Population Management

Population health management aims to improve the health of everyone in a clinical practice. For diabetes care providers, the goal is to satisfy the needs of every patient with diabetes under their care, even if the person has not made an appointment or been seen in the office for extended periods of time. Closely linked to the concept of a patient centered medical home, population health management techniques focus on providing proactive support to a defined and prepared patient population. Driven by increasing use of population-based process and performance improvement measures, population health management relies on the ability to provide patient support between clinical visits and to enhance clinical decision support for more comprehensive care delivery during a clinical visit. The ability of these techniques to improve both quality of care delivery and patient safety helps to explain why diabetes is the most commonly adopted focus of new patient centered medical homes.

“Successful practices know who their patients with diabetes are, and regularly mine the data to ensure they receive the care they need.1"

The ability to identify and track patients during the care process is an important advancement provided by creation of a diabetes registry. There are two basic types of electronic registries: registries that are built into an electronic health record (EHR) and those that stand alone outside of an EHR. Most systems are moving to EHR-integrated registries given their existing and potential advantages over stand-alone registries.

Visit the Information Systems section for more information about registries and EHRs.

What a Registry Can Do for Your Practice

A patient registry enables a practice to track its diabetes population and proactively organize and plan care. Successful registries drive change in practice and work flows. In addition, successful registries function at several levels, providing support for population management, individual care management, and point-of-care management.

Population Management

Process and performance reporting allows health care practices and providers to measure compliance across their patient population around a specific measure. For example, a common diabetes measure is the number of patients in the defined population with an A1C less than 7%. The definition of the specific population that forms the “denominator” can vary widely. For a payer organization or a closed health care system, the population may be defined as all patients with continuous health care coverage provided by the payer. For independent practices, all patients who have visited the practice twice over the last 24 months are generally included. Population-based reports provide information on quality and patient safety. They may also provide insight into practice patterns and a comparison between peer groups.

Care Management

The registry can generate lists of patients that can be used to remind patients and health care team members about services that are needed. By reminding patients of recommended lab tests and visits, registries support active care coordination between visits and encourage patients to return for necessary care. Patient-specific physician reminders can then be used during pre-visit planning to ensure that when a patient does return to the practice, opportunities to receive recommended care are not missed. If lists of patients are not easily generated from the EHR, ask your lab or billing provider whether they can generate specific lists. For example, your lab may be able to quickly generate a list of all of your patients with an A1C between 8% and 10% and between a certain age group.

Point of Care

The ability to support clinical decision making at the point of care can be very effective in improving care. This includes interventions that are provided at the time of the patient visit, such as the development of patient-specific alerts that notify the provider during the patient visit of specific recommended care processes. For example, an alert can notify the provider during a visit that a patient is overdue for an A1C or a foot exam. Point-of-care interventions are technically challenging since they must be integrated into existing work flows and may require modification or interaction with the existing EHR.

Effective registries change the existing work flow in a practice. They require accurate and granular data, and they need to organize data so that patterns in care delivery are apparent. A good registry should provide staff with actionable information and perform reliably. Barriers include cost, the disruption of process and workflow changes, and challenges of interoperability between systems. Current limitations of existing systems are common, and reimbursement for the work of coordination is often limited. However reimbursements are clearly moving away from fee-for-service to value-based models.

Evaluating Registries

Not all EHRs support a good registry. The Department of Health and Human Services (HHS) criteria for certification from the Certification Commission for Health Information Technology (CCHIT) require that all certified EHRs provide:

  1. A list of patients by condition
  2. Reports per Centers for Medicare & Medicaid Services (CMS) measures
  3. Reports for public health and surveillance

These requirements focus on population measurement but do not ensure that EHRs provide effective care management or point of care support.

The National Committee for Quality Assurance (NCQA) Physician Practice Connections—Patient Centered Medical Home (PPC-PCMH) scoring standards describe recommended population health management functions, including generating lists of patients and reminding patients and clinicians of services needed.

The health care team can identify patients at risk and obtain reports based on projected plans for follow-up and feedback. For example, the system can identify high-risk patients, such as those with an A1C higher than 9%, those not seen in the practice over the last six months, or those at high risk for vision complications.

