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Population Health for Patients Most at Risk from COVID-19

Providers check in with patients remotely to monitor their health

Angie is a 39-year-old mom of two who recently completed chemotherapy, and her immune system hasn’t yet fully recovered. The CDC and other organizations have found that patients like Angie who are immunocompromised, as well as older patients and those with conditions like heart disease, are more likely to be seriously ill or die if they get COVID-19.

Health systems across the Epic community are using population health tools to follow up with higher-risk patients like Angie. Confluence Health in Washington State uses a risk score to find the most vulnerable patients. The score is based on information in a patient’s Epic chart, such as her age and whether she has lung disease.

The risk score, co-developed by several Epic community members including Confluence Health, is newly available in Epic’s Foundation System for other organizations to use. Clinicians can see each patient’s score in their list of patients to call for regular care management and can review what contributes to a patient’s higher risk.

Epic’s Foundation System also includes two new patient registries to track which of a health system’s patients have a confirmed or suspected case of COVID-19.

Clinicians at Advocate Aurora Health in Illinois and Wisconsin use a similar registry to follow up with patients who have returned home from the hospital or emergency department and have a positive COVID-19 test, making sure that each patient is recovering safely.

Epic community members can learn more about the new risk score and registries in the Managing Coronavirus Disease 2019 (COVID-19) With Epic white paper, which is being updated daily with new guidance related to COVID-19.