new data-driven primary care and population health model

[AJ Chen]

CHCF has just released a good report that lists The Building Blocks of High-Performing Primary Care:

1. Data-driven improvement: Performance data are used in all corners of the organization to spur effective action.
2. Empanelment and panel size management: Patients are assigned to a clinician, and clinics actively manage panel size, balancing capacity with demand.
3. Team-based care: Teams comprised of clinicians, medical assistants, registered nurses, front desk personnel, and behaviorists are created, with all members responsible for the quality of care.
4. Population management: Population management is used to address the needs of various subgroups of the patient population.
5. Continuity and availability of care: Clinicians are required to work a minimum number of hours and days each week to ensure continuity of care, and front desk personnel are trained to encourage continuity in scheduling.
6. Prompt access to care: Practices offer alternatives to in-person visits with a physician.

Read more: http://www.chcf.org/publications/2012/04/building-blocks-primary-care

It's pretty clear that new information platform will be an essential part of the new primary care and population health model.  Pophealth Booster open source project is working in this direction.

-aj