Using Your EHR for Chronic Disease Management

Annapolis Internal Medicine has been a part of an accountable care organization (ACO) since 2013. One of the ways the practice helps keep tabs on its patients is through campaigns they organize from within the EHR. So far, the practice has done outreach campaigns to remind patients about annual wellness visits, flu vaccines, breast cancer screenings, and A1C levels for diabetes patients.

"Our goal is to provide the highest quality and most affordable healthcare," said Yvette L. Perry, practice manager at Annapolis Internal Medicine. "Part of that means we need to reach out to patients at risk of becoming diabetic or having hypertension. It's going to save patients money, it's going to save insurers money, and it's going to save money for [our practice]. We have to take care of those patients before it becomes catastrophic."

The Annapolis, Md.-based practice mines its EHR for data on patient populations such as women over the age of 50 who haven't had a mammogram and patients who haven't had a colonoscopy in 10 years, and then sends out campaigns via its patient portal asking patients to make appointments, said Claudia Cicchetti, the practice's office manager. She noted that nearly 70 percent of the practice's patients are signed up for the patient portal and the campaigns she and her team works on are reaching thousands of patients.

"Our [EHR] will tell us where we're missing data and help us increase compliance with preventative screenings," said Cicchetti. This is the type of data mining that the practice never would have been able to do with paper charts. There's no way, for example, that a doctor could go through every chart during every visit to determine if the patient needs a shingles shot or a flu shot.

"If our staff had to do all of those phone calls and [all of that] patient contact ourselves, we would probably have had to hire two or three more people. It's a 'no brainer' to use this system to reach out to patients, and we've been pleased with the results," said Perry.

Customizing outreach to patients has been very important. Patients can choose to be notified by e-mail or text message or by phone, according to Perry. After patients receive a notification, they can either call the practice or go online to the patient portal to book an appointment.

"You'd be surprised how many people over the age of 65 use the system to set up appointments," said Perry. "You'd think it would be younger patients, those with more technological savvy. But our older patients are definitely users of the system."

While Annapolis Internal Medicine hasn't realized any appreciable savings or quality targets from their ACO involvement to date, the team is optimistic and views their ACO involvement as an opportunity with a long horizon.