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Feb 19 2013   3:15PM GMT

Use advanced IT tools to proactively manage high-risk patient populations



Posted by: Jenny Laurello
coordinated care, health IT tools, longitudinal care, proactive care, Risk assessment

Guest post by Blair Butterfield, President, VitalHealth Software

The need for coordinated, proactive care focused on caring for chronically ill, high-risk, multiple comorbid patient populations is becoming a critical focus for health care providers as accountable care organizations (ACOs) begin to gain traction.

Providing advanced solutions utilizing cloud-based eHealth application development, Mayo Clinic and the Noaber Foundation co-founded VitalHealth Software in 2006 to address just this very need. This unique platform focuses on point-of-care patient population management to help bend the cost and quality curve and improve outcomes. Conditions targeted include diabetes, chronic obstructive pulmonary disease, asthma, Alzheimer’s, multiple sclerosis, eczema, schizophrenia, obesity, and smoking cessation. The functional design was conceived to be effective utilizing role-based, multi-disciplinary views, coordinated scheduling, structured intake forms, risk assessment, decision support with alerts based on scientific guidelines, referral management, outcome reporting, and patient self-management. On the technical side, the architecture had to be cloud-based, web-enabled, and integrated with existing EMRs and labs.

As a leader in health care delivery, Mayo Clinic leveraged this platform to assist with its goals of better managing primary care patients.[1] Mayo wanted a system “to enable longitudinal care compared to ‘usual’ episodic care,  … providing preventive services for 140,000 patients (cancer screenings, immunizations, metabolic screenings and wellness counseling), chronic disease management  for patients with hypertension, depression, diabetes, asthma, CAD  (coronary artery disease), and CHF (congestive heart failure).”[2]  The goal was to engage “allied health staff to offload responsibilities from MDs both at population level and for patients being physically seen for preventive care and care for chronic conditions so that our MDs can spend their valuable time caring for patients and not … searching for information.”[3] Data revealed that time saved per patient for preventive services, diabetes and CAD care was 3.9 minutes per patient for MDs, 2.7 minutes per patient for licensed practical nurses, and 2.17 minutes per patient for administrative staff.[4] A number of clinical studies resulting from this implementation have been published, validating reduced hospital readmissions in frail elderly[5], increased advance care planning[6], and higher rates of osteoporosis screening[7].

For organizations going down the path of stratifying and managing patient populations, tools become a critical component of the health IT environment and a key enabler for assuming the risk-sharing required under accountable care models, patient-centered medical homes, and clinically integrated networks — while enhancing quality and outcomes of care.


[2] Ibid.
[3] Ibid.
[4] Ibid.
[5] BMC Health Services Research 2010, 10:338; Use of an Electronic Administrative Database to Identify Older Community Dwelling Adults at High-Risk for Hospitalization or Emergency Department Visits: The Elders Risk Assessment Index; Sarah J Crane, Ericka E Tung, Gregory J Hanson, Stephen Cha, Rajeev Chaudhry, and Paul Y Takahashi.
[6] Journal of Hospice & Palliative Medicine® 000(00) 1-6, 2010: Clinical Decision Support Technology to Increase Advance Care Planning in the Primary Care Setting; Ericka E. Tung, MD, MPH, Kristin S. Vickers, PhD, Kandace Lackore, BA, Rosa Cabanela, PhD, Julie Hathaway, MS, and Rajeev Chaudhry, MBBS, MPH.
[7] Journal of Evaluation in Clinical Practice ISSN 1365-2753, Use of a clinical decision support system to increase osteoporosis screening; Ramona S. DeJesus MD, Kurt B. Angstman MD, Rebecca Kesman MD, Robert J. Stroebel MD, Matthew E. Bernard MD, Sidna M. Scheitel MD MPH, Vicki L. Hunt MD, Ahmed S. Rahman BS and Rajeev Chaudhry MBBS MPH.

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