CAPP Physician Group: HARVARD VANGUARD
Project: CHRONIC ILLNESS CARE PROJECT

Summary: Physicians and other clinicians at Harvard Vanguard use medical information to integrate population management and chronic care programs into primary care with positive results in improved diabetes quality measures. Early management of such chronic illnesses will result in better lives for their patients and cost savings for employers.

Harvard Vanguard Medical Associates of greater Boston, Massachusetts, has developed new programs to address proactively the needs of patients with chronic illnesses. Their goal is to improve early management of chronic illnesses to delay the onset of long-term complications.

To accomplish this, Harvard Vanguard has leveraged its electronic medical record and extensive patient data warehouse to create the informatics support to integrate novel care management processes* into the frontlines of primary care:

1. Population management utilizes clinical informatics to facilitate data-driven continuous chronic illness care improvement.

2. Systems-based practice allows for coordinating resources effectively to reliably deliver, high quality chronic illness care.

3. Planned chronic illness care includes-a series of proactive patient visits dedicated to chronic illness management where clinicians and the nursing staff address comprehensive patient needs, including evidence-based care and promotion of patient self-management through behavioral counseling.

For example, to support population management, every primary care clinician receives a quarterly set of patient-level “dashboard” reports of all diabetics in their practice, including their clinical, pharmaceutical, and care utilization data. Clinicians can sort through the data rapidly to identify gaps in care in order to generate a specific action plan involving the patients who compose those gaps. To support planned care, the electronic medical record is used to create bundled order sets for routine follow-up diabetic visits. In addition, a designed progress note template has been created that allows for each chronic disease planned visit to promote comprehensive care.

Harvard Vanguard began the design and development of these interventions in 2003. When looking at the change in diabetes quality of care from 2004 to 2006, the overall diabetes composite quality measures improved consistently.

*Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4

For more information about this project or for an interview with Dr. Joe Kimura, please contact Marci Sindell at (617) 559-8323.

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