Three Key Capabilities to Manage Population Health

Posted on April 7, 2015 I Written By

The following is a guest blog post by Marc Willard, President of Transcend Insights.
Marc Willard - Trascend Insights
The health care industry’s transition from fee-for-service to value-based reimbursement models demands a dramatic shift in how medical information is used and shared. The ability to generate a single, comprehensive patient view from an individual’s acute care, ambulatory care and wellness data is vital to support this transition. Ten years ago, the technology to move data out of silos to create real-time, physician-friendly, patient-centered population health management (PHM) systems was simply not available.

Fast-forward to 2015, where recent technological breakthroughs are fueling a new era in PHM that promises to help patients achieve their best health while allowing health care systems to create population health platforms that reward value, improve outcomes and reduce costs. For PHM vendors to successfully navigate this profound shift in the health care industry and provide actionable insights on an individual’s complete health care and health status, they need to deliver three key technologies:

  • Community-wide interoperability;
  • Real-time health care analytics; and
  • Intuitive care tools.

Community-Wide Interoperability

In developing a successful PHM system, one of the greatest challenges is working with disparate electronic health record systems that are not designed to communicate with each other, consequently keeping patient data entrenched in silos. Nothing is more frustrating for health care systems, physicians and care teams than dealing with multiple views and logins that impede the flow of information.

For PHM vendors to be successful, they must offer sophisticated health information exchange technology that integrates both clinical and claims data from diverse sources into a single, comprehensive patient view. Recent advances in cloud-based interoperability technology allow health care systems, physicians and care teams to literally get on the “same (electronic) page” with their patients’ complete health care history and real-time treatment strategies.

Interestingly, for health information exchange technology to successfully meet the needs of PHM, we must think beyond traditional electronic health record system interoperability. In addition to integrating data from health information generated outside the four walls of the hospital in ambulatory settings, successful PHM companies will be able to incorporate the valuable insights generated from the latest wearable health technologies that track activity levels, heart rate and other health information into a single, comprehensive patient view. This patient engagement is crucial in the new value-based reimbursement environment, with its focus on wellness and preventive medicine. PHM companies must know how to capture it and deliver meaningful insights to physicians and care teams without overwhelming them.

Several capabilities are required to ensure successful PHM, including bi-directional semantic interoperability, master patient indexing, both clinical and claims data capture and integration, real-time information sharing, results distribution and order processing, care and consent management tools, and of course privacy and security.

Another aspect that is crucial for interoperability is unobstructed access to patient information within traditional silos, so that data can truly be shared. Allowing data to flow requires open systems and interoperability standards that are clean, and widely and easily adopted.

Real-Time Health Care Analytics

A strong PHM tool combines community-wide interoperability with real-time health care analytics capabilities. Effective health care analytics should be able to identify evidence-based gaps in care, drug safety concerns and other opportunities for health improvement while ensuring compliance with the latest clinical guidelines and national quality measures to maximize reimbursement.

Yet the true value in health care analytics is the ability to deliver these insights quickly and simply at the point of care. Every minute counts in health care delivery, and even a five-minute delay in processing information is unacceptable during an office visit, as the physician needs to move on to his or her next patient in a timely manner.

Rather than processing health care data in batch mode, over hours or days, a real-time analysis engine should process data in milliseconds. This enables more informed decisions at the point of care to further ensure that every individual can achieve his or her best health. Physicians now have the ability to take a longitudinal view of how these analytic insights contribute to their patients’ past, present and future health.

Effective real-time health care analytics also allows physicians and care teams to compare an individual’s health status against population benchmarks. By doing so, they can track clinical trends such as readmission rates to further support intervention strategies, reduce risk and decrease costs.

Intuitive Care Tools

Physicians and care teams are more willing to utilize real-time insights generated by sophisticated analytics if they can be easily accessed in a matter of seconds, with just one or two clicks. Even more useful is mobile technology that provides a single, comprehensive view at the physician’s fingertips.

When developing intuitive care tools, PHM vendors should consult directly with physicians to better match and accommodate their unique information needs. For example, offering physicians access to comprehensive clinical trends across a population provides vital insights. When equipped with this information, physicians can improve care delivery through proactive interventions that create meaningful change.

Getting patients involved in the health care equation is equally important when developing intuitive care tools. For example, real-time insights available via mobile point of care solutions allow physicians to maintain eye contact with their patients, have a more meaningful discussion and improve the overall patient experience. As a result, mobile point of care solutions can help physicians encourage their patients to become active participants in their own health, for example, increasing a patient’s medication adherence to help with reducing readmissions.

In addition, once we understand a patient’s total health status and health care needs, physicians and care teams can recommend customized wellness programs that directly address current or future health care concerns. Patient engagement tools as well as a single, comprehensive consumer view can help empower individuals to take control of their own lifestyle choices. For example, smoking cessation classes, nutrition counseling or exercise programs, can help keep individuals healthy and minimize the need for medical interventions.

Keep the Focus on the Patient

With the movement from fee-for-service to value-based reimbursement models, the demand has never been greater for population health management systems that accomplish the industry’s triple aim: improving population health, enhancing the patient experience and reducing costs.

PHM vendors can simplify this transition by developing platforms that offer community-wide interoperability, real-time health care analytics and intuitive care tools. The health IT industry’s transformation must continue to be centered on the patient, whose health and well-being remain the focus of today’s population health management initiatives.

About Marc Willard
Marc Willard is the president of Transcend Insights, a wholly owned subsidiary of Humana Inc., dedicated to simplifying population health. The company, which launched in March 2015, represents the merging of three leading health care information technology businesses: Certify Data Systems, Anvita Health and nliven systems. For more information about Transcend Insights, visit: www.transcendinsights.com.