Health IT central to population health in the medical neighborhood

Health IT offers the opportunity to expand upon the patient-centered medical home, according to a report from the Patient-Centered Primary Care Collaborative.

Though many providers are working closely with other medical providers, they should include a wider range of partners including schools, employers, public health agencies and faith-based organizations to improve health in their "medical neighborhood," the report argues.

While the patient-centered medical home (PCMH) serves as a person's primary care hub, the medical neighborhood incorporates a range of organizations to encourage wellness and safety. The report aims to provide guidance to primary care physicians in this population health approach.

The report cites five attributes of population health management--including that it's patient-centered, comprehensive, accessible--and its five "domains"--such as examining detailed characteristics of identified subpopulations and tracking performance measures. It explores a  "top 10" list of IT tools to make it all happen, including:

  • Electronic Health Records (EHRs)
  • Patient registries
  • Health information exchange
  • Risk stratification
  • Automated outreach
  • Referral tracking
  • Patient portals
  • Telehealth / telemedicine
  • Remote patient monitoring
  • Advanced population analytics

However, for such a model to truly take root, several challenges still must be worked out, including a payment model that encourages population health, improvements in the technology and patient engagement.

For instance, Twin City Pediatrics in Winston-Salem, N.C., has established care teams for families with a child with special needs or mental illness. Among its strategies was creating a patient registry accessible at all three locations. Its EHR isn't compatible with the registries, but one of its pediatricians provided a custom-designed solution to complement the EHR.

One of its most successful strategies was incorporating mental health professionals in the care teams, a tactic highlighted in FierceHealthcare's newest free eBook, Population Health Management: How to Manage High-Risk Patients. Montefiore Medical Center in the Bronx, N.Y., found that for patients who have behavioral health issues on top of chronic illness, multidisciplinary efforts lead to better outcomes and lower costs.

To learn more:
- find the report