With Population Health, it's Not All in the EHR

With the dawn of value-based care, the bar is set really high, says Jessica Chen, MD, chief quality officer at ChenMed, a Miami Gardens, Fla.-based primary-care provider. Any physician is going to agree with that statement, she adds - that's because they're in healthcare to improve patients' lives.

Still, with all the incentives for practices to invest in EHRs, ChenMed was unable to find a system that helped providers keep tabs on their patients whether they were at their practice - or had spent time at a nearby hospital. Access to this patient information is increasingly important as practices are on the hook for managing the health of their patients, says Chen. "We're held accountable when our patients are in the hospital….While we can do that on the outpatient side, it's impossible to find out what really happens [with our patients during their time at the hospital]."

That's why ChenMed built their own "home-grown" EHR that allows them to assess physicians' overall quality and outcomes regarding the patients on their panel. The practice's EHR also provides physicians with insight into their patients throughout the entire continuum of care, which includes getting daily updates via the EHR from hospitalists on patients in the hospital. Access to this information enables ChenMed to shift resources to care for these patients after their hospital stay. For example, that could involve matching up a case manager with a patient for follow up after the patient has been discharged from the hospital.

"We really build all of this around the primary-care provider. They're the 'quarterback' of care," says Chen. Denise Hatzidakis, chief technology officer at ChenMed, adds that the tools at their practice used by primary-care physicians have actually been designed by other primary-care physicians, which means the user experience is important.

'That means the EHR becomes a data source for primary-care [physicians] who are now 100 percent responsible for the health of their patients," says Hatzidakis. For example, the EHR gives physicians access to alerts on diabetic patients' A1c levels and when their eye exams are due, says Chen.

Primary-care physicians also need access to high quality information about specialists when they need to refer patients. One potential technology can give primary-care physicians access to information about which orthopedists, for example, are likely to be higher in cost and request a lot of extra exams and services. This technology applies to different specialties. With access to this information, physicians can also determine if their patients even went to their appointments with these specialists, says Edwin Miller, chief technology officer at Aledade.