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Accountable Care Organizations

IT components needed for each population management functionality Data

Population management functions

Quality, cost, performance reports

Identify and stratify patients

Care coordination

Population- based care management

Evidence-based surveillance


engagement with risks/illness

Integrate data from multiple sources

Questionnaires, assessments and surveys

warehouse /data


Population and care

management system

Population surveillance rules engine

++ + ++

++ + ++ + ++ + ++

+ ++ + + + + Clinical integration

Advanced reporting

Analytic tools

Remote monitoring

Patient and family

engagement technologies


+ +

+ + +

+ +

+ + + + + +


Patient and family engagement technologies Patient and family engagement technologies include

Web-based portals linked to personal health records; lifestyle tracking tools; handheld technologies for education, tracking, reminders and interactive learning; Web-video technologies for virtual provider visits, health coaching and case manage- ment; and interactive assessments, questionnaires and con- nectivity to measure patient outcomes and provide feedback on patient experience. Patients are now being provided access to their own medical record information and encouraged to learn more about and manage their own health risk factors and chronic illnesses. Mobile and tablet technologies, Web-based patient portals and Web-video technologies are allowing patients to have better access to their care teams, medical knowledge and tools that help them to improve their life- styles and achieve better results in managing their illnesses. These technologies can be linked to both their population and care management tools and their EHRs. Patient experi- ence questionnaires, interactive assessments for depression screening, assessment of activities of daily living, pain management follow up, etc., can be administered using email, patient portals and/or handheld technologies.

14 April 2012

Population health information technology Population health information technology is complex to implement but critical for ACO performance. All the pioneering organizations participating in the Medicare Physician Group Practice demonstration, such as Marshfield Clinic, have significantly redesigned care workflows and introduced population health informa- tion technology that makes clinical data more readily available to the practitioners and care teams, including “add-on” disease registries or embedded tools within their EHRs. It may be disappointing that after having spent significant amounts of time, effort and money to implement electronic medical records, there is more work ahead in assimilating a complete set of population health information technologies to become a successful ACO. The consolation is that none of these pioneering organizations have used all of the population health and care management tools that are now available and yet most of them accomplished positive results. One of the keys going forward will be to prioritize the functions that are most likely to achieve results and implement those first. See chart for a matrix of population health IT and functionalities.


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