PRP062: COVID-19 Pandemic Response with EHR and Patient Reported Measurement for Risk Stratification, Triage and Clinical Pathways

rodger kessler, MD; Mindy McEntee, PhD; Brad Doebbeling


CONTEXT The COVID-19 pandemic amplifies the importance of current and ongoing surveillance of patients and families directly affected by the virus, and those at high risk for infection. There is also a large population of patients who may not get infected, but whose overall function, quality of life and engagement in health care, such as elders and/or those with 2 or more chronic medical and/or behavioral conditions, leave them at high risk of poor outcomes. These issues are magnified among populations from racial and ethnic groups, and those with significant social determinants of health. OBJECTIVE We have recently been funded to implement and evaluate an EHR and patient reported measurement based surveillance system to ; identify a most vulnerable patients, and assess identified quality of life and social determinants of health. This data will create a real time risk score and risk stratification sub groups and implement care pathways for identified sub groups. DESIGN Mixed Methods. POPULATION Three Phoenix Arizona based community based health care systems who primarily work with underserved racial and ethnic populations. INTERVENTION 1.Extract a limited data set from each partners EHR on a monthly basis. 2.Apply a Vulnerability Index to identify the top 20% of patients (larger depending on ultimate practice capacity) at highest risk for poor health outcomes; 3. Clinic staff will reach out to identified patients by combination of phone, text or email, and assess for quality of life, and social determinants of health 4.Generate a risk score and risk stratification sub groups. 5. Concurrently, practice clinical, IT, and leadership generate a rapid quality improvement project to develop and implement care and surveillance pathways associated with category of risk.OUTCOMES; Implementation- Is the intervention successfully accomplished in each practice; Reach-proportion of eligible patients assessed and assigned to risk pool; Adoption- What modifications were made because of site variation and organizational characteristics. RESULTS If successful we will create a rapidly generalizable infrastructure for surveillance, intervention and monitoring and identify facilitators and barriers to implementation. CONCLUSION Successful outcomes are rapidly relevant for COVID-19 application and equally relevant to population health management post COVID.

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