Disease Management, EHR Technology, Hypertension Management, Diabetes, Million Hearts, Stroke, Heart Attack, CEHRT, Meaningful Use, Hypertension Control, PQRS
Disease Management

Population Health Management with EHR Technology


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

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


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

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

AACE Diabetes Treatment Algorithm

MCEITA SMBP Implementation Tool v1

MCEITA Undiagnosed Diabetes Identification Protocol

MCEITA Undiagnosed Hypertension Identification Protocol

MDHHS Procedure for Measurement of BP

MCEITA 2015 CQM Selection Guide


To learn more or sign up for assistance, CONTACT US.






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