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EHRs and Chronic Disease Management

Douglas A Gentile, MD1

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Chronic Diseases: Current Status

Average % at goal per JNC -7 for HTN is ~31%(~25% for diabetics, less for renal) Triple Diabetes Goal

BP of 129/79; Lipids of 70 or 100; A1c of

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What Do We Need?

Tracking and reminders Dynamic, impactful, actionable information display Rules Engines Workflow and process support

Care Coordination Engage patients Analytics to support population management

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DIABETES EXAMPLE

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Diabetes Goal/Indication Schedule Most Recent Trend To Do Order

BMI i 27 Q 3 Months 31 25Dec2010

BP i 129/70CKDMicroalbuminemia

Lisinopril 40mgdaily

25Sep2011

Metformin i Hgb A1C < 7% Metformin850mg twicedaily

25Sep2011

Retinal Exam i Yearly dilated retinalexam

Q 1 Year Complete 10Aug2011

Foot Exam i SensationPulsesSkin

Q1 Year Complete 25Sep2011

Hgb A1C i

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Diabetes Goal/Indication Schedule Most Recent Trend To Do Order

BMI i 27 Q 3 Months 31 25Dec2010

BPi

129/70CKDMicroalbuminemia

Lisinopril 40mgdaily

25Sep2011

Metformin i Hgb A1C < 7% Metformin850mg twicedaily

25Sep2011

Retinal Exam i Yearly dilated retinalexam

Q 1 Year Complete 10Aug2011

Foot Exam i SensationPulsesSkin

Q1 Year Complete 25Sep2011

Hgb A1C i

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| Copyright 2010 Allscripts Healthcare Solutions, Inc. A Connected Community of Health

Diabetes Goal/Indication Schedule Most Recent Trend To Do Order

BMI i 27 Q 3 Months 31 25Dec2010

BPi

129/70CKDMicroalbuminemia

Lisinopril 40mgdaily

25Sep2011

Metformin i Hgb A1C < 7% Metformin850mg twicedaily

25Sep2011

Retinal Exam i Yearly dilated retinalexam

Q 1 Year Complete 10Aug2011

Foot Exam i SensationPulsesSkin

Q1 Year Complete 25Sep2011

Hgb A1C i

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CDS with Workflow and Process Support

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PatientStratification

CareCoordination

Transitions of Care Analytics

Identification of Patient

to Manage

Coordinating Care

across Continuum

Coordinate Transition of Care between Care

Settings

Capture and report on data as well as share with

analytics tool

Assessments

Plan of Care

Interventions

Outcomes

High RiskDisease

Mgt

FrequentFlyer

HighUtilization

Home Care

Physician

NursingHome

CommunityServices

Hospital

CareCoordinator

Care Coordination Requirements

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