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From Best Practice Advisories for ambulatory practices to composite scores, Epic@UNC Healthy Planet provides tools to help clinics manage patient populations – a key to success in a rapidly changing health care market.

The transformation of the health care reimbursement model from encounters to outcomes has required a revision to the ways that clinics and providers deliver care. Now more than ever, providers and clinics are evaluated on their ability to meet quality measures related to preventive services and chronic disease management for the patients they care for.

This approach, as many of us already know, is called population health management, described by UNC Physicians Systems Vice President of Practice Quality, Innovation, and Population Health Services Robb Malone as, “the design, delivery, and coordination of high-quality health care services with the express purpose of improving the patient experience of care and the health of populations while reducing the per capita cost of health care.”

Thanks to the tools built by the Epic@UNC Healthy Planet team, the ability to meet key ambulatory quality measures and deliver standardized care across the UNC Health Care system has become even easier. Epic@UNC Healthy Planet is a unique interdepartmental effort between the Population Health Program Team within Practice Quality and Innovation (PQI) and Epic@UNC Healthy Planet analysts within ISD.

Some examples of Healthy Planet tools are Ambulatory Best Practices Advisories (BPAs), Health Maintenance, Chronic Disease Registries, Composite Scores, My Department Metrics and the Patient Outreach Encounter.

“For the first two years that Healthy Planet existed, we focused on building out Health Maintenance and tools for Primary Care Improvement Collaborative (PCIC) measures,” said Annie Whitney, MS, Population Health Program Manager for PQI. “Most of our Best Practice Advisories (BPAs) and Healthy Planet reporting have been focused on supporting clinics in meeting these measures.”

Best Practice Advisories mine a patient’s history as it appears in the electronic health record, and prompt providers and support staff to take action. These BPAs might prompt for preventive services that are due such as immunizations, cancer screenings or depression screening. They can also prompt a provider that a patient should be taking certain medications based on clinical guidelines or to consider interventions for uncontrolled diabetes or depression.

This approach requires integration that brings together clinical best practices, technological support and an informed network of providers, and focuses them all on ways to provide the best care across a population.

“It’s an approach to care delivery that utilizes a team-based approach to ensure that all patients are meeting standards of care, while dedicated resources focus on identification of needs and support of patients to maximize health outside of conventional office visits,” said Malone.

While BPAs address gaps in care when a provider is in a visit with a patient, reports from Epic@UNC’s Healthy Planet module assist clinics in identifying populations of patients who may need attention or outreach. For example, clinics can run reports to identify their patients with uncontrolled diabetes or depression.

PQI has also supported workgroups that encourage providers and staff from PCIC practices to learn and share how to put these population management tools into practice. Some recent workgroups have focused on how to use depression registry reports to find patients who are high risk and need outreach or follow-up.

“After we had tools in place to support preventive services and chronic disease management, we spent time building out infrastructure and tools to support care management activities for high risk patients,” said Whitney.

These tools include:

  • The Patient Outreach Encounter, for documenting care management and outreach activities in Epic
  • Tools to support Chronic Care Management services billing through the Centers for Medicare and Medicaid Services
  • The Health Composite Score, which assists in identifying patients at risk for high utilization and poor outcomes based on multiple factors

These tools will be invaluable to the UNC Senior Alliance, the accountable care organization (ACO) launched at the beginning of the year with the goal of providing the highest quality care to Medicare patients.

“Epic-based solutions built by the Health Planet team, specifically the Health Composite Score, are important tools to help us identify patients at high risk and target resources to those patients,” said Mark Gwynne, Senior Medical Director, UNC Health Alliance. “Our care management team uses the menu of Epic@UNC Healthy Planet tools to help providers and practices identify patients who would benefit from enhanced care after leaving the hospital or the Emergency Room, for example, and to even identify patients who could benefit from services that would help them avoid needing the emergency department or hospitalization in the first place. Our partnership with the Epic@UNC Healthy Planet team has been and will continue to be critical to making our ACO successful.”

One team tasked with managing patients covered under value-based contracts like the UNC Senior Alliance is the Population Health Services Team, which is led by Executive Director Jan Hutchins. She explained some of the ways Healthy Planet tools have helped improve care.

“Our collaboration with PQI and ISD to develop tools supporting delivery of care management services has improved efficiency and communication across the health care continuum by allowing us to prioritize the highest risk patients and reach out to them to address barriers to care and drivers of health care utilization,” said Hutchins. “The tools already in use are critical to communicating effectively with the patient’s health care team and ensuring our efforts are coordinated, and we look forward to refining out coordination even further with tools that are currently in development.”

Providing health care under the population health model is a long term proposition, but the Healthy Planet tools created by PQI and the Epic@UNC Healthy Planet team help providers and clinics across the UNC Health Care System meet the challenge. And new tools are on the horizon.

“Recently we have been focused on engaging with specialties to adopt tools being used in Primary Care and to build new ones,” said Whitney. “We released our primary care depression BPAs to psychiatry last summer and right now we are working with cardiology to build heart failure tools. The other big item we are starting work on now, in close conjunction with ISD, is the Happy Together and Caboodle projects which will allow us to integrate external data into our existing suite of Healthy Planet tools.”

To learn more about the Healthy Planet tools that are currently available, please see Population Health Tools Resource Guide. The guide also contains information on Learning Street classes that cover Healthy Planet tools – Population Health Fundamentals and Ambulatory Care Manager.