What if providers could create a map of patients who need focused attention, much like a star map plotting the universe’s constellations? With a new tool, enabled by Partners HealthCare’s shared electronic health record (EHR) system, Partners providers can do just that—eliminating lags in care and better matching chronic and preventive care with patients who need it.

Using real-time data from patient EHRs, the tool creates online reports that support patient outreach and condition-specific interventions. The database of clinical information allows users to track gaps in their patients’ care—such as poorly controlled blood pressure, cholesterol, or blood sugar, or a missed cancer screening—and act accordingly to close those gaps.

“With this tool we can organize a vast amount of data into usable information,” says Mary Merriam, RN, Director of Program Operations for Central Population Management at Brigham and Women’s Hospital. “It’s like having a star map of the universe. Having this type of data helps both the Population Health Coordinators and care teams manage their patients and their needs both in and outside of practice.”

The new approach enabled by the Partners EHR overcomes previous barriers to population health management, such as disparate databases, manual reports, and multi-step processes. With the tool’s reports that indicate each patient’s needs, and designated Population Health Coordinators equipped to take action based on the information, Partners providers are poised to both enhance care and better measure its quality and outcomes.

Read more about the new tool here.