPIC® EHR provides evidence-based support; its patient portal an opportunity to review past visits and perform a myriad of tasks; its proprietary integrated registry tool the identification of care gaps for all members and specific patient recommendations.

With Kaiser’s health registries in high demand within the organization, how does the health plan determine which ones to develop? “It comes down to a Triple Aim assessment where we think we can do the best job of improving health, improving care and improving the affordability of our system,” answers Burrows.

Kaiser Permanente has achieved excellent results in public reporting: the plan leads the five-star space, notes Burrows, with ninety percent of Americans in five-star Medicare Advantage plans belonging to a Kaiser plan. It can also boast of having the most HEDIS® measures in which it’s the number one health plan not in the local market area, but in the country.

Click here for an audio interview with Jim Burrows in which he discusses Kaiser’s registry use in more detail.