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Improving Population Health Outcomes by Creating Patient Registries in Washington State

August 14, 2014
by Rajiv Leventhal
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Sarah Miller

With the goals of delivering better care for patients and aligning themselves to better succeed in an era of healthcare reform and accountable care, organizations are aiming to transform care through population health management.

At a panel discussion entitled “Innovations in Population Health Management,” industry leaders will ponder a variety of issues around the connections between population health management strategies and innovations and the leveraging of healthcare IT. That discussion will take place at the Health IT Summit in Seattle, to be held August 19-20 at the Seattle Waterfront Marriott. The summit is sponsored by the Institute for Health Technology Transformation, or iHT2. (Since December 2013, iHT2 has been in partnership with Healthcare Informatics through HCI’s parent company, the Vendome Group LLC.) For further information on the Summit, please click here.

In Seattle, Group Health Cooperative (GHC)—which is both a health plan and a provider organization— has been practicing some form of accountable care since it was founded in 1947. Today, Group Health and its subsidiary health carriers, Group Health Options, Inc. and KPS Health Plans, serve more than 600,000 residents of Washington and northern Idaho. Sarah Miller is the executive director of its Care IT Delivery Department, which has the goal to build tools within the electronic health record (EHR) that providers can use at the point of care.

To this end, Miller says GHC has leveraged its Verona, Wis.-based Epic System’s EHR’s capabilities to build out patient registries and documentation tools for providers to use at point of care as well as for doing outreach.  As Miller told HCI contributor Cynthia Keen, “We have developed hundreds of registries.  One of the first was to track medication usage of patients with multiple sclerosis (MS). Prescription drugs to treat MS are very expensive and they are not effective for a percentage of patients. This registry enables us to track the medication and use of these drugs,” she adds. “We can make sure that patients are taking them correctly and determine if they are effective in reducing symptoms. Alerts are automatically generated and we can intervene in a timely manner.”

Miller adds, “Customized documentation tools identify care gaps and record how our clinical staff addresses them.” GHC’s EHR has hundreds of reporting and notification tools embedded in the clinical workflow. Miller says that any caregiver can review a list of patients with appointments for the day to see what registry a patient is on and what care gaps there may be. The gaps won’t be overlooked and can be efficiently addressed during the patient visit, she says.

“Some people think of population health as patients using mobile apps and that sort of thing. But even though we have [those tools], that’s not what we’re building here. Most of our population health tools are really just a part of regular care,” Miller says.

This is because of a really robust rules engine, she explains. “Combing through the chart, looking through documented diagnoses or lab results, and common discharge summaries add to the registries. Physicians can then look at which conditions a patient has or might have prior to seeing him or her in the exam room. Or we have support staff who uses tools to reach out to patients via phone calls or secure messaging.”

Additionally, in 2012, Group Health and 10 other integrated health systems, with more than 16 million members, combined de-identified data from their EHRs to form one of the largest diabetes registries in the nation.. According to a study published in the Centers for Disease Control and Prevention’s Preventing Chronic Disease, the SUPREME-DM DataLink provides a unique and powerful resource to conduct population-based diabetes research and clinical trials.

According to the Group Health Research Institute, the research arm of GHC, most other registries are smaller and are associated with a single health or hospital system in one region of the country. The U.S. Department of Veterans Affairs maintains a valuable diabetes research database containing a similar number of patient records, but most of those patients are men, and they are sicker than the general population, the Institute notes.

The DataLink contains test results, prescription records, hospital and clinic visit information, and vital statistics of more than one million people with diabetes. The project also brings together 33 diabetes researchers with diverse backgrounds, expertise, and interests.

Miller further attributes much of GHC’s success to having a strong physician informatics team that both understands technology and possesses the necessary clinical background needed to advise programmers to build the tools. “I have worked at other healthcare organizations, and Group Health is really good at rolling out standard processes and tools for clinicians, and getting them to use [the tools],” she says. “Whether it’s part of patient visit flow or outreach flow, we get the physicians to use them. And it takes clinical leadership to be engaged—that is something that seems to hold back other organizations.”

These and other topics will make for a lively discussion in Seattle, as these three panelists and others discuss key topics around this important subject. To learn more, please check out the Health IT Summit in Seattle, August 19-20,, sponsored by the Institute for Health Technology Transformation.

The Health IT Summits gather 250+ healthcare leaders in cities across the U.S. to present important new insights, collaborate on ideas, and to have a little fun - Find a Summit Near You!


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