It may seem overwhelming knowing where to start or what to do next within your population health programs. There are opportunities, often driven by the EHR, to take small steps toward building out a robust population health program. Successful programs can transform your clinical workflows and set up your organization for success in a value-based care world. In addition, these programs support your organization’s financial health.
As a healthcare leader, you can start this work by engaging your governance, operational, and analytics teams to achieve quick wins by
- Targeting sick patients by building a registry in your EHR
- Following up with these patients and improving care coordination
- Encouraging patients to become more engaged in their care through patient portals
Let’s dive deeper into these simple ways of using your EHR to optimize patient outreach and engagement.
Target a population in need
You likely have high-risk patient populations or groups of individuals with common conditions/challenges or a high cost of care. Define these populations and determine how to use your EHR data to identify and target patients and then mine your data for key information and metrics about each patient. This may be centered on specific diseases or a population of rising risk. After targeting these patients, you can more easily focus patient care and quality measure improvement to positively impact patient care or reimbursement. A great place to start may be congestive heart failure (CHF) patients, chronic care management, or transition of care management.
Coordinate patient outreach
Once you’ve identified your population, it’s time to formalize outreach to patients at high risk. You may be able to leverage your EHR to create dynamic worklists for care managers that prioritize outreach to the right patients at the right time. You can also build your EHR to allow staff to efficiently document care and preferred follow-up methods and timing. Many of these patient outreach tools can be implemented in a matter of weeks. Coordinated outreach can be particularly value to Medicare Advantage patients with a high risk-adjustment factor (RAF). Tying this outreach to annual wellness visits can help structure patient care and ensure reimbursement while also reducing organization risk, a triple win!
Improve patient engagement through portals
Many organizations have implemented patient portals, but few are using these portals to their full potential. A quick survey of your specialty clinics can identity patient populations that could benefit from pre- and post-visit questionnaires or other patient-entered data. These tools can streamline workflows by capturing important information prior to or after the visit while also keeping patients engaged in their care. It can also be beneficial to provide bios and directories while sharing quality metrics. These workflows can also improve provider and patient satisfaction and increase organization transparency while saving time for all parties. Patient portals can also support telehealth such as e-visits and patient-provider communication. An engaged patient population, routinely using your portal, will be much more likely to use these more advanced tools in the future.
