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In the first newsletter I introduced you to the Fort HealthCare Population Health initiative.  In the second newsletter I tied that initiative to the Fort HealthCare Mission and Vision.  In this newsletter I will lay out the Fort HealthCare rollout plan for the Cerner HealtheRegistries.

Bikers-IllustrationThe first step with Population Health is we must know our populations.  The Cerner HealtheRegistries is a tool that allows us to know our Fort HealthCare populations in almost real time.  HealtheRegistries encompass 13 registries related to chronic diseases or wellness (asthma, diabetes, hypertension, hyperlipidemia, depression, ischemic vascular disease/coronary artery disease, chronic obstructive pulmonary disease, heart failure, atrial fibrillation, senior wellness, adult wellness, pediatric wellness, and maternity health).  Each registry has a population of patients.  Each registry has anywhere from 6 to 23 measures that not only provide us with quality indicators but also identify opportunities for improvement.  The real power in the tool is the ability to drill down to a patient list level where we can actually address gaps in care, in real time.

The focus is to improve healthcare quality, to get better at the care we deliver, every day.  We do this by identifying and solving for our gaps in data, gaps in workflow/resources, and gaps in care.  [In actuality, Population Health is more than just improving the quality of care we provide but for the purposes of this issue of Insights we will focus on care quality].

Family-IllusIn April 2016 we began piloting the HealtheRegistries (and supportive workflows) at the Fort HealthCare Integrated Family Care clinic (IFC).  The pilot focused on seven measures in three registries: diabetic eye exams, diabetic foot exams, diabetic A1C checks, diabetic lipid checks, breast cancer screening, colon cancer screening, and cervical cancer screening.  The pilot was focused on bringing visibility to these measures and developing workflows we feel are necessary to create impact.

Those workflows are:

  1. Pre-visit chart prep.  This process involves looking at the clinic schedule 2-3 days in advance and performing two primary functions.
    a. Complete the record.  This entails systematic records review to ensure certain elements (immunizations, cancer screenings, health maintenance, etc) are complete and accurate.
    b. Identify opportunities (and create actions).  Based on the relatively narrow focus of the pilot there is a list of opportunities we feel chart prep staff can both identify and create action around.
  2. Surveillance.  This process relies on clinic leaders to frequently review scorecard information, identify opportunities for improvement, facilitate quality improvement discussions, create and track quality improvement projects based on the data for their particular population.
  3. Capture external knowledge.  This means we need to ensure any outside knowledge coming into Fort HealthCare, whether that’s acquired from patient interaction or outside records, is captured in our electronic health record in a manner that is usable and timely.
  4. Patient outreach.  This is where the real population health work will be done.  We need to use the tools available to us to effectively reach out to patients.  This work will primarily be done thru invitations.  To be clear, the purpose is not to send the invitation; the purpose is to get impact from the invitation.  Invitations are dependent on Health Maintenance.  Health Maintenance is dependent on staff using it to make Health Maintenance a reliable source of information. Related to invitations, an effective means of outreach is the patient portal.  It is vitally important to get patients enrolled and engaged in the patient portal.  Patients become enrolled and engaged with the portal if the portal brings value.  This is why it is vitally important to make our patient portal a valuable resource and means of communication with healthcare providers.  Future portal enhancements like Open Notes will continue to add value for patients.

Fisherman-IllustrationThe results of the pilot at IFC have been promising.  By adding real-time visibility to quality measures, supporting clinics with roles and workflows to identify and act on opportunities, we are moving the needle on population health.  Thank you to the collaborative efforts of the IFC Clinic for making the pilot a success and a special thanks to Denise Lefave for taking on the chart prep role for purposes of the pilot.  Denise will assist us with training as we roll out these tools and processes to other primary care clinics.

We are excited to begin our next phase in Population Health by deploying the HealtheRegistries to the remainder of our primary care clinics.  About a year ago we identified Subject Matter Experts (SME) at our clinics.  I will be working with clinic leadership and our SME’s to prepare for and deploy the HealtheRegistry tool and supportive workflows at our primary care clinics.  This next phase will be focused on the same three registries and seven measures as the pilot, so unfortunately at this time we are not prepared with measures specific to Fort HealthCare Center for Women’s Health (CWH) or Pediatrics.  Both CWH & Pediatrics have measures in development for future deployment.