A focus on population health to motivate systems change is integral to the chronic care model’s delivery system design. Its potential value lies in showing positive results and exposing opportunities for improvement. Systems that provide in-depth population reporting require a robust data warehouse. Opportunities for improvement often require drilling down in the data set to determine the factors leading to poor outcomes, and having the ability to change those factor. For example, identifying the population with an A1C over 9% provides a list of patients at risk and for whom interventions can be targeted. Adding metrics to monitor whether treatments were intensified1 in those patients can provide assurance that intensification occurred.
The clinical information system in the chronic care model primarily refers to three tools: the electronic health record, a data warehouse, and a registry.