Lessons from a Utah Community Health Center: 7 Ways to Use Your EHR for Population Management

In a compelling Health Resources and Services Administration webinar held Friday, Feb. 22, clinicians got several valuable and concrete tips on how put electronic health records and quality reporting to use to improve hypertension control.

Sarah Woolsey, M.D., a family physician at CHC Inc., which has four federally qualified health centers in Salt Lake City, told how her organization improved its percentage of patients with blood pressure under control by 10 percent, so that they are very close to meeting the standard of care in their region among commercial and academic medical settings. (CHC went live with eClinicalWorks’ system in 2010.)

Woolsey, who is also medical director of quality improvement organization HealthInsight Utah, offered seven ways to use an EHR for population management. First, she says, focus in on a compelling clinical problem. Hypertension is a good one, she said, but you may have another condition important to you. Let that drive your effort.

1. Develop registries/patient lists/reminders. As you are setting them up, determine if your registries have reliable and complete data in them. If not, get a billing or clinical team to pull data on hypertensive patients another way and enter them into the registry, and them make sure the EHR automatically updates the registry every time a patient arrives for a visit and clinical work is done. If not, get the EHR vendor to assist in setting this up properly.

2. Make good templates and use them. Make sure templates that are used are capturing data accurately. If not, fix them. Ensure all staff and provider training on the process for using templates and satisfying alerts or captures.

3. Start up some clinical decision support tools. Use reminders, alerts, or flow sheets for evidence-based care, Woolsey said. Use alerts to remind the team of missing care, and teach team members to respond and satisfy these. “Turn on a few meaningful alerts, but remember that if you have too many alerts, people ignore them.”

4. Develop medication management support. Put a Medication Adherence Assessment into your templates. Ask patients every visit about adherence. Ensure formularies are added to your E-prescribing lists. If it is available, enable medication fill review in the EHR and recall patients not filling medications.

5. Use visit summaries well. Visit summaries are one of the most difficult meaningful use measures to achieve for CHC, Woolsey says. One approach is to use the visit summary as a “teach back” approach. That is, have the patient express back what they are going to do when they walk out of office and what they understand about the medications. Another approach is to prepare a visit summary ahead of the visit and have the patient review medications for you. She says another goal is to make the visit summary “speak” to the patient in their language at their health literacy level.

6. Enable self-management. Woolsey recommends using a recall functions to support patients with self-care goals. (Reminders make a difference, she says. Use prompts to call, e-mail or text them). Upload motivating patient education tools into the EHR for easy printing. Use a portal to contact them or have them report home blood pressure readings to you, she adds.

7. Report quality (Inside and out). Create team- or provider-specific report cards on their measures. Make sure the doctors have buy-in on what is measured and how. Let them correct errors, she says. Trend improvements. Watching them improve can spur activity. User your EHR’s Clinical Quality Measures (CQM) functions. It may take some work to make them represent data accurately.

“You have invested lots of time and money in your EHR,” Woolsey concluded. “You want to make a difference for patients and add value. In meaningful use Stage 2 we must demonstrate the ability to manage population health, so it is time to get going!”

The HRSA webinar also featured an inspirational presentation by Christopher Tashjian, M.D., president of the River Falls, Ellsworth and Spring Valley Medical Clinics in Wisconsin and medical director of the Wisconsin Health Information Technology Extension Center (WHITEC). To achieve dramatic change in hypertension control, Ellsworth didn't have to build a fancy data warehouse. It just figured out how to pull data from the EHR into an Excel spreadsheet and from there into an Access database. By taking a team-based approach and creating some basic registry tools as well as patient and provider scorecards, Ellsworth Medical Clinic was able to achieve the following:
• Among patients with diabetes, hypertension control increased from 73% to 97% (2007–2011).
• Among patients with cardiovascular disease, BP control increased from 68% to 97% (2007– 2011).

For achieving those results, Ellsworth Medical Clinic won a 2012 Hypertension Control Champion by the Million Hearts initiative, a public-private effort by the Department of Health and Human Services to prevent a million heart attacks and strokes by 2017.