Office-based medical practice is changing fast. The government is providing incentives to those practices that use electronic prescribing and electronic records systems and will soon penalize those that don’t. Health reform will shortly deliver many newly insured patients to your office. A host of new patient care models aimed at making healthcare more team-based are emerging. Reimbursement tied to outcomes will demand a greater level of patient management and engagement in the care process.

Often, though, an EHR alone cannot provide the functionality necessary to manage a specific population of patients.

There are many reasons a practice may need to identify and proactively work with a defined group of patients. Primarily, it’s to insure they are receiving care according to the evidenced-based standards agreed upon by the practice.

Practices may also be participating in an incentive program designed by an insurer to manage all health plan members who have a disease, regardless of the severity of individual cases. For example, a health plan in Tennessee is paying providers a bonus for working with their patients with diabetes to achieve these targets:

• 70% have a HbA1c below 9
• 50% have LDL less than 100
• 75 % have BP below 140/80.

By managing an entire population with a given disease, interventions can be targeted to subpopulations to achieve improved individual outcomes that, in turn, improve outcomes measures for the entire population.

For instance, a practice may choose to concentrate resources on those patients who do not meet the targets. This has a triple benefit of improving the outcomes for these at-risk patients, decreasing the likelihood of debilitation and high-cost complications, and ensuring revenue by participating in P4P programs.

A population health management (PHM) system supports coordinating the delivery of care across a population of patients to improve clinical and financial outcomes, through disease management, case management, and demand management. The work begins with the identification of a patient population and flows through the entire process of delivering and evaluating interventions, ending with concurrent measurement.

As health IT solutions have evolved, providers have become more adept at using these solutions to meet their needs.

For example, when there were only practice management systems available, we figured out that we could use the system to create a report that would list all the patients with a specific diagnosis based on billing (claims) data. Today, with only a practice management system, thousands of physicians receive incentive payments – a percentage of their Medicare reimbursement for the year, from the national Patient Quality Reporting System (PQRS) by entering and submitting special billing codes transmitted on the insurance claim to reflect the care given to patients.

But actual clinical data (vs. claims data) about populations of patients is now more readily available because so many physician practices use an EHR. An EHR is designed to support documentation needed for billing, but it also collects and stores data for each individual patient, creating a care plan and a chronological record of their care.

In the traditional practice setting, a physician records, reviews and evaluates patients’ records, one patient at a time. The EHR performs well around a single patient encounter.

However, when the care team looks simultaneously at all patients with a particular diagnosis, or who are in need of preventive services, a PHM system facilitates access to the clinical data that has been collected in the EHR.

In a typical EHR, the registry can be used to query the data. For instance, EHR registries are commonly used to identify patients who are receiving a medication for which some change is recommended or required, as in the case of a safety recall or the availability of a new and more effective or less expensive alternative. EHR registries can also be used to identify patients overdue for cancer prevention screening tests or those with a chronic disease who need a single lab test.

But there are limitations. For example, using the P4P measures above, it is cumbersome, if not impossible to simultaneously identify patients with diabetes who are overdue for an appointment, do not have an appointment scheduled, and are outside of the targets for their HbA1c, LDL and BP.

Doing so would most likely require multiple separate queries and then it would require someone to manually reconcile them, without custom programming skills in the practice.

But with a PHM, multiple unique populations, and subpopulations, are identified and proactively managed to bring them into compliance with standards of care.

The effective use of health IT depends on integrating diverse systems in order to record, organize, and use data to maintain a longitudinal patient record, for decision making, proactively working with patients and reporting.

At the practice level, the EHR and a PHM system form the informatics backbone that will allow you to successfully manage patient health and survive reimbursement changes.

Of course, that means you’ll have to ante up to purchase a PHM or an add-on module for your EHR (if one’s available). Next month, we’ll go through the details — costs, implementation, benefits — of introducing a PHM to your practice. Once you see what your investment can deliver, the old saying “you have to spend money to make money” should make sense.

Rosemarie Nelson is a principal with the MGMA Health Care Consulting Group.