12 Initiatives That Use Health IT to Manage Patients With Complex Conditions

A recent report from the Agency for Healthcare Research and Quality profiled 12 projects across the country that use health IT to improve the management of patients with complex care needs.


1. The Southeast Nebraska Behavioral Health Information Network is designed to serve patients in rural areas receiving mental health services from urban-based providers due to a lack of specialists in their own area by making the patients' health information available to all of the patient's providers. A survey of participating clinicians found 81 percent thought the technology was beneficial in improving care coordination, though many worried about the cost and increased staff time required.

2. The Billings (Mont.) Clinic Foundation developed and implemented a system to facilitate the exchange of information between the hospital and ambulatory providers after a patient from a rural area is discharged from the hospital by prompting rural providers to access a patient's medical information through the hospital's electronic health record system. Discharged patients also receive electronically-generated discharge instructions. After the system's launch, patients were more likely to visit their primary care provider within 30 days of discharge (49 percent visited a PCP, up from 40 percent during the baseline period), and 25 percent more rural clinicians saw the care transition process as effective.  

3. The Oregon Health and Science University in Portland assessed the effectiveness of using financial incentives, specially trained care managers and tracking software to help primary care clinicians better manage patients with complex conditions or multiple comorbidities. In the six months following implementation, the program saw a significant decrease in hospital bed days through better care coordination and quality improvement in the primary care setting.

4. Researchers at Emory University in Atlanta designed a personal health record for mental health patients and used clinical care specialists to teach patients how to use and understand the PHR. In addition to displaying patient information and health tips, the record also allows for physician-patient communication. Results showed patients using the PHR increased their use of preventative health services.

5. Visiting Nurse Service of New York (City) developed an algorithm to provide alerts, reminders and point-of-care decision support to home health nurses in charge of patients at risk for serious medication problems. Patients whose nurse used the system were significantly less likely to be hospitalized (17.9 percent compared with 21.3 percent).

6. University of Massachusetts Medical School–Wooster researchers created an electronic medical record-based medication reconciliation system to enhance medication monitoring and follow-up care for patients transitioning from a skilled nursing facility back home. The system provides alerts to ambulatory clinicians and nurses making home visits about medication or health changes. Emergency department visits within 30 days of discharge were significantly lower in the intervention group as compared with the baseline period (7 percent and 17 percent, respectively).

7. Researchers at Boston Medical Center developed a system that uses conversational computerized telephone calls to monitor patients with complex needs after discharge from the hospital to identify clinical issues or inadequate self-care. The system then organizes flagged conversations for nurses' review. The intervention allows clinicians to begin appropriate follow-up with at-risk patients.

8. An enhanced personal health record developed at the University of California San Francisco helps HIV/AIDS patients better understand their health information and connects them support resources, including an online forum with clinicians and other patients, to help manage related conditions such as depression and drug abuse.

9. Researchers at Duke University in Durham, N.C., created a regional HIE to connect providers in a six-county region and enhanced existing HIE decision and support tools to help detect transitions in care and provide patient-specific information to each of a patient's providers. Results showed patients whose providers received notifications about care transition events through the HIE had more contact with their provider, usually over the phone.

10. An Emory University researcher created a PHR for pediatric cancer survivors that provides evidence-based recommendations and other educational materials to clinicians treating these patients as adults. Accessing this information allowed clinicians to better understand patients' risk profiles and late effects experienced following cancer treatment.

11. A project team at the University of Alabama at Birmingham developed a program that automatically calls rural patients at specific intervals following hospital discharge and stores patient responses on their health for review by a nurse. The nurse then follows up on any warning signs by telephone. More than 90 percent of patients responded to one or more phone calls, and nearly two-thirds of patients had a 'red flag' that initiated a follow-up call from a nurse, potentially adverting a more serious issue.

12. Baylor College of Medicine in Houston has developed an ongoing program that uses EMR data-mining to identify patients who experience delays during the cancer diagnosis process and facilitate the process by sharing patient information with relevant clinicians.

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