As providers seek new capabilities to help them in their journey to population health, one of the first items they usually target is analytics. Analytics are undoubtedly an important piece of a population health strategy, however, this is just one of a number of important capabilities providers must obtain. In my experience collaborating with providers, a sometimes overlooked capability is creating and sharing a comprehensive, enriched longitudinal patient record. With the shift from physician-focused, episodic-care to team-based care involving multiple clinicians and care givers, it has become essential to have a real-time, 360 degree view of the patient that is shared among the entire team. With that enriched view, a care team can more effectively and efficiently deliver coordinated and proactive patient-centered care that drives improved outcomes. Let’s explore this issue in greater detail.

The reality is that clinical information from a single electronic health record (EHR) provides only a small portion of the information needed for population health management. If there are multiple EHR’s in a clinically integrated network, clinical data for patients may be siloed in disparate EHRs. Also absent from patient records are numerous other key pieces of information such as:

• Claims data (e.g. services obtained, medications, etc)
• Care plans
• Lab results
• Patient outreach information
• Patient submitted / supplied information (biometrics, logs/journals, preferences, etc.)
• Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
• Analytics that measure medication compliance
• Gaps in care/quality measures that need to be closed
• Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

Enriching the patient record with this information enables a depth of patient understanding required to support the transformation to value-based care. Here are a few examples of how the enriched patient record can have an impact.

Scenario 1

With pharmacy benefits claims data automatically augmenting the patient record, a care manager can quickly see which prescriptions have been filled without having to log into multiple systems. They can complete a medication review faster and more accurately and can share this with the care team. It is well known that improper or inadequate medication management can play a major factor in readmissions and complications (shown to cause as much as 20 percent of hospital readmissions[1]). However, having just EHR based medications (list or prescriptions) and pharmacy benefit / fill data is not enough. Being able to capture what the patient is actually taking can provide enhanced insight. After medication review, a care manager can determine that a pharmacist needs to be added to the care team to help manage dosing regimens and timing of medications. The care manager can then assign a task to the appropriate care team member working at top of license to make arrangements with the pharmacist and add a note to the patient record that is shared with all other care team members.

While completing medication review, a care manager may also discover life events that are barriers to medication compliance such as an inability to pay for medications, not having transportation to pick them up, or patterns such as sharing/splitting doses with a spouse. The care manager can then assign a task to an appropriate care team member to make transportation services arrangements for the patient or enroll them in an financial assistance program, and add another note to the patient record that is shared with all other care team members.

Scenario 2

The same high-risk patient described above goes to see a primary care physician who is part of a clinically integrated network. When the physician looks up the patient’s record in their own EHR, the enriched longitudinal information and actions taken in Scenario 1 are carried forward to the point of care. In this scenario, the physician or nurse can have a deeper and more informed conversation with the patient about medication compliance. Furthermore, easy access to a comprehensive, validated medication review as part of the enriched longitudinal record, can help speed up the medication reconciliation process in the clinic. With full context on the patient that also includes all care programs they are enrolled in, lab results, visits history, readmissions risk score and relevant patient documents such as a care plan, the provider is better equipped to evaluate and direct additional care. Simultaneously, the provider can also see gaps in care and quality measures (e.g. need for a depression screening) that can be closed while the patient is still in the clinic. From a patient perspective, the provider’s enhanced understanding of issues and plan of care can improve the overall experience. The physician can even see what motivates the patient (perhaps the care manager noted that the patient has a goal to be able to attend their grand daughter’s college graduation) and encourage continued participation.

In the big picture, successful population health management requires addressing a population of patients as individuals. An enriched longitudinal patient record as described here can help providers gain a better understanding of their patients and enable the care team to be more effective, efficient, coordinated and patient-centered.

To learn more about how your organization can obtain and share a longitudinal patient record across a care team, send us a note here to schedule a discussion.