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Hospital pop health program increases cancer screenings, patient engagement


A hospital system is adapting population health data to create a blueprint for a cost savings patient care program.

One hospital is showing how population health programs can positively affect patients with cancer, diabetes, cardiovascular disease and hypertension.

The program, rolled out by Massachusetts General Hospital (MGH) in 2011, started as a cancer screening initiative. Researchers used data from a “non-visit” IT tool and an automated reminder system to identify patients who were not following their suggested screenings schedule for breast, colorectal, and reproductive cancers.

The initial program was conducted within individual practices, however, MGH, wanted to see if a more “centralized approach” would be more effective, and how such a program would affect a broader group of patients.

Program expansion

MGH used two different models to track the progress of its population health program-one that created centralized standards using health IT platforms (the centralized population health program), and one that allowed each practice within the system to manage patients using existing standards.

In 2014, researchers chose eight practices that would use the centralized program with the population health coordinators to see how it would affect care for patients with diabetes, cardiovascular disease, and hypertension. Ten other practices using existing MGH standards were also monitored.

“We did this using validated algorithms, not just using billing claims, but basically all the data that we had in a healthcare system-lab tests, problems, medications or procedures, depending on the registry,” said Steven J. Atlas, MD, MPH, director of primary care research and quality improvement at MGH, during a presentation at the 2017 Healthcare Information and Management Systems Society (HIMSS) conference in February 2017, as reported by AMA Wire. “We had a control in that we were focusing this time on rolling this out for chronic disease, but we had already established procedures for doing preventive health for cancer screening, so we continued that at the same time.”

The hospital system had about 13,000 patients with diabetes, 10,000 patients with cardiovascular disease, and 45,000 patients with hypertension.  

The centralized program also involved the use of population health coordinators, nonclinical staff who worked with physicians to perform administrative tasks including appointment scheduling, chart reviews, and ordering labs and other outside tests.

Program results

In six months, researchers found that practices that were a part of the centralized population health program had better results in helping patients receive cancer screenings. There was a 14.8% increase in cancer screenings for underserved patients that were a part of the centralized care program.

MGH also reported an increase in patients being treated for diabetes; higher engagement from the population health coordinators, which allowed more time and resources to the primary care physicians; and a savings of $1.6 million.

Atlas said at HIMSS that the use of the population health coordinators is now a network-wide standard because of their impact on increasing quality measures.


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