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Identifies six steps to help implement panel management in your practice.
Provides answers to common questions and concerns you may have about panel management.
Shares examples, exercises, and quizzes to increase your team's understanding of the need for preventive care.
Quiz Ref IDPanel management, or population health management, is a proactive approach to ensuring that all patients whom a physician or practice is responsible for receive preventive care, not just those who come in for appointments. For example, your practice may use panel management to ask, “Have all of our patients between 50 and 75 years of age received colorectal cancer screenings at the appropriate time intervals?” or, “Have all of our patients with diabetes had laboratory tests for HbA1c, cholesterol, and renal function at the appropriate times?” This approach leads to better health outcomes for your patient population.
Develop a registry.
Use a health maintenance template.
Adopt clinical practice guidelines.
Select and train staff to serve as panel managers.
Identify care gaps.
Close care gaps through in-reach and out-reach.
A registry is a database with medical information such as immunizations, cancer screenings, and disease-specific lab results for the patients in your practice. You might search a registry to identify patients who are overdue for mammograms, pap smears, colorectal cancer screening, immunizations, HbA1c, cholesterol blood tests, or diabetic eye exams. You can also use the registry to identify patients who do not have specific lab values, such as HbA1c, cholesterol, or blood pressure, under control. Your team can generate reports to help track patients' preventive and chronic care measures. Your practice's electronic health record (EHR) may include a registry function, but it is also common to use a separate registry program.
Qualified Clinical Data Registries (QCDRs) are a “Centers for Medicare & Medicaid Services-approved entity that collects clinical data on behalf of clinicians for data submission.”1 As of 2018, there were more than 140 QCDRs approved by CMS for physicians to use for reporting quality measures. More than 30 QCDRs are sponsored by a state or medical society that may offer their members use of the QCDR at no or very low cost beyond a setup fee. (Please note that the number of QCDRs change annually.)
How can I manage my patient panel if my practice does not have an EHR or a separate patient registry program?
You can manage your panel without an EHR or separate patient registry program by using common spreadsheet software to create a simple patient registry that monitors patient information. To create a patient registry that is unique to your practice, use billing data and chart data to identify a specific patient population or health condition that you would like to track. For example, search for patients by using ICD-10 codes or health maintenance data for conditions such as diabetes or hypertension. Include these patients and select health indicators related to the condition of interest in your registry (e.g., for patients with diabetes the date of the last eye exam and most recent HbA1c, etc.). Use visual cues or color-coded cells to flag overdue laboratory tests or visits. Flagging will help you proactively identify patients in need of preventative care visits, and will help your practice effectively implement a panel management system to improve the health outcomes of your patients.
Many EHRs have a health maintenance screen with a list of routine preventive and chronic care tests, such as mammograms, immunizations, and HbA1c tests. The EHR health maintenance functionality can be programmed to:
Quiz Ref IDPrompt physicians and staff to screen patients for diseases and for recommended services based on their age, sex, diagnosis, etc. (e.g., pap smears, mammograms, and colorectal cancer screening). Prompts should be individualized and not appear for patients who are up to date.
Remind physicians and staff to provide preventive care services to patients (e.g., immunizations).
Help physicians and staff better manage patients with chronic conditions (e.g., HbA1c tests and eye exams for patients with diabetes).
Your practice should decide on clinical practice guidelines for preventive and chronic care services and use them to establish target levels for selected health indicators. Many practices use evidence-based national guidelines that are created and updated by specialty societies. If this is your first effort at panel management, start with a pilot project. It is important to choose an attainable clinical practice guideline agreed upon by all physicians within the practice. Celebrate success and lessons learned. Be sure to check if your practice has a dominant payor that requires use of their specific preventive and chronic care guidelines. Determine which targets your practice will set for each indicator.
Quiz Ref IDYou will want to train nurses, medical assistants (MAs), and/or reception staff in panel management. The initial time investment will lead to better care for your patients and improved efficiency in your practice. Some practices may start by training a few key staff members, who then train their counterparts to adopt the new process throughout the practice.
Our team members haven't had this amount of responsibility before and our physicians are reluctant to entrust this work to them. What should we do?
Start with staff members who are energized and can act as champions for change. When they enthusiastically motivate patients to receive needed immunizations or get screening tests, they can win over those in your practice who are reluctant to change. You will know that the culture is changing when you no longer hear your staff saying, “These are the doctor's patients,” but instead saying, “These are our patients.”
How can we train our nurses, MAs, and/or receptionists in panel management?
This module contains resources you can use for training purposes, including suggested scripts for practicing health coaching, discussion questions, and registry quizzes to test understanding of the data in a registry. Also included are teaching exercises for creating out-reach phone scripts, letters, and email templates that your team can use with patients.
A gap in care exists when a patient is overdue for a service that should be done periodically (known as a process care gap) or when a patient is not meeting the goal range for a particular disease or condition, such as having an HbA1c greater than the recommended target (known as an outcome care gap). Care gaps of selected indicators are identified from the registry or from the EHR health maintenance screen. Training on how to identify these gaps is provided as part of this module.
Use this document to learn how to identify care gaps within a chronic care registry.
Use this document to learn how to identify care gaps within a preventative care registry.
Quiz Ref IDIn-reach is a panel management method for patients who are physically present in the office. In some practices, doing in-reach is protocol, regardless of the reason for the visit. During visit preparation or at the time of patient rooming, the nurse or MA reviews the EHR health maintenance screen. If care gaps are identified, they are discussed with the patient and orders are queued up in the EHR for the physician to validate and submit.
