The Four Success Factors in Pop Health Connected Care

While many entities are grappling with how to succeed in these value-based care models, the truth of the matter is that population health actually requires a patient-centric approach in order to be effective.
12:41 PM

As the US healthcare industry shifts from the long-standing fee-for-service model to a more quality-based standard, healthcare organizations across the country are looking for tactics to help them succeed in the value-based care world. Population health is one of those tactics that has been placed at the forefront of this search. Dr. Turner Billingsley, InterSystems Chief Medical Officer, sees the approach to population health as critically important for health­care organizations and clinically integrated networks. Ideally, the methods chosen will create care models that are durable and sustainable.

While many entities are grappling with how to succeed in these value-based care models, the truth of the matter is that population health actually requires a patient-centric approach in order to be effective. Billingsley believes that healthcare organizations need to think specifically about how they can empower clinicians to be more effective in improving the overall health status of a population by optimizing care for individuals. Among other things, this requires standardization, localization, personalization and adaptation.


In healthcare, standardization implies the use of evidence-based best practices. For population health management priorities, it also requires estab­lishing a consistent measurement standard. While the type of care element can vary, such as the outcome, cost, utilization or patient’s satisfaction, the way that each facet is measured needs to be standardized and consistent. Consistent standards, such as HL7, CDA and FHIR, are also needed to ensure the repeatable and measurable exchange of population health data. Care plan documents and care team member and role representation are both areas that are seeing increased attention from vendor implementations. These consistencies are essential for reducing gaps in care, adhering to best practice standards and ensuring the overall success of the population health initiative.


Regardless of the telemedicine capabilities that exist today, healthcare is still local at its core and reflects the available services, payment models, cultural notes and regulatory environment within a patient’s community. While a patient can receive care that is being directed by a case manager halfway across the country, it is still up to the local health facility to see those best practices and care delivery tactics through. Because of this, it is important that care plans take local conditions into account and that all members of the care team have appropriate access to comprehensive, shared and longitudinal health records to ensure that all care constituents are on the same page. Health information exchange (HIE) capabilities can provide a beneficial platform for building a community-wide connected healthcare record. By facilitating data aggregation, information exchange and information presentation to all care team members within their preferred workflow, HIE allows providers to deliver more comprehensive and efficient care plans to patients within their local communities.


Healthcare has always been, and will always be, all about the patient. It needs to be individualized based on a person’s unique health history and care needs. Providing personalized care can range from modifying common medications to finding a cus­tomized therapeutic plan that is tailored based on a patient’s lifestyle and financial needs. It also includes engaging with the patient to become aware of their health goals and care preferences and building them into the development of the care plan. High-tech precision medicine requirements should also be addressed, which allow for appropriate diagnosis and customized pharmaceuticals for individualized treatment strategies. Finally, personalized health­care needs to support shared clinical decision mak­ing, giving providers across the care continuum full access to shared health records at any point in the care journey. Sharing resulting documentations digitally or in print can help to build awareness, increase buy-in and, hopefully, improve clinical decision making for each individual patient, which can then be replicated at the population level.


The idea of the learning health system – which recognizes that the ideal way that care is delivered is a continuous work in progress – is something healthcare entities must keep in mind. Organizations should be able to analyze the health histories of an entire patient population and use that insight as a way to understand what is, and is not an effective care plan in the future. They should also be able to see which approaches to patient engagement reduced unnecessary hospitalizations and select the lowest cost option from a number of equally effective treatments. By constantly adapting and changing the way that care is delivered, continuous improvements will be made and more effective care tactics will be established as industry best practices and standards.

By applying these four characteristics to a population health initiative, healthcare entities can ensure that patient health data across the full population is con­sistent, well communicated and effectively coordi­nated across care teams to reduce gaps in care deliv­ery. All too often, individual providers are still trying to deliver superior care in an unconnected manner. However, in order to optimize the outcome and costs of care for individuals – and ultimately succeed in population and value-based care initiatives – being part of a care team with an evidence-based, multidis­ciplinary connected care plan is critical.

Caring for patient populations is really about the individual patient care. Applying these principles can position healthcare organizations to build a sustain­able and connected system that gives providers the tools, knowledge and support they need to manage populations while focusing on the individual.

About the Author:

M. Turner Billingsley, MD, FACEP, Chief Medical Officer

As InterSystems’ Chief Medical officer (CMO), Dr. Turner Billingsley brings a unique combination of medical and technology expertise as well as thought leadership. In this role, he works with healthcare customers, assisting with ongoing develop­ment of healthcare technology offerings, and representing InterSystems in the healthcare IT sector. Billingsley practiced clinically for nearly 30 years including work as a flight surgeon with the U.S. Air Force and as an emergency Department (ED) physician at St. Vincent’s Medical Center in Jacksonville, FL., where he held leadership positions in quality assurance and risk management. He also is the co-founder of Xpress Technologies, where he served as CMO and participated in development of an ED documentation system.

Want to get more stories like this one? Get daily news updates from Healthcare IT News.
Your subscription has been saved.
Something went wrong. Please try again.