Panel Management: A new approach to delivering community-based, preventive care using an electronic health record and shared outreach workers

Background The high costs and inefficiencies of the U.S. health care system are largely attributable to antiquated and fragmented care that fails to properly collect and use health information. Electronic health record (EHR) adoption provides new opportunities to use health information in more efficient ways. The NYC Primary Care Information Project (PCIP) is at the forefront of community-based EHR adoption, particularly for independent small practices. Objective/Purpose PCIP provided small primary care offices with an outreach worker, a prevention outreach specialist (POS), who is shared among different practices to help identify gaps in patient follow-up care. The POS would act as extensions of the physician offices and have access to the EHRs of the practices they cover. Method The POS used the EHR registry features at the practices to identify patients at risk for cardiovascular events who did not have scheduled follow-up visits. They contacted the patients by phone or mail, recommending that they make appointments, fill prescriptions, and follow up with appropriate lab tests and vaccines. Results The program was deployed at 3 pilot practices. More than 567 patients with the targeted risk factors were identified, of which 475 were contacted. There were several lessons learned during the pilot, including issues related to practice size, patient workflows, staff turnover, and data quality. Data collection was limited to information that was routinely documented in the EHR, which restricted the analysis of operational and clinical outcomes. Conclusion This pilot demonstrated the feasibility of embedding a POS in primary care practices located in underserved communities in order to ensure the delivery of timely and appropriate care. Future efforts will focus on identifying the practice parameters that would influence the successful implementation of the program and determining the impact of the intervention on both operational and clinical metrics.