EHRs and care gaps

How do electronic health records (EHRs) help close the existing care gaps? Gaps in care happen when the patient is not following up on appointments, not securing their prescriptions, or not adhering to post-visit instructions. Care gaps can also occur when the patient is not aware that a certain test or procedure is necessary for preventive care. The latter incident can be a result of lack of communication between the independent physician and the patient. It can also arise out of an insufficient patient engagement in their own healthcare.

Care gaps can be costly and harmful to the patient, particularly so for patients with chronic conditions. When a patient with diabetes, for example, is not properly managed, it can lead to serious complications and more expensive treatment. When the independent physician has the tools necessary to resolve gaps in care, it can benefit the patient and the practice, leading to improved quality scores and reimbursement potential.

The Healthcare Effectiveness Data and Information Set (HEDIS) has care gaps as one of its focuses. HEDIS is one of the most widely used set of healthcare measures. Risk adjustment measures stipulate eligibility requirements for identifying care gaps for patients based on condition, complications, age, and gender.

Having access to appropriate and relevant data is the key to closing these care gaps. That data is available in the EHRs used by the independent practice. The provider must then leverage that data to identify patients at risk and to share information with patients, their other providers, and the payers.

Information sharing through effective communication is critical to being able to close the gaps in care and to improve quality measures. Working with interoperable EHRs enables the independent physician to share relevant data with specialty providers and other healthcare facilities that may be caring for the patient. The EHR’s communication tool also enables the physician to connect directly with the patient, to ensure that post-visit instructions are being followed and recommended tests are being scheduled.

Direct messaging can further aid the independent physician in reaching out to engage the patient with reminders and instructions for follow-up care. Direct secure messaging (DIRECT) is a simple method of communication for practices to transfer patient health information while maintaining a high level of privacy and security. These messages are encrypted and meet the protection standards in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Learn more about Elation’s direct messaging capabilities here.

Communication between the independent physician, patients, and payers allows important information to be captured and used to achieve the desired outcomes, including:

  • Providers having the tools to coordinate and align care across care settings
  • Patients and their caregivers having the knowledge and resources they need to better manage their own health
  • Payers engaging providers and their patients in prevention and wellness.

Documentation is also critical to closing the care gaps. Using the available patient data in the EHR can help the provider track the activities necessary within a defined measurement window, such as annual preventive tests or screenings. Using this information and communicating it in a timely manner with patients can increase the provider’s efforts to reduce the number of non-compliant patients and to better manage population health.