Population health coordinators in Massachusetts General Hospital’s primary care network, who received special training in the use of electronic health records and clinical registries, were able to achieve significant care improvements for patients with cardiovascular disease, diabetes, and hypertension.

MGH developed and implemented the population health management program for chronic conditions by leveraging an established health IT clinical registry in its primary care network.

According to Jeffrey Ashburner, an epidemiologist and staff researcher in the MGH Division of General Internal Medicine, the registry was originally focused on comprehensive cancer screening. However, the PHM health IT tool—called TopCare—was augmented to include registries for patients with cardiovascular disease, diabetes, and hypertension.

As part of a pilot study, four network-based population health coordinators were assigned to eight of MGH’s 18 primary care practices in the Boston area. These coordinators were so successful in improving process and outcome measures for patients that the healthcare organization has since rolled out the PHM program to all practices in the MGH primary care network.

“We found that patients cared for at practices that were assigned centralized support as part of a population health program for chronic disease management had greater improvements in outcomes than did patients at practices not receiving this centralized support,” says Ashburner. “Population health management and clinical registries can identify patients with gaps in care outside the context of a face-to-face clinical visit, allowing the healthcare team to take action.”

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The population health coordinators—who were trained on optimal use of the clinical registry tool and the EHR—met regularly with practice physicians to review information on patients who needed additional clinical intervention and to come up with action plans including ordering overdue lab tests, obtaining results of in-home blood pressure monitoring, and scheduling office visits.

“Their workflow would be to use the clinical registry and identify patients who needed action to be taken,” adds Ashburner. “The registry identified patients’ status in pretty close to real time by extracting data from our electronic data sources at the hospital. The tool could also create reports to see how a particular practice was doing and identify areas where they could improve.”

In fact, practices that were assigned population health coordinators showed greater improvement in the percentages of patients who received appropriate testing—such as target A1C levels for diabetic patients and cholesterol levels for those with cardiovascular disease—and in those who achieved clinical targets.

“We actually saw improvements in all practices—the improvements were just greater in the practices that had the centralized support,” observes Ashburner, who is also an instructor of medicine at Harvard Medical School.

Results of the six-month study were published online this week in the American Journal of Managed Care.

“Since our study was limited to six months, after which the program was expanded to all MGH primary care practices, we need longer-term follow-up to assess outcomes over time,” says Ashburner. “But our results clearly show that a population health management program in which centralized coordinators work closely with practice staff provides even greater improvement in clinical outcomes for patients with diabetes, cardiovascular disease or hypertension.”

During the pilot, MGH had a homegrown EHR but last year the healthcare organization as part of Partners HealthCare completed implementation of an Epic system. Ashburner would not speculate on what affect—if any—the new EHR might have. However, he did note that Epic has its own population health management registries.

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