5 elements of effective population health

By Kent Locklear, MD
08:25 AM

Although more than half of healthcare managers expect to recoup the investments in their population health management program within three to four years, less than a quarter describe their programs as "mature," according to a survey conducted by KPMG LLP, the audit, tax and advisory firm.

This lack of maturity is partially due to the fact that provider organizations are only now learning how to proactively manage populations rather than simply treat individual patients who are actively seeking care. PHM adoption among providers is being driven by the shift in the healthcare industry from fee-for-service payment models, which still comprise approximately 85 percent of revenues, to value-based payment models, which place organizations' revenue at risk if costs exceed pre-determined thresholds.

[On sister site Healthcare IT NewsPopulation health vendors face a 'high level of uncertainty' from providers, HIMSS Analytics said.]

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To manage this shift, organizations will require care managers to identify and engage high-cost, high-risk patients in their care. Comprehensive data analysis and patient engagement efforts can quickly become major cost drivers if organizations do not have the strategy and information technology tools to make the outreach more targeted, accurate and efficient.

To ensure your PHM program is effective, it should include the following five elements:

1. Continuum-wide claims and clinical data. Capturing as much relevant data as feasible is the first step to effectively manage populations. The challenge that providers often face is that they must analyze their own clinical data from EHRs separately from claims because many enterprise data warehouse (EDW) platforms only allow organizations to analyze claims without the more timely and complete EHR data. Analyzing both data sources together, as well as pharmacy activity and lab results, is crucial for a holistic patient view.

2. Data cleansing and normalization. Once the comprehensive data is captured, it must be cleansed and normalized to ensure the information can be utilized for accurate and reliable guidance about care gaps. An advanced EDW should manage probabilistic patient matching and provide similar matching algorithms for entities such as providers, locations, and hospitals. This creates an Enterprise Master Patient Index that eliminates duplicate patient records when combining data from disparate systems. The data must also be transformed from the numerous data languages used at organizations around the continuum to conform to accepted internal standards.

3. Risk Stratification. With data combined, cleansed, normalized and analyzed, organizations must be able to risk stratify patients and deliver prioritized lists to care managers so they can conduct outreach and engage patients in their care. Here is where combined claims and clinical data and a robust EDW are important for presenting a timely and accurate risk profile. Advanced PHM technology platforms leverage algorithms that combine healthcare data as well as patient demographics and other relevant information to not only help determine risk, but also calculate where the organization can make the greatest impact on outcomes and cost. Care managers can then differentiate patients that will require more intensive outreach efforts or special clinical assistance.

4. Actionable insights. All of these powerful data analytical tools will not help care managers if clinicians cannot understand the reporting or if they are required to search results for actionable insight. Any PHM technology designed to support these care managers, as well as providers, must present easily interpreted dashboards.  It must also include intuitive charts and graphs that assist providers and care managers at the point-of-care in identifying care gaps and help organizational leaders identify resource overutilization. The graphical interface should be customizable so care managers and providers can readily display the care quality and financial metrics that matter most to their organization. This insight supports clinical decision making, but also drives more efficient workflows that derives the largest clinical benefit.

5. Patient engagement. With clearly presented insight and actionable tasks based on care gaps and trends in utilization/cost, care managers can begin conducting outreach using multiple communication methods based on patient preferences. More advanced PHM tools can help reduce care managers' workload by automating the outreach process via text, phone, or secured email. Outreach efforts engage patients in their care and help them better manage their multiple chronic conditions, which can increase the organization's fee-for-service revenue, as well as satisfy quality measures for value-based payment contracts.

Once effective PHM workflows have been established, organizations can concentrate on long-term strategies. Using their PHM technology, organizations should be able to easily create and access reports to identify opportunities for improvement, isolate root causes, and leverage verifiable data to encourage provider behavior changes in support of program guidelines. Through this data-driven collaboration, providers and organizational leadership can focus on achieving the care-quality and cost metrics that help improve outcomes while generating adequate revenue for enterprise-wide growth and sustainability.

Kent Locklear, MD is chief medical officer for Lightbeam Health Solutions.

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