Improved patient management

While in a discussion last week that was focused on the post EHR adoption era, one of the participants present mentioned the desire for improved patient management by accessing and utilizing data that resides outside of the institution providing care.

His comment brought to mind a compelling example where this is being done. In July, I watched a PBS Frontline episode, which featured the Camden Coalition and the work of Dr. Jeffrey Brenner. A summary of program can be found at:

http://blogs.cooperhealth.org/news/2011/07/pbs-frontline-series-to-debut-in-depth-piece-on-the-camden-coalition/

Here's a link to the online version of the program:

http://video.pbs.org/video/2070853636

Dr. Brenner was focused on Emergency Room visits. These events are very costly, and generally patient follow-up is very weal to non-existent. Brenner used Medicare payment data and GIS to identify frequent and clusters of ER users. Once these were identified he used RN and social workers for the in-home contacts focused on preventive care and education. The results were significant reductions in repeat ER visits, reduced medical costs and improved outcomes.