Electronic health records (EHR) have been implemented in over 95 percent of hospitals, according to the Office of the National Coordinator of Health Information Technology. As a result, many patients and healthcare providers have seen the benefits of the EHR and the importance of exchanging patient information among all healthcare systems. 


Interoperability, or the easy exchange of EHRs among healthcare systems, allows healthcare providers greater access to a patient’s medical history, regardless of where and when a patient received care. This avoids redundancies in testing and exams, reduces costs and allows the healthcare provider to offer better quality and more individualized care. It also helps to improve population health. Consider this scenario: A physician is performing an annual exam on a diabetic patient and notices that the patient’s blood sugar levels have become unpredictable. The patient also mentions that his eyesight has begun to decline. Through the patient’s EHR, the physician can see when the patient last received a diabetic eye screening, predict how long it will take to regain control of the patient’s hemoglobin A1C, see trends among other patients with similar symptoms, and establish a care plan with follow-up reminders for the patient and physician to follow. If the patient visits other providers, they will see that -the patient is following a diabetes care plan and should administer care accordingly. 


As a value-based network and accountable care organization, Nebraska Medicine, a two hospital system sees value in incorporating population health into its EHR. According to Healthcare IT News, its goal “is to help private practice physicians work more collaboratively across the state [of Nebraska] to improve care, reduce costs, benefit from group purchasing agreements and participate in new federal incentive programs.”At Novant Health, a broader approach to incorporating population health into the EHR is being applied. This allows other healthcare systems to access its patient information and vice versa. In early 2017, Novant Health became the first health system in the United States to provide access to Epic’s Healthy Planet Link module to allow care providers, both affiliated with and unaffiliated with Novant Health, to access key health trends for patients. Healthy Planet link is an analytical tool that gives healthcare providers information about Novant Health’s patients, such as historical prescription trends, the frequency of hospitalizations or preventive care measures.

 Over their lifetime, most people will see multiple providers, undergo a variety of screenings and experience health emergencies. It is important that healthcare providers within the Novant Health system and those practicing outside of our system have access to this valuable patient information so they can provide appropriate preventive care.Epic’s Healthy Planet Link is a tool with an associated dashboard that provides healthcare systems and providers with information that can help coordinate care delivery, monitor quality and cost, reduce financial risk, and engage patients through a centralized data warehouse. It also allows providers the opportunity to track performance on several utilization and preventive care quality metrics, which can assist in improving overall population health.

Novant Health has identified 15 trackable measures. Those are:
•Screening for future falls
•Poor control of hemoglobin A1C
•Diabetes eye exam
•Use of imaging studies for low back pain
•Controlling high blood pressure
•Use of aspirin or another antithrombotic for ischemic vascular disease
•Depression remission over a 12-month period
•Breast cancer screening
•Colorectal screening
•Influenza immunization
•Pneumonia vaccine for older adults
•Body mass index, or BMI, screening and follow-up plan.