Division of Gastroenterology, University of California at San Diego.
Division of Gastroenterology, University of California at San Diego; Health System Department of Biomedical Informatics, University of California at San Diego.
Health System Department of Biomedical Informatics, University of California at San Diego.
Inflammatory bowel diseases (IBD) are chronic and impose significant, multi-dimensional burdens on patients and healthcare systems. The increasing prevalence of IBD will only worsen this problem globally-population health management (PHM) strategies are needed to increase quality of care and population health outcomes while reducing healthcare costs. We discuss the key components of PHM in IBD. Effective implementation of PHM strategies requires accurate identification of at-risk patients and of key areas of variability in care. Improving outcomes of the at-risk population requires implementation of a multi-component chronic care model designed to shift delivery of ambulatory care from acute, episodic, and reactive encounters, to proactive, planned, long-term care. This is achieved through team care of an activated patient with the help of remote monitoring, clinical information systems and integrated decision support, with accompanying changes in delivery systems. Performance measurement is integral to any PHM strategy. This involves developing and implementing meaningful metrics of different phases of quality of IBD care and measuring them efficiently using modern clinical information systems. Such an integrated framework of PHM in IBD will facilitate the delivery of high-value care to patients.