Solutions Guide: Population Health

May 28, 2015

Consider these four analytic integrations at the point of care for population health

Brian Drozdowicz, Senior Vice President and General Manager, Global Population Health, Caradigm

We know that integrating analytics at the point of care contributes significantly to population health success. But which integrations should your organization tackle first? Consider these four:

  1. Real-time data: In population health, it’s critical that staff work as efficiently as possible, making proactive decisions based upon solid and timely information. As such, analytics should work against real-time data to ensure that health organizations are focusing on the right patients at the right time. For example, consider the discharge of a congestive heart-failure patient who has been a frequent visitor to the emergency room. Knowing exactly when the discharge occurs in order to take proactive action to prevent complications and near-term readmissions is an effective way to both improve the patient’s health and manage costs.We know that integrating analytics at the point of care contributes significantly to population health success. But which integrations should your organization tackle first? Consider these four:
  2. Risk stratification: Employ risk stratification to drive care management processes. When closely integrated into a care manager’s workflows, he/she can be notified of risk scores and then take immediate action. Risk stratification is an important tool to allow care managers to focus on patients that have the highest return on intervention. Traditionally, as risk scores changed, they bounced between spreadsheets or other software systems that don’t talk to each other. That resulted in a tremendous amount of manual intervention – and increased odds for manual errors. Automate risk stratification so that a score that passes a given threshold is routed directly to the appropriate care manager for immediate action. This forces a consistent approach for all patients and is an extremely effective means of ensuring consistent care – one of the core tenants of accountable care.
  3. Clinical workflow tools: Integrate analytics with clinical workflow tools to identify care gaps in standard quality measure steps (ACO33, HEDIS, PQRS, etc.) and facilitate the closure of those gaps. Consider the diabetic who needs annual eye and foot exams. Integrating this information into a workflow saves time and is much more effective than if that information was sitting in a standalone spreadsheet or other system. Automating the workflow in value-based settings is a simple way to ensure that physicians are providing quality care through a consistent approach and are rewarded appropriately.
  4. Automated communications: Integrate quality-improvement data with automated tools, such as text messages, emails, or integrated voice response, to close care gaps. This is more cost effective than using clinicians to make patient phone calls. Their time is better spent focusing on caring for sick patients rather than attempting to close gaps in care. That’s where automated systems, based upon patient preferences, come in. These technology-based approaches can motivate patients to take actions with the same results and at lower costs.

While you may also wish to consider other analytic integrations at the point of care, these four are an excellent place to begin.

Surveys and Studies

Is communication population health’s major pain point?

Results from a new survey of 955 healthcare professionals commissioned by PerfectServe identify doctors and nurses struggling to get in touch with each other to coordinate care as a fundamental obstacle to improving population health. Conducted online by Harris Poll between February 12 and

March 6, 2015, the survey represents a broad cross-section of the healthcare provider ecosystem, including physicians (hospitalists, primary care physicians in large offices, specialists in both hospital and office settings), nurses in hospitals, case managers, and hospital administrators and office managers.

While 95 percent of respondents agree that successful care collaboration leads to reduced readmissions, 96 percent say that inefficient communication is a barrier to effective population health management. Sixty-nine percent of clinicians feel patient care is often delayed while waiting for important patient information. Interestingly, four in 10 respondents (40 percent) do not believe that the electronic health record (EHR) is enough to successfully coordinate and communicate with other members of the extended care team. Among clinicians, the EHR is used as the communications mechanism only 12 percent of the time. On the security front, about three in five respondents (61 percent) say that HIPAA regulations pose an obstacle to communication and collaboration within the care team.

Noteworthy other connectivity findings from the study include:

  • More than half of clinicians (52 percent) admit they don’t always know the correct care team member to contact in a given situation;
  • 71 percent of responding physicians say they have wasted time trying to communicate with the broader care team;
  • Only 25 percent of physicians strongly agree with the assertion that they can usually contact colleagues for collaboration or consults in an effective manner; and,
  • Nearly half of physicians (48 percent) report being frequently contacted erroneously when they’re not caring for the patient in question.

