CHRONIC DISEASE

Chronic diseases are the leading cause of disability and death across many states. Population health interventions may focus on multiple factors that contribute to chronic diseases, such as tobacco use and socioeconomic and clinical factors. The first step lies in identification and education of chronic disease-bearing subpopulations (Kukafka and others, 2007). Current federal support for chronic disease programs includes establishment of support through the PPACA to expand and enhance the epidemiology of Congestive Heart Failure (CHF), including organization of a National Congenital Heart Disease Surveillance System (Sec. 10411).

Health information systems can have significant impact on population health initiatives surrounding chronic disease patients. Chapter Six describes a few Partners initiatives undertaken by the disease management team of its high performance medicine framework that illustrate how clinical information systems provide for the effective identification and management of chronic disease patients.