The system also can create a report on aspects of a defined patient population and provide graphical summaries that help the team project needs, analyze possible cause-effect relationships, and plan interventions. Registry population management can help physicians, clinic managers, and regional service organization administrators manage their patient population appropriately. Printed progress notes, patient lists, and summary reports can be generated from the registry database.

Electronic Health Records and Meaningful Use

The technology for EHRs is rapidly expanding. With a properly structured database, reports can be run as desired and patients can receive appropriate interventions, including a phone call, a postcard reminder, or scheduling an exam or visit. Providing patients with reminders and ongoing support is an important facet of patient-centered care. It has been shown that high performance is associated with use of provider alerts. In addition, population-based reports can be generated.

Meaningful Use

Meaningful use describes ways in which EHRs can be used to measure, report, and exchange health information. Medicare and Medicaid incentive payments are offered to health care practices that use certified EHR technology to achieve meaningful use objectives that are set in three distinct stages:

  • Stage 1 primarily requires standardization of the electronic capture and use of health information.
  • Stage 2 criteria further underscore the concept of using standardized formats and fields for exchange of data.
  • Stage 3 criteria include more population-based health objectives that require health care practices to generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.

To learn more about meaningful use:

Reporting Specific Metrics with the EHR/Registry

To assess your system’s capacity to report on the measures you have selected, consider the source of the data, types of information you will need to produce, and how often you will need this information. List the capabilities needed to support reporting, then align these components with the functional requirements for reporting. For example, you may want to be able to:

  • Identify a subpopulation of patients (e.g., patients with type 2 diabetes, ages 40 to 70 years, with A1C values > 9%)
  • View and manipulate data
  • Export data
  • Create notifications for patients and providers (e.g., for patients with elevated A1C levels or those who have not been in for an appointment in the past year) and track quality measures (e.g., A1C, blood pressure, lipids)

Networked and Interactive Systems

Secure, networked systems can help different practice team members access information, such as test results or long-term management plans. This sharing of information can make team decision-making, communication, and coordination of care more effective and efficient. Interactive systems into which patients input daily blood glucose values, blood pressure readings, or food selections allow the team to monitor a patient's progress electronically from a remote location, provide education, answer questions, renew prescriptions, send reminders, and provide other interactions. Patient education materials and behavioral assessment tools can be integrated into the system.

Resources for Information Systems and Population Health Management

  1. Agency for Healthcare Research and Quality (AHRQ)
    Healthcare Cost and Utilization Project (HCUP) describes a multi-state health data system for health care research and decision making.
    National Quality Measures Clearinghouse™ (NQMC)
    NQMC is a public resource for evidence-based quality measures and measure sets. It also hosts the HHS Measure Inventory
  2. American Health Quality Association (AHQA)
    AHQA represents Quality Improvement Organizations (QIOs) and professionals working to improve health care quality and patient safety, Medicare, Medicaid, and private payers and purchasers.
  3. CMS: Quality Improvement Organizations
    The Medicare Quality Improvement Community (MedQIC) is a national knowledge forum for health care and quality improvement professionals.
  4. Physician Quality Reporting System
    This CMS initiative provides financial incentive for eligible professionals who successfully report a designated set of quality measures.
  5. Health Insurance Portability and Accountability Act (HIPAA)
    HIPPA health information privacy rules safeguard privacy and confidentiality. HIPAA regulations need to be met, and access should always be limited to providers of care who have been trained in the expected standards of confidentiality. For all providers, signed statements protecting the rights of the individual patient regarding data (both in print as well as electronic format) should be on file.
  6. AmericanEHR Partners™
    AmericanEHR Partners was developed by the American College of Physicians and Cientis Technologies to provide physicians and other professionals with tools to identify, implement, and effectively use EHRs and other health care technologies.
  7. QualityNet
    CMS established QualityNet to provide health care quality improvement news, resources, and data reporting tools and applications used by health care providers and others.
  8. Resource and Patient Management System (RPMS) from the Indian Health Service
    RPMS integrates the management of clinical and administrative information in health care facilities of various sizes and orientations using hardware configurations, software applications, and network communication components.
  9. Patient-Centered Primary Care Collaborative
    The Patient-Centered Primary Care Collaborative is dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home.
  10. STEPS Forward™
    STEPS Forward™ is a practice-based initiative developed by the American Medical Association that includes learning modules and toolkits to assist primary care practices in selecting and implementing EHR software and using it for panel management. Specific elements are highlighted below.