Where is population health heading?

July 28, 2015
Fauzia Khan, M.D., CMO and Co-Founder Alere Analytics
Nick van Terheyden, M.D., CMIO, Nuance
Mary Hardy, Director, Health Data Analytics, ZirMed
Sarah Mihalik, Vice President of Provider Programs, Explorys
Manu Varma, Vice President, Strategy, CEO, Philips Hospital to Home
Michael Hunt, D.O., CMO/CMIO,
Vincent’s Health Partners
Greg White, Senior Vice President and General Manager, TouchWorks, Allscripts
Jonathan Niloff, M.D., MBA, Vice President, CMO, Connected Care & Analytics, McKesson

Conceptually, population health enjoyed a banner year of promotion and publicity as one of the newest additions to the industry lexicon.

But has its performance and practice so far kept pace with its marketing momentum? Even though some argue that it’s early, reviews largely are mixed.

So what strategies and tactics will it take for population health to progress more this year and next?

“There needs to be continued and meaningful support by CMS to help [accountable care organizations] to succeed,” says Fauzia Khan, M.D., CMO and Co-Founder, Alere Analytics. “As the healthcare industry continues to shift away from fee-for-service to value-based care, it is vital for these newer risk-sharing models to find their footing in mining and analyzing population health data, thus identifying care gaps that can ultimately improve outcomes, while reducing spending and waste.”

Providers and payers alike err when they ignore or overlook patients during the process – patients who also need to feel comfortable sharing their own information, according to Khan.

“Patients are continuously left out of the conversation when it comes to the population health discussion,” she says. “With ubiquitous use of mobile devices and more people opting for home healthcare, many patients want to take a more active role in managing their own health. As technology companies work to develop cutting-edge population health solutions, it will become increasingly more important to actually involve the patient in the process.”

Khan cites a study that examined real-world, patient-controlled access to electronic health records that found that almost half of the participating patients withheld clinically sensitive information in their EHR from some or all of their healthcare providers. “Until patients feel more comfortable with sharing all of their health information with providers, there will remain barriers with true patient engagement and having them embrace positive and lasting behavior changes,” she adds.

Khan also calls for data liquidity, regardless of how it’s captured or transmitted, and that it be accurate, accessible, actionable, and comprehensive. “What’s still missing from the equation is the ability to measure and report on at-risk populations, essentially, better tools for identifying gaps in care and pinpointing population segments most in need of improvement,” she says. “Comprehensive population analytics will be essential to unlocking critical information that cannot only manage but hopefully improve the outcomes of at-risk and high-risk populations.”

Make it count

Data composition matters, too, according to Nick van Terheyden, M.D., CMIO, Nuance.

“Without sufficient data in semantically interoperable form, it is challenging to build, test, and refine any population health measures,” he says. “As Lord Kelvin said, ‘To measure is to know. If you cannot measure it, you cannot improve it.’ Data sharing and integration will be the key to the future. A combination of user-driven data accessibility and some regulatory incentives is required to make sharing of data integral to all health providers and systems.”

Because the amount of data will increase in the years ahead, providers and payers must streamline their processes for tracking and reporting on quality measures, according to Mary Hardy, Director, Health Data Analytics, ZirMed.

“They need to prioritize their ability to aggregate data [because] existing stop-gaps that rely on manually compiling, normalizing, and submitting data will only become less feasible as the demand for that data among payers grows, and as the need to integrate data from other providers becomes more critical to value-based and accountable care models,” Hardy says. “Without effective data aggregation, assigned risk scores may not reflect the realities of your patient populations, setting off a cascading detrimental effect on reimbursement and undercutting your ability to make progress toward specific quality targets.

“Comprehensive data aggregation helps organizations identify clinical best practices at the physician level, and it’s the key to accurately assessing the effectiveness of disease management programs,” she continues. “Like anything else, there’s a twofold risk: That what you’re doing isn’t working, or that it is working and you don’t realize it because another problem is masking the success.”

At its core, population health management redefines and redirects patient care toward keeping members as healthy as possible and minimizing the need for expensive interventions that drive “sick care,” according to Saeed Aminzadeh, CEO, Decision Point Healthcare Solutions.

To date, the main focus of healthcare organizations – including both providers and payers – has been in caring for the sick and controlling costs associated with the top 10 to 20 percent of the population,” Aminzadeh says. “For population health to progress in 2015 and beyond, there needs to be a greater focus on anticipating the future needs of specific populations, and targeting and impacting behavioral, social, economic, and clinical determinants of health outcomes at both the group and individual level. This means predicting the needs of individuals and addressing their barriers to improved health in a systematic manner.”

