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    Making population health work for small practices


    SAMA’s EHR vendor developed a referral management system, and added features to categorize patients by their health risks and identify care gaps. (As a beta site, SAMA helped the vendor develop these features.)

    However, the EHR did not provide the actionable, patient-level data that SAMA needed for population health management. The group obtained access to that data only after it joined an ACO that had its own population health management software.


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    Pete Atkinson, MHA, administrator of the SAMA clinic, says that the group had a choice between buying a population health suite from their EHR vendor or using the ACO’s proprietary software. The practice’s EHR already had some of the functions that SAMA needed, such as referral management. SAMA picked the ACO partly because it had access to claims data from payers and because its application was much easier to use.

    How the software helps

    The ACO’s population health management software, which analyzes community EHR and claims data, allows care coordinators to examine information on any patient. 

    For example, the software can identify how many times the patient has filled a particular prescription, how many times she has seen a particular doctor outside the practice, how many times she has gone to the emergency department, and what all of that costs, Callaway says.

    With this kind of data in hand, he adds, “We can isolate that high-spend group [of patients] and get them in and discuss with them how can we improve these processes to keep them out of the ER and the hospital, and it’s actually working.”

    The group’s readmission rates are low compared to the national average, Callaway notes. Aided by the software, the care coordinators follow up with patients after their hospital discharges and make sure their medication lists are correct. He also cites the example of a patient with COPD who did not receive an oxygen tank after being discharged from the hospital, but got one after a care coordinator contacted him.


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    The dashboard on the ACO’s web portal tells the care coordinators who they need to call each day and allows them to set up reminders for weekly or monthly calls, says Atkinson. The software shows which patients are coming into the office, who they’re seeing, and whether they should be considered for care management, he says. In weekly care team huddles, the care coordinators tell the providers what they need to know about these patients.

    Because the population health management application is not integrated with the group’s EHR, the care coordinators have to go to the ACO’s website to use it. That isn’t a problem for them, because they all have  dual screens showing the population health management software and the EHR, notes Atkinson. But Callaway and his colleagues don’t have the time to go to the website when they’re seeing patients. 

    “We hope that in the future, our ACO might work with our EHR vendor to incorporate it into a one-view screen in the EHR,” Callaway says.  


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