Predicting Patients’ Next Healthcare Moves: How HIT Stakeholders are Keying in on Advanced Population Health Management

Jan. 29, 2018
Providers, payers and vendors are well-aware of the changing healthcare paradigm in front of them, and how value-based care has become a driver for more enhanced population health management.

Population health is hardly a new term in health IT circles, but a recent report from Black Book Research has shed some light into how serious stakeholders are about being able to holistically under­stand patients as they move across the care continuum.

The report, which included responses from 140 chief information officers (CIOs), 159 chief financial officers (CFOs) and 448 hospital managers involved in planning and executing population health initiatives at their or­ganizations within the next year, revealed that in an ideal world, next-generation population health management systems will be able to identify a plethora of patient groups and predict where, when and how to best en­gage them. In addition, they should have the ability to coordinate care across the entire healthcare continuum, support care team collaboration and measure the ac­tivities, outcomes and overall performance of providers within the network, according to the report’s authors.

While many IT systems have long been developed with fee-for-service healthcare in mind, a shifting landscape (EHR) vendors to tap into new, non-fee-for-service teth­ered platforms for population health. According to the Black Book report, 90 percent of healthcare leaders said that future population health management systems will essentially be projected to perform as next-generation patient accounting systems. Said Doug Brown, manag­ing partner of Black Book Research in a statement that accompanied the report, “Some EHR systems have handled managed care for years, and those that have deep experience with capitation and managed care will be better able to translate that knowledge into value-based initiatives. Systems like Epic that were developed from the start as a single, longitudinal patient record spanning inpatient, outpatient, post-acute and billing will have the advantage.”

What might these “next-generation” systems look like and how will they be tailored to a value-based care environ­ment? Brown, who was also interviewed for this story, says, “We will have to start working on predicting all the coordi­nates of care where patients might end up and when and where they might engage.” He adds, “We have to support the collaboration from the differ­ent care teams. Did the activity happen? Was it ordered and not performed? What were the outcomes? How was the performance of the provider, be it a physician or an outpatient facility? All that data now has to be mea­sured, not for fee-for-service, but it now becomes all of these other data sources that need to be pulled in. So it becomes a patient accounting system.” Brown notes that Epic, Cerner and Allscripts, either via acquisition or through needs from other clients, “are putting funding into building what this appears to be.”


In Great Neck, N.Y., Northwell Health (formerly North Shore-LIJ), is the largest integrated healthcare system in New York State with 22 hospitals, 6,675 hospital and long-term care beds, and more than 550 outpatient fa­cilities. Simita Mishra, Ph.D., director/service line lead­er at Northwell, oversees the organization’s strategic population health initiatives from within the office of the CIO. Mishra says her job is to work in partnership with whoever is providing care management operational ser­vices on a day-to-day basis within Northwell.

“We [are] their strategic and advisory partners. We look to understand what would be the best business case so we can provide them with an IT infrastruc­ture that will help them provide evidence-based care management to the population that they are serving,” Mishra says. She adds that it’s not just about technol­ogy; rather, her team sits at the leadership level with clients and has councils where they work with them to better understand their requirements. “At times they don’t even understand their own requirements since they are primarily on the clinical side and don’t have that [business expertise]. So we will help in that re­gard,” she says.

Simita Mishra, Ph.D.

Mishra, who doesn’t have a technology background but has worked in population health and consulting for 14 years, has two core population health groups roll up to her leadership within the office of the CIO: the first is the standard population health management team at Northwell; and the second is the team in charge of the Delivery System Reform Incentive Payment (DSRIP) pro­gram for Medicaid patients. These two groups are kept separate, notes Mishra, since the DSRIP grant from New York State mandates that resources not be co-mingled, but essentially DSRIP is a subset of the broader popula­tion health organization.

One of the biggest focuses of Mishra’s work right now is the development and roll-out of Northwell’s homegrown Care Tool software. The tool is developed by the service line team and then designed to meet the requirements and features that are based on what the user wants, Mishra notes. The Care Tool might ca­ter to multiple programs such as a bundled payment program, the New York State Health Home program, or DSRIP.

An example of the tool being put in use, explains Mishra, would be a Northwell patient navigator who is in charge of patient outreach, reaching out to people in the Home Health population. In this scenario, the Care Tool will show the patients linked to that program, and once the navigator sees that, he or she can then see who the outliers are (the non-compli­ant patients), who might need appointment remind­ers, or who has been discharged within the last seven days. Those patients will then be pursued to see their primary care physician (PCP) if necessary, or a similar action will be taken, Mishra says, adding that a clini­cal snapshot in the EHR also gets sent from the Care Tool to the PCP, who can take a quick look to see if vaccines or immunizations are missing. The real-time alerts and ability to risk stratify in order to identify high-risk patients are all triggered by what’s originally entered into the tool, Mishra notes.

