Children - Appendix D

Identify care gaps for all people with behavioral health conditions against care protocol.

Care guidelines may be presentable to the clinical provider or support team at point of care through the EHR, in visit workflow as pre-visit prep or team huddle, through registries as above, and aspirationally as prompts to patients and caregivers.

Commercial EHR-embedded guidelines provided by the vendor or customized by the practice.

External source guidelines (clinical guidelines).

Reference sites made available electronically.

Ability to produce registries (list or cohort of patients) organized to facilitate population management (e.g., children in age ranges relevant to measures and/or clinical standards, children sharing designated high risk criteria, such as medical, behavioral, social needs).

Considerations for recognizing connection to the birthing person also include linking to registries of recently postpartum patients and pregnant patients in late third trimester or postpartum without delivery information, possibly due to delivery occurring at outside hospital system or birthing center.

These registries should contemplate inclusion of functionality to trigger automated pre-defined action(s) and/or human-initiated action(s) for all or a defined subset of patients comprising the registry.

A final consideration is the ability to manage children in the context of their families, requiring the ability to relate children to siblings for management purposes.

Suggested HIT assets that can be leveraged to achieve this function include:

EHR: Generate a list of patients who meet the criteria for inclusion in the population of focus. Track using an external database. Consider merging patients from an external data source, such as a payor, to have a complete roster.

Population health management tool:

EHR: Clinical data; scheduling data for appointments (e.g., how the WCVs are distinguished from other appointments or postpartum visits); pediatric-specific data (e.g., growth parameters, immunization data); immunization data; and screening data (see below).

External data sources, such as: prenatal records, reference labs, specialty care, immunization registries, school health records, and social service providers’ data..

Care gaps should be displayed based on what is due with insight into previous results to support clinicians' ability to make decisions at the point of care for the provider and care team members supporting non-point of care management.

Care guidelines may be presentable as clinical decision support to the clinical provider or support team at point of care, in visit workflow as pre-visit prep or team huddle, through registries as above, and as aspirational prompts to patients and caregivers. While her-based prompts are usually thought of as ideal, team-based care presents an opportunity for CDS to be presented to other members of the care team through other channels.

The Five Rights Framework Clinical Decision Support: More Than Just ‘Alerts’ Tipsheet—September 2014 (cms.gov)is useful guidance to help health centers support decision-making across a wide range of the care delivery lifecycle, broader teams, and technology other than the EHR to look beyond office visits and providers. This is especially important to avoid alert fatigue and burnout.

Internal EHR data.

External source clinical data.

Claims data (clinical lag should be noted).

Electronic guideline specifications.

Patient-contributed data.

Same as above (e.g., EHR data and external data sources, data from other sources of care).

Claims data.

Quality measure specifications.

Same as above (e.g., EHR data and external data sources, data from other sources of care).

Claims data.

The ability to categorize risk for patients and develop lists according to risk classification (e.g., tie to registry).

Can be imported as externally generated risk score or calculated internally according to proprietary or customized risk algorithm.

Data acquisition platform ingestion (already curated high-risk list ingested and utilized downstream in the journey).

and/or

Additional internal and external data sources to populate defined risk model.

Allow for outreach to support pre-visit planning or post-visit care needs, such as assessments.

Technology channels include population registry outputs; patient-facing applications, such patient portal; freestanding text messaging; and self-assessment or self-management applications.

Same as above (e.g., clinical, EHR, etc.).

Claims.

Allow for management of specific and unique care needs for high-risk patients. Care management requires the ability for multiple members of the care team to contribute to and rack elements of the plan. Challenges with freestanding care management applications include access to data from other sources of care, including the ability to track referrals, and workflow burden of staff utilizing multiple applications.

Ability of the care management application to draw from and write back to the EHR is desirable but difficult to achieve.

Care management protocols and appointment data (internal and external).

Clinical data from external service providers.

• Appointment reminders.
• Medication reconciliation.
• Consents.

• Appointment reminders.
• Pre-visit education regarding routine screening, health maintenance, and anticipatory guidance.
• Pre-visit planning and screening (e.g., social needs, development).

Identifying issues that need to be addressed before an office visit that can be converted to telehealth visits.

• Triage protocols for acute care needs.
• Conversion from triage dialogues to telehealth Visit for use cases that require synchronous communication with a member of a care team.
• Multimedia content sharing for patient education or diagnostic purposes (e.g., images of rashes, audio riles, video files).
• Sharing care plans based on patient-generated inquiries regarding health questions and conditions.

• Remote diagnostic technology for otoscopic, oropharyngeal, and cardiopulmonary examination.
• Remote blood pressure monitoring.
• Remote blood glucose monitoring.
• Continuous glucose monitoring.
• Remote spirometry.

• Risk prediction in behavioral health risk, chronic disease risk, and ED utilization risk.
• AI-enabled care plans with patient-specific instructions.