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Effective population health management involves more than just data


A common question facing healthcare executives is how to get started with population health management. Here are steps and strategies critical to success.

At a recent national conference of the Patient Centered Primary Care Collaborative (PCPCC), Patrick Conway, MD, said he anticipates 30% of Medicare payments will be value-based by the end of 2016. Conway, deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services (CMS) and chief medical officer at the U.S. Department of Health and Human Services (HHS),  added that population health management (PHM) will be an essential factor in reaching CMS' goal of 80% of payments being value based by 2018. Initiatives promoted through the Affordable Care Act are showing early positive results in this transition from fee for service, he said, noting that CMS has realized a 2% reduction in Medicare payments across all of its regions through population-based payments.

Still, succeeding in a value-based payment model is not easy, and a common question facing healthcare executives is how to get started with population health management, Fred Goldstein, president and founder of Accountable Health, LLC, and a member of the board of directors for the Population Health Alliance.

First steps

GoldsteinWhen considering a PHM system investment, Goldstein says organizations should first do some background work to become familiar with their patient populations' needs. “Start by picking a disease or condition-the one that's the most costly-and develop a program to manage that," he says.  

Marci Nielsen, executive director of the PCPCC, says the key to success is targeting the right interventions to the right patients before they get to the point of hospital admission. That often means identifying high-risk patients before they find their way into a physician's practice. “You don't have to do much for the healthy patients but those that present high cost [conditions or complexities] require a higher level of focus,” she says.

Reaching these patients requires data. As Goldstein says, “You can't do population health without data.” PHM systems can supply this data. At the outset, they can provide a means of stratifying the populations under care, to pinpoint those patients whose conditions call for the most scrutiny and management.

Next: Drilling down further




Drilling down further

While data can enable organizations to identify high-risk patients, Goldstein says it is essential to use the PHM system to stratify based on "impactable risks."

“The data must be relevant and actionable," he says. “You might find someone with a high risk for Parkinson's, but there's nothing you can do about that.” On the other hand, “For type II diabetes, you can assign a case manager to help walk the patient through the protocols for better care and management of their condition,” averting or eliminating the risk of costly complications and keeping them out of the emergency room.

KharraziThis is where the data management and risk stratification capabilities of a PHM system come into play. Hadi Kharrazi, assistant director of the Center for Population Health Information Technology (CPHIT) at Johns Hopkins Bloomberg School of Public Health, says most PHM systems on the market “perform comparably well” in this essential risk stratification function. However, he says there are other important selection criteria to consider.

In the current healthcare informatics universe, in which health practitioners nationwide employ a diverse smorgasbord of more than 500 different electronic health record (EHR) systems, he says it is important to find a PHM system that can smoothly integrate its risk stratification and other data management capabilities into the practice's or health organization's existing health information system.


NielsenNielsen agrees. She says it is essential “to find out what works well with your own EHR” and engage with a PHM system that interfaces well with it. To add another level of complexity to the decision of where to turn for help, Kharrazi says it is critical that the EHR system and the selected PHM system prove capable of interoperability, not just within the practice, but across the geographic region or administrative environment providing health resources to the patient population. Interoperability, he says, facilitates the aggregation of data from each of the diverse partners in the given population's medical care, collating data from lab tests, diagnoses, and billing and encounter information, to feed into the system seamlessly with little human intervention. 

Next: Moving beyond data


Moving beyond data

Goldstein says the key to a successful PHM strategy involves a lot more than data. Ultimately, it's people that turn the information the systems provide into action that affects health outcomes. “We have to engage the population," he says. By sorting through information on each member's preferences and predilections, a PHM system can help practices determine what interventions individual patients are likely to respond to, and how best to engage them as partners in their care.

“There's a big effort on the analytic side, but there are also initiatives that provide options ranging from automated electronic outreach to those that provide nurses to work one-on-one with the members, ranging all the way up to companies that do the same thing health plans do,” Goldstein says. “It's got to be a seamless integration into healthcare. This person is at high risk for this condition or that, but is this person more likely to respond to an e-mail or take a call from a nurse? Companies are becoming very specialized and can do this.”

Realizing savings and delivering quality care through PHM “is a journey,” Conway says. With any journey, the key to success is stepping in the right direction.

David Richardson is an award winning writer specializing in science and public policy. He is based in Baltimore.


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