Guide for developing an information technology investment road map for population health management.

Many health systems recovering from a massive investment in electronic health records are now faced with the prospect of maturing into accountable care organizations. This maturation includes the need to cooperate with new partners, involve substantially new data sources, require investment in additional information technology (IT) solutions, and become proficient in managing care from a new perspective. Adding to the confusion, there are hundreds of population health management (PHM) vendors with overlapping product functions.

Team-based care approach to cholesterol management in diabetes mellitus: two-year cluster randomized controlled trial.

Background: Creative, cost-effective interventions to improve the quality of care of chronic illnesses are needed. This study was designed to evaluate the impact of remote physician-pharmacist team-based care on cholesterol levels in patients with diabetes mellitus (DM).

Methods: This 2-year prospective, cluster randomized controlled trial was conducted within the Providence Primary Care Research Network in Oregon.

A randomized controlled trial of team-based care: impact of physician-pharmacist collaboration on uncontrolled hypertension.

Objective: Evaluate the effectiveness of collaborative management of hypertension by primary care-pharmacist teams in community-based clinics.

Study Design: A 12-month prospective, single-blind, randomized, controlled trial in the Providence Primary Care Research Network of patients with hypertension and uncontrolled blood pressure.

Methods: As compared to usual primary care, intervention consisted of pharmacy practitioners participating in the active management of hypertension in the primary care office according to established collaborative treatment protocols.

Evaluation of patient care interventions and recommendations by a transitional care pharmacist.

A "transitional care pharmacist" (TCP) was deployed within an acute care setting to identify opportunities for improved continuity of care. The provision of medication reconciliation services, drug consultation, patient counseling and planning for after-hospital care was time consuming but also fruitful, resulting in roughly nine interventions per patient. Areas with the greatest potential for morbidity reduction were the resumption of home medications during the acute stay and at discharge.

Oral antidiabetic medication adherence and glycemic control in managed care.

Objective: To evaluate adherence to oral diabetes medications (ODMs) in patients with type 2 diabetes and the impact of ODM adherence on glycemic control.

Study Design: Retrospective observational study.

Methods: Medical and pharmacy claims from a managed care plan in Oregon were used to identify adults with diabetes who newly initiated ODM therapy (n = 2741); a subset of this cohort linked to electronic health records was used to evaluate the relationship between adherence and glycemic control (n = 249).

Provider feedback to improve 5A's tobacco cessation in primary care: a cluster randomized clinical trial.

The electronic health record (EHR) may be an effective tool to help clinicians address tobacco use more consistently. To evaluate the impact of EHR-generated practice feedback on rates of referral to a state-level tobacco quitline, we conducted a cluster randomized clinical trial (feedback versus no feedback) within 19 primary care clinics in Oregon. Intervention clinics received provider-specific monthly feedback reports generated from EHR data.

Depression screening interfaced with an electronic health record: a feasibility study in a primary care clinic using optical mark reader technology.

Objective: Strategies to effectively and efficiently screen for depression remain elusive in the primary care setting. The purpose of this study was to assess the feasibility of a depression screening program in which patients completed a validated questionnaire in the waiting room. Using Optical Mark Reader technology (PatientLink), patient responses were interfaced into the electronic health record (EHR), where the responses and score were available to practitioners at the time of the visit.

Effect of patient withdrawal on a study evaluating pharmacist management of hypertension.

Study Objectives: To examine potential threats to internal and external study validity caused by differential patient withdrawal from a randomized controlled trial evaluating pharmacist management of hypertension, to compare the characteristics of patients who withdrew with those of patients who completed the study, and to identify characteristics that predispose patients to withdraw from hypertension management.

Design: Prospective, randomized, comparative study.

Setting: Network of primary care clinics.

Clinical implications of an accurate problem list on heart failure treatment.

Context: The premise of the problem-oriented medical record is that an accurately defined problem list will directly result in more thorough and efficient patient care. However, little empirical evidence exists demonstrating improved patient outcomes as a result of an adequately structured problem list.

Objective: To determine the impact of problem list documentation of heart failure on the likelihood that evidence-based pharmacotherapy has been prescribed.

A first step towards translating evidence into practice: heart failure in a community practice-based research network.

Objective: To determine the validity of an electronic health record (EHR) in the identification of patients with left ventricular dysfunction in a primary care setting.

Design: A cross-sectional study.

Setting: Nine clinics participating from the Providence Research Network (PRN) comprising 75 physicians serving approximately 200,000 patients.

Impact of educational mailing on the blood pressure of primary care patients with mild hypertension.

Objective: To assess the effectiveness of mailed hypertension educational materials.

Design: Prospective, randomized, controlled single-blind trial.

Setting: Primary care practice-based research network in which 9 clinics located in Portland, Oregon participated.

Cholesterol management of patients with diabetes in a primary care practice-based research network.

Objective: To determine the proportion of diabetic patients with and without coronary heart disease (CHD) who attained the American Diabetes Association recommended low-density lipoprotein cholesterol (LDL-C) target level of < or = 2.60 mmol/L (< or = 100 mg/dL).

Study Design: Retrospective cross-sectional study.