The Care Management Plus team is partnered with the Oregon Health Authority (OHA) to develop and provide services to their Patient Centered Primary Care Home program. Services primarily include a web-based framework to facilitate the collection of, and reporting on quality-of-care metrics from participating clinics, in an effort to improve care for vulnerable populations.
The Care Management Plus team is partnered with OHSU's School of Nursing (SON) to develop and provide services to their Interprofessional Care Access Network (ICAN), a web-based system for allowing authorized SON personnel to view, add, and modify information for participating individuals using a collection of dynamically generated forms, which replaces their previous paper-based method. Forms may be adapted with new questions and structure over time, while allowing previously generated forms to retain their structure and data. The ICAN system additionally provides functionality to generate customizable data sets for export to facilitate reporting and downstream processing and analysis by SON.
Implementation of electronic Clinical Quality Measures (eCQMs)
Implementation of eCQMs comprises a primary product and service developed by the Care Management Plus team. eCQMs are utilized to describe the coverage and quality of care for a specific conditions, and consists of comparing a specific patient population against those receiving the prescribed care for said condition. The Care Management team has the capability to implement eCQMs to specifics supplied by various publishing authorities (National Quality Forum, Centers for Medicare & Medicaid Services, etc.)
The Care Management Plus team, in collaboration with Dr. Cosmin A. Bejan, has implemented a Java-based tool for using Natural Language Processing (NLP), word2vec, and related method to process clinical notes in an EHR using collections of regex-based “seeds” that aim to detect unstructured concepts, especially with respect to social determinants of health.
CDS Tool for Hypertension Management
Through a U18 grant funded by AHRQ, the Care Management Plus team is developing a patient-facing, FHIR-based CDS tool to facilitate reviewing patient data as it relates to hypertension, and for applying different, relevant recommendation guidelines (e.g. Alper) to assist with diagnosis, and the downstream prescribing of medications and / or behavioral modifications, using HL7's Clinical Quality Language (CQL).
MCC eCare Plan
OHSU is partnered with RTI International to implement a FHIR-based patient-facing app related to eCare Plans for Multiple Chronic Conditions (MCCs). The Care Management Plus team is coordinating the deployment effort of this software at OHSU.
Clinical Quality Metrics Registry
The Clinical Quality Metrics Registry (CQMR) is a project connecting the Oregon Health Authority with experts in health informatics (members of the Care Management team) through consultation services to assist with various aspects of clinical quality measure reporting. Areas of consultation services include but not limited to technical assistance for eCQM submissions, review of annual technology plans, review and analysis of quality measures and advising on workflow formatting of clinical quality measures within EHRs. In addition, to these services we also have experience in analysis and validation of eCQM submissions and development of analysis guides for users.