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Looking For TroubleMichael Morgenstern

Looking for Trouble

How electronic medical records can help find high-risk “missing” patients

Every year, Regina Richardson spends a lot of time looking for trouble.

Richardson directs Care Management for Johns Hopkins HealthCare (JHHC), which serves more than a quarter-million members across Maryland.

Her team’s goal is simple: Find women at high risk for premature births and other costly complications, yet who probably don’t know free help is available. Then give them the extra care they need—saving lives and money.

Their task is not so simple: Every year, JHHC cares for more than 8,000 pregnant women insured by Medicaid across the state. Often doctors know to refer special cases to Richardson’s team. Often they don’t. So Richardson and her team comb through patient claims and electronic medical records (EMRs), where signs of potential trouble come in many forms. Maybe a note buried somewhere reads “husband smokes,” “lost apartment” or “history of substance abuse.” Reviewing a single patient’s records can easily take an hour, says Richardson.

“We’ve always known there’s gotta be a better way.”

But what is it?

That’s not an easy question to answer. Even with the arrival of ever-more sophisticated technology, many products are focused on perfecting a traditional paradigm: visit doctor, feel better. It’s familiar, and it’s essential. But, as Jonathan Weiner, DrPH ’81, MS, points out, it’s not public health.

The problem, he explains, is that the patients at highest risk—the ones JHHC’s nurse case managers are searching for—aren’t the ones coming in or accessing follow-up care.

Fortunately, there are glimmers of a new trend in health IT: Tapping EMRs to find these “missing patients” before trouble arises and to target resources efficiently across entire communities. It’s a trend Weiner, a professor of Health Policy and Management, hopes to accelerate through his newly founded Center for Population Health IT (CPHIT, pronounced “see-fit”).


  • Ed Childs

    Nashville T n 06/12/2013 01:09:57 PM

    I have worked for 8 years trying to address the needs of patients with multiple chronic conditions. Using ICD and CPT diagnostic codes matched with prescriptions and then scanned with episode-based predictive software works best. Long-term solutions require individual medical records monitored by nurse navigators.

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