Improved population management requires management: Care coordination

The new electronic health record (EHR)-based application would provide clinicians and care teams real-time information on health status, needed preventive measures for individual patients, all within the providers’ EHR interface display. Patients could be grouped by age, health status, and preventive care measures needed or up to date. Elements evaluated included the number by which of emergency department visits were reduced, reduction of inpatient admissions, and cost savings. Following the evaluation, the plan was that new care processes, procedures, and EHR-based application would be disseminated throughout this growing healthcare system. Ad hoc measures were put in place to record training time and work effort for care-coordination data, but the measures were not integrated with the patient care data and workflows in the EHR, making it difficult to effectively analyze the financial impact of the program.