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Although physicians know the essential elements of good clinical care for people with chronic conditions, there is a gap between what we know and what we are able to do. Physicians are doing their best, but too often the systems in which they work make it difficult to access clinical data that would improve medical care.   

By implementing a change right now, you can bridge that gap — other health care provider organizations have already shown impressive improvements in the health of those they serve.  

"We have already seen improvement in the quality of care our patients receive with the data we've been able to generate. Patients are getting more of the indicated tests that they need to have done and their outcomes have improved,” says John Anderson, MD, Chief Medical Office, Duke University Affiliated Physicians. 

The Problem
Did you know…

  • 46 percent of people in the U.S. have a chronic medical condition
  • 49 percent of these persons have more than one chronic condition
  • A recent study published in the New England Journal of Medicine concluded that patients with chronic conditions received only 56 percent of recommended care

The Solution

Enhance your quality improvement efforts and chronic care management with the BridgingCare® Planner (BCP) patient registry.

A registry is a practical tool that enables you to monitor patient care on a routine basis.  A registry provides a systematic approach to documenting the quality of care provided.  The information is organized in one place for tracking and monitoring the care of either individual patients or a group of patients over time. Through a dynamic reporting capability, a practice can identify patients due for evaluation or intervention and follow specific indicators (e.g. A1c).

“We understand first-hand how difficult managing a patient with one or more chronic conditions in a busy clinical practice can be, but help with managing patients is just one of the benefits of using Bridging Care Planner,” says Kathleen Miller, MD, IAFP President.

Why BridgingCare Planner?

Thanks to a collaborative effort by the Illinois Academy of Family Physicians (IAFP), GlaxoSmithKline (GSK) and participating local health plans, the Bridging Care Planner patient registry is being offered to physicians. 

Benefits for using the BCP include:

  • GSK will license the BCP at no cost to participating physicians in exchange for access to a limited data set, as defined by Health Insurance Portability and Accountability (HIPAA) guidelines, to be used by GSK for research purposes only. (You will retain ownership of your practice data and the HIPAA-compliant limited dataset will only be used by program sponsors for research purposes.).
  • Physicians can earn CME credit (provided by IAFP) for quality improvement and meet board re-certification requirements.
  • Web-based training and support will be provided.

 How does the practice benefit?

The BridgingCare Planner, a web-based system, is embedded with nationally accepted quality measures developed by the Ambulatory Care Quality Alliance (AQA).  These measures support adherence to evidence-based medicine guidelines for asthma, diabetes, and other chronic conditions. By tracking key indicators over time, BCP may assist in achieving the following:

  • Facilitate communication between physician and patient
  • Improve patient outcomes and satisfaction with care
  • Fulfill quality improvement reporting requirements

Practices also have the option to have patient data pre-loaded into the BridgingCare Planner which will allow healthcare providers access to:  

  • Their patients’ demographic and clinical data for selected chronic conditions, such as diabetes
  • Historical claims, lab, pharmacy data (as available from participating local health plans)

What’s required to participate?

  • Participating provider groups or practices must:

-   Sign a License Agreement and a Data Use Agreement with GSK

 -   Agree to track a minimum set of AQA care measures in the first year.  

-   Sign a Business Associate Agreement (BAA) with DocSite.
DocSite is the trusted third party, housing the patient data, and also provides 24-hour help desk support for BCP.  

  • Your group will need to identify and provide contact information for a clinical champion and an administrative champion to support the initiative
  • You will be given the option to participate in a train-the-trainer program and user groups.

EMR vs. BCP  

Q:  We have an Electronic Medical Record (EMR). Isn’t that good enough to manage chronic illness care?

A:  It depends on whether or not your EMR has the following functionality typically found in registries, like BCP:

  • Ability to identify patients with gaps
    in care
  • Produce population reports that can be segmented by clinical indicators and disease severity
  • Produce patient summaries that incorporate all patient co-morbidities
  • Can capture outcomes by provider

 Get Started Now!

To schedule a presentation of the BridgingCare Planner in your office, e-mail Kristen Jackson at kjackson@iafp.com.