Electronic health records are an important component of the management of chronically ill patients, but a big effort for providers, according to the American Medical Group Association (AMGA) in a recent letter to the Senate Finance Committee Chronic Care Work Group.
In its June 22 letter offering recommendations to discuss policies that support caring for the chronically ill, AMGA noted that care management is integral to treating these patients, and pointed out that EHR data--particularly when combined with administrative claims data--is used to identify and risk stratify patients with multiple chronic conditions. The data is analyzed and organized into action reports, which are used to discover trends and guide interventions to best treat and manage patients. It also is used in real-time in the hospital setting to determine which patients need more complex discharge planning.
What's more, AMGA notes, providers use "sophisticated predictive analytic software" to identify those patients that may be admitted or readmitted to the hospital; these patients are contacted proactively for appropriate care management.
"While easy to describe, the information technology and staff needed to create the infrastructure necessary to identify and care for chronically ill patients is enormous," the letter states. "Functions, data definitions and clinical activities must be standardized and integrated into the IT and provider workflow across the system. EMR fields must be developed to capture data, data from many systems must be integrated, dashboards must be built to demonstrate care gaps and performance and consistent education and support teams must be in place. Importantly, medical group leadership must champion the change management effort."
Studies have found that EHRs and data sharing are key to care coordination and improved care. EHR models have also been found to be effective predictors of which hospital inpatients are at high risk for readmission shortly after admission, enabling clinicians to take responsive action sooner.
Members of AMGA consist of medical specialty groups and integrated delivery systems. In addition to health IT, they have invested in the staff to treat this particular patient population, such as multi-disciplinary teams, care coordinators and behavioral health integration.
AMGA also pointed out impediments to treating the chronically ill, and recommended financial and operational tools to support the care for this "vulnerable" population. The recommendations included care management incentives, access to full claims data, data exchange with CMS and private payers and reimbursement for care management from Medicare Advantage plans.
To learn more:
- read the letter (.pdf)