Disease Management

Population Health Management with EHR Technology

Leverage your health IT to improve patient management and clinical outcomes.

CVD Chart

Health professionals are well aware of the heart attack and stroke prevalence in the United States. Currently there are more than two million heart attacks and strokes each year, and they are the first and fourth leading causes of death, claiming over 800,000 lives annually. Hypertension and diabetes are the biggest contributors to these diseases, but are not managed as well as they could be.

Utilizing EHR technology

The problem has been spelled out through many communication channels. The tactical issue for physicians lies in the ongoing identification and management of patients who have hypertension and diabetes as well as uncovering those at risk or on the cusp that may not realize it. When under control, hypertension and diabetes pose a much lower risk for heart attack and stroke. That’s why M-CEITA teaches providers how to utilize their existing EHR technology to help health care teams monitor and regulate this population. We have identified a process that any provider with EHR technology can implement to manage their patient population, regardless of vendor or time constraints.

Patient management protocol

MH Flow Graphic


target population, including potentially undiagnosed patients with hypertension and diabetes.


patients with hypertension.


patients to improve compliance with treatment, proactive provider management, and patient self-monitoring.


patient outcomes and reduce costs by reviewing health data.

Webinar Toolkit

Million Hearts HTN Control Change Package

  • A wealth of information for any practice looking to incorporate hypertension clinical quality improvement initiatives. In our webinar series we stress the importance of evaluating your staff’s BP measurement skills. Page 5 of this guide includes links to videos and assessment tools to measure skills and re-train.

Million Hearts SMBP Action Guide for Clinicians

  • An excellent, comprehensive guide for any office looking to incorporate a program of Patient Self-Monitoring of Blood Pressure.

HealthIT.gov - Detailed Ambulatory CDS-QI Worksheet (zip file; download then extract)

  • A fantastic tool for planning/developing/implementing Clinical Decision Support (CDS) interventions. As a bonus this tool is packed with Hypertension related examples.

HealthIT.gov - Diabetes CDS Toolkit

  • A CDS starter kit for Diabetes follow-up care with examples that can help implementers think about how different CDS intervention types can match work processes for a particular clinical condition.

AACE Diabetes Treatment Algorithm

  • This document represents the official position of the American Association of Clinical Endocrinologists and the American College of Endocrinology for the treatment of diabetics. Newly updated and released in April of this year, this comprehensive algorithm should be an integral component in your clinic(s) for improved diabetic outcomes. When the MCEITA Undiagnosed Diabetes Identification Protocol references a management tool, this is it.

MCEITA SMBP Implementation Tool v1

  • A condensed, 2-page “Provider Guide” for implementing a Patient Self-Monitoring of Blood Pressure program at the office level.

MCEITA Undiagnosed Diabetes Identification Protocol

  • Referenced in the first webinar in the series and in more detail in the “Identify” session, this tool walks you through a protocol for mining the existing data in your EHR to find undiagnosed diabetics by examining the relationship between Diagnosis, Labs and Meds.

MCEITA Undiagnosed Hypertension Identification Protocol

  • Similar to the previous tool, this is a simple protocol you can follow to identify undiagnosed hypertensive patients in your current patient panel./li>

MDHHS Procedure for Measurement of BP

  • Pared with the BP measurement tools and videos referenced in the previous guide, a step-by-step guide from the Michigan Department of Health & Human Services for proper BP measurement.

MCEITA 2015 CQM Selection Guide

  • Designed to assist you in choosing clinically relevant CQMs to report, this tool lists the 64 CQMs approved for the Meaningful Use program with columns for listing those offered by your EHR, CQMs related to the Million Hearts initiative, as well as the measures you are encouraged to report on by both Michigan Department of Health and Human Services and CMS.

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