Dr. Chatman Leads Efforts to Improve Care Coordination
Dr. Robyn Chatman is a family medicine physician in Cincinnati, Ohio. She currently serves as the Director of Clinical Informatics at HealthBridge, a non-profit organization that houses the Tri-State Regional Extension Center, a health information exchange, and the Greater Cincinnati Beacon Community. Before joining Healthbridge full-time, Dr. Chatman was the managing partner at Trinity Family Medicine, a three-physician practice in the Cincinnati area. Under Dr. Chatman’s lead, Trinity successfully transitioned from a paper records system to an electronic health record (EHR) system and used the EHR system to improve care coordination for patients with complex chronic conditions.
Health IT Drives Improved Care Coordination
Two years after adopting an EHR system, Trinity’s providers decided to build on their Health IT capabilities and work towards becoming a patient-centered medical home to improve care for patients with complex chronic conditions. To kick off the initiative, the practice added a care coordinator to its staff and acquired a clinical data warehouse, a database that aggregated patient records from their EHR into useful reports.
The care coordinator used the EHR system to generate lists of patients scheduled for upcoming appointments and used the lists to help the patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and other complex chronic diseases manage their care. For patients with diabetes, for example, the care coordinator ensured that recent diagnostic studies, lab results, and consultation notes were in patients’ charts before seeing the doctor. The care coordinator also consulted the clinical data warehouse, which assigned green, yellow, and red indicators according to whether patients met, were close to meeting, or were not in the normal ranges for clinical measures like hemoglobin A1C levels. Armed with this information, the care coordinator could identify patients with out-of-range clinical markers, conduct targeted follow up with identified patients, and help them better manage their care.
Improved Patient Outcomes
After implementing and meaningfully using Health IT to improve care coordination, Trinity Family Medicine saw improved patient outcomes. “The ability to access patients’ clinical information electronically allowed us to spend more time one-on-one with the patient,” Dr. Chatman said. “That increased attention dramatically improved outcomes, not to mention patient and provider satisfaction.” The practice also saw a dramatic drop in patient visits to the emergency room and very low rates of hospital readmission within 30 days of discharge.
Dr. Chatman’s Commitment to Quality Improvement
To pursue more Health IT work, Dr. Chatman transitioned from Trinity to her current full-time position at HealthBridge. As HealthBridge’s Director of Clinical Informatics, she supports several Health IT and quality improvement projects, including the Comprehensive Primary Care (CPC) initiative. Dr. Chatman also remains involved in clinical work, with an eye on quality improvement. She continues to see patients each month at a Cincinnati area federally qualified health center (FQHC). The FQHC participates in the Million Hearts initiative, a quality improvement program aimed at preventing 1 million heart attacks and strokes by 2017. In all of her Health IT work, Dr. Chatman has been thrilled with the cooperation among Cincinnati-area providers and hospitals. “I’m very proud of our community,” she said. “It’s great to see health systems put down their swords and say, ‘We need to work together on improving patient care.’”