Improving Chronic Illness Care
Improving Chronic Illness Care

Four: Clinical Data

Understand Care Needs of Patients
The Chronic Care Model supports the concepts of proactive population-based care. Population-based care is attention to the health care needs of the entire population of patients, not just those that show up for appointments. Population-based care relies on several different support activities, including:
  • identifying health problems within a defined population of patients to create a subpopulation;
  • defining and assuring evidence-based interventions for members of each subpopulation;
  • regularly monitoring patient progress.
Bear in mind that a single patient may belong to several different subpopulations. For example, a 65-year old woman with diabetes who smokes is in at least three subpopulations: >65 for preventive health care needs; people with diabetes; and tobacco use. Identifying your subpopulation and understanding their general planned care needs is the backbone of the population-based care delivery system. Without identification of the subpopulation members, changes in care cannot be achieved.

To identify members, a clinic requires data distinguishing patient subpopulations with different health problems. ICD 9 or CPT codes from billing data are the most common source for making these distinctions. The ability to link billing codes to individual patients allows lists to be generated, giving providers the information needed to contact patients for delivery of proven interventions, in addition to monitor their progress over time.

Once you've identified a subpopulation, try choosing a subset of patients to become your "pilot population", with which small tests of change can be conducted. Recommended size for this group is 200 patients or less. If the disease population is less than 200, simply work with the entire subpopulation. Once you have tested changes in the pilot population and have stable processes of care, it's time to expand the change to the rest of the clinical subpopulation.

For the pilot subpopulation you will need to get a general idea of their care to date. To identify the gaps in your care, review a small (10-20) non-purposeful sample of charts and compare their current care to the expectations for care on the preceding pages. This process allows you to monitor your delivery of guideline-based care, as well as determine which care elements tend to be overlooked in your target population. This brief review will help you target your key changes, which then become the basis for measuring how you will affect your patients’ care.
 
Assemble Key Clinical Database for the Patient
In order to care for your patients you need data that is readily accessible at the point of care. The paper chart isn't always the most useful tool for this purpose, because it can be disorganized and often is unavailable at the time of care.
 
Electronic data systems such as simple registries are one way to store patient data on populations for use in individual care and to track outcomes across the population. The advantage of this type of system is that summaries of care can be printed at the time of the visit. You can then use the summaries to collect new data to update the registry. You can also extract population data for monthly reports that track your progress. Teams that implement registries are better prepared for patient visits, and often find that it makes for simpler charting.

There are both public domain and proprietary registries available to use in practice. The California Health Care Foundation (CHCF) has two excellent resources for registry information:
If you're currently using an electronic medical record (EMR), make sure that the registry functionality is available in your system.
The most important thing is to not wait for a technological solution to the challenge of creating a clinical database. If neither a registry nor an EMR is an option for you, a simple hard copy card file [DOC] can be employed to track key measures for guiding better clinical care.