title: Long-Term Impact of an Electronic Health Record-Enabled, Team-Based, and Scalable Population Health Strategy Based on the Chronic Care Model.
abstract: The Chronic Care Model (CCM) is a promising framework for improving population health, but little is known regarding the long-term impact of scalable, informatics-enabled interventions based on this model. To address this challenge, this study evaluated the long-term impact of implementing a scalable, electronic health record (EHR)- enabled, and CCM-based population health program to replace a labor-intensive legacy program in 18 primary care practices. Interventions included point-of-care decision support, quality reporting, team-based care, patient engagement, and provider education. Among 6,768 patients with diabetes receiving care over 4 years, hemoglobin A1c levels remained stable during the 2-year pre-intervention and post-intervention periods (0.03% and 0% increases, respectively), compared to a 0.42% increase expected based on A1c progression observed in the United Kingdom Prospective Diabetes Study long-term outcomes cohort. The results indicate that an EHR-enabled, team- based, and scalable population health strategy based on the CCM may be effective and efficient for managing population health.
authors.affiliation: Departments of Biomedical Informatics.
authors.forename: Kensaku
authors.initials: K
authors.lastname: Kawamoto
authors.affiliation: Pharmacotherapy, University of Utah, Salt Lake City, Utah.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Anstrom
authors.affiliation: Departments of Biostatistics and Bioinformatics.
authors.forename: John B
authors.initials: JB
authors.lastname: Anderson
authors.affiliation: Community and Family Medicine; Medicine.
authors.forename: Hayden B
authors.initials: HB
authors.lastname: Bosworth
authors.affiliation: Departments of Biostatistics and Bioinformatics; Community and Family Medicine.
authors.forename: David F
authors.initials: DF
authors.lastname: Lobach
authors.affiliation: Psychiatry and Behavioral Sciences.
authors.forename: Carrie
authors.initials: C
authors.lastname: McAdam-Marx
authors.affiliation: Pediatrics; Duke Health Technology Solutions, Duke University, Durham, NC.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Ferranti
authors.affiliation: Duke Health Technology Solutions, Duke University, Durham, NC.
authors.forename: Howard
authors.initials: H
authors.lastname: Shang
authors.affiliation: Departments of Biostatistics and Bioinformatics.
authors.forename: Kimberly S H
authors.initials: KS
authors.lastname: Yarnall
mesh_terms: D003920:Diabetes Mellitus / Q000097:blood / Q000628:therapy*; D057286:Electronic Health Records; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D008134:Long-Term Care; D010348:Patient Care Team; D019095:Point-of-Care Systems; D011320:Primary Health Care; D011446:Prospective Studies; D006113:United Kingdom
chemical_list: D006442:Glycated Hemoglobin