Electronic Health Records (EHRs) are invaluable for providers interested in population health analytics. Why? Health plans have medical and pharmacy claims data to use as the basis for analysis, while providers do not. But what health systems do have is a wealth of structured and unstructured data available in their own EHRs. Today we are sharing how organizations can use their EHR data for analysis in a practical and actionable way.

Segmenting Patient Populations

One size does not fit all in health care. Even patients with the same diagnosis can have vastly different needs based on various factors. Using EHR data, the ACG^® System addresses this by segmenting patient populations into distinct Patient Need Groups (PNGs). This segmentation enables you to tailor your approach, offering targeted interventions and more effective care.

The ACG System categorizes patients based on their health needs, diagnoses and prescription medications. Additional neighborhood factors such as income, education, employment and housing quality provide insight into the geographic challenges faced by patients. By understanding these nuances, clinics and providers can predict costs more accurately, allowing for better resource allocation and proactive care management.

Generate Incremental Revenue

Chronic health conditions often require specialized management programs, many of which are covered by Medicare. The ACG System can use EHR data to help identify patients who would benefit from these services, leading to healthier outcomes for patients and potential revenue boosts for you. By leveraging this information, you can ensure that patients receive the care they need while also capitalizing on available community and health plan programs to enhance your revenue stream.

Using Existing EHR Data for Enhanced Care

Efficiently managing chronic conditions is crucial, and delays in processing pharmacy or medical claims can significantly impact patient outcomes. The ACG System utilizes EHR data to assess risk and need, allowing for quicker and more informed interventions. This approach ensures that high-risk patients receive timely care, reducing the likelihood of unplanned emergency visits and improving overall health management.

Improve and Coordinate Patient Care

Patients with complex health conditions often require input from multiple providers. The ACG System facilitates better care coordination by ensuring that all providers involved are aligned with the patient’s needs. This coordination minimizes duplicate tests, prevents scheduling conflicts and reduces unnecessary hospital admissions, ultimately lowering costs and enhancing patient satisfaction.

Moreover, the ACG System identifies social needs that may indicate the patient would benefit from community-based programs such as Meals on Wheels. For instance, a patient’s frailty due to unexplained weight loss could signal difficulty preparing food or food insecurity. By addressing these basic needs, you can significantly improve health outcomes and foster a more comprehensive approach to care.

Download Our E-Guide

Want to learn more about these practical applications for EHR data? Download our e-guide “Using EHR Data for Risk Stratification Analysis.” This resource is designed to help your health system or provider practice leverage EHR data for better patient care and accurate future planning. Click here to download the e-guide.

For more information on utilizing the ACG System for risk stratification, visit hopkinsacg.org or contact us at acginfo@jh.edu. If you are a current ACG System customer, reach out to your Account Manager.