Chronic Conditions - Appendix E

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

External source guidelines (clinical guidelines). 

Reference sites made available electronically. 

Identify care gaps for all adults with chronic conditions against care protocol.

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

Ability to produce registries (list/cohort of patients) organized to facilitate population management:

Adults in age ranges relevant to measures and/or clinical standards.

Adults sharing designated high-risk criteria (medical, behavioral, social needs) impacting their ability to achieve guidelines.

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

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

EHR – generates 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 – specialized chronic disease management applications (some of which include patient-facing components).

EHR:

• Clinical data.
• Scheduling data: appointments (e.g., adult wellness and sick visits).
• Preventive screening history.
• Screening data (see below).

External data sources, such as: reference labs, specialty care, immunization registries, social service clinicians’ data. 

Data from home devices such a glucometers and home blood pressure monitoring devices.

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 (POC) for the provider and care team members supporting non-POC management.

Care guidelines may be presentable as clinical decision support to the clinical provider/support team at the point of care, in the visit workflow as pre-visit prep/team huddle, through registries as above, and aspirationally as prompts to patients/caregivers. While EHR-based prompts are usually thought of as ideal, team-based care presents an opportunity for clinical decision support 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 is a useful guidance to help health centers to support decision-making across a wider range of the care delivery life cycle, 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.

Adults with chronic conditions dashboard: population view by eligible study with sorting/filtering capability based on characteristics to be defined by the practice, with ability for care team/case managers to document the actions completed; ability to see care gaps at a patient level and population level according to health center-prioritized care guidelines. Note that to automate these reports, it is necessary to apply standardized data collection strategies against electronically specified protocols. 

Same as above (EHR data and external data sources. Data from other sources of care).

Claims data.

Quality measure specifications.

Same as above (EHR data and external data sources).

Data from other sources of care.

Claims data.

Ability to categorize risk for patients and develop lists according to risk classification (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 previsit planning or post-visit care needs, such as assessments.

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

Same as above (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. 

Appointment data: internal/external.

Clinical data from external service providers.