Population health success depends on good data
Editor's note: In the three-part cover story of our January issue, Healthcare IT News takes a look at the three big challenges health information technology is trying to help solve: quality improvement, improved access to care and cost reduction.
The famous "Triple Aim" framework developed by the Institute for Healthcare Improvement seeks to improve the patient experience of care, improve population health and reduce the per capita cost of healthcare. As the industry tries to tackle all three of these goals at once, IT – whether it's electronic health records, patient portals, health information exchanges, telemedicine technologies or business intelligence and revenue cycle tools – is instrumental.
"I'm someone who believes we're heading toward a world of extraordinary healthcare abundance – a world in which every man, woman and child is going to have access to healthcare at a level that is democratized and de-monetized around the world."
So said physician, engineer and entrepreneur Peter Diamandis, striding the stage before a roomful of healthcare chief information officers this past October at the CHIME CIO Fall Forum in San Antonio.
It's an exciting vision. But how close are we to actually getting there?
Improving the health of populations and expanding access to care for those who need it most is a challenging goal – but also one that could have the most far-reaching positive impacts as healthcare moves toward reimbursing for value-based care.
Diamandis' rosy vision is based on his expectations about what consumer and clinical technology – its power and reach advancing exponentially as its price drops – can do for huge swathes of people worldwide. And certainly, it's difficult to be skeptical of his barely-bridled optimism.
[See also: IT seen as critical to population health.]
But there are challenges to getting to that world of widespread access. Most notably, issues around interoperability and data liquidity – whether it's EHR vendors who don't play ball or privacy laws that hamstring well-meaning population health initiatives. Simple geography is a big hurdle too, as much for those living in Bronx walk-ups as for those in the Maine woods.
Luckily, as telemedicine finds its footing and providers sort out how best to use patient portals and personal health records, many of those challenges are being addressed.
Certainly the Office of the National Coordinator for Health IT is optimistic – at least in the long term.
"By 2024, the nationwide use of interoperable health IT will be pervasive," the agency predicted in its 10-year vision, "Health IT Enabled Quality Improvement." Across the healthcare ecosystem, stakeholders will "seamlessly interact with on a daily basis for multiple purposes such as: healthy habits of daily living, delivery of care, care coordination, population management and value based reimbursement."
In the much shorter term, though, there's plenty of work to be done. So, in its just-updated Health IT Strategic Plan, ONC made improving "clinical and community services and population health" one of the lynchpins.
"Sharing information, tracking these patients and keeping these costs down is very dependent on being able to uniquely identify that it is the same patient."
"Having complete information about the person is critical to achieving population health goals," officials wrote. "This requires health IT capable of receiving and integrating individual health information from multiple sources to enable providers to aggregate and trend information within and across groups."
Providers on the ground are facing hurdles with this, of course. Even leading-edge organizations pursuing advanced pop health programs.
"When you get into population health, sharing information, tracking these patients and keeping these costs down is very dependent on being able to uniquely identify that it is the same patient," Jack Wolf, chief information officer of Bronx, N.Y.-based Montefiore Medical Center, told Healthcare IT News.
"Obviously, when you get into certain areas, it's critical you're certain you have the right person for allergies and medications," said Wolf. "When you start to talk about the population in the Bronx, our patients make their decisions about where they want to go for their own healthcare, and it's not always to the same provider each time."
[See also: Data is key to population health management.]
But rules such around New York's opt-in patient ID law make that much more challenging.
"It creates a lot of added work," he said. "And in some cases is even precludes the referral, until such time as you can get the consent form. You start to talk about, as you move through different systems and really focus on population health, about creating care plans and populating medical records with the care plans, it makes it very difficult."
Montefiore is pioneering some novel ways around that – "ways that you can identify the patient and still meet all the concerns (about) privacy" – primarily by rethinking master patient indexes at the HIE and RHIO levels.
It's also focusing on efforts to reach vulnerable citizens in city and getting them the care they need with help from affiliated neighborhood groups.
