Deb Friesen, M.D., knows chronic disease up close and personal. The internist is also a devotee of electronic health records, and says that without one her job would be much more difficult than it already is. A member of the Kaiser Permanente's Colorado Medical Group, she says that three-fourths of the patients in her internal medicine practice suffer from at least one chronic condition.

"Diabetes is really common," says Friesen, whose practice is located in Wheat Ridge, Col., a Denver suburb. "I also treat hypertension, obesity and back pain." Left unchecked, such conditions can be debilitating, and patient involvement in their own care is critical, Friesen says.

That's why Friesen was glad to see one of her older female diabetic patients come in for a recent appointment. Two years had passed since this patient's last exam, well beyond the recommended interval. When the patient's visit was finished, she remarked, on her way out the door, that "her period had returned," the internist recalls. Concerned about uterine bleeding, Friesen ordered an immediate outpatient biopsy, which revealed the patient had endometrial cancer. "She had a hysterectomy and is now cancer-free," Friesen says.

The internist credits the EHR-and its adjoining analytics features-with saving the patient's life.

Here's how: First, Friesen was provided a quality report from Kaiser that compared the relative control her panel of diabetic patients had of their disease compared with similar patients treated by the internist's peers in the 800-physician multi-specialty practice. Friesen's next step was to act on the data. "I saw I was lagging so we did outreach, and started calling patients" who were overdue for a visit, a chore also facilitated by the EHR, from Epic.

The system cycled the data on patient lab scores and other indicators through an adjoining analytics feature called Health Trak, which greatly expands her capabilities to track and monitor her chronic patients, says Friesen. She worked in a private group practice-one without an EHR-for over a decade before joining Kaiser, a highly automated integrated delivery system with its own health plan and employed physicians. "In the private world, no way would I have gone through the charts, pulled out all the labs and visits, and said, 'Hey, you have to call this patient.'"

The Cover Story in Health Data Management's August issue examines how information technology is being poured into chronic care management, but there are no silver bullets out there.


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