The patient-centered medical home model has the potential to reduce the cost and increase the quality of care for patients with multiple chronic conditions. But are the health IT tools available today adequate to support the tasks of clinic care managers? And will electronic health records themselves evolve to better meet those needs or will other supplementary innovations fill the gaps? The requirements for Stage 3 of meaningful use will ask for more care coordination and patient engagement features to be deployed, but those won’t go into effect until 2016.

Recently I had the chance to speak with David Dorr, MD, an associate professor in Oregon Health & Science University’s Department of Medical Informatics & Clinical Epidemiology. He has spent the last several years developing IT tools for care managers and studying issues around incentives, work flow changes and informatics in the medical home. “What we find is that technology is about 20 percent of the solution and 80 percent is more sociological: how the tool fits into the workflow and what type of incentives work best,” he said. But even though the technology itself is only 20 percent of the solution, it has to be the first 20 percent, he noted, because you can’t work on the transformative changes without it. The EHR is the first step, he said, but you need to filter the information from an EHR to get the valuable population management information into providers’ hands.

The tool created at OHSU, the Integrated Care Coordination Information System (ICCIS), incorporates population management techniques, patient-centered goals, quality measures, and clinical reminders to support clinical care teams and patient self-management.
 “ICCIS is a web-based external registry that takes feeds from EHRs and allows a care management team to focus on a core set of functions,” he said. For instance, the ICCIS care coordination workflow features a centralized reminder list of tasks and communications that were proactively planned but incomplete. It allows population-based tasks to be merged with individual encounter tasks.

One lesson the ICCIS team learned is that the work doesn’t stop after the feeds from EHRs are set up. “You have to devote time and resources to continually fine-tune it,” he said. “When we started we weren’t getting immediate information about emergency department visits. But we found that within and between EHRs there are many types of messages we could tap into,” Dorr explained. “My favorite thing is working with health system IT staffers who say we can’t do something. It is impossible, they say. I tell them it is possible but difficult. And after we work together to figure out how to get the information we need out of the system, it catalyzes them.”

He added that the meaningful use effort is helping his efforts to pull data from multiple EHRs. “It is forcing people to tie data to standard vocabularies using LOINC and SNOMED codes,” he said. “There is still a long way to go, but at least it’s a start.”

With funding from AHRQ, Dorr and his team are studying the difference between clinics using health IT to monitor and deliver care for high-risk patients with a care coordination model vs. a quality performance model. The team is evaluating how well care coordination functions are used at the clinics. Measures include indicators of patient engagement, clinic-level quality of care, clinic-level process, and patient health outcomes.

Dorr’s goal is to get ICCIS into the hands of more care management teams. OHSU hosts the web-based system for a charge that covers its costs. It is currently used by approximately 20 clinics around the country. The Veterans Administration in Portland, he noted, has worked to embed the tool into its population management approach.

“Real transformation is a complex process,” Dorr said. Having a care manager embedded in the process is crucial to looking at the population's health. “We want to make ICCIS more broadly available and get these tools in the hands of care managers.”