Keywords

disease management, health promotion, primary care, primary prevention

Authors

1. Denberg, Thomas D. MD, PhD
2. Lin, Chen-Tan MD
3. Myers, Beth A. BA
4. Cashman, Joyce M. RN, MHA
5. Kutner, Jean S. MD, MSPH
6. Steiner, John F. MD, MPH

Abstract

Patient receipt of recommended preventive and chronic disease care is suboptimal, partly because of poorly organized clinical information and time-limited and sporadic appointments with medical care providers. To overcome these problems, we describe the features of a novel health-promotion outreach system based on electronic data queries, active patient-centered outreach, and minimizing patient barriers to adherence. We describe advantages of this system over traditional preventive care delivery systems and chronic disease management programs, and explain how it complements and helps to promote the type of clinical practice change contemplated by the chronic care model.