The most common current communication technologies used in optimizing population health management represent the tried and true: Phone calls (83 percent) and online patient portals (74 percent) lead the pack.

Read the complete research findings at


Patient outreach certified for Meaningful Use

PatientPoint Outreach 3.2 is now certified for Meaningful Use in an ambulatory setting and is compliant with the ONC 2014 Edition Stage 1 and Stage 2 criteria (patient list creation and patient reminders) for certified EHR (CEHRT). Driven by a population health analytics engine, PatientPoint Outreach 3.2 provides automated outreach by email, text, and interactive voice response (IVR), depending on the patient’s stated preference. PatientPoint

Motivate healthcare consumers

Allscripts FollowMyHealth Achieve helps providers and patients stay connected between formal visits or encounters. Clinicians can use Achieve to monitor patient compliance with care plans remotely and initiate interventions. Providers enter care management instructions into an Allscripts TouchWorks EHR or Allscripts Sunrise EHR, which then are made available to their patients through their Allscripts FollowMyHealth account. Remote monitoring and the use of home-based devices can be interfaced with the system portal, which can send alerts regarding patient status. Patients can use Achieve to carry out orders at home using wireless devices such as scales, glucose meters, and blood pressure monitors. Readings and results are forwarded to the applicable Allscripts EHR. Allscripts

Promote holistic care for chronic conditions

McKesson Care Manager helps identify and manage patients needing high levels of care and intervention. This solution provides a streamlined, analytics-informed workflow that identifies, stratifies, and prioritizes patients needing support. A single work queue helps care managers manage their daily tasks. The solution uses automated rules-based algorithms to update care plans with recent changes to clinical, lab, and medication data, along with risk scores and utilization cost and likelihood of admission data. It fosters a proactive team approach to patient care using consistent guidelines and access to a comprehensive patient record and care plan. McKesson

Simplify population health

The HealthLogix platform provides a single, comprehensive patient view to easily identify individuals in need of health improvement opportunities. This solution connects disparate EHR systems and transforms both clinical and claims data into real-time Actionable Health Intelligence to enable better health outcomes and more informed decisions at the point of care. Insights are made available via a Web and mobile application so healthcare systems, physicians, and care teams can review and manage community-wide patient data. Transcend Insights

Get the big picture

New data visualization enhancements to Decision Point Healthcare Solutions’ Population Health Management platform enable healthcare plans to see whether they are targeting the right people and whether or not their program is helping them achieve performance targets. Using the Performance Report Card, analysts can integrate health plan data from multiple sources and then collate, analyze, and express predictions and micro segmentations in visual charts and graphs. With Data Exploration, they can measure key member engagement attributes and their outcomes impact. Decision Point Healthcare Solutions

Patient portal for 300 hospitals and counting

More than 300 hospitals have gone live on YourCareCommunity, a vendor-agnostic, cloud-based portal that connects all stakeholders in a care community, from primary care physicians and hospitals to clinics and patients. This platform shares information across locations and providers and makes data available on demand throughout the continuum of care. YourCareCommunity has been certified as both a modular inpatient and ambulatory EHR, and positions hundreds of providers on the path to attestation for the 2014 Edition of Meaningful Use. MEDHOST

Try the suite life

Verisk Health offers a suite of population health analytic and reporting solutions that use disparate data sources and apply powerful predictive science, business intelligence and clinical insight to identify risk and drive performance improvement. Organizations use these solutions to establish cost-effective programs for managing their population’s health. This solution suite enables users to measure network variation and provider efficiency, as well as inform improved risk contract partnerships between payers and providers. Verisk Health

Power up your analytics

The Children’s Hospital Association (CHA) has selected Health Catalyst’s Late-Binding Enterprise Data Warehouse (EDW) to enhance comparative analytics for its 220 member hospitals. CHA will use the EDW to aggregate clinical and operational data, accelerating the evaluation of evidence-based practices and benchmarking performance. The EDW will enable the children’s hospitals to submit data for analysis using automation and centralize the data on a single platform. Health Catalyst

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