Long-Term Impact of an Electronic Health Record-Enabled, Team-Based, and Scalable Population Health Strategy Based on the Chronic Care Model.

Journal Article (Journal Article)

The Chronic Care Model (CCM) is a promising framework for improving population health, but little is known regarding the long-term impact of scalable, informatics-enabled interventions based on this model. To address this challenge, this study evaluated the long-term impact of implementing a scalable, electronic health record (EHR)- enabled, and CCM-based population health program to replace a labor-intensive legacy program in 18 primary care practices. Interventions included point-of-care decision support, quality reporting, team-based care, patient engagement, and provider education. Among 6,768 patients with diabetes receiving care over 4 years, hemoglobin A1c levels remained stable during the 2-year pre-intervention and post-intervention periods (0.03% and 0% increases, respectively), compared to a 0.42% increase expected based on A1c progression observed in the United Kingdom Prospective Diabetes Study long-term outcomes cohort. The results indicate that an EHR-enabled, team- based, and scalable population health strategy based on the CCM may be effective and efficient for managing population health.

Full Text

Duke Authors

Cited Authors

  • Kawamoto, K; Anstrom, KJ; Anderson, JB; Bosworth, HB; Lobach, DF; McAdam-Marx, C; Ferranti, JM; Shang, H; Yarnall, KSH

Published Date

  • 2016

Published In

Volume / Issue

  • 2016 /

Start / End Page

  • 686 - 695

PubMed ID

  • 28269865

Pubmed Central ID

  • PMC5333318

Electronic International Standard Serial Number (EISSN)

  • 1942-597X


  • eng

Conference Location

  • United States