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.

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.

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.