An informatics approach to chronic disease management in primary care: blending business intelligence and care process models

Asthma, diabetes, and depression are chronic diseases managed through the Primary Care Clinical Program at Intermountain Healthcare. Primary Care Providers (PCPs) receive monthly reports on their patients with these conditions. The reporting paradigm focuses on individual diseases. PCPs have asked for a consolidated view of chronic disease, one that is patient-centric rather than disease-centric. A clinical decision support tool was developed using data from Intermountain's enterprise data warehouse. A cube was built to report on asthma, diabetes, and depression patients simultaneously. 183, 000 patients were included in the study. The tool measures PCP's adherence to best practices for chronic disease management. It also allows ad-hoc analysis of large data sets as well as actionable reports for PCPs to identify gaps in adherence to best practices. Primary care providers can view their patient populations with asthma, diabetes and depression in a consolidated report. The decision support tool was successfully built as a prototype for chronic disease management. The tool has the potential to scale and include many chronic conditions for reporting. It was demonstrated to executives, directors, and PCPs at Intermountain. Chronic disease management should be done with a patient focus rather than a disease focus. Information technology has an important role to play in the support of iv primary care and the medical home. Clinical decision support tools can be built to improve population-level and patient-level chronic disease management.