Use this document to read in-reach discussions that your practice can use.
Quiz Ref IDOut-reach is a panel management method for patients who rarely come to the office or who have fallen out of care. These patients still need preventive and/or chronic care and panel managers can identify them using the registry. The panel managers generate lists of patients with care gaps and then send mailings, email messages, or place phone calls asking patients to come into the office to close these gaps. Some panel managers even make home visits to follow up with patients personally. Much of the communication can be done by sending computerized reminders to patients, and panel managers can follow up by phone with patients who do not respond. Out-reach is most effective when the care team knows the patient they are contacting.
Use this template to create out-reach letters for the patients in your practice.
Use this script to learn how to make out-reach phone calls to patients in your practice.
Can we use standing orders to increase efficiency?
Yes. For example, if a patient is overdue for a mammogram, the MA or nurse can talk to the patient, enter the mammogram order, and help the patient make the appointment. This discussion between the patient and nurse or MA follows your practice's standing orders. In some settings, care provided by established standing orders does not require physician signatures for each test. The training and licensure of the panel manager will determine their scope of practice, based on state law.
Can you give an example of an in-reach approach to panel management?
A patient with a urinary tract infection visits the practice. In addition to addressing the primary reason for the visit, the MA or nurse reviews the health maintenance screen and identifies any overdue immunizations or cancer screenings during the visit, then arranges for these to be addressed before the patient leaves the office. The training and licensure of the panel manager will determine their scope of practice, based on state law.
We find it easier to check for preventive care gaps once a year at the annual wellness visit. Is this okay?
Yes. Some practices routinely manage preventive care gaps during annual comprehensive care visits and do not need to repeat this work at interval visits. By systematically addressing them at a dedicated visit, staff can close multiple care gaps during a single patient encounter, eliminating the need to contact the patient several times throughout the year. In these practices, in-reach at interval appointments is reserved for new patients and those patients who missed their annual appointments.
My EHR does not have a health maintenance template. How can we use in-reach to manage care gaps for patients in our practice?
Prior to the patient's visit, your care team can review the patient's chart to identify care gaps and discuss them with the patient during the visit. Using pre-visit planning tools and checklists will help the care team manually identify gaps and upcoming preventive care needs.
Panel management can assist your practice in monitoring the preventive and chronic care needs of your patients. With the approaches and training resources provided in this module, you can close gaps in care to improve outcomes and the health of your patients.
Transitioning your practice mindset and approach from providing episodic care at appointments to a more proactive approach to managing your patients' health can seem daunting. Start with in-reach panel management and use complementary tactics to ease the transition, such as pre-visit laboratory testing, pre-visit planning, and expanded rooming, to help you simplify your workflow and let you focus on providing more proactive care. Once you and your team feel ready, start to think about developing your out-reach approach.
There is no “one size fits all” solution.
One “best” way to approach panel management does not exist; different practices and organizations succeed with various approaches to both in-reach and out-reach. Some practices empower reception staff to schedule appointments if they see that patients need preventive care or are overdue for their lab testing based on their last HbA1c. Others have MAs or nurses who address care gaps or schedule upcoming preventive appointments during the rooming process. Some practices have care managers or health coaches contact patients when they miss appointments or are overdue for preventive or chronic condition management. Assess your practice and your resources, and create a model that will work best for you and your patients.
panel managementpanel management:
The panel is the patient population of the individual physician or practice. Panel management is the process of monitoring the patient population for important preventive and chronic care milestones based on guidelines determined by the practice.
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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
AMA CME Accreditation Information
Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Target Audience: This activity is designed to meet the educational needs of practicing physicians, practice administrators, and allied health professionals.
*Disclaimers: Individuals below who are marked with an asterisk contributed towards Version 1 of this learning activity.
Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.
Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association*
Marie Brown, MD, MACP, Senior Physician Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association & Associate Professor, Rush Medical College, Rush University Medical Center
Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association
Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association
Julia McGannon, Segment Marketing Manager, Member Programs & CME Program Committee, American Medical Association
Rita LePard, AMA CME Program Committee, American Medical Association*
Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*
Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*
Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association*
J. James Rohack, MD, FACC, FACP, Senior Advisor and former President, American Medical Association
Thomas Bodenheimer, MD, MPH, Co-Director, Center for Excellence in Primary Care, University of California, San Francisco*
Amireh Ghorob, MPH, Director of Practice Coaching and Training, Center for Excellence in Primary Care, University of California, San Francisco*
David Margolius, MD, Chief Resident, Department of Medicine, University of California, San Francisco*
Christina Harris, MD, Internal Medicine Clinician Educator, West Los Angeles VA*
Peter Kaboli, MD, MS, Professor and Chief of Medicine, Iowa City VA Medical Center*
Norifumi “Norris” Kamo, MD, MPP, Primary Care Physician, Downtown General Internal Medicine Clinic, Virginia Mason Medical Center*
Andrea Sikon, MD, FACP, Chair, Department of Internal Medicine & Geriatrics, Medicine Institute Center for Specialized Women's Health, Women's Health Institute, Cleveland Clinic*
About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
ABMS MOC Statement: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.
Original Publication Date: June 5, 2015
Renewal Date: February 22, 2016; May 23, 2019
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