"One of the areas that I think is a perfect opportunity for us all is to start to reach out to community organizations and incorporate them into the structure of your care plans," said Wolf.
"If you're discharging a patient who's on the third floor of a walk-up apartment, and they're a diabetic, maybe they've had foot surgery, well, now you've got to get medications to them and healthy meals, and you've got to provide resources that can help the patient stay compliant with your care plan," he said. "We've started to work with a lot of the community programs, and I think that needs to be expanded.”
Montefiore is focused on "connecting with them electronically and keeping track of the patients that are in their programs and in ours," he added. Texting and e-mail are key. As are "personal health records, the future of that is definitely something we're looking forward to."
The medical center has also been thinking of developing "a pilot using Fitbits in our school health program, where kids could be challenged and compete with other kids on getting more exercise," he said – the better to start population health management early.
Deploying these novel technologies will be key to the shift "from fee-for-service to population health," said Wolf. "It's the future of healthcare."
Recognizing that, many other providers are making investments in technology to deliver healthcare to populations who need it – even if the ROI isn't immediate. Consider the recent report from Foley & Lardner LLP, which polled healthcare organizations about how they're approaching telehealth initiatives in the face of regulatory challenges and spotty reimbursement.
Impressively, the poll found that nine out of 10 respondents are moving forward with telemedicine projects – even though 41 percent said they currently don't get reimbursed at all for them. These C-suites recognize the future value of distance-based care, with 84 percent saying that "meaningful telemedicine services will be central to the success of their organizations" in the wake of the Affordable Care Act.
"In the post-Obamacare paradigm, providers bear a much greater responsibility for the sustained wellness of their patients," said Nathaniel Lacktman, a partner and healthcare lawyer at Foley, in a statement. "Telemedicine offers new ways for providers to manage this new level of risk and keep their patients healthy, happy and out of the hospital."
But even if the regulatory and reimbursement hurdles are addressed, there are still other challenges. As ONC officials pointed out in its strategic plan, "While efforts are underway to bring broadband to all Americans, in rural areas, nearly one-fourth of the population, and in tribal areas, nearly one-third of the population lack access to broadband services. Even in areas where broadband is available, approximately 100 million Americans still do not subscribe" – inhibiting the ability to leverage video for telehealth.
Personal health records hold great potential for population health efforts too, but still are under-utilized, according to Jessica Ancker, associate professor of healthcare policy and research at Weill Cornell Medical College in New York. As Healthcare IT News contributor Neil Versel reported in November, Ancker said, "results have been a little mixed and certainly not a real home run.
"There's some hope that they could improve patient motivation by strengthening the patient-provider relationship," she said, but "there hasn't been a coherent model for what this is going to do."
One problem, said Ancker, is that most patient portals are not all that patient-friendly. "In fact, they tend to be doctor-centered," she said.
On the other hand, there's the recent success of the OpenNotes project, which offers patient access not just to a PHR with lab results, but to the physician's notes themselves. The uptake has seen almost stratospheric success since its first pilot in 2010.
"We've gone from 20,000 people two years ago to, we think, between 4.5 million and 5 million now," said the initiative's founder, Tom Delbanco, MD. "The patients were extraordinarily enthusiastic: 80 percent of them read their notes."
Even better, there were results: "About 70 percent of patients said they were taking medicines better," he said. "Which, even if it's a five-fold exaggeration would be mind-blowing."
Still, for those encouraging returns to truly catch fire on a large scale – especially among the far-flung populations that need access the most – real, system-wide data sharing is a problem that needs solving.
"The progress toward the interoperability vision we set out will have to be incremental," said ONC's interoperability portfolio manager Erica Galvez, speaking at RSNA in Chicago this past November. "It takes time. We have to work together and build progressively."
In the short term, that means "getting some basic stuff right for care coordination," said Galvez. "We have to be very specific, and very clear about the data we want to have interoperate.
"We're not interested in interoperability for the sake of interoperability," she added – pointing once again to a three-part mission: enabling better quality, lowering cost, and "improving the health of our populations."