Development of an operable population-based clinical dashboard to provide decision support for care coordination in primary care

Background: Because nurse care coordinators need access to timely information from a single source, an electronic dashboard was developed to provide decision support in the rollout of care coordination across the 12 sites of Community Health Center, Inc. (CHCI), a Federally Qualified Health Center and Patient-centered Medical Home (PCMH). 

Purpose: The dashboard enables nurses to identify high-risk patients who would benefit from enrollment in care coordination.  It is also a source of ongoing monitoring regarding the size and demographics of populations at high risk for adverse outcomes related to uncontrolled chronic conditions and repeated hospitalizations. 

Methods: The dashboard was built through the collaboration of CHCI Business Intelligence, the quality improvement department, and nurses. The dashboard, which is updated daily, mines data from individual electronic health records based on an algorithm using Uniform Data System (UDS) measures, and populates the dashboard with the medical record numbers of patients who meet the UDS criteria for uncontrolled hypertension, diabetes and asthma.  The dashboard also lists a patient’s last recorded blood pressure and hemoglobin A1c, smoking status, whether there has been two or more visits to an emergency room within six months, and if the patient has a diagnosis of four or more chronic conditions. The dashboard also imports data from the state Medicaid database, which identifies patients currently hospitalized and/or recently discharged from a hospital.  Given delays in receiving admission and discharge notifications, the dashboard information provides more timely and centrally located means to ensure rapid intervention. 

Results: In the first 3 months of use, there was a significant increase in the number of patients enrolled in care coordination.

Conclusions:  Care coordination is a core element of the PCMH. Tools such as this dashboard can help practices seeking to coordinate care identify appropriate, high-risk patients, and provide timely decision support.