Long-Term Impact of an Electronic Health Record-Enabled, Team-Based, and Scalable Population Health Strategy Based on the Chronic Care Model

Kensaku Kawamoto, Kevin J. Anstrom, John B. Anderson, Hayden B. Bosworth, David F. Lobach, Carrie McAdam-Marx, Jeffrey M. Ferranti, Howard Shang, Kimberly S.H. Yarnall

Research output: Contribution to journalArticle

3 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)686-695
Number of pages10
JournalAMIA ... Annual Symposium proceedings. AMIA Symposium
Volume2016
StatePublished - 2016

ASJC Scopus subject areas

  • Medicine(all)

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