Quality measurement and reporting. Government regulations require health care providers to report on quality measures, using either administrative or EHR data. Many private payers use claims data to evaluate the quality and cost of providers. To show meaningful use, providers must extract data from their EHRs. They may report it directly to CMS or use special registries for reporting. Because of the deficiencies of structured data in EHRs, many organizations must assign clinical staff to comb through patient records to locate the desired data. EHR vendors also have difficulty in programming their systems to meet CMS quality reporting requirements.
Referral tracking. Patients don't always see the specialists to whom their primary care doctors refer them, and specialists don't always send reports on the patients they do see to the referring physicians. To close this information gap, some organizations use EHR modules or third party software that alert physicians when they have not received a report back from a specialist. Some hospitals use automated messaging applications that surveys recently discharged patients to find out, among other things, whether they have made an appointment to see a primary care physician. If not, a nurse will call the patient and refer them to a doctor in the organization if they don't have one.
Registries. Patient registries show the services that have been provided to each patient, when that service was performed, and when people with particular conditions are due for follow-up visits or tests. They also include demographic information, lab results, and medications. Registries have analytics that can be applied to populations and subgroups, such as patients with diabetes or hypertension who have out-of-range lab values. While some EHRs include registries, they're usually rudimentary and lack basic analytic tools. Robust registries, which may be standalone or incorporated into data warehouses are considered more useful in PHM.
Risk management tools. While a relatively small number of healthcare organizations are now taking financial risk for care delivery, this method of payment is expected to spread in coming years as large healthcare systems and medical groups seek to maximize their return on investment in PHM infrastructure. Today, most risk-bearing provider entities outside of California are accountable care organizations (ACOs). ACOs use data warehouses and registries to aggregate and analyze data. They measure their own performance on quality and efficiency, and they use budgeting and forecasting tools to manage financial risk. When they partner with health plans, ACOs may also analyze claims data to track the movement of patients to non-network providers.
Risk stratification. The classification of patients by health risk is a cornerstone of population health management. At the population level, risk stratification allows health leaders to monitor and track the health status of various subpopulations and to review the organization's performance in caring for those groups. At the level of individual patients, risk stratification enables the organization to identify the patients who are likely to incur the highest health costs in any given year. Patients can be classified as low-, medium- and high-risk so that care teams can intervene to prevent people who have moderate chronic diseases from becoming acutely ill. This approach can reduce the number of costly ER visits and hospitalizations.
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