There is little question that healthcare is undergoing a significant transformation. Patient-centered, accountable care and pay-for-performance reimbursements are converging to create a unique environment for payers, providers and patients alike. Most experts agree that in order for emerging care delivery models to achieve their full potential and deliver on the promise of lower costs and higher quality, the industry must become more sophisticated in its application of care and population health management programs.
Standing in the way of progress, however, is the highly fragmented nature of today’s healthcare system that prevents the seamless flow of information among all constituents. According to the recent report from the Institute for Health Technology Transformation, titled Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare:
“Efficient, systematic data collection, storage and management drive automation, quality measurement, and performance analysis; and, comprehensive, timely, relevant information is essential to high-quality patient care. But current EHRs are not designed for [population health management] or for interoperability with other systems. To fill these gaps in information technology, organizations need registries, other supplemental applications and health information exchanges.”
Presumably, “other supplemental applications” include solutions that automate workflow intelligently based on health plan business rules and facilitate collaboration between payers, providers and members. Such solutions can be found in care management technologies that are designed to promote vertical data integration by consolidating information across the continuum of care delivering rich, meaningful content to providers and members quickly and efficiently.
Data Drives Outcomes
A care management solution is among the most sophisticated technologies that health plans will deploy. Integrating data from disparate data sources, including medical and pharmacy claims; medication, lab and diagnostic reports; health risk assessments and EMRs, complex algorithms apply a variety of clinical and business rules to identify and stratify populations and high risk members. When enabled with communication tools such as a portal service designed to connect all constituents, this multi-channel care management platform will help improve decision support, member engagement and ultimately, healthcare outcomes.
For example, a health risk assessment could be configured to gather information on a member's dietary habits and present it through the member portal. Combined with existing information on the member, the platform can determine the potential risk of the individual developing a chronic condition. Business rules are then applied to this information to create an actionable item such as a referral to a weight loss program or contact by a case manager for nutrition counseling.
With a care management platform, providers also have the opportunity to recognize gaps in care. Configured with rules for identifying missed opportunities in the care delivered to a member, such as a prescription that is not refilled in a timely fashion or an immunization not received, the care manager, physician or member can receive an automatic alert, appointment request or other notification, empowering them to address the situation. Similarly, a health plan has the ability to identify members with one or more major chronic conditions and can automatically initiate multiple activities or interventions, according to the severity of their condition.
Getting Providers, Patients on Board
Of course, care and population management programs will ultimately fail without the support of the medical community. Health plans are considering how they can encourage providers and members to take advantage of these free care management resources. It will likely come down to a combination of rewards and penalties linked to quality levels for providers and higher or lower out-of-pocket costs for consumers based their willingness to participate in these programs.
Fortunately, payers are receiving help with care management—albeit indirectly—with efforts such as the Health Information Technology for Economic and Clinical Health (HITECH) Act’s Meaningful Use incentive program, which designed rules that will ultimately drive vertical data integration. Stage 1 meaningful use requirements are focused on tools that assist healthcare providers in improving the care quality, efficiency and safety. They are also designed to help engage patients and their families, reduce health disparities, improve care coordination and, notably, facilitate population and public health initiatives.
Alone, however, EHR technology simply cannot achieve these lofty objectives and significantly move the bar toward lower delivery costs and healthier populations. Health plans, therefore, have an excellent opportunity to step up and successfully engage both providers and members on a new level. This will require them to employ care management platforms capable of consolidating data across multiple, disparate information sources and delivering meaningful information within a collaborative care and highly automated and integrated population health management paradigm.
Sam Rangaswamy, MS, is Chief Executive Officer and Founder of ZeOmega.