Multiple trends are pushing the healthcare delivery system in the direction of population health management (PHM). These include the “meaningful use” requirements for government health IT subsidies, patient-centered medical home pilots, the prospect of payment bundling and Medicare’s incentives for accountable care organizations. But the familiar obstacles to this approach still exist: the fragmentation of healthcare providers, poor communication across care settings, misaligned financial incentives, the difficulty of tracking and managing healthcare outside of office visits and the inability of providers to keep track of all the services that patients need.
Electronic health records (EHRs) can help physician practices and healthcare organizations overcome these barriers by making information more accessible at the point of care. If EHRs are interfaced with labs, pharmacies, and other providers, and they include some degree of decision support, they can be even more useful.
But to achieve the goals of population health management, care teams also need a new generation of tools that automate routine PHM tasks. For example, the EHR can be enhanced to deliver Web-based health-risk assessments and educational tools that stratify patients and help them manage their own health. Electronic registries can help physicians monitor patients’ health status and the services that have been provided to them, and evidence-based protocols in those registries can trigger automated interventions with patients when they’re overdue for care. Powerful new applications for analyzing EHR data can help care managers improve care for both individuals and populations. By using these techniques in conjunction with EHRs, providers can reduce the cost and increase the effectiveness of population health management.
To do PHM properly, physicians and their care teams must strengthen their relationships with patients in a variety of ways, including making sure that they come in for needed preventive and chronic care. Care teams must optimize the services they provide to patients before, during and after office visits. And they must extend their reach beyond the four walls of their offices to provide a continuous healing relationship. The appropriate IT tools can facilitate achievement of all three goals while lessening the burden on practices.
Combining an electronic registry with an automated method of communicating with patients who are overdue for preventive and/or chronic care services will provide solid inroads to strengthen the doctor-patient relationship. Patient demographic and clinical data in the registry can come from billing systems and electronic health records, as well as hospitals, labs and pharmacies. Advanced registry dashboards identify patients with particular health conditions and deliver insights into improving care across a population. By using evidence-based clinical protocols, the registry can trigger outbound messaging to patients who need to make an appointment with their doctor for particular services at specific intervals.
Optimization of visits requires preparation by both the patient and the care team. Patients that complete health risk assessments – either online or at a computer kiosk in the office – can show the state of their health and how they’re managing it. After they have completed an HRA, automated tools can provide educational materials tailored to their conditions; these tools can also direct them to appropriate self-help programs for, say, smoking cessation or losing weight.
The registry-based technology, meanwhile, can provide care managers and coordinators with actionable reports that combine data from their EHRs with data from registries, other providers, and HRAs to show what has been done for the patient and the gaps in their care that need to be filled. Care managers can also supply this information to physicians prior to a patient visit and expand the care plan for the patient after they receive care.
For the global approach to population health management, providers need a sophisticated rules engine that combines disparate types of data with evidence-based guidelines, generating reports and dashboards that provide many different views of the information. For example, the entire patient population could be filtered by activity center, provider, health condition and care gaps. The same filters could be applied to patients with a particular condition, such as diabetes, to find out where the practice needed to improve its diabetes care.
Reports on individual patients could be generated the same way. A diabetes report, for instance, would show the patient’s blood pressure and body-mass index, whether they had had an HbA1c test within a certain period of time, and their HbA1c level, among other data points. By combining these reports with an integrated registry and the patient messaging software, the physician or midlevel practitioner would be able stratify their population and invoke the correct treatment plan and intervention across the right communication channel, changing patient behavior and improving the overall health of their community.
Technology is not a substitute for the physician-patient relationship, which is the basis of continuous care and can have a major, positive effect on health behavior. But to the extent that automation tools are used to strengthen that relationship and enable physicians to provide value-added services that help patients improve their health, this type of technology can help drive population health management.
Richard Hodach, MD, MPH, Ph.D., is the chief medical officer of Phytel.
