Article Figures & Data
Tables
Practice Characteristics Practice Responses (N = 15) Size Large (>8,000 patients) 8 Medium (3,000 to 8,000 patients) 7 Ownership Part of a health system 10 Independent 5 Location Urban 10 Rural 4 Suburban 1 Risk stratification algorithm type Automated 5 Manual 5 Hybrid 5 Self-assessment of risk stratification workflow Low confidence 2 Moderate confidence 8 High confidence 5 Domains used to calculate risk scores Diagnoses 15 Utilization data 11 Behavioral health 9 Medications 8 Social determinants of health 7 Other 4 Frequency of stratification At point of care 5 Monthly 5 Quarterly 3 Bi-annually 2 - Table 2.
Benefits and Challenges Associated With Adopting Existing Risk Calculation Criteria Versus Developing Novel Criteria
Adopting Existing Criteria (N = 6) Developing New Criteria or Modifying Existing Criteria (N = 9) Benefits Evidence-based approach Specific to patient population Easy to adopt Customized weight of criteria Validated criteria Can include information external to the EHR Challenges Not specific to practice's patient population Requires clinician and staff input Lack of clarity in weighting/criteria Technical expertise required May not utilize validated criteria Explanations “Our Branch Medical Director… and some of our care managers looked at a few different models and felt like this one resonated the most with them… There [were] the appropriate amount of levels that they felt like six levels was a good amount. There were some [models] with fewer, maybe didn't break it out as much.” —Director of process improvement, Practice C0.1 “The challenge of the risk tool is finding your population in your community and that you have to know your community to make it. It's not a one size fits all tool. I mean, the criteria will change per the population.” —Nurse manager of care management, Practice F0.2 [AAFP] was already embedded in our [EHR] system, so it was easy to switch over. They had just implemented it, put in [the risk score] as an embedded feature.” —Care coordinator, Practice E0.1 “Although there were reasonable approaches, they were… too broad and didn't encompass some of the things that we thought would place a patient in higher risk.” —Physician, Practice G0.1 EHR, electronic health record; AAFP, American Academy of Family Physicians.
Automated (N = 5) Manual (N = 5) Hybrid (N = 5) Description Programming in the EHR or other database uses pre-selected criteria to assign patients a risk score. Practice staff or clinicians review patients to generate a risk score, often based on pre-selected criteria. Any mixture of clinical intuition, automated algorithm, and manual algorithm. Practice Characteristics Size: 2 Medium, 3 Large Size: 3 Medium, 2 Large Size: 2 Medium, 3 Large Location: 2 Rural, 2 Urban, 1 Suburban Location: 5 Urban Location: 2 Rural, 3 Urban Ownership: 2 Independent, 3 System Ownership: 2 Independent, 3 System Ownership: 1 Independent, 4 System Workflow Algorithm is programed into EHR or other database, and mapped to data sources Criteria are developed to systematically assess risk Criteria are developed to systematically assess risk, and data sources are identified Risk scores are generated Empaneled patient lists are generated for each clinician Algorithm is programed into EHR* or other database to generate risk scores Care team members review each patient Care team members review each patient Benefits Efficient for large populations Care team member(s) generates risk score Care team member(s) generates risk score Automatically generates and updates scores Can include information not reportable from EHR Can include information not reportable from EHR Pre-packaged algorithms available Technical expertise not required Validated algorithm criteria available Risk scores generated within EHR or database Validated criteria Challenges Technical skills required Time-intensive Time-intensive Dependent upon consistent EHR documentation Risk score manually entered into EHR or database Technical skills required Difficulty including psychosocial criteria Developing new criteria Dependent upon consistent EHR documentation EHR, electronic health record.
