How to Manage Multi-Chronic Patients with Integrated EHR Dashboards

Care teams must have a broad perspective while managing patients who have several chronic conditions. Chronic illness patients frequently see several specialists, take various medications, and produce vast amounts of data from lab work, connected devices, and clinic visits. Clinicians may find it difficult to anticipate health hazards, coordinate care, or involve patients in shared decision-making if the proper procedures are not in place.

A useful method for converting this constant stream of data into insights that can be put to use is through integrated dashboards that are linked to Electronic Health Records (EHRs). When properly constructed, these dashboards provide physicians with a clear, up-to-date picture of each patient’s medical history, present state of health, and course of therapy for various chronic illnesses.

This blog shares the ways in which integrated dashboards might enhance the administration of multi-chronic care, identifies the salient characteristics that contribute to their effectiveness, and talks about implementation tactics.

Why Multi‑Chronic Patients Need Integrated Dashboards

Diabetes, heart disease, hypertension, and chronic kidney disease are just a few of the disorders that patients with multiple chronic conditions frequently manage concurrently. Typically, their care is complicated. To properly manage each illness, they see many medical professionals and take a variety of drugs.

Missed warning signs, contradictory advice, or redundant testing can result from fragmented information. Integrated dashboards address this by:

• Providing a real‑time view of a patient’s health: A dashboard built from EMR offers a “reliable portrait of the provider’s own practice and how it compares with peers”, giving clinicians context for decision‑making.
• Keeping an eye on trends and risk factors: Quality dashboards assist medical teams in monitoring important clinical indicators and evaluating their performance in relation to peers or standards. These dashboards provide the simultaneous monitoring of several indicators, including blood pressure, HbA1c levels, renal function, and other disease-specific metrics, for patients who are managing various chronic illnesses.
• Encouraging proactive care: Clinicians can respond promptly to abnormal readings when data from remote monitoring seamlessly connects with the EHR. A comprehensive, real-time picture of each patient’s health is provided via the integration of remote patient monitoring and EHR data. Better coordination within the care team and prompt interventions are supported by this integration.

Core Elements of an Integrated Dashboard for Multi‑Chronic Patients

A well-designed dashboard combines key information to drive action, making it more than just a collection of data. Key components include:

Comprehensive Data Integration

• Data from several sources should be combined in an efficient dashboard. This covers both general care and specialized EMRs, pharmacy systems, laboratory platforms, and remote monitoring devices. Additionally, it should record data provided by patients via questionnaires or online health resources.
• Clinicians can do meaningful comparative analysis and real-time monitoring when EMR data smoothly interacts with these sources. Select EHR and remote monitoring programs that adhere to interoperability standards like HL7 or FHIR to enable this. This ensures reliable data transmission and easy connectivity for future equipment.
• As new data becomes available, the dashboard ought to immediately update. Clinicians can act before problems worsen by having real-time access to test reports or vital signs.

Related: How To Boost Patient Health Literacy by 800% Using Interactive EHR Dashboards

Tailored Indicators for Multiple Conditions

• Clearly display each condition’s primary clinical indicators. Emphasize the glomerular filtration rate in cases of renal disease. Show the ejection fraction for heart failure. Measure blood pressure for hypertension and use HbA1c levels to monitor diabetes control. Physicians can quickly and easily see each patient’s health status when these signs are presented together. In the development of a primary‑care access dashboard, researchers selected eight carefully curated indicators to capture meaningful trends over time.
• Tools like Premier’s Quality Continuum combine acute and ambulatory EHR data, national benchmarks, and social determinants of health to provide a cross‑continuum risk score. Similar composite scores can help identify multi‑chronic patients at the highest risk of hospitalization.
• Multi‑chronic patients often manage multiple medications. Current medications, doses, refill status, and warnings for possible drug interactions should all be shown on a dashboard.
• Incorporating PROs enhances shared decision‑making. A pilot study showed that patients and clinicians valued PRO dashboards for increasing shared decision‑making.

Intuitive Visualisation and Drill‑Down Capability

• Clear data visualisation: Data should be displayed through graphs, colour‑coded alerts, and trend lines that highlight patterns.
• Population versus patient‑level views: Dashboards should allow clinicians to view performance across a patient panel and compare their performance with peers or national benchmarks. Providers can then dive deeper into a patient’s record to investigate specifics.
• Reminders and alerts: When values fall outside of desired ranges or patients are due for testing, built-in notifications can notify clinicians. Planned population‑management tools can even batch notifications to patients for follow‑up tests or medication information.

Security and Privacy Protections

• Integrating RPM data into the EHR requires secure transmission and storage. Guidelines recommend encrypting data and using a HIPAA‑compliant platform.
• Role‑based permissions ensure that only authorized providers can view sensitive health data. Patients should also have controlled access to their own dashboards to promote transparency and engagement.

Implementation Strategies

Creating a dashboard is as much about change management as it is about technology. Consider the following strategies when implementing integrated dashboards for multi‑chronic care:

Co‑Design with Clinicians and Patients

To make sure the dashboard satisfies actual demands, end users should be included from the start. Patients and clinicians were asked to assist in deciding on the PRO dashboard’s look, content, and information presentation using a co-design approach. Early involvement builds buy‑in and identifies pain points before deployment.

Workflow Integration and Training

Technology should fit seamlessly into clinicians’ workflows. In evaluations of smart forms and quality dashboards, researchers noted that technology must “fit clinicians’ existing workflow” and that initial efficiency can dip during adoption. Training programs should focus on:

• Dashboard navigation and interpretation – showing how to switch between population and patient views and how to act on alerts.
• Presenting the dashboard to patients: Physicians ought to be able to have a conversation with their patients about dashboard information. Clear and relatable communication of this information promotes cooperative decision-making and aids patients in understanding their progress.
• Documentation and follow-up: Keep track of any actions performed via the dashboard, including changing prescriptions or placing lab test orders. Accurate and current patient records are maintained by proper documentation, which also guarantees continuity of service.

Phased Deployment and Iteration

Begin with a pilot project that involves just one care team or a small number of professionals. Utilize comments to improve the dashboard’s usability, data sources, and functionality. In order to allow for user experience-based adjustments, the AHRQ-funded quality dashboard initiative implemented smart forms and dashboards in phases across various clinics.

Continuous Monitoring and Improvement

Following deployment, monitor clinical results and usage metrics (such as login frequency and dashboard time). To determine which features need improvement and which are most useful, use analytics. Continue to update the dashboard to reflect new indicators, changing policies, or input from patients.

Collaboration and Governance

Multi‑chronic care involves multiple specialists and settings. Create a dashboard governance team that includes patient representatives, IT professionals, clinical executives, and data analysts.

This group can ensure regulatory compliance, establish priorities, and maintain data quality. Data availability can be increased through cooperation with health information exchanges (HIEs). Real-time insight into patterns of chronic diseases can be obtained by utilizing HIE infrastructure.

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