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Well over 100 million Americans suffer from one or more chronic illnesses … Americans without optimal treatment are experiencing morbidity and high health care cost [1]. Since the 1990’s, Dr. Ed Wagner and his team at MacColl Institute for Healthcare Innovation have been developing a comprehensive model, the Chronic Care Model (CCM), to improve the outcome of chronic disease care.
The CCM strives to change health systems with the use of evidence-based guidelines and coordinated, planned care. It provides a framework for improving care at the community, organization, practice, and patient levels to transform health care from a reactive system to a proactive system that produces better health outcomes. The CCM can be applied to a variety of chronic illnesses, health care settings, and target populations. For the last five years the Bureau of Primary Health Care (BPHC) has been helping health centers implement the CCM,improving healthcare and outcomes for many thousands of patients.
One of the core components of the CCM is a Clinical Information System, (CIS). The CIS is based on a registry of patient and clinical information that can be drawn upon for a detailed view of an individual patient as well a to obtain information about populations of patients. A comprehensive CIS can enhance the care of individual patients by providing timely reminders about needed services and summarized data to track and plan care. For the population level, the system identifies groups of patients that need additional care and facilitates monitoring performance and quality improvement efforts [2].
Hundreds of health care organizations have been applying the CCM, using the Patient Electronic Care System (PECS) as the clinical information system within the BPHC Health Disparities Collaboratives. From this effort has evolved PECSYS®, a CIS that is now available commercially to all health care organizations who want to improve the care they provide to their patients. PECSYS® supports the CCM in the following ways:
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