CALIFORNIA DEPARTMENT OF PUBLIC HEALTH Electronic Health Record Best Practices for Managing Patients with Hypertension and Diabetes Contents ACKNOWLEDGEMENTS Introduction .................................................................................... 1 We would like to extend special thanks to the following individuals for their assistance in the development and Population Health Management ............................................ 2 review of this document: Intrepid Ascent Point of Care Clinical Decision Support ............................. 3 John Weir, MS Wendy Jameson, MPP, MPH Rupinder Colby, MPH Patient Portals .............................................................................. 5 Mark Elson, PhD California Department of Public Health Health Information Exchange Participation ..................... 6 Chronic Disease Control Branch Jessica Núñez de Ybarra, MD, MPH, FACPM Care Coordination ....................................................................... 8 Laurel Cima-Coates, MPP Alexandria Simpson, BS ePrescribing ................................................................................... 9 Laurissa Haydu, BA Mary Rousseve Vanessa Lopez Conclusion .................................................................................... 10 This publication was produced with funding from Centers for Disease Building an Integrated Environment ...................................11 Control and Prevention (CDC) Grant Numbers DP005499 and DP004795 through the California Department of Public Health. Its contents are solely Appendix I: Meaningful Use ...................................................12 the responsibility of the authors and do not necessarily represent the official views of the CDC or the Appendix II: Merit-based Incentive U.S. Department of Health and Payment System Summary ....................................................13 Human Services. The content included in this report may be reproduced with the Appendix III: Meaningful Use/MIPS following citation: Related Objectives and Measures ...................................... 14 Weir J, Jameson W, Colby R, Elson M (2018). Electronic Health Record Best Practices for Managing Patients with Hypertension and Diabetes. Commissioned by the Chronic Disease Control Branch, California Department of Public Health, Sacramento, CA April 2018 ii ii Introduction One in every three American adults has diseases such as hypertension and diabetes. This hypertension (HTN)1 and the Centers for Disease informational document describes six EHR tools Control and Prevention (CDC) estimates that one that help health systems identify, engage, track, in every three Americans could have diabetes by and monitor patients: 2050.2 These diseases pose a significant threat to • Population health management quality of life and impose a heavy financial burden on our health care system. Because of the current • Clinical decision support (CDS) and prospective impact to the health of the • Patient portals United States (US) population, both hypertension and diabetes are a major focus of quality • Health information exchange (HIE) improvement programs such as Meaningful Use • Care coordination (MU) and the Merit-based Incentive Payment System (MIPS). Both of these federal programs • ePrescribing emphasize the appropriate management of For each technology best practice, we have patients using technology. appended a list of MU (Modified Stage 2) and See Appendix I for a summary of MU and MIPS MIPS measures and objectives that may be requirements. satisfied through effective use of the tool. In addition to the information within this document, Electronic Health Records (EHR) enable a the Million Hearts EHR optimization guides for variety of technology tools to improve health Allscripts, Cerner, and NextGen EHRs may be care delivery and management of chronic useful.3 1. Centers for Disease Control and Prevention. “High Blood Pressure Facts.” https://www.cdc.gov/bloodpressure/facts.htm 2. State of Obesity. “Diabetes in the United States.” https://stateofobesity.org/diabetes/ 3. HealthIT.gov. “Resource Center: Million Hearts.” U.S. Department of Health & Human Services. https://www.healthit.gov/providers-professionals/ million-hearts 1 Population Health Management Population health management is defined4 as health, which may include supporting patients managing “the health outcomes of a group of in accessing services beyond the four walls of individuals, including the distribution of such the clinic. outcomes within the group” and leverages It is important to keep in mind, implementing electronic tools, data, and engagement population health technology is a long- techniques. Populations with chronic diseases, term investment and results are achieved such as hypertension and diabetes, particularly over time. An article by Dr. Jonathan Niloff benefit from the coordinated management of in HealthcareITNews outlines five steps to a care and tracking and monitoring of fluctuations successful implementation.7 in key disease markers. Organizations are able to measure how well care is being delivered 1. Centralizing access to data is important and to a particular patient population in order to can be the biggest initial barrier to adoption. prevent disease or help patients stay as healthy Often, data resides in clinical silos and across as possible. Many health care organizations disparate IT systems making it difficult to have implemented disease registries to support access and aggregate. effective population health programs by serving 2. Once information has been connected, the as the backbone for defining the population(s) next step is to begin analysis of the data. By of focus. A disease registry is a collection of applying analytics, an organization can uncover information about individuals, usually focused populations in need of improved care delivery on a specific diagnosis or condition, and may and begin to take actions towards better be integrated into an EHR.5 Nevertheless, outcomes. Categories of analysis often include while EHRs typically provide some population high utilization, significant comorbidities, health management capabilities, many health specific clinical factors such as A1c and blood care organizations are adopting electronic pressure control, substance abuse and/or systems specifically designed for this function to mental health issues, and socioeconomic complement their EHR. criteria such as homelessness. Population health activities include outreach, 3. Once patient populations are identified, screening, public education, self-management interventions such as targeted preventive support, and treatment. These modes of health services, or intensive chronic care care can be applied to both diabetes and management, may be implemented. hypertension. As suggested by the National Institute of Diabetes and Digestive and Kidney 4. Next, patient engagement is critical. Diseases, population health management tools Empowering patients to take an active role such as EHRs and disease registries enable in their care is an important enabler of any “the ability to provide patient support between population health management strategy. clinical visits.”6 Once patients are identified using 5. Finally, supporting the ongoing program is population health management tools, the care a critical step in successful implementation. team can partner with them to manage their Providing adequate personnel and IT solutions 5. National Institutes of Health. “List of Registries.” https://www.nih.gov/health-information/nih-clinical-research-trials-you/list-registries 6. National Institute of Diabetes and Digestive and Kidney Diseases. “Population Management.” https://www.niddk.nih.gov/health-information/health- communication-programs/ndep/health-care-professionals/practice-transformation/practice-changes/population-management/Pages/default.aspx 7. Niloff J. “5 Steps to Population Health Management.” Healthcare IT News. 11 February 2015. http://www.healthcareitnews.com/blog/5-steps- population-health-management 2 3 can make the difference in the impact of a the use of disease registries, data reporting population health management program. for MU, MIPS, and other quality improvement Another online article (Health IT Analytics) programs is facilitated by the use of population introducing Population Health Management is health management. For example, MU (eCQM referenced below.8 Additional resources are CMS122v6) requires reporting of the percentage available through the Learning and Action of patients 18-75 years of age with diabetes who Network9 and Quality Innovation Network.10 had hemoglobin A1c > 9.0 percent during the measurement period. MU requirements and MIPS measures related to population health incentivize data aggregation See Appendix II for MU/MIPS Population Health and analysis. Because an effective population Management Related Measures. health management strategy often relies on Point of Care Clinical Decision Support Electronic clinical decision support (CDS) tools at Community Health Coalition).13 The Center the point of care improve the ability of providers successfully paired CDS with a comprehensive to manage patient outcomes. CDS tools such team-based approach to identify and treat as standard order sets, alerts for potentially patients with hypertension. By leveraging the dangerous situations, and evidence-based care evidence-based protocols and timely availability suggestions offer efficient and timely information of clinical data, the organization was better able