1. Kwame A. Kitson, MD VP of Quality Improvement Institute for Family Health 16 East 16 th St New York, NY 10003 kkitson@ institute2000.org 212-633-0815 www. institute2000.org HIT Workshop New York, NY September 30, 2010 Session III: Managing Population Health and Health Disparities Who is at risk? Patient Identification and Outreach THE INSTITUTE FOR FAMILY HEALTH

2. MEANINGFUL USE OF HIT DATA  “MORE DATA = MORE PROBLEMS”

3. MEANINGFUL USE OF HIT DATA  A mountainful of data yet a finite amount of resources to handle it.

4. MEANINGFUL USE OF HIT DATA  “Beware lest you lose the substance by grasping at the shadow.” Aesop  Solution- Target measures and target resources in the most efficient ways possible.

5. MEANINGFUL USE OF HIT DATA  Electronic Patient Outreach Team Created

6. Patient Identification

7. THE IFH RESPONSE TO THE VIOXX RECALL FDA SENDS AN ALERT BY EMAIL INTERNAL VIOXX REPORT GENERATED 664 PATIENTS IDENTIFIED VIA REPORTING WITHIN 35 MINUTES OF RECEIVING FDA EMAIL ALL BUT SIX PATIENTS CONTACTED BY TELEPHONE OR MAIL WITHIN 10 DAYS

8. NON-ACCESS TO CARE OUTREACH

9. CENTRALIZED VS DECENTRALIZED OUTREACH  CENTRALIZED OUTREACH TEAM - HIGH DEGREE OF FLEXIBILITY/MULTITASKING - WELL TRAINED - HANDLES MORE COMPLEX OUTREACH  DECENTRALIZED OUTREACH TEAM - RECEIVE TRAINING FROM THE CENTRALIZED TEAM - SITE SPECIFIC STRENGTHS - LARGER NUMBERS OF PATIENTS CAN BE OUTREACHED

10. PATIENT IDENTIFICATION REGISTRY  MORE EFFICIENT IDENTIFICATION OF PATIENTS.  ALLOWS AVOIDANCE OF DUPLICATIVE OUTREACH EFFORTS.  FUTURE REGISTRIES – HIV, PRE-DIABETES, CONTROLLED SUBSTANCES.

11.  The greatest danger for most of us is not that our aim is too high and we miss it, but that it is too low and we reach it. Michelangelo