Sarah Mihalik, Vice President of Provider Programs, Explorys, emphasizes the need for “infrastructure development to accelerate population health strategies that enable value-based contracting.” This includes investing in care coordination, team-based care delivery, and IT infrastructure.

“The ability to leverage an IT platform that enables the integration and linking of clinical data from the EMR with claims data provided by payers will be critical to targeting the right populations for care coordination through risk stratification, closing care gaps leveraging a longitudinal view of the patient to avoid redundancy, and analyzing the financial trends that correlate with the clinical outcomes,” she says. “Risk models and stratification should leverage clinical, demographic, and financial data.”

Further, objectives and incentives must be aligned between providers and payers. “Until we can realign the strong incentives that reward payers for short-term savings at the expense of patients and long-term costs, the healthcare systems will not be able to achieve the desired objectives,” she says.

Various options, processes

Manu Varma, Vice President, Strategy, Philips Hospital to Home, says he foresees growth in the adoption of telehealth and remote patient monitoring that can help bring critical scale to population health initiatives. “We’ll also start to see initiatives to simplify and streamline care management and customer service operations,” he says. “Providers will start to think holistically about patient relationship management by creating more multichannel strategies to keep patients engaged and supported within their networks.”

Michael Hunt, D.O., CMO/CMIO, St. Vincent’s Health Partners, Bridgeport, CT, highlights the challenges of competing operational models that need to be managed carefully.

“Outcome data will need to be published with consistency by these models to bring improved insight into how long-term medical delivery can be cost effective at industry-defined levels of quality,” Hunt says. “Transparency both internally and externally to the outcomes and a commitment to respond efficiently to the data will be necessary to generate new and aggressive patient care dynamics.”

But Hunt rallies for technology advances in the areas of data consolidation, integration, and normalization for meaningful change to occur. These advances by providers and suppliers alike must make the technology affordable and supportable, particularly if your organization has limited resources, he says.

“Tactically, organizations must have confidence in the tools and process they have employed to facilitate population health efforts,” says Greg White, Senior Vice President and General Manager, TouchWorks, Allscripts. “Optimizing mobility, strengthening integration of systems and population health solutions, as well as improving organizational governance are resounding urgencies. In order for providers to focus on what matters most – patient care – we, as vendors, need to continually enhance workflow capabilities, system outputs, and community connectivity.”

To combat the lack of expertise in population health and public health informatics, training and education must be appropriate, Hunt says. “Clinical and business intelligence and predictive analytics expertise must lead the way until population health informatics systems platforms are fully implemented and mature,” he notes. “[Healthcare organizations] will need to strategize for the near and long term to break their information silos and bring acute, ambulatory, analytics, and population/public health technologies under one consolidated and interoperable umbrella to reach and exceed population health goals.”

Technology may be required to implement population health, but it’s not sufficient alone to make the program succeed, according to Jonathan Niloff, M.D., MBA, Vice President, CMO, Connected Care & Analytics, McKesson.

“Providers need to be engaged, fueled by aligned incentives, and processes need to be modified and programs built to support the population health delivery model,” Niloff says. “Some organizations – especially those that are in geographies where provider risk contracts have not been common – lack the internal domain expertise to implement population health programs. These organizations are recruiting leaders with the requisite experience to lead their programs.  First steps typically focus on physician alignment, including related incentives, data and analytics, deploying a registry, and implementing care management programs for high-cost patients. There is increasing interest in practice-based care management programs. In this model, in contrast to traditional centralized care management, care managers are deployed to the point of care and serve as members of the care team.”

Largest ACO puts population health to the test

Advocate Lutheran General Hospital, Park Ridge, IL

When Chicago-based Advocate Health Care, the nation’s largest accountable care organization (ACO), decided to delve into predictive analytics to reduce readmissions, the organization turned to a solution from Cerner that aggregates clinical, financial, operational, and claims data from disparate sources in near real time. The year was 2013, and the goal was to collect and analyze high-volume patient data to identify and improve at-risk penalty dollars.

Using Cerner’s population health platform, HealtheIntent, the team of Cerner and Advocate associates collected data from more than 600,000 Advocate patients across six EHRs, for both billed and paid claims, in the Chicagoland and Central Illinois areas. The effort focused on the acute care venue and produced rewarding results by the end of the year, including a drop in readmission penalties from 68 to 13 percent of at-risk dollars (about an $800,000 reduction from the previous year).

As project time and experience progressed and new measures were rolled out, Advocate experienced a string of improvement successes. In just one example, the readmissions rate for heart failure patients was reduced markedly in a single year – down 21 percent since May 2014.