Meanwhile, Northwell’s DSRIP work creates broader population health challenges, since the state mandates that every physician practice associated with the pro­gram has to have an EHR by 2018, something that some of the health system’s voluntary practices still lack. Also, the practices have to all be Level 3 PCMH (patient-cen­tered medical home), meaning having the ability to col­lect and use data for population health management, as designated by the NCQA (National Committee for Quality Assurance). Like with the EHR mandate, North­well is also currently short of this requirement. Says Mishra, “We are still working towards DSRIP’s goal of 25 percent reduced [avoidable hospital] readmissions over a period of five years. The grant, which I wrote along with other folks on my team, was [based on] proving to the state that your health system was already invested in doing population health management. So you show them that you would have used the health system’s money to invest in population health,” she says. “It’s a lot of contracting and negotiating. Plenty of work is still ahead of us.”


Most experts would agree that although efforts to im­prove healthcare in the U.S. have largely been focused on the clinical side, it would be unwise to ignore the many social, economic, and environmental factors that influence a person’s health.

At Humana, the Louisville, Ky.-based health insurer, a “Bold Goal” program was put into place two years ago with an overarching aim to make the communities it serves 20 percent healthier by 2020. For this goal to be achieved, it’s necessary to understand that social deter­minants of health are fundamentally important in terms of how to care for populations, says Roy Beveridge, M.D., chief medical officer at Humana. He notes an ex­ample of a diabetic patient being food insecure; the likelihood that this patient will have a prescribed diet and can control his or her sugar intake is quite small. “In the U.S., we have 5.4 million seniors who are food insecure, and if you don’t address that issue, treating someone’s diabetes—meaning also taking care of blind­ness, diabetic foot ulcers, and kidney disease—becomes very hard. But we do know that by working with grocery stores, hospitals, the local government and others in the community, you can begin to take care of food insecu­rity,” Beveridge says.

However, despite a growing recognition that looking at these social determinants of health is a critical com­ponent of improving one’s care, just four or five years ago, most physicians would have said that it’s a social worker’s problem rather than a clinical issue, says Bev­eridge. “This is why the move from fee-for-service to val­ue-based care has begun to focus in on [the notion] that treatment is more than giving someone a prescription. Fundamentally, how can I influence this person’s health as opposed to giving him or her a medication and then saying the patient is non-compliant?” he asks.

Drilling down deeper, Vipin Gopal, enterprise vice presi­dent, clinical analytics at Hu­mana, notes the importance of integrating the internal Hu­mana data that the payer has on its members with the data it has about its communities, and with the social determi­nant data. “That gives us a broader view about the health of a community that we didn’t have by just looking at primary claims from a payer perspective,” Gopal says. What’s more, he notes, understanding the given population in detail is also critical. “What would lead a person to progress from their diabetes condition into getting ad­ditional complexities, be it congestive heart failure or something else?” he asks. “It helps us move things from a population perspective and enables us to be more personalized in the solutions we offer to our members.”

Vipin Gopal

To this end, one of the biggest challenges in Humana’s senior population is that one-third of them have a fall every year. As such, Humana is using advanced analytics to figure out who’s most likely to fall among that senior population, and then enabling them with the right so­lutions to prevent a fall, or making sure that they are in a program in which they have a device that triggers an alert if there’s a fall. “That makes a big difference in their quality of life,” says Gopal. “It increases mobility and confidence, and these are the fundamentals we are tackling, with analytics as the starting point. You need to identify members and communities first, and then put solutions in place.”

In the end, sources interviewed for this piece are in agreement that healthcare’s traditional fee-for-service mentality in which physicians want to maximize the pa­tients they see—thus maximizing their charges—does not encourage an environment in which it’s important to spend time looking at a patient’s social determinant data. But when that physician is getting paid for qual­ity outcomes, all of a sudden, it makes sense to look at these other health factors.

And that right there is the crux of population health management—using analytics and insight to focus on a group of individuals with similar healthcare needs, and improve those patients’ outcomes. Says Gopal, when asked about putting all of this together for improved care: “It’s a nice sweet spot, the intersection of data and medicine that is coming together and revolutionizing this population health management space.”