Guest Author: Kim Smith-Whitley, MD
As a clinician leading a multidisciplinary team caring for patients with sickle cell disease, the migration toward population health management tools to improve patient engagement and their outcomes away from the hospital cannot be overstated. Prior to our work with the population health management teams that eventually became the inspiration for Wellconnex, our program had tried many different approaches over the years that fell short in managing our large population of patients. Our electronic health record (EHR) is sophisticated but was originally designed to work best at the point of care during patient visits, not to manage follow-up care between visits and to anticipate upcoming outreach needed for our most vulnerable patients. All of our team members – scheduling coordinators, social workers, nurses, etc. – had created their own systems as workarounds to this challenge of tracking patients, and these systems were often paper-based or highly individualized and not sharable. During care team huddles, we found it difficult to review recent and upcoming patients in a cohesive and streamlined way.
About five years ago, we embarked on a process to design population-based patient dashboards, risk scores, and outreach tracking systems, all fully integrated within the EHR. These tools revolutionized the way that we conduct our team meetings, but more importantly, the ways in which we can reach out to our patients more proactively and in a more tailored way. By using our EHR tools to organize our weekly huddles, we more efficiently reviewed patients by focusing on those with high risk scores and seeing all pertinent information at a glance. Instead of digging through a patient’s entire record, we could skim a patient’s most recent clinical impression, lab, social work, and other data in one customized dashboard. Depending on the patient needs that we identified, then our nursing, social work, or scheduling staff would reach out to the patient/family to address very specific issues.
These tools allowed me as a clinical leader to create a truly multidisciplinary care team model where I could delegate concrete patient outreach tasks to different team members, especially our scheduling, social work, and nursing teams, and empower them to take ownership of certain metrics. For example, our administrative coordinator became primarily accountable for ensuring that our patients at risk of stroke received outreach and support to complete important stroke risk screening through annual transcranial doppler ultrasounds (TCDs). Tracking stroke risk screening is essential as those with abnormal TCDs are eligible for primary stroke prevention provided by chronic therapies such as monthly scheduled red cell transfusion.
These weekly team huddle changes grew into larger transformation for our program, and over time the new proactive workflows allowed us to improve significantly on key quality measures for our patient population, such as the percentage of patients at risk for stroke who received those annual ultrasounds, the percentage of eligible patients counseled about certain medications that can decrease acute pain crises, and rates of pneumococcal, COVID-19 and influenza vaccination.
Aside from the clinical and psychosocial benefits that more proactive outreach provides to our patients and families, and the efficiencies achieved by our providers, these rapid segmentation data tools also helped me in the area of research. So often, as a clinical researcher, I need to estimate the number of patients that would be eligible for a specific program or part of an upcoming grant. Previously, my choices were either to manually review charts and rely on individual patient recollection by my colleagues, or to put in a data request that might sit in a queue for many months due to limited analytics resources. But now, with these self-service population health tools, information designed around my specific clinical population was available at my fingertips. Within minutes, I can estimate the number of patients we care for that meet certain criteria for an upcoming study, or analyze the characteristics of patient panels across our program. This allowed for efficiencies with grant applications, and also ensured that I would be ready to hit the ground running with population statistics as soon as a research project began.
Finally, this innovative platform allows our program to be more responsive to new clinical initiatives facing this chronically ill patient population. For example, the COVID-19 pandemic hit the sickle cell community hard. We have provided timely outreach to ensure that our patients had the tools necessary to limit exposure to SARS-CoV-2 and to access COVID-19 vaccines. Tracking telehealth visits, contacts with patients and their families, and COVID-19 vaccination using our EHR population health tools assures me that we are more fluid in providing services regardless of the care setting. Overall, these population health tools allowed our clinical program to improve care coordination, clinical research, and patient outreach with a constant focus on providing high-quality, respectful, and compassionate care. Given this success, I look forward to continuing to broaden our tools and outreach processes to patients with sickle cell disease, and know that other organizations would benefit tremendously from implementing them as the standard of care now that they are available from Wellconnex’s population health platform.