Harnessing Electronic Health Records for Population Health Management

  • 1 Varsha Danda is a BA candidate at Washington University in St. Louis, MO. Sri Lekha Tummalapalli, MD, MBA, MAS, is an Assistant Professor in the Division of Healthcare Delivery Science & Innovation in the Department of Population Health Sciences at Weill Cornell Medicine and Research Associate at The Rogosin Institute, New York, NY.
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Electronic health records (EHRs) have untapped potential for population health management. Population health focuses on the health outcomes of a group of individuals, rather than considering the health of one person at a time (Figure 1) (1). New value-based care models, such as Kidney Care Choices, provide an additional incentive to use EHRs for population health management. Value-based care models tie performance on quality metrics to financial bonuses or penalties and increasingly hold practices at financial risk for total costs of care. If EHR-based tools are effective in improving quality metric performance and preventing unnecessary hospitalizations, they may provide a return on investment.

Figure 1.
Figure 1.

Medical and Population Health Models.

Citation: Kidney News 13, 8

Three key applications of EHRs for population health management include the following: 1) generating quality reports, 2) tracking care milestones, and 3) ensuring patients are not lost to follow-up. Current EHR systems provide a variety of features to accomplish these goals (Table 1).


The most commonly used EHR by nephrology practices is Epic Systems. Epic's Reporting Workbench, under the Epic button > Reports > My Reports tab, contains pre-built quality reports, which are also customizable. Clinicians or health systems can also construct chronic kidney disease (CKD) quality dashboards. Epic's SlicerDicer allows clinicians to examine trends in clinical data and stratify by sub-populations. Several institutions, including Cleveland Clinic, Mass General Brigham, Providence St. Joseph Health, and the University of California, Los Angeles (Center for Kidney Disease Research, Education and Hope [CURE-CKD]), have gone further to create CKD registries, which are structured databases of clinical information that can be readily queried. DaVita and Fresenius Medical Care have separately partnered with Epic to create CKD EHR platforms, which combine nephrology-specific workflows with predictive analytics.

Other EHRs have additional population health tools. Allscripts offers an interoperability platform, care coordination software, and transitions of care software. Athenahealth provides helpful features, including >140 pre-built quality reports and automated outreach tools to improve patient engagement.

Many nephrology practices are partnering with practice management and startup companies to implement EHR-based strategies. For example, Global Nephrology Solutions is a practice management platform that uses predictive modeling to identify and coordinate care for potentially high-risk patients. Nephrology Care Alliance is another clinical technology service that connects to EHRs and provides specialized nephrology workflows.

Many nephrology practices are partnering with practice management and startup companies to implement EHR-based strategies.

Several key challenges remain. First, publicly available data on the effectiveness of these tools for driving care improvements are still limited. Second, there is often lack of alignment with metrics used for internal quality improvement and those used in national quality programs, such as the Merit-Based Incentive Program. The development of more electronic clinical quality measures (eCQMs) related to CKD could decrease manual data entry requirements, which are burdensome and costly.

In sum, as nephrology practices are shifting their focus onto population health management, EHRs are rising to the challenge with innovative, specialty-focused features that can help identify and bridge health gaps and improve health outcomes as a whole.