“In some respects, readmissions is the measurement of quality for an ACO and an indicator of how well your patients are transitioning throughout your system,” says Tina Esposito, Vice President, Center for Health Information Services, Advocate Health Care.

But there is no silver bullet, she says.

“Advocate has been actively working on the opportunity to positively impact readmission rates as part of a large set of system-wide initiatives, including implementing a risk prediction tool that automatically calculates risk of readmission every two hours for all inpatients, targeting high-risk patients for outpatient care management services and transition visits, [and] leveraging Advocate’s own home health division and post-acute network of affiliated skilled nursing facilities for necessary post-acute services.”

With the Advocate Physician Partners (APP) group bringing together more than 4,900 physicians, the push to coordinate, implement, and evaluate even incremental improvements is no small feat, especially when it comes to what Esposito describes as the “uncharted territory of population health management.”

Still, the rewards for the Cerner/Advocate effort and its multitude of participants can be great, and the lessons valuable for clinicians and patients alike.

“Together, we have gained further insight into issues around appropriate transitions to post-acute care, the impactability of patients so that interventions like outpatient care management can be better targeted to the right patients, and the implications of improved medication adherence,” says Esposito. “These learnings have been made possible through the integration of all clinical and claims data via Cerner’s HealtheIntent population health management platform and a focused analytic effort to both ask and answer very tough population health management questions.”

“Additionally, we have been able to leverage the platform to support the creation of next-generation wellness and condition-based registries and outpatient care management solutions,” she says, “providing care team members’ information at the point of care to further improve the health of entire populations.”

3M offers population health backed by 30 years of data

Providers can tap the massive analytics potential of three decades of 3M clinical and claims data on 45 million covered lives through the new Web-based 3M Health System Performance Suite. The 3M Health Information Systems solution aims to help providers manage the health of populations, measure provider performance, determine total cost of care, and succeed under a value-based payment system – key components needed to participate in an accountable care organization (ACO), take part in state initiatives such as Delivery System Reform Incentive Payment (DSRIP) programs, or understand issues such as patient outward migration or network “leakage.”

The 3M Health System Performance Suite is built on 3M’s time-tested risk stratification methodologies, including the 3M APR DRG Classification System and 3M Potentially Preventable Events (3M PPEs) software, which identifies hospital readmissions, complications, admissions, and other events that may be avoidable. The first modules are now available, which offer easy-to-navigate interactive dashboards and internal, state, and federal data reporting tools for performing State Compare and Patient Compare actions. Four additional modules are scheduled to be released over the next several months to provide incremental risk adjustment and further insight into provider performance, quality, population cost of care and risk, and a risk-scenario modeling tool.

A quartet for quality improvement

By Rick Dana Barlow, Editor-at-large

David Bennett

David Bennett, Executive Vice President of Healthier Populations, Orion Health, offers a four-pronged blueprint for population health progress in the near future.

1. Develop the technology infrastructure for data analytics and reporting.
Data quality and data management are fundamental to quality population health. Providers today are realizing that even if they have sufficient technology capabilities, they need a range of relevant data sources before they can benefit from accurate, consistent, and robust information to turn it into action that improves clinical outcomes.

Software vendors need to understand the providers’ worldview and help them especially during this disruptive stage by assuring that their data structures support their clinical and operational needs, and have the flexibility to easily accommodate new population health initiatives and business intelligence needs.

2. Expand IT infrastructure to support identification and outreach.
Successful organizations penetrating market share have spent substantial resources developing their IT infrastructure. Many have invested in EHR implementation across the continuum of care – one that integrates to a single HIE platform. The benefit of a longitudinal patient record in the community has been proven. Providers can now have connectivity and collaboration capabilities among all parties.

3. Set relevant measures and enable the monitoring of outcomes.
To curtail costs and deliver more value with population health management, it is essential to align the quality metrics and performance-reporting indicators with the perceived needs of care providers to deliver better patient care. Providers need to be able to change the outcomes that they are being measured on. This alignment would help healthcare networks reach the required clinician’s adoption level they need to affect outcomes.

Addressing the complexity of the rules for quality reporting would improve the clarity on population health progress. Hospitals have reluctantly adopted CMS 30-day readmission measures even though they reflect quality of community care and nature of the population demographics much more than they reflect hospital quality of care.

4. Change the model of care delivery.
The model of care delivery utilized in the fee-for-service world will no longer suffice in this new era. All healthcare professionals will need to practice to the level of their license in order to assist physicians to care for entire populations. There needs to be a concentrated effort to maximize talents at all levels and areas of care delivery. Mid-level providers can often see 80 percent of patients and manage their care, and nurses can handle triaging to ensure the patient gets the right care at the right time with the right provider for every encounter.

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